Box and Block Test (BBT): Reference Guide
Outcomes Research Committee Resource created by Rachel Rudolf & Barber Prosthetics
Introduction
The Box and Block Test (BBT) is an outcome measure used to assess and monitor unilateral
upper extremity manual dexterity1. It has been found to be a valid and reliable outcome
measure in a variety of populations including people with Cerebral Palsy1(CP), Fibromyalgia2,
Charcot-Marie-Tooth (CMT)3, Multiple Sclerosis4,8(MS), Stroke5,6,7,8,9,10, Traumatic Brain Injury
(TBI)5,8, traumatic upper extremity injury11, children12,13 and community-dwelling adults14,15,16.
Establishing author: Ayres and Holser1 Data Type: Ratio
Measurement Type: Performance-based Assessment Type: Observer
Required Resources
Time: ~5 minutes
Personnel: 1 clinician
Equipment: Standard table, chair, stopwatch, Box and Blocks kit
Space: Clinic room
Cost: One time cost of ~$200 to purchase Box and Block box, no cost to administer test
Test Administration
Box and Block set-up includes: a wooden box with dimensions 21.5” by 10.1” divided into two
equal compartments by a wooden partition with a height of 6.0”. The box should be opened
and placed on a table top in a horizontal orientation in front of the patient, who is seated in a
chair. All cubes of 1” are placed on one side of the partition and the patient is asked to transfer
as many blocks as they can in 60 seconds to the other side of the box1. The blocks must be
transferred one at a time, the patient must only use one hand and the hand should cross the
partition in the transfer. The score is indicated by the number of blocks that can be transferred
in 60 seconds. The patient should be given a minimum of 15 seconds to practice prior to
beginning the test and should start with the dominant hand. At least two trials should be done
for each hand and the score averaged.
For standardized instructions see [Link]
06/Box%20and%20Blocks%20Test%[Link].
Psychometric Properties
Reliability.
Excellent test-retest reliability was found in the populations with CMT3, children ages 3-1012,
stroke8,9, MS8, TBI8, and traumatic upper extremity injury or amputation (ICC=0.95-0.96, 0.85,
0.963, 0.98, and 0.91, respectively). Excellent interrater reliability was established for
populations with fibromyalgia2, children ages 3-1012, stroke8,9, MS8, TBI8 and adult16 (ICC = 0.85,
0.99, 0.993, respectively). Excellent intra-rater reliability was established for populations with
fibromyalgia (ICC=0.90)2.
Validity.
In community-dwelling adults, moderate correlation with the BBT was found with the 9HP,
NMSE, and MVPT-3 (r=0.357, 0.420, and 0.341, respectively)14. Construct validity was
established for populations with Fibromyalgia as the BBT is able to distinguish between the
control and fibromyalgia groups2. In children ages 3-10, there was a significant correlation with
the MABC-212. In pediatric populations with CP, there was a strong correlation with MACS (r=-
0.81)13. In populations with stroke, MS, and TBI, concurrent validity was found to have a strong
correlation with the following tests: Grip Strength (r=0.87)5, TEMPA (r=0.73-0.78)5, Fugl-Meyer
Assessment (motor) (r=0.91-0.92)5,8, Action Research Arm Test (r=0.64-0.95)8,5, Motricity Index
(r=0.798)5, UE STREAM (r=0.76)10, 9HP (r=-0.71)7, MAL-QOM (r=0.522)7, and SIS Hand Function
(r=0.52)7. Moderate correlation was found with the Fugl-Meyer Assessment (joint movement
and pain) (r=0.43)5, Barthel Index (r=0.44)5, FMA (r=0.35)7, and MAL-AUO (r=0.49)7. In the
traumatic upper extremity injury and/amputation group, there was a strong correlation with
the AM-ULA and a moderate correlation with the UNB skill and spontaneity (r=0.63 and 0.42-
0.43, respectively)11.
Responsiveness.
In populations with CMT, the MDC(95) has not been established, however, a change of 11.5
blocks/minute has been suggested3. In populations with MS, a deterioration MIC of between -
3.48 and -5.23 was noted4. The SRM was found to be between 0.67-0.74 in the stroke
population and 0.56 in other populations7,15. The SRD was found to be 5.5 blocks/minute in the
stroke population9. The MDC(95) was found to be 7.7 in the traumatic upper extremity injury
group11.
