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Driving and Stroke

Hilary Knox MSc.O.T. Out-patient Neuro RehabilitationRed Deer Regional Hospital Centrehilary.knox@albertahealthservices.ca

Christine Gregoire Gau BSc. O.T.Professional Practice Lead MSK & CRP Clinic Camrose christine.gregoiregau@albertahealthservices.ca

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Objectives

• Understand how impairments common to stroke impact driving

• Be familiar with guidelines and responsibilities related to driving

• Describe the approach to screening, assessment and remediation

• Become aware of local services• Be familiar with common vehicle adaptations to support

return to driving

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Incidence of Stroke

50 000 Canadians suffer the effects of a stroke each year. (Heart and stroke)

70% of survivors will have residual perceptual and cognitive dysfunctions. (Heart and Stroke)

30% of stroke survivors with moderate to severe stroke will return to driving. (Marshall, S., et.al.)

87% of those returning to driving have not received any formal evaluation of driving ability. (Marshall, S., et.al.)

The crash rate for drivers post-stroke was nearly three times the risk of crash involvement compared to healthy, older drivers. (Perrier, M., Korner-

Bitensky, N., Petzold, A., and Mayo, N., 2009)

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Impact of Stroke on Driving Performance

Dependent on the location and severity of brain damage

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Memory

Executive Function

Attention

Visuospatial perception

Impact of Stroke on Driving Performance

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Impact of Stroke on Driving Performance

Language comprehension

Vision

Sensory and Motor Functions

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Red flags• Forgetting familiar routes, getting lost

• Stopping in traffic when there is no need to stop due to demands on complex or fast cognitive processing

• Confusion between pedals in a stressful situation

• Failing to yield right-of-way appropriately

• Easily frustrated or confused while driving

• Drift across lane markings into other lanes

• Difficulty thinking clearly about the traffic around you

.

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Whose Responsibility is it?

Driver’s license holder

A person who holds or applies for a driver’s license must immediately disclose to the Registrar a disease or disability that may interfere with the safe operation of a vehicle.

The presence of a related medical condition does not necessarily mean that a person’s ability to drive will be restricted.

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Whose Responsibility is it?Driver Fitness and Monitoring

Is a program/service within the Government of Alberta’s Ministry of Transportation.

Responsible for reviewing driving privileges of individuals and assessing their ability to safely operate motor vehicles.

The final decision pertaining to whether a person loses the privilege to drive is up to Driver Fitness and Monitoring.

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Whose Responsibility is it?

Health Care Professional

Identify

Advocate

Report

Assessment

Remediation “Why can’t you people get organized?” One day you take my license away and the next

day you ask to see it.”

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CCMTA Licensing Guidelines

• Canadian Council of Motor Transport Administrators

• Guidelines relate to specific medical conditions for a class 5 license

• Cerebrovascular diseases start on page 19

For full guidelines see www.ccmta.ca

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Stroke

Patients should not drive for at least one month.

Driving may resume if:

No significant motor, cognitive, perceptual or visual deficits. Where there is loss of function and ability, a road test is recommended.

Neurological assessment discloses no obvious risk of sudden recurrence.

Underlying cause has been appropriately treated.

No post stroke seizure has occurred.

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Cerebral Aneurysm

• Symptomatic aneurysm is an absolute barrier to driving any vehicle.

• In case of an asymptomatic, incidentally discovered aneurysm, the driver may be eligible for any class of licensure upon receipt of a favourable opinion from a neurologist/neurosurgeon.

• Surgically treated cerebral aneurysm warrants a waiting period of 3 months private driving, 6 months commercial driving

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Single or Recurrent TIA

Should not be permitted to drive until:

• A neurological assessment and appropriate investigations

are completed.

• May resume if the neurologic assessment shows no

residual loss of functional ability, discloses no obvious risk

of sudden re-occurrence and any underlying causes have

been addressed with appropriate treatment.

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Seizures or Epilepsy

Class 5 or 6 if • free from seizures for six months, provided

medication prescribed does not cause significant side effects that would impair driving

AND• the physician believes the individual is being truthful

about the frequency of seizures, will take medication in the manner prescribed and is under regular medical supervision

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Visual Acuity

• Not less than 20/50 both eyes open

and examined together

• Must at least be such that there is

time to detect and to react to

obstacles, pedestrians, other

vehicles and signs.

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Visual Field Deficits

• If a visual field deficit is suspected, the patient should be referred to an ophthalmologist or optometrist for further testing

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Visual Field Deficits

• Complete homonymous or bitemporal hemianopsia -

suspended from all driving privileges

• 120 continuous degrees along the horizontal meridian

and 15 continuous degrees above and below fixation

with both eyes open and examined together.

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So…how do we screen and assess?

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CCMTA Best Practice Strategy

• Individual assessment strategy for safe return to driving

• Specifically for vision loss, although process is similar post-stroke

• OT specific model for driving to be published in Jan/Feb 2011 (AJOT)

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Approach to Driving Assessment

In house– Clinical based assessment usually focused on

assessment of cognitive, perceptual and other skills believed to impact on driving ability

On road– Actual driving assessment – Often seen as gold standard but issues exist related

to lack of structure, standardization, reliability and validity

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MMSE

• MMSE Routinely used to assess driving ability with a cut off of 24/30

• Not designed for this application• Low specificity

– Proportion of clients who were predicted to pass an on road test based on a cut off of 24/30, who did pass, was low (Dobbs and Schopflocher, 2010).

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SIMARD MD

• Paper and pencil screening tool for identifying cognitively impaired drivers

• Used by health care professionals and driver licensing agency personnel

• Composed of four subtests

• Early, but has some promising applications to predict on road performance in some situations…lacks adequate research!

