The Occupational Therapy
Pre-Driving Clinical Assessment
Judith Joseph, OTR, MA, CDRS
jajoseph@houstonmethodist.org
TOTA MCC
November 6, 2014
Objectives
• Develop an occupational profile that addresses the client’s driving
needs.
• Select specific evidence-based assessments and assessment methods
to assist in determining driving readiness.
• Using the information gathered from the occupational profile,
assessments, and goals determine the need to refer client’s to the
DRS.
• Gain knowledge in the laws and agencies in the state of Texas that
determine driving fitness to assist OT practitioners in establishing
treatment plans and goals.
About the speaker
• Introduced to clinical driving evaluations in 1987
• Attended my first ADED conference in 1989?
• Developed a pre-driving clinical screen and evaluation in 2010
• Passed CDRS exam August 2013
“So, what are you going to do about driving?”
Why should occupational therapist evaluate
fitness to drive?
Things to consider
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There are 20 million drivers in the U.S. 70 and older.
Every year, more than 795,000 people in the United States have a stroke.
400,000 individuals estimated to have MS.
Approximately 60,000 Americans are diagnosed with Parkinson's disease
each year, and this number does not reflect the thousands of cases that go
undetected.
• One in four adults−approximately 61.5 million Americans−experiences
mental illness in a given year
• Approximately two million Americans have mild low vision which affects
driving and reading.
Why Should OT evaluate fitness to drive?
• Because driving is an instrumental activity of daily living within the
domain of occupational therapy practice.
• practitioners should be able to accurately determine who is a safe
driver, who is at risk for unsafe driving, and who needs further
evaluation by a driving rehabilitation specialist (DRS).
AOTA Driving and Community Mobility
Occupational Therapy Roles
• Generalist: general knowledge and understanding of performance
and processing skills related to driving.
• Advanced Training: Further education to evaluate the integration of
sub-skills associated with driving and provide specific sub-skill training
• Specialized Training: Received specialized education, examination,
and/or certification.
University of Florida
What is in our domain of practice?
• Musculoskeletal disorders
• Neurological impairments
• Cognitive impairment
• Memory disorders
• Visual impairments
• Perceptual impairments
• Mobility
• Mental impairment
Consider the diagnosis and resulting
impairment
Medical condition examples
Diagnosis/condition
• Sleep apnea
• TBI
• CVA
• Dementia/Alzheimer’s
• MS
Impairment Risk
• Impaired arousal, responsiveness,
daytime sleepiness
• Attention, orientation, visual field
• Visual, cog, motor, visual field
• Executive functions
• Muscle weakness, sensory loss,
fatigue, cognitive or perceptual
deficits, symptoms of optic neuritis
Sherrilene Classen, Miriam Monahan ADED Conference 2013
Let’s Start with the
law!
Texas MAB
Texas Medical Advisory Board (MAB)
• The Texas Medical Advisory Board (MAB) for Driver Licensing was
established in 1970 to advise the Texas Department of Public Safety
(DPS) in the licensing of persons having medical limitations which
might adversely affect driving.
• Guidelines established using the following:
AMA Physician’s Guide for Determining Driver Limitation
Driver Fitness Medical Guidelines (NHTSA)
The American Association of Motor Vehicle Administrators
Texas Medical Advisory Board/DPS
• The ultimate goal is to allow all who can drive safely to do so and to
continue to reduce the number and severity of motor vehicle
accidents in Texas
Functional Ability Profiles
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General Debility
Cardiovascular disease
Syncope
Neurological Disorders
Psychiatric Disorders
Excessive Alcohol use/abuse
Drug use/abuse
Metabolic Diseases
Musculoskeletal Defects
Eye Defects
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Aging
Recurrent syncope
CVA, Seizures, Dementia
MS, Parkinson's, Peripheral
neuropathy
PTSD
DM
CP, MD
Diplopia, Peripheral vision
Visual acuity
Where do I start?
The Association For Driver Rehabilitation
Specialists (ADED)
ADED Mission Statement
Promoting excellence in the field of driver rehabilitation in support of
safe, independent community mobility
ADED Best Practices For The Delivery of
Driver Rehabilitation Services
• Section 1:
• Section 2:
• Section 3:
• Section 4:
Interview/Medical History
Clinical Visual Assessment
Clinical Physical Assessment
Clinical Cognitive Assessment
www.ADED.net
Interview/Medical History
• History of Present Illness
• Past Medical History
• Determine medical consent
• Review current medications (side effects)
• Assess communication status
• Review driving history
• License status
• Driving goals
• Vehicle availability
Clinical Visual Assessment
ADED recommendation
• Visual history
• Visual acuity
• Field of vision
• Other visual skills
Possible Deficits
• Cataracts, glaucoma, HH, etc.
• Feinbloom eye chart, BiVaba, Snellen
• Scatomos, HH
• Visual short term memory, figure
ground, form constancy, visual
discrimination, visual scanning skills,
High/Low contrast sensitivity
Visual Assessments and Observations
Assessments
• biVABA Brain Injury Visual
Assessment Battery for Adults
• The cover test
• UFOV Useful Field of View
• Dynavision
• Motor Free Visual Perception Test
(MFVPT)
• Clock drawing test
• Trails B
• Pursuits and Saccades
Observations
• Bumping into walls, furniture,
etc.
