EEG Correlates of Upper Limb Function During the Box and Block Test After Stroke.

Trunk control ability greatly influences functional movement of the upper limbs. Our primary aims were to assess trunk control ability, sway, and upper limb functions in children with cerebral palsy (CP), and to investigate the relationship between trunk control ability and upper limb function. We included 15 children (8 boys and 7 girls) with CP. We used the Trunk Control Measurement Scale (TCMS) to evaluate trunk control ability and sway. We employed the Jebsen-Taylor Hand Function Test (JTHFT), the Quality of Upper Extremity Skills Test (QUEST), the Box and Blocks Test (BBT), and the ABILHAND-Kids questionnaire to explore upper limb function and arm movement acceleration. We calculated correlations between trunk control ability and parameters of upper limb function. TCMS scores correlated positively with the QUEST, BBT, and ABILHAND-Kids data, but negatively with the JTHFT findings. Anteroposterior acceleration correlated positively with JTHFT data, but negatively with QUEST, BBT, and ABILHAND-Kids data. Mediolateral acceleration correlated positively with the JTHFT outcomes, but negatively with those of QUEST, BBT, and ABILHAND-Kids. Upper limb function test data exhibited moderate to strong correlations with trunk control ability, as measured via the TCMS and triaxial accelerometry, in children with CP. Our results suggest that trunk control ability should be assessed when evaluating upper limb function in such children.

A comprehensive assessment of upper limb (UL) function is mandatory in people with multiple sclerosis (PwMS), and the use of multiple objective and subjective measures is advisable. Findings on the role of cognitive impairment on the assessment of UL function are scant and inconclusive. The present study investigated the influence of cognitive function on the distribution of objective and subjective UL measures and on their association. In the cross-sectional study, subjects with a diagnosis of MS, age ≥ 18years, right-hand dominance, no presence of orthopedic UL impairment, or other neurological diseases were recruited. The assessment protocol included the Nine-Hole Peg Test (9-HPT), Box and Block Test (BBT), and hand grip strength (HGS), a validated PROM (MAM-36), and the Symbol Digit Modalities Test (SDMT). Two hundred forty-six PwMS were recruited (158 females, mean age = 51.65 ± 13.45years; mean EDSS = 5.10 ± 1.88) Subject with mild-to-moderate cognitive impairment (SDMT ≤ - 2 SD of normative values) scored lower on the 9-HPT and higher on the BBT and MAM-36 when compared with subject with no cognitive impairment. Cognitive impairment showed a small but significant effect on the association between 9-HPT scores and the MAM-36. Findings suggest that cognitive impairment is associated with subjects' performance on 9-HPT, BBT, and MAM-36 (but not HGS), resulting in scores indicating a poorer UL function. Interestingly, cognitive impairment slightly affected the congruence between subjective and objective UL measures, although only minor differences in the correlation pattern across groups reporting different cognitive performances emerged.

IntroductionVirtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).MethodsThis study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.ResultsThe most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70–6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47–7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = − 0.58–4.72, P = 0.13),ConclusionsVAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

Quantification of upper limb dysfunction in the activities of the daily living in persons with multiple sclerosis

