Transcript Slide 1

An Overview of Driving Rehabilitation:
What a Therapist Should Know
August 23, 2008
Meredith Sweeney
and Tina Young
Primary Driver Rehabilitation Team
 Members
– Physician
– Client (and Caregiver optional)
– Driver Rehab Specialist: CDRS, OTR, Driving
educators, licensed/certified driving instructors
– Vehicle Modifiers/Equipments Dealers (NMEDA)
– Case Manager (optional)
2
Rehab Team Roles:
Physician
 Assess driving fitness
AMA guide-Assessment of Driving Related Skills [ADReS]
 Refer
 Report as needed to DMV
 Discuss driving with client (educate and counsel)
 Review effects of medications in regards to driving
3
Physician Role Continued
 Refer client to program with a prescription:
Occupational Therapy Driver Evaluation and Training
 Client needs to be seizure free, medically stable and
should be final step in rehab recovery process
 Final report and Final recommendation reviewed
4
Client Role
 Provides prescription, insurance verification, list of
current medications and Valid Driver’s License upon
arrival
 Complete Medical History Questionnaire
 Consent for Participation Form (mandatory)
 Authorization to Release Medical Information (optional)
 Meet State Vision Requirements
5
Caregiver Role
 Get client’s permission to attend
 Assist in gathering information for evaluation as
necessary
 Transportation and support system
 Critical link to getting unsafe driver off the road, key
to successful intervention
 Accept and reinforce recommendations
 Assist with transition to non-driving status
6
Driver Rehab Specialist Role
 Complete clinical evaluation and on the road
evaluation
 Provide training and recommendations
 Education on driving cessation and alternatives
 Send final report to physician
 Complete 30 day and 1 year follow up calls
7
Driver Rehab Specialist Role Continued

Options:
1. OTR for clinical evaluation then DI for
on-the-road evaluation
2. OTR for clinical evaluation then
DI/OTR for
on-the-road evaluation
3. OTR does both clinical and on the road
evaluations
4. Training is done by OTR or DI
8
Driver Rehab Specialist Role Continued
 CDRS can be OTR, DE, DI, or others
 Certification not mandatory, but strongly
recommended, through ADED
 DRS- OT specializing in Driver Rehab
9
Vehicle Modifiers and Equipment
Dealers Role
 Requires prescriptions for equipment: medically
required to drive
 Installs adaptive equipment in a vehicle
 Ensures proper equipment fitting
 Collaborates with CDRS/OTR
 Look for NMEDA certified vendors- National Mobility
Equipment Dealers Association: ensures proper
training to install equipment
10
Case Manager Role
 Assists with setting up services - coordinates services
and is the communication link
 Assists with funding sources - advocates for client
 Assists with matching to the appropriate Driving Rehab
Program:
Technology ability
Car vs. Van needs
Cost and billing procedures
Who the evaluator is/ Services
Scheduling procedures
11
Services of the Driving
Rehabilitation Program
 Clinical Evaluation-physical, vision, and cognitive
components
 On road driving evaluation
 Recommendations for adapted driving aids and vehicle
modifications or prescriptions
 Driver Education and Training: off street and
on-the-road training
12
Services of the Driving
Rehabilitation Program continued
 Client Vehicle Fittings
 Driving Cessation Planning
 Exploration of Alternatives to Driving
13
Service Delivery Models
Traditional Medical Model
 Housed within a hospital, rehabilitation center and/or
free-standing clinic
 May or may not be licensed by the state as a driving
school
 Use of clinical reasoning based on evidence based
practice
 Requires prescription from physician
 Bills third party payers and/or fee for service
15
Traditional Medical Model –
Multi-Disciplinary Team Approach
 Certified driver rehabilitation specialist (CDRS)
 Occupational therapist
 Driving instructor
 Physician
 Seating specialist
 Neuropsychology
 Neuro-ophthalmology
 Social worker
 Speech therapist
 Physical therapist
16
Traditional Medical Model – Program
Components
 Clinical assessment
 Driving simulator/Virtual reality technology
 Closed circuit course
 On-road assessment
 On-road training
 Vehicle modification recommendation/prescription
 Patient education re: NMEDA certified vehicle
modifiers
 Final inspection of client’s modified vehicle
 Follow-up with client
17
Community-Based Model
 Driving Schools licensed by the state
 Employ driver educators, driving instructors, CDRS,
and occupational therapists
 No prescription required (exception: OT operated
independent entrepreneur for-profit driving program)
 Fee-for service
18
Community-Based Model – Program
Components
 Pre-driving assessment at a client’s home or at a
driving school
 On-road assessment
 On-road training
 Vehicle modification recommendation/prescription
 Often accompanies a client during BMV testing
19
Vocational Rehabilitation Model
 State funded
 Employ CDRS (typically an occupational therapist
and/or driving instructor)
 Primary focus is developing skills required for gainful
employment, including driving
20
Vocational Rehabilitation Model –
Program Components
 Pre-driving assessment
 On-road assessment
 On-road training
 Vehicle modification recommendation/prescription
 Bids modification installation and informs client
who will provide the work
 Final inspection of modified vehicle
21
University Model
 State and/or federally funded (often grants)
 Located on a university campus or within a
university-affiliated teaching hospital
 Employ occupational therapists, driving
instructors and CDRS
 Requires prescription from physician
 Focus on research and education
22
University Model –
Program Components
 Same as traditional medical model
 Typically, additional requirements
for clients such as questionnaires,
test/re-test, etc. for research
purposes
23
Veterans Affairs Model
 Federally funded
 Offered in 40 of 225 veterans’ hospitals
 Service veterans only (2 exceptions, in Virginia and
Texas, who provide fee-for-service treatment to
general public)
 Veterans with a service connected health condition,
injury or disease viewed as a higher priority
24
Veterans Affairs Model
 Employment requirements include a 2 week course in
driving rehabilitation and a baccalaureate degree in
one of the following:
– Adapted physical education
– Occupational therapy
– Kinesiotherapy
– Physical therapy Health science field of study
25
Veterans Affairs Model –
Program Components
 Initial referral to the physical medicine and
rehabilitation department for physical and
psychological examination
 VA driving program completion
 Prescription for vehicle modifications submitted to
Prosthetic Department in VA central office for review
 If approved, prescription sent to VA’s Acquisition and
Material Management Services for completing
equipment procurement process
 Veteran can apply for a vehicle grant for $11,000
26
Clinical Evaluation
Comprehensive Driver Evaluation ProcessIndustry Approved Process

