Comparing Performance and Reliability of 50-Step and 100-Step Fukuda Stepping Tests in Older Adults

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Impact of the Number of Steps on the Fukuda Stepping Test in Older Adults
Article in Physical & Occupational Therapy in Geriatrics · January 2016

DOI: 10.3109/02703181.2015.1128510
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Physical & Occupational Therapy in Geriatrics
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Impact of the number of steps on the Fukuda Stepping test
in older adults
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Journal: Physical & Occupational Therapy in Geriatrics
Manuscript ID Draft
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Manuscript Type: Original Papers
Vestibular Rehabilitation, Fukuda Stepping Test, Older Adults, Within-

Keywords:
subject Variability, Test-Retest Reliability
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URL: http://mc.manuscriptcentral.com/wpog Email: ellentaira@earthlink.net

Page 1 of 15 Physical & Occupational Therapy in Geriatrics
50- and 100-step Fukuda Stepping test

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ABSTRACT. Aims: This study aimed to compare performance, within-subject
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6 variability and test-retest reliability between the 50-step and 100-step Fukuda test in
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8 healthy older adults. Methods: Fifty participants aged between 65 and 75 years performed
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three trials of both the 50- and 100-step tests on two separate sessions seven days apart.
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13 Their final foot position was measured relative to the starting line. Results: Absolute
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15 values of body rotation and lateral and longitudinal displacements were significantly
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18 larger on the 100-step than on the 50-step test. The mean standard deviations of these
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20 measures on the three trials were significantly larger on the 100- compared to the 50-step
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22 test, indicating larger within-subject variability. Intraclass correlation coefficients were
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25 similar for both tests, suggesting comparable test-retest reliability. Conclusion: The 50-
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27 step test is recommended over the 100-step as it may have reduced measurement error.
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34 KEYWORDS Fukuda Stepping test, older adults, test-retest reliability, vestibular
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37 rehabilitation, within-subject variability.
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Physical & Occupational Therapy in Geriatrics Page 2 of 15

