**5. Discussion**

Scientific studies involving box and blocks test in its virtual version are emerging in the context of rehabilitation in patients with neurological diseases, such as Parkinson's Disease (PD), Cerebral Vascular Accident (CVA), and Multiple Sclerosis (MS), among others, intending to study the validity, feasibility, and psychometric properties of the test [3, 10, 15]. However, few studies have developed the virtual BBT (VBBT) [10].

The interest in developing virtual tests is multiple [10]. It can reduce the interobserver subjectivity in the classic assessment, providing a complete virtual rehabilitation at home where patients can assess their cognitive and motor improvements using validated virtual evaluation.

**Table 1** shows some studies that addressed the topic, including author, study population, research country, goals, method, and the main results.

Researchers [3] assessed the validity of BBT and VBBT in participants with Parkinson's Disease (PD). They developed the VBBT using an immersive headset (Rift eyewear) and the LMC to evaluate unilateral manual dexterity in this audience. Participants were instructed to perform the physical BBT (once) and the virtual BBT (twice, one immersive and one non-immersive) separately. The results indicated a moderate correlation between the physical BBT and the VBBT scores.


*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*

**Table 1.** *Summary of studies.*

The results show that the 3D depth perception allowed the movement of more cubes in the immersive virtual BBT regarding BBT. This study presented three relevant findings: the gap in the number of blocks transported in the physical and virtual systems seems to tend to be a constant, the correlation between the obtained result between the physical and virtual systems is statistically significant, and the test-retest analysis shows an excellent statistically considerable correlation between

attempts with the virtual system. In this sense, the relationship between physical and virtual systems can be improved using fully immersive VR due to better depth perception.

In a study [11], researchers present their version of the VBBT and the results of a pilot study in which participants completed the BBT and VBBT, comparing their scores and opinions. The authors also compared how the participants handled time during both versions running. The Unity 3d platform and the LMC device were used for the virtual version. For gameplay, timers were implemented for the participants' 15-second practice and the 60 seconds of the entire session. During the whole session, the LMC data were recorded for future analysis. These data include participant position, palm position, fingertip position, and joint angles.

The results compared the scores and opinions of participants who took both versions of the test, showing that the number of video games and VR experience was positively correlated with task performance. The results also showed that participants with less knowledge of video games and VR performed in a slower time than those with more experience, who reported greater enjoyment than those who did not have VR contact. Finally, the authors conclude that the participants found the virtual version more frustrating. However, they still preferred to deal with this version rather than the physical one to have one more chance at performance. On average, healthy participants moved more 35 blocks in the BBT than in the VBBT.

In another study by [27], they developed a form of application of the VBBT using the LMC. The sample in the research consisted of 24 individuals, divided into two groups: the typical group (n = 12) and the group with neurological diseases (n = 12) and, consequently, impairment of upper limb motor function. The study is conducted in a single experimental session by performing the physical and virtual BBT with the dominant hand. Firstly, the physical BBT was performed, starting with a practice test lasting 15 seconds. Once the test was completed, the participants had a 5-minute rest before running the VBBT. Before beginning this version, there was also a practical period in which the participant performed two 1-minute tests to make him comfortable and familiar with the virtual environment. The 15-second test period started with the dominant or less affected hand, followed by 60 seconds with the automatic counting of correctly transported blocks.

This research presented some limitations reported by the authors, such as difficulties with the technology used (LMC), whose performance was strongly conditioned by the environmental conditions and the computer's performance. However, this study showed that considering the physical BBT, upper limb motor skill was statistically higher in the typical population than in the people with neurological diseases. The same behavior was observed for the VBBT. Besides, within each analyzed group, the performance in the BBT was superior to that of the VBBT. However, BBT and VBBT high performance showed corresponding final results, with a high tendency between the two tests.

The VBBT version developed in this work showed high consistency in its application in a sample of typical individuals and patients with neurological diseases. According to the authors, the next step is that the VBBT, integrated with LMC, serves as an element to assess motor dysfunctions, allowing manual dexterity training in the population with neurological diseases.

Other researchers [28] present a tool developed from the BBT for its virtual version, using the LMC and Unity 3d. The authors included some feedback in this version

## *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*

(VBBT) to increase the patients' motivation, with the intention that they become aware of their competence while performing exercises for rehabilitation. The developed game can be configured according to the needs of each one. It offers facilities to define the dominant hand, the number of blocks the patients will have to pick up and their size. After that, the game starts so that the player can interact with the blocks, lasting until all the blocks have been placed on the non-dominant side area of the screen or until the participant gives up playing.

During the VBBT execution, patients receive information about the current game and their progression concerning previous moves. While the participant performs the task, the game simultaneously shows the number of moved blocks (score), the number of blocks they need to move to finish the game correctly (goals), the elapsed time, and the current speed related to the number of blocks moved per minute. In addition, to complete this information, a dynamic status bar is also shown to describe the relationship between the patient's current speed and the speed of their previous best and worst performance. The value of this status bar changes in real time, decreasing if the patient does not move new blocks or increasing when a new block is moved. When finished, additional information is presented to the patient on a result screen, showing the player's final score, goal, elapsed time, and speed.

The authors emphasize that upper limb rehabilitation has become a critical need due to the number of people affected by this condition when they have a neurological disease, for example. They also point out that the existing treatments for these conditions are demanding and expensive. Therefore, the VBBT enables the therapists to customize therapy according to each patient's specific needs, exploring an important feature, which is the introduction of different motivation facilities to attract this audience to perform a repetitive task, which, on the other hand, could be tedious.

From the studies discussed, it can be noticed some of the advantages and disadvantages of using the LMC [27], which can be a device dependent on the conditions presented by the computer to which it will be connected. Some results [11] showed that participants with less knowledge of video games and VR performed in a slower time than those with more experience, who reported greater enjoyment than those who did not have VR contact. Therefore, the use of LMC may also be related to the individual's previous contact with technology.

When used with the BBT, the LMC proved to be more acceptable in its immersive version [3], mainly because users are able to transfer more blocks when inserted in the 3d view, which consequently generates less fatigue in the manual function and an increase in the motivation. Another advantage of using this technology is that together with the virtual BBT, health professionals have the possibility to meet the needs of each patient individually, through time, the number of blocks, feedbacks, among others [28].

It is important consider that the use of MC associated with the virtual BBT allows the execution of the task of transferring blocks in a situation of evaluation and training for the manual function without the need to the physical blocks, reducing the chance of any type of contamination, BBT the manual dexterity, promoting the development and health of users.

Therefore, there is a need for expansion in studies that encompass the rehabilitation of manual dexterity, technology, and its devices and the tests involved in this context, such as BBT in its virtual version.