Referral

Interview

Clinical Assessment

Vehicle Assessment

Equipment Assessment

In-Traffic Assessment

Driver Education/Training

Bid and Solicitation

RX

Vendor Selection

Final Vehicle/Equipment Inspection/Fitting

Driver Education/Training in clients’ Vehicle
Pierce, Davis, Wheatley 05
28
Driver Rehab Programs – Who to Refer
 Orthopedic Conditions
 Neuro and Cognitive Conditions
 Metabolic Disorders
 Learning Impairments
 Visual Disorders
 New Drivers
 Older Drivers
29
Driver Rehab Programs – When to Refer
 When client has reached maximum recovery potential
 Medically stable, seizures and meds
 Vision stable
 Final step in rehab
 And physician clearance for driving
30
Clinical Evaluation
 Purpose: Paints a picture of the client and their
deficits, prepares for on the road evaluation by
predicting performance (manifestations of deficits),
guides the CDRS on what to be ready for on the road.
 Final determination and driving recommendation
should always be based by the on the road evaluation,
not the clinical evaluation = Gold Standard.
31
Clinical Evaluation Overview
 Approximately 2 hours in length, varies
 Review completed prep paperwork:
Reminder Letter, Medical History Questionnaire,
Consent for Participation Form Mandatory,
Authorization to Release Medical Information
Optional, Physician Prescription provided, List of
Current Meds Provided and Driver’s License
32
Clinical Evaluation –
Medical History Review / Interview
 Diagnosis and Onset
 Time Line of Medical Situation
 Current Medications
 Review of Therapy, past and present
 Past Medical History
 Social/Work Status
 Hearing Status
33
Clinical Evaluation –
Driving History Review / Interview
 Client’s Driving Goals
 Client’s Vehicle
 Year began driving/formal instruction
 Date last drove
 Current License/Permit and Restrictions
 Citation History
34
Clinical Evaluation – Visual Assessment
 Date of Last Vision Exam
 OPTEC = Visual Fields
 Acuities- near and far
 Color Perception
 Depth Perception
 Fusion
 Color Recognition
 Contrast Sensitivity
35
Clinical Evaluation – Visual Assessment
continued
 Visual Pursuit
 Tropia Test (Strabismus)
 Saccades
 Right / Left Discrimination
 Porto Clinic: Night Vision
 Glare Recovery
 Reaction Time
(Visual Stimulus)
36
Clinical Evaluation –
Perceptual Skills Assessment
 MVPT
 Right / Left Discrimination
 Color Recognition
37
Clinical Evaluation –
Physical Assessment / Observation
 Functional Range of Motion
 Functional Strength
 Endurance
 Coordination
 Sensation
 Mobility- transfers, ambulation, devices
 Reaction Time-Porto Clinic
 Possible Vehicle Modification Needs
38
Clinical Evaluation –
Cognitive Assessment
 Short term memory
 Direction Following - Basic and Complex
 Judgment/Safety Awareness - 8 driving
related scenarios
 Road Sign Identification - 15 Traffic Signs
 Divided Attention and Selective Attention -
UFOV or Trailmaking B
 Insight to Deficits
 Impulsiveness
39
Clinical Evaluation - Summary
 Develop profile of strengths and weaknesses related
to driving
 Identify need for referrals to specialists
 Determine potential for learning compensatory
strategies and develop a customized training plan
 Review adaptive equipment recommendations
 Determine if state requirements are met
40
Clinical Evaluation – Other Tools
Utilized per Research/Other Programs
 Symbol Digit Modalities Test
 Letter Cancellation
 Digit Span
 MMSE
 Short Blessed
 Cognitive Linguistic Quick Test
 Block Design
 Rules of the Road Test
 DPT
41
Clinical Evaluation – Other Tools
Utilized continued
 Stroop Neuropsych
 Clock Drawing Test
 ACLS
 Keystone Vision Tester
 Perimetry
 TVPS, TVMS-R, VMI
 Bender-Gestalt
 Rey Osterrieth Complex Figures Test
 Vericom Reaction Timer
42
Clinical Evaluation – Other Tools
Utilized continued
 Rapid Pace Walk
 GRIMPS
 Simulators - i.e., Doron Precision Systems
 WayPoint
 DriveABLE
 Trip Routing
 Dynavision
 Eye charts- Snellen, Contrast Sensitivity
 CLOX 1 &2
43
Clinical Evaluation – Other Tools
 Hooper Visual Organization Test
 Driver Risk Index
 Cognitive Behavioral Driver’s Inventory
 Road Smart Judgment Test
 Balance Tests
 Self Awareness-i.e., Driving Decisions Workbook, Driving Health
Inventory, RoadWise Review AAA, AARP, AMA Guide
44
Clinical Evaluation – Other Tools
Continued
 Money Road Map Test
 Brake Reaction Timer
 VRST-Usyd
 Foot Tap Test
 Arm Reach Test
 Logical Memory subscale of Wechsler
 Memory Scale
45
Clinical Evaluation - Choosing Tools for
the Driver Rehab Program
 Cost Effectiveness
 Time Factor
 Funding/Resources
 Client Specific Issues and Goals
 Majority of Population Testing
 Correlation to Driving Directly
 Evidence Based Practice- reliability
46
Clinical Evaluation –
Criteria of Subskills to “Pass”
 Driving- based on client’s goals
 Visual- Acuity for State of Ohio
Visual Fields
Fusion/Depth Perception/Tropia
Night Vision and Glare Recovery
MVPT*
 Motor- Reaction Time
 Cognition- UFOV*
Trailmaking B*
Road Signs
Traffic Scenarios
47
Clinical Evaluation – Criteria to Pass
“Behind the wheel performance
is the MOST DEFINITIVE test
for driving safety.”
BTW is the only Criteria to Pass or Fail the entire driving
evaluation. Final recommendation will only be made
when the BTW eval is complete, not the clinical
evaluation.
Pierce, Davis, Wheatley 05
48
Clinical Evaluation – Criteria to Pass
 99% clients move on to the on the road
 1% don’t meet vision requirements or clinical
judgment (we couldn’t keep them safe in an
empty parking lot)
49
Visual Perception
Visual Perception
 Visual Perception – the total process responsible for
the reception and cognition of visual stimuli
 Visual-Receptive Component – process of extracting
and organizing info from the environment
 Visual-Cognitive Component – ability to interpret and
use what is seen
51
Visual-Receptive Component
 Oculomotor System
