SMALL STEPS. GIANT STRIDES.

Cruising Down Independence Lane: A Look at a Driver Rehabilitation Program

Kelsee Hove, OTD, OTR/L, CBIS, DRSNora Frigo, OTD, OTR/L, CBIS

About the Speakers

● Kelsee Hove, OTD, OTR/L, CBIS, DRS

● Nora Frigo, OTD, OTR/L, CBIS, DRS

Session Objectives

● Examine the importance of driving as an occupation

● Understand what a driver rehabilitation program is and the role of a transdisciplinary team

● Explore a variety of diagnoses and their impact on driving

Driving as a Daily Occupation

● Driving as an IADL

● Impact on meaningful activities & roles○ Work, education, leisure, social

participation

● If concerned with an IADL, it is our ethical duty to determine next steps

*Slide used with permission from Miriam Monahan

Driving Cessation and QOL

● Increased depression

● Decline in psychological well-being

● Reduced social opportunities & interactions

● Reduced community participation

● Restricted independence

Driving After Brain Injury

● Most important goal & functional limitation

● Approximately 40-60% of individuals post TBI are found fit to drive

Driver Rehabilitation Specialist (DRS)

● May have advanced training and education in driver evaluation

● Educational/professional backgrounds○ Healthcare professionals○ Driver educators/instructors

*Slide used with permission from Miriam Monahan

Certified Driver Rehabilitation Specialist (CDRS)

● The Association for Driver Rehabilitation Specialists (ADED)

● Meet educational and experiential requirements to sit for exam

● Successfully pass the CDRS examination*Slide used with permission from Miriam Monahan

Driver Rehabilitation Program

• Referral required• Out of Pocket• Comprehensive Driver

Evaluation• Clinical• On-Road

• Interventions• Training on compensatory

strategies or aids (In-clinic or on-road)

• Outcomes of Evaluations• Fit to drive• Fit to drive with restrictions• Intervention and/or training

needed• Unfit to drive

Why a Driver Rehabilitation Program is Important

● Addressing Independence

● Assessment of○ Cognition○ Vision○ Physical

Recognizing Cognitive Impairments

● Difficulty focusing on a driving task for periods of time● Inattention to traffic in front and to the rear ● Distracted driving● Difficulty recalling directions, remembering the rules of the road or signs

once out of sight● Difficulty with following steps to back out of a parking space● Delayed brake time● Difficulty with speed regulation● Difficulty with intersection management● Appropriate response to detours or other drivers

Executive Functions

● Insight● Reasoning● Planning● Judgment● Initiation● Abstract Thinking● Problem Solving

Executive Functions

Problem solving Planning ahead

Divided attention

*Slide used with permission from Miriam Monahan

Mental flexibility

Executive Functioning

*Slide used with permission from Miriam Monahan

Cognitive Overload

*Slide used with permission from Miriam Monahan

Information Processing Model

Stimuli in the environment

Perceive, attend, and

interpret stimuli

Plan action or responseExecute action

Behavior modification

Vision and Attention

Executive FunctionsMotor Skills

Executive Functions

*Slide used with permission from Miriam Monahan

Recognizing Vision Impairments

● Lack of scanning an intersection● Inadequate gaps between vehicles ● Difficulty managing a curve with the correct speed and

adjustment of the wheel● Going too far or not far enough when initiating a left

turn at an intersection● Drifting left or right in the lane

Recognizing Motor & Sensory Impairments

● Utilization of a mobility device (i.e., wheelchair, walker, cane, scooter, etc.)

● Ambulating with a limp or using the wall or other stable surfaces to balance

● Difficulty transferring in and out of vehicle

Recognizing Motor & Sensory Impairments

● Difficulty opening and closing door/trunk

● Difficulty gripping the wheel● Difficulty pressing and releasing

the brake and accelerator pedals (too slow, or too fast)

● Uses left foot on brake and accelerator pedals

● Utilization of adaptive equipment

Right Hemisphere Damage

● Can they close a door?● Reach seat belt?● Use left hand to steer? ● Manage turn signal?● Manage other devices such as cruise control, wiper

control?● Cognitive or perceptual issues?

Left Hemisphere Damage

● Manage seat belt? ● Start ignition?● Manage gear selector?● Can they use right hand for steering?● Manage other controls?● Use right foot gas and brake?