BackgroundVirtual reality (VR) has emerged as a promising tool, offering immersive environments, real-time feedback, and kinematic data to support both evaluation and training in rehabilitation. The Box and Block Test (BBT) is a simple yet well-validated clinical tool commonly used to assess upper extremity function. This study aimed to develop and validate two versions of the virtual reality Box & Block Test (VR-BBT) in healthy adults and patients with stroke.MethodsParticipants completed the conventional BBT as well as two versions of a VR-BBT developed for this study: a physical interaction version (VR-PI) and a non-physical interaction version (VR-N). Primary outcome measures included the number of blocks transferred in the BBT, VR-PI, and VR-N. In patients with stroke, additional kinematic parameters (e.g., movement speed and distance) from the VR-BBT were analyzed.ResultsTwenty-four healthy adults and 24 patients with stroke were enrolled. Patients with stroke scored 55.65 ± 12.04 and 27.04 ± 16.88 in BBT, 28.40 ± 12.44 and 14.19 ± 10.24 in VR-PI, and 30.69 ± 11.29 and 16.21 ± 11.92 in VR-N for the unaffected and affected hands, respectively. The VR-BBT showed strong correlations with the BBT (r = 0.841 for VR-PI, r = 0.827 for VR-N). Intraclass correlation coefficients (ICC) indicated excellent reliability (BBT = 0.982, VR-PI = 0.940, VR-N = 0.943). Correlations with FMA-UE were 0.839, 0.657, and 0.676 for BBT, VR-PI, and VR-N, respectively. The affected hand exhibited statistically significantly lower movement speed than the unaffected hand. Movement distance was greater in the affected hand than in the unaffected hand for VR-N (p = 0.046), with a similar but non-significant trend for VR-PI (p = 0.062).ConclusionsThe VR-BBT demonstrated strong reliability and validity despite differences in performance counts compared to BBT. The affected hand showed greater movement distance but lower speed, indicating inefficient motor control. These parameters were significantly associated with FMA-UE, suggesting their potential as objective markers of upper limb motor impairment. These findings suggest that the VR-BBT could serve as a complementary tool for motor function assessment, with potential applications in tele-rehabilitation and virtual reality-based rehabilitation.Trial registration KCT0009584 (Clinical Research Information Service, Republic of Korea).Supplementary InformationThe online version contains supplementary material available at 10.1186/s12984-025-01779-6.

Severe upper limb paresis is a major contributor to disability after stroke. This study investigated the efficacy of task-related training (TRT) with transcutaneous electrical nerve stimulation (TENS) on recovery of upper limb motor function in chronic-stroke survivors. Thirty patients with chronic stroke were randomly allocated two groups: the TRT+TENS group (n = 15) and the TRT+placebo (TRT+PLBO) group (n = 15). Patients in the TRT+TENS group received TENS stimulation (two to three times the sensory threshold), while subjects in the TRT+PLBO group received TENS without real electrical stimulation. TENS was applied to muscle belly of triceps and wrist extensors, while placebo (PLBO) stimulation was administrated without real electrical stimulation. Both interventions were given for 30 minutes per day, 5 days per week, for a period of 4 weeks. The primary outcomes were assessed with Fugl-Meyer assessment scores (FMA), Manual function test (MFT), Box and block test (BBT), and Modified Ashworth scale (MAS), each of which was performed one day before and one day after intervention. Both groups showed significant improvements in FMA, MFT, and BBT after intervention. When compared with the TRT+PLBO group, the TRT+TENS group showed significantly greater improvements in FMA (p = 0.034), MFT (p = 0.037), and BBT (p = 0.042). In MAS score, significant improvement was observed only in the TRT+TENS group (p = 0.011). Our findings indicate that TRT with TENS can reduce motor impairment and improve motor activity in stroke survivors with chronic upper limb paresis, highlighting the benefits of somatosensory stimulation from TENS.

Upper limb (UL) function is often affected in people with multiple sclerosis (PwMS) and is typically assessed through objective measures, including the Nine Hole Peg Test (9-HPT), Box and Block Test (BBT), and Hand Grip Strength (HGS). It is important to include the subjective perspective of PwMS in the assessment. This study aims to evaluate associations between Manual Ability Measure-36 (MAM-36) and 9-HPT, BBT, and HGS in MS. The cross-sectional study included five Italian centers. Inclusion criteria were age ≥ 18 years, MS diagnosis, and stable disease course. Exclusion criteria were bilateral UL paralysis, and concomitant orthopedic or neurological diseases. A total of 199 PwMS were included: 128 female, mean age=50.7± 13.0 years, 119 relapsing-remitting MS (RRMS), 31 primary and 49 secondary progressive MS, mean disease duration=14.0± 10.4, years, mean Expanded Disability Status Scale (EDSS)=4.6± 2.0. The MAM-36 showed small correlations with 9-HPT, BBT, and HGS. Correlations between MAM-36 and 9-HPT and BBT were highest among subjects with EDSS ≥ 6 and progressive MS. MAM-36 and HGS showed the highest correlations in subjects with EDSS ≤ 5 and RRMS. Combining 9-HPT and HGS provided the strongest predictive power over the MAM-36. Correlations between objective measures and MAM-36 were small to moderate, meaning that objective measures do not match subjects' perception of UL function. The combination of 9-HPT and HGS measures can help improve the assessment of UL function in activities of daily living.

