Box and Block Test (BBT)

Evidence Reviewed as of before: 09-06-2011
Author(s): Sabrina Figueiredo, BSc
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

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.

In-Depth Review

Purpose of the measure

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.

Available versions

The original version of the BBT was developed, in 1957, by Jean Hyres and Patricia Buhler. This version was modified into the current one by E. Fuchs and P. Buhler (Cromwell, 1976). In 1985, normative data on the BBT was established by Mathiowetz, Volland, Kashman, and Weber.

Features of the measure

Items:

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 (Mathiowetz, Volland, Kashman, & Weber, 1985-1).

Scoring:

Clients are scored based on the number of blocks transferred from one compartment to the other compartment in 60 seconds (Mathiowetz et al., 1985-1). 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.

Mathiowetz et al. (1985-1) reported that healthy male adults, aged 20 to 80 years, transfer an average of 77 blocks (SD ±11.6) with the right hand and 75 blocks (SD ±11.4) with the left hand within the 60 second limit. Scores for normal healthy men, aged 60 years old or more ranged from 61 to 70 blocks. Healthy female adults, aged 20 to 80 years, transfer an average of 78 blocks (SD ±10.4) with the right hand and 76 blocks (SD ±9.5) with the left hand. Scores for normal healthy women, aged 60 years old or more, ranged from 63 to 76 blocks. The score on the BBT and age are inversely correlated, meaning that average scores on the BBT decrease with older age.

Time:

The BBT requires 2 to 5 minutes to administer (Finch, Brooks, Stratford, & Mayo, 2002; Mathiowetz et al., 1985-1).

Subscales:

None.

Equipment:

The standardized equipment consists of:
A wooden box dimensioned in 53.7 cm x 25.4 cm x 8.5 cm. The partition should be placed at the middle of the box, dividing it in two containers of 25.4 cm each. (Mathiowetz et al., 1985-1).
150 wooden cubes – 2.5 cm in size (Mathiowetz et al., 1985-1). Stopwatch.

Training of administrator:

None typically reported.

Alternative forms of the Box and Block Test

None.

Client suitability

Can be used with:

  • Clients with stroke.

Should not be used in:

  • The BBT cannot be used with clients who have severe upper extremity impairment.
  • The BBT cannot be used with clients with severe cognitive impairment.

In what languages is the measure available?

There are no official translations of the BBT. The specific instructions provided to the client are in English. Clinicians and researchers may be using “home-grown” translations of the instructions as evidenced from peer-reviewed publication from Sweden, French Canada, Italy and Germany that have used the BBT as an outcome measure. (Broeren, Rydmark, Bjorkdahl, & Sunnerhagen, 2007; Dannenbaun, Michalsen, Desrosiers, & Levin, 2002; Mercier & Bourbonnais, 2004; Platz, Pinkowski, Kim, di Bella, & Johnson, 2005; Schneider, Schonle, Altenmuller, & Munte, 2007).

Summary

What does the tool measure? Unilateral gross manual dexterity.
What types of clients can the tool be used for? The BBT can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer From 2 to 5 minutes.
Versions There are no alternative versions.
Other Languages There are no official translations.
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the BBT.
  • Two studies have examined the test-retest reliability of the BBT. Both reported excellent test-retest reliability using ICC’s.
  • Two studies have examined the inter-rater reliability of the BBT and reported excellent inter-rater reliability using correlation coefficients and ICC.
  • One study used Pearson correlation and the other, ICC and Spearman rho correlation.
Validity

Criterion:

Predictive Validity:

One study has examined predictive validity and reported that the BBT, compared to the Nine-Hole Peg Test (NHPT), the Frenchay Arm Test, Grip Strength and the Stroke Rehabilitation Assessment of Movement (STREAM) was the best predictor of upper limb function 5 weeks post-stroke.

Concurrent:

One study has examined the concurrent validity of the BBT and reported adequate to excellent correlations with the Action Research Arm Test (ARAT) and the NHPT at pre and post-treatment.

Construct:

Convergent validity:

Three studies have examined convergent validity of the BBT and reported excellent correlations between the BBT and the Minnesota Rate of Manipulation Test, the ARAT, the Hemispheric Stroke Scale and the motor function score of the Fugl-Meyer Assessment (FMA). Adequate correlations were reported between the BBT and the SMAF, the Ashworth scale and the Passive Joint Motion/Joint Pain subscore of the FMA. Poor correlations were reported between the BBT and the Sensation subscore of the FMA and the Modified Barthel Index.