 Occupational therapy provides screening
 Ophthalmologist, optometrist, neuro-ophthalmologist,
provide formal screening
 Vision therapist provides therapy
52
Eye Anatomy
53
Visual-Receptive Component
 Fixation
 Acuity
 Pursuit
 Saccades
 Accommodation
 Binocular vision
 Stereopsis
 Convergence/Divergence
54
Visual Fixation
 Ocular fixation on a stationary object
 Prerequisite skill for other ocular motor
response
 Evaluation
55
Acuity
 Discriminate the fine details of objects
 Evaluation
56
OPTEC 5000P
57
Snellen Charts
58
Visual Pursuit/Tracking
 Continued fixation on a moving object
 Image is maintained continuously on the fovea
 Slow, smooth movement
 Evaluation
59
Saccades
 Rapid change of fixation
from one point in the field
to another
 Evaluation
60
Accommodation
 Process the eye uses to obtain clear vision
 Transition from focusing at near point to
far point
 Evaluation
61
Binocular Fusion
 Ability to mentally combine the images from two eyes
into a single percept
 Eyes must be aligned (motor fusion)
 Strabismus vs. Phoria
 Evaluation
62
Stereopsis
 Depth perception
 Evaluation
63
Convergence / Divergence
 Ability of the eyes to turn
toward the medial plane
(inward) and away from
the medial plane
(outward)
 Evaluation
64
Visual-Cognitive Components
 Interpretation of the visual
stimulus is a mental process
involving cognition, which
gives meaning to the visual
stimulus
65
Visual-Cognitive Components
 Visual attention
 Visual Memory
 Discrimination
 Integration of the visual stimulus
66
Visual Attention
 Selection of visual input
 Requires:
–
–
–
–
Localization
Fixation
Ocular pursuit
Gaze shift
 Evaluation
67
Components of Visual Attention
 Alertness
 Selective Attention
 Vigilance
 Shared Attention/Divided Attention
68
Visual Memory
 Integration of visual
information with previous
experiences
 Evaluation
69
Visual Discrimination
 Ability to detect features of stimuli
for
– Recognition
– Matching
– Categorization
 Evaluation
70
Object Vision
 Visual identification of objects by color,
texture, shape and size
 Form constancy
 Visual closure
 Figure ground
 Evaluation
71
Spatial Vision
 Visual location of objects in space
 Position in space
 Depth perception
 Topographical orientation
 Evaluation
72
Visual Imagery
 Ability to “picture” people,
ideas, and objects in the
mind’s eye when objects are
not present
73
Contrast Sensitivity
 “Real world” vision is not always high contrast
black and white
 Objects have a wide range of sizes viewed
under a variety of visually degrading conditions
–Fog
–Night
–Bright sun
 Evaluation
74
Contrast Sensitivity
75
Visual Perception Tests
 Developmental Test of Visual Perception (DVPT)
 The Beery-Buktenica Developmental Test of Visual
Motor Integration (VMI)
 Test of Visual Motor Integration (TVMI)
 Motor Free Visual Perception (MVPT)
 Test of Visual Perceptual Skills (TVPS)
 Visual Object and Space Perception Battery
 Benton Visual Retention Test
 Visual Skills Appraisal (VSA)
 Hooper Visual Organization Test
76
Neuropsychology
and Driving
Role of Executive Functioning in Driving
– What is executive functioning?
 The ability to formulate a plan and
execute the plan
 Planning, decision making and response
selection
 Problem solving, planning and judgment
 Volition, planning, purpose of action-
effective performance
78
Executive Functioning
 Volition = what one needs or wants, initiation, self
awareness, motivation
 Planning = identify and organize steps
 Purpose of Action = put plan into activity, manage
sequences in orderly manner
 Effective Performance = monitor, self-correct and
regulate intensity
Wheatley and Davis 2005
79
Neuropsychology and Driving
“The same cognitive skill they require to be able to
accurately assess their own difficulties is also at the
root of their other dysexecutive problems”
Burgess, et.al. 1998 p555;
Wheatley and Davis 2005
80
Neuropsychology and Driving
Performance on tasks of executive functioning is
predictive of on road driving ability and
accident risk, strong correlations researched
81
Neuropsychology and Driving
 Executive Functions = selective and divided attention,
tested best with UFOV (Useful Field of Vision/View)
 UFOV (Useful Field of Vision/View) - has strong
predictive validity for crashes and driving evaluations
and correlated strongly with Trails B*
 Other test options: CLQT, Stroop*, Rey Osterrieth-
Complex Figure Test, Matrix Reasoning, Letter
Number Sequencing, Colored Trails Test, Tower of
London, Wisconsin Card Sorting Test, Rey Complex
Figure, MVPT, Clock Drawing Test, Benton Visual
Retention Test, Block Design Test, ACLS
82
Michon Hierarchy of Driving
1. Operational - Basic Vehicle Control = steer, brake,
accelerator
2. Tactical - In Traffic = speed, wipers, lights, lane
placement
3. Strategic - Hazards = route choice, strategies
83
Executive Function and Deficits
 Can be masked in structured assessments.
 Fatigue, anxiety and distractions affect
executive function.
 Speed of responses is critical.
 Last to develop and last to return after injury.
 Self awareness precedes initiation of strategy
or compensation.
84
Role of Insight of Deficit in Driving
 Self regulation, self reflection and self awareness are
executive functions.
 Self awareness is key to decide if one will be able to
learn and utilize compensatory strategies.
 Decreased self awareness is important in predicting risk
for accidents to increase.
 If intact, less likely to put themselves and others in
harm; if unaware of deficit then no reason to change it.
85
Neuropsychology and Driving
“Overestimate is common across
tasks/abilities, but driving encourages poor
insight because it is a high value task,
supporting: roles, independence, selfesteem, quality of life, and mood.”
Davis and Stern; Katz et al. 1990
86
Neuropsychology and Driving