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INTRODUCTION
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6 The Fukuda Stepping test, otherwise known as the Unterberger test, is part of the
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8 rehabilitation test battery that assesses labyrinthine function in patients with vestibular
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disorders (Fukuda 1959; Tusa 2014). In this test, blindfolded patients march in place
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13 usually for 50 or 100 steps while attempting to remain on the starting line. Typically,
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15 patients exhibit undetected forward and rotational displacements, resulting in an
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18 erroneous final position (Fukuda 1959, Hickey et al., 1990, Cohen et al., 2014).
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20 Unperceived rotation is presumed to occur as a result of asymmetrical tonic
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22 vestibulospinal influence on antigravity muscles associated with unilateral vestibular
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25 dysfunction (Takemori et al., 1985). A slight difference in lower limb loading would
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27 cause patients to progressively turn as they step in place. Indeed, patients with unilateral
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vestibular lesions exhibit body rotation on the Fukuda Stepping test, usually towards the
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32 lesion side (Peitersen 1967). However, this result has been contested as no difference in
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34 rotation was found between healthy individuals and patients with peripheral labyrinthine
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37 dysfunction (Hickey et al., 1990). More recently, 25% of patients with unilateral
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39 vestibular dysfunction were found to have similar rotations as those obtained in healthy
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41 individuals (Zhang & Wang, 2011). Furthermore, substantial body rotation on the Fukuda
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44 Stepping test has been reported in healthy young and older adults (e.g. Previc & Saucedo,
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46 1992; Nyabenda et al., 2004; Paquet et al., 2014). In spite of these shortcomings, the
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48 Fukuda Stepping test continues to be used by clinicians who practice in the field of
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51 vestibular rehabilitation.
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53 This study sought to examine whether the number of steps influences the outcome
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of the Fukuda Stepping test. Bonanni and Newton (1998) compared the performance of
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30 healthy participants on the 50-step and 100-step Fukuda test and reported that the
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6 mean signed value of rotation was not significantly different between the two tests (i.e., -
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8 14º for the 50-step test and -18º for the 100-step test). However, since some participants
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turned clockwise and others turned counter-clockwise, the mean signed values did not
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13 expose the magnitude of rotation exhibited by the group of participants. Accordingly, in
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15 the present study, signed measures were transformed into absolute values. The sets of
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18 signed and absolute data were analysed and reported to better describe performance on
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20 the Fukuda Stepping test.
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22 The purpose of this study was to compare test results of healthy older adults on
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25 the 50-step and 100-step Fukuda test. We have investigated older adults because a large
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27 portion of patients with dizziness, balance impairments and falls are elders (Stel et al.,
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2003; Jönsson et al., 2004). In order to correctly interpret test results in older patients
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32 with dizziness and vestibular disorders, it is important to characterize performance in
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34 healthy older adults on the Fukuda Stepping test.
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37 The specific aims were to compare body rotation, lateral displacement and
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39 longitudinal displacement of the final body position obtained on the 50-step and 100-step
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44 determine test-retest reliability with a 7-day interval for the two tests. It was expected that
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46 the extent of body rotation and linear displacements would be doubled on the 100-step
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48 than on the 50-step test because there are twice the number of steps on the 100-step
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51 compared to the 50-step test. It was also expected that within-subject variability of
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53 measures would be larger on the 100-step than on the 50-step test.
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6 METHODS
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8 Research Design and Participants
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This is a cross-sectional study with a single group of 50 healthy community
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13 dwellers (16 men and 34 women) aged between 65 and 75 years (mean = 69 years, SD =
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15 3 years). Exclusion criteria consisted of a history of dizziness in the last six months, a
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18 history of neurological condition, taking benzodiazepines or any other medication
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20 affecting cognition or spatial orientation. All participants signed an informed consent
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22 form approved by the institution’s Research Ethics Board.
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27 Testing Procedures
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The testing procedure was conducted in a large, quiet room. Participants were
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32 positioned in front of a starting line marked on the ground and were instructed to step in
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34 place at a comfortable pace while staying on the same spot at all times. They were in
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37 socked feet, had their arms by their sides, and wore opaque goggles that completely
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39 blocked their vision. Steps were counted by the investigator.
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41 Three trials of each test were completed and the order of the test (50- or 100-
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44 steps) was randomly determined. Participants did not receive any feedback about their
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46 performance. They kept the opaque goggles at all times and they were guided back to the
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48 starting line by an assistant through a complex pathway after each trial so that they would
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51 not gain information about their final position relative to the starting line. At the end of
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53 each trial, participants’ final foot position was marked on the floor with a 20 cm piece of
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masking tape using the toes as a reference. Participants attended two testing sessions (test
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6 and retest) separated by seven days.
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Measures
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13 Participants’ final positions were measured relative to the starting line. Body
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18 represented the angle between the final foot position and the starting line and was
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20 measured with a goniometer within 1º of accuracy. Lateral displacement represented the
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22 distance in the x-axis between the final foot position and the starting line, and
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25 longitudinal displacement represented the distance in the y-axis. These distances were
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27 measured with a ruler and recorded within 1 cm of accuracy. Negative signs were
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attributed to counter-clockwise body rotation, lateral displacement to the left of the
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32 starting line and longitudinal displacement behind the starting line.
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37 Data Analyses
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39 Signed values were transformed into absolute values and the two data sets were
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41 used for analysis. First, outliers were identified with the use of IBM SPSS Statistics 20
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44 software and removed from the two data sets. Outliers were defined as values 1.5 times
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46 or greater than those in the interquartile range representing 50% of the cases. Outliers
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48 were found to represent 1.6% of all the data. After the within-subject variability analyses
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51 were completed, data from the three trials were averaged and used for subsequent
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Statistical Analyses
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6 Measures obtained on the 50-step and 100-step tests were compared with the non-
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8 parametric Wilcoxon Signed Ranks tests because the variance of the outcome variables
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was not homogeneous. To establish within-subject variability of each measure for the two
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13 stepping tests, values obtained from the three trials were compared using Friedman tests.
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15 Furthermore, the standard deviation (SD) of the three trials was calculated and compared
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18 between the two stepping tests with paired-samples t-tests. Measures obtained at test and
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20 retest for the two stepping tests were compared with Wilcoxon Signed Ranks tests
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22 because the variance of the data was not homogeneous. Test-retest reliability was
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25 assessed with average measures intra-class correlations (ICC; McGraw & Wong, 1996).
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27 Statistical significance was set at p≤.05.

