NeuroRehabilitation 35 (2014) 279289 279

DOI:10.3233/NRE-141122
IOS Press

The Four Square Step Test in individuals

with Parkinsons disease: Association with
executive function and comparison with
older adults
Kathleen E. McKeea,b and Madeleine E. Hackneyc,d,
a Emory University School of Medicine, Atlanta, GA, USA
b Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
c Atlanta Veterans Affairs Rehabilitation R&D Center of Excellence for Visual and Neurocognitive Rehabilitation,

Atlanta, GA, USA

d Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine,

Atlanta, GA, USA

Abstract.
BACKGROUND: In Parkinsons disease (PD), motor and cognitive impairments interact to affect functional performance
adversely. A valid mobility test, the Four Square Step Test (FSST) involves multidirectional stepping over obstacles. FSST
performance may also be associated with cognitive performance.
OBJECTIVES: This study determined the feasibility and reliability of an obstacle-based FSST in older individuals with versus
without PD, and evaluated the association of PD performance of FSST with tests of cognition.
METHODS: Thirty-one individuals with mild-moderate PD, evaluated while ON medications, completed the obstacle-based
FSST, other mobility and cognitive measures. FSST performance was compared between a PD participant sub-set (n = 24) and 24
age-matched older adults. Data were analyzed with independent t-tests, correlations, and linear regression.
RESULTS: Obstacle-based FSST was feasible and reliable within sessions in those with PD. Median best FSST time among
individuals with PD was 11.72 s (9.99, 13.98) and FSST had concurrent validity with tests of mobility, and cognitive dual-tasking.
Among cognitive tests, Trails Making Test B, which evaluates executive function, emerged as a sole contributor (49%) of variance.
FSST performance did not differ between those with PD and older adults.
CONCLUSION: The obstacle-based FSST is feasible and reliable in those with PD. The relationship between cognitive status
and performance on the FSST did not appear to be strongly disease-stage dependent. Using FSST in the clinic may help assess
the health status of a motor-cognitive interaction in individuals with PD.

Keywords: Parkinsons disease, mobility limitation, cognition, accidental falls

Address for correspondence: Madeleine E. Hackney, Ph.D.,
Division of General Medicine and Geriatrics, Research Health
Scientist, Rehab R&D Center (151R), Atlanta VA Medical Cen-
ter, 1670 Clairmont Rd. (12C145), Decatur, GA 30033, USA. Tel.:
+1 404 321 6111 x 5006; Mobile: +1 314 412 4852; E-mails:
mehackn@emory.edu, madeleine.hackney@gmail.com.
1. Introduction
Individuals with Parkinsons disease (PD) have
motor and cognitive impairments that interact, impair-
ing the ability to complete activities of daily living
(ADLs), increasing fall risk and decreasing qual-
ity of life (QOL). Motor symptoms include postural

