Prediction of Return to Driving Post-CVA: An Evidence-Based Review Presented by Melissa Arakelian Melissa Arakelian

Introduction… Currently CVA is the most frequently encountered diagnosis by occupational therapists in the adult setting Currently CVA is the most frequently encountered diagnosis by occupational therapists in the adult setting Leading cause of disability in the U.S. Leading cause of disability in the U.S. Driving is relatively new problem faced by clinicians Driving is relatively new problem faced by clinicians Identified as one of top 10 emerging practice areas by The American Occupational Therapy Association (AOTA) Identified as one of top 10 emerging practice areas by The American Occupational Therapy Association (AOTA)

Impact of Driving… Clients often identify driving as the most important IADL Clients often identify driving as the most important IADL Viewed, within our culture, as a symbol of independence and adulthood Viewed, within our culture, as a symbol of independence and adulthood Greater incidence of depression noted in non-drivers Greater incidence of depression noted in non-drivers Decreased participation in social activities Decreased participation in social activities

Defining OT Roles… Occupational Therapy Generalist: Possess general knowledge and understanding of performance and processing skills related to driving. Occupational Therapist with Advanced Training: Further educated to evaluate the integration of sub-skills associated with driving, and provide specific sub-skill training. Occupational Therapist with Specialized Training: Received specialized education, examination, and/or certification.

Occupational Therapy Generalist… Expected to have greatest knowledge of expertise among team members Expected to have greatest knowledge of expertise among team members Responsible for clinical evaluation of sub-skills necessary for driving Responsible for clinical evaluation of sub-skills necessary for driving Knowledgeable of driving programs and resources available Knowledgeable of driving programs and resources available

In order to Drive… Physical Abilities Physical Abilities Perceptual skills Perceptual skills Cognitive abilities Cognitive abilities Vision Vision Attention Attention Emotion Emotion Reaction Time Reaction Time Mobility Mobility Hearing Hearing Visual Attention Visual Attention Planning/Problem Solving Planning/Problem Solving Physical and Mental Endurance Physical and Mental Endurance Information Processing Speed Information Processing Speed Visual Memory Visual Memory Visuocognitive abilities Visuocognitive abilities Visual Attention Visual Attention Visuomotor coordination Visuomotor coordination

Assessments Currently Employed… Trail Making Test (Part A) Trail Making Test (Part A) Visual Form Recognition Test Visual Form Recognition Test Single and Double-Letter Cancellation Single and Double-Letter Cancellation Cognitive Behavioral Driver’s Inventory (CBDI) Cognitive Behavioral Driver’s Inventory (CBDI) Dynavision Assessment Battery (DPAB) Dynavision Assessment Battery (DPAB) Bells Test Bells Test Motor-Free Visual Perception Test Motor-Free Visual Perception Test TMT-A and TMT-B TMT-A and TMT-B UFOV (useful field of vision) UFOV (useful field of vision) Complex Reaction Timer Complex Reaction Timer Money Road Map of Direction Test Money Road Map of Direction Test Charron Test Charron Test

Where to Focus… Currently there are no universally accepted clinical guidelines defining what constitutes a complete assessment battery for determining the ability to return to driving General clinical evaluation should consist of Vision Vision Perceptual skills Perceptual skills Cognitive skills Cognitive skills

Vision… An estimated 90% of informational input received during driving is visual An estimated 90% of informational input received during driving is visual Necessary to evaluate basic visual skills first… Necessary to evaluate basic visual skills first…

Vision… Adaptation Through Vision Visuocognition Visual Memory Pattern Recognition S c a n n i n g Attention: Alertness and Attending Oculomotor Control Visual Fields Visual Acuity *Adapted from original work by Margaret Horger, OTR

Vision… In a study by Fisk, G. D., Owsely, C., & Mennemeier, M. (2002), impairment of visual attention measured by the UFOV indicated greater impairment among post-stroke non-drivers versus post-stroke drivers Useful Field of Vision (UFOV) : Test of visual attention, measuring information processing, ability to divide attention, and the speed of processing

