2ObjectivesDevelop an occupational profile that addresses the client’s driving needs.Select specific evidence-based assessments and assessment methods to assist in determining driving readiness.Using the information gathered from the occupational profile, assessments, and goals determine the need to refer client’s to the DRS.Gain knowledge in the laws and agencies in the state of Texas that determine driving fitness to assist OT practitioners in establishing treatment plans and goals.
3About the speaker Introduced to clinical driving evaluations in 1987 Attended my first ADED conference in 1989?Developed a pre-driving clinical screen and evaluation in 2010Passed CDRS exam August 2013
5Why should occupational therapist evaluate fitness to drive?
6Things to considerThere are 20 million drivers in the U.S. 70 and older.Every year, more than 795,000 people in the United States have a stroke.400,000 individuals estimated to have MS.Approximately 60,000 Americans are diagnosed with Parkinson's disease each year, and this number does not reflect the thousands of cases that go undetected.One in four adults−approximately 61.5 million Americans−experiences mental illness in a given yearApproximately two million Americans have mild low vision which affects driving and reading.
7Why Should OT evaluate fitness to drive? Because driving is an instrumental activity of daily living within the domain of occupational therapy practice.practitioners should be able to accurately determine who is a safe driver, who is at risk for unsafe driving, and who needs further evaluation by a driving rehabilitation specialist (DRS).AOTA Driving and Community Mobility
8Occupational Therapy Roles Generalist: general knowledge and understanding of performance and processing skills related to driving.Advanced Training: Further education to evaluate the integration of sub-skills associated with driving and provide specific sub-skill trainingSpecialized Training: Received specialized education, examination, and/or certification.University of Florida
9What is in our domain of practice? Musculoskeletal disordersNeurological impairmentsCognitive impairmentMemory disordersVisual impairmentsPerceptual impairmentsMobilityMental impairment
13Texas Medical Advisory Board (MAB) The Texas Medical Advisory Board (MAB) for Driver Licensing was established in 1970 to advise the Texas Department of Public Safety (DPS) in the licensing of persons having medical limitations which might adversely affect driving.Guidelines established using the following:AMA Physician’s Guide for Determining Driver LimitationDriver Fitness Medical Guidelines (NHTSA)The American Association of Motor Vehicle Administrators
14Texas Medical Advisory Board/DPS The ultimate goal is to allow all who can drive safely to do so and to continue to reduce the number and severity of motor vehicle accidents in Texas
17The Association For Driver Rehabilitation Specialists (ADED)
18ADED Mission Statement Promoting excellence in the field of driver rehabilitation in support of safe, independent community mobility
19ADED Best Practices For The Delivery of Driver Rehabilitation Services Section 1: Interview/Medical HistorySection 2: Clinical Visual AssessmentSection 3: Clinical Physical AssessmentSection 4: Clinical Cognitive Assessment
20Interview/Medical History History of Present IllnessPast Medical HistoryDetermine medical consentReview current medications (side effects)Assess communication statusReview driving historyLicense statusDriving goalsVehicle availability
21Clinical Visual Assessment ADED recommendationPossible DeficitsVisual historyVisual acuityField of visionOther visual skillsCataracts, glaucoma, HH, etc.Feinbloom eye chart, BiVaba, SnellenScatomos, HHVisual short term memory, figure ground, form constancy, visual discrimination, visual scanning skills, High/Low contrast sensitivity
22Visual Assessments and Observations biVABA Brain Injury Visual Assessment Battery for AdultsThe cover testUFOV Useful Field of ViewDynavisionMotor Free Visual Perception Test (MFVPT)Clock drawing testTrails BPursuits and SaccadesBumping into walls, furniture, etc.nystagmusHead tilting or positionsquintingPosition of test paperVisual scanning efficiency
23Clinical Physical Assessment Range of MotionStrengthGrip strengthPrehension statusSensationProprioceptionCoordination (rapid pace walk)Muscle tone (MAS)Mobility status (TUG)Balance (Berg, Teniti,)Orthotic devicesMobility aidsTransfer skillsReaction times (Dynavision)
24Clinical Cognitive Assessment Mini Mental State Exam (MMSE)Short Blessed TestClinical Dementia Rating ScaleMontreal Cognitive Assessment (MoCA)Maze Navigation TestSingle Digit Modality Test (SDMT)Assessment of Motor Processing Skills (AMPS)
