Driver Rehabilitation Services
to Support Persons after a
Traumatic Brain Injury
Teresa Valois, OTR/L, ATP, CDRS
What Happened?
Traumatic Brain Injury?
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An injured person may safely return to driving
and this should be addressed early in recovery.
The injured person, family members, caregivers
and health professionals should all be included
in this important decision.
If anyone has concerns that that driving may
put the injured person or others in danger,
health professionals may recommend predriving testing.
Driving safely is even important
for your doggie!
The Goal: To Drive!
Knowledge Enhances Your Safety= KEYS
Dignity
Responsibility
Safety,
route planning
execution and return
Independence
Freedom
Choice
The presentation goals:
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Learn the details of a Driver Rehabilitation
assessment
Vehicle modifications will be demonstrated
Brake reaction time testing will be demonstrated
Department of Licensing guidelines will be
provided
Learn about legal issues of returning to driving
and possible unsafe driving reporting
Physician's Legal and Ethical Duties
Document thoroughly and reiterate safety
Protect the patient/client
Protecting the safety of the public
Be aware that the physician-patient privilege does
not prevent you from reporting to the DMV
Ethics and Legal continued
Commit to breaching the patient’s confidentiality
vs. allowing a potential injury to himself and
third party
Know, advise and adhere to State Reporting Laws
Counsel your patient- recommend driving
retirement as needed
Suggest a second opinion
Seizures?
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Having experienced a seizure after the TBI may
be a barrier to driving.
States often require that a person be free of
seizures for a period of time, such as 6 months,
before resuming driving.
People who want to return to driving need to
check with the laws in their state.
Initial Screening:
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Medical Clearance by Physician
Seizures/medications/stable condition
Understand if there is support of family
Ask about the availability of
vehicle/insurance/how to manage emergency
situations
Ask to see the Driver License status
Inquire about driving history/restrictions
Observe!
Poor hygiene and grooming
 Difficulty with walking, getting into/out of chairs
 Difficulty with visual tracking
 Difficulty with attention, memory, comprehension
 Impulsivity, willingness to participate in evaluation
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Questions/discussion
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Patient’s or family member concern (example:
recent crashes)
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Medical history: Chronic medical conditions?
Medical conditions with unpredictable/episodic
events- (example: sleep apnea)
Medications?
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Prescription
Non-prescription
Combination of drugs
Discussion of each medication class, dosage,
schedule and side affects
My goal is to drive in Seattle. How
do we decide if I am safe?
What are the medical concerns?
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Partial loss of the visual field from traumatic
brain injury
Problems with heart rhythm
Seizures
Low or high blood pressure
Alcoholic intoxication
Fatigue
What can cause unsafe driving?
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Loss of feeling in the feet
Loss of muscle power, or weakness and
coordination
Loss of judgment
Loss of coordination
Loss of sleep
Limitations in left side visual and
depth perception can cause a crash
Warning signs of unsafe drivers after
Traumatic Brain Injury
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Drives too fast or too slow for road conditions or
posted speeds
Needs help or instructions from passengers
Doesn’t observe signs or signals
Makes slow or poor distance decisions
Gets easily frustrated or confused
Often gets lost, even in familiar areas
Has accidents or near misses
Drifts across lane markings into other lanes
CDRS test question:
Which of the following is inappropriate when
attempting a left lane change?
a. scanning rear-view mirror and left side-view mirror
b. applying the left indicator and applying the brake
hard
c. checking the blind spot over the left shoulder
d. gradually guiding the vehicle into the left lane
Answer is B
Which of the following is inappropriate when
attempting a left lane change?
b. applying the left indicator and
applying the brake
hard
What are common driving errors?
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Incorrectly making a left-hand turn
Driving too fast or too slowly for the road
conditions
Making sudden turns
Not using the turn indicator or forgetting to
turn it off
Getting lost or seeming disoriented
Review of Systems
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General- weakness, fatigue
HEENT- headache, head trauma
Respiratory-shortness of breathe
Cardiac-palpitations, loss of consciousness
Musculoskeletal- muscle pain, joint stiffness,
decreased range of motion
 Neurological-paralysis, tremors, loss of sensation
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Psychiatric- depression, anxiety, memory loss,
confusion, mania
Assessment and Plan
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Formulate diagnosis and treatment plan for
medical condition
Prescribe or change medications
Work-up new-onset disease or treat unstable
condition
Referral for objective tests- OT/PT/Speech,
Neuropsych and Driver Rehabilitation
Assessment
Tests:
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Snellen E chart
Visual Fields
Trail-Making Tests A and B
Clock Drawing test
Rapid Pace Walk
Manual test of range of motion
Manual test of motor strength, balance
Auditory
Sensory
Trail Making B sample
Trail
B sample
Short Blessed Test Sample
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1. What year is it now?
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2. What month is it now?
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3. Say the months of the year in reverse order
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4. Please repeat this name and address after me:
John Brown, 42 Market Street, Chicago-remember
this
Clinical Driver Assessments:
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Vision
Visual Perception
Physical Functioning
Cognitive skills
BRAKE REACTION
TIME
Tests done by Driver Rehabilitation
Specialist
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Optec Vision Tester
Motor Free Visual Perception Test
Block Design- Constructional Apraxia, Spatial
Relations, Depth Perception
Symbol Digit Modalities Test
Vision screening:
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Visual acuity
Night vision/glare recovery
Far and Near vision
Peripheral vision
Color perception
Depth perception
Road sign recognition
Visual tracking
Visual Perception:
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Form constancy- the ability to recognize the same shape among a variety of
shapes
Figure ground- the ability to identify one object or design from a series of
superimposed objects or designs
Position in space- the ability to understand the spatial concept of
positioning such as differentiating the same form in various orientations.
