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Brief Report
Reliability of the Box and Block Test of Manual Dexterity
for Use With Patients With Fibromyalgia
Mark L. Canny, Jeffrey M. Thompson, Mikel J. Wheeler
KEY WORDS
• disability evaluation
• fibromyalgia
• hand
• motor skills
• reproducibility of results
OBJECTIVE. The aim of this study was to determine the reliability of the Box and Block (B&B) Test of
Manual Dexterity for upper-extremity function in patients with fibromyalgia and to compare their results with
those of healthy control participants.
METHOD. We assessed reliability of the B&B Test within and between testers using the intraclass correlation
coefficient (ICC). We compared fibromyalgia patient (n = 30) and control group (n = 30) scores using analysis
of variance and population-based normative data.
RESULTS. The B&B Test was reliable with ICCs of .90 to .85. Fibromyalgia patients’ B&B Test scores were
significantly lower (more impaired) than those of the control group and standardized norms.
CONCLUSIONS. The B&B Test is a reliable measure of upper-extremity function in fibromyalgia patients
and is able to reveal a reduction in upper-extremity function in these patients compared with both healthy
control participants and normative scores.
Canny, M. L., Thompson, J. M., & Wheeler, M. J. (2009). Brief Report—Reliability of the Box and Block Test of Manual
Dexterity for use with patients with fibromyalgia. American Journal of Occupational Therapy, 63, 506–510.
Mark L. Canny, OTR, is Staff Therapist, Department
of Physical Medicine and Rehabilitation, Mayo Clinic,
Rochester, MN.
Jeffrey M. Thompson, MD, is Associate Professor
of Physical Medicine and Rehabilitation, Department of
Physical Medicine and Rehabilitation, Mayo Clinic College
of Medicine, Rochester, MN 55905; thompson.jeffrey@
mayo.edu
Mikel J. Wheeler, COTA, is Staff Therapist, Department
of Physical Medicine and Rehabilitation, Mayo Clinic,
Rochester, MN.
F
ibromyalgia syndrome (FMS) is characterized by widespread musculoskeletal
pain, multiple tender points, easy fatigue,
and exacerbation of pain with activity. The
etiology of the muscular pain has yet to be
conclusively determined, and hypotheses
are moving away from peripheral causes,
such as local muscle ischemia and microtrauma (Simms, 1998), toward etiologies
that may involve central sensitization and
lowered pain thresholds (Bennett, 1996;
Crofford & Demitrack, 1996; Weigent,
Bradley, Blalock, & Alarcon, 1998).
Nevertheless, some investigators still hold
fast to the belief that muscle dysfunction
plays a central role in the development and
continuance of some symptoms associated with FMS (Veierstad, Westgaard, &
Andersen, 1993).
Among the various symptoms associated with FMS, stiffness is one of the most
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common complaints, after pain and fatigue
(Mannerkorpi, Svantesson, Carlsson, &
Ekdahl, 1999). No joint pathology that
would explain this stiffness, however, has
ever been found in patients with FMS.
What is its source? One could consider
stiffness to be a result of central sensitization
and altered somatic sensation. Conversely,
one could consider it to result from resistance to movement in the muscles or
other connective tissues. Investigators have
pointed to poor muscle-firing patterns
as a possible source of this resistance to
movement (Madeleine, Lundager, Voigt,
& Arendt-Nielsen, 1999; Sterling, Jull, &
Wright, 2001); a common clinical observation is that FMS patients exhibit multiple
muscle co-contraction patterns resulting in
nonsmooth movements and reduced range
of motion (ROM; Donaldson, Snelling,
MacInnis, Sella, & Mueller, 2002). This
July/August 2009, Volume 63, Number 4
poor coordination of muscle firing may
be the result of chronic pain, or it may
be an important factor in the initiation of
muscle pain.
Our purpose in this study was not to
provide verification for one theory over
another but rather to evaluate the reliability
and concurrent validity of a tool that may
aid researchers and clinicians who work
with patients with FMS. Finding a way
to reliably and objectively measure upperextremity function may lead to a better
understanding of the role of muscular
dysfunction in musculoskeletal pain, and
it could potentially lead to more effective
treatment for those experiencing FMS.
Historically, various assessments have
been used to measure functional capacities of patients with FMS; the assessments
vary in their approach. Some have focused
on performance of activities of daily living
(ADLs); others have examined component
performance, targeting strength and endurance at the muscular level; and still others have combined both task performance
and component performance. Panton et al.
