GMT Vol. 52 No. 5

Box and Block Test of Wan al Dex, Norms for 6-19 Year Olds

by Virgil Mathiowetz, Susan Federman and Diana Wiemer

Occupational therapists frequently evaluate and treat persons with deficits in manual dexterity. Therefore, it is essential for occupa-tional therapists to have objective tools to measure an individual's level of dexterity skill. The Box and Block Test (Trombly, 1983) is one tool that has been suggested for measuring gross or manual dexteri-ty. However, there is limited nor-mative data for individuals age 6-19 years which makes interpretation of the test difficult for these ages.

According to Smith (1961) the Box and Block Test was designed by

Virgil Mathiowetz, M.S., 0.T.R., Assistant Professor, Department of Occupational Therapy, College of St. Catherine, 2004 Randolph, St. Paul, MN 55105. He was formerly Assistant Professor, Occupational Therapy Program, University of Wisconsin-Milwaukee, Milwaukee, WI. Susan M. Federman, 0.T.R. and Diana M. Wiemer, 0.T.R. were Senior occupational therapy students, University of Wisconsin-Milwaukee, Milwaukee, WI at the time of the study. Diana M. Wiemer is presently staff occupa-tional therapist at the Milwaukee County Mental Health Complex, Milwaukee, WI 53266.

Ayres and Holser to evaluate the gross manual dexterity of adults with cerebral palsy. It was later changed and copyrighted in its pre-sent form in 1957 by Holser (cur-rently Buehler) and Fuchs. The test was designed to be durable and sim-ple enough that persons with severe dexterity deficits could be tested.

Therapists should be certain that the test

measures the abilities they are trying to

quantify.

Test-retest reliability at six month intervals has been reported as a rho coefficient of .976 and .937 for the right and left hands respectively (Cromwell, 1976). Inter-rater reliability produced correlations of r = 1.000 and r = .999 for the right and left hands respectively (Mathiowetz, Volland, Kashman, & Weber, 1985). Concurrent validity

of the Box and Block Test has been supported by a previous study which correlated it with the Minnesota Rate of Manipulation Test (placing subtest) at r = .91 and with the General Aptitude Test Battery (Part 10) with r = .86 (Cromwell, 1976). These correlations would indicate these three tests measure similar types of dexterity. Therefore therapists who use the Minnesota Rate of Manipulation Test might consider the Box and Block Test as an alternative measure of manual dexterity.

In selecting the Box and Block Test for evaluation, therapists should be certain that the test measures the abilities they are trying to quantify. Through research, Henry (1968) found that there were many different types of dexterity and that a slight change in a task may require a different type of dex-terity. This conclusion is in contrast wit h t he occupational therapy literature which typically suggests there are two types of dexterity: gross and fine (Hopkins & Smith, 1983). Fleischman (1964) identified five types of dexterity and defined

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manual dexterity as, "the ability to make skillful, well-directed, arm-hand movements in manipulating fairly large objects under speed con-ditions." In Fleishman's study, the Minnesota Rate of Manipulation Test (placing and turning subtests) was found to be the best measure of this ability. Since the blocks of that test and the Box and Block Test are similar in size and the two tests cor-relate highly (r = .91) with each other (Cromwell, 1976), it would appear that either test could be used to measure manual dexterity.

Related to dexterity is the issue of hand dominance or manual laterali-ty. These terrns refer to the tendency of an individual to preferentially use the same hand in voluntary motor acts. The assumption that an indivi-dual is more dextrous with their dominant than nondominant hand was generally true for right handers but not for left handers (Benton, Meyers, & Polder, 1962; Mathiowetz, Volland, et al., 1985) In both studies, left-handed subjects, aged 16-75 + years were less lateralized than right-handed subjects when asked to perform tests of manual dexterity. In fact. left-handed sub-jects often performed better with their right or nondominant hand A third study (Mendell, Nelson, & Cermak, 198a) demonstrated similar results of diminished lateralization in left-handed children, ages five and seven years. However, an increase in lateraliz,- tion was shown at age nine when there was virtually no difference in degree of lateralization between right-handed and left-handed sub-jects. Thus most subjects with the exception of these nine year olds were less lateralized with their left hands than their right hands. This third study primarily used writing skills as an indicator of hand dominance. Roszkowski & Smelbecker (1981) evaluated 15 dif-ferent tasks to determine which tasks correlated most highly with hand dominance. They found that for individuals, 9 to 18 years old, the highest task correlations were drawings (r = .87), hammer (r = .86), and writing (r = .86). Thus their study would support the use of

writing as an indicator o hand dominance.

The Box and Block Test can be used as a measure of manual dex-terity and can provide one indica-tion of hand dominance. In 1961, normative data were collected on seven, eight, and nine year old children (Smith, 1961). Data has also been collected on normal adults (Mathiowetz, Volland et al., 1985)

and adults with neuromuscular involvement (Cromwell, 1976). However, there is limited normative data for the Box and Block Test for individuals age 6-19 years. There-fore, the primary purpose of this study was to collect normative data on the Box and Block Test for these ages. The secondary purpose of this study was to describe the effects of age, sex, and hand dominance on manual dexterity.

