Purpose
Test of dynamic balance that clinically assesses the person’s ability to step over objects forward, sideways, and backwards.
Acronym
FSST
Area of Assessment
Activities of Daily Living
Balance – Vestibular
Balance – Non-vestibular
Assessment Type
Observer
Administration Mode
Paper & Pencil
Cost
Free
- Test procedure may be demonstrated and one practice trial is allowed prior to administering the test.
- Two trials are then performed, and the better time (in seconds) is taken as the score.
- Timing starts when the right foot contacts the floor in square.
- Instructions:
“Try to complete the sequence as fast as possible without touching the sticks. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence.”
- Repeat a trial if the patient:
1) Fails to complete the sequence successfully
2) Loses balance
3) Makes contact with the cane
- Patient steps over four canes set-up like a cross on the floor with the tips of the canes facing together.
- At the start of the test, the patient stands on the upper left square (in Square 1, facing Square 2).
- The stepping sequence is (clockwise):
Square 1, Square 2, Square 4, Square 3, return to Square 1 with both feet.
- Then (counterclockwise): Back to Square 3, Square 4, Square 2, and end in Square 1 with both feet.
- *Patients who are unable to face forward during the entire sequence and may turn before stepping into the next square and are timed accordingly.
Required Training
No Training
Instrument Reviewers
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. Updayed 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 Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. 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 post)
|
Vestibular EDGE
|
R
|
|
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
|
R
|
UR
|
R
|
UR
|
TBI EDGE
|
NR
|
LS
|
LS
|
LS
|
LS
|
Recommendations for use based on ambulatory status after brain injury:
|
Completely Independent
|
Mildly dependant
|
Moderately Dependant
|
Severely Dependant
|
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
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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