1. AutO&Mobility: driving with a visual impairment in the Netherlands dr. Bart Melis-Dankers PhD Royal Dutch Visio Centre of expertise for blind and partially sighted people SMS-conference December 5, 2012 København

2. Shared Space 2  16.7 million inhabitants  316,000 visually impaired people [1.9%]  primary care:700 optometrists and 2,500 opticians.  secondary care:707 ophthalmologists [1:23,600].  tertiary care: visual rehabilitation centres: -- Royal Dutch Visio: 3,200 employees -- Bartiméus: 2,200 employees The Netherlands

3. Shared Space 3  Optimization of independent mobility is important for social participation.  Driving is the main form of transport in NL. 7.7 million passenger cars.  Driving itself is not the goal. Independent mobility is!  Safety first. Rehabilitation programme AutO-Mobility: Individual advice and training programme to optimize independent mobility, if possible in motorised vehicles. AutO-Mobility

4. Shared Space 4 fitness to drive: NL in 1998 medical  visual acuity:0.5 in best eye [6/12, 20/40]  visual field:≥ 140° practical  the ability to drive safely and smoothly despite one’s visual impairment.  on road driving test by the Netherlands Bureau of Driving Skills Certificates [CBR].

5. Shared Space 5 VA = 0.2 visual acuity 0.5 : reading licence plate at 35m

6. Shared Space 6 Step 1: Coeckelbergh & Kooijman 1998 – 2002  N = 67 participants.  Visual acuity loss and/or visual field defect.  All had insufficient medical fitness to drive.  Practical fitness to drive test [CBR]. [Human Factors, 2004, 46(4): 748-760]

7. Shared Space 7 central peripheral central and peripheral VA Snellen horizontal field diameter (degrees) (n=24) 0.23 142 (n=36) 0.74 84 (n=7) 0.19 91 Visual Field Defect passed failed practical fitness to drive: 6 (25%) 15 (42%) 2 (14%) 21 (58%) 5 (86%) 18 (75%) N = 67 participants Step 1: Coeckelbergh & Kooijman 1998 – 2002: data

8. Shared Space 8 Step 1: Coeckelbergh & Kooijman 1998 – 2002: conclusion  N = 67  All had insufficient medical fitness to drive.  34% passed practical fitness to drive test [CBR] The medical fitness to drive (visual acuity and visual field) provides not sufficient information to decide about the practical fitness to drive. [Human Factors, 2004, 46(4): 748-760]

9. Shared Space 9  Netherlands Bureau of Driving Skills Certificates [CBR]  Ministery of Transport  2 driving schools  University Medical Center Opthalmology  Univeristy Medical Center Traffic Medicine  Royal Dutch Visio: clinical physicist optometrist occupational therapist neuro-psychologist Step 2: build a consortium 2000 - 2004

10. Shared Space 10  Impaired visual acuity: Bioptic Telescope System [BTS]  Visual field defect: homonymous hemianopia Scanning Compensatory Therapy [SCT] Step 3: development of training 2004 - 2007

11.  Road design  Traffic signs / traffic lights  Route signs  Other road users VA = 0.16 = 20/125

12. Shared Space 12 Bioptic telescope system [BTS]  monocular  2x - 3x magnification  field of view: 15°  weight: 12 gr.

13. Shared Space 13 Correct BTS use driving  road signs  crossings / traffic lights  pedestrians / cyclists  overtaking safety first  right moments  short  goal directed  in time (not too early)

14. Shared Space 14 Step 3a: pilot project BTS 2004 - 2007  inclusion: 0.16 <= BBCVA < 0.5  BTS-programme:  assessment day  fitting BTS [optometrist]  O&M-training 4 x 3 hours [O&M-trainer]  driving lessons [driving instructor]  practical fitness to drive test [CBR]  9 subjects passed fitness to drive test with BTS [Visual Impairment Research, 2008, 10: 1-6] [Visual Impairment Research, 2008, 10: 7-22]

15. 15 The Effects of Compensatory Scanning Training on Driving for Hemianopia Patients Gera de Haan MSc. University of Groningen, The Netherlands Clinical and Developmental Neuropsychology

16. 16 Current study Aim: Examining the effect of compensatory scanning training on mobility for homonymous hemianopia. Compensatory Scanning Training: 1. Increase of awareness 2. Systematic scanning strategy 3. Transfer to mobility in daily life

17. 17 Systematic scanning strategy Based on training Pizzamiglio (1992) and Tant (2002) Scanning strategy: ◦ Fixate straight ahead ◦ Large saccade towards blind hemifield ◦ Saccade back to seeing hemifield ◦ Fixate straight ahead ◦... Right hemianopia:

18. 18 Participants in driving study RCT of 60 hemianopic patients with mobility problems Effect of Scanning Compensatory Training on mobility and Quality of Life ------------------------------------------------------------------------------- N = 27 adults reporting mobility problems because of a homonymous hemianopia, the hemianopia existing for at least 6 months N = 21 left-sided hemianopia, N = 6 right-sided hemianopia N = 18 male, N = 9 female M(age) = [27-71] M(TimeSinceLesion) = 24 months [6.5-122] No severe motor, neuropsychologic or hearing impairments No ophthalmologic dysfunctioning and binocular visual acuity > 0.5