Perceptual Skills… Mazer, B., Korner-Bitensky, N. A. & Sofer, S. (1998) assessed the ability of the following perceptual tests to predict on-road driving outcomes: The Complex-Reaction Timer The Complex-Reaction Timer Motor-Free Visual Perception Test (MVPT) Motor-Free Visual Perception Test (MVPT) Single & Double Letter Cancellation Tests Single & Double Letter Cancellation Tests Money Road Map Test of Direction Sense Money Road Map Test of Direction Sense Trail Making Test A and B Trail Making Test A and B Bells Test Bells Test Charron Test Charron Test

Perceptual Skills… Findings by Mazer, B., Korner-Bitensky, N. A. & Sofer, S. (1998): MVPT found to have the highest positive and negative predictive ability MVPT found to have the highest positive and negative predictive ability Logistic model found best at predicting on-road driving outcomes included use of the MVPT and Trail Making B tests Logistic model found best at predicting on-road driving outcomes included use of the MVPT and Trail Making B tests Reaction time noted as near significance in prediction Reaction time noted as near significance in prediction

Cognitive Skills… Research indicates neuropsychological testing of executive functions should be included in pre-driving assessment Research indicates neuropsychological testing of executive functions should be included in pre-driving assessment Klavora, P., Heslegrave, R. J., & Young, M. (2000) compared the effectiveness of Cognitive Behavioral Driver’s Inventory (CBDI) and the Dynavision Performance Assessment Battery (DPAB) Klavora, P., Heslegrave, R. J., & Young, M. (2000) compared the effectiveness of Cognitive Behavioral Driver’s Inventory (CBDI) and the Dynavision Performance Assessment Battery (DPAB) Only the Endurance Dynavision Task (EDT) and the CBDI were found significant in predicting on-road outcomes Only the Endurance Dynavision Task (EDT) and the CBDI were found significant in predicting on-road outcomes

Additional Off-Road Tests… Implementation of simulators in clinical evaluation Implementation of simulators in clinical evaluation Able to provide face-valid context for observing driving behaviors Able to provide face-valid context for observing driving behaviors Study by Lee, H. C., Lee, A. H., & Cameron, D. (2003) validated the use of the STISIM Driving Simulator for assessing visual attention Study by Lee, H. C., Lee, A. H., & Cameron, D. (2003) validated the use of the STISIM Driving Simulator for assessing visual attention

Impact of Off-Road Tests… Cost Effective Cost Effective Less intimidating to client Less intimidating to client Safer form of evaluation Safer form of evaluation Allow for task break down, assessing performance of driving sub-skills Allow for task break down, assessing performance of driving sub-skills

In Summary… Driving is an IADL, and within the scope of practice for occupational therapists Driving is an IADL, and within the scope of practice for occupational therapists General clinical evaluations of driving should include standardized assessment of visual, perceptual, and cognitive skills General clinical evaluations of driving should include standardized assessment of visual, perceptual, and cognitive skills Impossible to determine ability to return to driving using one assessment tool Impossible to determine ability to return to driving using one assessment tool Clinical evaluation should be followed by on-road testing prior to judgment of driving ability Clinical evaluation should be followed by on-road testing prior to judgment of driving ability

References… Fisk, G. D., Owsley, C., & Mennemeier, M. (2002). Vision, attention, and self- reported driving behaviors in community-dwelling stroke survivors. Archives of Physical Medicine and Rehabilitation, 83, Hopewell, A. C. (2002). Driving assessment issues for practicing clinicians. Journal of Head Trauma and Rehabilitation, 17, Klavora, P., Heslegrave, R. J., & Young, M. (2000). Driving skills in elderly persons with stroke: Comparison of two new assessment options. Archives of Physical Medicine and Rehabilitation, 81, Korner-Bitensky, N. A., Sofer, S., Gelinas, I., & Mazer, B. (1998). Evaluating driving potential in persons with stroke: A survey of occupational therapy practices. American Journal of Occupational Therapy, 52, Lee, H. C., Lee, A. H., & Cameron, D. (2003). Validation of a driving simulator by measuring the visual attention skill of older adult drivers. American Journal of Occupational Therapy, 57, Mazer, B., Korner-Bitensky, N. A., & Sofer, S. (1998). Predicting ability to drive after stroke. Archives of Physical Medicine and Rehabilitation, 79,