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

• FSST has excellent and moderate interrater reliability for children with CP and DS, respectively, 5–12 years.
• Test–retest reliability of FSST varies from moderate to excellent across 3 raters.
• FSST test–retest reliability appears to be related to pediatric therapy experience.
• FSST has concurrent validity, with high positive relationship with the TUG.
• Test sequence recall and attentional ability are critical to FSST completion.

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 1.91 s and 5.29 s, respectively. Scores on the FSST of children with CP and DS between 5 and 12 years of age are reliable and valid.