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Subject of the scale: Impairment: prehension

Box and Blocks Test (BBT)


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The BBT was created originally for adult patients with cerebral palsy, to be a measure of gross dexterity. This test was then validated in patients within the framework of a stroke, a CT, MS and other neurological disorders [5], such as Charcot Marie Tooth disease [14], and also in the elderly [7].

It has recently been evaluated in fibromyalgia [2].

This test was patented in 1957 by Patricia Buehler Holser and Elizabeth Fuchs.

It goes like this: The patient is seated at a table in front of him with a wooden box with 2 compartments of equal size (25 x 15 x 7.5 cm). At the beginning of the test, all coloured wooden cubes (150 in number, 2.5 cm edge) are placed in a compartment. The aim is to move the most cubes possible, cube after cube, from one compartment to another, in 60 seconds, and with one hand.
The examiner is opposite the patient.

The total score is the number of cubes located in the initially empty compartment. [1].

Norms in healthy [9] and healthy adult children were defined. And for adults under 50, the average score is higher than 80, between 50 and 70 years it is between 70 and 80, and for patients older than 70 years it is between 64 and 69 [1].

The total time for performing the test is less than 5 minutes. A complete kit costs about 250-300 Euros.

> Access to the scale is free

Psychometric properties:


Psychometric properties



Face validity


Content validity


Criterion validity

Concurrent validity

[3] [6] [8]

Predictive validity


Construct validity

Convergent validity

[7] [10]

Divergent validity

[7] [10]

Discriminant validity
(sensitivity and distinctiveness)

[7] [10]


Intra-rater reliability


Inter-rater reliability

[4] [9] [10]


[6] [7] [9] [10] [12]

Internal consistency (alpha)



[3] [8]

General comment on reliability:

Very good inter-judge reproducibility [10] and high test-retest reliability [4, 7, 10, 12].
The BBT has a sensitivity to change ranging from high [3] to moderate [8] as well as excellent concurrent validity with the ARAT.
It can effectively evaluate the function of paretic MS [3].
The ARAT also seems more appropriate for evaluating dexterity than the Nine Hole Peg Test [8].
The significant correlations between the BBT, upper limb performance and functional independence measurements show the validity of BBT [7].
Also strong correlations with ARAT and FMA but different ceiling and floor effects between these 3 tests [10].
The MDC (Minimal Change Detection, which is a statistical estimate of the smallest amount of change that can be detected by measuring and representing a significant change) is quite high: for the most affected side, 5.5 cubes / min and the least affected side 7.8 cubes/min [4].
A literature review was performed [5] to examine the psychometric properties and clinical utility of various assessment tools of the upper limbs in people with motor disabilities of neurological origin in order to provide recommendations for practice. Of a total of 31 tools identified, only two measures meet the psychometric properties and clinical utility criteria: the BBT and ARAT.
Among fibromyalgia patients, the BBT is a reliable measurement of upper extremity function and is able to reveal a reduction of upper limb function in these patients compared to healthy individuals and standard scores [2].

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For more details of the scale, the comments or the psychometric properties presented here, please contact Dr. Thibaud Honoré :


Inaugural references:

[1] Mathiowetz V, Volland G, Kashman N, Weber K. "Adult norms for the Box and Block Test of manual dexterity." Am J Occup Ther. 1985 Jun;39(6):386-91.

Psychometric references:

[2] Canny ML, Thompson JM, Wheeler MJ. "Reliability of the box and block test of manual dexterity for use with patients with fibromyalgia." Am J Occup Ther. 2009 Jul-Aug;63(4):506-10.

[3] Chanubol R, Wongphaet P, Ot NC, Chira-Adisai W, Kuptniratsaikul P, Jitpraphai C. "Correlation between the action research arm test and the box and block test of upper extremity function in stroke patients." J Med Assoc Thai. 2012 Apr;95(4):590-7.

[4] Chen HM, Chen CC, Hsueh IP, Huang SL, Hsieh CL.. "Test-retest reproducibility and smallest real difference of 5 hand function tests in patients with stroke." Neurorehabil Neural Repair. 2009 Jun;23(5):435-40. doi: 10.1177/1545968308331146. Epub 2009 Mar 4.

[5] Connell LA, Tyson SF. "Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review." Arch Phys Med Rehabil. 2012 Feb;93(2):221-8. doi: 10.1016/j.apmr.2011.09.015.

[6] Cromwell FS. "Occupational Therapist's Manual for Basic Skill Assessment; Primary Prevocational Evaluation". Altadena, CA: Fair Oaks Printing, 1976, pp 29-30c.

[7] Desrosiers J, Bravo G, Hébert R, Dutil E, Mercier L. "Validation of the Box and Block Test as a measure of dexterity of elderly people: reliability, validity, and norms studies." rch Phys Med Rehabil. 1994 Jul;75(7):751-5.

[8] Lin KC, Chuang LL, Wu CY, Hsieh YW, Chang WY. "Responsiveness and validity of three dexterous function measures in stroke rehabilitation." J Rehabil Res Dev. 2010;47(6):563-71.

[9] Paltamaa J, West H, Sarasoja T, Wikström J, Mälkiä E. "Reliability of physical functioning measures in ambulatory subjects with MS." Physiother Res Int. 2005;10(2):93-109.

[10] Platz T, Pinkowski C, van Wijck F, Kim IH, di Bella P, Johnson G. "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 Jun;19(4):404-11.

[11] Smith DA. "The Box and Block Test: Normative Datafor 7, 8, 9 Year-Old Children (master's thesis)". Los Angeles: Univ of Southern California, 1961.

[12] Svensson E, Häger-Ross C. "Hand function in Charcot Marie Tooth: test retest reliability of some measurements." Clin Rehabil. 2006 Oct;20(10):896-908.

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