(2006) compared 29 women with FMS to
those without FMS using the ContinuousScale Physical Functional Performance Test
(Cromwell, 1976). This assessment includes
performance of tasks such as pouring water
from a jug to a cup, putting on and removing a jacket, putting a Velcro strap over a
shoe, and picking up scarves. In this study,
patients with fibromyalgia were found to
have lower functionality scores than ageand weight-matched controls. Mannerkorpi
et al. (1999) found the combined 6-min
walk test, chair rising, component testing of
hand grip strength, upper-extremity active
ROM, and shoulder endurance to be a
valid measure of upper-extremity muscular
performance. Gowans, deHueck, Voss, and
Richardson (1999) defined an increase in
function using the 6-min walk test and
measured change in function after 6 and
12 months of exercise. The protocol of
examining specific activity performance and
muscular components together seems a logical approach to assessing function, given the
close relationship each has to the other.
Despite the tools already used by clinicians for assessing function, an extensive
search of the literature did not identify
any specific assessments targeting muscle
coordination dysfunction in FMS. The
Box and Block (B&B) Test of Manual
Dexterity (Cromwell, 1976) has been used
to measure upper-extremity coordination
in clients with functional impairments
(Desrosiers, Hebert, Dutil, & Mercier,
1994; Paltamaa, Sarasoja, Wikstrom, &
Malkia, 2005; Svensson & Häger-Ross,
2006) and, when paired with other tools
focused on task performance, could potentially be used to provide clinicians with
valuable information regarding function
in patients with FMS. The advantages of
the B&B Test are that it has been standardized, is quick to administer (requiring
<5 min), and is inexpensive to purchase
or can even be handmade (Mathiowetz,
Volland, Kashman, & Weber, 1985). The
test involves grasping and moving 1-in.
square wooden blocks from one side of an
8-in. square box to the other by passing
them over a wooden partition 5 in. high.
The patient is scored according to the number of blocks passed from one side to the
other in 1 min. Lower scores correspond to
greater upper-extremity impairments.
Normative data for the B&B Test have
been documented for adults on the basis of
628 people without disabilities between
ages 20 and 70+ years (Mathiowetz et al.,
1985). Test–retest reliability was established at a 6-month interval and found
to be high at .94 for the left hand and
.98 for the right hand (Cromwell, 1976).
Convergent validity was supported using
a Minnesota Rate of Manipulation Test
subtest (Cromwell, 1976). Further validation of the test targeted more specific clients, including elderly adults (Desrosiers et
al., 1994), patients with multiple sclerosis
(Paltamaa et al., 2005), and patients with
Charcot–Marie–Tooth disease (Svensson
& Häger-Ross 2006). Svensson and HägerRoss (2006) was the only study that compared patient scores with documented
norms, with patient scores being significantly lower than the norms. We found no
studies, however, describing the use of the
B&B Test in patients with FMS.
Our purpose in this study was to assess
the test–retest reliability of the B&B Test
and its utility in identifying upper-extremity
dysfunction in patients with FMS.
The American Journal of Occupational Therapy
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Method
Research Design
This study was an inter- and intratester,
test–retest design reliability study with the
addition of comparisons between a control
group and an experimental group consisting of FMS patients. We assessed the reliability of the B&B Test within and between
testers using the intraclass correlation coefficient (ICC) and compared control and
experimental group scores using analysis of
variance and population-based normative
data. A convenience sample of 30 women
with FMS and 30 women in good health
without FMS participated in this study in
the Mayo Clinic’s biofeedback clinic. The
B&B Test data used in this study were collected as part of a larger study examining
surface electromyography information.
Participants
We recruited 30 female patients from
the Fibromyalgia Treatment Program at
the Mayo Clinic. Patients attending the
program had the diagnosis of FMS confirmed by a physician using the American
College of Rheumatology 1990 criteria
(Wolfe et al., 1990) before enrollment
in the program. Thirty-two participants
were identified and agreed to take part;
however, 2 were not able to complete the
testing because of scheduling conflicts. The
healthy control group was a convenience
sample consisting of staff members working
in Mayo Clinic’s Fibromyalgia Treatment
Program and Pain Rehabilitation Center.
All volunteers were pain free, had no musculoskeletal pain requiring medication in
the previous month, and had no history
of neuromuscular disease. Baseline data
collected included age, height, and weight.
This study was approved by the Mayo
Clinic Institutional Review Board, and
all participants completed a consent form
before enrollment in the study.
Procedure
Each participant was asked to sit comfortably at a table and complete the B&B Test
using the dominant upper extremity. The
raw score was recorded as the number of
blocks passed over the divider within 1 min.
507
Each participant performed the test three
times—twice on the same day with the
same examiner and once the next day with
a second examiner. We calculated ICCs
within examiner (ICC[2]) and between
examiners (ICC[1]) for the 30 patients
with FMS and the 30 control participants
(Fleiss, 1981). Each participant’s mean
score for the three trials was determined
and used in the between-groups comparison using an unpaired t test. Finally, we
compared both groups’ scores to normative
data collected by Mathiowetz et al. (1985),
using each participant’s average score.