Floor/Ceiling Effects No studies have examined floor/ceiling effects of the BBT
Sensitivity/ Specificity No studies have examined sensitivity/specificity of the BBT
Does the tool detect change in patients?

Two studies have examined the responsiveness of the BBT and reported that the BBT has moderate to large Standardized Response Mean, therefore, is able to detect change in clients with stroke.

Acceptability The BBT should not be used clients with severe upper extremity impairment and severe cognitive impairments.
Feasibility The administration of the BBT is quick and simple, however requires standardized equipment.
How to obtain the tool?

The BBT instructions can be obtained in the study by Mathiowetz et al. (1985)

Standardized equipment can be obtained at the website:
http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=7531

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Box and Block Test (BBT) in healthy individuals and individuals with stroke. We identified four studies. The BBT appears to be responsive in clients with stroke.

Floor/Ceiling Effects

No studies have examined floor/ceiling effects of the BBT.

Reliability

Test-retest:
Desrosiers, Bravo, Hebert, Dutil, and Mercier (1994) examined test-retest reliability of the BBT in 34 elderly with upper limb sensorimotor impairments from stroke (n=13) and other conditions. Participants were re-assessed with a 1-week interval by the same rater and under the same conditions. The test-retest reliability for the BBT was reported as excellent (ICC = 0.97; ICC = 0.96) for the right and left hand, respectively.

Platz, Pinkowski, van Wijck, Kim, di Bella, and Johnson (2005) estimated test-retest reliability of the BBT, the Action Research Arm Test (Lyle, 1981), and the Fugl-Meyer Assessment (FMA) upper extremity items including items from the motor function, sensation and passive joint motion/joint pain sub-scores, (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) in 23 participants with upper extremity paresis either from stroke, multiple sclerosis, or traumatic brain injury. The participant’s most affected arm was re-assessed after a 1-week interval by the same rater. The test-retest reliability of the BBT, as calculated using ICC’s and Spearman rho correlation, was excellent (ICC = 0.96 and r = 0.97).

Note: This result applies only to the most affected upper limb.

Inter-rater:
Mathiowetz, Volland, Kashman, and Weber (1985-1) assessed the inter-rater reliability of the BBT in 26 healthy young females. Participants were evaluated simultaneously and independently by two raters. Pearson correlationcoefficients showed excellent agreement (r = 1.00; r = 0.99) for the right and left hand, respectively.

Note: Pearson correlation coefficient is not the statistical analysis of choice for assessing inter-rater reliability as it may artificially inflate agreement.

Platz et al. (2005) as described earlier also analyzed inter-rater reliability of the BBT, the Action Research Arm Test (Lyle, 1981), and the FMA upper extremity items including items from the motor function, sensation and passive joint motion/joint pain sub-scores (Fugl-Meyer et al., 1975) in 44 individuals with upper limb paresis either from stroke, multiple sclerosis, or traumatic brain injury. Participants had the most affected arm videotaped and scored independently by two raters. Inter-rater reliability for the BBT, as calculated using the ICC and Spearman rho correlation, was excellent (ICC = 0.99 and r = 0.99).

Note: This result applies only to the most affected upper limb.

Validity

Content:

Not available.

Criterion:

Concurrent:
No gold standard exists against which to compare the BBT.

Lin, Chuang, Wu, Hsieh and Chang (2010) compared the concurrent validity of the BBT, Action Research Arm Test (ARAT) and Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with stroke. The Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL) and Stroke Impact Scale (SIS) were also administered to assess the concurrent validity of the BBT, ARAT and NHPT. Using Spearman rank correlation coefficient, the BBT, ARAT and NHPT were found to have adequate to excellent correlations at pre-treatment (ranging from rho=-0.55 to -0.80) and post-treatment (ranging from rho=-0.57 to -0.71). In addition, the BBT and ARAT were found to have adequate correlations with the FMA, MAL and SIS (ranging from rho=0.31-59); however, the NHPT had only poor to adequate correlations with the FMA and MAL (ranging from rho=-0.16 to -0.33); and adequate to excellent correlations with the SIS (ranging from rho=-0.58 to -0.66). When considering both the results of responsiveness and validation components of the study, the BBT and ARAT are believed to be more appropriate than the NHPT for evaluating dexterity.