1053-8135/14/$27.50 2014 IOS Press and the authors. All rights reserved
280 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
instability, gait impairment, and bradykinesia. Cog-
nitive difficulties include impaired spatial cognition
(Possin, Filoteo, Song, & Salmon, 2008), set-switching
(Cools, Barker, Sahakian, & Robbins, 2001), execu-
tive function, and attention (Hausdorff et al., 2006). An
added cognitive task in a dual-task paradigm can exac-
erbate PD motor symptoms (Leroi, Collins, & Marsh,
2006). Axial impairment and postural instability in PD
indicate increased risk of dementia (Taylor et al., 2008).
Likely, these problems stem from the impairment of
overlapping neural systems serving both cognitive and
motor function (Domellof, Elgh, & Forsgren, 2011).
For example, people with PD have trouble with both
planning and initiating movement. Because of signif-
icant and overlapping effects of motor and cognitive
symptoms on ADLs, QOL, and fall risk, clinical tests
that provide a window into the health status of neuro-
motor processes involving motor-cognitive interaction
are imperative to enhance clinical care in PD.
Given the strong relationship between dynamic bal-
ance tasks and cognitive function (Paul, Sherrington,
Fung, & Canning, 2013), performance on the Four
Square Step Test (FSST), a valid test of mobility involv-
ing movement initiation, planning, and coordination,
may provide information about the relative health of the
motor-cognitive interaction in people with PD. Feasi-
ble and reliable in older adults (Dite & Temple, 2002),
stroke survivors (Blennerhassett & Jayalath, 2008),
those with vestibular disorders (Whitney, Marchetti,
Morris, & Sparto, 2007), and multiple sclerosis (Wag-
ner, Norris, Van Dillen, Thomas, & Naismith, 2013), the
FSST requires participants to initiate multidirectional
movement in a challenging sequence, while stepping
over 2.5 cm diameter rods arranged in a cross (Dite
& Temple, 2002). Because many individuals with PD
exhibit deficiencies in planning and executing com-
plex, goal-directed behavior (Plotnik, Giladi, Dagan,
& Hausdorff, 2011), completing the FSST may reveal
deficits related to neuromotor processes that are neces-
sary for dividing attention between mental processing
and postural control. However, the extent to which cog-
nitive resources are involved in FSST performance is
equivocal.
Duncan & Earhart previously demonstrated FSST
reliability for individuals with PD using flat measuring
sticks to form four squares on the floor over which the
patient should step (Duncan & Earhart, 2013). How-
ever, age and neurological impairment progressively
affect the ability to avoid raised obstacles during gait
(Weerdesteyn, Nienhuis, & Duysens, 2005). To eval-
uate the real world impact of PD impairments, it is
important to investigate the effect of an obstacle-based
FSST in those with PD. Here, the FSST was studied in
older adults with idiopathic PD to 1) establish feasibil-
ity and reliability in those with PD, using 2.5 cm rods, as
per the original Dite & Temple protocol (Dite & Temple,
2002), 2) examine concurrent validity with motor, cog-
nitive, and cognitive dual-tasking tests, and 3) compare
PD performance on FSST to that of age-matched older
adults. Because a) an association between mobility
and executive function exists and b) negotiating raised
obstacles while performing the FSST likely requires
divided attention, cognitive dual-tasking and executive
function tests were expected to predict performance on
the FSST. Given the known impairments in movement
initiation and planning experienced by individuals with
PD, it was hypothesized that individuals with PD would
need more time to complete the FSST and would be
more variable in performance than age-matched older
individuals without PD.
2. Materials and methods
2.1. Participants
The Institutional Review Board at Emory University
School of Medicine approved this work. All participants
provided written informed consent before participat-
ing. Participants with PD were recruited through flyers,
referral, PD newsletters, support groups, and web-
sites. Telephone interviews were used to screen for
PD diagnosis. On the day of testing for the present
study, all participants with PD were rated on the Uni-
fied Parkinsons Disease Rating Scale motor subscale
III (UPDRS-III) (Fahn & Elton, 1987) by two trained
evaluators and scores were subsequently averaged.
PD participants included individuals with a diagnosis
of idiopathic definite PD (Hoehn and Yahr (H&Y)
stages I-III) (Racette, Rundle, Parsian, & Perlmut-
ter, 1999), demonstrated benefit from anti-parkinsonian
medication, no other history of neurological insult and
were at least 50 years old. All older adults were recruited
from several senior independent living communities in a
large urban metro area. Because Dite and Temple (Dite
& Temple, 2002) established FSST as a valid measure
in older adults over age 65, a sub-analysis of individu-
als over age 65 with PD (mean age 73 y, range 6582 y)
and older adults without PD (mean age 75.75 y, range
6582 y) was conducted here. Older adult participants
independently resided in senior living communities,
were screened briefly on the telephone for cognitive
 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
impairment, and had no history of progressive neuro-
logic disorder. Both groups could walk 3 or more meters
with or without an assistive device.
2.2. Procedure
Trained raters administered all tests. Individuals with
PD and older adults were questioned about their medi-
cal history, and fall history. Participants were classified
as fallers if they reported they had experienced an
unintentional loss of balance that resulted in landing on
a lower surface or the ground one or more times in the
previous year. They also answered a single item ques-
tionnaire about their fear of falls (on a 7 point scale).
Testing for those with PD occurred while they were
ON medications at a participant-determined opti-
mal time. PD participants were tested with all the
measures described below in a single testing session.
Older adults without PD participated in only the FSST,
Berg Balance Scale (BBS), gait speed assessments, and
completed the Activities-specific Balance Confidence
Scale (ABC), and Beck Depression Inventory (BDI)-II
questionnaires.
2.3. Measures
The Four Square Step Test (FSST) (Dite & Tem-
ple, 2002) required participants to step clockwise then
counterclockwise into four squares created by rods
measuring approximately 100 cm in length and 2.5 cm
in diameter, arranged on the ground in a cross. One
trained rater demonstrated, administered, and timed
the test with a stopwatch while a second rater spot-
ted the participant and provided verbal cues. The test
was demonstrated at least two times. As in Blennerhas-
set et al. (Blennerhassett & Jayalath, 2008), directions
were modified slightly from the Dite and Temple proto-
col (Dite & Temple, 2002) for safety. Participants were
instructed to perform the test as quickly and as safely
as you can. Cues were provided regarding direction
of travel and safety (Pick up your feet.). Participants
were instructed to complete the step sequence without
touching the rods and ensuring both feet contacted the
floor in each square. The participant started with both
feet in square 1, with their back to square 4 and stepped
over the rods and into the squares in this order: 2, 3, 4,
1, 4, 3, 2, 1. Timing began when the participant initi-
ated movement and stopped when both feet were back
in square 1 after completing the entire sequence. Tri-
