Crosswalk #6: Four Square Step Test (4SST) and Haas Balance Book

The 4SST is a dynamic balance test that assesses a patient’s ability to step over small obstacles forward, backward, and to each side. The Haas Balance Book: 100+ Exercises for PTs & OTs is a collection of over 100 exercises to improve static, dynamic, and reactionary balance. Based on results of the 4SST, exercises can be selected (from the book or elsewhere) that target elements of the 4SST noted to be slow and/or unsteady. Elements of the 4SST include stepping in clockwise manner over small obstacles (right side, backwards, left side, and forwards). Sequence is repeated in counterclockwise direction. Efforts are made during stepping to move quickly, avoid hitting foot on obstacles, and to face forward during test. Exercises that more closely simulate slow, unsteady, or difficult elements of the 4SST will have a higher potential for positive training benefits. The crosswalk below references exercises from Haas Balance Book that help simulate aspects of the 4SST:

Exercise 41: Gait – Side Steps

Exercise 42: Gait – Back Steps

Exercise 43: Gait – Cross-Over Steps

Exercise 44: Gait – High Steps

Exercise 51: Gait Over Obstacles

1. Obstacles far apart for longer strides
2. Taller obstacles for higher steps
3. Sidestep over obstacles

Exercise 53: Gait Around Obstacles

1. Position point obstacles close together for tighter turns
2. Position line obstacles close together for narrow walkways

Exercise 55: Stepping Drills

1. Side steps
2. Back steps
3. Over an obstacle

Exercise 56: Tapping Drills

1. Side taps
2. Back taps
3. Stable target
4. Unstable target

Exercise 57: Stepping On/Off Obstacles

1. Increase step height for harder challenges
2. Step to the side
3. Unstable surfaces

Exercise 58: Quadrant Stepping

1. Step in counterclockwise direction
2. Raise quadrant off of ground to add difficulty

Exercise 59: Diagonal Stepping

Exercise 60: Pivoting Drills

Exercise 61: Combo: Progressively Higher Hurdles

Exercise 73: Randomized Stepping

1. Right side
2. Left side
3. Backwards
4. Dual-task challenges

Exercise 74: Randomized Stepping On/Off Obstacles

1. Increase step height
2. To the sides
3. Backwards
4. Dual-task challenges

Exercise 75: Randomized Stepping + Clock Yourself

Exercise 76: Randomized Stepping + Quadrant Hurdle

Exercise 77: Randomized Tapping Colored Cones

Exercise 78: Randomized Turning

Exercise 81: Randomized Gait – Forward/Backward

Exercise 83: Gait + Start-Stops

Exercise 85: Combo: Randomized Sidestepping + Obstacles

Exercise 86: Combo: Random Stepping + Obstacles

Exercise 94: Simon – Lower Extremity

Other Crosswalks:

Crosswalk #1: Berg Balance Scale & Haas Balance Book

Crosswalk #2: Dynamic Gait Index and Haas Balance Book

Crosswalk #3: Tinetti Performance Assessment and Haas Balance Book

Crosswalk #4: Activities-Specific Balance Confidence Scale and Haas Balance Book

Crosswalk #5: Timed Up & Go (TUG) and Haas Balance Book