The Kawa Model in Neurology


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The Kawa Model applied in Neurological Setting

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit
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  • After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
    Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube.
    Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.
    Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.
    Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.
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The Kawa Model in Neurology

  1. 1. Occupational Therapy Case Presentation (Neurology)<br />Prepared by: Teoh Jou Yin (A 118729)<br /> Occupational Therapy Programme<br /> Faculty of Allied Health Sciences<br /> National University of Malaysia<br />Occupational Therapy: Helping people live lives THEIR way.<br />~ British Association of Occupational Therapy<br />
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  3. 3. What is Occupational Therapy’s role?<br />To FACILITATE / ENABLE / EMPOWER clients to engage and participate in life processes and activities that are important and of value to them, i.e. to do the things in life that they want to do and need to do.<br />(Teoh et al. 2010)<br />How to do that?<br />
  4. 4. CONCEPTUAL MODEL<br />OF PRACTICE<br />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.<br />(Iwama 2010)<br />
  5. 5. The Kawa Model<br />The essence of the Kawa Model (Iwama 2006) is basically to enable occupational therapists everywhere to “just ask the client how they want to live their lives so that it is more meaningful to them, and look together with them at what we can do to achieve that.”<br />The Kawa Model can be used as a conceptual model of practice, frame of reference, assessment tool and modality. (Iwama 2010)<br />It can be used with any population since it is based on the client's own perceptions of what is important to them, and the only possible contraindication is an occupational therapist unskilled in the therapeutic use of self.<br />DISCUSS THE KAWA MODEL ON FACEBOOK!<br /><br />
  6. 6. FRAMES OF REFERENCE<br />FORs can be defined as the principles behind practice specific to a client population.<br />FORs include a statement of the population to be served, guidelines for determining adequate function or dysfunction, and principles for remediation. <br />(Bruce & Borg 1987)<br />
  7. 7. Neuro Developmental Frame of Reference (Pendleton & Schultz-Krohn 2006)<br />Neuro: brain function<br />Developmental: Components of movement required to develop.<br />Core principles:<br />Individualize functional outcomes – provide interventions specfic to client’s context.<br />Emphasise motor control – quality of movement<br />Increase active use of the involved side – manual cues and progressive challenge<br />Provide Practice to improve motor performance leading to motor learning.<br />24 Hour management to increase retention and turnover.<br />Interdisciplinary approach. <br />
  8. 8. OCCUPATIONAL THERAPY<br />PERFORMANCE FRAMEWORK<br />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.<br />(AOTA 2008)<br />
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  11. 11. Kawa Interview (23/9/2010, 30/9/2010)<br />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.<br />
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  17. 17. AREAS OF OCCUPATION<br />Categories articulating “the many types of occupations in which clients might engage” (AOTA 2008)<br />Activities of daily living (ADL), Instrumental activities of daily living (IADL), Rest and sleep, Education, Work, Play, Leisure, Social participation<br />
  18. 18. Areas of Occupation<br />1. Activities of Daily Living (MBI) – 23.9.2010<br />
  19. 19. CLIENT FACTORS<br />Specific abilities, characteristics or beliefs that reside within the client and may affect performance in occupation. (AOTA 2008)<br />Values, beliefs & spirituality; body functions; body structures<br />
  20. 20. Client Factors: Body Functions<br />Neuromuscular skeletal and movement related functions<br />Dominant hand: Rt Affected hand: Rt <br />Joint Range of Motion: (23 / 9 / 10)<br />Lt UL AROM: full<br />Rt UL ROM:<br />1. Shoulder external rotation: AAROM 90, AROM 502. Shoulder abd/add: AAROM 80, AROM 603. Shoulder Extension: AROM 20,4. Shoulder Flexion: AAROM 120, AROM 20 (will produce compensatory movements)5. Elbow: AAROM 70-160, AROM 70-1106. Forearm: No movement, remains in supine postition7. Wrist: No movement.<br />Muscle Tone (Modified Ashworth Scale)<br />Right arm and forearm: 0 / 5<br />Right wrist and fingers: 3 / 5<br />Left upper limb: 0 / 5<br />
  21. 21. Activity Demands<br />Specific features of an activity that influence the type and amount of effort required to perform the activity. (AOTA 2008)<br />
  22. 22. Activity Demands (Activity Analysis) – 30 / 9 / 10<br />#1 Ambulation- pt walks with abnormal gait- rt knee straightened- rt hip in abduction- rt ankle shows eversion when lowering foot#2 Toileting- pt's toilet and bathroom layout was evaluated and drawn out- pt's tap and hose is on rt side of toilet bowl, towards the back end close to the wall.- pt has difficulty reaching for hose with left hand.- pt does not use toilet paper at home- pt can wash self using hose only, but not clean enough as unable to douche with other hand- pt is able to wipe self and put on garments including panties.<br />
  23. 23. Contexts & Environments<br />The variety of interrelated conditions surrounding the client in which the client’s daily life activities occur. (AOTA 2008)<br />
  24. 24. Home (Bathroom Assessment) – 30 / 9 / 10<br />Problems:<br /><ul><li>Client unable to reach for pipe to wash after toileting.
  25. 25. Client might have safety concerns getting up from toilet bowl
  26. 26. Client at risk of falls (instable gait + potentially slippery floor due to shower area being right in front of toilet bowl).</li></li></ul><li>INTERPRETATION<br />Identifying and prioritising AIMS.<br />STEP 3: IDENTIFYING AND PRIORITISING AIMS.<br />