“Results from research have revealed that most
individuals fail to recognize their decline in
driving competence and adjust to lower levels
of (performance naturally) such as visual acuity,
reaction time and cognition.”
Hunt, Morris, Edwards & Wilson 1993
Kartje 05
87
Decreased Self Awareness / Insight
Equals:
 Decreased compliance with restrictions
 Decreased Motivation
 Decreased Decision Making
 Increased Resistance to Treatment
 Increased Risk Taking
 Clients struggle with understanding how
tests relate to skills required to drive.
88
How to Increase Self-Awareness and
Positive Impact on Driving Behaviors
 Driving Decisions Workbook
 KEYS (Knowledge Enhances Your Safety)
 The Driver Perceptions and Practices
 Questionnaire
89
Medications as Predictors
of Driving Performance
Medications as Predictors of
Driving Performance
 An increase in age leads to an increase in medical
conditions/disabilities which leads to an increase in
medications and decrease in memory (higher risk also
for Alzheimer’s Disease and Depression) which can
lead to impaired driving performance
 “Older clients’ driving skills may deteriorate as a
result of medications, not a loss of inherent skills.”
Kartje 2005 and OT Practice 3/5/07
91
Medications as Predictors of
Driving Performance
 Three or more drugs increases the risk of functional
decline in elderly by 60%
 Decrease in functional ability secondary to increase in
polypharmacy (2-10 meds) = increases risk of MVA
 PharMetrics Database Analysis reported that 64% of
drivers 50+ with a MVA was on a PDI within 60 days
OT Practice 3/5/07
92
Medications as Predictors of
Driving Performance
 Potentially Driving Impaired (PDI) prescription
medications effect CNS, blood sugar level, blood
pressure and vision
 Side effects of PDI: sedation, blurred vision,
dizziness, fainting and loss of coordination
 Most common conditions are for HTN, Arthritis,
Heart disease, Cancer, Diabetes and Sinusitis
93
Medications as Predictors of
Driving Performance
 Prescriptions and/or over the counter drugs can
create accessory functional problems such as motor
performance, vision, attention and information
processing and undermine driving performance.
 Older drivers may be less aware of their surroundings
and less able to react in inappropriate and timely
manner to a dangerous situation on the road.
Pellerito 2006 p 198 and Stav 2004 p 21
94
Medications as Predictors of
Driving Performance
 Resource: www.drivinghealth.com
Tool for those who need to educate and
counsel older clients about medications
and associated driving risks
OT Practice 3/5/07
95
2 Classen Studies’ Findings
1. Pharmacological intervention is cornerstone of
CVA management and prevention:
– increases in polypharmacy.
– increases associations between drugs.
– increases adverse drug reactions.
– increases nonadherence to regimes.
– increases in IPD with multiple meds.
– increases drug drug interactions with more
than 3 meds.
96
2 Classen Studies’ Findings
2. Correlation between number of comorbidities and
number of medications.
3. Correlation between number of comorbidities and
number of IPDs (Inappropriate Prescribed Drugs).
4. The Beers Criteria identified 28 medications
potentially harmful to older adults.
5. Polypharmacy associated with increased risk of
potential drug-drug interactions (PDDIs).
6. Increase in number of meds and increase in age leads
to polypharmacy.
97
2 Classen Studies’ Findings
7. Increase in age and gender (being male) = decrease
in cognition.
8. Association between number of medications and
variables such as age, gender and total chronic
illnesses.
9. Increase age/increase number of
medications/increase in chronic illness= increase
morbidity, decrease cognition, decrease IADLs,
decrease health, decrease QOL, decrease in
functional status.
98
Potential Effects of Medications
 Slower reaction time
 Difficulty visually tracking objects
 Alteration of depth perception
 Diminished coordination while steering the
vehicle and accessing the braking system
 Lack of attention
 Confusion
 Drowsiness
99
Potential Effects of Medications continued
 Lack of awareness of surroundings
 Decreased accuracy of movements
 Decreased ability to perceive hazards
and identify risks
 Hyperactivity
 Reduction of peripheral vision
Pellerito 2006 p 198
100
Medications that Can Impair Driving
 Alcohol-containing medicines
 Allergy medicines
 Amphetamines
 Anti-anxiety medications
 Antibiotics
 Anti-depressants
 Anti-nausea medicines
 Anti-seizure medicines
 Barbiturates
 Blood pressure medicines
101
Medications that Can Impair Driving continued
 Blood sugar medicines
 Caffeine-containing medicines
 Cough syrups
 Decongestants
 Motion sickness medicines
 Narcotic pain medications
 Sedatives
 Stimulants
 Tranquilizers
 Ulcer medication
102
Driving Simulators
Best Practices and Appropriate Role
 Until more research is conducted,
driving simulation should not replace
an on-the-road driving evaluation.
 Gold standard is to test the client
behind the wheel so how and why are
simulators utilized?
104
Driving Simulators
Road tests are considered costly to
administer, dangerous, sometimes
unavailable and can be stressful and
impractical for routine testing of older
persons where as simulators allow
ability to repeatedly practice high-risk
skills safely and cost-effectively.
AJOT 2003 & Pellerito 2006
105
Driving Simulators
 Helpful for clients to practice driving and see their
abilities and limitations. Assist with
insight/awareness with driving and other IADLs.
Increase willingness to follow
suggestions/recommendations.
 Help identify drivers that are at risk for traffic
violations and accidents.
 Assess challenging stimuli (inclement weather,
animate and inanimate obstacles, night driving).
106
Driving Simulators
 Help connect abstract interventions with a personal




