A case study of Retinitis Pigmentosa in Low Vision setting using Kawa Model

1. KAWA MODEL
FACULTY OF HEALTH SCIENCES
NAME: KHOR WAI ON
MATRIX NUMBER: A124590
PROGRAM/YEAR: OCCUPATIONAL THERAPY/ 4TH YEAR
SUBJECT: NNNK 4065 ORIENTATION AND MOBILITY
CLINICAL PLACEMENT

2. INTRODUCTION
• According to ICD – 9:
– Retinitis Pigmentosa (RP) is a name to a group of
hereditary disease that cause degeneration of retina.
– Progressive deterioration:
1. Loss of night or low light vision due to affected Rod.
2. Peripheral vision may deteriorate until left only straight-ahead
or “tunnel vision”.
3. Cones concentrated in the center of the retina (macula) may
slowly lose function, resulting in central blurred vision lacking
color perception.
– A form of RP known as Usher's syndrome also causes
nerve damage creating deafness.
– Research underway for artificial retina & replacement
of defective genes.

3. PRELIMINARY INFORMATION
Description
Name Mr. M
Age 54
Gender Male
Marital status Married
Race Malay
Religion Islam
Occupation Admin assistant
Diagnosis Retinitis Pigmentosa
Date referred to OT clinic 19.4.12
Referred by Optometrist

4. KAWA MODEL
Ryuboku
(Driftwood)
Mizu (Water)
Iwa (Rocks)
KAWA Model was used as
conceptual model of
practice, frame of Torimaki: Kawa no
reference, assessment tool soku –heki (river
and modality to this client. side-wall) and Kawa
no zoko (river floor)

5. Mr. M’s Kawa
Phase 1: Active and
disease free.
Phase 2: married life,
Phase 4: Accident, DM started after.
RP gets severe
affecting more
aspects of life Phase 3: surgery at both legs.
Blur vision and hearing
problem started, RP detected.

6. WATER
(Life Flow and Overall Occupations)
Subjectively:
• Family History:
Client
– Among siblings, client was the only one with RP.
– Married at the age of 25.

7. WATER
(Life Flow and Overall Occupations)
• Medical History:
– Blur vision and partial hearing loss started since
2004 – detected RP
– Surgical history: both leg surgery in year 2004 due
to swelling at both legs.
– Other illnesses:
• DM 20 years back (Insulin injection)
• HPT (Given medication)
– Medication:
• Insulin injection

8. WATER
(Life Flow and Overall Occupations)
• Work History:
– Pre-morbid
• Client was a bus driver – One secondary school for over
10 years. .
– Post-morbid
• Switch job to administrative assistant in the same school
year 2009.
• Not planning to retire so soon.
• Leisure:
– Pre-morbid
• Gardening, travel around and jog in evening at park.
– Post-morbid
• Watching television, reading newspaper, and listening to radio.

9. WATER
(Life Flow and Overall Occupations)
• Routine:
Time Working Days Week Days
7.00 am Wake up, bath and Wake up, bath, watch
breakfast television and breakfast
8.00 am – 10.00 am Go to work Newspaper and nap
10.00am – 12.00pm Go back home and Lunch, newspaper and
lunch television
12.00pm – 3.00pm Newspaper and nap Newspaper and relax
3.00pm – 5.00pm Go back to work Listen to radio and nap
5.00pm – 10.00pm Dinner, television, and Dinner, television and
newspaper radio
10.00pm Sleeps Sleeps
* Client read 3 sets of newspapers a day.

10. WATER
(Life Flow and Overall Occupations)
Objectively:
• Self Care
– ADL using MBI scored 98/100 indicating minimum
dependency level – minimal supervision for stair
climbing.
– IADL scored 6/6, fully independent.
• Phone, shopping, housekeeping, mode of transportation,
medications, and finances.

11. ROCKS
Subjectively:
Visual
Risk of limitation
falls
Feel helpless
Unable to travel
around freely
Weakness
at legs
Berg’s Balance Test biVABA
Cross sectional view Mr. M’s river diagram

12. ROCKS
(Obstacles and challenges, Circumstances that block life flow
and cause dysfunction/disability)
Objectively:
• Balance – Assessed using Berg’s Balance Test scoring
40/56 indicates medium risk of falls.
• From assessment, noted that client losses balance
when:
– Sudden change of position.
– Standing with feet together or in-front of each other.
– Standing with one leg.
– Standing for more than 10 minutes.

13. ROCKS
(Obstacles and challenges, Circumstances that block life flow
and cause dysfunction/disability)
• From file:
– Distance vision RE 6/12 and LE 6/12
– Near vision N20@ 40 cm – able to read newspaper without
glasses on.
i. 1/12 for Right eye.
• Visual – Assessed using biVABA. ii. 1/12 for Left eye.
• From assessment, noted that: iii. 1/4 for both eyes
together
– Visual acuity – Snellen chart
– Client’s pupil does not constrict instantly in respond to light
stimulation. ( 1 – 2 minutes to respond)
– Size of pupil changes very slightly in respond to
accommodation.
– Visual field – unable to see in all 6 position for red dot.
– Kinetic 2 person confrontation test, client has limited vertical
visual field – only less than 10 degree for both eyes.

