Four Square Step Test

Original Editor - Candace Goh

Top Contributors - Candace Goh, Kim Jackson, Vidya Acharya, George Prudden and Lucinda hampton  

Objective[edit | edit source]

The Four Square Step Test (FSST) is used to assess dynamic stability and the ability of the subject to step over low objects forward, sideways, and backward.[1]

Intended Population[edit | edit source]

Method of Use[edit | edit source]

Test Description:

  • The subject is required to sequentially step over four canes set-up in a cross configuration on the ground.
  • At the start of the test, the subject stands in Square 1 facing Square 2.
  • The aim is to step as fast as possible into each square with both feet in the following sequence: Square 2, 3, 4, 1, 4, 3, 2, 1 (clockwise to counterclockwise)
  • Test procedure may be demonstrated, 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 first foot contacts the floor in Square 2 and finishes when the last foot comes back to touch the floor in Square 1.
  • Instructions: “Try to complete the sequence as fast and as safely 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.”[2][3]
  • Repeat a trial if the subject:
    • Fails to complete the sequence successfully 
    • Loses balance 
    • Makes contact with the cane 
  • Subjects who are unable to face forward during the entire sequence may turn before stepping into the next square and are timed accordingly.
  • Any assistive device used during the test are noted down accordingly.

Equipment[edit | edit source]

  • Stopwatch
  • 4 canes/ rods (approximately 100cm in length and 2.5cm in diameter[4])

Time to Administer[edit | edit source]

Less than five minutes

Cut-off scores[edit | edit source]

  1. Older adults/geriatrics: > 15 seconds = increased risk of falls
  2. Stroke: > 15 seconds or failed attempt = increased risk of falls
  3. Parkinson's: > 9.68 seconds = increased risk of falls
  4. Vestibular Disorders: > 12 seconds = increased risk of falls
  5. Limb Loss/Amputation: > 24 seconds = at risk for fall

Evidence[edit | edit source]

The FSST may be an effective and valid tool for measuring dynamic balance and the subject's fall risk. It has been shown to have strong correlations with other measures of balance and mobility with good reliability shown in a number of populations.[5] A recent study showed a stronger relationship between gait and balance disorder and TIA/minor stroke, which was measured by logistic regression analysis of six measurements (Four Square Step [OR, 24.07; 95% CI 5.90–98.13; p<0.001], Tandem, Functional Reach, Gait and Pivot Turn, Timed “Up and Go”, and Single Leg Balance tests).[6]

Reliability[edit | edit source]

Older adults/geriatrics

(Dite & Temple, 2002)

  • Excellent test-retest reliability (ICC = 0.98)
  • Excellent inter-rater reliability (ICC = 0.99)


(Duncan & Earhart et al, 2013)[7]

  • Excellent reliability on medication (ICC = 0.78)
  • Excellent reliability off medication (ICC = 0.90)
  • Excellent inter rater reliability (ICC = 0.99)

Vestibular Disorders

(Whitney et al, 2007)[8]

  • Excellent test retest reliability (ICC = 0.93)

Resources[edit | edit source]

References[edit | edit source]

  1. Shirley Ryan Ability Lab. Rehabilitation measure: four square step test. (accessed 12 March 2018).
  2. Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Archives of physical medicine and rehabilitation. 2002 Nov 1;83(11):1566-71.
  3. Blennerhassett JM, Jayalath VM. The Four Square Step Test is a feasible and valid clinical test of dynamic standing balance for use in ambulant people poststroke. Archives of physical medicine and rehabilitation. 2008 Nov 1;89(11):2156-61.
  4. McKee KE, Hackney ME. The Four Square Step Test in individuals with Parkinson's: Association with executive function and comparison with older adults. NeuroRehabilitation. 2014 Jan 1;35(2):279-89.
  5. Moore M, Barker K. The validity and reliability of the four square step test in different adult populations: a systematic review. Systematic reviews. 2017 Dec;6(1):187. (accessed 12 March 2018).
  6. Li N, Li J, Gao T, Wang D, Du Y, Zhao X. Gait and balance disorder in patients with transient ischemic attack or minor stroke. Neuropsychiatric disease and treatment. 2021;17:305.
  7. Duncan RP, Earhart GM. Four square step test performance in people with Parkinson disease. Journal of Neurologic Physical Therapy. 2013 Mar 1;37(1):2-8.
  8. Whitney SL, Marchetti GF, Morris LO, Sparto PJ. The reliability and validity of the Four Square Step Test for people with balance deficits secondary to a vestibular disorder. Archives of physical medicine and rehabilitation. 2007 Jan 1;88(1):99-104.