Results
Demographics
The average age of patients was 46.9
years (range = 20–68). The average age of
healthy control participants was significantly younger at 41.2 years (range = 29–52).
Of the 30 participants in each group, 29
were right-hand dominant. Groups showed
no statistically significant differences on
weight or body mass index (see Table 1).
Reliability
For this study, we defined fair reliability as
an ICC of .4 to .6, good reliability as an
ICC of .6 to .75, and excellent reliability
as an ICC of .75 to 1.00. We found ICCs
for the raw score on the B&B Test to be
excellent, ranging from .80 to .98 for both
within- and between-examiner trials (see
Table 2).
Between-Group Comparisons
The average B&B Test score for the FMS
patients was significantly lower than that
for the control group (61.8 and 71.1,
respectively; unpaired t = 5.2154, df =
58, p = .0001). When compared with the
normative values provided by Mathiowetz
et al. (1985), the FMS patients’ average
score was 3 standard deviations below and
the control group’s average score was 1.9
standard deviations below the age-matched
mean. Table 3 shows the raw score comparisons between the two groups.
Discussion
Patients with FMS often experience loss
of function as a result of the variety of
symptoms associated with the syndrome.
These symptoms include widespread musculoskeletal pain, more fatigue than usual,
activity intolerance, and joint stiffness.
The symptom of stiffness has not been
studied in any detail. Marques et al.
(2004) described morning stiffness; however, they focused their evaluation on
flexibility testing and quality of life via
the Fibromyalgia Impact Questionnaire.
Adams and Sim (2005) identified principal rehabilitative approaches to FMS,
finding that exercise combined with a
psychologically based treatment such as
cognitive–behavioral therapy is becoming
more frequently used without any specific
mention of treatments for stiffness. When
rehabilitation efforts include occupational
therapy, emphasis is placed on improving
the patient’s ability to perform functional
activities (Lindberg, 2002).
A key issue leading to the initiation of
this study was that FMS patients attending
our treatment program often complain
of decreased upper-extremity function,
including complaints of slowed fine motor
performance and “dropping things,” yet
we have not adopted any formal testing
procedures to assess muscle coordination.
Unfortunately, we found no studies specifically targeting assessment or treatment of
muscle incoordination in FMS. This lack
of focus on upper-extremity coordination
may result from several reasons, including
Intratester
(ICC[2])
Intertester
(ICC[1])
Patients
.90
.85
Control participants
.98
.80
Reliability
lack of attention to upper-extremity function during the evaluation process. Hints
that the problem exists come from findings
on some assessment tools that identify difficulty with ADLs (Lindberg, 2002) and
from studies of more localized muscle pain
syndromes such as neck and shoulder pain
(Madeleine et al., 1999).
Although many forms of evaluative
tools for measuring gross and fine motor
coordination can be found in the literature,
they have not been used in patients with
FMS. Our purpose in this study was to
determine whether the B&B Test, chosen
because of its ease of administration with
minimal equipment, can be used to measure the upper-extremity performance of
patients with FMS.
The authors of a study establishing
reliability and validity of the B&B Test
with elderly people underscored the importance of “measuring the reliability of an
instrument with the targeted clientele”
(Desrosiers et al., 1994, p. 754). The B&B
Test as described by Mathiowetz et al.
(1985) was shown in our study to be reliable in both healthy control participants
and FMS patients whether repeated by the
same examiner or a different examiner, thus
supporting its use in patients with FMS.
The B&B Test also successfully discriminated between FMS patients and the
control group, lending some credence to
the common patient complaint of upperextremity dysfunction and to the use of
the B&B Test to measure upper-extremity
dysfunction in FMS patients.
Limitations and Future Research
Table 1. Patient and Control Participant Demographics
Patients
(n = 30)
Control
Participants
(n = 30)
t
(df = 58)
p < .05
Age in years, mean (SD)
46.9 (11.8)
41.2 (6.6)
2.33
.02
Weight in kilograms, mean (SD)
72.3 (12.6)
68.3 (10.8)
1.32
.19
Body mass index, mean (SD)
25.9 (3.7)
25.7 (3.8)
0.27
.78
Variable
Table 2. Patient and Control Participant
Intraclass Correlation Coefficients (ICCs)
Note. SD = standard deviation; df = degrees of freedom.
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This study was completed in a clinical
treatment setting in which clinical concerns were given priority over research.
