Appendix. Medical Review Board’s (MRB) 84 recommendations and/or motions to date as summarized.* All votes unanimous unless otherwise noted.

Topic Date Recommendations

Parkinson’s Disease (PD)

January 2010

Recommendation 1: Parkinson’s Disease and CMV Driver Certification. The MRB recommends that FMCSA adopt the following MEP Opinions on the certification of drivers with PD. A diagnosis of PD precludes an individual from obtaining

unconditional certification to drive a CMV for interstate commerce. A diagnosis of PD should not exclude all individuals; CMV

certification may be possible in some instances. A person with PD may be considered for CMV certification if he/she

meets a set of criteria based upon an evaluation by appropriate, qualified specialists. This qualified specialist (e.g., neurologist, movement disorders specialist, neuropsychologist, as appropriate) should assess for symptoms that may adversely affect driving ability.

Shows mild symptoms only, as indicated by a Hoehn Yahr (HY) scale stage 1 or less, and a high score (90 percent or higher*) on the Schwab and England Activities of Daily Living Scale**.

o *HY1 – Signs and symptoms on one side only, symptoms mild, symptoms inconvenient but not disabling, usually present with tremor of one limb.

o **90 percent – Completely independent. Able to do all chores with some degree of slowness, difficulty, and impairment. Might take twice as long. Beginning to be aware of difficulty.

o Tolerates medications well, without cognitive, motor, or other side effects that might affect driving.

o Shows no significant fluctuations in motor response or “on-off” effects (i.e., sudden fluctuations in disability involving rapid and abrupt alterations between periods of good mobility and periods of hypokinesia, tremor, and dyskinesia).

o Demonstrates satisfactory functioning on a battery of tests assessing key cognitive functions important for safely driving a motor vehicle (e.g., processing speed, attention, perception, memory, executive functions, and emotion).

o Satisfactory functioning should be defined as performing within or above the normal range using test norms that adjust for relevant factors, such as age and education.

o Shows no evidence of a mood disorder or satisfactory control of an existing mood disorder (see psychiatric disorders MEP report).

o Provides written documentation of the specialist’s report at the time of the CMV medical evaluation.

The medical examiner form should be updated by adding a place to indicate that the applicant has been referred to a specialist who has documented the individual’s condition relevant to safely operating a

Topic Date RecommendationsCMV.

An individual with PD who meets the criteria for certification should be re-evaluated on a semi-annual basis by a neurologist or other qualified specialist, and obtain an annual neuropsychological evaluation.

The choice of a qualified specialist should be based on the judgment of the medical examiner in the context of the complexity of the examinee’s case.

This choice depends on factors of illness severity, symptoms, duration, stability over time, and such interventions as medications required for management.

It also depends on the available resources, with general preference given to more highly trained and experienced consultants.

Multiple Sclerosis

January 2010

Recommendation 1: MS and CMV Driver CertificationThe MRB recommends that FMCSA adopt the following MEP Opinions on the certification of drivers with MS. A diagnosis of MS precludes an individual from obtaining

unconditional certification to drive a CMV for interstate commerce. A diagnosis of MS, however, should not exclude all individuals with

the disorder from driving a CMV; certification may be possible in some instances.

An individual with a diagnosis of MS may be considered for certification to drive a CMV if that individual meets a set of criteria (to follow).

o Based upon an evaluation by a qualified specialist (e.g., neurologist, MS specialist, neuropsychologist, ophthalmologist, occupational therapist, as appropriate, depending upon the signs and symptoms of the individual being evaluated).

Shows no signs of recent relapse or chronic progression. Tolerates medications well, without cognitive, motor, or other side

effects that might affect driving. Has satisfactory vision, including acuity, fields, and ocular alignment

(see vision MEP report). Demonstrates satisfactory cognitive functioning based upon a

standardized neuropsychological test battery assessing key domains important for safely driving a motor vehicle (e.g., processing speed, executive functioning, attention, perception, memory, and emotion). Satisfactory functioning should be defined as performing within or above the normal range using test norms that adjust for relevant factors, such as age and education.

Shows no evidence of a mood disorder or satisfactory control of an existing mood disorder (see psychiatric disorders MEP report).

Shows satisfactory motor function and mobility (see musculoskeletal MEP report).

Has no history of excessive fatigability or periodic fluctuations of motor performance, as in relation to heat, physical and emotional stress, and infections.

Provides written documentation of the specialist’s report at the time

Topic Date Recommendationsof his or her medical examination.

o The medical examiner form should be updated by adding a place to indicate that the applicant has been referred to a specialist who has assessed the individual’s condition relevant to safely operating a motor vehicle.

An individual with MS who meets the criteria for certification above should be re-evaluated on a semi-annual basis by a neurologist or other qualified specialist and obtain an annual neuropsychological evaluation.

The choice of a qualified specialist should be based on the judgment of the medical examiner in the context of the complexity of the examinee’s case. This choice depends on factors of illness severity, symptoms, duration, stability over time, and interventions, such as medications required for management. It also depends on the available resources, with general preference given to more highly trained and experienced consultants.

Note: The MRB accepts the aforementioned opinions of the MEP on MS with the addition that not only are they semi-annually evaluated by a neurologist or other qualified specialist, but also recertified.

Functional Evaluation

January 2010

Recommendation 1: Functional Evaluation/Fitness to Drive FrameworkThe MRB recommends that FMCSA adopt the following MEP Opinions on the functional evaluation of CMV drivers. FMCSA should adopt a general framework for determining fitness to

drive a CMV that relies upon a “functional” evaluation of multiple domains (cognitive, motor, perceptual, and psychiatric), which are important for safe driving.

o Such a framework could be applied across many diseases/conditions, including ones that have rarely been studied with respect to CMV driving.

