FAR EASTERN UNIVERSITY

EVIDENCE-BASED NURSING

Submitted By: Abantao, Kiven Loyd Adalla, Maria Rizza Carmela Andaya, Kristine Alexis Andrade, Maureen Angeles, Nichola Jane Asenjo, Richelle Anne Atienza, Ian Kristopher Barredo, Liza Bautista, Jamee Jessica Besa, Edna Marie Borja, April Joy BSN218 Group 69

I. Clinical Question Does the position of the chair characterized by functional seating assist a child with cerebral palsy to improve their communication without speaking or use writing? Does a seated position characterized by the conventions of functional seating increase the frequency of accurate selection and speed of accurate target selection on a computer-based AAC device compared with the childs typical seating? II. Citation: Effect of Seated Position on Upper-Extremity Access to Augmentative Communication for Children With Cerebral Palsy: Preliminary Investigation (F. Aileen Costigan and Janice Light , 2010) o The effect of positioning for children with cerebral palsy on upperextremity function: a review of the evidence (Carrie Stavness, 2006 ) Seat inclinations affect the function of children with cerebral palsy: A review of the effect of different seat inclines (Linda Mcnamara and Mrs Jackie Casey, 2007)

III. Study Characteristics Patient/s included (Population and sample): Only one participant is used in this study. The patient is a child with quadriplegia spastic cerebral palsy. The patients name is Cole aged 5 years old who volunteered to be used in this study.

Interventions compared: Two seating positions were compared in the study: Position A: Baseline position or the clients typical sitting position The baseline position or position A is the typical sitting position of the client. The seat back of Coles push chair was reclined to 135 relative to the horizontal seat base, and the footplate was elevated such that Coles knee angle was extended beyond 90. Position B: Intervention position or the seated position During the B phases, simple modifications were made to Coles baseline position to place him in the intervention position, defined by (1) a neutral or slight anterior pelvic tilt; (2) the presence of appropriate weight-bearing surfaces for the thighs and feet that fully support the segment

without impinging on circulation or limiting joint range of motion at the hips, knees, or ankles; and (3) vertical alignment of the upper body. Modifications made to achieve the intervention position included provision of a custom back cushion and soft lateral supports, adjustment of the seat back angle to 90 relative to the seat base, adjustment of the foot plate angle and height such that knee angle approached 90, and physical readjustment of the participants position in the push chair.

Outcomes Monitored: The outcomes to be monitored in this study are frequency of accurate selection and response time to accurate selection. Frequency of accurate selection is defined as the number of times the client was able to correctly follow the spoken instruction. The response time to accurate selection is the time from when the spoken instruction is given up to the completion of this instruction. Response time was recorded only for accurate responses. Using a stopwatch, the researcher (Costigan) recorded response time to accurate selection for each accurate selection trial from session videotapes. Does the study focus on a significant problem in clinical practice? The study focused on a significant problem in clinical practice. The study focused on the effect of seated position to upper extremity function to be able to help a child with cerebral palsy to express their self using augmentative and alternative communication (AAC). AAC is defined as strategies, devices, and techniques that supplement or replace vocal or written communication IV. Methodology/Design Methodology used: The methodology used is quantitative. Design: the study used a single-subject ABAB design with 1 participant

Setting: Ontario, Canada

Data sources: Nwaobi O. M. (1987) Seating orientations and upper extremity function in children with cerebral palsy. Physical Therapy 67:12091212 Pope P. M., Bowes C. E., Booth E (1994) Postural control in sitting the SAM system: Evaluation of use over three years. Developmental Medicine and Child Neurology 36:241252 McEwen I. R.,Lloyd L. L (1990) Positioning students with cerebral palsy to use augmentative and alternative communication. Language, Speech, and Hearing Services in Schools 21:1521 Subject selection: The inclusion criteria were (1) diagnosis of CP; (2) age 117; (3) use of a wheelchair for mobility; (4) use of AAC or potential to benefit from AAC; (5) ability to follow one-step instructions given in English; (6) ability to directly select targets from an AAC device using the hands; and (7) presence of motor skill limitations likely to affect accuracy, speed of target selection, or both in direct selection. Parents of potential participants, teachers, and other professionals were consulted to determine adherence to Criteria 14.

Has the original study been replicated? No, the study has not been replicated. What were the benefits of the nursing action/interventions tested in the study? This study aims to help children with cerebral palsy to assist in learning. Other studies showed that seating position improves upper extremity function. V. Results of the study Cole was 100% accurate in selecting the upper right target during intervention (i.e., a mean of 2 of 2 accurate selections per session), but he was only 25% accurate in this location at baseline (i.e., mean of 0.67 of 2 accurate selections per session in the A1 phase and mean of 0.33 of two accurate selections per session in the A2 phase). Response time was recorded on only three to four selections during the A phases and five to seven selections during the B phases because of Coles low frequency of accurate selection. Recorded response times to accurate selection were highly variable within phases (i.e., A1: mean = 8.28 s, range = 1.3615.56 s; B1: mean = 8.14 s, range = 1.3119.80 s; A2: mean = 6.10 s, range = 1.2714.27 s; B2: mean = 7.00 s, range = 1.4519.80 s). Given the small number of measures collected and the high variability observed, further analyses were not conducted on these data.