25Case Study 1: CVA76 y/o male with R MCA infarct, s/p thrombectomy, left hemiparesis, DM-2, HTN, BPH, small tear in left supraspinatus.+ multiple fallsPoly pharmacyWants to run errands and drive to any appointmentsh/o getting lost while driving when blood sugar is uncontrolledBacked into parked car in grocery store parking lotTotaled a vehicle 6-7 years agoHas not driven since onset of stroke
26Case Study 1 continued: CVA test results Impaired left peripheral vision+nystagmusRapid pace walk= 10 sec.Impaired head/neck flexibilityVisual closure, mild impairmentTrail Making B Test- 111sec.UFOV- unable to complete. Could not see 2nd vehicleShort Blessed=2Multiple angry outburst during testing
27Case Study 1: recommendations Referred to U of H low vision clinic by Neuro-ophthalmologistComplete program at U of H prior to attempting to drive or being referred to CDRS for BWT only after being cleared by OphthalmologistConsider driving cessation
28Case Study 2: Parkinson’s Disease 91 y/o male with h/o Parkinson’s Disease, loss of balance, peripheral neuropathy, spinal stenosis, lumbar laminectomy+ multiple fallsUsing walker with seatLast eye exam 2-3 years agoHistory of falling asleep spontaneously“minor” accident in parking lot when he could not stop in time when another vehicle pulled out in front of him causing a rear end collisionTotaled a car 3 yrs ago when he backed out of the drivewayWants to cont. driving without restrictions
29Case Study 2: Test results High low contrast sensitivity intact+nystagmusFailed cover testBells Test 3:57 sec.Trails B test 161 sec.Right ankle strength 2/5, hip/knee strength 3/5Limited head/neck flexibilityUnable to locate 50% items on UFOVFell asleep during testingRapid pace walk= 36 sec.Scored 100% on sign recognition, map reading (items on MFVPT)
30Case Study 2: Recommendations Patient should not resume driving without a BWT.High risk for having a crashConsider driving cessation
31Case Study 3: Left Hip fracture 82 y/o female with dx of left hip fxHas trouble looking over her shoulder, difficulty backing up, and has gotten lost while drivingWants to be able to drive to the store, etc. She does not plan on driving on the freeway or at night.She has not driven in 6 months since hip surgery
32Case Study 3: Test Results Mild impairment of low contrast visionMild impairment of working memoryImpaired visual closureTrails Making B test: 353 secondsImpaired visual processing speedImpaired UFOVRapid pace walk- 17 secondsNo errors on clock drawing testImpaired head/neck flexibility
33Case Study 3: Recommendations Further assessment through BWTReferral to optometrist
34Case Study 4: MS57 y/o female diagnosed with MS. Referred due to recent black out.h/o ventricular tachycardia, osteoporosis, cataracts, severe scoliosis+ fallsWears built up right shoe for leg length discrepancy and R AFOGets lost while driving, trouble finding and reading signs in time to respond, feeling tired after driving, had “near misses”, bothered by head light glare, trouble looking over shoulder when backing up.Recently hit a pole at the drive through bank and backed into trash cans at the end of her driveway.
35Case Study 4: Test Results Impaired visual acuity20/50 in left eyeHigh low contrast intactNo deficits noted with visual closureTrials Making B test 73 secondsMild deficit with visual processing speed on UFOVMild deficit with working memoryNo errors on clock drawing testRapid pace walk 5.8 secondsRight shoulder flex limited to 90Limited head/neck flexibility3+/5 strength in Bil hips, and anklesBecame fatigued during test
36Case Study 4: Recommendations Begin to seek alternative transportation if deficits worsenUse power chair instead of RW for appointments to conserve energyDo not drive on unfamiliar tripsDo not drive when fatiguedConsult with MDReferral to PTReferral to CDRS for BWT
37Case Study 5: Impaired memory 73 year old female with dx of impaired memory.Cataract removalCurrently drivingUnable to recall last eye examHad one speeding ticketWears a hearing aid (not wearing during exam)No fallsAdmits to getting lost while driving, feels others drive too fast, being stressed out by driving, difficulty at busy intersections, friends will no longer ride with her.
38Case Study 5: Test Results 20/25 binocular visionImpaired horizontal fixation to rightBells Test: 1:54, 3 errorsRapid pace walk- 6 secondsScored 14 on the Short BlessedTrials Making B Test 194 secondsIntact visual closure, visual processing speed showed mild deficit
39Case Study 5: Recommendations Driving should be restricted at best to her immediate neighborhood, however without being able to control what happens such as weather conditions, and changes in traffic volumes driving cessation may need to be considered. If family insist on pt. continuing to drive a referral to CDRS for BWT should be completed.