Depth Perception- the ability to judge distances as in differentiating close
and farthest from oneself
Spatial Relations- the ability to perceive the relationship between two or
more objects to each other and to oneself
Visual closure- The ability to identify incomplete figures when only
fragments are presented
Visual memory- the ability to recall dominant features on one stimulus item
or to remember the sequences of several items
Visual Perception
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Form constancy- the ability to recognize the
same shape among a variety of shapes
Visual Perception
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Figure ground- the ability to identify one
object or design from a series of superimposed
objects or designs
Visual Perception
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Position in space- the ability to understand the
spatial concept of positioning such as
differentiating the same form in various
orientations.
Visual Perception
Depth Perceptionthe ability to judge
distances as
in differentiating
close and farthest
from oneself
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Visual Perception
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Spatial Relations- the ability to perceive the
relationship between two or more objects to
each other and to oneself
Visual Perception
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Visual closure- The ability to identify
incomplete figures when only fragments are
presented
Visual Perception
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Visual memory- the ability to recall dominant
features on one stimulus item or to remember
the sequences of several items
Physical Functioning
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Range of
motion/strength/coordination/sensation
Use of mobility devices
Potential skills for transfers in and out of car
Balance
Fine motor skills- use of keys, secondary
switches
Reaction time/right foot/left foot/need for
hand controls or other modifications
Reaction time testing machines
Cognitive skills
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Mental status
Information processing
Decision making
Divided attention
Multiple task sequencing
Distractibility and the ability to focus
Recognizes abilities/limitations
Cognitive continued
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Understands and appreciates levels of acceptable risks
Consistency in behavior
Self regulation for accuracy
Memory
Path finding
Endurance and fatigue
Recognition of error/correction
Judgment and recognition of skills and limitations
Planning a route
Path finding
without a
GPS system?
Simulator and monitors with
driving views
Hand Controls and Spinner Knob
Who does the Behind-the-Wheel
Driving Assessment?
Behind-The-Wheel Evaluation
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A clinical evaluation prior to a
BTW evaluation
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BTW evaluations should include a
number of driving maneuvers and
a variety of settings
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Progress the driving
evaluation/experience to meet
the person’s physical and
cognitive skills
Behind-the-wheel evaluation
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Clinical evaluation before a behind-the-wheel
evaluation
Orientation in the vehicle- mirrors, seat belt
Established driving route in residential,
commercial traffic
Perform numerous driving maneuvers such as
lane changes and merging
Assessment of driving skills
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Beginner/previous driver skill knowledge
Steering of the vehicle- speed and consistency
Gas/brake functions- reaction time
Secondary functions – use of turn signals, wipers, parking brake
Visual scanning skills
Motor planning-repetitive, fatigue
Sequencing- secured parking
Problem solving- impulse control
Driving behavior- aggressive, indecisive
Following rules and regulations of the road
Route planning
Vehicle Modifications needed?
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Clinical evaluation and hands on assessment to
trial and match the appropriate equipment with
the client’s needs
Collaboration with vendor (equipment installer),
therapist and client
Vehicle fittings with client and vendor
Types of modifications
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Mirrors, wide angle and spot mirrors
Seating, positioning, seat belt
Transfer/wheelchair loading
Hand controls, steering devices
Left foot accelerator
Entry systems, lifts, ramps
Secondary Switches for electronics
Voice control of switches
Back up sensors, rain tracker for wipers
Turn signal cross over to right side
Spinner Knob for steering
with one hand
Steering device and electronic
secondary switches
Mechanical Hand Controls
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Push forward for braking, downward for
acceleration.
Left foot accelerator
Move left foot from pedal to the brake
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Needs to have a right side guard too
Pedal guard is required for safety
Lifts
Rear and loading lifts
Vehicle Entry Options
Passenger side door entry with ramp
Full size van with under vehicle lift
Rear door entry mini van
Ramp vans
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Side entry with power door, ramp and lowered
flooring- Honda Odyssey conversion by
Vantage
Vehicle Selection
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Assessing the person’s needs
and the vehicle
What is the appropriate
seating? WC 19 standards for
safe use of wheelchair as
seating in the vehicle
Can the individual use their
own vehicle?
Fitting and Training
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New skill development with modifications
Understanding of limitations
Training in adaptive techniques
Memory/orientation/behavioral management
Preparation for re-licensing
Interpretation of the evaluation
Combined feedback
of clinical
and behind-the-wheel
evaluation
using clinical reasoning
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Documentation
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Notifying physician- copy of report to
client/patient family
Reporting to the Department of Motor
Vehicles/Licensing
Summary
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Recommendations with a plan to not drive
Explore alternative to driving
Monitor for depression and social isolation
Vehicle Modifications, fitting
Behind-the-wheel driver’s training
Licensure/restrictions/re-examination
Follow up re- assessment as needed- 6 months
The
Road
Ahead
Resources:
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ADED- Association for Driver Rehabilitation Specialists
(Model Practices for Driver Rehabilitation for Individuals with
Disabilities) www.aded.net
AOTA-American Occupational Therapy Association (Driving
Evaluations by Occupational Therapists) www.
aota.olderdriver
RESNA-an interdisciplinary association of people with a
common interest in technology and disability www.resna. org
AARP- (AARP Driver Safety Online Course)
www.aarp.org/drive
AAA -(AAA Driver Improvement Classes) www.AAA. Com
www.oregon.gov.ODOT/DMV
www.dol.wa.gov/driverlicense