Consequently, some errors in data collection may have occurred that would
not occur in a laboratory-based research
project. Because the study did not include
July/August 2009, Volume 63, Number 4
Table 3. Patient and Control Participant Comparison to Standardized Norms
Patients
Participant
Number
Control Participants
Average Scores
Mathiowetz et al.’s
(1985) Norms
1
55.7
82.1
2
77.7
86.0
3
51.3
4
5
Participant
Number
Average Scores
Mathiowetz et al.’s
(1985) Norms
1
73.3
84.8
2
73.3
85.2
82.1
3
83.7
85.2
63.7
82.1
4
69.7
82.1
66.0
74.7
5
82.0
85.2
6
55.7
77.7
6
82.0
81.1
7
75.3
85.2
7
70.3
81.1
8
58.3
82.1
8
79.3
82.1
9
59.0
82.1
9
56.7
85.2
10
48.0
72.0
10
57.3
84.8
11
65.3
76.1
11
73.0
79.7
12
65.0
82.1
12
66.0
82.1
13
72.3
77.7
13
79.3
84.8
14
47.7
74.7
14
56.0
81.1
15
60.0
77.7
15
81.3
81.1
16
53.0
72.0
16
73.7
81.1
17
55.7
84.8
17
65.3
86.0
18
72.3
83.4
18
73.7
82.1
19
52.0
81.1
19
68.0
82.1
20
61.0
81.1
20
71.3
85.2
21
70.3
82.1
21
74.0
82.1
22
65.0
82.1
22
65.0
81.1
23
64.0
82.1
23
73.7
84.8
24
55.7
85.2
24
67.3
77.7
25
48.7
74.7
25
64.7
82.1
26
59.3
88.0
26
71.7
84.4
27
73.7
82.1
27
66.0
77.7
28
75.7
77.7
28
72.0
77.7
29
55.7
74.7
29
68.7
82.1
30
71.7
82.1
30
75.0
85.2
Note. All scores are represented as blocks per minute.
male participants, it is not clear whether the
B&B Test would have the same reliability
with them.
Our control group consisted of a convenience sample of health care workers
recruited from the tertiary clinical setting
where this study was conducted. Because
this sample may not be representative of
the normal population, its accuracy must be
considered before judgments can be made.
In the same way, the FMS patients referred
to the treatment program may not represent
the population seen in a community-based
setting. The information for this research
project was gathered as a part of a larger
project that included measurement of muscle activity using biofeedback electromyography while participants engaged in a variety
of tasks. This project’s sample size was consequently restricted; however, we still found
a statistically significant difference between
the control and patient groups. The possibility of uncontrolled variables influencing
the results, however, is greater with a small
sample size. The patient group members
were significantly older than the control
group members (46.9 vs. 41.2), which may
have influenced their performance, although
they also scored much worse than controls
when compared with age-matched norms.
The control participants and patients
both scored significantly below the published norms by 1.9 and 3 standard deviations, respectively. The reason for this
result is not clear. One possibility is that
the presence of surface electromyography
The American Journal of Occupational Therapy
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electrodes attached to cervical paraspinals,
upper trapezii, and lumbar paraspinals as
part of a different study may have influenced the participants’ speed of movement
(although there was no mechanical impediment to movement). Another possibility is
a difference in the level of encouragement
provided in this study during data collection compared with that provided in
the study that established normative data.
Because the instructions provided for this
test are not scripted, it is unknown how the
original researchers provided instructions.
Variations in wording between facilitators
may have influenced the intensity provided
by the participants. These issues should be
addressed in a larger study using a more
representative control group rather than a
convenience sample.
As mentioned, the B&B Test was one
of the activities used in a larger study. For
this reason, we made no direct comparison to other upper-extremity coordination
tests; therefore, we can make no convergent validity judgments. Other tests in the
literature used to evaluate this population
are more functionally based; there does not
appear to be a gold standard assessment
tool for measuring coordination problems
in people with FMS. Construct validity is
supported by the success in distinguishing
between the control group and patients
with FMS using the B&B Test.
Another variable that may have influenced outcomes was the motivation to
succeed at a performance test rather than
a functional test. Moving blocks from
one place to another may not have the
same inherent reward offered by other
functional tasks. Related to this, the B&B
Test requires rapid movements, which may
add a stress component not found in more
routine tasks. We selected the B&B Test
for this study because of its ease and speed
of delivery in contrast to other tests that
require increased time and effort to administer. Further research comparing the validity of this test to that of a variety of other
tests of upper-extremity coordination in
patients with FMS is recommended.
Conclusion
FMS is characterized by multiple subjective symptoms. The B&B Test appears
509
to represent a reliable and objective measure of one of those symptoms, decreased
upper-extremity function. Future work
should seek to correlate the findings from
the B&B Test with other measures of severity and with treatment outcomes. Ideally,
the test would aid in directing more specific
and appropriate treatment for those with
FMS. s
Acknowledgments
This study was supported by a research
grant from the Mayo Clinic College of
Medicine and the Department of Physical
Medicine and Rehabilitation.
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