Of note, this framework is compatible with MRB considerations regarding approach to drivers with multiple conditions.

o The framework would serve as a functional “screen” comprising elements of cognitive, psychomotor, and psychiatric function. It would screen for primary effects of illness (e.g., cognitive dysfunction), effects of medications (e.g., sedation), and illness-medication interactions. Examples include:

Cognitive: processing speed, attention, perception, memory, executive functions, and emotion.

Psychomotor: heel-to-toe walking, rapid alternating movement, and measures of perseveration for psychomotor function.

Psychiatric: Patient Health Questionnaire (PHQ) or PHQ-2 for depression, among others.

o The screen would be administered by the medical examiner, based on the obtained medical and psychological history, and

Topic Date Recommendationsused as an additional guide for referral.

o Two key elements of this approach are validity of each element of screening and practicality.

The screen would need to comprise validated testing measures and not be easily defeatable by examinees.

The evaluation would need to be easily teachable to medical examiners (e.g., through the National Registry Program process) and relatively quickly and effectively administered during the certification examination.

o We suggest revisiting evidence reports on other conditions (e.g., stroke, diabetes, TBI, etc.) and pooling these data to examine the predictive value of various factors (e.g., cognitive, motor, medication, etc.) in determining ability to drive safely and crash risk.

Narcolepsy January 2010

Recommendation 1: Narcolepsy. Retain the current regulation on narcolepsy, which indicates that people with narcolepsy are ineligible for a commercial driver’s license, even if treated.

Traumatic Brain Injury (TBI)

January 2010

The MRB recommends that FMCSA adopt the following MEP Opinions on the certification of CMV drivers with TBI:Recommendation 1: TBI and CMV Driver Certification. Individuals who have sustained a penetrating injury to the brain or severe TBI (i.e., loss of consciousness ≥ 24 hours) should be permanently precluded from obtaining certification to drive a CMV for interstate commerce. Recommendation 2: Moderate TBI and CMV Driver Certification. Individuals with moderate TBI should be precluded from obtaining certification to drive a CMV for interstate commerce for 3 years. After a 3-year wait, the individual must be cleared by the treating provider (minimum qualifications of M.D. or D.O.). The treating provider should assess for the following symptoms of concern: headaches, irritability, dizziness, imbalance, fatigue, sleep disorders, inattention, decreased concentration and memory, noise and light sensitivity, thinking slowed, difficulty recalling new material, personality change, difficulty starting or initiating things, difficulty sequencing information, impaired attention to details, impaired ability to benefit from experience, and deficits in planning and carrying out activities. If seizure occurred during the waiting period, follow current FMCSA guidance for individuals with a seizure disorder. If cleared by the treating provider, then the driver should be evaluated by a neurologist who is aware of the functional and cognitive requirements of operating a CMV. Additional evaluation by a neurologist should:

Include complete neurological assessment. Access motor speed and dexterity, cognitive

function, and symptoms of depression through

Topic Date Recommendationsobjective testing.

Refer individual to a neuropsychologist, psychologist, or other specialist, as appropriate, based on specific symptoms.

Recommend that the following cognitive domains should be assessed (suggested assessment tools listed):

Verbal memory and verbal learning (Hopkins Verbal Learning Test).

Visual scanning, visual motor speed (Trail Making Test A).

Cognitive flexibility, executive function (Trail Making Test B).

Word fluency (COWAT – Controlled Oral Word Association Test).

Attention (Digit Span forward). Working memory (Digit Span backward). Visual scanning, visual motor speed, visual

memory (Symbol Digit Modalities). Motor speed and dexterity (Grooved

Pegboard Test). Delayed recall (Hopkins Verbal Learning

Test).o Neurologist and medical examiner should assess the effects

of treatment, including medications, on functional and cognitive abilities.

o Drivers with no or minimal abnormalities who are cleared should be recertified every six months while under active treatment.

o Examiner should be M.D./D.O.o Once an individual is no longer under active treatment,

annual recertification is required for 3 years and then as determined by the medical examiner.

Recommendation 3: Mild TBI and CMV Driver Certification: Individuals with mild TBI can be deemed medically qualified if

they are determined by their treating provider (minimum qualifications of M.D./D.O.) to be clinically symptom free.

No LOC – 30-day waiting period. LOC – 90-day waiting period to ensure individual remains

symptom free. Individuals with mild TBI should be free of the

following symptoms of concern before they are qualified: headaches, irritability, dizziness, imbalance, fatigue, sleep disorders, inattention, decreased concentration and memory, noise and light sensitivity, thinking slowed, difficulty recalling new material, personality change, difficulty starting or initiating things, difficulty sequencing information, impaired attention to details, impaired ability to

Topic Date Recommendationsbenefit from experience, and deficits in planning and carrying out activities, seizures and no evidence of intracranial blood if imaging was done

Individuals who have experienced mild TBI and lost consciousness as a result and/or are found to be symptomatic at exam time should be referred to a neurologist for additional evaluation.

Evaluation should be the same as for those who have experienced moderate TBI.

Waiting period following mild TBI as symptoms of concern may not be immediately apparent.

The more severe the injury, the greater the risk of symptoms development.

If loss of consciousness, the driver should have evaluation by specialist prior to returning to work.

Recommendation 4: Anti-Seizure Medication and CMV Driver Certification. Individuals placed on anti-seizure medication either following a single provoked seizure or prophylactically should not be medically qualified to drive a CMV until they meet the current FMCSA criteria for individuals taking anti-seizure medication.Recommendation 5: Extremity Impairment and CMV Driver Certification. Individuals who meet earlier criteria for certification after TBI and whose only residual deficit is impairment of an extremity may be eligible for a Skill Performance Evaluation (SPE) certificate and should be referred to apply for one if otherwise medically qualified.Recommendation 6: TBI and Medical Examiner Qualifications. Due to the risk of seizures and neurological and cognitive dysfunction after TBI, physicians (M.D. or D.O.) should perform the commercial driver medical examination on those who have sustained TBI.