Multiple Sclerosis

● Weakness either side or upper vs lower extremity or any combination

● Spasticity● Vision loss● Sensory loss● Mobility limitations● Cognitive issues● Side effects from medications

Parkinson’s Disease

● Weakness either side or upper vs lower extremity involvement

● Spasticity● “Freezing”● Mobility limitations● Sensory loss● Tremors● Cognitive issues● Study related to early intervention

Vehicle Adaptive Equipment

Scoping Review

A Scoping Review to Examine Brain Injury Interventions for Fitness to Drive

Kelsee Hove, OTD, OTR/L, CBISa,DRS, James Wersal, OTD, OTR/L, CBISb,DRS, Sherrilene Classen, PhD,

MPH, OTR/L, FAOTAb

aDepartment of Occupational Therapy, Drake University; bDepartment of Occupational Therapy, Florida University

Results

●8/9 of the simulator-based studies demonstrated efficacy and/or effectiveness in improving driver fitness although specific dose, frequency, intensity/time, and active ingredients that improve driver fitness is unclear.●An occupational therapy driving intervention with use of a simulator addressing common driving errors that impact fitness to drive was found to be efficacious for returning male Combat Veterans.●Examples of non-simulator interventions: use of a scooter to target visual attention and maneuvering, Dynavision for visual and motor skills, Useful Field of ViewTM (UFOV) for visual attention and processing and cognitive skill training within and beyond multidisciplinary team.●The main findings of this review suggest that simulator-based interventions may have beneficial training effects to improve driver fitness of individuals with TBI and stroke and non-simulator based interventions may provide beneficial training for visual, cognitive and physical driving skills.

Fitness to Drive Screening Measure

http://fitnesstodrive.phhp.ufl.edu/us/

Transdisciplinary Team Approach

● A treatment approach that integrates expertise and experience from several different disciplines and professionals

At On With Life:

● OTR● COTA● PT● Vision specialists● Physician

Required to Schedule Appointment

● Physician referral

● Vision assessment within 1 year

● Valid driver’s license (or permit)

● Full payment

Evaluation Outline

● In-take○ Hx of illness ○ Review of survey (ie: previous driving experience, etc)

■ Sent to PS prior to evaluation

● In-clinic assessment○ Vision○ Cognition○ Physical○ Reaction time

● On-road assessment

Case Study- Background Info

● 68 y/o female s/p CVA

● Time since injury: ~4 months ○ Skilled facility: 1 week (discharged home) ○ Outpatient rehabilitation: 3 months

● Main limitations: weakness, vision, cognition, word finding

Case Study- Background Info

● General Info

○ No hx of seizures

○ Valid driver's license■ No restrictions

○ Hx of driving: daily, suburb/highway/long distance■ Avoided night driving

○ Last date driven: At time of CVA, ~4 months

Cast Study - In Clinic Assessment

● Vision

○ Snellen chart■ R eye: 20/25■ L eye: 20/70■ Both eyes: 20/20

○ Oculomotor control: ■ Pursuits: intact■ Saccades: impaired■ Convergence: intact

○ Depth perception: impaired

○ Peripheral vision: intact

○ Contrast Sensitivity: intact

Case Study- In Clinic Assessment

● Cognition

○ Trail Making Test■ Part A: 43 sec ■ Part B: 2 min 22 sec ■ # of errors: 4, cues to correct errors

○ SLUMS: 20/30

○ Traffic Sign Recognition: 8/8

○ Snellgrove Maze Test: 33 sec, 0 errors

Case Study- In Clinic Assessment

● Physical assessment○ B UE strength: WFL○ B LE strength: WFL○ Cervical ROM: WFL○ Trunk rotation: WFL ○ Motor coordination: intact

■ finger-to-nose■ toe tapping

● Sensation in B LE (shoe on)○ R foot: intact○ L foot: slight impairment

● Driving Simulator○ Brake pedal reaction time

■ R only: just below average

Case Study- In Clinic Results

● Red flags: ○ Vision, cognition, processing speed ○ Based on clinical results, determined starting

point of on-road assessment ■ ie: parking lot, residential area

● No adaptive equipment required

Case Study - On Road Assessment

● On-road assessment components

● Physical vehicle operation○ Satisfactory skills

■ Steering wheel management, mirrors ■ Turn signal, brake & gas pedal access

● Maneuvering vehicle○ Turn signal: required cues○ Lane positioning: good

■ Off road: x1 ○ Speed: good

■ Initially slow/cautious, improved with time ○ Merging: good ○ Parking: good

Case Study- On Road Assessment Cont.

● Intersection management○ Reaction time: good○ Turn signal usage: fair

● Executive functions & Behaviors ○ Following distance: good○ Problem-solving skills: good

Fit to Drive Recommendations

● Red flags identified in-clinic assessment○ Minimal impact on performance on road

● Satisfactory skills during on-road components

● Recommendations○ Consistent turn signal usage○ Ease into return to drive environments○ Cautious with night driving ○ Head and trunk turn when changing lane○ Reversing from parking spot

■ attend to front of vehicle/vehicle positioning○ Utilize GPS for unfamiliar areas

Questions?

ReferencesMiriam Monahan, OTD, OTR/L, CDRS, CDI, Miriam@driverrehabinstitute.org, www.driverrehabinstitute.org

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