  27. 27. Long Term Goals<br /> To regain participation and engagement and participate in life processes and activities that are important and of value to client.<br />
  29. 29. Problem: Client has safety concerns: fear of falls. (30/9/10)<br />Aim: To address safety concerns during functional ambulation.<br />Intervention: Gait training (Pendleton & Schultz-Krohn 2006)<br />Method:<br /><ul><li> Pt was given prompts to raise knee while walking, hip will naturally align into proper position.
  30. 30. Pt was also given prompts to invert ankles when lowering foot.
  31. 31. Duration for practice was also provided: 10 mins.
  32. 32. Therapist uses modelling, walking alongside patient at a diagonal angle in order for patient to mimic movements.
  33. 33. Carer was also educated to observe patient movements during ambulation in order to provide cues when appropriate.</li></li></ul><li>Problem: Client is experiencing disengagement from therapeutic process. (Noted since 23/9/10)<br />Aim: To involve client in more participatory role in therapeutic process.<br />Intervention: Collaborative Goal Setting Activity between therapist and client. (30/9/10)<br />Method:<br /><ul><li>Pt was asked to evaluate and express feelings about progress in therapy from referral and first visit to present.
  34. 34. Pt was then educated on why she has to take responsibility and initiative to perform home programme
  35. 35. i.e. that once a week therapy was insufficient, that she cannot depend on therapist entirely to take responsibility for her recovery.
  36. 36. Pt was encouraged to set timeline for herself to evaluate progress with goals
  37. 37. Metaphor of running a race and training for race so can reach finish line was used.</li></ul>It is not what the therapist “does” to the patient, but how the client takes on board the info presented and uses it himself. (Cotton 2005)<br />
  38. 38. Problem: Client has difficulty with emotional regulation (easily anxious) to extent of affecting performance.<br />Aim: To develop emotional regulation strategies for anxiety.<br />Intervention: Relaxation techniques are incorporated into home programme i.e. deep breathing and imagery. (30/ 9/ 10)<br />Method:<br /><ul><li>Pt is taught to exhale when performing movements that are more strenous (i.e. require high muscle tension) and inhale for less strenous movements.
  39. 39. Pt is also taught to close eyes and take deep breaths when aware that she is beginning to feel anxious.
  40. 40. While closing eyes, client is taught to think of calming soothing images i.e. beachside scenery, etc.
  41. 41. Outcomes: Pt is now able to perform movements smoothly and easily with minimal fatigue. </li></ul>Source: Conscious Relaxation (Cotton 2005)<br />
  42. 42. Problem: Client wants to regain hand function in affected hand.<br />Aim: To regain hand function in affected hand.<br />Intervention: Bilateral isokinematic training (Cotton 2005) - 23 / 9 / 10<br />Method:<br />- Air splint was first applied to affected hand to address flexor synergy.<br /><ul><li> Visual imagery was used, together with deep breathing.
  43. 43. Pt was asked to relax, close eyes, and visualise both hands opening and closing in slow, controlled movements. (Fine motor movements.)
  44. 44. Gross motor movements were addressed by means of shoulder extension exercises (both hands clasped together.)
  45. 45. Pt was also educated about purpose of activity and how to perform it at home.
  46. 46. Pt was also encouraged to involve affected side in typical everyday movements i.e. wiping, raising hand to switch, etc.</li></li></ul><li>Problem: Client neglects to use affected hand in daily activities and to perform therapeutic exercises as prescribed.<br />Aim: To correct learned non-use of affected hand.<br />Intervention: To develop home programme that is appropriate to client’s condition and life schedule. (23 / 9 / 2010)<br />Method:<br /><ul><li>Client’s daily life schedule was evaluated via interview.
  47. 47. Pt is taught to make use of television viewing times as home programme exercise times.
  48. 48. Pt watches tv at 11am, 6pm and 10pm.
  49. 49. Pt was told to perform programme throughout the entire duration of the show (typically 1 hour.)- Exercises as taught in bilateral isokinematic training are applied into home programme (gross and fine motor movements.)</li></ul>Rationale: According to Bobath principle to provide interventions specfic to client’s context. (Pendleton & Schultz-Krohn 2006)<br />
  50. 50. Reevaluation (30/9/2010)<br />Activity Analysis - Execution of home programme (Upper extremity gross motor movements, bilateral shoulder raises.)<br />Aim: To identify possible reasons why pt is not compliant to home programme.<br />Method: Pt is asked to demonstrate how she performs exercises at home.<br />Findings: Pt is easily agitated when trying to perform movements, will tense muscles and hold breath, causing easy fatigue. <br />To address: Pt was taught to utilise proper body movements and alignment and incorporate with emotional regulation exercises. Rhythmic breathing was also taught. (Cotton 2005)<br />
  51. 51. Prognosis<br />Good.<br />Client has good environmental supports, however much depends on client’s internal locus of control and ability to engage as active part of therapeutic process. Further therapy recommended to address psychosocial issues especially by means of therapeutic use of self.<br />Future Plans<br />Continue occupational exploration.<br />Home visit.<br />Reevaluate interventions.<br />Further assessment of hand disabilities.<br />Community mobility.<br />Driving assessment.<br />
  52. 52. "We simply come into (our clients‘) lives as a visitor/tourist - short period.“<br />~ Dalai Lama<br />Further Questions or Discussion?<br /><br />Dr Michael Iwama will be happy to hear from you.<br />(As well as 1500+ OTs from 6 continents all around the world.)<br />