• nystagmus
• Head tilting or position
• squinting
• Position of test paper
• Visual scanning efficiency
Clinical Physical Assessment
• Range of Motion
• Strength
• Grip strength
• Prehension status
• Sensation
• Proprioception
• Coordination (rapid pace walk)
• Muscle tone (MAS)
• Mobility status (TUG)
• Balance (Berg, Teniti,)
• Orthotic devices
• Mobility aids
• Transfer skills
• Reaction times (Dynavision)
Clinical Cognitive Assessment
• Mini Mental State Exam (MMSE)
• Short Blessed Test
• Clinical Dementia Rating Scale
• Montreal Cognitive Assessment (MoCA)
• Maze Navigation Test
• Single Digit Modality Test (SDMT)
• Assessment of Motor Processing Skills (AMPS)
Case Study 1: CVA
• 76 y/o male with R MCA infarct, s/p thrombectomy, left hemiparesis,
DM-2, HTN, BPH, small tear in left supraspinatus.
• + multiple falls
• Poly pharmacy
• Wants to run errands and drive to any appointments
• h/o getting lost while driving when blood sugar is uncontrolled
• Backed into parked car in grocery store parking lot
• Totaled a vehicle 6-7 years ago
• Has not driven since onset of stroke
Case Study 1 continued: CVA test results
• Impaired left peripheral vision
• +nystagmus
• Rapid pace walk= 10 sec.
• Impaired head/neck flexibility
• Visual closure, mild impairment
• Trail Making B Test- 111sec.
• UFOV- unable to complete. Could not see 2nd vehicle
• Short Blessed=2
• Multiple angry outburst during testing
Case Study 1: recommendations
• Referred to U of H low vision clinic by Neuro-ophthalmologist
• Complete program at U of H prior to attempting to drive or being
referred to CDRS for BWT only after being cleared by Ophthalmologist
• Consider driving cessation
Case Study 2: Parkinson’s Disease
• 91 y/o male with h/o Parkinson’s Disease, loss of balance, peripheral
neuropathy, spinal stenosis, lumbar laminectomy
• + multiple falls
• Using walker with seat
• Last eye exam 2-3 years ago
• History of falling asleep spontaneously
• “minor” accident in parking lot when he could not stop in time when
another vehicle pulled out in front of him causing a rear end collision
• Totaled a car 3 yrs ago when he backed out of the driveway
• Wants to cont. driving without restrictions
Case Study 2: Test results
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High low contrast sensitivity intact
+nystagmus
Failed cover test
Bells Test 3:57 sec.
Trails B test 161 sec.
Right ankle strength 2/5, hip/knee strength 3/5
Limited head/neck flexibility
Unable to locate 50% items on UFOV
Fell asleep during testing
Rapid pace walk= 36 sec.
Scored 100% on sign recognition, map reading (items 14-24 on MFVPT)
Case Study 2: Recommendations
• Patient should not resume driving without a BWT.
• High risk for having a crash
• Consider driving cessation
Case Study 3: Left Hip fracture
• 82 y/o female with dx of left hip fx
• Has trouble looking over her shoulder, difficulty backing up, and has
gotten lost while driving
• Wants to be able to drive to the store, etc. She does not plan on
driving on the freeway or at night.
• She has not driven in 6 months since hip surgery
Case Study 3: Test Results
• Mild impairment of low contrast vision
• Mild impairment of working memory
• Impaired visual closure
• Trails Making B test: 353 seconds
• Impaired visual processing speed
• Impaired UFOV
• Rapid pace walk- 17 seconds
• No errors on clock drawing test
• Impaired head/neck flexibility
Case Study 3: Recommendations
• Further assessment through BWT
• Referral to optometrist
Case Study 4: MS
• 57 y/o female diagnosed with MS. Referred due to recent black out.
• h/o ventricular tachycardia, osteoporosis, cataracts, severe scoliosis
• + falls
• Wears built up right shoe for leg length discrepancy and R AFO
• Gets lost while driving, trouble finding and reading signs in time to
respond, feeling tired after driving, had “near misses”, bothered by
head light glare, trouble looking over shoulder when backing up.
• Recently hit a pole at the drive through bank and backed into trash
cans at the end of her driveway.
Case Study 4: Test Results
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Impaired visual acuity20/50 in left eye
High low contrast intact
No deficits noted with visual closure
Trials Making B test 73 seconds
Mild deficit with visual processing speed on UFOV
Mild deficit with working memory
No errors on clock drawing test
Rapid pace walk 5.8 seconds
Right shoulder flex limited to 90
Limited head/neck flexibility
3+/5 strength in Bil hips, and ankles
Became fatigued during test
Case Study 4: Recommendations
• Begin to seek alternative transportation if deficits worsen
• Use power chair instead of RW for appointments to conserve energy
• Do not drive on unfamiliar trips
• Do not drive when fatigued
• Consult with MD
• Referral to PT
• Referral to CDRS for BWT
Case Study 5: Impaired memory
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73 year old female with dx of impaired memory.
Cataract removal
Currently driving
Unable to recall last eye exam
Had one speeding ticket
Wears a hearing aid (not wearing during exam)
No falls
Admits to getting lost while driving, feels others drive too fast, being
stressed out by driving, difficulty at busy intersections, friends will no
longer ride with her.
Case Study 5: Test Results
• 20/25 binocular vision
• