Box and Block Test

Objective

The Box and Block Test (BBT) measures unilateral gross manual dexterity. It is a quick, simple and inexpensive test. It can be used with a wide range of populations, including clients with stroke.

Intended Population

Those with a range of neurological diagnoses including:

  • Stroke
  • Multiple Sclerosis
  • Traumatic Brain Injury (TBI)
  • Neuromuscular Disorders
  • Geriatric
  • Spinal Cord Injury (SCI)
  • Fibromyalgia

The BBT cannot be used with clients who have severe upper extremity impairment or those with sever cognitive impairment.

Features of the Measure

The BBT is composed of a wooden box divided in two compartments by a partition and 150 blocks. The BBT administration consists of asking the client to move, one by one, the maximum number of blocks from one compartment of a box to another of equal size, within 60 seconds. The box should be oriented lengthwise and placed at the client’s midline, with the compartment holding the blocks oriented towards the hand being tested. In order to practice and register baseline scores, the test should begin with the unaffected upper limb. Additionally, a 15-second trial period is permitted at the beginning of each side. Before the trial, after the standardized instructions are given to clients, they should be advised that their fingertips must cross the partition when transferring the blocks, and that they do not need to pick up the blocks that might fall outside of the box[2]

Method of Use

Equipment Required:

  • Stopwatch
  • Wooden box dimensioned in 53.7 cm x 25.4 cm x 8.5 cm
  • Partition (should be placed at the middle of the box, dividing it in two containers of 25.4 cm each)
  • 150 wooden cubes (2.5 cm in size)

Set-Up:

  • A test box with 150 blocks and a partition in the middle is placed lengthwise along the edge of a standard-height table
  • The patient should be seated on a standard height chair facing the box
  • 150 blocks should be in the compartment of the test box on the side of the patient’s dominant hand
  • The examiner should face the patient so she or he could view the blocks being transported

Description:

The patient is allowed a 15-second trial period prior to testing

  • Individuals are seated at a table, facing a rectangular box that is divided into two square compartments of equal dimension by means of a partition.
  • One hundred and fifty, 2.5 cm, colored, wooden cubes or blocks are placed in one compartment or the other.
  • The individual is instructed to move as many blocks as possible, one at a time, from one compartment to the other for a period of 60 seconds.
  • Standardized dimensions for the test materials and procedures for test administration and scoring have been provided by Mathiowetz et al, 1985.
  • To administer the test, the examiner is seated opposite the individual in order to observe test performance.
  • The BBT is scored by counting the number of blocks carried over the partition from one compartment to the other during the one-minute trial period.
  • Patient’s hand must cross over the partition in order for a point to be given, and blocks that drop or bounce out of the second compartment onto the floor are still rewarded with a point.
  • Multiple blocks carried over at the same time count as a single point.
  • Higher scores on the test indicate better gross manual dexterity

Scoring:

Clients are scored based on the number of blocks transferred from one compartment to the other compartment in 60 seconds[2]. Score each hand separately. Higher scores are indicative of better manual dexterity. During the performance of the BBT, the evaluator should be aware of whether the client’s fingertips are crossing the partition. Blocks should be counted only when this condition is respected. Furthermore, if two blocks are transferred at once, only one block will be counted. Blocks that fall outside the box, after trespassing the partition, even if they don’t make it to the other compartment, should be counted.

Patient Instructions:[2]

Detailed patient instructions as outlined by Mathiowetz et al.

“I want to see how quickly you can pick up one block at a time with your right (or left) hand [point to the hand]. Carry it to the other side of the box and drop it. Make sure your fingertips cross the partition. Watch me while I show you how.”

Transport three cubes over the partition in the same direction you want the patient to move them. After a demonstration say the following:

“If you pick up two blocks at a time, they will count as one. If you drop one on the floor or table after you have carried it across, it will still be counted, so do not waste time picking it up. If you toss the blocks without your fingertips crossing the partition, they will not be counted. Before you start, you will have a chance to practice for 15 seconds. Do you have any questions?”

“Place your hands on the sides of the box. When it is time to start, I will say ready and then go.”

Trial period: Start the stop watch at the word go. When 15 seconds has passed, say "stop." If mistakes are made during the practice period, correct them before the actual testing begins.

On completion of the practice period, transport the cubes to the original compartment.

Continued with the following directions:

“This will be the actual test. The instructions are the same. Work as quickly as you can. Ready.” [Wait 3 seconds]

“Go.”

“Stop.” [After 1 minute, count the blocks and record as described above]

“Now you are to do the same thing with your left (or right) hand. First you can practice. Put your hands on the sides of the box as before. Pick up one block at a time with your hand, and drop it on the other side of the box.”

“Ready.” [Wait 3 seconds] “Go.”

“Stop.” [After 15 seconds]

Return the transported blocks to the compartment as described above.

“This will be the actual test. The instructions are the same. Work as quickly as you can.”

“Ready.” [Wait 3 seconds]

“Go.”

