Four Square Step Test (FSST): Clinical Physiotherapy

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.

The subject is required to sequentially step over four canes set-up in a cross configuration on the ground.

Four Square Step Test (FSST)

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.”

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

• Stopwatch
• 4 canes/ rods (approximately 100cm in length and 2.5cm in diameter[4])
• Time to Administer
• Less than five minutes

Evidence

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.

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).