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32 RESULTS
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34 Table 1 lists signed and absolute mean and SD values of the three measures on the
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37 50-step and 100-step Fukuda tests. On the 100-step test, mean absolute values of body
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39 rotation, lateral and longitudinal displacements were significantly larger than those
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44 = -5.69, p < .001, r = .80; Longitudinal displacement z = -4.55, p < .001, r = .64). For
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46 signed values, only the mean value of longitudinal displacement on the 100-step test was
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48 significantly larger than that of the 50-step test (z = -3.36, p < .001, r = .48).
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51 The mean of participants’ SD for each measure are listed in Table 2. The mean
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53 SDs for all measures were significantly larger on the 100-step test than the 50-step test (p
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< .001 for all paired t-tests).
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There were no significant differences in the means of measures at test compared
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6 to the retest (see Table 1, p > .05 for all Wilcoxon Signed Ranks tests). ICC of measures
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8 ranged between .57 and .71 for the 50-step test and between .57 and .77 for the 100-step
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test.
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15 DISCUSSION
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18 Our study revealed that the absolute (unsigned) values of body rotation and lateral
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20 and longitudinal displacements were significantly larger on the 100-step than on the 50-
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22 step Fukuda test (Table 1, last two columns). This indicates that the extent of unperceived
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25 angular and linear displacements while stepping in place without vision was larger when
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27 the number of steps was doubled. This effect was not observed with the signed values, as
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mean signed body rotation and mean signed lateral displacement were not significantly
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32 different between the 50-step and 100-step tests (Table 1, first two columns). This finding
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34 is consistent with previous research as Bonanni and Newton (1998) also reported that the
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37 signed values of rotation were not significantly different between the two tests.
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39 Interestingly, they reported mean values (-14º for the 50-step test and -18º for the 100-
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44 the 100-step test). The negative signs indicate that on average, participants turned
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46 counter-clockwise regardless of the number of steps. A previous study showed that the
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48 direction of rotation on the 100-step Fukuda test was significantly correlated to foot
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51 dominance in healthy young adults (r = -.32), with counter-clockwise rotation reflecting
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A more detailed analysis of absolute values shows that body rotation was 2.2
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6 times larger, lateral displacement was 2.8 times larger, and longitudinal displacement was
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8 1.6 times larger on the 100-step than on the 50-step test (Table 1, last two columns).
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These results support our hypothesis because, in general, as the number of steps doubled,
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13 the extent of undetected rotation and linear displacements also doubled. However, the
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18 larger on the 100-step than the 50-step test and longitudinal displacement only 1.6 times
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20 larger. This suggests that the perception and control of body displacements are different
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22 depending on the direction of displacement during the Fukuda Stepping test. In the
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25 absence of vision, vestibular, proprioceptive and tactile cues aid in the maintenance of a
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27 sense of position and orientation in space (Wolbers and Hegarty, 2010). Perhaps body
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displacements in the sagittal plane were better detected by these self-motion cues than
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32 displacements in the frontal plane in our older participants. Previous studies have shown
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34 that sway in the medio-lateral direction when standing on one leg and when walking
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37 increased with age (Nitz et al., 2003; Schrager et al., 2008). Accordingly, it is possible
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39 that the control of lateral displacements when stepping in place was difficult because
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44 right and left leg. As a result, their center of gravity likely moved back and forth in the
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46 medio-lateral direction and these movements were probably larger than those in the
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48 antero-posterior direction. Thus, perhaps the perception and control of displacements in
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51 the frontal plane were more challenging for older adults than perception and control of
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Our study showed that performance on the Fukuda Stepping test is determined by
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6 the number of steps, at least when 50 steps and 100 steps are compared. In a recent study
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8 by Cohen and colleagues (2014), older adults performed a Fukuda Stepping test with only
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20 steps. Mean absolute rotation was 11º and mean distance forward was 42 cm. These
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13 values are roughly 2.5 times smaller than the ones we found on the 50-step test, which
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18 further supports the notion that the final position relative to the starting line (regardless of
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20 direction) on the Fukuda Stepping test is related to the number of steps in older adults.
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25 from trial-to-trial, as shown by the mean SDs of three trials reported in Table 2. Thus, it
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27 is recommended that more than one trial of the Fukuda Stepping test be executed because
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performance on one trial may not accurately represent typical performance. In addition,
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32 we found that within-subject variability was significantly larger on the 100-step than on
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37 influenced by the number of steps. Because the 100-step test is more strenuous than the
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39 50-step test, this may have contributed to the increased variability. Therefore, the 50-step
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44 subject variability in performance associated with the 100-step test.
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46 Mean values obtained at test and retest were not significantly different. Three
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48 ICCs values for signed and absolute lateral displacement on the 100-step test and
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51 absolute lateral displacement on the 50-step test were in the range of high reliability (ICC
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53 ≥ .7). However, all of the other measures were moderately reliable with ICCs between .50
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and .69. These ICCs are comparable with those previously reported for the Fukuda
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Stepping test performed on two consecutive days (i.e., .66 for the 50-step test and .52 for
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6 the 100-step test; Bonanni and Newton, 1998). These findings highlight the high
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complexity of the Fukuda Stepping test, which involves the integration of self-motion
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18 al.1997; Wolbers & Hegarty, 2010).
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22 CONCLUSIONS
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25 Fifty healthy older adults exhibited significantly larger body rotation and lateral
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27 and longitudinal displacements, as well as significantly larger within-subject variability