Psychiatric Disorders

January 2010

Recommendation 1: Psychiatric Disorders. The MRB recommends to FMCSA that the following matrix be adopted for evaluating CMV drivers with chronic psychiatric conditions. Patients with acute psychiatric conditions are not able to be potentially qualified until the condition is evaluated, diagnosed, and successfully treated.

Examiner GuidancePsychiatrist or advanced-degree mental health professional

May be qualified**

Psychiatrist or advanced-degree mental health professional

May be qualified***

Psychiatrist Unqualified§§Treating healthcare and/or mental health professional

May be qualified**

Psychiatrist or advanced-degree mental health professional

May be qualified***

Topic Date RecommendationsExaminer Guidance

Psychiatrist Unqualified§§Treating healthcare and/or mental health professional

May be qualified**

Psychiatrist or advanced-degree mental health professional

May be qualified***

Psychiatrist Unqualified§§*Severity is inferred largely based on prior history. Mild is considered minimally incapacitating, readily controlled with one medication or no medication. Moderate is sometimes incapacitating, recurring, and/or persistent, requiring one or two medications to control, but control is generally complete or nearly complete. Severe is substantially incapacitating, frequent and/or prolonged, requiring multiple medications to control; control is incomplete. Those with severe disorders may be able to qualify at a later date. They generally should not have had severe conditions in the prior 5 years.**Supportive letter from the treating healthcare professional is required.***Supportive letter from a psychiatrist is required.†Active psychosis are not qualified. At least 1 year without symptoms must be present prior to consideration of commercial driving. Those with a brief, reactive psychosis may be re-evaluated earlier, at 6 months, if the clinical condition has resolved.‡This includes anxiety, depressive, and bipolar disorders. Drivers with mania, severe major depression, or suicidal behavior or ideation are not qualified. At least 1 year without symptoms must be present prior to consideration of commercial driving. Non-psychotic major depressive disorder without suicidal behavior and symptom free may be re-evaluated at 6 months. §This includes obsessive compulsive and antisocial personality disorders. Individual clinical assessment is recommended with determination of suitability for commercial driving based upon whether the disorder and behavior pose a driving risk to the public. These traits include aggression, hostility, impulsivity, disregard for the law, and other psychological symptoms.Recommends the duration of certification be a maximum of 1 year for mild conditions and 6 months for moderate conditions.§§These individuals are believed to nearly always be unable to be qualified. There may be limited, highly select exceptions. Careful evaluation of those cases is recommended prior to consideration of potential ability to operate commercial vehicles.The MRB affirms a prior recommendation to FMCSA that these psychiatric conditions be included in the Fitness for Duty matrix on multiple conditions. Special consideration (scrutiny) should be given to

Topic Date Recommendationsthe certification of drivers handling hazardous materials/waste or driving buses.Recommendation 2: Anti-convulsants Taken for Non-epileptic Conditions. The MRB recommends to FMCSA that CMV drivers taking anti-convulsant medications be evaluated individually by the healthcare providers prescribing the medication, and that a supportive opinion regarding driving safety be obtained prior to consideration of CMV operation. The supportive opinion should state the purpose of the medication and that the medication is not used for control of a seizure disorder. Those with mild, stable conditions and lack of adverse effects may be qualified for up to 1 year. Other individuals may be qualified for a maximum of 6 months, and some with adverse effects may not be qualified.Note: The MRB voted and unanimously approved these recommendations to include the revisions discussed by the MRB. Revisions are indicated in italics.

Fitness for Duty Matrix

January 2010

Recommendation 1: Fitness for Duty. See Table 3 above.

Psychiatric Disorders

July 2009 Recommendation 1 (approved 3-1-1). The MRB recommends to FMCSA that all individuals with the following psychiatric disorders undergo psychological evaluation by a licensed mental health professional that is prepared at or above the master’s degree level in order to further assess the functional ability of the driver:

Psychotic disorder. Bipolar disorder. Major depressive disorder with a history of psychosis,

suicidal ideation, homicidal ideation, or a suicide attempt. Obsessive compulsive disorder. Antisocial personality disorder.

Stroke January 2009

Recommendation 1: StrokeThe MRB recommends to FMCSA that the following changes be made to the current guidance about stroke (first outlined in the report of the Conference on Neurologic Diseases and Commercial Driving, 1988):

To be qualified to drive at the appropriate time after a stroke (1 or 5 years depending on the type of stroke) requires an examination by a neurologist who is an MD or DO, in addition to a commercial driver medical examiner (CDME) examination by an MD or DO.

o If the neurologist identifies cognitive or neuromuscular deficits, then a neuropsychological evaluation or functional evaluation, respectively, shall be performed.

o Functional evaluation could include aspects previously recommended by the MRB. (Musculoskeletal Disorders

Topic Date Recommendationsand CMV Driver Safety, April 7, 2008)

o Neuropsychological evaluation could include aspects recommended by the Medical Expert Panel (MEP). (Stroke and CMV Driver Safety, January 12, 2009)

o Subsequent re-evaluations should be done on at least an annual basis by a neurologist who is an MD or DO, in addition to a CDME examination by an MD or DO.

Recommendation 2: Transient Ischemic Attacks (TIAs) The MRB recommends that commercial drivers who have had a

TIA should not drive for 1 year. o To be qualified to drive after a TIA requires an

examination by a neurologist who is an MD or DO, in addition to a CDME examination by an MD or DO.

o Re-evaluations should be done on at least an annual basis by a neurologist who is an MD or DO, in addition to a CDME examination by a MD or DO.

General/CDME

January 2009

Recommendation 1: Educational Standards for CDMEsThe MRB recommends that FMCSA implement minimum educational standards for qualifying CDMEs. The MRB recommends the following minimum professional qualifications: physicians (MD or DO), advanced practice nurses (APNs), or physician assistants (PAs).

Psychiatric Disorders

October 2008

Recommendation 1: Psychiatric StandardsThe MRB stated that input is needed from the psychiatric field before they consider any motions on this topic.

Hearing/Vestibular Function

October 2008

Recommendation 1: Hearing Standards. The MRB recommends that FMCSA retain the current standards on hearing. Note: The motion was approved with a 3 to 1 vote.