This study aimed to evaluate the efficacy of virtual reality (VR) in upper limb rehabilitation in subacute stroke, including the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE), Box and Block Test (BBT), and Action Research Arm Test (ARAT). Subgroup analysis was performed to explore the optimal intervention parameters for VR treatment. PubMed, Embase, Cochrane Library, and Web of Science were thoroughly searched for randomized controlled trials (RCTs) on the use of VR for the rehabilitation of upper limb dysfunction in post-stroke hemiplegic patients until December 2025. Eligible studies were analyzed via RevMan 5.3 statistical software, with study quality assessed by the AOS scoring system, and data analysis performed using Stata 15. Fifteen studies were encompassed, comprising 612 cases overall, with 318 cases in the experimental group and 294 cases in the control group. VR rehabilitation was superior to traditional rehabilitation in FMA-UE score (SMD = 0.68, 95% CI [0.30-1.05], P=0.000), but there was no significant difference in BBT (SMD = 0.44, 95% CI [-0.02-0.90], P=0.058), ARAT (SMD = 0.63, 95% CI [-0.01-1.27], P=0.052) scores (P>0.05). Subgroup analysis showed that FMA-UE scores were significantly improved when VR training exceeded 30 minutes/session, the frequency was 4-5 days/week, and the total intervention time was 3-4 weeks. Immersive VR training showed advantages in FMA-UE, BBT, and ARAT scores. According to the Cochrane 1.0 quality assessment system, the overall methodological quality of this study was rated as moderate. A total of eight follow-up studies were included: Four of the follow-up studies showed differences in outcome measures between the two groups. VR may have advantages in promoting FMA-UE scores in the upper limbs of patients with subacute stroke. VR training with more than 30 minutes per session, more than 4 days per week, and a total intervention time of more than 3 weeks may be more conducive to the recovery of upper limb function (ULF) in subacute stroke. However, the efficacy of VR in improving fine motor skills and dexterity of the hand, assessed by the BBT and ARAT, remains to be elucidated. Although these findings are informative, the conclusions should be interpreted with caution in consideration of the study's limitations. Registry number: CRD42025610757.

The Box and Block Test (BBT) is a reliable outcome measure in upper limb rehabilitation. The present work aims to automate the test of unilateral manual dexterity of a patient's hand. A box consisting of 80 blocks was divided into two partitions. A motion tracking sensor (MPU6050) was placed on a wrist to obtain the orientation of hand movement. Thirty-four healthy participants were chosen for the test. Each participant completed both traditional and automated versions of BBT within a one-week interval, with each session lasting 60 seconds. A colour sensor at the box monitored block movements across the partitions. A Liquid Crystal Display (LCD) and a 4-digit 7-segment display provided feedback on the number of cubes moved and timing information, respectively. An independent t-test revealed a non-significant difference between traditional BBT and automated BBT. Concurrent validity was established by correlating the results of the automated BBT with the traditional BBT. A positive correlation (r= 0.94) was found between traditional and automated BBT. This validates the automated BBT report with the same result as traditional BBT. Automated BBT can assist a broad range of patients in independently tracking the progress of their hand injuries or conditions without needing a clinician. This can be conveniently done from the comfort of their homes. HighlightsLack of fine motor skills and dexterity is a primary concern affecting the person’s daily living activity; hence, the automated box and block test (BBT) is valid for assessing hand dexterity quantitatively.The traditional BBT is an old and golden test used in dexterity assessment with neurological patients, which only provides outcomes in the form of box count, which is insufficient for hand assessment.The need for this work arises from the limitations of the traditional BBT, which only provides a basic outcome in the form of box counts, insufficient for comprehensive hand dexterity assessment, particularly in neurological patients.Automated BBT is developed, which reduces the clinician’s burden during assessment and makes the test foolproof by adding a mechanism to capture hand trajectory during block movements.Along with the block count, the accelerometer gives hand orientation during the test process, which helps the clinician further analyze the results, such as motion pattern analysis, temporal analysis and comparative analysis.The independent t-test between traditional BBT and automated BBT, p = 0.109, was observed with a 0.95 confidence interval. Levene’s test revealed no significant difference between the scores of the traditional and automated BBT (t = 2.03; p = 0.109), also between dominant and non-dominant hand (t = 1.99; p = 0.74). A positive Pearson’s correlation (r = 0.94, p < 0.05) between traditional and automated tests was obtained.