19. 19 Training group T1T2 Control group T3 Training T1 T2 Training pre post -3mth Design Tests on T1, T2 and T3: Impaired Mobility Questionnaire (IMQ; Turano, 1999) Tracking Task Obstacle course (with dual task) Hazard perception (Vlakveld, 2011)

21. 21 Training group T1T2 Control group T3 Training T1 T2 Training pre post -3mth Design Tests on T1, T2 and T3: Impaired Mobility Questionnaire (IMQ; Turano, 1999) Tracking Task Obstacle course (with dual task) Hazard perception (Vlakveld, 2011) Driving simulator Fitness to drive

22. Shared Space 22  inclusion: homonymous hemianopia  SCT-programme:  assessment day  optimizing optics [optometrist]  SCT-training 10 x 1.5 hours [O&M-trainer]  driving lessons [driving instructor]  practical fitness to drive test [CBR] Step 3b: scanning compensatory therapy 2007 - 2012

23. Result

25. 25 Practical Fitness to drive: TRIP Test Ride for Investigating Practical fitness to drive 57 items: insufficient, doubtful, sufficient Driving test taken by ‘blind’ CBR-expert Factors: ◦ VIS: visual factor ◦ OPER: operational factor ◦ TACT: tactical factor

26. 26 Fitness to drive N = 27 Hemianopia patients (total N = 57) N = 21 left-sided, N = 6 right-sided hemianopia N = 18 male, N = 9 female M(Age) = 52 [27-71] CBR (Dutch department of motor vehicles) 2 on-road driving assessments: Before onset of training (N=27) 15 passed (56%) 12 failed (44%) After training (N=10) 6 failed4 passed

27. 27 Fitness to drive: TRIP TRIP-factors improve after training

28. 28 Conclusion Self-reported mobility in daily life improved (IMQ) Faster responses to stimuli in the blind periphery (Tracking Task) Higher walking speed in obstacle course with cognitive dual task Part of patients with hemianopiae is practical fit to drive, even without training. Visual aspects of driving are most problematic. Negative judgement due to insufficient viewing strategy, but also due to operational and tactical driving. Training improves visual and tactical aspects. No age-related effect found. -------------------------------------------------------------------------------------- Hemianopia does not necessarily impair fitness to drive

29. Shared Space 29  report to the minister of Transport  decisions: May 2009 and February 2010 visual acuity impairment:  VA >= 0.50 : unrestricted driving license  0.40 <= VA < 0.50 : CBR-test without BTS  0.16 <= VA < 0.40 : CBR-test with BTS visual field defect:  HVF >= 120° : unrestricted driving license  90° <= HVF < 120°: CBR-test Step 4: lobby to change regulations 2007 - 2010

30. Shared Space 30 South NW North SW Step 5: extending consortium 2009 - 2010 ° °  4 regions: 12 locations  education of:  9 information officers  31 optometrists  25 O&M trainers  6 clinical physicists  5 neuro-psychologists  23 driving instructors  8 CBR experts on practical fitness to drive  12 CBR driving examiners  September 2010: AutO-Mobility nationally available

31. Shared Space 31 BTS:SCT:  driving licenses issued: 70 19  not fit to drive: >250 >80 Remember: AutO&Mobility is about mobility (and not driving per se). ------------------------------------------------------------ 2012: BTS-program for nystagmus patients Current situation December 2012

32. Shared Space 32 New programmes for:  mobility scooter [16 km/h = 10 miles/h]  microcars [45 km/h = 30 miles/h]  patients with combined acuity and field impairment  patients with visual and neurological impairment Step 6: future developments 2012 - 2015

33. Shared Space 33 ITMA 2012: May 19-22 International Traffic Medicine Association Hamburg www.trafficmedicine.org ----------------------------------------------------------------- ESLRR 2012: September 13-15 European Society for Low Vision Research and Rehabilitation Oxford www.eslrr.eu Interesting congresses

34. Shared Space 34 Royal Dutch Visio www.auto-mobiliteit.org BartMelis@visio.org Please contact

35. 35 Practical fitness to drive: TRIP Main reason for negative judgement

36. VISOPERTACTGLOBTOT Mean (SD) Drive1 (N=27) 2.60 (0.51) 2.70 (0.48) 2.67 (0.41) 2.52 (0.64) 2.66 (0.43) Failed (N=12) 2.20 (0.53) 2.40 (0.58) 2.36 (0.44) 1.92 (0.52) 2.32 (0.45) Passes (N=15) 2.92 (0.10) 2.95 (0.10) 2.92 (0.10) 3.00 (0.00) 2.93 (0.06) p-value.001.007.001<.001.001 LHH (N=21) 2.50 (0.54) 2.64 (0.52) 2.61 (0.45) 2.38 (0.67) 2.58 (0.46) RHH (N=6) 2.94 (0.10) 2.93 (0.13) 2.88 (0.10) 3.00 (0.00) 2.93 (0.07) p-value.002.032.019<.001.003 Men (N=18) 2.61 (0.41) 2.73 (0.41) 2.71 (0.35) 2.56 (0.57) 2.69 (0.31) Women (N=9) 2.58 (0.70) 2.64 (0.61) 2.58 (0.52) 2.44 (0.80) 2.60 (0.62) p-value.896.643.451.667.609 ratings on the individual TRIP-items, split by factor (N=27)