General Recommendations (including Fitness for Duty)

July 2008 Recommendation 1: Fitness for Duty StandardThe MRB recommends that FMCSA change the fitness for duty standard to the following:

CMV drivers shall have the physical and mental fitness required to safely operate a CMV. Drivers who are not fit may present a safety hazard to themselves and to the public.

Physical and mental disorders may reduce driver performance and increase the risk of CMV crashes. Drivers with multiple medical disorders and/or taking licit or illicit drugs may pose additional increased risk for crash.

Recommendation 2: Evaluation of Fitness for Duty See Table 3 above. Note the matrix was drafted for further study at this meeting.Recommendation 3: Fitness for Duty – Remediation

Topic Date RecommendationsThe MRB recommends to FMCSA that remediation of some physical or mental conditions is possible, and drivers may be eligible for certification to drive a CMV following resolution of these conditions. Recommendation 4: Mental Fitness for DutyThe MRB recommends to FMCSA that drivers who physically or verbally threaten medical staff have demonstrated a lack of mental fitness to drive. They should not be qualified pending an evaluation, counseling, or other appropriate measure. Recommendation 5: Review of GuidelinesThe MRB recommends that FMCSA seek and receive adequate funding for regular review of the guidelines. This includes all of the guidelines that have been discussed to date and those to be generated in the future. Reviews of each guideline should be conducted at least every 3 years to determine whether existing guidelines should be reaffirmed or revised.

Chronic Kidney Disease

July 2008 Recommendation 1: Identification of Individuals with Chronic Kidney Disease (CKD) The MRB recommends that FMCSA accept most of the Renal Disorders MEP advice and to require a blood test to measure serum creatinine and glomerular filtration rate (GFR) estimated through creatinine clearance for those drivers who have any of the following conditions: personal history of potential CKD, age over 65 years, diabetes mellitus, hypertension (as specified on the CDME examination form), and proteinuria.Recommendation 2: Screening of Individuals in Stages 1, 2, or 3 Chronic Kidney DiseaseThe MRB recommends that FMCSA accept the Renal Disorders MEP recommendation that drivers screened for renal disease be staged.

Drivers with a more severe, higher stage renal disease should be screened more frequently.

Drivers in Stages 1, 2, or 3 should have screening with repeat creatinine measurement and GFR performed with each CDME examination.

Drivers in Stages 1 or 2 should be re-evaluated at least every 2 years.

Drivers in Stage 3 should be re-evaluated at least annually.Recommendation 3: Certification of Individuals in Stage 4 Chronic Kidney DiseaseThe MRB recommends that FMCSA require those drivers with renal disease in Stage 4 (GFR 15-29 mL/min), be recertified at least every 6 months, including a GFR measurement and a supportive letter from their treating nephrologist. They should also receive a cardiovascular evaluation at least annually. Recommendation 4: Certification of Individuals in Stage 5 Chronic Kidney Disease and/or on DialysisDrivers in Stage 5 and/or on hemodialysis or peritoneal dialysis are

Topic Date Recommendationsrecommended to be precluded from driving a CMV. Patients with successful kidney transplantation may seek certification.

Musculoskeletal Disorders

April 2008

Recommendation 1. The focus of the evaluation of musculoskeletal conditions should be on function rather than diagnosis. Recommendation 2. FMCSA should obtain information about the physical requirements needed to safely drive a CMV, to include pre-trip and en route safety inspections.Recommendation 3. FMCSA should convene an expert panel tasked with developing a physical screening instrument for the medical examiner. Recommendation 4. FMCSA should standardize the driving-specific work capacity evaluation (road test) to include pre-trip and en route safety inspections.

Vision April 2008

Recommendation 1: Monocular Vision. The current standard which precludes individuals with monocular vision from driving a CMV for the purposes of interstate commerce should not be changed at this time. Recommendation 2: Red-Green Color Deficiency. The current standard regarding red-green color deficiencies should not be changed at this time, and a revision in testing guidelines should be considered with regard to specific tests. Recommendation 3: Visual Field (VF) Loss. The current standard of 70º may be adequate and whether this needs a modification and what that modification should be has yet to be determined. The methods of VF testing should be clarified. Recommendation 4: Cataracts. There is insufficient evidence to modify the current standard to include the possible impact of cataracts on CMV driving ability. Recommendation 5: Diplopia. There should be no change to the standard on diplopia.

Topic Date Recommendations

Chronic Kidney Disease

April 2008

Recommendation 1: Individuals with Renal Transplants Individuals who have undergone renal transplant with successful

kidney transplantation may drive a CMV 90 days postoperatively provided that they have been cleared as fit for duty by their transplant physician.

With the exception of differences in recertification periods, individuals who have undergone successful renal transplantation should be assessed as per recommendations 1 through 4. (See July 2008 recommendations.)

All individuals who have undergone successful renal transplantation should be recertified at 3, 6, and 12 months postoperatively. Thereafter, individuals should be recertified on an annual basis.

Other Motions

April 2008

Recommendation 1. The MRB recommends to the FMCSA that they seek and receive appropriate resources to develop, implement, and maintain a nationwide database on all CMV operators involved in fatal vehicle crashes for the purposes of developing quality data from which evidence-based guidance may be used to reduce the unacceptably high number of fatalities among CMV operators. Such data should include:

CDME examination forms (most recent and prior). Driver records, including citations and prior crashes, injuries

whether occupational or not. Post-mortem data (including cause of death and evidence of other

condition(s). Toxicological test results from the post-mortem studies. Personal medical records including evidence of diagnoses and/or

treatment for any prior disorders.Recommendation 2. The MRB recommends to the FMCSA that they seek and receive appropriate resources to develop, implement, and maintain a prospective nationwide database of CMV operators. This national resource would collect medical and safety information on CMV drivers to assess the relationship between the driver’s physical and mental health and driver safety.

