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RehabMeasures Instrument

Four Square Step Test

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Purpose

A test of dynamic balance and coordination that clinically assesses the participant’s ability to step over objects forward, sideways, and backwards.

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Instrument Details

Acronym FSST

Area of Assessment

Activities of Daily Living
Balance – Vestibular
Balance – Non-vestibular
Coordination

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Vestibular Disorders

Key Descriptions

  • Test may be demonstrated by administrator and one practice trial allowed to ensure understanding
  • Two trials are performed, and the better time (in seconds) is taken as the score.
  • Participant steps over four canes that are placed in a ‘plus’ sign arrangement
  • Instruction: “Complete the test as quickly as possible. Both feet must touch the floor in every square. Try to remain facing forward for the entire test and do not touch the canes as you step from square to square."
  • Participant begins test by standing in Square 1 facing Square 2. Square 4 is to the right of Square 1
  • Stopwatch should start when the first foot makes contact with square 2 and stops when the last foot makes contact with the square 1.
  • Stepping Sequence with both feet touching each square:
    - Clockwise: Square 1, Square 2, Square 3, Square 4, Square 1
    - Counter-clockwise: Back to Square 4, Square 3, Square 2, Square 1
  • Can be completed on a foam surface

Number of Items

1

Equipment Required

  • Stopwatch
  • Four canes

Time to Administer

Less than 5 minutes

Required Training

No Training

Age Ranges

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

(2020) Updated By: Taylor Geringer, SPT and Jana Schammel, SPT; Faculty Advisors: Kathleen Luedtke-Hoffmann, PT, PhD; Kenneth Miller, PT, DPT, MA University of North Texas Health Science Center

Reviewed By Shirley Ryan AbilityLab RMD Team: Rudy Chiu, MS and Dhrumil Shah, MPH

(2013) Initially reviewed by the Rehabilitation Measures Team; Updated by Katie Hays, PT, DPT and the TBI EDGE task force of the Neurology Section of the APTA. Updated by Linda B. Horn, PT DScPT, MHS,NCS, Karen H. Lambert PT, MPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA.

ICF Domain

Activity

Measurement Domain

Activities of Daily Living
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Scelerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PDEDGE), Spinal Cord Injury Taskforce (SCI EDGE), Stroke Taskforce (StrokEdge), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE). These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group / Unable to Recommend

NR

Not Recommended

 Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks

Vestibular EDGE

R

N/A

R

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

 

I

II

III

IV

V

PD EDGE

LS/UR

R

R

R

NR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

U

UR

R

UR

TBI EDGE

NR

LS

LS

LS

LS

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly

Dependent

Moderately Dependent

Severely Dependent

TBI EDGE

LS

LS

LS

NR

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

UR

R

R

NR


Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal

Positional Vertigo (BPPV)

Other

Vestibular EDGE

R

R

R

R

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

Yes

No

No

PD EDGE

No

No

Yes

Not reported

TBI EDGE

No

No

No

Not reported

Vestibular EDGE

Yes

Yes

Yes

Yes

Considerations

Participants may be given a demonstration and one practice trial prior to their timed attempts.

Participants may need rest breaks between trials to avoid fatigue.

40-62% of participants had unsuccessful trials at least once during testing, Participants found the test more difficult to perform than the Step Test. However, FSST was preferred by participants because they felt it was relevant to daily life and examined challenging skills (Blennerhassett and Jayalath, 2008).

The Four Square Step Test may be helpful in identifying individuals (older adults > 65 y/o) with vestibular disorders who have difficulty changing directions (Whitney 2007).