Limited data are available in the literature for upper limb impairment in multiple sclerosis (MS). This study aimed to report the distribution of values of hand grip strength (HGS), of the box and block test (BBT) and of the nine-hole peg test (9HPT) correlated with demographic and clinical data in subjects with MS. This study involved five Italian neurological centres. The inclusion criteria were age ≥18, MS diagnosis, stable disease phase, right-hand dominance. All subjects underwent HGS, BBT and 9-HPT evaluation. In all, 202 subjects with MS were enrolled: 137 females; mean age 48.4years; mean Expanded Disability Status Scale (EDSS) 4.17; mean disease duration 14.12years; disease course 129 relapsing-remitting, 21 primary progressive and 52 secondary progressive MS subjects; mean right HGS 25.3 kg, left 23.2 kg; mean right BBT 45.7 blocks, left 44.9 blocks; mean right 9-HPT 30.7 s, left 33.4 s. All results were statistically significantly different compared to healthy controls. HGS, BBT and 9-HPT were associated with age, EDSS and disease duration, whilst disease course correlated with BBT and 9-HPT. The BBT and 9-HPT scores significantly differed according to level of disability (EDSS ≤3.0, 3.5-5.5, ≥6.0). Hand grip strength and BBT value distribution in a large MS population is reported. Correlations between HGS, BBT and 9-HPT were generally low.

Distribution and relation of two arm function tests, Box and Blocks test and Nine Hole Peg test, across disease severity levels and types of multiple sclerosis

One of the greatest limitations to measuring outcomes in pediatric orthopaedics is the lack of effective instruments. Computer adaptive testing, which uses large item banks, select only items that are relevant to a child's function based on a previous response and filters items that are too easy or too hard or simply not relevant to the child. In this way, computer adaptive testing provides for a meaningful, efficient, and precise method to evaluate patient-reported outcomes. Banks of items that assess activity and upper extremity (UE) function have been developed for children with cerebral palsy and have enabled computer adaptive tests that showed strong reliability, strong validity, and broader content range when compared with traditional instruments. Because of the void in instruments for children with brachial plexus birth palsy (BPBP) and the importance of having an UE and activity scale, we were interested in how well these items worked in this population. Cross-sectional, multicenter study involving 200 children with BPBP was conducted. The box and block test (BBT) and Stereognosis tests were administered and patient reports of UE function and activity were obtained with the cerebral palsy item banks. Differential item functioning (DIF) was examined. Predictive ability of the BBT and stereognosis was evaluated with proportional odds logistic regression model. Spearman correlations coefficients (rs) were calculated to examine correlation between stereognosis and the BBT and between individual stereognosis items and the total stereognosis score. Six of the 86 items showed DIF, indicating that the activity and UE item banks may be useful for computer adaptive tests for children with BPBP. The penny and the button were strongest predictors of impairment level (odds ratio=0.34 to 0.40]. There was a good positive relationship between total stereognosis and BBT scores (rs=0.60). The BBT had a good negative (rs=-0.55) and good positive (rs=0.55) relationship with the clinical category of BPBP and Raimondi classification, respectively. There was a moderate negative (rs=-0.36) and moderate positive (rs=0.47) relationship between total stereognosis and clinical category of BPBP and Raimondi, respectively. Individual stereognosis items had moderate (rs=0.34 to 0.45) to good (rs=0.52 to 0.74) correlation with total stereognosis score. In children with BPBP, there was little to no DIF with item banks of activity and UE functioning. The BBT is a good predictor of degree of impairment. Stereognosis with 2 items may provide comparable information as 12 items. Level II.

