Construct Validity of the Four Square Step Test in Multiple Sclerosis

  • Alon Kalron
    Corresponding author Alon Kalron, PhD, Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, 60 HaBanim St, Tel-Aviv, Israel 46379.
    Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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  • Uri Givon
    Multiple Sclerosis Center, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel

    Department of Pediatric Orthopedics, Sheba Medical Center, Tel Hashomer, Tel-Aviv, Israel

    Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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      To expand the construct validity of the Four Square Step Test (FSST) in people with multiple sclerosis (PWMS).


      Cross-sectional study.


      Multiple sclerosis center.


      PWMS (N=218; 133 women, 85 men; mean age, 43.2±13.5y; mean disease duration, 7.5±7.7y since diagnosis) were enrolled in the study. The Expanded Disability Status Scale score was 3.1±1.3, indicating minimal to moderate neurologic disability.


      Not applicable.

      Main Outcome Measures

      The FSST, posturography measures, 2-minute walk test, timed Up & Go test, timed 25-foot walk, fall status, Falls Efficacy Scale International, Modified Fatigue Impact Scale, instrumented cognitive assessment, and 12-item Multiple Sclerosis Walking Scale.


      The FSST score of the total sample was 11.0±4.9. Significant differences were observed between the very mild, mild, and moderate disability groups: 8.8±3.4, 11.1±4.9, and 14.1±5.3, respectively. In terms of fall status, the fallers demonstrated a significant slower FSST score than the nonfallers (12.5±5.7 vs 9.0±2.6, respectively). Modest significant correlation scores were found between the FSST and the timed Up & Go test and 2-minute walk test (Pearson ρ=.652 and ρ=−.575, respectively). In terms of posturography, all measures were significantly associated with the FSST scores. A significant positive relation was observed with the visual spatial cognitive domain (Pearson ρ=−.207).


      The current study supports and broadens the construct validity of the FSST in PWMS.


      List of abbreviations:

      COP (center of pressure), EDSS (Expanded Disability Status Scale), FSST (Four Square Step Test), MS (multiple sclerosis), MSWS-12 (12-item Multiple Sclerosis Walking Scale), PWMS (people with multiple sclerosis)
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