als were repeated if the participant performed such that
it was clear he/she did not understand the instructions,
281
failed to complete the sequence accurately, lost balance,
touched a rod, or turned his/her hips from facing for-
ward. Three successful trials were recorded as trials 1,
2, and 3. The fastest time was selected for concurrent
validity and group analyses. Participants were asked to
stop in place at the end of the test, and were offered bal-
ance assistance while research assistants removed the
rods.
2.3.1. Measure of disease severity
Unied Parkinsons Disease Rating Scale Motor
Subscale III (UPDRS-III) (Fahn & Elton, 1987) and
Hoehn & Yahr (H&Y) Stage of Disease Severity were
administered and scored by two qualified and trained
raters. UPDRS-Motor Subscale scores range from 0
(asymptomatic) to 108. H&Y stages range from 0
(asymptomatic) to 5 (wheelchair bound/bedridden).
Scores from the two raters, which were highly corre-
lated, were averaged to provide a final score assessing
disease severity in individuals with PD.
2.3.2. Measures of motor function
Timed Up and Go Test (TUG) (Morris, Morris, &
Iansek, 2001), valid in those with PD, measures func-
tional mobility and was administered as published.
Six Minute Walk Test (6MWT) (Guyatt et al., 1985)
assesses exercise tolerance. Participants were instructed
to walk as far as they could in six minutes.
Thirty Second Chair Stand (Rikli & Jones, 2001)
assesses lower body strength. Participants were asked
to rise from a chair to full standing as many times as
possible in 30 seconds.
Berg Balance Scale (BBS) (Berg, Wood-Dauphinee,
& Williams, 1995) is a 14 item performance-oriented
measure of balance in older adults. The BBS has excel-
lent inter- and intra-rater reliability (0.980.99). The
items, Time to Turn and Steps to Turn, which measure
the time and number of steps needed for a participant to
complete a 360 degree turn were individually analyzed.
Turns in both directions were timed and steps counted;
the greatest time and largest number of steps needed
were used for analyses.
Gait Speed (Bohannon, 1997) assesses multi-
directional preferred and fast walking speeds. Partici-
pants performed three trials each of walking forward at
preferred pace, backward at preferred pace, and forward
as fast as possible, all over 20 feet. For the latter, partic-
ipants were instructed to walk as quickly but as safely
as they could. Qualified raters timed participants with a
stopwatch as the first heel passed the starting line, and
stopped when the second heel passed the second line.
282 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
The three trials from each condition were averaged and
speed (m/s) was derived.
2.3.3. Measures of cognitive function
The Montreal Cognitive Assessment (MoCA) is a 30
point test, administered in approximately 10 minutes,
which provides a measure of global status of cogni-
tive impairment through the assessment of a range
of executive functions including orientation, memory
recall, visuospatial function, attention/concentration,
and language. The MoCA achieves high sensitivity
and specificity for detecting mild cognitive impairment
(Nasreddine et al., 2005) and is valid and reliable in
people with PD (Chou et al., 2010). In order to per-
form subanalyses on the PD group dichotomized by
cognitive status (i.e., some cognitive impairment vs. no
cognitive impairment), a cutoff of 26 and greater was
used for those with no cognitive impairment (Hoops
et al., 2009).
Trails Making Tests A and B (Reitan & Wolfson,
2004) is a neuropsychological task of visual attention,
processing speed, and executive function. In Trails A,
a test of visual motor speed and numeric sequencing,
the participant connects numbers scattered on the page
in ascending order. In Trails B, a test of global frontal
lobe dysfunction and executive function, the participant
connects numbers and letters on a page in alternat-
ing ascending order (i.e., 1-A-2-B-3-C, etc.). Research
assistants instructed participants to connect the let-
ters or numbers as quickly as possible, without lifting
the pen/pencil from the paper, and allowed a practice
attempt for both Trails A and B. Errors made while com-
pleting the task were pointed out immediately so the
participant could correct them. Time to complete each
trial (up to a maximum of 300 seconds) was recorded,
including time required to correct errors. Four individu-
als with PD exceeded the maximum of 300 s on Trails B.
Brooks Spatial Task (Brooks, 1967) employs mental
imagery to visualize and remember spatial locations.
It requires participants to remember the placement of
numbers on a 4x4 matrix visualized in their mind and
then repeat the location of the numbers back to the
rater. Participants began with a practice span of three
numbers and progressed up to 8 numbers. All levels
were completed regardless of performance on preced-
ing levels. The percentages correct (out of 50 items)
were considered for analyses.
Reverse Corsi Blocks Visuospatial Task (Kessels, van
den Berg, Ruis, & Brands, 2008) requires participants to
watch the examiner point to a series of blocks on a tray,
and then repeat the pattern backwards. The examiner
began with two moves, and progressed to a maximum
of 9 moves, with 2 trials per level. Participants were
given one practice trial of 2 moves. Participants contin-
ued to the next level if at least one trial was correctly
performed. Span (number of moves remembered) was
considered for analyses.
Body Position Spatial Task (BPST) (Hackney, Hall,
Echt, & Wolf, 2013) is modeled after Corsi blocks.
In BPST, the rater demonstrated (verbally and visu-
ally) a pattern of side, forward and quarter turning (in
place) steps after which the participant repeated the pat-
tern. The rater began with two moves, and progressed
to a maximum of 9 moves, with 2 trials per level.
Participants were given one practice trial of 2 moves.
Participants continued to the next level if at least one
trial was correctly performed. Span (number of moves
remembered) was considered for analyses.
2.3.4. Measures of dual-tasking
Dual Timed Up and Go Test (Morris et al., 2001) is
a measure of functional mobility that is valid in those
with PD. Participants were timed while they performed
both single TUG (as described above) and a concur-
rent cognitive component (Cognitive-TUG; counting
backwards by 3 s (serial 3 s) from a random number
between 20 and 100) or manual component (Manual-
TUG, carrying full glass of water). Before completing
Cognitive-TUG, the participant was given three,
15-second trials of serial 3 s while seated.
2.3.5. Questionnaires
The participants completed the following question-
naires within one week prior to their testing session.
Parkinsons Disease Questionnaire-39 (PDQ-39)
(Peto, Jenkinson, Fitzpatrick, & Greenhall, 1995) is a
health-related quality of life measure for persons with
PD that is validated. The summary index score was used
in analyses.
Freezing of Gait Questionnaire (FOGQ) (Giladi
et al., 2000) is a subjective evaluation of perception
of freezing of gait phenomenon. Participants were clas-
sified as freezers by having a score greater than 1 on
item 3 of the FOGQ.
Activities-specic Balance Condence Scale (ABC)
(Powell & Myers, 1995) asks 16 questions related to
confidence the participant would feel about not losing
his/her balance in life situations.
Beck Depression Inventory-II (BDI-II) (Silberman
et al., 2006) is a well-validated test of depression
recommended by the American Academy of Neurology
for screening individuals with PD.
 K.E. McKee and M.E. Hackney / Four Square Step Test in PD 283