Interpretation
Table 1. Normative BBT data for ages 3-5
Mean
Age Hand SD Range
(blocks/minute)
Dominant 24.2 7.4 15-39
3 Non-
22.8 6.6 12-35
dominant
Dominant 35.7 7.3 16-45
4 Non-
34.1 8.8 11-49
dominant
Dominant 40.6 6.7 27-56
5 Non-
38.7 5.8 21-47
dominant
Gathered from sample of 215 participants aged 2-10 (101 Male, 114 Female)12
Table 2. Normative BBT data for ages 6-19
Male Female
Mean Mean
Age Hand SD Range SD Range
(blocks/minute) (blocks/minute)
R 54.5 6.6 48-77 57.9 5.3 44-68
6-7
L 50.7 6.3 36-67 54.2 5.6 43-67
R 63.4 4.3 55-76 62.8 5.1 53-76
8-9
L 60.1 4.9 53-71 60.4 5.2 52-71
R 68.4 6.9 53-81 70.0 7.6 52-85
10-11
L 65.9 6.8 52-82 67.6 8.6 54-91
R 74.6 8.3 57-92 73.6 8.1 57-89
12-13
L 72.4 8.2 58-87 70.5 6.2 55-83
R 76.6 8.7 61-94 75.4 8.5 61-94
14-15
L 74.6 7.9 57-86 72.1 7.6 58-88
R 80.3 8.7 62-101 77.0 9.0 50-92
16-17
L 77.6 5.1 71-87 74.3 9.1 54-91
R 79.9 8.9 58-96 77.9 9.4 56-94
18-19
L 79.2 8.8 60-93 76.0 8.5 51-90
1
Gathered from sample of 471 participants aged 6-19 (231 Male, 240 Female)
Table 3. Normative BBT data for adults
Male Female
Mean Mean
Age Hand SD Range SD Range
(blocks/minute) (blocks/minute)
R 88.2 8.8 70-105 88.0 8.3 67-103
20-24
L 86.4 8.5 70-102 83.4 7.9 66-99
R 85.0 7.5 71-95 86.0 7.4 63-96
25-29
L 84.1 7.1 69-100 80.9 6.4 63-93
R 81.9 9.0 68-96 85.2 7.4 75-101
30-34
L 81.3 8.1 69-99 80.2 5.6 66-92
R 81.9 9.5 64-104 84.8 6.1 71-95
35-39
L 79.8 9.7 56-97 83.5 6.1 72-97
R 83.0 8.1 69-101 81.1 8.2 60-97
40-44
L 80.0 8.8 59-93 79.7 8.8 57-97
R 76.9 9.2 61-93 82.1 7.5 68-99
45-49
L 75.8 7.8 60-88 78.3 7.6 59-91
R 79.0 9.7 62-106 77.7 10.7 56-94
50-54
L 77.0 9.2 60-97 74.3 9.9 54-85
R 75.2 11.9 45-97 74.7 8.9 56-94
55-59
L 73.8 10.5 43-94 73.6 7.8 54-85
R 71.3 8.8 52-84 76.1 6.9 60-82
60-64
L 70.5 8.1 47-82 73.6 6.4 61-89
R 68.4 7.1 55-80 72.0 6.2 60-82
65-69
L 67.4 7.8 48-86 71.3 7.7 61-89
R 66.3 9.2 50-86 68.6 7.0 53-80
70-74
L 64.3 9.8 45-84 68.3 7.0 51-81
R 63.0 7.1 47-75 65.0 7.1 52-79
75+
L 61.3 8.4 46-74 63.6 7.4 51-81
Taken from sample of 628 participants ages greater than 19 (310 Male, 318 Female). Peak
manual dexterity reached within age group of 20-2416.
Table 4. Average BBT scores for upper extremity amputees11
Average scores for Known-group
UE levels validity
Average
Level
(blocks/minute)
Transradial 13.4
Transhumeral 9.1
Shoulder 4.5
Limitations
As the focus of the BBT is primarily on grasp and release ability, this does not adequately assess
all domains within activities of daily living and thus limiting the applicability of the results11.
Documentation in Clinical Notes
Example: Jane has a transradial amputation. Last month she scored 59 blocks/minute with her
sounds hand and 8 blocks/minute with her old prosthesis. Today, Jane scored 61 blocks with
her sound side. This score falls below the mean of 73.6 blocks/minute but within the range of
54 – 85 blocks/minute for established age and gender normative values. On her affected side,
she scored 17 blocks. This score falls above the average of 13.4 blocks/minute for people with
transradial amputations. In comparison to her old prosthesis, there was a change of 9
blocks/minute. This is above the established MDC indicating that there was an improvement
with the new prosthetic device.
Acknowledgement: This document format was adapted from material published by The
Australian Orthotic and Prosthetic Association, Inc.
Disclaimer: The authors, Outcomes Research Committee, and the American Academy of
Orthotists and Prosthetists recommend use of outcome measures in routine clinical practice.
Selection of specific outcome measures should be based on the patient, setting, and
application. No recommendation of any particular outcome measure over another is made of
implied. The authors declare no conflict of interest in the presentation of this measure.