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on the 100-step than on the 50-step Fukuda test. It is recommended to select the 50-step
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32 test over the 100-step test because it is likely associated with less measurement error and
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34 it is less strenuous for patients. It is also recommended to perform more than just one trial
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37 to avoid unrepresentative results.
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5 REFERENCES
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7 Bonanni M, Newton R. (1998). Test-retest reliability of the Fukuda Stepping Test.
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9 Physiotherapy Research International 3:58-68.
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12 Cohen HS, Sangi-Haghpeykar H, Ricci NA, Kampangkaew J, Williamson RA. (2014)
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14 Utility of stepping, walking, and head impulses for screening patients for vestibular
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impairments. Otology and Neurotology 151:131-136.
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19 Fukuda T. (1959). The stepping test: Two phases of the labyrinthine reflex. Acta Oto-
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21 Laryngologica 50:95-108.
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Jönsson R, Sixt E, Landahl S, Rosenhall U. (2004). Prevalence of dizziness and vertigo in
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26 an urban elderly population. Journal of Vestibular Research 14:47-52.
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28 Hickey SA, Ford GR, Buckley JG, Fitzgerald O’Connor AF. (1990). Unterberger
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stepping test: A useful indicator of peripheral vestibular dysfunction? Journal of
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33 Laryngology and Otology 104:599-602.
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35 McGraw KO, Wong SP. (1996). Forming inferences about some intraclass correlation
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40 Nitz JC, Choy NL, Isles RC. (2003). Medial-lateral postural stability in community-
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dwelling women over 40 years of age. Clinical Rehabilitation 17:765-767.
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45 Nyabenda A, Briart C, Deggouj N, Gersdorff M. (2004). A normative study of the
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47 vestibulospinal and rotational tests. Advances in Physiotherapy 6:122-129.
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50 Paquet N, Taillon-Hobson A, Lajoie Y. (2014). Fukuda and Babinski-Weil tests: Within-
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52 subject variability and test-retest reliability in nondisabled adults. Journal of
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54 Rehabilitation Research and Development 51:1013-1022.
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Peitersen E. (1967). Vestibulospinal reflexes. X. Theoretical and clinical aspects of the
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6 stepping test. Archives of Otolaryngology-Head and Neck Surgery 85:192–198.
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8 Previc FH, Saucedo JC. (1992). The relationship between turning behavior and motoric
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dominance in humans. Perceptual and Motor Skills 75(3 Pt 1):935-944.
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13 Schrager MA, Kelly VE, Price R, Ferrucci L, Shumway-Cook A. (2008). The effects of
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15 age on medio-lateral stability during normal and narrow base walking. Gait & Posture
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18 28:466-471.
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20 Stel V, Pluijm S, Deeg D, Smit JH, Bouter LM, Lips P. (2003). A classification tree for
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22 predicting recurrent falling in community-dwelling older persons. American Journal of
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25 the Geriatric Society 51:1356-1364.
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27 Takemori S, Ida M, Umezu H. (1985). Vestibular training after sudden loss of vestibular
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function. ORL Journal of Otorhinolaryngology and Related Specialties 47:76-83.
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32 Trullier O, Wiener SI, Berthoz A, Meyer JA. (1997) Biologically based artificial
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34 navigation systems: Review and prospects. Progress in Neurobiology 51:483-544.
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37 Tusa RJ. (2014). History and clinical examination. In: Herdman SJ and Clendaniel RA,
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39 eds. Vestibular Rehabilitation. Fourth edition. Philadelphia, PA:FA Davis Company,
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41 160-177.
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44 Wolpers T, Hegarty M. (2010). What determines our navigational abilities? Trends in
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46 Cognitive Sciences 14:138-146.