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Bottom Line

Nothing predicts on road performance but....

On road evaluation!

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Where can I refer?

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Central Zone Services

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Driver Evaluation and Training Service

Glenrose Rehabilitation Hospital’s

Driver Evaluation and Training Service (DETS)

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Calgary: Pre-driving Assessment Service

• Central CAR clinic • Only public funded pre-driving assessment service in

Calgary• Referrals by physicians for clients 16 years of age or

older who have a physical, cognitive or perceptual disability resulting from a neurological diagnosis

• Psychiatric disorders, dementia, and pervasive developmental disorders, or homonymous hemianopsia are excluded

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DriveABLE

• In office and on-road evaluation

• Fee is $200

• Locations in Edmonton, Calgary, Medicine Hat, Lethbridge, Peace River, Wainwright, Red Deer

www.driveable.com

A University of Alberta spin-off company founded to provide evidence-based practices for identifying the

medically impaired driver

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Driver Safety Concern Form

• Form to request that the Ministry of Transport look into driving ability

• Available online from the Canadian Association of Occupational Therapists…

http://www.caot.ca/pdfs/Recommendation2.pdf

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Compensatory Strategies

Adaptive equipment can compensate for some physical impairments in the absence of cognitive impairments

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Spinner Knob (single and tripod)

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Signal Cross Over

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Left Foot Accelerator

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Mirror Extensions

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Vehicle Modifications

Approximate costs for modifications:

• Spinner knob $ 150-250• Left foot accelerator $ 450 + • Hand Controls $ 1190• Signal extension $ 120-200• Pedal extension $ 120 +

Recommend NMEDA approved vendor:www.nmeda.org

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Features of the DETS modified van

Standard Hand Controls Wheelchair tie down

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Horizontal Steering

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Electronic Gas-Brake

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Joystick Control & 6-way Power Seat

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Touch Controls

– ignition

– cruise

– gears

– wipers

– lights

– air/heat

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Impact of driving cessation

Negative psychological, social and functional implications associated with driving cessation

Driving represents freedom, control and independence. • Go where you want, when you want

Mobility is a right, driving is a privilege. What are the alternatives if driving cessation is necessary?

Process of acceptance and grieving for license loss is individual

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Stay SHARP program• McGill University initiative – currently funded for a phase

1 pilot study

• Acronym Stay SHARP (See, Hear, Attend, Respond, Perform) (Korner-Bitensky, N. & Kua, A., 2010).

• Includes retraining focused on– Physical and behavioral skills– Visuo-spatial and cognitive skills– Driving specific knowledge.

Funded by CIHR/Candrive

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Questions?

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References

Akinwuntan AE, DeWeerdt W, Feys H, Baten G, Amo, P, Kiekens C. The validity of a road test after stroke.

Arch Phys Med Rehabil. 2005; 86:421–426.

CAOT website, http://www.caot.ca/pdfs/Recommendation2.pdf

CCMTA Canadian Medical Standards for Drivers 2008 website. http://www.ccmta.ca/english/pdf/medicalstandardsjune08.pdf

Dickerson, A., OT Process for Driving & Community Mobility(to be published in AJOT Jan/Feb 2011

Dobbs, B. M., & Schopflocher, D. (2010). The introduction of a new screening tool for the identification of cognitively impaired medically at-risk drivers: The SIMARD A Modification of the DemTect. Journal of Primary Care and Community Health, 1(2), 119-127

Driver Monitoring and Fitness website, http://transportation.alberta.ca/2567.htm

Heart and Stroke website, http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.3581583/k.F7E3/Heart_Disease_Stroke_and_Healthy_Living.htm

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ReferencesMarie-Josée Perrier, Nicol Korner-Bitensky, Anita Petzold, and Nancy Mayo The risk of motor vehicle accidents and

traffic violations post-stroke: a structured review March 16, 2009 Journal of the American Heart Association

Marshall , S., et. al. Top icsStroke Rehabil itation2007;14(1):98–114 © 2007 Thomas Land Publishers, Inc. www.thomasland.com doi: 10.1310/tsr1401-98

Korner-Bitensky, N., Gelinas, I., Man-Song-Hing, M., & Marshall, S. (2005). Recommendations of the Canadian Consensus Conference on driving evaluation in older drivers. Physical & Occupational Therapy in Geriatrics, 23(2/3), 123-144.

Korner-Bitensky, N. & Kua, A. (2010). The occupational therapist’s role in keeping older drivers safe: refreshing driving skills – the Stay SHARP program. Occupational Therapy Now, 12(5):7-8

Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M. In-office evaluation of medical fitness-to-drive. Practical approaches for assessing older people. Can Fam Physician 2005;51:372–9

Rabbitt, P., Carmichael, A., Shiling, V., & Sutcliffe, P. (2002). Age, health and driving: longitudinally observed changes in reported general health, in mileage, self rated competence and in attitudes of older drivers.

Manchester: AA Foundation for Road Safety Research.SIMARD MD website, http://www.mard.ualberta.ca/Home/SIMARD/

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Thanks to Cherie Henderson

Occupational Therapist

Glenrose Rehabilitation Hospital Edmonton

For permission to use her resources

cherie.henderson@albertahealthservices.ca

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Thank you

Hilary Knox MSc.O.T. Out-patient Neuro RehabilitationRed Deer Regional Hospital Centrehilary.knox@albertahealthservices.ca

Christine Gregoire Gau BSc. O.T.Professional Practice Lead MSK & CRP Clinic Camrose christine.gregoiregau@albertahealthservices.ca