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Older Adults and Geriatric Care

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Standard Error of Measurement (SEM)

Older Adults with Hip Osteoarthritis: (Choi et al., 2014, n=30; mean age = 63.3 (5.71) years)

  • SEM for between raters at session 1 (n =30): 0.77
  • SEM for within rater 1 at 1 week follow-up (n=27): 0.86
  • FSST had sufficiently low error of measurement (<10%) for both test situations

Minimal Detectable Change (MDC)

Older Adults with Hip Osteoarthritis: (Choi et al., 2014)

  • MDC90 for between raters at session 1 (n = 30): 1.8
  • MDC90  for within rater 1 at 1 week follow-up (n = 27): 2.00

Cut-Off Scores

Older Adults/Geriatric: (Dite & Temple, 2002; n = 81 community dwelling adults > 65 years old)

  • > 15 second = at risk for multiple falls

Older Adults: (Mathurapongsakul and Siriphorn, 2018, n=54)

  • Cut-off score in order to discriminate between a faller and non-faller was 10.14 seconds with a specificity= 0.667 and sensitivity= 0.667

 

Cut-off score

Sensitivity

Specificty

FSST performed on foam surface

11.21

0.889

0.611

FSST performed on hard surface

10.14

0.667

0.725

  • Cutoff Score, Sensitivity, Specificity, AUC, LR+, and LR− of FSST, and FSST + foam for Discriminating Between Nonfaller Older Adults and Adults

 

Cut-off score

Sensitivity

Specificty

FSST performed on foam surface

8.16

1.00

0.94

FSST performed on hard surface

7.42

0.89

0.89

Older Adults: (Clearly and Skornyakov, 2017)

  • Cut-off score of the FSST to discriminate between multiple fallers and non-multiple fallers was 15 seconds (p=0.02)

Older Adults: (Dawson et al., 2018)

  • A cut-off score of 15 seconds serves as threshold of older adults at risk for multiple falls; specificity=88%, sensitivity=85%

Normative Data

Older Adults/ Geriatric: (Dite et al, 2007)

Balance and Mobility Assessments between groups

 

 

Assessments

Multiple Fallers

Non-multiple Fallers

FSST (s)

32.6 (10.1)

17.6 (8.3)

TUG test (s)

25.0 (6.9)

16.2 (5.3)

Turn time (s)

5.2 (1.6)

3.1 (1.0)

Turn steps (n)

5.2 (1.2)

6.8 (1.2)

LCI advanced (score)

12.9 (4.3)

17.6 (4.2)

mean (SD)

 

 

 

Non-Faller Older Adults: (Mathurapongsakul and Siriphorn, 2018, n=18)

  • 11.03 seconds (IQR=9.08-12.36) for FSST+foam
  • 9.80 seconds (IQR=7.82-10.41) for FSST without foam

Faller Older Adults: (Mathurapongsakul and Siriphorn, 2018, n=18)

  • 12.25 seconds (IQR=11.30-26.08) for FSST+foam
  • 10.63 seconds (IQR=9.16-19.37) for FSST without foam

Older Adults: (Cleary and Skornyakov, 2017)

  • 14.2 seconds (±1.3) for non-fallers (n=22)
  • 12.0 seconds (±2.0) for single-fallers (n=4)
  • 22.8 seconds (±4.7) for multiple-fallers (n=7)

Older Adults with Hip Osteoarthritis: (Choi et al, 2014)

  • Entire group (n = 30):
    • Rater A: 8.97 (2.32) seconds
    • Rater B: 8.56 (2.01) seconds
  • Follow-up group (n = 27):
    • Session 1: 9.07 (2.35)    seconds
    • Session 2 (~1 week later): 8.31 (2.45)

Hip Osteoarthritis: (Batting and Barker, 2019, n=58; mean age=70.6 (7.1) years old, 55% female, recruited from specialist orthopaedic hospital)

  • First assessment mean: 13.7 (5.6) seconds
  • Second assessment:
    • Rater A: 14.2(6.5) seconds
    • Rater B:  13.6(5.6) seconds
  • Follow-up assessment:
    • Time 1: 11.1 (3.2) seconds
    • Time 2: 10.8(3.0) seconds

Test/Retest Reliability

Geriatric: (Dite & Temple, 2002)