significant goal (such as strengthening, ROM or
cognition).
Allow practice of adapted driving aids in low risk
virtual environment before getting on the road.
Allow remediation and training of driving skills in a
controlled environment.
Help predict failure of on the road evaluation and
elevated crash risk
Help decide the optimal time to test on the road
(Watch Out for Simulator Sickness)
107
AJOT 2003 Findings
 Visual attention skill declined with age was consistent
with the literature and validated the driving simulator
as an effective screening tool for older adult drivers.
 Visual attention skill as the most important outcome
measure of traffic violations and automobile crashes.
 Visual attention/speed of reaction times skill slowed
down during the second half across a time of 45
minutes simulated driving test.
108
AJOT 2003 Findings - continued
 STISIM was validated as an off-road
screening tool for older adult drivers in
respect to their visual attention skill.
 Suggests working memory or performing 2
tasks simultaneously may be tested with a
similar approach (selective attention and
divided attention mentioned too)
 Suggests driving simulators are economical
and efficient clinical tools to measure skills
for driving
109
AJOT 2003 Findings - continued
 PC-based Driving simulators were able to identify
unsafe older drivers at risk of traffic violations if
appropriate simulated driving tasks were used such as
working memory and use of indicator. They were able
to generate complex traffic scenarios comparable to
the on-road environment and conditions.
 Confirms that a low-cost driving simulator can be used
by OTs as an off-road screening tool to identify older
drivers at risk of traffic violations.
 Simulator technology can be employed for training
incompetent drivers too.
110
AJOT 2003 Findings - continued
 Confirmed that cognitive skills such as working
memory, ability to make rapid decisions, judgment
under time pressure and confidence in driving at high
speed, were associated with the crash event.
 Assess various levels of visual attention skill.
 Could explain/reflect over 67% of on-road driving
behaviors and functions.
 Confirmed that driving skills generally decline with age
(well-timed reaction and dexterous motor coordination
may deteriorate with physiological aging).
111
AJOT 2003 Findings - continued
 Should target working memory and correct use of
indicator when assessing older adults for safe driving.
 Use of indicator-Drive around “road work” obstacles
blocking the road and return to the inner lane as soon
as possible.
 Working memory- remember 5 street names and 5
maneuvers marked on a route on a road map to a
fictitious park in 5 minutes and recall them after 10
minutes’ simulated driving.
 Used the STISIM Driving Simulator for the study.
112
Doron Precision System’s Simulator
Strong validity in predicting road
performance with adults with CVAs and
adolescents with disabilities.
Pellerito 2006, p 507 and 229
113
Driving Simulators
 Demonstration
114
Adaptations for Driving
Adaptations for Driving
 Manufacturers
– Vehicle
– Adaptive equipment
 Dealers
– Sell and install adaptive equipment for vehicles
 Driver Evaluators/Trainers
– Complete training
– Write prescription for dealer
 NMEDA
– Develops standards, quality measures and guidelines for
manufactures and dealers
– QAP
116
Funding for Adaptations
 Primarily an out-of-pocket expense for client
 Vocational Rehabilitation Programs
 Veterans Administration
 Mobility Rebate Programs
 Charitable Organizations
 Grant Funding
117
Affected Extremities:
Bilateral Lower Extremities
 Potential Problems with Driving
–
–
–
–
–
–
–
–
–
Brake and accelerator pedals
Steering
Clutch Pedal
Foot-operated parking brake
Wheelchair/Scooter storage
Balance/Trunk control
Pedal interference
Horn
Dimmer switch
118
Affected Extremities:
Bilateral Lower Extremities
 Potential Solutions
–
–
–
–
–
–
–
–
–
Hand control
Steering device
Automatic clutch system
Parking brake extension lever
Wheelchair/Scooter loader
Torso restraint
Pedal block
Remote horn button (hand control mounted)
Remote dimmer switch (hand control mounted)
119
Case Study
 Billie, 57 y.o. female, sustained crushing injury of
feet and ankles at an industrial work site when struck
by a backing tow vehicle causing her pants to get
caught into a press.
 5 surgeries over 9 days and then subsequent skin
graphs
 Complications included infection, chronic pain and
emotional trauma
 Prior to accident, Billie lived alone. Adult daughter
currently residing with Billie.
120
Case Study
 Referred to driver rehabilitation 18 months post injury
 Clinical evaluation found
– Non-functional lower extremities for driving (reaction time of
right foot = 2.6 seconds, left foot = .86 seconds)
– Intermittent but severe pain of bilateral lower extremities
– Scooter is primary mode of mobility but, Billie can ambulate
short distances with a quad cane
 On-road evaluation with adaptations
– Completed vehicle inspection for adaptations (‘06 Dodge
Caravan – automatic transmission)
– Recommended 8 hours of on-road training
 D/C after 6 hours of training with prescription for adaptations
121
Case Study
 Recommended adaptations for van:
–
–
–
–
–
Foam grip push/pull hand control
Right mounted single pin foam grip
Scooter loader
Pedal block guard
Secondary control device attached to the
right mounted single pin foam grip
steering device for proper operation of
wipers, horn, dimmer and turn signals
122
Case Study
 Adaptations funded by Bureau of Vocational
