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Rehab Measures: Box and Block Test

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Box and Blocks Test Instructions 

Title of Assessment

Box and Block Test 

Acronym

BBT

Instrument Reviewer(s)

Initially reviewed by Jason Raad, MS of the Rehabilitation Measures Team and Dorian Rose, PT, PhD of the StrokEdge Taskforce of the Neurology Section of the APTA in 9/2011; Updated with references for Stroke and Fibromyalgia populations by Denise Toombs, SPT and Marina Yusupova, SPT in 2011

Summary Date

4/26/2012 

Purpose

Assesses unilateral gross manual dexterity

Description

  • 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.

Area of Assessment

Activities of Daily Living; Coordination; Dexterity; Upper Extremity Function 

Body Part

Not Applicable 

ICF Domain

Activity 

Domain

Motor 

Assessment Type

Observer 

Length of Test

05 Minutes or Less 

Time to Administer

2-5 minutes

Number of Items

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)

Training Required

No Training

Type of training required

No Training 

Cost

Not Free 

Actual Cost

Commercially produced versions of the test can be purchased for approximately $200.00 (as of 2011)
 
 
 

Age Range

Child: 6-12 years; Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Multiple Sclerosis; Stroke; Traumatic Brain Injury 

Populations Tested

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

Standard Error of Measurement (SEM)

Acute and Chronic Stroke: (calculated from statistics in Chen et al, 2009; n = 62 volunteer participants who had sustained a stroke; mean age = 61 (9.9) years; median time post-stroke = 8 months)
 
(**Note: To calculate the Smallest Real Difference (SRD; aka Minimal Detectable Change MDC) the authors averaged the standard deviations from time points 1 & 2 rather than using the baseline standard deviation; thus, to calculate the SEM, an average standard deviation was used).
  • BBT More Affected Hand: SEM= 1.99
  • BBT Less Affected Hand: SEM= 2.84
  • BBT Spastic Group: SEM= 2.92
  • BBT Non-spastic Group: SEM= 2.23

Minimal Detectable Change (MDC)

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

  • MDC: 5.5 blocks per minute
  • Percentage change: 18%

Spastic Hemiplegia: (Siebers et al, 2010; n = 17 patients with spastic hemiplegia; median age = 54(22-67) years; 2 week training program; 6 month follow-up)

  • MDC for 2 week training program: 4 blocks per minute
  • MDC for 6 month follow-up: 6 blocks per minute

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Normal adults: (Mathiowetz et al, 1985; n = 310 normal adult males, 318 normal adult females; aged 20 and up) 

Average Number of Cubes Transferred in One Minute
Male Female
Age
Hand
Mean
SD
Mean
SD
40-44
R
83.0
8.1
81.1
8.2
L
80.0
8.8
79.7
8.8
45-49

R

76.9

9.2

82.1

7.5

 

L

75.8

7.8

78.3

7.6

50-54
R
79.0
9.7
77.7
10.7
L
77.0
9.2
74.3
9.9
55-59
R
75.2
11.9
74.7
8.9
L
73.8
10.5
73.6
7.8
60-64
R
71.3
8.8
76.1
6.9
L
70.5
8.1
73.6
6.4

65-69

R

68.5

7.1

72.0

6.2

 

L

67.4

7.8

71.3

7.7

70-74

R

66.3

9.2

68.6

7.0

 

L

64.3

9.8

68.3

7.0

75+

R

63.0

7.1

65.0

7.1

 

L

61.3

8.4

63.6

 

Normal children: (Mathiowetz et al, 1985; n = 471 normal children, 231 males, 240 females; age range =  6-19 years)

Average Number of Cubes Transferred in One Minute

Male

Female

Age

Hand

Mean

SD

Mean

SD

6-7

R

54.4

6.6

57.9

5.3

L

50.7

6.3

54.2

5.6

8-9

R

63.4

4.3

62.8

5.1

L

60.1

4.9

60.4

5.2

10-11

R

68.4

6.9

70.0

7.6

L

65.9

6.8

67.6

8.6

12-13

R

74.6

8.3

73.6

8.1

L

72.4

8.2

70.5

6.2

14-15

R

76.6

8.7

75.4

8.5

L

74.6

7.9

72.1

7.6

16-17

R

80.3

8.7

77.0

9.0

L

77.6

5.1

74.3

9.1

18-19

R

79.9

8.9

77.9

9.4

L

79.2

8.8

76.0

8.5

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)

Internal Consistency

Not Established

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)

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

R

R

R

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

R

R

R

R

R

StrokEDGE

R

R

R

R

R

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

R

R

R

R

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

Yes

Yes

No

StrokEDGE

No

Yes

Yes

Not reported

Considerations

Not Established
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Bibliography

Canny, M. L., Thompson, J. M., et al. (2009). "Reliability of the box and block test of manual dexterity for use with patients with fibromyalgia." Am J Occup Ther 63(4): 506-510. Find it on PubMed
 
Chen, H. M., Chen, C. C., et al. (2009). "Test-retest reproducibility and smallest real difference of 5 hand function tests in patients with stroke." Neurorehabil Neural Repair 23(5): 435-440. Find it on PubMed
 
Desrosiers, J., Bravo, G., et al. (1994). "Validation of the Box and Block Test as a measure of dexterity of elderly people: reliability, validity, and norms studies." Arch Phys Med Rehabil 75: 751-755. Find it on PubMed
 
Lin, K. C., Chuang, L. L., et al. (2010). "Responsiveness and validity of three dexterous function measures in stroke rehabilitation." J Rehabil Res Dev 47(6): 563-571. Find it on PubMed
 
Mathiowetz, V., Ferderman, S., et al. (1985). "Box and Block Test of Manual Dexterity: Norms for 6-19 Year Olds." Canadian Journal of Occupational Therapy. Revue Canadienne d'ergothérapie 52(5): 241-246.
 
Mathiowetz, V., Volland, G., et al. (1985). "Adult norms for the Box and Block Test of manual dexterity." Am J Occup Ther 39(3160243): 386-391. Find it on PubMed
 
Platz, T., Pinkowski, C., et al. (2005). "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 19(4): 404-411. Find it on PubMed
 
Platz, T., Vuadens, P., et al. (2008). "REPAS, a summary rating scale for resistance to passive movement: item selection, reliability and validity." Disabil Rehabil 30(1): 44-53. Find it on PubMed
 
Siebers, A., Oberg, U., et al. (2010). "The effect of modified constraint-induced movement therapy on spasticity and motor function of the affected arm in patients with chronic stroke." Physiother Can 62(4): 388-396. Find it on PubMed

Year published

1957 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 10/1/2015 1:19 PM  by Jason Raad