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Methods

Subjects This study included 471

volunteers (231 males and 240 females) aged 6 to 19 years. Sub-jects, aged 6-17 years, were required to have signed parental consent prior to participation in the study. Subjects were recruited from schools within the seven county Milvvaukee area which included ur-ban, suburban, and rural areas. Male and female subjects were divided into seven, two year age groups (Table 1). All subjects reported that they were free from disease or injury that could affect their upper extremity dexterity or strength. Individuals identified as learning disabled by their teachers were excluded from the study. This study was part of a larger study of hand strength and dexterity (Mathiowetz, Wiemer, & Federman, in press). The Box and Block Test was administered first, followed by four tests of hand strength.

Description of Test The Box and Block Test consisted

of a wooden box 53.7 cm by 25.4 cm which was divided into two equal compartments by a 15.2 cm high partition. The subject was in-structed to transfer as many 2.5 cm cubes as possible from one compart-ment to the other in one minute. The subject's score was the number of cubes transferred in one minute.

Procedures

After a brief interview to evaluate whether subject criteria were met, subjects were asked, "Are you right-handed or left-handed?" If the subjects reported that they were unsure as was the case with some younger subjects, the writing hand was used as the indicator of hand dominance.

Complete Box and Block Test construction information and admi-nistration procedures have been reported (Mathiowetz, Volland et al., 1985). However, one adaptation of the standardized procedures was made in the case of small children.

Booster seats were used to increase their sitting height so that their chins were at least 10.15 cm (four inches)

There is a steady increase in scores from

age six to nineteen.

above the middle partition of the test while sitting erect. This height was selected after observation and feedback from several children determined the minimal height necessary to achive optimal perfor-mance.

Results As would be expected, the highest

scores were achieved by the oldest subjects and the lowest scores were achieved by the youngest subjects. There was a steady increase in scores from age 6 to 19 (Table 2). When adult norms for the Box and Block Test (Mathiowetz, Volland et ai., 1985) were added to the norms from this study (Figure 1) it is clear that maximal performance occurs in the 20 to 24 year old age groups for both males and females. Figure I also demonstrates that performance gradually decreases with age after the 20-24 year age groups.

When male scores were compared to female scores, females generally scored better than males from age six to eleven. From age 12 to 19 the male scores were slightly higher than the female scores. Subjectively it ap-peared that adolescent males were more competitive than adolescent females which may account for their slightly better performance.

On average, right-handed sub-jects performed better with their dominant hand, while left-handed subjects performed better with their nondominant hand (Table 3). Clear-ly right-handed subjects were more lateralized than left-handed sub-jects. Since left-handers generally scored better with their right hands, data for left hand dominant subjects were combined with the data for right-hand dominant subjects in Table 2. The normative data col-lected for the Box and Block Test was compared to the normative data collected by Smith (1961) for seven to nine year olds. The mean scores for this study averaged 3.4 blocks /mi ute less than the Smith study.

Discussion The trend of hnproving perform-

ance from age 6 to 19 years was expected based on recent studies on the Purdue Pegboard (Gardner & Broman, 1979; Mathiowetz,

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Rogers, Dowe, Donahoe, Rennells in press). The curvilinear relation-ship between age and dexterity (Figure 1), would suggest the need for norms stratified by age. Most dexterity tests have generalized "adult" norms which are frequently applied to both adolescents and the elderly. This practice should be questioned in light of the results of this and other recent studies.

There were several differences between this study and Smith's study which may account for the variance in scores. For example, Smith grouped her subjects' scores according to dominant and non-dominant hands (right hand of right-handers combined with left hand of left-handers) whereas this study grouped subjects as "right" and "left" regardless of hand dominance. Smith used a 60 second practice trial before testing whereas this study used 15 seconds. With adults (Mathiowetz, Volland et al., 1985) the shorter practice trial did not affect scores. However, with children the extra practice may have improved scores. Other possible variables include geographical dif-ferences (Southwest vs. Midwest), year differences (1961 vs. 1984), or differences in blocks used (sanded hardwood vs. colored blocks).

Future research should systemati-cally address hand dominance,

block, year, anci geographic dif-ferences, as possible variables that might affect test scores. The latter is particularly important since the nor-mative data for this study was col-lected in a small geographic area. In addition research should assess whether manual dexterity tests as the Box and Block Test or Min-nesota Rate of Manipulation Test correlate with functional activities (e.g. self-care, homemaking, work and leisure) when performed by individuals with impaired dexterity. Currently it is assumed that per-formance on dexterity tests cor-relates highly with performance of functional activities. This relation-ship needs to be documented. Other research should evaluate the effec-tiveness of occupational therapy activities for improving manual dex-terity.

