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1 CRITICALLY APPRAISED PAPER (CAP) Wu, W., Wang, C., Chen, C., Lai, C., Yang, P., & Guo, L. (2012). Influence of therapy ball seats on attentional ability in children with attention deficit/hyperactivity disorder. Journal of Physical Therapy Science, 24(11), CLINICAL BOTTOM LINE Occupational therapists frequently use sensorimotor interventions, including adaptive equipment used in the classroom to improve attention. Measuring whether such equipment improves a child s attention can be challenging because of potential biases in teacher-reported outcomes and subjective observational biases. Measuring attention through analysis of a child s brain waves, including the P300, can provide objective, direct evidence of attention responses. This study examined children s attention to a task while they were sitting on a therapy ball, compared with sitting in a traditional classroom chair. The study included children with attention-deficit/hyperactivity disorder (ADHD) as well as children who were typically developing. Using a ball chair improved attention for children with ADHD in this study. Exploring adapted seating options may be appropriate as an environmental adaptation in the classroom for children with ADHD. Adapted seating options include the use of a ball chair, stability ball, air cushion, or other inflated seating that provides movement similar to the stability ball used in this study. Findings are limited because the research occurred in an isolated environment, not in a natural classroom environment, where more distractions are likely present. RESEARCH OBJECTIVE(S) Determine the effectiveness of a ball chair versus a regular chair for increasing attention among children with ADHD, as measured by participants brain-wave response (P300) and reaction time to an auditory oddball task DESIGN TYPE AND LEVEL OF EVIDENCE 1

2 Level II: Two groups, nonrandomized PARTICIPANT SELECTION How were participants recruited and selected to participate? Participants were recruited from a local hospital or rehabilitation clinic. The researchers did not report specific recruitment methods. The control group came from a local school. Inclusion criteria: Participants in the experimental group had been diagnosed with ADHD at a hospital or local rehabilitation clinic. Exclusion criteria: A combined diagnosis, such as autism PARTICIPANT CHARACTERISTICS N= 29 (15 ADHD, 14 control) #/ % Male: ADHD group: 11/73% Ethnicity: Control group: 7/50% Disease/disability diagnosis: #/ % Female: ADHD group: 4/26% Control group: 7/50% Intervention group: Children with ADHD Control group: No disability INTERVENTION AND CONTROL GROUPS Group 1: Intervention group Brief description of the intervention How many participants in the group? Where did the intervention take place? Participants sat on a 48-cm ball with feet flat on the floor, with the ball slightly deflated to ensure proper positioning. Auditory tones were issued from a sound-operating system. Children were instructed to press a button on a held trigger for a high-pitch tone and to do nothing for a low-pitch tone. All 2

3 Who delivered? How often? For how long? Three test sessions Participants heard 120 nontarget and 30 target tones, with no 2 target tones occurring consecutively. The task lasted approximately 5 minutes. Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Participants sat on a standard wooden classroom chair. Auditory tones were issued from a sound-operating system. Children were instructed to press a button on a held trigger for a high-pitch tone and to do nothing for a low-pitch tone. All Three test sessions Participants heard 120 nontarget and 30 target tones, with no 2 target tones occurring consecutively. The task lasted approximately 5 minutes. INTERVENTION BIASES Contamination: Contamination bias was not directly reported; however, the researchers used a protocol for each group and each participant. Co-intervention: Timing of intervention: Site of intervention: No students with ADHD were taking medication during the study. Participants took a medication holiday during the study. Each group received the same protocol; therefore, the control group did not inadvertently become exposed to an intervention. All interventions occurred at the same site. 3

4 Use of different therapists to provide intervention: Not reported directly in the article Baseline equality: YES Groups were matched to be similar in height, weight, and age. MEASURES AND OUTCOMES Measure 1: Electroencephalography Name/type of measure used: What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? Measure 2: Reaction time Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Electroencephalography (EEG) P300 waves, which are brain waves required in the decision-making process Not Reported Not Reported Measured continuously during the auditory experiment while the participant was seated on the ball chair or wooden classroom chair. Reaction time Measure 3: Accuracy of responses Name/type of Time in milliseconds from target tone to when child activated the trigger Not Reported Not Reported Measured continuously during the auditory sound experiment Accuracy of responses 4

5 measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Ratio of correct responses to total number of target tones Not Reported Not Reported Measured continuously during the auditory experiment MEASUREMENT BIASES Were the evaluators blind to treatment status? Was there recall or memory bias? Explanation: Each child sat on both the ball chair and the classroom chair. The authors did not disclose whether the examiner knew which diagnosis group each child belonged to (ADHD or no diagnosis). Explanation: Participants responded to a stimulus and thus were not required to recall information. Other measurement biases: (List and explain) RESULTS List key findings based on study objectives: Children without ADHD had a faster reaction time in the standard classroom chair compared with children with ADHD. Children with ADHD had a faster reaction time on a therapy ball when compared with a standard classroom chair. Accuracy between the two groups was not statistically significant. Children with ADHD had a shorter P300 latency on the ball chair compared with a typical classroom chair and demonstrated delayed latency in the typical classroom chair. Was this study adequately powered (large enough to show a difference)? 5

6 Not reported in the article Were the analysis methods appropriate? (Check yes or no, and include a brief explanation) YES Researchers used two-way repeated-measures analysis of variance, an appropriate measure of determining differences between the two groups. Were statistics appropriately reported (in written or table format)? YES Results were reported in written form, with information on average measurements and level of statistical significance. Was participant dropout less than 20% in total sample and balanced between groups? YES NO No participants dropped out. What are the overall study limitations? This study was conducted in a controlled environment, which limited the influence on the data of other distractions that might occur in typical classrooms. The sample size was small compared with the general population. Demographic data on geographical location were not reported. The researchers did not specifically state other limitations. CONCLUSIONS State the authors conclusions related to the research objectives. The researchers sought to determine whether children with ADHD demonstrated improved attention, as measured by P300 brain-wave EEG data, when sitting on a therapy ball, compared with a regular classroom chair, and to compare findings with children who were typically developing. Findings revealed that for children with ADHD, sitting on a therapy ball did increase their attention and reaction time to a novel task, compared with a typical classroom chair. Children without ADHD had a faster reaction time on a ball chair compared with children with ADHD. The accuracy was not different between the two groups, which indicates that response times might have been different but that the response time did not affect the child s accuracy. In regard to attention, therapy-ball chairs improved attention among children with ADHD. Overall, a ball chair may improve attention and learning outcomes for some children with ADHD in a controlled environment, but further research is needed regarding implications for these findings in a natural school classroom environment. Future researchers should also include occupation-based outcome measurement in tandem with EEG measurement. 6

7 This work is based on the evidence-based literature review completed by Joy Burkley, MS, OTR/L, and Sarah L. Smith, DSc, OTR/L, faculty advisor, Creighton University. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 7

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