Date of Award


Document Type

Scholarly Project

Degree Name

Doctor of Physical Therapy (DPT)


Physical Therapy

First Advisor

Meridee Danks


Accidental Falls; Aged; Exercise Test -- methods; Gait; Postural Balance; Risk Assessment; Risk Factors


Background/Purpose: The Four Square Step Test (FSST) measures dynamic standing balance and agility and was developed to identify older adults at risk for falls. It has a cognitive component for remembering the stepping sequence but has never been tested with an additional cognitive task. The purpose of this study was to collect normative data for the FSST and Cognitive FSST in community dwelling adults for various age groups.

Materials/Methods: Eighty-seven community-dwelling adults (55 females, 32 males) between the age 21 and 86 (48.22 years) were included in the study. Participants completed a fall risk checklist and a cognitive screen prior to the FSST. The best time of the first two successful trials was recorded for statistical interpretation. The participant then performed the FSST without and with a cognitive task involving subtraction by 3s.

Results: Ages were organized into three categories, 20-39 (n=31), 40-59 (n=23), and > 60 years (n=31). Times of the FSST and Cognitive FSST tended to increase within age groups, indicating slower performance. When adding a cognitive task to the FSST, female times were consistent throughout age groups, but male times increased in the oldest age group (60+). There was a trend between fall risk and cognitive memory scores on the Mini-Cog. Two of the three participants were identified as a fall risk on the FSST (cut off score >15 seconds) and CDC Fall Risk Checklist (score of > 4), and had a positive Mini-Cog score.

Conclusion: Age was a factor in performance with the FSST and Cognitive FSST. Gender also appeared to have a greater influence in older individuals. The Cognitive FSST results tended to show a slower time and an increase in errors in performance on a previously learned multi-directional stepping task. There was a more significant challenge noted in adults over the age 60. Further research is needed to identify a fall risk cut off score and establish normative data with the Cognitive FSST.

Clinical Relevance: The FSST is a quick and inexpensive balance assessment commonly used in the clinic to determine if a patient is at risk for falling. It creates a more challenging assessment integrating a multi-task activity when assessing balance allowing the physical therapists to further assess functional abilities.