  • Excellent test-retest reliability (ICC = 0.98)

Interrater/Intrarater Reliability

Inter-rater Reliability

Geriatric: (Dite & Temple, 2002)

  • Excellent inter-rater reliability (ICC = 0.99)

Older Adults with Hip Osteoarthritis: (Choi et al., 2018)

  • Excellent inter-rater reliability in individuals 1-week post (ICC = .86)

Older Adults with Hip Osteoarthritis: (Batting and Barker, 2019)

  • Before Total Hip Replacement, Inter-rater reliability between two assessors (A vs B) had a mean difference of 0.6 seconds

 

Intra-rater Reliability

Older Adults with Hip Osteoarthritis: (Choi et al., 2018)

  • Excellent intra-rater reliability in individuals 1-week post (ICC = .83)

Older Adults with Hip Osteoarthritis: (Batting and Barker, 2019)

  • Before Total Hip Replacement, Intra-rater reliability with Bland and Altman limits of agreement were 3.5 to -3.2 with mean difference of 0.14 seconds

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Geriatric: (Dite & Temple, 2002)

  • Excellent concurrent validity with the Step Test (r = -0.83)

  • Excellent concurrent validity with the Timed Up and Go test (r = 0.88)

  • Adequate concurrent validity with the Functional Reach Test (r = -0.47)

 

Hip Osteoarthritis: Batting and Barker, 2019(n=58; mean age=70.6 (7.1) years)

  • Excellent correlation with the figure of 8 walk test (r = 0.7, p < 0.01)
  • Excellent correlation with the Berg Balance Scale (r = -0.6, p < 0.01)

 

Older Adults: (Clearly and Skornyakov, 2017); n = 45; mean age = 84.2 (6.3) years

Instrument

Spearman Rho (p) / Pearson Correlation Coefficient (r)

Berg Balance Scale

ρ = -0.74

Timed Up and Go

r = 0.89

Tinetti balance assessment

ρ = -0.60

 

Predictive Validity

Older Adults: (Clearly and Skornyakov, 2017)

FSST ability to predict falls at:

R2  coefficient

3 months

0.38

6 months

0.37

12 months

0.42

Responsiveness

Geriatric: (Dite & Temple, 2007)

Score Multiple (n = 13) vs Non multiple Fallers (n = 27)

Measures

Cutoff

Sensitivity (%)

Specificity (%)

Positive (%)

Negative (%)

FSST

> 24s

92

93

86

96

TUG test

> 19s

85

74

61

91

Turn time

> 3.7s

85

78

65

91

Turn steps

> 6 steps

100

74

65

100

Turn steadiness

NO

31

85

50

72

LCI advanced

< 15

43

91

75

72

NOTE. Predictive value positive reflects the probability that scoring above the cutoff correctly identified multiple fallers, and predictive value negative reflects the probability that the non- multiple fallers were correctly identified as scoring at or below the cutoff (Dite & Temple, 2002). 

Parkinson's Disease

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Minimal Detectable Change (MDC)

Parkinson’s Disease: (Wagner et al., 2013, n=25, mean age = 41.6 (9.8))

  • MDC = 4.6 sec

Cut-Off Scores

Parkinson's Disease: (Duncan & Earhart et al, 2013; n = 53; mean age = 70 (7.4) years)

  • > 9.68 seconds = increased risk for falls

Normative Data

Parkinson's Disease: (Duncan & Earhart et al, 2013)

 

On Drug

Off Drug

Mean

9.6

11.02

Range

8.73 - 10.62

9.42 - 12.56

Parkinson’s Disease: (McKee and Kackney, 2014; n=31)

  • Mean time of Trial 1 = 15.9±5.8 seconds
  • Mean time of Trial 2 = 14.5±6.7 seconds
  • Mean time of Trial 3 = 13.0±4.6 seconds
  • Mean best time = 12.9±4.5 seconds

Test/Retest Reliability

Parkinson's Disease: (Duncan & Earhart et al, 2013)