Sleep Apnea January 2008

Recommendation 1: General GuidanceThe FMCSA’s current guidelines for individuals who have OSA should be replaced with the following general guideline statement:

A diagnosis of OSA precludes an individual from obtaining unconditional certification to drive a CMV for the purposes of interstate commerce.

A diagnosis of OSA, however, should not exclude all individuals with the disorder from driving a CMV; certification may be possible in some instances. An individual with a diagnosis of OSA may be certified to drive a CMV if that individual meets the following criteria:

o Has untreated OSA with an apnea-hypopnea index (AHI) ≤ 20 AND

o Has no daytime sleepiness OR o Has OSA that is being effectively treated.

Topic Date Recommendations An individual with OSA who meets the requirements for

certification described above should be recertified annually, based on demonstrating satisfactory compliance with therapy.

Recommendation 2: Specific Guidance: Drivers Who Should be Disqualified Immediately or Denied Certification The MRB believed that the following populations of individuals should not be certified or recertified as being medically qualified to drive a CMV.

Individuals who report that they have experienced excessive sleepiness while driving.

Individuals who have experienced a crash associated with falling asleep.

Individuals with an AHI greater than 20, until such an individual has been adherent to Positive Airway Pressure (PAP). They can be conditionally certified based on the criteria for Continuous Positive Airway Pressure (CPAP) compliance as outlined in Recommendation 3.

Individuals who have undergone surgery and who are pending the findings of a 3-month post-operative evaluation.

Individuals who have been found to be non-compliant with their treatment at any point.

Recommendation 3: Specific Guidance: Conditional Certification The following groups of individuals with OSA should be conditionally allowed to drive a CMV:

Individuals with a body mass index (BMI) ≥ 33 kg/m2 may be conditionally certified for 1 month pending the findings of a sleep study. This period should be less than 1 week. However, given the current infrastructure for sleep studies in the United States, obtaining a sleep study within 1 week is unlikely to be feasible in many cases. Consequently, the Board recommends a transition period of 2 years during which timely efforts are made to improve the infrastructure so that the period between requesting a sleep study and obtaining that study can be reduced to 1 week for certification purposes.

Individuals recently diagnosed with OSA may be conditionally certified for 1 month during which time they will be started on CPAP therapy. At the end of this month, they can be conditionally certified for 3 months if compliance to CPAP is documented in the 2 previous weeks. Compliance should be reassessed at 3 months. At the 3-month assessment, individuals who demonstrate treatment compliance may be certified for 1 year. Commercial drivers need to be informed that if they stop using their CPAP during the 1-year period, they should stop driving a commercial vehicle. They should be warned that if they stop using their CPAP and are involved in a crash, it is likely they will be considered legally liable. At 1 year, future recertification should depend on proof of continued compliance with treatment. At the end of 1 year, the certifying physician should review all compliance data for that year. Ideally, in time,

Topic Date Recommendationswith newer CPAP machines, these data will include not only compliance but information about efficacy of treatment. It is conceivable that if at the end of 1 year the individual is no longer compliant with therapy, certification may not be renewed or only renewed for a brief period to allow compliance with therapy to be re-established.

Minimally acceptable compliance is defined here as more than 4 hours of use for at least 70% of the days, based on current standards of practice. (Gay et al., 2006)

Recommendation 4: Specific Guidance: Referral for Confirmation of Diagnosis or Stratification of Severity The MRB recommended the following guidelines to confirm a diagnosis of OSA and its stratification by severity:

Individuals who meet the following criteria should be required to undergo an evaluation to confirm the diagnosis of, and, if necessary, stratify the severity of OSA:

o Those categorized as high risk for OSA according to the Berlin Questionnaire OR

o Those with a BMI ≥ 30 kg/m2 OR o Those judged to be at risk for OSA based on a clinical

evaluation. Recommendation 5: Specific Guidance: Identification of Individuals with Undiagnosed OSA The MRB believed one of the roles of the medical examiner is to identify individuals who may have undiagnosed OSA and consequently proposes the following guideline:

Medical examiners should actively screen for OSA in all individuals who request fitness-for-duty certification for the purposes of driving a CMV in interstate commerce.

o Symptoms suggestive of OSA include: chronic loud snoring, witnessed apneas or breathing pauses during sleep, and daytime sleepiness.

o Risk factors for OSA are: advancing age, BMI ≥ 28 kg/m2, small jaw, large neck size (≥ 17 inches (male) ≥ 15.5 (female)), small airway (a narrow or edematous oropharynx), and family history of sleep apnea.

o Conditions known to be associated with a high risk of OSA include the following: hypertension (treated or untreated), Type 2 diabetes (treated or untreated), and hypothyroidism (untreated).

Recommendation 6: Specific Guidance: Method of Diagnosis and SeverityThe MRB recommended that the FMCSA consider adopting the following guidelines on the appropriate methods to confirm a diagnosis of OSA and stratify its severity:

The preferred method of diagnosis and assessment of disease severity is overnight polysomnography (PSG).

Topic Date Recommendationso Acceptable alternative methods for assessment of risk in

CMV drivers include objective recording devices validated against PSG that include at least 5 hours of measurements of: oxygen saturation AND nasal pressure AND sleep/wake time.

Regardless of the type of study performed, individuals should be tested while on their usual chronic medication regime.

Recommendation 7: Specific Guidance: Treatment of OSA – Positive Airway Pressure (PAP) The MRB recommended the following guidelines on the appropriate treatment of individuals with moderate-to-severe OSA:

All individuals with OSA who require treatment should be referred to a qualified physician with relevant expertise in sleep apnea.

PAP is the preferred method of therapy. Adequate PAP pressure should be established through one of the

following means: o An in-laboratory titration study.o An auto-titration system without an in-laboratory

titration. Individuals with OSA who have been treated with PAP may be

certified if they have been successfully treated for a minimum of 1 week.

o Successful PAP treatment is defined as follows:• Demonstration of good compliance with treatment (see below). • Resolution of excessive sleepiness when driving.

