**4. Box and blocks test**

A. Jean Ayres and Patricia Holser Buehler created the first Box and Blocks Test (BBT). They used a bowl and blocks to assess gross manual dexterity in adults with cerebral palsy [24]. Later, Patricia Holser Buehler and Elizabeth Fuchs changed the shape of the test to a gift box, obtaining copyright in 1957 [16].

As described by [16, 17], the BBT (**Figure 3**) is used to verify manual function to assess and quantify unilateral gross manual dexterity in children and adults. It consists of a wooden box, 53.7 cm long, with a partition, also made of wood, higher than the edges of the box, separating it into two compartments of equal dimensions. The blocks, also made of wood and in the form of colored cubes (primary colors), are 150 in number, measuring 2.5 cm on a side divided equally by color. The box's long sides are 53.7 cm by 8.5 cm and are nailed 1 cm thick from the base. The short ends are 7.5 cm by 25.4 cm and have been fixed to the top of the bottom between the long sides.

As a prerequisite for the application of the test, a quiet environment is required, with the examinee seated in a chair suitable for his/her height. The wooden box should be placed horizontally in front of him so he can fully view the area and equipment in question. It consists of moving as many cubes as possible from one compartment to another for 1 minute [25]. The BBT was proposed [16] with parameters between 20 and 94 years old. In Brazil, the BBT was used for the age group between

**Figure 3.** *Box and blocks test (BBT). Source: MENDES et al., 2001 [17].*

*The Use of Leap Motion in Manual Dexterity Testing by the Box and Blocks Test: A Review Study DOI: http://dx.doi.org/10.5772/intechopen.108191*

15 and 86 years, with typical groups and multiple sclerosis [17]. For the lower ranges, from 7 to 14 years old, the test parameters for Brazilians were mentioned by [12].

These functional measures of dexterity contrast with neuroscientific investigations that show that skill is multicomponent, including the ability to control force, control the timing of movements, execute independent finger movements, and execute motor sequence [26].

## **4.1 The virtual box and blocks test**

Our researchers from the Game Therapy and Virtual Reality Laboratory (Lab GameVR) created a virtual application of BBT, which we call Virtual BBT (desktop version and HTC Vive). The main requirements raised were the following:


Based on these requirements, a game prototype was conceived in VR using the Unity 3D game engine integrated into the LMC. When executing the game file, the Virtual BBT start screen is presented to the user with the following configuration and selection options (**Figure 4**) "Right or left hand," "Start," "Training," and "? [Help]." At that moment, the user must plug the LMC into the computer where the application is running.

**Figure 4.** *Virtual BBT home screen. Source: Author.*

**Figure 5.** *Virtual BBT screen in run mode. Source: Author.*

When selecting the "Start" option, the Virtual BBT screen is shown to the user (**Figure 5**). The screen shows the Wooden Box and the blocks modeled with Unity 3D. The user can observe the virtual hand moving around the scenario by placing the hands on the LMC. The screen displays the timer counting down. In this game scenario, the user has 60 seconds to transfer the blocks from one box compartment to the other. The same game scenario is displayed by selecting the "Training" option but without the countdown. In this scenario, the user can stay as long as he wants to interact with the Virtual BBT. An immersive version of BBT Virtual is being developed for use with HTC Vive.

At the end of use, the data referring to the player's score, date, time, patient's name, time, and laterality score of the executed hand are stored locally on the user's computer in a file in the csv format.