Background: Stroke patients usually have arm weakness, which affects trunks and arms. Objective: To investigate the effects of paretic side and non-paretic side arm training on trunk control and upper limb functions. Design: Randomized Controlled Trial (single blind). Methods: Twenty patients with stroke in hospital were enrolled in the study. Twenty subjects were randomly assigned to paretic side arm training group (PATG, n = 10) or non-paretic side arm training group (NATG, n = 10). Trunk impairment scale (TIS) was used for trunk control, and box and block test (BBT) was used for upper limb function. Training was conducted for 4 weeks. Results: PATG showed significant difference in TIS (static balance, dynamic balance, coordination, total score) and BBT. NATG showed significant differences in static balance, and dynamic balance and total score except for coordination and BBT. PATG also showed a more significant difference in BBT and coordination and total score than NATG. Conclusions: The arm training performed on the paretic side are more effective than those performed on the non-paretic side in improving both upper limb function and trunk control in stroke patients.

BackgroundVirtual reality and arm cycling have been reported as effective treatments for improving upper limb motor recovery in patients with stroke. Intermittent theta burst stimulation (iTBS) can increase ipsilesional cortical excitability, and has been increasingly used in patients with stroke. However, few studies examined the augmented effect of iTBS on neurorehabilitation program. In this study, we investigated the augmented effect of iTBS on virtual reality-based cycling training (VCT) for upper limb function in patients with stroke.MethodsIn this randomized controlled trial, 23 patients with stroke were recruited. Each patient received either 15 sessions of iTBS or sham stimulation in addition to VCT on the same day. Outcome measures were assessed before and after the intervention. Primary outcome measures for the improvement of upper limb motor function and spasticity were Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Modified Ashworth Scale Upper-Extremity (MAS-UE). Secondary outcome measures for activity and participation were Action Research Arm Test (ARAT), Nine Hole Peg Test (NHPT), Box and Block Test (BBT) and Motor Activity Log (MAL), and Stroke Impact Scale (SIS). Wilcoxon signed-rank tests were performed to evaluate the effectiveness after the intervention and Mann–Whitney U tests were conducted to compare the therapeutic effects between two groups.ResultsAt post-treatment, both groups showed significant improvement in FMA-UE and ARAT, while only the iTBS + VCT group demonstrated significant improvement in MAS-UE, BBT, NHPT, MAL and SIS. The Mann–Whitney U tests revealed that the iTBS + VCT group has presented greater improvement than the sham group significantly in MAS-UE, MAL-AOU and SIS. However, there were no significant differences in the changes of the FMA-UE, ARAT, BBT, NHPT and MAL-QOM between groups.ConclusionsIntermittent TBS showed augmented efficacy on VCT for reducing spasticity, increasing actual use of the affected upper limb, and improving participation in daily life in stroke patients. This study provided an integrated innovative intervention, which may be a promising therapy to improve upper limb function recovery in stroke rehabilitation. However, this study has a small sample size, and thus a further larger-scale study is warranted to confirm the treatment efficacy.Trial registration This trial was registered under ClinicalTrials.gov ID No. NCT03350087, retrospectively registered, on November 22, 2017

The purpose of this study was to investigate the effect of rTMS on upper limb dysfunction and hemineglect patients after stroke and to find out the most effective application method. This study was conducted with 25 subjects who were diagnosed as a hemiparesis by stroke. Participants in the experimental (12 members) and control groups (13 members) received rTMS and sham rTMS during a 20 minutes session, five days per week for four weeks, respectively, followed by task-oriented training during a 30 minutes session. Motor recovery evaluation was performed by fugl meyer assessment (FMA), box and block test (BBT), albert test (AT) and grip strength test. The experimental group showed significant increments in FMA, BBT, AT, and grip strength test, compared to the pre-intervention results (p 〈 0.01). Furthermore, the control group showed significant increments in the FMA, BBT, AT, compared to the pre-intervention results (p 〈 0.05). A significant difference in the post-training gains in FMA, AT, and grip strength test were observed between the experimental group and the control group (p 〈0.05). In addition, the effect size for gains in the experimental and control groups was very strong in FMA, AT, grip strength test (effect size = 1.29, 1.45, 0.96 respectively) and the effect size for gains in the experimental and control groups was very weak in BBT (effect size = 0.20). The findings demonstrate that application of 1 Hz rTMS combined with task-oriented training can be helpful in improving upper limb function and hemineglect of stroke.