2.4. Data analysis
Data were entered and cross-verified by research
assistants. Descriptive analyses were performed on
intrinsic participant characteristics and outcome mea-
sures. Trial to trial variability of each individuals three
trials was determined by calculating the coefficient of
variation (CV): the standard deviation divided by the
mean and multiplied by 100. The stability of mea-
sures was examined within sessions by conducting
intraclass correlation coefficient analyses (ICC) (model
3,1 single measures, consistency one way random).
FSST data were not normally distributed; therefore,
the association between FSST and concurrent motor
and cognitive measures and self-reported data (demo-
graphics, fall incidence, psychosocial measures) were
determined with Spearmans correlation coefficient.
After exploring associations through correlational anal-
yses, mobility and cognitive variables were entered into
separate simultaneous linear regressions to determine
predictive validity for FSST performance. By examin-
ing the strength of association (standardized weights)
of independent variables to the dependent variable, the
models were refined. To further explore key relation-
ships, post hoc regressions investigated the independent
contributions of disease stage, executive function and
cognitive status to performance on the FSST. F-tests
determined equality of variance between outcome mea-
sures performance of older adults and those with PD,
and independent t tests were used to determine dif-
ferences between them. Independent t-tests or Mann
Whitney U tests (in the case of nonparametric samples)
were also performed on the fastest of three mean FSST
times (i.e., the best time) for PD groups, stratified by
fall, freezing and cognitive status. Alpha was 0.05.
3. Results
Thirty-four individuals with mild-moderate PD
(stage 1.5: n = 6, stage 2: n = 13, stage 2.5: n = 9, stage
3: n = 6) and 26 older adults, agreed to participate. One
PD participant (stage 2.5) was excluded for suspected
malingering. Two PD (stage 2.5 & 3) and two older
adult participants were excluded because they could not
attempt the FSST on the day of assessment. Thirty-one
PD and a subset of 24 PD and 24 age matched older
adult participants are characterized in Table 1.