  • Excellent reliability on medication (ICC = 0.78)
  • Excellent reliability off medication (ICC = 0.90)

Parkinson’s Disease: (McKee and Kackney, 2014); n = 31; mean age = 69.65 (7.7) years; UPDRS-III used to determine severity of disease; all participants were on PD medication

  • Adequate to Excellent test-retest reliability, ICC = 0.55-0.88 between three trials

Interrater/Intrarater Reliability

Parkinson's Disease: (Duncan & Earhart et al, 2013)

  • Excellent inter rater reliability (ICC = 0.99)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Parkinson's Disease: (Duncan & Earhart et al, 2013)

Test

Spearman Correlation

MDS UPDRS Scale III

0.61

Mini Best

-0.65

5 Times to Sit to Stand

0.58

6 Minute Walk Test

-0.52

9 Hole Peg Test

0.65

Freezing of Gait Questionnaire

0.44

(All significant at p < 0.001)

 

Parkinson’s Disease: (McKee and Kackney, 2014; n=31)

Outcome Measure

Spearman Correlation Coefficient (ρ)

TUG (s)

0.734 (Excellent)

TUG-Cognitive (s)

0.634 (Excellent)

TUG-Manual (s)

0.556 (Adequate)

BBS (/56)

-0.659 (Excellent)

360 Degree Turn Test

0.492 (Adequate)

6MWT (m)

-0.476 (Adequate)

30 Second Chair Stand (s)

-0.475 (Adequate)

Activities Specific Balance Confidence Scale (%)

-0.468 (Adequate)

(For all correlations, p<0.01)

Responsiveness

Parkinson's Disease: (Duncan & Earhart et al, 2013)

Measures

Cut Off

Sensitivity (%)

Specficity (%)

Positive (%)

Negative (%)

FSST

9.68 s

73

57

1.7

0.48

Stroke

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Cut-Off Scores

Acute Stroke: (Blennerhassett and Jaylath, 2008; n = 37; mean age = 53(range 23-75) years, time since stroke = 66 (range 9-1094) months; FIM walking item range 4-7, Australian sample):

  • Failed attempt or > 15 seconds = increased risk for falls

Chronic Stroke: (Goh et al., 2013; n = 15; mean age = 57.3 (3.6) years); minimum 6 months post stroke)

  • Time of 11 seconds was found to differentiate between subjects with chronic stroke and healthy control subjects
  • Sensitivity (73.3%); Specificity (93.3%); AUC = .867; P ≤ 0.001

Normative Data

Acute Stroke: (Blennerhassett & Jayalath, 2008)

FSST Normative Data:

 

 

 

 

Initial (n = 37)

2 Weeks (n = 28)

4 Weeks (n = 20)

Mean (SD)*

20.8 (15.0)

17.9 (11.6)

17.5 (14.5)

Range*

6.1–60.1

5.8–54.9

5.1–53.3

Participants with unsuccessful trials n (%)

23 (62%)

11 (39%)

8 (40%)

Participants unable to be scored n (%)

5 (14%)

3 (11%)

3 (15%)

*Time in seconds

 

 

 

 

Chronic Stroke: (Goh et al., 2013; n = 15; mean age = 57.3 (3.6) years)

  • Mean time was 17.44±9.12 seconds

Test/Retest Reliability

Acute Stroke: (Blennerhassett & Jayalath, 2008)

FSST Change Over Time:

 

 

 

 

Initial to 2 weeks

2 Weeks to 4 weeks

Initial to 4 Weeks

Participants:

n = 24

n = 17

n = 16

Significance:

p = 0.008

p = 0.01

p = 0.01

Difference

d = 0.26

d = 0.08

d = 0.33

95% CI

0.4 to 5.2

-3.4 to 5.8

-2.0 to 10.7

Chronic Stroke: (Goh et al., 2013)

  • Excellent test-retest reliability (ICC = 0.93 - 0.98)