Individuals with OSA who are treated with PAP must demonstrate compliance with treatment and this must be documented objectively.

o Compliance is defined as using PAP for the duration of total sleep time. • Optimal treatment efficacy occurs with 7 hours or more

of use during sleep; however, 4 hours of documented time at pressure per major sleep episode is minimally acceptable.

Based on current standards of practice, an acceptable CPAP use is at least 4 hours of use per night on at least 70% of nights.

Recommendation 8: Specific Guidance: Treatment of OSA – Alternatives to PAPThe MRB recommended the following guidelines on the appropriate treatment of individuals with moderate-to-severe OSA who require a treatment other than PAP:

Dental appliances and surgery are considered to be potential alternatives to PAP for the treatment of OSA. o Currently there is no method of measuring compliance

among individuals treated with dental appliances.

Topic Date RecommendationsConsequently, use of dental appliances cannot be considered an acceptable alternative to PAP in individuals who require certification to drive a CMV in interstate commerce. Compliance among individuals who have undergone surgical treatment for OSA is less of an issue. Consequently, surgical treatment (bariatric, upper airway soft tissue, facial bone, and tracheostomy) is deemed an acceptable alternative to PAP (see later recommendations).

Recommendation 9: Specific Guidance: Treatment of OSA — Bariatric SurgeryThe MRB recommended the following guidelines pertaining to obese individuals with moderate-to-severe OSA who undergo bariatric surgery:

Individuals who have undergone bariatric surgery may be certified if they are:

o Compliant with PAP (see guideline for PAP requirements) OR

o Six months post-operative (to allow time for weight loss) AND

o Cleared by treating qualified physician with relevant expertise in sleep apnea AND

o Sleep exam indicates that AHI ≤ 10 AND o No longer excessively sleepy.

For individuals certified based on these criteria, there should be re-evaluation by sleep study within 2 years if they are not on PAP therapy.

Individuals who are off PAP therapy should be given information that they need to seek re-evaluation if they gain significant weight (> 5%) or their symptoms of OSA recur.

Recommendation 10: Specific Guidance: Treatment of OSA — Oropharyngeal SurgeryFor individuals with moderate-to-severe OSA who undergo oropharyngeal surgery:

Individuals with OSA who have been treated with oropharyngeal surgery may be certified if they:

o Are > 1 month post surgery AND o Are cleared by treating qualified physician with relevant

expertise in sleep apnea AND o Do not experience daytime sleepiness AND o Have an AHI < 10.

Annual recertification required o Annual objective testing with AHI < 10 AND o No daytime sleepiness.

Recommendation 11: Specific Guidance: Treatment of OSA – Facial Bone SurgeryFor individuals with moderate-to-severe OSA who undergo facial bone surgery:

Individuals with OSA who have been treated with facial bone

Topic Date Recommendationssurgery may be certified if they:

o Are > 1 month post surgery AND o Are cleared by treating qualified physician with relevant

expertise in sleep apnea AND o Do not experience daytime sleepiness AND o Have an AHI < 10.

Annual Recertification required o Annual objective testing with AHI < 10 AND o No daytime sleepiness.

Recommendation 12: Specific Guidance: Treatment of OSA – TracheostomyThe MRB recommended the following guidelines for individuals with moderate-to-severe OSA who undergo tracheostomy:

Individuals with OSA who have been treated with oropharyngeal surgery may be certified if they:

o Are > 1 month post surgery AND o Are cleared by treating qualified physician with relevant

expertise in sleep apnea AND o Do not experience daytime sleepiness AND o Have an AHI < 10.

Annual recertification required o Annual objective testing with AHI < 10 AND o No daytime sleepiness.

Recommendation 13: Patient Education. For the education of individuals who meet the criteria for certification to drive a CMV, individuals with OSA who meet the criteria for certification should be provided with education on the following: the importance of adequate sleep, lifestyle changes (weight loss, smoking cessation, exercise, reduced alcohol intake), importance of treatment compliance (if relevant), consequences of untreated OSA (loss of certification, crash, hypertension, cognitive dysfunction, heart disease, reduced quality of life, reflux, headaches, shorter survival, and sleep disruption), and effects of respiratory or central nervous system depressants on OSA.Recommendation 14: Additional Recommendations. The FMCSA should consider creating incentives for large trucking companies to develop fatigue management models (e.g. Schneider Model), as well as couple a dissemination program with these models.

Seizure Disorders

January 2008

Recommendation 1: Fitness-to-Drive Certification of Individuals With a History of EpilepsyFor individuals with a history of epilepsy, retain the existing guidance on the management of seizures and commercial drivers, supporting a minimum of 10 years off anti-seizure medications and seizure free. Recommendation 2: Fitness-to-Drive Certification of Individuals With a History of a Single Unprovoked SeizureFor individuals with a history of a single, unprovoked seizure, retain the

Topic Date Recommendationsexisting guidance on the management of seizures and commercial drivers, supporting a minimum of 5 years off anti-seizure medication and seizure free.Recommendation 3: Fitness-to-Drive Certification of Individuals with a History of a Provoked Seizure or SeizuresIndividuals with cases of provoked seizures that are caused by structural brain lesions (e.g., tumor, trauma, and infection) should be assessed more stringently than those with other causes (e.g., a single, unprovoked seizure caused by exposure to a medication such as lidocaine). The MRB recommended individualization of time restrictions from driving for a minimum of 5 years, but up to 10 years—based on consultation with a neurologist. This applies only to individuals who are off medication and seizure free. Recommendation 4: Additional RecommendationsIndividuals with a probable, single episode of drug toxicity may be treated less restrictively than those with structural brain lesions depending on the outcome of the neurological consultation.