Table 1
Participant characteristics and selected mobility measuresa
PD (n = 31) PD Subset (n = 24) Older Adults (n = 24) p values
UPDRS-III Motor Subscale 27.30 (6.6) 28.60 (6.0)
Hoehn & Yahr Stage 2.00 (2.0, 2.5) 2.00 (2.0, 2.5)
Bradykinesia Item 0.81 (0.8) 0.88 (0.8)
Duration of PD (years) 7.23 (5.3) 6.25 (4.6)
Freezer (%) 29% 33%
Freezing of Gait Questionnaire 5.03 (4.9) 5.13 (4.5)
PDQ39 Summary Index 18.97 (8.8) 18.59 (7.5)
Sex 12F; 19M 8F; 16M 17F; 7M 0.019
Age (years) 69.65 (7.7) 73.00 (5.0) 75.75 (5.0) 0.063
Height (meters) 1.70 (0.1) 1.70 (0.1) 1.66 (0.1) 0.155
Weight (kg) 65.66 (27.1) 74.96 (13.1) 68.66 (13.2) 0.104
Number Comorbidities 3.10 (1.5) 3.38 (1.6) 3.50 (1.9) 0.805
Number Prescription Medications 6.20 (5.0) 6.39 (5.3) 3.68 (2.8) 0.038
Use of Assistive Device (%) 23% 29% 38% 0.760
Hx of 1 falls in Past Year (%) 55% 54% 42% 0.564
Fear of Falling 2.97 (1.5) 3.17 (1.5) 2.58 (1.7) 0.214
Activities Specific Bal. Conf. Scale 80.47 (15.0) 78.40 (15.6) 78.01 (19.9) 0.945
Quality of Life 5.21 (0.9) 5.21 (1.0) 5.33 (1.1) 0.675
Beck Depression Inventory-II (/63) 11.50 (6.0) 10.68 (6.2) 6.46 (3.8) 0.009
Berg Balance Scale (/56) 51.94 (3.0) 51.88 (2.9) 50.98 (3.8) 0.364
Forward Preferred Gait Speed (m/s) 1.00 (0.2) 0.98 (0.2) 1.03 (0.2) 0.451
Backward Preferred Gait Speed (m/s) 0.67 (0.3) 0.63 (0.2) 0.66 (0.3) 0.709
Fast (Forward) Gait Speed (m/s) 1.36 (0.3) 1.35 (0.3) 1.25 (0.2) 0.211
Abbreviations: PD, Parkinsons Disease; UPDRS, Unified Parkinsons Disease Rating Scale; Hx, History. a Values are means (standard deviation)
except Hoehn & Yahr is reported median (first, third interquartile) and dichotomous variables are reported as percentages. P values are calculated
between PD Subset and OA groups. Rating worry about falling/Rating quality of life from 1 (low) to 7 (high). Fishers Exact Test Equal
Variances Not Assumed.
284 K.E. McKee and M.E. Hackney / Four Square Step Test in PD