Interrater/Intrarater Reliability

Intra-rater Reliability

Chronic Stroke: (Goh et al., 2013)

  • Excellent intra-rater reliability (ICC = .83)

 

Interrater Reliability

Chronic Stroke: (Goh et al., 2013)

  • Excellent interrater reliability (ICC = .99)

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Blennerhassett & Jayalath, 2008)

FSST and Step Test Correlations:

 

 

 

Tests Examined

Initial

2 Weeks

4 Weeks

Step test: right and left stance

0.86*

0.92*

0.96*

FSST and step test right stance

-0.86*

-0.78*

-0.81*

FSST and step test left stance

-0.78*

-0.73*

-0.84*

Spearman rho correlation coefficients
*p < 0.01

 

 

 

Construct Validity

Chronic Stroke: (Goh et al., 2013)

Construct Validity Evidence: Pearson correlation coefficients relating FSST times with other measures

Measures

Pearson Correlation

Coefficient (r)

BBS

-.28

LOS EPE - Forward

-.58*

LOS EPE - Backward

.34

LOS DC - Forward

.21

LOS DC - Backward

.64

TUG

.59*

*Indicates r value that is close to significance with p≤.02

  • No statistically significant correlation between FSST and BBS scores.
  • FSST times show close-to-significant correlation with TUG scores.
  • Among the LOS data, the observed FSST times correlated significantly only with DC in the backward direction & correlated significantly with EPE in the forward direction

Floor/Ceiling Effects

Stroke: (Blenerhassett and Jayalath, 2008)

  • Floor effect: 40-62% of participants had unsuccessful trials at least once during testing

Responsiveness

Acute Stroke: (Blenerhassett and Jayalath, 2008, measured over a 4 week period of outpatient rehabilitation)

  • Moderate Change:
    • Baseline to 2 weeks (ES = 0.260)
    • Baseline to 4 weeks (ES = 0.33)
  • Small Change:
    • 2 weeks to 4 weeks (ES = 0.08)

Chronic Stroke: (Goh et al., 2013; n = 15; mean age = 57.3 (3.6) years); minimum 6 months post stroke)

  • Time of 11 seconds was found to differentiate between subjects with chronic stroke and healthy control subjects
  • Sensitivity (73.3%); Specificity (93.3%); AUG = .867; P<= .001

Vestibular Disorders

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Cut-Off Scores

Vestibular: (Whitney et al, 2007; n = 32; mean age = 63.7 (17.8) years)

  • > 12s = at risks for falls

Test/Retest Reliability

Vestibular Disorders: (Whitney et al, 2007)

  • Excellent test retest reliability (ICC = 0.93)

Criterion Validity (Predictive/Concurrent)

Vestibular Disorders: (Whitney et al. 2007)

  • Adequate concurrent validity with the Timed Up and Go test (r = 0.69)

  • Adequate concurrent validity with Gait Speed (r = 0.65)

  • Adequate concurrent validity with the Dynamic Gait Index (r = -0.51)

  • Poor concurrent validity with the Dizziness Handicap Inventory (r = -0.13)

  • Poor concurrent validity with the Activities-Specific Balance Confidence (r = -0.12)

Limb Loss and Amputation

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Cut-Off Scores

Transtibial Amputation: (Dite et al, 2007; n = 40; 13 multiple fallers mean age 65.23 (11.18) years, & 27 non-fallers mean age 59.93 (14.28) years, retest 6 months later)

  • > 24 seconds = at risk for falls

Pediatric Disorders

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Standard Error of Measurement (SEM)

Children with Down Syndrome: (Bandong et al., 2015, n=14; mean age = 8.7 (1.9) years)

  • SEM = 2.32 seconds

Minimal Detectable Change (MDC)

Children with Down Syndrome: (Bandong et al., 2015, n=14)

  • MDC = 6.43 seconds

Normative Data

Children with Down Syndrome: (Bandong et al., 2015)

