EVIDENCE BASED RATIONALE PAPER 1

Evidence-Based Rationale

Master of Science in Occupational Therapy, Pacific Northwest University of Health Sciences

Alexis Smith, Cassidy Crider, & Austin Walker

OTH 535: Environment, Technology, and Occupation

Dr. Wendell Nakamura

April 9th, 2024

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Evidence-Based Rationale

Assistive Technology Prescription

The Tobii Dynavox is a communication device that will be effective in addressing

Remy’s communication goals. This assistive technology (AT) device is available in many

models, but for Remy, the TD Snap 1-16 model was the most appropriate fit. The specs for this

specific device include a 15.6” screen with 1920x1080 pixel (FHD), an overall size of

39.1x26.9x8.1 cm with a square shape and weight of about 2.7kg or 6lbs (Tobii Dynavox US,

2024). Additional features include multiple access methods, outdoor eye tracking, powerful

speakers, and a partner window screen on the back. There are many other unique features for a

user to use when navigating the device that can be found within the manual. With these features,

the Tobii Dynavox is built for independence and a range of communication styles.

The Tobii Dynavox compensates for various communication barriers, which enhances the

user's social interaction skills. Our client, Remy, has a diagnosis of Ataxic Cerebral Palsy (CP)

resulting in fine and gross motor difficulties. Remi also has a diagnosis of dysarthria, meaning he

has difficulty using the muscles used for speech, making it hard for him to verbally produce

words. The Dynavox is a more dynamic and suitable device than a Picture Exchange

Communication System (PECS), which Remy’s currently uses for communication. We observed

Remy’s need for assistance when turning the PECS pages, as well as localizing on a certain

picture while communicating. Remy’s mother has spent many hours working with him in

understanding specific verbal sounds that can now be expressed clearly through this device, this

creates a more independent relationship, rather than relying on his mother for interpretation.

Therefore, this device will allow Remy to initiate and terminate communication with others. It

will also allow him to accurately produce speech that others can understand accompanied by his
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nonverbal communication methods. Different from the PECS, the Dynavox promotes proper

ergonomics while the device is in use. This also promotes optimal body posture when

communicating with other people. Typing is another skill that is enhanced by this device. In

addition, Remy will be able to write his school assignments and participate in his dream of

narrative storytelling using eye gaze technology.

To operate and set up this device, Remy may need a caregiver/support present to assist

with device access through touch screen, which is always active, for simultaneous partner use.

The caregiver may also assist in maintaining proper ergonomics throughout use. Due to Remy’s

spasticity, his fine motor control is compromised, leading to difficulties navigating the device

through touch. In addition, his ability to position his body in midline in his wheelchair with

minimal assistance supports the optimal position for usage of the eye gaze. Once the device is in

eye gaze, Remy possesses the visual, cognitive and process skills needed when operating the

device, selecting relevant icons, and self-educating using the manual (American Occupational

Therapy Association [AOTA], 2020).

Intervention and the Human Activity Assistive Technology Model

The Human Activity Assistive Technology (HAAT) models core concepts provide a

simple and clear description of the AT prescription process. This model continues to be

developed with new theoretical components integrated, with respect to the conceptual framework

for the interaction between the person and AT (Giesbrecht, 2013). This framework guided our

process of identifying AT with respect to our clients personal and social contexts. Remy’s

strengths include his cognition and sensory skills to participate in daily activities. The barriers

our client faced were the physical capabilities of fine and gross motor functioning related to his

diagnosis of ataxic cerebral palsy. Our clients' main concern was communicating with others in
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different settings, more specifically in school settings. The simplicity of the system did not

accurately portray or include all the words needed to communicate his personal wants, needs or

expectations. By incorporating the human, activity, and assistive technology contexts, we

identified strengths and barriers of the desired activity and chose the AT tech that was most

suitable for Remy to accomplish his communication goals for increased independence.

Addressing Occupational Performance

The performance patterns addressed by the Dynavox are roles, rituals and routines. The

role as a student, son, and friend is enhanced by having further communication and participation

in his expected daily activities throughout school and the community. His rituals are enhanced by

being able to accurately express his thoughts. The Occupational Therapy Practice Framework:

Domain and Process- Fourth Edition gives an example of how communication changes rituals.

“Shares a highlight from the day during evening meals with family” (AOTA, 2020). This AT

allows our client to effectively communicate with his words, emotions and thoughts with others

in different settings, increasing his opportunity for socialization and participation in different

activities of interest to him. Additionally, his routines change due to the transfer from a PECS

method to an eye gaze AT method. The client factors are indirectly impacted by this device. The

dynavox increases the opportunity to communicate and participate in activities. This can impact

his values, beliefs and spirituality. The environment category, specifically products and

technology are greatly impacted by this device. Using this device will create more opportunities

for him to participate in communication, education, and future aspirations such as employment

or finance management. This form of communication builds upon existing relationships and

increases the opportunity for future relationships. From our session, we observed how this

opportunity to use AT impacted him and his family’s attitude. They showed excitement,
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optimism and were eager to begin using this system to communicate and increase independence

with his activities of daily living performance.