16. RIVER WALLS & FLOOR
Friends
School
House
Colleagues principle
Children Wife & physical
environment
Cross sectional view
Family Work
Mr. M’s river diagram

17. RIVER WALLS & FLOOR
(Physical and Social Environment)
• Social Environment:
1. Family
– Staying with wife, son and daughter.
– Currently son is the one that drives client around.
– Children has limited knowledge about client’s condition and
technique in sighted guide.
– If necessary, son will take leave to bring client for medical
check up, close relationship with client – can joke around.
– Wife will stop work and stay at home to take care of client
soon.

18. RIVER WALLS & FLOOR
(Physical and Social Environment)
2. Friends
– His used to go out and hang out with friends at restaurant.
3. Work
– Other colleagues that were new wasn’t satisfy with client.
– Client’s office table was situated at the end of the room with
clutters and narrow pathway.
– Client was not given much work in office.
• House Environment:
– 4th floor Flat without lift.
– Cemented stairs with handle.
– 2 Sitting toilet.

19. Strong sense Stable
Motivated to Reluctant to
of financial
remain active take medication
responsibility income
Self coping
Reluctant to use
skill
walking aids
DRIFTWOOD
Cross sectional view
Mr. M’s river diagram

20. Strong sense Stable
Motivated to Reluctant to
of financial
remain active take medication
responsibility income
Self coping
Reluctant to use
skill
walking aids
Visual
Risk of limitation
falls
Feel helpless
Unable to travel
around freely
Weakness
Friends at legs
School
House
Colleagues principle
Children Wife & physical
environment
Cross sectional view
Family Work
Mr. M’s river diagram

21. PROBLEM IDENTIFICATION
1) Client was not taking other medication – not knowing
implication.
2) Client reluctant to use walking aids – dignity.
3) Client was unable to travel freely - limited visual function
and has medium risk of fall due to weakness at both legs.
Visual function limitation includes:
i. Response to light.
ii. Response to accommodation.
iii. Limitation on vertical visual field.
4) Misunderstanding between client and colleagues due to
lack of psycho-education for both client and colleagues.
5) Feeling helpless - not able to perform effectively at work.

22. TREATMENT AIMS
Short Term Goal:
1. Educate client and care-giver – importance of
medication intake and the condition itself.
2. Reduce risk of falls – home and community.
3. To improve client’s mobility around community.
4. Increase client’s efficiency in work.
5. Improve social interaction between client and
other colleagues in work place.

23. Strong sense Stable
Motivated to Reluctant to
of financial
remain active take medication
responsibility income
Self coping
Reluctant to use
skill
walking aids
1
Visual
Risk of limitation
falls
Feel helpless
Unable to travel
around freely 2 4
5 Weakness
Friends at legs
3
School
House
Colleagues principle
Children Wife & physical
environment
Cross sectional view
Family Work
Mr. M’s river diagram

24. Strong sense Stable
Motivated to
of financial
remain active
responsibility income
Self coping
skill
Visual
Risk of limitation
falls
Unable to travel
around freely
Weakness
Friends at legs
School
House
Colleagues principle
Children Wife & physical
environment
Cross sectional view
Family Work
Mr. M’s river diagram

25. TREATMENT AIMS
Long Term Goal:
1. Pre-retirement plan for client.
2. Improve quality of life.

26. TREATMENT
Treatment implemented: (10.5.12)
1. Education to both client and care-giver (son) about
the condition includes: (STG 1)
 Etiology
 Progression
 Client’s current functionality level
2. Environmental (home) modification
recommendation: (STG 2)
 Marking and labeling technique. (E.g., stairs)
 Lighting

27. TREATMENT
Treatment implemented: (17.5.12)
3. Teach client and care-giver sighted guide technique:
(STG 3)
 Approaching narrow space
 Approaching stairs
 Guiding client to sit on chair
 Approaching a doorway.
4. Further assess on client’s color perception
– Assessment: non-standardized (using 6 different
colored rings)
– Results: client able to recognize red, green, orange but
seeing yellow as white, blue as greenish blue, and pink
as orange-light red.

28. TREATMENT
5. Expose client to walking aids that are suitable to
client including education on it. (STG 2)
– Method: Consulted with client without showing.
– Results: Client re-considered and agreed to try.
Future plan:
6. Home visit – possible physical environment &
identification with client on possible purposeful
activities. (STG 2 & 3)
7. Work place visit: (STG 4 & 5)
 Job place physical environment modification and task
modification.
 Educate other colleagues and employer about client’s
condition.

29. TREATMENT
Based on LTG:
LTG 1
• Pre-retirement planning – preparation in exploring and
then legitimize a new activity patterning for retirement.
• Elements for successful retirement: life roles,
purposeful activity, and maximizing function.
– Alternative: volunteerism or part-time employment.
– New interest exploration.
LTG 2
• Orientation and Mobility program – with cane.

30. PROGNOSIS
Rehabilitative: (Good)
• Cooperative and compliant to treatment given.
• Strong family support.
• Client was very motivated to improve himself.
*RP is a degenerative disorder.
*Client has other illnesses other than RP.

31. REFERENCES:
1. International Classification of Disease (ICD-9-CM:
362.1, 362.74, 362.76)
2. Mitchell S., Maxine S., & Stephen G., 2007. Low
Vision Rehabilitation: A Practical Guide for Occupational
Therapy. SLACK Incorporated.
3. Sandra C., 2003. Elder Care in Occupational Therapy. 2nd
Edition. SLACK Incorporated.
4. Michael K. Iwama, 2006. The Kawa Model: Culturally
Relevant Occupational Therapy. Churchill Livingstone
Elsevier.