Rehabilitation – Billie had already returned to work 2
hours a day,5 days a week with cab service providing
transportation
 Billie self reported medical status change and need
for adaptations to Ohio Bureau of Motor Vehicles
 Billie reported in F/U calls she is driving
independently with the adaptations and returned to
work full time. She reports no accidents or citations
since completion of the program.
123
Affected Extremities:
Right Upper and Lower Extremities
 Potential Problems with Driving
–
–
–
–
–
–
–
Steering
Accelerator
Ignition
Parking brake (hand operated)
Pedal interference
Horn
HVAC
124
Affected Extremities:
Right Upper and Lower Extremities
 Potential Solutions
– Steering device
– Left hand gear selector
lever
– Left foot accelerator
– Key holder
– Power parking brake
– Pedal block
– Remote horn switch
– Remote dash controls
125
Case Study
 Pat is a 73 y.o. female diagnosed with a CVA resulting
in right upper extremity and lower extremity
hemiplegia.
 Pat received botox injections of the right upper
extremity to decrease tone and utilizes a right elbow
extension Dynasplint.
 Pat is a widow who active in her community and has a
small but strong support system of neighbors and
friends.
126
Case Study
 Referred to driver rehabilitation 6 months post CVA
 Clinical evaluation found:
– Non-functional right upper and lower extremity for
driving (reaction time of right foot = 1.75 seconds)
– Ambulates with AFO and quad cane
 On-road evaluation with adaptations
– Completed vehicle inspection for adaptations ( ’99
Chrysler Town and Country minivan – automatic)
– Recommended 8 hours of on-road training
 D/C after 8 hours with prescription for adaptations
127
Case Study
 Recommended adaptations for van:
– Left mounted knob steering device
– Left foot accelerator
– Pedal block for manufacturer installed
accelerator
– Secondary control device attached to
her left mounted steering device for
proper operation of turn signals, wipers,
dimmer and horn
128
Case Study
 Adaptations funded by Delaware County Council for
Older Adults grant funds awarded to the Grady
Memorial Hospital DRIVE program
 Pat self reported the medical status change and need
for adaptations to the Ohio Bureau of Motor Vehicles
 Pat reported in F/U phone calls she is driving
independently in her home town and planned to
expand her driving radius after winter. She reports no
accidents or citations since completion of the
program.
129
Lab
 View vehicles with installed adaptations
130
On-Road Evaluation
Determine Route by the Client’s Goal
 Standard route vs. specialty routes
 Standard- 2-3 hour route in all areas such
as rural, residential, commercial and
highway (50 minutes minimum on road)
 Specialty- preplanned routes with
directions; i.e., house to the grocery
132
On-Road Evaluation – Common
Practices and Test Procedures
 Common practices and test procedures increase the
reliability of outcomes, if followed.
 Follow a standard, predetermined, clear documented
route.
 Score predetermined aspects of behavior at
predetermined points along the route.
 Include directions to the driver that are documented
clearly in the same form each test.
133
Common Practices and Test
Procedures - continued
 Assessment criteria are operationally
defined and documented in specific terms
 Follow a closely defined scoring procedure
 Entails extensive training of testers
Pellerito 2006 p 264
134
Typical On Road Evaluation
Components
 Basic Operations- in vehicle
 Basic Maneuvers- in empty parking lot
 Minimal Traffic- rural roads
 Moderate/Heavy Traffic
 Speed Control
 Defensive Driving
 Navigation
135
Key Factors of Assessment
 Must have license with them.
 Explain AE in vehicle.
 “Follow the rules of the road.”
 Are they comfortable with the vehicle?
 Look for a pattern of errors- more than 3 or a
general pattern of errors, severity of error.
 Can they fix the error; do they do better with
training; response to cues?
136
Key Factors of Assessment - continued
 Determine bad habits vs. driving errors
 Look for automatic responses to basic maneuvers
 Tell them how they are doing throughout
 Tell them what you would like improved, explain
errors immediately
 Assumptions: reaction time will be slower in car
than in the clinic. You should see best
performance since it is a testing situation.
137
On-Road Evaluation Recommendations
 Resume independent driving
 Resume driving with AE
 Resume driving with restrictions
 Begin driver rehab training
 No driving due to high risk for accidents
( only based on today’s performance)
(has to be able to be enforced)
138
Research –
AJOT July/August 2006 p 428-434
 Concluded that most programs do not use
standardized on the road evaluations
 Standardized Options: Miller Road Test,
Performance-Based Driving Evaluation,
Washington University Road Test and
DriveABLE Road Test
139
Research –
AJOT May/June 2004
 Suggests that the evaluation have a
portion of self navigational
instruction vs. all directed navigation.
 “Self-navigation challenges the driver
in a way that replicates real world
driving”
 “Actively engaged in multiple tasks,
higher degree of cognitive and visual
ability”
140
Research - ADED 2007
 Dementia clients recommended to have
revaluation every 6 months per best
practices of clinical standards.
 Clinic test and on the road test need to
be close in time.
 Frequency of re-evaluations (change in
condition, failures on the road).
141
Research
 Validity and Reliability Focus
 Validity- tool is measuring what
says it measures
 Reliability- a tool measures the
same thing each time (inter-rater