3.1. Feasibility of FSST for clinical use for Table 3

participants with PD, with obstacles and Spearmans correlation coefficients between FSST and concurrent
measures of physical and cognitive function and self-reported data
external cueing for individuals with PD (n = 31)

No adverse events (falls or injuries) occurred during Motor and dual tasking
testing. The safety precautions described in Methods Timed Up and Go (s) 0.734
Timed Up and Go-Cognitive (s) 0.634
were observed. Many participants demonstrated poor Timed Up and Go-Manual (s) 0.556
obstacle-awareness during the FSST and several had to Berg Balance Scale (/56) 0.659
initiate more than three times to obtain three valid trials. 360 degree Turn Time (s) 0.492
No participants refused to complete the test. Forward Preferred Gait Speed (m/s) 0.463
Backward Preferred Gait Speed (m/s) 0.575
Fast (Forward) Gait Speed (m/s) 0.564
3.2. Reliability within sessions for individuals with 6 Minute Walk Test (m) 0.476
PD 30 Second Chair Stand (s) 0.475
Steps to Turn 360 degrees 0.339
Trials 1 and 2 were strongly correlated (ICC = 0.735 Cognition
(0.5120.865), F value 6.539, p < 0.001), as were tri- Trails A (s) 0.715
Trails B (s) 0.513
als 2 and 3 (ICC = 0.876 (0.7590.939), F: 15.194, Corsi Blocks Spatial Task (span) 0.460
p < 0.001). There was moderate correlation between Brooks (% correct) 0.405
trials 1 and 3 (ICC = 0.543 (0.2240.758) F: 3.376, Montreal Cognitive Assessment (/30) 0.453
Body Position Spatial Task (span) 0.355
p = 0.001).
Psychosocial
Activities Specific Bal. Conf. Scale (%) 0.468
3.3. Concurrent validity for individuals with PD Fear of Falls 0.419
PDQ39 Summary Index 0.023
PD participant performance on outcome measures Freezing of Gait Questionnaire 0.216
Beck Depression Inventory-II 0.255
is described in Table 2. The median FSST-best time
Disease Severity/Demographics
for individuals with PD was 11.72 seconds (Confi- UPDRS 0.499
dence Interval (CI): 9.99, 13.98) and the trial-to-trial H&Y Staging 0.470
variability was CV: M = 14.1, SD = 11.5. Table 3 lists Bradykinesia 0.163
Time with PD 0.036
Spearmans correlation coefficients between FSST and Number of Comorbidities 0.270
concurrent measures of motor, dual-tasking, cognitive Number of Rx Medications 0.249
and psychosocial function, disease severity and demo- Age 0.077
graphics. Sex 0.118
Education (y) 0.177
Correlation is significant at the 0.01 level (2-tailed).
Table 2
PD Participant Performance on Measures of Motor and Cognitive
Function (n = 31)
3.4. Motor and dual-tasking
Mean (SD) Range
Four Square Trial 1 (s) 15.9 (5.8) 8.329.8
Four Square Trial 2 (s) 14.5 (6.7) 8.332.6 The FSST was strongly correlated with the TUG,
Four Square Trial 3 (s) 13.0 (4.6) 8.325.4 BBS, time to turn, forward, fast, and backward gait
Four Square Best (s) 12.9 (4.5) 8.327.9 speed, 6MWT, and chair stand. FSST was weakly
360 degree Turn Time (s) 4.6 (3.0) 2.719.0
correlated with steps to turn. FSST was strongly corre-
Steps to Turn 360 degrees 9.3 (3.4) 6.020.0
6 Minute Walk Test (m) 409.8 (95.3) 171.0631.2 lated with Cognitive-TUG and Manual-TUG (Table 3).
30 Second Chair Stand (s) 11.8 (2.7) 7.019.0 To determine which of the motor and dual-tasking
Timed Up and Go (s) 9.9 (2.8) 6.719.3 variables had the most predictive validity for FSST
Just Counting Accuracy (# correct/s) 0.5 (0.3) 0.11.0
Timed Up and Go-Cognitive (s) 14.3 (7.1) 6.942.6
performance, the variables forward, fast, and back-
TUG-c Accuracy (# correct/s) 0.4 (0.2) 0.00.9 ward gait, 6MWT, 30 s chair stand, time to turn, BBS,
Timed Up and Go-Manual (s) 12.7 (3.6) 7.525.5 TUG, Manual-TUG, and Cognitive-TUG were simul-
Trails A (s) 48.5 (41.8) 22.5252.3 taneously entered as predictors in a linear regression.
Trails B (s) 122.4 (90.0) 44.4300.0
Brooks (% correct) 62.6 (18.8) 4.090.0
Through a series of refinements of the model, 84.8
Body Position Spatial Task (span/9) 3.7 (1.0) 2.05.0 percent (F: 50.226) of the variance was explained
Corsi Blocks Spatial Task (span/9) 4.4 (1.3) 2.08.0 by Cognitive-TUG (standardized = 0.471, p = 0.002),
Montreal Cognitive Assessment (/30) 25.5 (3.0) 20.030.0 TUG (standardized = 0.350, p = 0.018), and time to
 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
turn (standardized = 0.236, p = 0.009). To determine
the relationship FSST may have had with dual-tasking
motor and cognitive skills, a forward stepwise linear
regression was performed on TUG, Manual-TUG and
Cognitive-TUG. Cognitive-TUG emerged as the sole
contributor accounting for 75.9% of the variance (F:
91.185) of FSST performance (standardized = 0.871,
p < 0.001).
3.5. Cognition
FSST was strongly correlated with Trails A, Trails B,
and Corsi Blocks, and correlated with Brooks, MoCA,
and BPST (Table 3). The variables Corsi span, BPST
span, percent correct on the Brooks spatial test, and time
to complete Trails A and B were entered in a simulta-
neous regression. Through a series of refinements of
the model, Trails B (standardized : 0.696, p < 0.001)
emerged as the sole significant contributor accounting
for 48.5% of the total variance (F: 27.211).
3.6. Psychosocial function
FSST was strongly correlated with balance confi-
dence as measured by the ABC Scale, and correlated
with fear of falls. FSST was only weakly correlated with
PDQ39-SI, FOG, or BDI-II (r < 0.300) (Table 3).
3.7. Disease severity and demographics
FSST was correlated with disease severity, as mea-
sured by both the UPDRS and H&Y staging. FSST
correlations between the bradykinesia score on the
UPDRS, time with PD, sex, number of comorbidities,
number of prescription medications, age, or years of
education were not of clinical relevance or practical
significance (r < 0.300) (Table 3).
3.8. Post-hoc analyses exploring relationship
between stage of disease, executive function,
cognitive status, and performance on FSST
To further explore the relationship between stage of
disease, cognitive status (MoCA), and performance on
FSST, the PD group was subdivided into H&Y stages
1.5, 2, 2.5 and 3. There was an inverse correlation
between performance on FSST and performance on
MoCA (lower FSST score with higher MoCA score);
whilst the correlation between stage of disease and
performance on FSST appeared weaker. These relation-
ships are graphically depicted in Fig. 1.
285
Fig. 1. The relationship of cognitive status and stage of disease
with performance on the FSST. The PD group was subdivided into
H&Y stage 1.5 (diamonds), 2 (squares), 2.5 (triangles) and 3 (cir-
cles), and the correlation of FSST performance to performance on
Montreal Cognitive Assessment (MoCA) is depicted. Cognitive sta-
tus is more strongly related to FSST performance than is disease
stage.
To further explore these relationships, a regression
was performed that looked at the independent contri-
butions of disease stage, executive function (Trails B),
and cognitive status (MoCA) to performance on the