Predictive:
Higgins, Mayo, Desrosiers, Salbach and Ahmed (2005) estimated wheter the BBT, Nine-Hole Peg Test (Kellor, Frost, Silberberg, Iversen, & Cummings, 1971; Mathiowetz, Weber, Kashman, & Volland, 1985-2), Frenchay Arm Test (Heller, Wade, Wood, Sunderland, Hewer, & Ward, 1987), Grip Strength (Mathiowetz, Kashman, Volland, Weber, Dowe, & Rogers, 1985-3), and Stroke Rehabilitation Assessment of Movement (STREAM – Daley, Mayo, Wood-Dauphine, Danys, & Cabot, 1997) were able to predict upper limb function, measured by the BBT, at 5 weeks post-stroke. Predictive validity of the BBT was measured in 55 participants with acute stroke. Assessments were performed at two points in time: one and five weeks post-stroke. Compared to the other upper limb performance tests, the BBT when performed at one week post-stroke, was the best predictor of upper limb function at five months post-stroke, followed by the STREAM.

Construct:

Convergent/Discriminant:
Cromwell (1976) examined the convergent validity of the BBT by comparing it to the Minnesota Rate of Manipulation Test (American Guidance Service, 1969) in an unspecified population. The correlation between BBT and the Minnesota Rate of Manipulation Test was excellent (r = 0.91).

Desrosiers et al. (1994) assessed the convergent validity of the BBT by comparing it to the Functional Autonomy Measurement System – FAMS, known as the SMAF in French (Hebert, Carries, & Bilodeau, 1988), and to the Action Research Arm Test (ARAT – Lyle, 1981) in 104 elderly with upper limb impairments secondary to stroke (n=53) amongst other conditions. Excellent correlations (r = 0.80) were found between the BBT and the ARAT. Adequate pearson correlations were found between the BBT and the FAMS (r = 0.47; r = 0.51) for the right and left hand, respectively.

Platz et al. (2005) tested the convergent validity of the BBT by comparing it to the Action Research Arm Test (ARAT Lyle, 1981) and to the Fugl-Meyer Assessment (FMA)upper extremity items including items from the motor function, sensation and passive joint motion/joint pain sub-scores (Fugl-Meyer et al., 1975) using Spearman Correlation, in 56 participants with upper extremity paresis either from stroke (n=37) or other conditions. Excellent correlations were found between the BBT and the ARAT (r = 0.95) and the Motor Function sub-score (r = 0.92) of the FMA. Furthermore, the BBT was correlated with more general measures of impairment and activity limitation, such as the Ashworth Scale (Ashworth, 1964), the Hemispheric Stroke Scale (Adams, Meador, Sethi, Grotta, & Thomson, 1986) and the Modified Barthel Index (Collin, Wade, Davies, & Horne, 1988). Excellent correlation was found between the BBT and the Hemispheric Stroke Scale (r = -0.67). Adequate correlations were found between the BBT and the passive joint motion/joint pain sub-score of the FMA (r = 0.43) and the Ashworth Scale (r = -0.38). Poor correlations were found between the BBT and the sensation sub-score of the FMA (r = 0.28) and the Modified Barthel Index (r = 0.04).

Note: Negative correlations are observed because a high score on the BBT indicates better performance, whereas a low score on the Hemispheric Stroke Scale or the Ashworth Scale indicates better performance.

Known groups:
No studies have examined known groups validity of the BBT.

Responsiveness

Higgings et al. (2005) evaluated the responsiveness on the BBT, Frenchay Arm Test (Heller et al., 1987), Grip strength (Mathiowetz et al., 1985-3) and the Stroke Rehabilitation Assessment of Movement (STREAM – Daley et al., 1997) in 50 participants with acute stroke. Participants were assessed one and four weeks post-stroke. The Standardized Response Mean (SRM) was used to calculate responsiveness. Amongst these upper extremity performance tests, the BBT was the most sensitive to detecting change, having a large SRM of 0.8.

Note: SRM is a variant of effect size and higher values indicate better responsiveness.

