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. 2008 Nov;89(11):2156-61. doi: 10.1016/j.apmr.2008.05.012.


Objective: To examine if the Four Square Step Test (FSST), a previously reported clinical test of dynamic standing balance, which involves stepping over obstacles and turning, was a feasible and valid test, and sensitive to change during stroke rehabilitation.

Design: Prospective observational cohort study over a 4-week duration.

Setting: Rehabilitation hospital.

Participants: People with stroke (N=37) who could walk at least 50m with minimal assistance were recruited consecutively when attending physical therapy during rehabilitation.

Interventions: Not applicable.

Main outcome measures: Dynamic standing balance was examined at 2 weekly intervals using 2 clinical tests: the FSST and the Step Test. Falls events were monitored using a falls diary and by an audit of medical histories.

Results: Strong agreement was observed between performance scores for the FSST and Step Test obtained within the same testing session (intraclass correlation coefficient(3,k), .94-.99). A moderate to strong inverse relationship (Spearman rho=-.73 to -.86) was observed between the FSST and Step Test scores at each assessment. Scores from both tests revealed significant improvements in dynamic balance across the 4-week period (P<.001-.010). Five of the participants reported falls during the study. These 5 people had low scores for both clinical tests and difficulty clearing their foot when stepping over objects in the FSST.

Conclusions: The FSST is a feasible and valid test of dynamic standing balance that is sensitive to change during stroke rehabilitation.

Publication types

  • Validation Study

MeSH terms

  • Accidental Falls / prevention & control*
  • Adult
  • Aged
  • Disability Evaluation*
  • Feasibility Studies
  • Female
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Postural Balance*
  • Reproducibility of Results
  • Sensitivity and Specificity
  • Stroke Rehabilitation*
  • Treatment Outcome
  • Victoria
  • Walking