Reliability and validity of the Four Square Step Test in children with cerebral palsy and Down syndrome

Res Dev Disabil. 2015 Dec;47:39-47. doi: 10.1016/j.ridd.2015.08.012. Epub 2015 Aug 27.


Little is known about the measurement properties of clinical tests of stepping in different directions for children with cerebral palsy (CP) and Down syndrome (DS). The ability to step in various directions is an important balance skill for daily life. Standardized testing of this skill can yield important information for therapy planning. This observational methodological study was aimed at defining the relative and absolute reliability, minimal detectable difference, and concurrent validity with the Timed Up-&-Go (TUG) of the Four Square Step Test (FSST) for children with CP and DS. Thirty children, 16 with CP and 14 with DS, underwent repeat testing 2 weeks apart on the FSST by 3 raters. TUG was administered on the second test occasion. Intraclass correlation coefficients (ICC [1,1] and [3,1]) with 95% confidence intervals, standard error of measurement (SEM), minimal detectable difference (MDD) and the Spearman rank correlation coefficient were computed. The FSST demonstrated excellent interrater reliability (ICC=.79; 95% CI: .66, .89) and high positive correlation with the TUG (r=.74). Test-retest reliability estimates varied from moderate to excellent among the 3 raters (.54, .78 and .89 for raters 1, 2 and 3, respectively). SEM and MDD were calculated at 1.91s and 5.29s, respectively. Scores on the FSST of children with CP and DS between 5 and 12 years of age are reliable and valid.

Keywords: Assessment; Child; Clinimetrics; Physical therapy; Postural control; Postural equilibrium.

Publication types

  • Observational Study

MeSH terms

  • Cerebral Palsy / complications
  • Cerebral Palsy / physiopathology*
  • Cerebral Palsy / rehabilitation
  • Child
  • Child, Preschool
  • Down Syndrome / complications
  • Down Syndrome / physiopathology*
  • Down Syndrome / rehabilitation
  • Exercise Test
  • Female
  • Gait Disorders, Neurologic / diagnosis*
  • Gait Disorders, Neurologic / etiology
  • Gait Disorders, Neurologic / physiopathology
  • Gait*
  • Humans
  • Male
  • Physical Therapy Modalities
  • Postural Balance*
  • Reproducibility of Results
  • Sensation Disorders / diagnosis*
  • Sensation Disorders / etiology
  • Sensation Disorders / physiopathology