# The Four‐Square Step Test With and Without Dual Tasks Among Older Adults With and Without a Fall History: A Retrospective Cohort Study

## TL;DR

This study shows that adding dual tasks to a balance test improves its ability to identify older adults who have a history of falling.

## Contribution

The study introduces the use of dual tasks with the Four-Square Step Test to better assess fall risk in older adults.

## Key findings

- The FSST with a cognitive dual task best distinguished fallers, especially among males.
- Cognitive dual task FSST had a cutoff score of about 13 seconds for identifying fallers.
- Motor dual task improved test accuracy in females compared to the standard FSST.

## Abstract

As the global population of adults aged 65 and older increases, so does the prevalence of falls, which are the second leading cause of unintentional injury deaths worldwide, according to the World Health Organization. The Four‐Square Step Test (FSST) is a widely used tool for assessing dynamic balance and mobility. The purpose of this study was to compare the use of the FSST and the FSST with dual task(s) (DT) for discriminating between older adult fallers and non‐fallers by sex.

Fifty community‐dwelling older adults (35 females, 15 males) participated. Based on self‐reported fall history, 28 were classified as non‐fallers and 22 as fallers. Participants completed the FSST, FSST with a motor DT, and FSST with a cognitive DT. The area under the curve (AUC) of the receiver operating characteristic curve was calculated and used to compare the FSST conditions to determine the best condition among the three used for discriminating between faller and non‐faller participants.

Among females, AUCs were 0.634 (FSST), 0.690 (motor DT), and 0.668 (cognitive DT). Among males, AUCs were 0.518 (FSST), 0.518 (motor DT), and 0.732 (cognitive DT). For all participants, cutoff scores for distinguishing fallers from non‐fallers were approximately 10.07 s (FSST), 10.05 s (motor DT), and 13.22 s (cognitive DT).

The FSST with a cognitive DT showed the highest overall accuracy in distinguishing fallers, particularly among males. The FSST with a motor DT demonstrated better discriminative performance than the standard FSST in females, while both test conditions were equivalent in males. Identified cutoff scores were approximately 13 s for the cognitive dual task and 10 s for both the standard and motor dual task conditions. These findings support the potential clinical utility of incorporating cognitive or motor dual tasks into the FSST, particularly for sex‐specific fall risk assessment in community‐dwelling older adults.

The clinical motivation for this study was to identify an alternative balance assessment for physical therapists to use in the identification of older adult fallers.In general, the Four‐square step test (FSST) with motor and cognitive dual tasks (DT) was more accurate in the identification of individuals with a fall history when compared to the FSST without DT.In the older adult population, the FSST with dual tasks could be used as an alternative assessment for discriminating between community‐dwelling older adult fallers and non‐fallers.

The clinical motivation for this study was to identify an alternative balance assessment for physical therapists to use in the identification of older adult fallers.

In general, the Four‐square step test (FSST) with motor and cognitive dual tasks (DT) was more accurate in the identification of individuals with a fall history when compared to the FSST without DT.

In the older adult population, the FSST with dual tasks could be used as an alternative assessment for discriminating between community‐dwelling older adult fallers and non‐fallers.