Diabetes July 2007 Recommendation 1: Specific GuidanceIndividuals are physically qualified to drive a commercial motor vehicle if they have an established medical history or clinical diagnosis of diabetes mellitus only if they:a) Are examined and certified annually by a commercial driver medicalexaminer (CDME) who is a licensed physician (MD/DO) at least annually.b) If on insulin, they must: 1. Be free of insulin reactions (an individual is free of insulin reactions if that individual does not have severe hypoglycemia). 2. Not have hypoglycemia unawareness. 3. Be able to and demonstrate willingness to properly monitor and manage their diabetes, and sign a questionnaire documenting adherence and awareness of hypoglycemic risk 4. Not be likely to suffer any diminution in driving ability due to their diabetic condition; 5. Agree to and comply with the following conditions: i) A source of rapidly absorbable glucose shall be carried at all times while driving; ii) Blood glucose levels shall be self-monitored 1 hour prior to driving and at least once every 4 hours while driving or on duty prior to

Topic Date Recommendations driving using a portable glucose monitoring device equipped with a computerized memory; iii) Submit blood glucose logs to the CDME at the annual examination or when otherwise directed by an authorized agent of the Federal Motor Carrier Safety Administration; and iv) Provide a copy of the physician’s report to the medical

examiner at the time of the annual medical examination.Certified Driver Medical Examiner

April 2007

Recommendation 1: CDME Description and Examiner QualificationsCommercial drivers are older, heavier, and sicker than ever before. Medicine and medical technology are more complex than at any time in history and our highways and roads are busier and more dangerous with each passing year. For these reasons, the Medical Review Board of the Federal Motor Carrier Safety Administration (FMCSA) believes that public safety is best served by having the best-trained medical professionals possible engaged in the evaluation and certification of commercial drivers. We urge that the FMCSA establish a prerequisite that Commercial Driver Medical Examiners be licensed MDs or DOs.

Schedule II Drugs

April 2007

Recommendation 1: Schedule II Drugs ExceptionAn individual is considered medically fit to drive if he/she:1. (b)(12)(i) Does not use a controlled substance or drug identified in 21

CFR 1308.11 Schedule I, an amphetamine, a benzodiazepine, a narcotic, a Schedule II medication, or any other habit-forming substance or drug;

2. (b)(12)(ii) Exception. A driver may use such a licit substance or drug if the substance or drug is prescribed for that individual for a legitimate medical reason by a licensed physician (MD or DO) who: Is familiar with the driver’s medical history and assigned duties

and Has warned the driver that the prescribed substance or drug may

adversely affect the driver’s ability to safely operate a commercial motor vehicle (CMV).

and:The driver is independently evaluated by a Commercial Driver Medical Examiner (CDME) who also:

Is a licensed physician (MD or DO); Is familiar with the driver’s medical history and assigned duties; Has warned the driver that the prescribed substance or drug may

adversely affect the driver’s ability to safely operate a CMV; Has informed the driver that if the driver does not take the

substance or drug as prescribed, the driver is using the substance or drug improperly and is not covered by this exception; and

Reviews a form for this purpose that is signed by the driver*.Specifically excluded from the exception are drivers who:

Use substances or drugs administered parenterally (e.g. intravenously, transdermally, subcutaneously, intrathecally, or

Topic Date Recommendationsintramuscularly);

Have initiated or increased doses of one of these substances or drugs within the past 2 weeks after such changes;

Have a history of substance, drug or alcohol abuse, or addiction; or

Require the ingestion of substances or drugs while driving.Factors to be considered by the CDME in determining whether to certify the driver include:

Driving history; Psychiatric and psychological history; Dose(s) of the prescribed substance or drug; Underlying and comorbid conditions; and Duration of action and pharmacokinetics of the prescribed

substance or drug.*The driver questionnaire would address the medication, purpose, side effects, proper usage, and whether it may have an impairing effect. If the driver does feel impaired, the driver must sign that he/she will stop driving. The questionnaire must have the driver assert that his/her statements are true and spell out the consequences of an untruthful declaration.

Cardiovascular Disease

April 2007

Recommendation 1: CMV Drivers Without Known Heart Disease:1. Revise the current definition for abnormal exercise tolerance

testing definition for abnormal exercise tolerance testing (ETT) to an inability to exceed 6 METS (metabolic equivalents) on ETT.

Recommendation 2: CMV Drivers With Known Chronic Heart Disease (CHD)

1. Clarify that for all guidelines in this section, the expectation is that drivers with known CHD will have had all of their medications titrated to the optimal dose.

2. CMV drivers with angina pectoris may be qualified if the pattern of angina is stable.

3. Current Federal Motor Carrier Safety Administration (FMCSA) guidelines state that an individual with angina pectoris who has undergone a percutaneous coronary intervention (PCI) may be qualified to drive if he or she meets four conditions. The MRB recommends removing the requirement for a normal ETT 3 to 6 months following PCI.

4. Current FMCSA guidelines require individuals who have undergone coronary artery bypass surgery to be recertified every year for 5 years, then undergo an exercise tolerance test annually. The MRB recommends an exercise tolerance test every 2 years.

Recommendation 3: CMV Drivers with Hypertension1. Add statements explaining the general principles of certification

of individuals with hypertension. These are:

Topic Date Recommendationsa) Certification and recertification of individuals with

hypertension should be based on a combination of factors: blood pressure, the presence of target organ damage, and co-morbidities.

b) To provide consistency in certification, blood pressure recorded at the certification (or recertification) examination should be used to determine blood pressure stage. The certifying examiner may decide on the length of certification for drivers with elevated blood pressure despite treatment.

c) All CMV drivers should be referred to their personal physician for therapy, education, and long-term management.

d) Add an expectation throughout this section that blood pressure has been measured appropriately.

2. Add an expectation throughout this section that blood pressure medication has been titrated appropriately. Target blood pressure for titration should be < 140/ < 90.

3. Add text that medical examiners should ensure that individuals with hypertension are properly educated about making appropriate lifestyle changes and complying with medication.