FSST. The overall model explained 55.2 percent of the
variance (F: 11.079, p < 0.001). Trails B was the only
variable that significantly contributed to the variance
(standardized = 0.517, p = 0.003).
3.9. Group comparisons
Fallers vs. non-Fallers among individuals with PD:
Time needed to complete FSST did not differ signifi-
cantly between fallers (M = 13.99, SD = 5.4 range: [9.1,
27.9]) and non-fallers (M = 11.64, SD = 2.8 range: [8.3,
17.5]) (equal variances not assumed, p = 0.133).
Freezers vs. non-Freezers among individuals with
PD: Time needed to complete the FSST did not dif-
fer significantly between freezers (M = 13.76, SD = 5.0
range: [9.2, 25.4]) and non-freezers (M = 12.60,
SD = 4.4 range: [8.3, 27.9]) (p = 0.524).
No cognitive impairment vs. some cognitive impair-
ment among individuals with PD (as measured by the
MoCA with cut off score 26): These two PD subgroups
were not significantly different on stage of disease
(Some cognitive impairment (n = 16): Median = 2.25,
1st interquartile = 2, 3rd interquartile = 3; No cognitive
impairment (n = 15): Median = 2.00 1st interquar-
tile = 1.5, 3rd interquartile = 2.5; p = 0.145), nor sex
distribution (p = 0.957), nor freezer status (p = 0.401).
286 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
However, performance on the FSST by those with some
cognitive impairment (M = 14.67 SD = 5.6 seconds) was
significantly slower (p = 0.026) than those with no cog-
nitive impairment (M = 11.08 SD = 2.0 seconds).
Individuals with PD versus Older Adults: Table 1
includes comparison of a subset of 24 individuals
with PD and 24 age-matched older adults. The two
groups were not significantly different in age, height,
weight, number of co-morbidities, use of assistive
device, falls history, fear of falling, balance confi-
dence, quality of life, performance on the BBS, nor gait
function (Table 1). The PD group had more prescrip-
tion medications, more depression, and more males,
but notably there was no correlation between sex and
FSST performance (Table 3). Time needed to com-
plete FSST did not differ significantly between the
PD subset (M = 13.27, SD = 4.99, range: [8.25, 27.93])
and older adults (M = 13.66, SD = 5.12, range: [6.59,
25.71]) (p = 0.790). Trial-to-trial variability was also
not significantly different (PD subset: CV: M = 13.8,
SD = 11.3; older adults: CV: M = 14.3, SD = 9.3;
p = 0.885).
4. Discussion
In individuals over age 50 with idiopathic PD, the
FSST involving the negotiation of raised obstacles, is
feasible, reliable, and a valid measure of motor function.
Additionally, because FSST performance was associ-
ated with executive function and cognitive dual-task
performance, FSST may have potential to evaluate the
health status of the motor-cognitive interaction, i.e.,
neuromotor processes involving overlapping or shared
motor and cognitive systems. Curiously, those with PD
performed similarly to age-matched individuals with-
out PD in both time to complete and variability in
performance. Further, PD performance on the FSST
did not appear to be strongly stratified by disease
severity.
4.1. Feasibility, reliability, and concurrent validity
with motor & disease severity measures
Obstacle-based FSST was feasible and reliable in
these participants. That FSST was only weakly cor-
related with demographics (e.g., age, education, sex)
suggests broad validity of the test for individuals
with PD regardless of demographic variables. Test-
retest reliability noted here and elsewhere (Duncan &
Earhart, 2013) are lower than correlations noted in
studies of FSST among older adults (Dite & Tem-
ple, 2002), stroke survivors (Blennerhassett & Jayalath,
2008), and individuals with vestibular disorders (Whit-
ney et al., 2007), potentially because motor learning
is slower and uses more brain activity in individuals
with PD than those without (Nieuwboer, Rochester,
Muncks, & Swinnen, 2009). These participants with
PD also needed 2 seconds more to perform the FSST
than previously reported values (Duncan & Earhart,
2013), likely because this studys participants nego-
tiated 2.5 cm rods rather than flat sticks. Similar to
previous work (Duncan & Earhart, 2013) motor out-
come measures and disease severity were significantly
correlated to FSST performance, in initial correla-
tional analyses. However, post-hoc regression analyses
exploring relationship between stage of disease, execu-
tive function, cognitive status, and performance on the
FSST revealed an inverse correlation between FSST
performance and performance on MoCA (faster FSST
time with higher MoCA score), and lack of a strong
correlation between stage of disease and performance
on FSST. FSST may thus provide a unique assess-
ment of motor-cognitive interactions not fully evaluated
by isolated measures of disease severity or cognitive
function.
4.2. Association of cognitive function with FSST
performance
Here, regression offered Trails Ba test of exec-
utive function, as a significant cognitive contributor to
variance in FSST performance. Further, that Cognitive-
TUG emerged as a stronger contributor than TUG, the
latter being a demonstrated predictor of FSST perfor-
mance (Dite & Temple, 2002; Duncan & Earhart, 2013;
Whitney et al., 2007), indicates that FSST may use
cognitive resources akin to those used in mental calcu-
lation and divided attention. These findings corroborate
work suggesting relationships between executive func-
tion and gait performance under dual-task conditions
(Plotnik et al., 2011) and tasks that demand anticipatory
postural adjustment with a change in base of support
(Paul et al., 2013). Additionally, correlations revealed
moderate-strong relationships between FSST perfor-
mance and performance on tests of attentional/mental
status, visuospatial cognition, and mental imagery. A
relationship between complex motor tasks like FSST,
and pure tests of cognitive function suggests that a
common dopaminergic system, with additional cholin-
ergic and cortical involvement, underlies performance
of both functions.
 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
4.3. Subgroup comparisons
It was surprising that age-matched older adults and
PD participants did not differ significantly on FSST
performance. It is possible that neurodegenerative pro-
cesses specific to PD may not affect the relationship
between executive and physical functioning above
and beyond that of normal aging processes. How-
ever, the healthy older sample was not evaluated for
cognitive performance and therefore, whether over-
all cognitive/executive status is most responsible for
FSST performance remains equivocal for the present
study. A possible explanation for the non-differential
results between those with and without PD could be the
attentional cues, which were provided during FSST to
maximize safety of participants. Such cues may have
allowed those with PD to compensate sufficiently for