  • Children with DS had a mean score of 21.7 s (SD = 5.1)

Children with Down Syndrome: (Verma et al., 2014, n=13; mean age= 12.76 (2.9) years old)

  • Mean FSST Score = 8.70 sec

Test/Retest Reliability

Children with Down Syndrome: (Bandong et al., 2015, n=14)

  • Adequate to Excellent test-retest reliability: (ICC Range = .67 - .81 across Raters 1, 2, and 3)

Children with Down Syndrome: (Verma et al., 2014, n=13; mean age= 12.76 (2.9) years old)

  • Adequate test-retest reliability (ICC = 0.70)

Interrater/Intrarater Reliability

Inter-rater Reliability

Children with Down Syndrome: (Bandong et al., 2015, n=14)

  • Adequate inter-rater reliability (ICC = .69)

Children with Down Syndrome: (Verma et al., 2014)

  • Excellent inter-rater reliability in individuals 7 days post (ICC = 0.78)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Children with Down Syndrome: (Bandong et al., 2015, n=14)

  • Excellent correlation with Timed Up-and-Go test:  ρ = 0.71

Children with Down Syndrome: (Verma et al., 2014)

  • Adequate negative correlation with fuctional reach test (FST): ρ = -0.58

Neurological Disorders

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Standard Error of Measurement (SEM)

Huntington’s Disease: (Kloos et al., 2014, n= 24; mean age 50.9 years old)

  • SEM = 1.14 seconds

Minimal Detectable Change (MDC)

Huntington’s Disease: (Quinn et al., 2013, n= 75; mean age= 52.12 (11.82) years old)

Diagnosis

 MDC

Pre-Manifest Huntington’s Disease (n=11)

1.95 seconds

Manifest Huntington’s Disease (n=59)

15.27 seconds

Early Stage Huntington’s Disease (n=20)

7.94 seconds

Middle Stage Huntington’s Disease (n=18)

22.40 seconds

Late Stage Huntington’s Disease (n=21)

13.02 seconds

Huntington’s Disease: (Kloos et al., 2014, n=19)

  • MDC = 3.25 seconds

Normative Data

Huntington’s Disease: (Quinn et al., 2013)

Diagnosis

 FSST Mean Score in sec (SD)

Pre-Manifest Huntington’s Disease

11.68 (2.36)

Manifest Huntington’s Disease

14.98 (11.19) 

Early Stage Huntington’s Disease

12.91 (6.82)

Middle Stage Huntington’s Disease

17.50 (8.71)

Late Stage Huntington’s Disease

14.79 (15.64)

Huntington’s Disease: (Kloos et al., 2014, n=19)

  • Mean time over two trials = 11.22 seconds

Test/Retest Reliability

Huntington’s Disease: (Quinn et al., 2013)

Diagnosis

 FSST: ICC Score 

Pre-Manifest Huntington’s Disease

0.91

(Excellent reliability)

Manifest Huntington’s Disease

0.78

(Excellent reliability)

Early Stage Huntington’s Disease

0.74

(Excellent reliability )

Middle Stage Huntington’s Disease

0.53

(Adequate reliability)

Late Stage Huntington’s Disease

0.91

(Excellent reliability)

Huntington's Disease: (Kloos et al., 2014)

  • Excellent test-retest reliability (ICC = .86)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Huntington’s Disease: (Kloos et al., 2014)

  • Adequate concurrent validity with the Activities-specific Balance Confidence Scale (ABC Scale) = -0.57
  • Excellent concurrent validity with the Tinetti Mobility Test = -0.67

Cerebral Palsy

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Standard Error of Measurement (SEM)

Adults with Cerebral Palsy: (Levin et al., 2019; n=18; mean age = 32.7 (9.3); Level I or II on the GMFCS-E&R with spastic CP)

  • SEM = 1.35 seconds

Children with Cerebral Palsy: (Bandong et al., 2015, n=16; mean age = 8 (2.4) years;  Level I and II on the Gross Motor Function Classification System (GMFCS))