“Stop.” [After 1 minute, count the blocks and record as described above]

Reference

Evidence

Reliability

Test-retest Reliability:

  • Acute and Chronic Stroke: (Chen et al, 2009) [3]
    • Excellent test-retest reliability when tested on more affected (r = 0.98) and less affected hand (r = 0.93)
  • Upper Limb Impairment: (Desrosiers et al, 1994; n = 35 able bodied subjects; mean age = 71.7(60-89) years; n = 34 subjects with impairment; mean age = 74.5(65-87) years) [4]
    • Excellent test-retest reliability of the right hand for able bodied subjects (ICC= 0.97)
    • Excellent test-retest reliability of the left hand for able bodied subjects (ICC= 0.96)
    • Excellent test-retest reliability of the right hand for subjects with impairment (ICC= 0.90)
    • Excellent test-retest reliability of the left hand for subjects with impairment (ICC= 0.89)
  • Upper Extremity Paresis: (Platz et al, 2005; n = 56 people with upper limb paresis as a result of stroke, Multiple Sclerosis (MS), and traumatic brain injury (TBI); median age = 54(13-92) years; n = 37 for stroke; median age = 62(22-92) years; n = 14 for MS; median age = 43(28-60) years; n = 5 for TBI; median age = 34(13-50) years) [5]
    • Excellent test-retest reliability (ICC = 0.96)
  • Spastic Hemiplegia: (Siebers et al, 2010) [6]
    • Excellent test-retest reliability (ICC = 0.95)

Interrater/Intrarater Reliability:

  • Normal Adults: (Mathiowetz et al, 1985) [7]
    • Excellent interrater reliability for the right hand (r = 1.00)
    • Excellent interrater reliability for the left hand (r = 0.99)
  • Upper Extremity Paresis: (Platz et al, 2005) [5]
    • Excellent interrater reliability (ICC = 0.99)
  • Spastic Hemiplegia: (Siebers et al, 2010) [6]
    • Excellent interrater reliability (r = 0.95)
  • Fibromyalgia: (Canny et al, 2009; n = 30 participants with fibromyalgia; mean age = 46.9(range 20-68) years; n = 30 healthy participants; mean age= 41.2(29-52) years) [8]
    • Excellent intrarater reliability for participants with fibromyalgia (ICC = 0.90)
    • Excellent intrarater reliability for healthy participants (ICC = 0.98)
    • Excellent interrater reliability for participants with fibromyalgia (ICC = 0.85)
    • Excellent interrater reliability for healthy participants (ICC = 0.80)

Validity

Criterion Validity (Predictive/Concurrent):

Stroke:

(Lin et al, 2010; n = 59 patients with stroke; sex = 47 males, 12 females; mean age = 55.5(11.66) years)

Concurrent Validity Pre- and Post- Treatment

Measure Pretreatment (r) Posttreatment (r)
NHPT -0.80 (Excellent) -0.71 (Excellent)
ARAT 0.63 (Excellent) 0.64 (Excellent)
FMA 0.44 (Adequate) 0.35 (Adequate)
MAL-AOU -0.37 (Adequate) 0.49 (Adequate)
MAL-QOM 0.52 (Adequate) 0.52 (Adequate)
SIS 0.59 (Adequate) 0.52 (Adequate)

(ARAT = Action Research Arm Test, BBT = Box and Block Test, CI = confidence interval, FMA = Fugl-Meyer Assessment, MAL-AOU = Motor Activity Log-Amount of Use, MAL-QOM = Motor Activity Log-Quality of Movement, NHPT = Nine-Hole Peg Test, SIS = Stroke Impact Scale)

Construct Validity (Convergent/Discriminant)

  • Upper Limb Impairment: (Desrosiers et al, 1994) [4]
    • Excellent convergent validity with the Action Research Arm Test (r = 0.80)
    • Adequate convergent validity with Functional Autonomy Measurement System (r (right hand) = 0.47; r (left hand) = 0.51)
  • Upper Extremity Paresis: (Platz et al, 2005) [5]
    • Excellent convergent validity with the Action Research Arm Test (r = 0.95)
    • Excellent convergent validity with the Fugl-Meyer Test (r = 0.92)
    • Excellent convergent validity with the Hemispheric Stroke Scale (r = -0.67)
    • Adequate convergent validity with the Passive Joint motion/Joint pain sub-scale of Fugl-Meyer Test (r = 0.43)
    • Poor convergent validity with the Modified Barthel Index (r = 0.04)
  • Central Paresis: (Platz et al, 2008; n = 33 neurological patients with central paresis due to stroke, ischemic/anoxic brain damage, traumatic brain injury, or spinal cord injury; n=3 patients with SCI(C3,C4,T8), 6 patients with TBI, and 23 patients with stroke; sex = 20 males, 13 females; mean duration of disease = 19.4 months; mean age = 49.7(17.3) years) [5]
    • Excellent convergent validity with Resistance to Passive Movement (r = -0.680)

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References

  1. Mathiowetz, V., G. Volland, et al. (1985). "Adult norms for the Box and Block Test of manual dexterity." Am J Occup Ther 39(3160243): 386-391.
  2. 2.0 2.1 2.2 Mathiowetz, V., G. Volland, et al. (1985). "Adult norms for the Box and Block Test of manual dexterity." Am J Occup Ther 39(3160243): 386-391.
  3. Chen, H. M., Chen, C. C., et al. "Test-retest reproducibility and smallest real difference of 5 hand function tests in patients with stroke." Neurorehabil Neural Repair 2009 23(5): 435-440
  4. 4.0 4.1 Desrosiers, J., Bravo, G., et al. "Validation of the Box and Block Test as a measure of dexterity of elderly people: reliability, validity, and norms studies." Arch Phys Med Rehabil 1994 75: 751-755
  5. 5.0 5.1 5.2 5.3 Platz, T., Pinkowski, C., et al. "Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study." Clin Rehabil 2005 19(4): 404-411
  6. 6.0 6.1 Siebers, A., Oberg, U., et al. "The effect of modified constraint-induced movement therapy on spasticity and motor function of the affected arm in patients with chronic stroke." Physiother Can 2010 62(4): 388-396
  7. Mathiowetz, V., Volland, G., et al. "Adult norms for the Box and Block Test of manual dexterity." Am J Occup Ther 1985 39(3160243): 386-391
  8. Canny, M. L., Thompson, J. M., et al. "Reliability of the box and block test of manual dexterity for use with patients with fibromyalgia." Am J Occup Ther 2009 63(4): 506-510