A clinical test of stepping and change of direction to identify multiple falling older adults

Arch Phys Med Rehabil. 2002 Nov;83(11):1566-71. doi: 10.1053/apmr.2002.35469.


Objectives: To establish the reliability and validity of a new clinical test of dynamic standing balance, the Four Square Step Test (FSST), to evaluate its sensitivity, specificity, and predictive value in identifying subjects who fall, and to compare it with 3 established balance and mobility tests.

Design: A 3-group comparison performed by using 3 validated tests and 1 new test.

Setting: A rehabilitation center and university medical school in Australia.

Participants: Eighty-one community-dwelling adults over the age of 65 years. Subjects were age- and gender-matched to form 3 groups: multiple fallers, nonmultiple fallers, and healthy comparisons.

Interventions: Not applicable.

Main outcome measures: Time to complete the FSST and Timed Up and Go test and the number of steps to complete the Step Test and Functional Reach Test distance.

Results: High reliability was found for interrater (n=30, intraclass correlation coefficient [ICC]=.99) and retest reliability (n=20, ICC=.98). Evidence for validity was found through correlation with other existing balance tests. Validity was supported, with the FSST showing significantly better performance scores (P<.01) for each of the healthier and less impaired groups. The FSST also revealed a sensitivity of 85%, a specificity of 88% to 100%, and a positive predictive value of 86%.

Conclusion: As a clinical test, the FSST is reliable, valid, easy to score, quick to administer, requires little space, and needs no special equipment. It is unique in that it involves stepping over low objects (2.5cm) and movement in 4 directions. The FSST had higher combined sensitivity and specificity for identifying differences between groups in the selected sample population of older adults than the 3 tests with which it was compared.

Publication types

  • Validation Study

MeSH terms

  • Accidental Falls* / statistics & numerical data
  • Activities of Daily Living
  • Aged / physiology*
  • Aged, 80 and over
  • Analysis of Variance
  • Canes
  • Case-Control Studies
  • Comorbidity
  • Exercise Test / methods*
  • Exercise Test / standards
  • Female
  • Gait*
  • Geriatric Assessment*
  • Humans
  • Male
  • Postural Balance*
  • Risk Factors
  • Sensation Disorders / complications
  • Sensation Disorders / diagnosis*
  • Sensation Disorders / physiopathology
  • Sensitivity and Specificity
  • Time Factors
  • Walking / physiology