This case study report demonstrates the use of motion analysis with a modification of the Box and Blocks test. The goal was to quantify observed improvements in compensatory movements and simultaneous control in a subject using different prostheses before and after targeted muscle reinnervation (TMR) surgery. This is a single case study with data collection using a body-powered prosthesis pre-TMR surgery and 6 mo postfitting with a TMR myoelectric prosthesis. The Box and Blocks test was modified for cyclical motion within a motion capture laboratory. With the TMR myoelectric prosthesis, the subject was able to simultaneously activate the hand and elbow. Task performance was slower, but there was improved elbow flexion and less trunk compensatory motion than with the body-powered prosthesis. There are several limitations to the case study because there is no direct comparison of myoelectric performance before and after TMR surgery; however, the current report presents a potential method to quantify quality of motion and compensatory movements of prosthetic users. With further study, this test procedure has the potential to be a useful outcome measure for future standardized assessments of upper-limb prosthetic function.

/pdf/case-report-of-modified-box-and-blocks-test-with-motion-2hjwmuy5xz.pdf

Case report of modified Box and Blocks test with motion capture to measure prosthetic function.

Background 
The Box and Block Test (BBT) is a functional outcome measure that is commonly used across multiple clinical populations due to its benefits of ease and speed of implementation; reliable, objective measurement; and repetition of motion. In this study, we introduce a novel outcome measure called the targeted BBT that allows for the study of initiation, grasping, and transport of objects, and also of object release. These modifications to the existing test may increase the ecological validity of the measure while still retaining the previously stated benefits of the standard BBT.


Methods 
19 able-bodied subjects performed the targeted BBT and two other standard tests. Using an integrated movement analysis framework based on motion capture and ground force data, quantitative information about how subjects completed these tests were captured. Kinematic parameters at the wrist, elbow, shoulder, thorax, and head, as well as measures of postural control, were calculated and statistically compared across the three tests.


Results 
In general, the targeted BBT required significantly higher RoM at the elbow, shoulder, thorax and head when compared to standard tests. Peak angles at these joints were also higher during performance of the targeted BBT. Peak angles and RoM values for the targeted BBT were close to those found in studies of movements of able-bodied individuals performing activities of daily living.


Conclusion 
The targeted BBT allows analysis of repetitive movements, and may more closely model common real-world object manipulation scenarios in which a user is required to control a movement from pick-up to release.

/pdf/targeted-box-and-blocks-test-normative-data-and-comparison-127ksl7cf0.pdf

Targeted box and blocks test: Normative data and comparison to standard tests

Gross-motor impairments are common after stroke, but efficient and motivating therapies for these impairments are scarce. We present an innovative musical sonification therapy especially designed to retrain patients' gross-motor functions. Sonification should motivate patients and provides additional sensory input informing about relative limb position. Twenty-five stroke patients were included in a clinical pre-post study and took part in the sonification training. The patients' upper extremity functions, their psychological states and their arm movement smoothness were assessed pre and post training. Patients were randomly assigned to either of two groups. Both groups received an average of ten days (M = 9.88; SD = 2.03; 30min/day) of musical sonification therapy (music group, MG) or a sham sonification movement training (control group, CG), respectively. The only difference between the two protocols was that in the CG no sound was played back during training. In the beginning, patients explored the acoustic effects of their arm movements in space. At the end of the training, the patients played simple melodies by coordinated arm movements. The 15 patients in the MG showed significantly reduced joint pain (F = 19.96, p < 0.001) in the Fugl-Meyer Assessment after training. They also reported a trend to have improved hand function in the Stroke Impact Scale as compared to the control group. Movement smoothness at day one, day five and the last day of the intervention was compared in MG patients and found to be significantly better after the therapy. Taken together, musical sonification may be a promising therapy for motor impairments after stroke but further research is required since estimated effect sizes point to moderate treatment outcomes.