Assistive Technology Intervention Literature Review

There is a significant amount of evidence that supports the benefit of AT use for

individuals with CP. Additionally, there are many methods used for individuals to operate AT.

These methods consist of touch, switch, multiple switches, eye gaze, and sip and puff. Different

methods work for different individuals; therefore, it is our professional opinion to fit each

individual properly, considering their direct needs. For Remy, the best fit is the eye gaze method.

With this method, Remy will be able to control the screen with just his eyes.

Individuals with CP often have dysarthria which can cause slurred speech, poor voice

quality, and/or no intelligible speech, making it very difficult to communicate (McFadd

&Hustad, 2020). This can be very frustrating to the individual as they are cognitively

neurotypical. The transition from middle school to high school is a crucial time in life when it is

necessary to communicate with teachers and peers. A study conducted by Chung et al. concluded

that with high tech augmentative and alternative communication (AAC) systems such as the

Dynavox, individuals with disabilities could communicate with anybody (Chung et al., 2012).

This just goes to show that the use of AT can have a tremendous impact on an individual's health

and well-being by being able to communicate with people they may not have been able to

communicate with before. Furthermore, many of the participants stated that the AAC device

assists with success in their lives in regard to work and future relationships.

When looking at a communication device for an individual, it is important to look at what

device will fit best for the client throughout the lifespan. Avagyan et al. (2021) found that AAC
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interventions have proven to be effective in improving communication throughout the lifespan in

individuals with CP. As occupational therapists, it is our desire to provide clients with the most

effective way for them to function independently. In this case, providing Remy with the device

best suited for him to be able to communicate now as well as in the future. Remy demonstrated

the willingness to learn a new device and to communicate with others, especially in school more.

In school and future careers, Remy will be able to use the Dynavox to communicate with those

around him.

As previously stated, the Dynavox use along with the eye-gaze feature will be best suited

for Remy. Borgestig et al. (2021), found that the use of an Eye-Gaze Controlled Computer

(EGCC) “can be an effective intervention in daily life for children and young people with

complex needs” (p. 511). They also stated that the participants “increased their expressive

communication skills and functional independence” (p. 511). Regarding Remy, it is necessary

that he is provided with the most effective way for him to be independent in communication.

Children with complex communication difficulties tend to be more respondents than initiators.

Using AT such as the Dynavox with eye gaze allows individuals to initiate conversations and

provide more information during the interactions (Hsieh et al., 2021). This will allow Remy to

initiate and conclude conversations with peers and teachers while at school more personally and

directly than with PECS. Due to the barriers associated with ataxic cerebral palsy, the eye gaze

option in this device allows Remy to communicate while reducing fatigue in extremities that he

has currently been using with the PECS system.

In conclusion, research suggests that the impact of AT is crucial for individuals with

complex needs to participate in activities they want to, need to and are expected to do. The direct

impacts from AT include participation from the individual in communication, improved quality
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of life, and increased independence. Indirect benefits include some relief of caregiver burden and

improving Remy’s mental health through social participation. Remy will be able to communicate

in a way that he hasn't been able to before and the use of Dynavox with the eye-gaze feature will

address his previous communication challenges and his desire to be more independent with his

daily life activities.

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References

American Occupational Therapy Association. (2020). Occupational therapy practice framework:

Domain and process (4th ed.). American Journal of Occupational Therapy, 74(2),

7412410010. [Link] Org/10.5014/ajot.2020.74S2001

Avagyan, A., Mkrtchyan, H., Shafa, F. A., Mathew, J. A., & Petrosyan, T. (2021). Effectiveness

and determinant variables of augmentative and alternative communication interventions in

cerebral palsy patients with communication deficit: A systematic review. CoDAS, 33(5),

e20200244. [Link]

Borgestig, M., Al Khatib, I., Masayko, S., & Hemmingsson, H. (2021). The Impact of Eye-gaze

Controlled Computer on Communication and Functional Independence in Children and

Young People with Complex Needs – A Multicenter Intervention Study. Developmental

Neurorehabilitation, 24(8), 511–524. [Link]

Chung, Y., Behrmann, M., Bannan., Brenda, & Thorp, E. (2012). Perspectives of high tech

Augmentative and Alternative Communication Users with Cerebral Palsy at the Post-

Secondary Level. Perspectives on Augmentative & Alternative Communication, 21(2),

43–55.

Giesbrecht, E. (2013). Application of the Human Activity Assistive Technology model for

occupational therapy research. Australian Occupational Therapy Journal, 60. 230-

240. [Link]

Hsieh, Y.-H., Borgestig, M., Gopalarao, D., McGowan, J., Granlund, M., Hwang, A.-W., &

Hemmingsson, H. (2021). Communicative interaction with and without eye-gaze

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technology between children and youths with complex needs and their communication

partners. International Journal of Environmental Research and Public Health, 18(10).

[Link]

McFadd, E. D., & Hustad, K. C. (2020). Communication Modes and Functions in Children with

Cerebral Palsy. Journal of Speech, Language & Hearing Research, 63(6), 1776–1792.

[Link]

Tobii Dynavox US. (2024, April 1). Assistive Technology for Communication. tobiidynavox.

[Link]