There are several advantages to the Box and Block Test. First, it is very easy to construct and cost is minimal. Blocks may be purchased commercially if a clinic does not already have them. Second, the test has general applicability to indivi-duals with limited cognitive ability, short attention span, or poor endur-ance. Finally the standardized sit-ting position is an advantage in con-trast to the Minnesota Rate of Manipulation Test which uses the standing position, since many pa-

tients seen in Occupational Therapy have difficulty or are unable to stand.

A disadvantage of the Box and Block Test was the amount of noise it made during testing. This was par-tially alleviated by placing self-adhesive foam cushions on the bot-tom (outside) of the test box and on the bottom (inside) of the box used to count the blocks.

Summary The Box and Block Test is a sim-

ple, inexpensive, and effective method for measuring manual dex-terity. It is well suited for children as well as adults because of the simple instructions and brief time of administration. With the normative data presented here, therapists can objectively assess their patients level of manual dexterity. This test should also be useful in assessing the effectiveness of treatment programs designed to improve manual dexter-ity.

REFERENCES Benton, Al. L., Meyers, R., & Polder, G.J.

(1962). Some aspects of handedness. Psychiathia et Neurologia, 144, 321-377.

Cromwell, F.S. (1976). Occupational Therapist's Manual for Basic Skill Assess-ment; Primary Prevocational Evaluation. Altadena, CA: Fair Oaks Printing Co.

Fleischman, E.A. (1964). The Structure and Measurement of Physical Fitness. Englewood Cliffs, NJ: Prentice-Hall.

Gardner, R.A., & Broman, M. (1979). The Purdue Pegboard: Normative data on 1334 school children. Journal of Clinical Child Psychology, Fall, 156-162.

Henry, F.M. (1968). Classical Studies on Phy.sical Activities. Englewood Cliffs, NJ: Prentice-Hall.

Hopkins, H.L., & Smith, H.D. (Eds). (1983). Willard and Spackman's Occupational Therapy (6th edition). Philadelphia, PA: J.P. Lippincottt Co.

Mandell, R.J., Nelson, D.L., & Cermak, S.A. (1984). Differential laterality of hand function in right-handed and left-handed boys. American Journal of Occupational Therapy, 38, 114-120.

Mathiowetz, V., Rogers, S.L., Dowe, M., Donahoe, L., & Rennells, C. (in press). The Purdue Pegboard: Norms for 14 to 19 year olds. American Journal of Occupa-tional Therapy.

Mathiowetz, V., Volland, G., Kashman, N., & Weber, K. (1985). Adult norms for the Box and Block Test of manual dexterity. American Journal of Occupational Therapy, 39, 386-391.

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Mathiowetz, V., Wiemer, D.M., & Federman, S.M. (in press). Grip and pinch strength: Norms for 6 to 19 year olds. American Journal of Occupational Therapy.

Roszkowski, M., & Snelbecker, G. (1981). Children's, adolescents', and adults' report of hand preference: Homogeneity and discriminating of selected tasks. Journal of Clinical Neuropsychology, 3, 199-213.

Smith, D.A. (1961). The Box and Block Test: Normative data for 7, 8, 9 year old children. Unpublished master's thesis,

University of Southern California, Los Angeles, Ca.

Trombly, C.A. (1983). Occupational Therapy for Physical Dysfunction (2nd edition). Baltimore, MD: Williams and Wilkins

Acknowledgements The authors wish to thank Franklin Stein, Ph.D., and James McPherson, M.S., for

research and statis:ical consultation; Cary Backman (Nicolet High School), Jean Bar-tow (Riverside High School), Eileen Wastak (Hartford Avenue School), Jeanne Johns (Templeton Middle School), Mary Beth Ahmed, and Dewey Snart (Maple Elementary School) for coordinating the study at their schools; Mary Dowe, Lori Donahoe, Sandra Rogers, Cheryl Rennells, and Kelly Beauchene for assisting in data collection; and the students for participating in the study.

Rsum Cette tude a eu pour but de recueillir les donnes normatives pour les personnes ges de 6 19 ans, sur la base du test des botes et des cubes (Box and Block test) servant valuer la dextrit manuelle. Quatre-cents soixante-et-onze sujets (231 fminins et 240 masculins) ont t recruts parmi les sept comts de la rgion de Milwaukee. Les sujets issus de milieu urbain, de la banlieue et de la campagne ont ainsi t reprsentatifs d'un registre tendu de milieux socio-conomiques. Les donnes ont t stratifies en sept groupes d'ges de deux ans d'inter-valle. Les rsultats ont dmontr que la dextrit manuelle accrot en proportion directe avec l'ge chronologique. Les sujets fminins ont gnralement dmontr des rsultats suprieurs entre 6 et 11 ans, alors que les sujets masculins ont atteint des rsultats lgrement suprieurs entre 12 et 19 ans. En moyenne, droitiers et gauchers ont obtenus de meilleurs rsultats avec la main droite, bien que les sujets droitiers ont clairement fait preuve d'une meilleure latralisation que les gauchers.

CJOT VoL 52 No. 5

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December/Dcembre 1985