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48 Zhang YB, Wang WQ. (2001). Reliability of the Fukuda stepping test to determine the
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51 side of vestibular dysfunction. Journal of International Medical Research 39:1432-
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53 1437.
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ACKNOWLEGEMENTS
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6 This project was financed by an internal grant from the University of Ottawa.
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5 TABLE 1. Mean (SD) of Measures and Intra-Class Correlation Coefficients (95%
6 Confidence Interval)
7 Signed Absolute
8 50-step 100-step 50-step 100-step
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Test
11 Rotation (º) -10 (38) -20 (88) 33 (22) 74 (45) *
12 Lateral (cm) -12 (49) -14 (120) 45 (30) 124 (61) *
13 Longitudinal (cm) 102 (57) 151 (116) * 103 (54) 165 (98) *
14 Retest
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Rotation (º) -13 (42) -13 (101) 39 (29) 87 (55)
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17 Lateral (cm) -15 (45) -12 (136) 43 (29) 121 (72)
18 Longitudinal (cm) 96 (47) 145 (91) 96 (47) 151 (84)
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19 ICC
20 Rotation .64 (.35-.79) .58 (.27-.76) .57 (.23-.76) .57 (.24-.76)
21 Lateral .57 (.24-.76) .77 (.60-.87) .71 (.50-.84) .72 (.51-.84)
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Longitudinal .63 (.39-.80) .68 (.44-.82) .65 (.38-.80) .65 (.38-.80)
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24 ICC: Intraclass correlation coefficient.
25 * p<0.001 relative to the 50-step test.
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TABLE 2. Mean SD of Three Trials
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5 Signed Absolute
6 Test 50-step 100-step 50-step 100-step
7 Rotation (º) 19 42 * 16 29 *
8 Lateral (cm) 27 71 * 20 42 *
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Longitudinal (cm) 15 58 * 15 52 *
11 * p<0.001 relative to the 50-step test.
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Comparing Performance and Reliability of 50-Step and 100-Step Fukuda Stepping Tests in Older Adults

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Comparing Performance and Reliability of 50-Step and 100-Step Fukuda Stepping Tests in Older Adults

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Article in Physical & Occupational Therapy in Geriatrics · January 2016

Nicole Paquet Deborah Jehu

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Journal: Physical & Occupational Therapy in Geriatrics

Manuscript Type: Original Papers

Vestibular Rehabilitation, Fukuda Stepping Test, Older Adults, Within-

URL: http://mc.manuscriptcentral.com/wpog Email: ellentaira@earthlink.net

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

27 Statistical significance was set at p≤.05.

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

50- and 100-step Fukuda Stepping test

27 and longitudinal displacements, as well as significantly larger within-subject variability

50- and 100-step Fukuda Stepping test

38 coefficients. Psychological Methods 1:30-46.

50- and 100-step Fukuda Stepping test

46 Cognitive Sciences 14:138-146.

50- and 100-step Fukuda Stepping test

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