and intra-rater)
142
On-Road Evaluation
 Interrater reliability increases with
standard routes and consistent procedures
and protocols
 Need for systems to observe, record and
interpret performance and more research
 Challenge - great interdriver variation in
performance and behaviors
Pellerito 2006 p 262-275
143
Driver Rehabilitation
Training
To Provide Training:
 Must be a Certified Driving Instructor,
licensed by the State of Ohio
 Currently, must be a certified driving
school, licensed by the State of Ohio
145
Driver Rehabilitation Training
 Instructor’s role is to carefully grade the
demand of driving tasks to challenge
learners without introducing situations
that are beyond their level.
 Who is appropriate for training?
 Client must have insight to their problem
areas for successful training.
– Simulator an option for clients with
decreased insight
146
Teen vs. Experienced Driver
 Ohio Driving Instruction Curriculum
 State minimum hours for teens = 8 (avg=20)
 Contract with driving school who provided
classroom instruction
 Training record can be inspected by Ohio
Department of Public Safety during driving
school inspection (parent must sign medical
records release for training record only)
147
Adaptations vs Non-adaptations
Driving Training
 Physical issues compared to cognitive
issues.
 Can be teen or experienced driver.
 Adaptation training usually results in an
independent driver.
 Non-adaptation training (cognitive issues)
has varied results.
148
Driving Cessation
and Alternative
Community Mobility
Driving Cessation and
Alternative Community Mobility
 Central Ohio Alternative Community Mobility Guide
 Individual Transportation Plans
 Follow up phone calls
 Practical and Symbolic Aspects
 Phases of Driving Cessation
 Support Groups
150
Driving Cessation and
Alternative Community Mobility
 Always ask, “How are you getting home today
if unsuccessful?”
 Always provide a discussion/education and
alternatives/transportation options and
resources if a clients fails the on the road
assessment, you should never end the
assessment with, “You can’t drive anymore,”
and leave them without solutions or options.
151
Driving Cessation and
Alternative Community Mobility
“An important component of an OT’s job
is to assist the older adult who is no
longer able to drive in maintaining a high
level of health, safety, and well-being.
This assistance can include counseling,
identifying meaningful activities that do
not require driving, or providing
appropriate information sources for the
older adult.”
Pellerito 2006 p 435
152
Remember the family is important in
the final discussion.
 Try to include in recommendation discussion with
client’s permission.
 Encourage supporting the final decision.
 Family dynamics will change based on the outcome
instantly, enable them with education.
 We can be the “bad” guy for the family- minimize
resentment of caregivers.
 Help with transition to retirement of driving
 Help with transportation plan
 Provide support for coping with the loss of driving
153
Impact of Driving Cessation
 Depression - decrease social, emotional and psychological
well-being
 Decrease in activities
 Premature placement in long-term care facility
 Forced retirement from work
 Changes life roles
 Feelings of regret, loss, isolation, grief
 Self-identity and self-esteem affected
 Decreased life satisfaction
 Marker for last stage of life
154
Impact of Driving Cessation continued
Isolation-fewer trips out
Limited resources
lack of knowledge of systems
Reluctant to ask for help
Reduced access to health care and community services
Loss of mobility and independence
Decreased spontaneity-inconvenient
Disrupts lifestyle and routines
155
Driving Cessation and Alternative
Community Mobility
 Men are more resistant to
relinquishing their licenses.
 Men are less likely to cease
driving voluntarily.
 Men are affected more in regards
to roles and self-esteem.
Pellerito, 2006 p 177
156
Driving Reduction - Medical Conditions
Affect Safe Driving Abilities
 Heart Disease
 Sleep Apnea
 Cardiac Arrhythmia
 Syncope
 Stroke
 Diabetes Mellitus
 Epilepsy
 Dementia/Alzheimer’s Disease
 Parkinson’s
 Disease
 Multiple Sclerosis
157
Driving Reduction – Aging Factors
Affect Safe Driving Abilities
 Vision: anatomic changes, eye movements, sensitivity
to light, dark adaptation, visual acuity, spatial
contrast sensitivity, visual field, space perception,
motion perception
 Cognition: attention, memory, problem solving,
spatial cognition
 Psychomotor function: flexibility, coordination,
strength
Pellerito, 2006, p 426-434
158
Driving Cessation is a
behavior change and
a life transition.
UQDRIVE
159
Driving Cessation 4 Phases
 Driving in the Past-shapes meaning and identity
 Predecision - some difficulty or changes to
driving routines, protects driving, challenge is
achieving awareness
 Decision Phase - challenge is making the decision
and owning the decision
 Post-Cessation phase- challenge is finding other
ways and coming to terms
UQDRIVE, Liddle; AOTJ 2007 p 303-306
160
UQDRIVE
Intensive support to manage driving cessation, 6
weeks, one morning a week group program:
1. Growing older
2. Driving later in life
3. Adjusting to losses and changes
4. Experiences of retiring from driving
5. Alternative transport
6. Lifestyle planning
7. Advocacy and support
www.uq.edu.au/uqdrive
AOTJ 2007 p303-306
161
Driving Cessation Solutions
 Start Early
 Before any final outcome (on the road) shift driving to
other persons
 Organize errands and tasks to consolidate outings that
require rides from others