Lin, Chuang, Wu, Hsieh and Chang (2010) evaluated the responsiveness of the BBT, the Action Research Arm Test (ARAT) and the Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with subacute stroke (< 6-months) and Brunnstrom stage IV to VI for proximal and distal upper extremity function. Patients were randomly assigned to receive constraint-induced therapy, bilateral arm training or control treatment and received 2 hours of therapy, 5 days per week for 3 weeks. Assessments were performed at baseline and 3 weeks. Using Standardized Response Mean (SRM) to calculate responsiveness, the BBT, ARAT and NHPT were all found to have moderate SRM (0.74, 0.64, 0.79 respectively), indicating sensitivity for detecting change in hand dexterity. When considering both the results of responsiveness and validation components of the study, the BBT and ARAT are believed to be more appropriate than the NHPT for evaluating dexterity.

References

  • American Guidance Service. The Minnesota Rate Manipulative Tests. Examiner’s manual. Circle Pines, (MN): Author; 1969.
  • Adams, R.J., Meador, K.J., Sethi, K.D., Grotta, J.C., & Thomson, D.S. (1986). Graded neurologic scale for the use in acute hemispheric stroke treatment protocols. Stroke 18, 665-669.
  • Ashworth, B. (1964). Preliminary trial of carisoprodol in multiple sclerosis. Practitioner, 192, 540-542.
  • Broeren, J., Rydmark, M., Bjorkdahl, A., & Sunnerhagen, K.S. (2007). Assessment and training in a 3-dimensional virtual environment with haptics: a report on 5 cases of motor rehabilitation in the chronic stage after stroke. Neurorehabilitation & Neural Repair, 21(2), 180-189.
  • Collin, C., Wade, D.T., Davies, S., & Horne, V. (1988). The Barthel ADL Index: a reliability study. International Disability Study, 10, 61-63.
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  • Dannenbaum, R.M., Michaelsen, S.M., Desrosiers, J., & Levin, M.F. (2002). Development and validation of two new sensory tests of the hand for patients with stroke. Clinical Rehabilitation, 16(6), 630-639.
  • Desrosiers, J., Bravo, G., Hébert, R., Dutil, É., & Mercier, L. (1994). Validation of the box and block test as a measure of dexterity of elderly people: reliability, validity and norms studies. Archives of Physical Medicine and Rehabilitation, 75, 751-755.
  • Desrosiers, J., Rochette, A., Hebert, R., & Bravo, G. (1997). The Minnesota manual dexterity test: reliability, validity and reference values studies with healthy elderly People. Canadian Journal of Occupational Therapy, 64(5), 270-276.
  • Finch, E., Brooks, D., Stratford,P.W, & Mayo, N.E. (2002). Physical Outcome Measures: A guide to enhance physical outcome measures. Ontario, Canada: Lippincott, Williams & Wilkins.
  • Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13-31.
  • Hébert, R., Carrier, R., & Bilodeau, A. (1988). The functional autonomy measurement system (SMAF): description and validation of an instrument for the measurement of handicaps. Age Ageing, 17, 293-302.
  • Heller, A., Wade, D.T., Wood, V.A., Sunderland, A., Hewer, R., & Ward, E. (1987). Arm function after stroke: measurement and recovery over the first three months. Journal of Neurology, Neurosurgery & Psychiatry, 50(6), 714- 719.
  • Higgins, J., Mayo, N.E., Desrosiers, J., Salbach, N.M., & Ahmed, S. (2005). Upper-limb function and recovery in the acute phase poststroke. Journal of Rehabilitation Research & Development, 42(1), 65-76.
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  • Kellor, M., Frost, J., Silberberg, N., Iversen, I., & Cummings R. (1971). Hand strength and dexterity. American Journal of Occupational Therapy, 25, 77-83.
  • Lin, K-C., Chuang, L-L., Wu, C-Y., Hseih, Y-W. & Chang, W-Y. (2010). Responsiveness and validity of three dexterous function measures in stroke rehabilitation. Journal of Rehabilitation Research and Development, 47(6), 563-572.
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  • Mathiowetz, V., Weber, K., Kashman, N., & Volland, G. (1985-2). Adult norms for the nine hole peg test of finger dexterity. Occupational Therapy Journal of Research, 5, 24 -33.
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  • Platz, T., Pinkowski, C., van Wijck, F., Kim, I.H., di Bella, P., & Johnson, G. (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. Clinical Rehabilitation, 19(4), 404-411.
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See The Measure

How to obtain the BBT

The BBT instructions can be obtained in the study by Mathiowetz et al. (1985)

Standardized equipment can be obtained at the website:
http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=7531

By clicking here, you can access a video showing how to administer the assessment.

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