References
1. Mathiowetz, V., Federman, S., & Wiemer, D. (1985). Box and Block Test of Manual
Dexterity: Norms for 6–19 Year Olds. Canadian Journal of Occupational Therapy, 52(5),
241–245. [Link]
2. Canny, M. L., Thompson, J. M., & Wheeler, M. J. (2009). Reliability of the Box and Block
Test of Manual Dexterity for use with patients with fibromyalgia. American Journal of
Occupational Therapy, 63(4), 506–510. [Link]
3. Svensson, E., & Häger-Ross, C. (2006). Hand function in Charcot-Marie-Tooth: Test-
retest reliability of some measurements. Clinical Rehabilitation, 20(10), 896–908.
[Link]
4. Paltamaa, J., Sarasoja, T., Leskinen, E., Wikstrom, J., & Malkia, E. (2008). Measuring
Deterioration in International Classification of Functioning Domains of People With
Multiple Sclerosis Who Are Ambulatory. Physical Therapy, 88(2), 176–190.
[Link]
5. Connell, L. A., & Tyson, S. F. (2012). Clinical reality of measuring upper-limb ability in
neurologic conditions: A systematic review. Archives of Physical Medicine and
Rehabilitation. [Link]
6. Park, J.-H., & Park, J.-H. (2016). The effects of game-based virtual reality movement
therapy plus mental practice on upper extremity function in chronic stroke patients with
hemiparesis: a randomized controlled trial. Journal of Physical Therapy Science, 28(3),
811–815. [Link]
7. Lin, Keh-chung, Chuang, Li-ling, Wu, Ching-yi, Hsieh, Yu-wei, Chang, W. (2010).
Responsiveness and validity of three dextrous function measures in stroke
rehabilitation. Journal of Rehabilitation Research and Development, 47(6), 563–572.
8. 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. [Link]
9. Chen, H. M., Chen, C. C., Hsueh, I. P., Huang, S. L., & Hsieh, C. L. (2009). Test-retest
reproducibility and smallest real difference of 5 hand function tests in patients with
stroke. Neurorehabilitation and Neural Repair, 23(5), 435–440.
[Link]
10. Ahmed, S., Mayo, N. E., Higgins, J., & Salbach, N. M. (2003). The Stroke Rehabilitation
Assessment of Movement (STREAM): A Comparison With Other Measures Used to
Evaluate Effects of Stroke and Rehabilitation. Physical Therapy, 83(7), 617–630.
[Link]
11. Resnik, L., & Borgia, M. (2017). Systematic Review of Measures of Impairment and
Activity Limitation for Persons With Upper Limb Trauma and Amputation. Archives of
Physical Medicine and Rehabilitation, 98, 1863–1892.e14.
[Link]
12. Jongbloed-Pereboom, M., Nijhuis-Van Der Sanden, M. W. G., & Steenbergen, B. (2013).
Norm scores of the box and block test for children ages 3-10 years. American Journal of
Occupational Therapy, 67(3), 312–318. [Link]
13. Ohrvall, A.-M., Krumlinde-Sundholm, L., & Eliasson, A.-C. (2013). Exploration of the
relationship between the Manual Ability Classification System and hand-function
measures of capacity and performance. Disability & Rehabilitation, 35(11), 913–918.
[Link]
14. Song, C.-S. (2015). Relationship between visuo-perceptual function and manual
dexterity in community-dwelling older adults. Journal of Physical Therapy Science, 27(6),
1871–1874. [Link]
15. Julien, M., D’Amours, J., Leduc, M. P., Côté, A. C., Oziel Rodier, R., Demers, L., &
Desrosiers, J. (2017). Responsiveness of the Box and Block Test with Older Adults in
Rehabilitation. Physical and Occupational Therapy in Geriatrics, 35(3–4), 109–118.
[Link]
16. Mathiowetz, V., Volland, G., Kashman, N., & Weber, K. (1985). Adult norms for the Box
and Block Test of manual dexterity. The American Journal of Occupational Therapy. :
Official Publication of the American Occupational Therapy Association, 39(6), 386–391.
[Link]
Box and Blocks Test (BBT): Reference Guide
Outcome Measure
Box and Blocks Test (BBT)
Instrument Review Version
v1.0
Version Date
September 1, 2019
Instrument Review Authors
Rachel Rudolf & Barber Prosthetics
All requests for additional information and any recommended updates/corrections to the
content may be directed to:
Tyler Klenow, MSOP, MBA, LCPO, FAAOP
Outcomes Research Committee
Attn: Outcome Measurement “How-To” Video Series
Phone: (202) 380-3663
Fax: (202) 380-3447
Website: [Link]
Email: orc@[Link]