VI. Authors conclusions/recommendations A seated position that ensured a neutral pelvic position, appropriate weight-bearing surfaces, and vertical alignment of the upper body was successful in improving access to a computerbased AAC device for a child with CP. Thus, this study provides important preliminary empirical evidence of the influence of seated position on access to AAC. Future research should strive to confirm the positive effect of the intervention position across other participants, dependent measures, and assistive technologies. A saddle seat improved alignment and postural control of the upper body and reduced the reaching path of children with CP compared with a flat bench. What contribution to client health status does the nursing action/intervention make? The study can promote the upper extremity function of a pedia cerebral palsy patient with quadriplegia. This can promote the augmentative and communication skills of the patient so that they can easily express their needs. What overall contribution to nursing knowledge does the study make? The study would give additional knowledge on VIII. Reviewers conclusion/commentary The study can be a great help to cerebral palsy patient with quadriplegia or any other types of paralysis and weakness, not only in children but also in adults. Positioning to prevent bed sores and pneumonic problems can be lessen and would be easier to facilitate through using this AAC device. Change instructions in accordance to the level of understanding of the patient.

IX. Evaluating Nursing Practice 1. Safety The intervention is safe for patients with cerebral palsy. Cushions and footplate were added to the specialized chair for the patients safety and also, professionals with seating expertise, such as an occupational therapist were included in the intervention. 2. Competence of the care provider The intervention included professionals with seating expertise, such as an occupational therapist. Moreover, other professional members of the AAC team (e.g., speech language pathologists) require basic knowledge of seating to address simple issues for people with mild motor impairments and to identify the need for expert involvement for those with greater impairments. Vigilance in ensuring a functional seated position were accomplished through regular seating analyses and modifications as demonstrated in this study and education of the individual, his or her family, and caregivers. 3. Acceptability

The study has been accepted because there is no ethical concern affected or violated. Further studies and greater no. of participants must be encourage for the study to be more accepted. 4. Effectiveness The study has been proven effective upon maximizing the upper extremity functions of a patient with Cerebral palsy with manifestation of Quadriplegia. . 5. Appropriateness The study is appropriate for helping children with cerebral palsy wherein their upper extremity functions are limited because of their condition. Especially for the said participant who is quadriplegic and has compromised motor functions, the intervention helps on promoting upper-extremity movement through simple modifications to the participants typical seating. 6. Efficiency The intervention was efficacious in improving the upper extremity functions for a child with cerebral palsy. It is possible that the intervention position in this study was well suited to the participant and may not necessarily apply to other children with CP. Replication of results with a larger group of children with CP would support the efficacy of the conventions of functional seating in improving access to AAC. 7. Accessibility The study used a special chair designed to support the body of a patient with cerebral palsy. Putting the patient in the specified position is not enough but it needs support to sustain the said position for a longer time. This is the reason why the study is not that applicable especially those people who dont have enough resources to avail the specialized chair.

8. Safety The intervention is safe for patients with cerebral palsy. Cushions and footplate were added to the specialized chair for the patients safety and also, professionals with seating expertise, such as an occupational therapist were included in the intervention. 9. Competence of the care provider The intervention included professionals with seating expertise, such as an occupational therapist. Moreover, other professional members of the AAC team (e.g., speech language pathologists) require basic knowledge of seating to address simple issues for people with mild motor impairments and to identify the need for expert involvement for those with greater impairments. Vigilance in ensuring a functional seated position were accomplished through regular seating analyses and modifications as demonstrated in this study and education of the individual, his or her family, and caregivers.

10. Appropriateness The study is appropriate for helping children with cerebral palsy wherein their upper extremity functions are limited because of their condition. Especially for the said participant who is quadriplegic and has compromised motor functions, the intervention helps on promoting upper-extremity movement through simple modifications to the participants typical seating. 11. Efficiency The intervention was efficacious in improving the upper extremity functions for a child with cerebral palsy. 12. Accessibility The study used a special chair designed to support the body of a patient with cerebral palsy. Putting the patient in the specified position is not enough but it needs support to sustain the said position for a longer time. This is the reason why the study is not that applicable especially those people who dont have enough resources to avail the specialized chair. References: http://informahealthcare.com/doi/abs/10.1080/17483100701661314 http://informahealthcare.com/doi/abs/10.1080/17483100701661314 http://ajot.aotapress.net/content/64/4/596.full