My presentation to the occupational therapists in Hospital Sungai Buloh (Bamboo River) about the Kawa (River) Model

1. Occupational Therapy Case Presentation (Medical setting) Prepared by: Teoh Jou Yin (A 118729) Occupational Therapy Programme Faculty of Allied Health Sciences National University of Malaysia Occupational Therapy: Helping people live lives THEIR way. ~ British Association of Occupational Therapy

3. Diagnosis: Inclusion Body Myositis (IBM) Inclusion body myositis (IBM) is an inflammatory muscle disease characterised by slowly progressive weakness and wasting of both distal and proximal muscles, most apparent in the muscles of the arms and legs. There are two types – sporadic inclusion body myositis (sIBM) and hereditary inclusion body myopathy (hIBM) The common type is sIBM and it strikes individuals apparently at random. The disease in itself is not fatal, but the sequelae (loss of function and mobility, causing a high risk for falls and dysphagia) can be dangerous. (Source: Wikipedia)

4. CONCEPTUAL MODEL OF PRACTICE Conceptual models of practice describe phenomena of interest like “occupation” or “occupational performance”, guide treatment approaches by easily allowing therapists to focus on the right problem areas, and help to predict outcomes in clinical interventions. (Iwama 2010)

5. The Kawa Model The essence of the Kawa Model (Iwama 2006) is basically to enable occupational therapists everywhere to move beyond the construct of "occupation" and its implications in various cultural contexts, yet still be able to adhere their practice as closely to the mandate of occupational therapy as is possible - which is to “support health and participation in life through engagement in occupation.” (AOTA 2008) Occupations: Activities that one participates in a day-to-day basis which are important and of value to us. (AOTA 2008) Let’s just ask the client how they want to live their lives so that it is more meaningful to them, and let’s look together with them at what we can do to achieve that. ~ stuck on Dr Michael Iwama’s monitor bezel.

6. FRAMES OF REFERENCE FORs can be defined as the principles behind practice specific to a client population. FORs include a statement of the population to be served, guidelines for determining adequate function or dysfunction, and principles for remediation. (Bruce & Borg 1987)

7. Biomechanical Frame of Reference Based on kinesiology. Combines neuromuscular physiology, musculoskeletal anatomy and biomechanics. Involves graded programmes of exercise for restoring neuromusculoskeletal and movement-related functions to normal or optimum, i.e. joint ROM, strength and endurance. Techniques involved include resistance, repetition, duration, range, speed, etc. (Hagedorn 1997)

8. Occupational Adaptation Frame of Reference Focuses on enabling and engaging in occupations - “life activities that are purposeful and meaningful” (AOTA 2008) rather than functional activities and treating performance components. A functional life devoid of meaning is merely existence, not living. Robots perform tasks, people engage in life activities to create and derive meaning ~ Charles Christiansen (2010) Emphasises on “the creation of a therapeutic climate, the use of occupational activity, and the importance of relative mastery.” (Schultz & Schkade 1992) Utilises occupation-based intervention: A type of occupational therapy intervention in which the occupational therapy practitioner and client collaboratively select and design activities that have specific relevance or meaning to the client and support the client’s interests, need, health, and participation in daily life. (AOTA 2008)

9. OCCUPATIONAL THERAPY PERFORMANCE FRAMEWORK A summary of interrelated constructs that represent and guide occupational therapy practice and articulate occupational therapy’s contribution to promoting health and participation through engagement in occupation. (AOTA 2008)

11. EVALUATION SUBJECTIVE EVALUATION

12. Kawa Interview (27/7/2010, 9/8/2010) Blue - river - life flow and overall occupationsRed - river walls and floor - environments, social & physicalLilac - rocks - circumstances that block the river flow and cause dysfunction/disabilityYellow - driftwood - personal resources that can be assets or liabilities.

18. EVALUATION OBJECTIVE EVALUATION

19. AREAS OF OCCUPATION Categories articulating “the many types of occupations in which clients might engage” (AOTA 2008) Activities of daily living (ADL), Instrumental activities of daily living (IADL), Rest and sleep, Education, Work, Play, Leisure, Social participation

20. Areas of Occupation 1. Activities of Daily Living (MBI) – 8.9.2010

21. CLIENT FACTORS “specific abilities, characteristics or beliefs that reside within the client and may affect areas of occupation” (AOTA 2008)

22. Client Factors Body Structures (observation and examination on 9/8/2010) Client is obese at body weight of 75kg with high concentration of fat at the abdomen. Client shows eversion of feet and hip abduction. This results in her being unable to bear weight on the soles of her feet. Hip flexion is obstructed by abdominal fat. Body Function Neuromusculoskeletal Functions MMT for Knee flexion and extension (27/7/2010): 2 (left), (2 right) MMT for Knee flexion and extension (9/8/2010): 2 (left), 2 (right) MMT for hip flexion (8/9/2010): 2 (left), (2 right)

23. Sensory Functions and Pain Semmes Weistein Monofilament Test (9/8/2010 – Left side) – sensations are normal (2.83)

24. ACTIVITY DEMANDS “the specific features of an activity that influence the type and amount of effort required to perform the activity.” (AOTA 2008)

25. Activity Demands Functional Transfers (Sit-to-stand) – Task analysis Client reports that the process of sitting to standing during transfering often causes her a lot of difficulty. A task analysis has been carried out on 9/8/2010 to determine the causes of her difficulty. The results of the task analysis are as follows: Client has involuntary bilateral hip abduction which causes ankle eversion. While trying to stand from a sitting position, client’s knee is slightly extended with feet placed in front of knees.br />Heels are not parallel with knees. Client does not scoot buttock to edge of seat while attempting to stand. Client maintains trunk in extension while trying to stand, with body weight backwards. Posterior pelvic tilt.

26. INTERPRETATION OF DATA Aims

27. Prioritised Problem List Safety concerns in transferring 1(a). Risk of falls because of incorrect biomechanics in sit-to-stand task 1(b). Discomfort from pins and needle sensation in left foot in mornings. 1(c). Foot eversion on both lower limbs. 2. Difficulties in functional ambulation 2(a). Weakness in lower limbs 2(b). Inability to participate in physical exercise causing obesity 3. Difficulty in performing life activities (occupational performance) due to fatigue. 4. Health concerns as part of aging process, aggravated by current condition, which can affect occupational performance.

28. Short Term Goals Prevention of falls during transfer 1(a). Educate client in proper body mechanics during sit-to-stand task. 1(b). Educate client on how to prevent or reduce pins and needle sensation before getting out of bed in mornings 1(c). Educate client on proper footwear to address foot eversion. 2. Facilitate functional ambulation 2(a). Compensate for weakness in lower limbs with walker. 2(b). Graded, aerobic exercise programme with resistance focusing on upper limbs and trunk. 3. Improve performance in life activities (occupational performance) by applying fatigue management principles. 4. Prevent and reduce possible difficulties in future occupational performance by health complications which can occur with aging and degenerative condition.

29. Long Term Goals Facilitate aging in place. Enabling participation in activities involving community

30. INTERVENTION

37. Prognosis Good. Client has good social environment supports and many personal traits and resources that she is able to use to her advantage in coping with her degenerative condition. Awareness and education is most important and future considerations must be taken into account, especially as her current degenerative condition and obesity will amplify the complications that come with aging. Future Plans Regular reassessments. Maintain body functions. Home assessment. Environmental modification to facilitate aging in place. Community mobility assessment. Fall management programme (i.e. teaching how to get up from the ground)