/pdf/sonification-of-arm-movements-in-stroke-rehabilitation-a-383lzxfk55.pdf

Sonification of Arm Movements in Stroke Rehabilitation - A Novel Approach in Neurologic Music Therapy.

Motion analysis is an important tool for examining upper-limb function. Based on previous work demonstrating a modified Box and Blocks (BB) test with motion capture to assess prosthetic performance, we collected data in 16 nondisabled participants to establish normative kinematics for this test. Four motions of the modified BB test were analyzed to establish kinematic data for upper-limb and trunk motion. The test was repeated for right and left arms in standing and seated positions. Data were compared using a nonparametric Friedman test. No differences were found between right- and left-hand performance other than for task completion time. Small but significant differences were found for standing and seated performance, with slightly greater ranges in standing for axial trunk rotation, medial-lateral sternum displacement, and anterior-posterior hand displacement. The kinematic trajectories, however, were very consistent. The consistency in our nondisabled data suggests that normative kinematic trajectories can be defined for this task. This motion capture procedure may add to the understanding of movement in upper-limb impairment and may be useful for measuring the effect of interventions to improve upper-limb function.

/pdf/normative-data-for-modified-box-and-blocks-test-measuring-3ybxg195va.pdf

Normative data for modified Box and Blocks test measuring upper-limb function via motion capture.

Gross-motor impairments are common after stroke, but efficacious and motivating therapies for these impairments are scarce. We present a novel musical sonification therapy especially designed to retrain gross-motor functions. Four stroke patients were included in a clinical pre-post feasibility study and were trained with our sonification training. Patients' upper-extremity functions and their psychological states were assessed before and after training. The four patients were subdivided into two groups, with both groups receiving 9 days of musical sonification therapy (music group, MG) or a sham sonification training (control group, CG). The only difference between these training protocols was that, in the CG, no sound was played back. During the training the patients initially explored the acoustic effects of their arm movements, and at the end of the training the patients played simple melodies by moving their arms. The two patients in the MG improved in nearly all motor function tests after the training. They also reported in the stroke impact scale, which assesses well-being, memory, thinking, and social participation, to be less impaired by the stroke. The two patients in the CG did benefit less from the movement training. Taken together, musical sonification may be a promising therapy for impairments after stroke.

Moving with music for stroke rehabilitation: a sonification feasibility study.

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.

Reliability of the box and block test of manual dexterity for use with patients with fibromyalgia.

Objectives: Although biofeedback has been considered an effective treatment component for pediatric chronic pain, little research has examined the generalizability to activities outside of the treatment setting. The current study aimed to examine the effects of a biofeedback intervention involving individual and group sessions to facilitate increased self-regulatory skills for chronic pain management and to translate these skills to meaningful activities promoting functional restoration. Methods: Participants included 104 adolescents (ages 12-18) attending an intensive interdisciplinary pain rehabilitation program for chronic pain/symptoms and completed biofeedback training as part of the program. The biofeedback protocol consisted of six sessions, including an assessment of baseline physiologic states, diaphragmatic breath training, and various biofeedback screens to reinforce self-regulatory skills within individual- and group-based formats. Results: As expected, patients showed significant reductions in respiration rates and muscle tension from admission to discharge. Ratings of perceived confidence also increased from admission to post-treatment, suggesting greater self-efficacy in patients using self-regulatory skills during their daily functional activities. Conclusions: An individual- and group-based biofeedback protocol with a focus on training skills in activities relevant to adolescents' lives has the potential to improve self-regulation skills and generalize these skills to real-world settings. Future randomized controlled trials are necessary to examine the efficacy of biofeedback interventions to improve physiologic regulation and enhance treatment outcomes for pediatric chronic pain.

Mark L Canny

Papers

Reliability of the box and block test of manual dexterity for use with patients with fibromyalgia.

An Innovative and Accessible Biofeedback Intervention for Improving Self-Regulatory Skills in Pediatric Chronic Pain: A Pilot Study.