Box and Block Test

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Objective

The Box and Block Test is an objective measure of assessing unilateral gross manual dexterity

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

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

Evidence

Reliability

Test-retest Reliability:

Acute and Chronic Stroke: (Chen et al, 2009) 

• 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) 

• 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) 

• Excellent test-retest reliability (ICC = 0.96)

Spastic Hemiplegia: (Siebers et al, 2010) 

• Excellent test-retest reliability (ICC = 0.95)

Interrater/Intrarater Reliability:

Normal Adults: (Mathiowetz et al, 1985) 

• 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) 

• Excellent interrater reliability (ICC = 0.99)

Spastic Hemiplegia: (Siebers et al, 2010) 

• 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) 

• 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) 

• 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) 

• 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) 

• Excellent convergent validity with Resistance to Passive Movement (r = -0.680)

Responsiveness

Not established

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Box and Block Test