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RehabMeasures Instrument

Four Step Square Test

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Purpose

Test of dynamic balance that clinically assesses the person’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

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Vestibular Disorders

Key Descriptions

  • 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.

Equipment Required

  • Stopwatch
  • Four canes

Time to Administer

Less than 5 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

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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Older Adults and Geriatric Care

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Cut-Off Scores

Older Adults/ Geriatric:

(Dite & Temple, 2002; n = 81 community dwelling adults > 65 years old)

  • > 15 second = at risk for multiple falls

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)

 

 

Test/Retest Reliability

Geriatric:

(Dite & Temple, 2002)

  • Excellent test-retest reliability (ICC = 0.98)

Interrater/Intrarater Reliability

Geriatric:

(Dite & Temple, 2002)

  • Excellent inter-rater reliability (ICC = 0.99)

Criterion Validity (Predictive/Concurrent)

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)

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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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

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)

Interrater/Intrarater Reliability

Parkinson's Disease:

(Duncan & Earhart et al, 2013)

  • Excellent inter rater reliability (ICC = 0.99)

Criterion Validity (Predictive/Concurrent)

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)

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

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

 

 

 

 

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

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

 

 

 

Floor/Ceiling Effects

Stroke:

(Blenerhassett and Jayalath, 2008)

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

Responsiveness

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)

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

Bibliography

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

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