Box and Block Test (BBT)

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
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