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RehabMeasures Instrument

Fukuda Stepping Test (Unterberger Step Test)

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Purpose

The purpose of the Fukuda Stepping Test is to assess labyrinthine function via vestibulospinal reflexes.

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Instrument Details

Acronym FST

Area of Assessment

Balance – Vestibular
Vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Vestibular Disorders

Key Descriptions

  • The amount of rotation and displacement are measured after taking 50 or 100 steps in place with the eyes closed and blindfolded in a quiet, dimlit room with arms outstretched at 90°.
  • Patients should stand on a grid marked with 2 concentric circles with radii of 0.5 and 1.0 m, and divided into angles of 30°.

Number of Items

1

Equipment Required

  • Grid marked with 2 concentric circles with radii of 0.5 and 1.0 m, divided into angles of 30°

Time to Administer

Less than 5 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Reviewed by Diane Wrisley, PT, PhD, NCS and Elizabeth Dannenbaum, MScPT for APTA Neurology Section Vestibular EDGE task force.

ICF Domain

Body Function

Measurement Domain

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

NR

 

NR

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

Vestibular EDGE

NR

NR

NR

NR

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)

Vestibular EDGE

No

Yes

No

No

Considerations

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Non-Specific Patient Population

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Standard Error of Measurement (SEM)

Healthy Controls:

(Bonanni and Newton, 1998; n = 30, aged 24-56 years, mean age 32.8 ± 8.4 years, tested 2 days apart)

  • Angle of rotation SEM = 26° (50 steps); 69° (100 steps)
  • Angle of displacement SEM = 18° (50 steps); 35° (100 steps)
  • Distance of displacement SEM = 24 cm (50 steps); 54 cm (100 steps)

Minimal Detectable Change (MDC)

Healthy Controls:

(Calculated based on SEM from Bonanni and Newton 1998)

  • Angle of rotation MDC (95%) = 14.1° (50 steps) and 23° (100 steps)
  • Angle of displacement MDC (95%) = 11.8° (50 steps) and 16.4° (100 steps)
  • Distance of displacement MDC (95%) = 13.6 cm (50 steps) and 20.4 cm (100 steps)

Cut-Off Scores

Fukuda, 1959, 500 normal subjects, rotation > 30° or displacement of 0.5 meter (50 steps) and rotation > 45° or displacement of > 1.0 meter (100 steps) indicates asymmetrical labyrinthine function Honaker et al, 2009 736 patients with chronic dizziness, 213 with unilateral caloric weakness. Used cut-off of rotation of 45° for a sensitivity of 0.43, specificity of 0.65° and a likelihood ratio of 1.24.

Normative Data

Healthy Volunteers

(Nyabenda et al 2004, 120 healthy volunteers aged 20-79 years (no known balance or orthopedic disorders))

Age group (years)

Forward displacement (cm)

Veering (°)

Rotation (°)

20-29

60.7 ± 30.7

19.9 ± 7.8

13.9 ± 6.9

30-39

62.5 ± 26.0

32.0 ± 10.1

23.2 ± 10.6

40-49

71.7 ± 35.0

35.0 ± 12.0

26.7 ± 11.3

50-59

73.3 ± 40.7

37.8 ± 13.4

31.9 ± 10.6

60-69

76.2 ± 40.2

39.1 ± 9.8

34.7 ± 11.4

70-79

75.0 ± 33.0

41.5 ± 10.9

42.1 ± 10.1

Test/Retest Reliability

Healthy Controls:

(Bonanni and Newton 1998; n = 30, aged 24-56 years, mean age 32.8 ± 8.4 years, tested 2 days apart)

  • Angle of rotation ICC = 0.66 (50 steps); 0.52 (100 steps)
  • Angle of displacement ICC = 0.66 (50 steps); 0.45 (100 steps)
  • Distance of displacement ICC = 0.69 (50 steps); 0.47 (100 steps)

Criterion Validity (Predictive/Concurrent)

Honaker et al 2009, retrospective chart review: 736 charts of patients with chronic dizziness, 213 with caloric weakness, age 15-89 years; FST independent of turn direction yielded an area under the curve of 0.54, with a cut score of 45° found sensitivity of 0.43, specificity of 0.65 and a likelihood ratio of 1.24, retrospective chart review of 736 patients with chronic dizziness, all able to perform Romberg. 533 without caloric weakness, 147 with mild caloric weakness (25-50%); 44 with moderate caloric weakness (50-75%) and 22 with severe caloric weakness (75-100%). For mild weakness FST independent of turn direction revealed an area with under the curve (AUC) of 0.47, for a cut score of 22.5 sensitivity was 0.25, specificity was 0.76 with a likelihood ratio (LR) of 1.04; For moderate weakness FST independent of turn direction revealed an AUC of 0.52, for a cut score of 27.5° the sensitivity was 0.34, specificity 0.76 with an LR of 1.42; For severe weakness the FST independent of turn direction revealed an AUC of 0.53, using a cut score of 37.5° the sensitivity was 0.37 and specificity 0.79 with a LR of 1.76.

Zhang and Wang 2011 evaluated 126 patients with unilateral vestibular dysfunction (idiopathic sudden sensorineural hearing loss, temporal bone trauma, vestibular neuritis) 20-70 years, mean age 46.8 ± 13 years

Hickey et al 1990 evaluated 49 healthy control subjects (mean age 37 ± 12 years) and 26 patients with suspected peripheral vestibular dysfunction (mean age 50 ± 16 years) 16 of which had significant canal paresis. There was no significant difference between the 2 groups in angle of rotation, angle of displacement or distance traveled. No correlation was found between angle of rotation and amount of canal paresis. No significant differences in performance were found with increasing age.

Face Validity

Healthy Controls:

(Gordon et al, 1995) Subjects exhibited rotation in same direction relative to the direction of the treadmill after walking 2 hours on a circular treadmill suggesting that the somatosensory/locomotor stimulation caused more consistent and marked rotation in the stepping test than physiologic and pathologic vestibular stimuli.

Bibliography

 

Bonanni, M. and Newton, R. (1998). "Test-retest reliability of the Fukuda Stepping Test." Physiother Res Int 3(1): 58-68. Find it on PubMed

Fukuda, T. (1959). "The stepping test: two phases of the labyrinthine reflex." Acta Otolaryngol 50(2): 95-108. Find it on PubMed

Gordon, C. R., Fletcher, W. A., et al. (1995). "Is the stepping test a specific indicator of vestibulospinal function?" Neurology 45(11): 2035.

Grommes, C. and Conway, D. (2011). "The stepping test: a step back in history." J Hist Neurosci 20(1): 29-33. Find it on PubMed

Honaker, J. A., Boismier, T. E., et al. (2009). "Fukuda stepping test: sensitivity and specificity." J Am Acad Audiol 20(5): 311-314; quiz 335. Find it on PubMed

Nyabenda, A., Briart, C., et al. (2004). "A normative study of the vestibulospinal and rotational tests." Advances in Physiotherapy 6(3): 122-129.

O'Connor, A. F. (1990). "Unterberger stepping test: a useful indicator of peripheral vestibular dysfunction?" The Journal of Laryngology and Otology 104: 599-602.

Reiss, M. and Reiss, G. (1997). "Further aspects of the asymmetry of the stepping test." Perceptual and motor skills 85(3f): 1344-1346.

Zhang, Y. B. and Wang, W. Q. (2011). "Reliability of the Fukuda stepping test to determine the side of vestibular dysfunction." J Int Med Res 39(4): 1432-1437. Find it on PubMed

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