  • SEM = 1.34 seconds

Minimal Detectable Change (MDC)

Adults with Cerebral Palsy: (Levin et al., 2019, n=18)

  • MDC = 3.7 seconds

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

  • MDC = 3.71 seconds

Normative Data

Adults with Cerebral Palsy: (Levin et al., 2019)

  • Mean score = 14.8±4.7 seconds on Test 1
  • Mean score = 14.0±4.3 seconds on Test 2

Test/Retest Reliability

Adults with Cerebral Palsy: (Levin et al., 2019)

  • Excellent test-retest reliability (ICC = .91)

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

  • Adequate to Excellent test-retest reliability: (ICC Range = .51-.92 across Raters 1, 2, and 3)

Interrater/Intrarater Reliability

Interrater Reliability

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

  • Excellent inter-rater reliability (ICC = .86)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Children with Cerebral Palsy: (Bandong et al., 2015, n=16)

  • Excellent correlation with Timed Up-and-Go test:  ρ = 0.70

Multiple Sclerosis

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Standard Error of Measurement (SEM)

Multiple Sclerosis (Wagner et al., 2013, n=25, mean age = 41.6 (9.8))

  • SEM = 1.67 sec

Normative Data

Multiple Sclerosis: (Kalron & Givon, 2016; n=218)

Population Subgroups

 FSST Mean Score in sec (SD)

Entire group (n=218)

11.0±4.9

Very mild disability subgroup (n=67)

8.8±3.4

Mild disability subgroup (n=111)

11.0±4.9

Moderate disability subgroup (n=40)

14.1±5.3

Fallers (n=111)

12.5±5.7

Non-fallers (n=107)

9.0±2.6

Test/Retest Reliability

Multiple Sclerosis (Wagner et al., 2013, n=25)

  • Excellent test re-test reliability (ICC= 0.922)

Criterion Validity (Predictive/Concurrent)

Multiple Sclerosis (Wagner et al., 2013)

Outcome Measure

Spearman Correlation Coefficient (ρ)

 

BBS

-0.84

Excellent

DGI

-0.81

Excellent

ABC Scale

-0.78

Excellent

Multiple Sclerosis: (Kalron & Givon, 2016, n=218; mean age = 43.2 (13.5) years old))

Test

Correlation Coefficient with FSST (Pearson’s ρ)

2-minute walk

-.575 (Adequate)

Timed Up and Go

.652 (Excellent)

Timed 25-foot walk

.494 (Adequate)

Multiple Sclerosis Walking Scale (score)

.400 (Adequate)

Modified Fatigue Impact Scale (score)

.210 (Poor)

Falls Efficacy Scale – International (score)

.481 (Adequate)

Expanded Disability Status Scale

.457 (Adequate)

Healthy Adults

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Normative Data

Healthy Adults: (Dawson et al., 2018, n=105; mean age = 24.5 (4.66) years old, 73.3% female, recruited at a university)

  • Mean score: 15.8 ± 8.3 seconds

Healthy Adults: (Mathurapongsakul and Siriphorn, 2018, n=18)

  • 7.37 seconds (IQR=7.10-8.03) for FSST+foam
  • 6.44 seconds (IQR=6-7.28) for FSST without foam

Healthy Adults: (Goh et al., 2013, n=15)

  • FSST Mean Score = 7.49 ± 2.34 seconds

Test/Retest Reliability

Healthy Adults: (Dawson et al., 2018, n=105; mean age = 24.5 (4.66) years old)

  • Excellent test-retest reliability (ICC = .92)

Construct Validity

Convergent Validity

Healthy Adults: (Dawson et al., 2018)

  • Poor construct validity
    • r = .14 between TUG;
    • r = -.15 between Biodex SD LOS,
    • r = .14 between Biodex SD m-CTSIB Stability Index;
    • r = .21 between Biodex SD m-CTSIB-Condition 1

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