4. Eliminate ambiguity about thresholds that define hypertension stage. Updated guidelines on hypertension stages should be consistent with those recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Recommendation 4: CMV Drivers With Supraventricular Tachycardias1. Resolve the ambiguity associated with “lone atrial fibrillation” by

making it clear that the diagnosis refers to individuals with atrial fibrillation with no identifiable underlying disease. This is usually diagnosed in younger persons.

2. Provide details of how risk for stroke from embolization among individuals with atrial fibrillation should be determined.

3. FMCSA requested clarification of the role of aspirin and vitamin K inhibitors in reducing stroke risk in individuals with atrial fibrillation. The MRB referred FMCSA to the current American College of Cardiology/American Heart Association/European Society of Cardiology (ESC) guidelines for appropriate antithrombotic treatment of those with atrial fibrillation.

4. Individuals with atrial fibrillation at moderate to high risk for a stroke should be recertified annually. In order to be recertified, the individual must have his or her anticoagulation monitored at least monthly and demonstrate adequate rate/rhythm control.

Recommendation 5: CMV Drivers with Pacemakers1. Revise current guidelines. The MRB no longer accepts a

Topic Date Recommendationspacemaker as definitive treatment for neurocardiogenic syncope.

2. Add text documentation accompanying the CVD guideline update that describes the appropriate evaluation of an individual who presents with syncope to ensure that efforts are made to distinguish individuals with cardiogenic syncope from those with syncope from other causes.

Recommendation 6: CMV Drivers and Cardioverter Defibrillators1. The MRB recommends that the current FMCSA CVD guidelines,

which preclude any individual with an implanted cardioverter defibrillator (ICD) from being certified to drive a CMV, be upheld.

Recommendation 7: CMV Drivers with Abdominal or Thoracic Aortic Aneurysms

1. The upper limit for the abdominal aortic aneurysm (AAA) diameter below which an asymptomatic individual may be certified should be increased to 5.5 cm for men and 5.0 cm be set for women.

2. Change the current guidelines to read: individuals with an AAA 4.0 to 5.4 cm in diameter can be certified if they are asymptomatic AND are cleared by a MD/DO vascular surgeon. Individuals with an AAA 4.0 to 5.4 cm in diameter cannot be certified if they are either symptomatic OR recommended they undergo surgery.

3. Add guidance to the current guideline for individuals who have undergone endovascular AAA repair (EVAR), ensuring that recertification after EVAR requires compliance with the follow-up protocol.

4. Increase the upper limit for the thoracic aortic aneurysm (TAA) diameter below which an asymptomatic individual may be certified from 3.0 cm to 5.0 cm.

5. The annual acceptable rate of expansion of thoracic aneurisms is .5 cm or less and for abdominal aneurisms is 1 cm or less.

Recommendation 8: CMV Drivers With Peripheral Vascular Disease1. Amend the current guidelines for certification of individuals with

intermittent claudication to disqualify CMV drivers only when pain occurs at rest.

Recommendation 9: CMV Drivers With Venous Disease1. Active deep vein thrombosis (DVT)

should disqualify an individual from driving a CMV.2. Individuals who have experienced

DVT that has resolved should be maintained on anticoagulation with a vitamin K antagonist for a minimum of 3 months (preferably 6 months) following resolution.

3. If on a vitamin K antagonist such as

Topic Date Recommendationswarfarin (Coumadin), drivers need to be regulated at least 1 month prior to certification (or recertification) and have their INR monitored at least monthly thereafter.

4. International normalized ratio (INR) should be maintained within the target range: 2.0–3.0.

5. Individuals treated with subcutaneous heparin or low molecular weight heparin may be certified (or recertified) to drive a CMV as soon as the DVT has resolved.

Recommendation 10: CMV Drivers With Cardiomyopathy1. Change the prohibition against individuals with hypertrophic

cardiomyopathy to reflect the fact that not all individuals with hypertrophic cardiomyopathy are at risk for sudden incapacitation or death. Permit those who meet all the following criteria to be certified to drive:

No history of cardiac arrest. No spontaneous sustained ventricular tachycardia (VT). Normal exercise blood pressure (e.g., no decrease at

maximal exercise). No non-sustained VT. No family history of premature sudden death. No syncope. Left ventricular (LV) septum thickness < 30mm.

Low-risk individuals must be followed closely for changes in risk status.

2. Change the criteria for individuals with idiopathic dilated cardiomyopathy who do not have symptomatic heart failure (HF) to:

Sustained ventricular arrhythmia for 30 seconds or more OR requiring interventionLeft ventricular ejection fraction (LVEF) ≤ 40%.

Schedule II Drugs

January 2007

Recommendation 1. The FMCSA should obtain additional information about how other entities (Federal agencies and non-U.S. transportation organizations) deal with similar issues. Recommendation 2. The FMCSA should review the current drug test regimen with an eye to expanding it to include drugs not currently covered. Recommendation 3. The absence of acceptable evidence-based research does not imply the absence of a potential effect that would adversely affect a driver’s abilities.

Diabetes Novembe Recommendation 1: General Guidance

Topic Date Recommendationsr 2006 1. Individuals with diabetes mellitus are at increased risk for a motor

vehicle crash when compared with individuals who do not have diabetes mellitus.

2. Hypoglycemia is an important risk factor for a motor vehicle crash among individuals with diabetes mellitus.

3. There is insufficient evidence to support the premises that treatment-related factors are associated with an increased incidence of severe hypoglycemia among individuals with diabetes mellitus, or that hypoglycemia awareness training is effective in preventing the consequences of hypoglycemia.

*Numerous recommendations and motions approved for more research enumerated largely in response to limited evidence in specific evidence reports are omitted for the sake of space limitations. There also are two specific and detailed recommendations for increased research that have been retained in the above table. **This table also omits additional, earlier recommendations regarding the multiple conditions matrix approved by the MRB January 2010 as largely redundant. It also omits specific calls for additional evidence reports and medical expert panels on additional topics.***Repeated recommendations regarding musculoskeletal disorders and implantable defibrillators, addressed July 2009, were omitted.