Test of dynamic balance that clinically assesses the person’s ability to step over objects forward, sideways, and backwards.
Less than 5 minutes
Adult
18 - 64
yearsElderly Adult
65 +
yearsInitially 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.
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
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Abbreviations: |
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HR |
Highly Recommend |
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R |
Recommend |
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LS / UR |
Reasonable to use, but limited study in target group / Unable to Recommend |
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NR |
Not Recommended |
Recommendations for use based on acuity level of the patient:
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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) |
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Vestibular EDGE |
R |
|
R |
Recommendations Based on Parkinson Disease Hoehn and Yahr stage:
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I |
II |
III |
IV |
V |
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PD EDGE |
LS/UR |
R |
R |
R |
NR |
Recommendations based on level of care in which the assessment is taken:
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Acute Care |
Inpatient Rehabilitation |
Skilled Nursing Facility |
Outpatient Rehabilitation |
Home Health |
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MS EDGE |
UR |
R |
UR |
R |
UR |
|
TBI EDGE |
NR |
LS |
LS |
LS |
LS |
Recommendations for use based on ambulatory status after brain injury:
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Completely Independent |
Mildly dependant |
Moderately Dependant |
Severely Dependant |
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TBI EDGE |
LS |
LS |
LS |
NR |
Recommendations based on EDSS Classification:
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EDSS 0.0 – 3.5 |
EDSS 4.0 – 5.5 |
EDSS 6.0 – 7.5 |
EDSS 8.0 – 9.5 |
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MS EDGE |
UR |
R |
R |
NR |
Recommendations based on vestibular diagnosis
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Peripheral |
Central |
Benign Paroxysmal Positional Vertigo (BPPV) |
Other |
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Vestibular EDGE |
R |
R |
R |
R |
Recommendations for entry-level physical therapy education and use in research:
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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) |
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MS EDGE |
No |
Yes |
No |
No |
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PD EDGE |
No |
No |
Yes |
Not reported |
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TBI EDGE |
No |
No |
No |
Not reported |
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Vestibular EDGE |
Yes |
Yes |
Yes |
Yes |
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).
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!
Older Adults/ Geriatric:
(Dite & Temple, 2002; n = 81 community dwelling adults > 65 years old)
> 15 second = at risk for multiple falls
Older Adults/ Geriatric:
(Dite et al, 2007)
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Balance and Mobility Assessments between groups |
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Assessments |
Multiple Fallers |
Non-multiple Fallers |
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FSST (s) |
32.6 (10.1) |
17.6 (8.3) |
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TUG test (s) |
25.0 (6.9) |
16.2 (5.3) |
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Turn time (s) |
5.2 (1.6) |
3.1 (1.0) |
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Turn steps (n) |
5.2 (1.2) |
6.8 (1.2) |
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LCI advanced (score) |
12.9 (4.3) |
17.6 (4.2) |
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mean (SD) |
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Geriatric:
(Dite & Temple, 2002)
Geriatric:
(Dite & Temple, 2002)
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)
Fair concurrent validity with the Functional Reach Test (r = -0.47)
Geriatric:
(Dite & Temple, 2007)
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Score Multiple (n = 13) vs Non multiple Fallers (n = 27) |
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Measures |
Cutoff |
Sensitivity (%) |
Specificity (%) |
Positive (%) |
Negative (%) |
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FSST |
> 24s |
92 |
93 |
86 |
96 |
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TUG test |
> 19s |
85 |
74 |
61 |
91 |
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Turn time |
> 3.7s |
85 |
78 |
65 |
91 |
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Turn steps |
> 6 steps |
100 |
74 |
65 |
100 |
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Turn steadiness |
NO |
31 |
85 |
50 |
72 |
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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:
(Duncan & Earhart et al, 2013; n = 53; mean age = 70 (7.4) years)
Parkinson's Disease:
(Duncan & Earhart et al, 2013)
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On Drug |
Off Drug |
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Mean |
9.6 |
11.02 |
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Range |
8.73 - 10.62 |
9.42 - 12.56 |
Parkinson's Disease:
(Duncan & Earhart et al, 2013)
Parkinson's Disease:
(Duncan & Earhart et al, 2013)
Parkinson's Disease:
(Duncan & Earhart et al, 2013)
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Test |
Spearman Correlation |
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MDS UPDRS Scale III |
0.61 |
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Mini Best |
-0.65 |
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5 Times to Sit to Stand |
0.58 |
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6 Minute Walk Test |
-0.52 |
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9 Hole Peg Test |
0.65 |
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Freezing of Gait Questionnaire |
0.44 |
(All significant at p < 0.001)
Parkinson's Disease:
(Duncan & Earhart et al, 2013)
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Measures |
Cut Off |
Sensitivity (%) |
Specficity (%) |
Positive (%) |
Negative (%) |
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FSST |
9.68 s |
73 |
57 |
1.7 |
0.48 |
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):
Acute Stroke:
(Blennerhassett & Jayalath, 2008)
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FSST Normative Data: |
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|
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Initial (n = 37) |
2 Weeks (n = 28) |
4 Weeks (n = 20) |
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Mean (SD)* |
20.8 (15.0) |
17.9 (11.6) |
17.5 (14.5) |
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Range* |
6.1–60.1 |
5.8–54.9 |
5.1–53.3 |
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Participants with unsuccessful trials n (%) |
23 (62%) |
11 (39%) |
8 (40%) |
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Participants unable to be scored n (%) |
5 (14%) |
3 (11%) |
3 (15%) |
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*Time in seconds
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Acute Stroke:
(Blennerhassett & Jayalath, 2008)
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FSST Change Over Time: |
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|
|
|
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Initial to 2 weeks |
2 Weeks to 4 weeks |
Initial to 4 Weeks |
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Participants: |
n = 24 |
n = 17 |
n = 16 |
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Significance: |
p = 0.008 |
p = 0.01 |
p = 0.01 |
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Difference |
d = 0.26 |
d = 0.08 |
d = 0.33 |
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95% CI |
0.4 to 5.2 |
-3.4 to 5.8 |
-2.0 to 10.7 |
Acute Stroke:
(Blennerhassett & Jayalath, 2008)
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FSST and Step Test Correlations: |
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Tests Examined |
Initial |
2 Weeks |
4 Weeks |
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Step test: right and left stance |
0.86* |
0.92* |
0.96* |
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FSST and step test right stance |
-0.86* |
-0.78* |
-0.81* |
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FSST and step test left stance |
-0.78* |
-0.73* |
-0.84* |
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Spearman rho correlation coefficients |
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Stroke:
(Blenerhassett and Jayalath, 2008)
Stroke:
(Blenerhassett and Jayalath, 2008, measured over a 4 week period of outpatient rehabilitation)
Vestibular:
(Whitney et al, 2007; n = 32; mean age = 63.7 (17.8) years)
> 12s = at risks for falls
Vestibular Disorders:
(Whitney et al, 2007)
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)
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
Blennerhassett, J. M. and Jayalath, V. M. (2008). "The Four Square Step Test is a feasible and valid clinical test of dynamic standing balance for use in ambulant people poststroke." Arch Phys Med Rehabil 89(11): 2156-2161. Find it on PubMed
Dite, W., Connor, H. J., et al. (2007). "Clinical identification of multiple fall risk early after unilateral transtibial amputation." Arch Phys Med Rehabil 88(1): 109-114. Find it on PubMed
Dite, W. and Temple, V. A. (2002). "A clinical test of stepping and change of direction to identify multiple falling older adults." Arch Phys Med Rehabil 83(11): 1566-1571. Find it on PubMed
Duncan, R. P. and Earhart, G. M. (2013). "Four Square Step Test Performance in People With Parkinson Disease." Journal of Neurologic Physical Therapy 37(1): 2-8.
Whitney, S. L., Marchetti, G. F., et al. (2007). "The reliability and validity of the Four Square Step Test for people with balance deficits secondary to a vestibular disorder." Arch Phys Med Rehabil 88(1): 99-104. Find it on PubMed
We have reviewed nearly 300 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.