 Transportation plans set up - formally, write a driving
needs list and a real schedule
162
Driving Cessation Solutions - continued
 Use public transportation, taxi services.
 Locate community resources available.
 Arrange for deliveries.
 Order from catalogs.
 Arrange for home visits from beautician, etc.
 Support Groups
 Consider relocation to an area that has transportation.
163
Driving Cessation Barriers
 Expensive alternatives (taxis and private services)
 Lack of services in rural areas - absence of
alternatives
 Fear of burdening social network
 Most people do not plan for cessation/retirement
of driving.
 Lack of flexibility to form new habits
 Lack of readiness for change
164
Legal and Professional
Ethics in Driver
Rehabilitation
Autonomy
 A form of personal liberty, where the individual is free
to choose and implement his/her own decisions, free
from deceit, duress, constraint, or coercion.
 A competent adult has the right to refuse medical
treatment/recommendation even if the refusal is life
threatening.
 What about public safety?
166
Autonomy - continued
 Autonomy can be positively confirmed by being
able to answer “yes” to the following
questions:
– Does the patient understand the nature of
the illness and the consequences of the
various options that may be chosen?
– Is the decision based of rational reasoning?
 The decision itself need not be rational but the
reasoning should be!
167
Autonomy - continued
 A therapist/physician who is not an entity of
the state Bureau of Motor Vehicles can only
make a “medical recommendation”.
 In Ohio, a therapist/physician does not have
the authority to issue/revoke a license, only
the BMV or court system can issue/revoke a
license.
168
Autonomy - continued
 Is a client legal to drive home from an
appointment in which the client received a
medical recommendation for driving cessation, if
he/she has a valid driver’s license?
 Is it ethical for a therapist to permit a client to
drive home after giving a medical recommendation
for driving cessation?
169
Veracity
 Veracity binds both the health care
practitioner and the patient in an
association of truth.
 The patient must tell the truth so
appropriate care can be provided.
 The practitioner needs to disclose
factual information so that the patient
can exercise personal autonomy.
170
Veracity - continued
 Quote from an ADED annual conference attendee
regarding his communication to clients whom he
is recommending driving cessation
– “I use a forceful tone of voice. The patients
do not know the difference between a medical
recommendation and having their license
revoked.”
 Can a health care provider, under the guise of
doing good, purposefully mislead a patient?
171
Justice
 Justice is the concept of fairness,
just deserts and entitlements.
 A therapist must treat all patients
equally and fairly.
172
Justice - continued
 A therapist plans to recommend an elderly client who
has suffered a CVA to a driver rehabilitation program,
as the client has stated their goal to resume driving so
he/she can return to his/her home. The client’s
daughter takes the therapist aside and requests of the
therapist not to make the referral and to recommend
driving cessation because the client lives alone and 2
hours away from any family. The daughter states her
parent is safer residing with family and she is happy to
have her parent living with her.
 How should the therapist respond?
173
Role Fidelity
 The ethics of health care require that
therapists practice faithfully within the
constraints of their role.
 Areas of acceptable practice are contained
and prescribed by the scope of practice of
the state legislation that enables that
profession’s practice.
174
Role Fidelity - continued
 In the State of Ohio, can a licensed
therapist make a medical
recommendation to a client for
driving cessation without consulting
with the physician?
175
Ohio BMV Reporting Procedures
 Ohio does not have mandatory reporting
laws.
 Yet, the AMA’s 1999 Code of Medical Ethics
states:
– Physicians have an ethical responsibility
to notify state motor vehicle authorities
about patients with medical conditions
that might make them unsafe drivers
(Tennery,1999)
176
Ohio BMV Reporting Procedures continued
 While ethical values and legal principles are
usually closely related, ethical obligations
typically exceed legal duties.
 Yet, Ohio does not protect medical professionals
who report patients from being sued for violating
HIPPA laws.
 Ohio will provide anonymity to reporting
physicians but, not to any other health care field.
177
Ohio BMV Reporting Procedures continued
 If a health care professional reports a patient to the
Ohio BMV – Medical Unit, the patient is notified in
writing that he/she has been reported and names the
person who reported him/her (unless reported by a
physician).
 The patient must complete a form that requests the
name of his/her personal physician and return it to
the BMV.
 The listed physician has 30 days to complete a BMV
form sent by the Medical Unit.
178
Ohio BMV Reporting Procedures continued
 The BMV – Medical Unit reviews the physician’s
completed form then notifies the patient he/she must
retake a written and on-road examination.
 Failure to complete the re-examination within a
reasonable time frame results in the BMV revoking the
patient’s license.
 Patient can pass or fail the re-examination.
 The patient is permitted 3 attempts to pass the re-
examination.
 During the time frame of this process, the patient
maintains his/her valid license.
179
?’s - Questions - ?’s