bradykinesia, movement initiation, planning and other
motor impairments, thus allowing them to perform
more like older adults without PD. Abundant evidence
has demonstrated that external, attentional cues have
improved mobility (Lohnes & Earhart, 2011) and move-
ment initiation (Jiang & Norman, 2006) in individuals
with PD. During externally cued movements, people
with PD might bypass the malfunctioning basal ganglia
(Freedland et al., 2002), and activate the Cerebellar-
Thalamo-Cortical (CTC) neural network, in a manner
similar to that noted in age-matched controls (Lewis
et al., 2007). The well-known facilitating effects of
cues for freezing of gait (Jiang & Norman, 2006) may
also explain lack of differential findings between freez-
ers and non-freezers, which is consistent with previous
work (Duncan & Earhart, 2013).
Post-hoc analysis was unable to generate a reliable
cut-off point to identify fallers vs. non-fallers among
individuals with PD. For the studys older adults, the
Dite and Temple (Dite & Temple, 2002) cut-off of 15
seconds (PPV 86%, NPV 94%) remained a reasonable
cut-off to identify multiple fallers (2 or more falls in
the last 6 months). However, in the PD sub-set a cut-
off of 15 seconds had sensitivity of 20%, specificity of
86%, a PPV of 50%, and an NPV of 60%, which indi-
cates that individuals with PD who are multiple fallers
can perform reasonably quickly on the FSST, reducing
the ability of the test to identify fallers. Other divided
attention, mentally involving paradigms (i.e., the dual-
task), with which FSST appears to be related, have also
been found to have minimal predictive value for falls in
individuals with PD (Smulders et al., 2012). Because
individuals with PD with severe balance impairment
may retain capacity to move relatively quickly, timed
287
tests may have decreased predictive validity for PD fall
status.
4.4. Limitations
A key limitation of this study is that cognitive per-
formance data from the healthy older adult sample are
unavailable. It is thus challenging to determine from
this studys results whether individuals who have more
cognitive symptoms (regardless of the presence of a
movement disorder) perform more poorly on the FSST.
Other limitations include a small sample size, which
limited power, and the differing sex distribution of the
two cohorts (PD and healthy older adult). Although
sex distributions were appropriate for the given pop-
ulation, the fact that there were more women in the
older adult group than in the PD group may have
impacted performance on the FSST. Notably, there were
no strong correlations between FSST performance and
sex. Several additional limitations should be addressed
in future studies. Confirming test-retest reliability of
the obstacle-based FSST for people with PD over longer
intervals, i.e., weeks and months, is necessary. Employ-
ing additional cognitive dual-tasks and demonstrating
correlation would strengthen the findings observed here
with serial 3 s dual-tasking. Future testing should also
include assessment of FSST without cueing, and while
PD participants are OFF medications. Testing with-
out cueing may demonstrate a difference in FSST
performance between individuals with PD and older
adults. Testing those with PD while OFF medications
is important to determine if the relationships between
bradykinesia, executive performance, and FSST perfor-
mance are stronger. Increased bradykinesiaa reliable
clinical measure of the nigrostriatal lesion in PDis
associated with the presence of MCI and impaired
executive performance (Poletti et al., 2012). However,
bradykinesia was not shown to be a significant contrib-
utor here, potentially because participants were tested
ON medications.
5. Conclusions
The FSST, a test of multi-directional mobility
and obstacle avoidance, is feasible, reliable, and a
valid measure of motor function and possibly motor-
cognitive interaction. Although falls are a functional
outcome of high relevance to independence, morbidity
and mortality in both older adult populations and those
with PD, no clear relationship was established between
288 K.E. McKee and M.E. Hackney / Four Square Step Test in PD
fall status and FSST in this study. However, a num-
ber of other significant relationships were demonstrated
between FSST and other functional abilities. FSST per-
formance had a demonstrated strong relationship with
motor skills such as turning in place, mobility, and cog-
nitive dual-taskingall of which are necessary to be
able to function independently, and fully participate in
life situations. Additionally there was lack of a strong
correlation between stage of disease and performance
on FSST. The FSST may thus shed light upon motor-
cognitive interactions independent of disease severity
that affect functional abilities in those with PD. Given
limited knowledge about relationships between cogni-
tive state, motor skill, and PD, the FSST test should
be considered to be included in a battery of tests uti-
lized for impairments that might not be observed with
pure motor, cognitive, or disease severity assessments
in individuals with PD. Given that specific impairments
may be elicited with specific balance and mobility tests
(Paul et al., 2013), understanding the effects of real
world tasks like FSST upon motor-cognitive interac-
tions may help elucidate the neuropathology of clinical
signs in PD.
Acknowledgments
We would like to thank those who assisted in data
acquisition and entry: Allison Bascas, Marco Coelho,
Dabin Choi, Carly DiLeo, Kevin Huang, Virginia Pow-
ers, Adrienne Wimberly, Kedra Woodard and Nathalie
Angel. We acknowledge the Emory Center for Health
in Aging. We also acknowledge Clairmont Oaks, Clair-
mont Place, Kingsbridge and Wesley Woods Towers
retirement communities for providing space for the
assessments and we thank the administrative staff for
each institution. We acknowledge Dr. William De
LAune for statistical assistance.
Declaration of interest
There are no conflicts of interest. The study spon-
sors played no role in the study design, collection,
analysis and interpretation of data, the writing of the
manuscript, the final conclusions drawn, or in the deci-
sion to submit the manuscript for publication. The
Dan and Merrie Boone Foundation, the Emory Center
for Injury Control, and the Emory Center for Health
in Aging supported the study. This study was also
supported by the National Center for Advancing Trans-
lational Sciences of the National Institutes of Health
under Award Number UL1TR000454. The content is
solely the responsibility of the authors and does not
necessarily represent the official views of the National
Institutes of Health. The Emory School of Medicine
Discovery Program supported KE McKee, and Depart-
ment of VA R&D Service Career Development Awards
(E7108M and N0870 W) supported ME Hackney.
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