The Four Square Step Test in individuals with Parkinson's disease: association with executive function and comparison with older adults

NeuroRehabilitation. 2014 Jan 1;35(2):279-89. doi: 10.3233/NRE-141122.


Background: In Parkinson's disease (PD), motor and cognitive impairments interact to affect functional performance adversely. A valid mobility test, the Four Square Step Test (FSST) involves multidirectional stepping over obstacles. FSST performance may also be associated with cognitive performance.

Objectives: This study determined the feasibility and reliability of an obstacle-based FSST in older individuals with versus without PD, and evaluated the association of PD performance of FSST with tests of cognition.

Methods: Thirty-one individuals with mild-moderate PD, evaluated while ON medications, completed the obstacle-based FSST, other mobility and cognitive measures. FSST performance was compared between a PD participant sub-set (n = 24) and 24 age-matched older adults. Data were analyzed with independent t-tests, correlations, and linear regression.

Results: Obstacle-based FSST was feasible and reliable within sessions in those with PD. Median best FSST time among individuals with PD was 11.72 s (9.99, 13.98) and FSST had concurrent validity with tests of mobility, and cognitive dual-tasking. Among cognitive tests, Trails Making Test B, which evaluates executive function, emerged as a sole contributor (49%) of variance. FSST performance did not differ between those with PD and older adults.

Conclusion: The obstacle-based FSST is feasible and reliable in those with PD. The relationship between cognitive status and performance on the FSST did not appear to be strongly disease-stage dependent. Using FSST in the clinic may help assess the health status of a motor-cognitive interaction in individuals with PD.

Keywords: Parkinson's disease; accidental falls; cognition; mobility limitation.

Publication types

  • Comparative Study
  • Controlled Clinical Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Accidental Falls / prevention & control
  • Aged
  • Aged, 80 and over / physiology*
  • Cognition Disorders / complications*
  • Executive Function*
  • Exercise Test
  • Feasibility Studies
  • Female
  • Gait / physiology
  • Gait Disorders, Neurologic / etiology
  • Gait Disorders, Neurologic / physiopathology*
  • Gait Disorders, Neurologic / rehabilitation
  • Humans
  • Male
  • Mobility Limitation
  • Parkinson Disease / complications*
  • Parkinson Disease / physiopathology*
  • Parkinson Disease / rehabilitation
  • Reproducibility of Results
  • Severity of Illness Index
  • Surveys and Questionnaires
  • Task Performance and Analysis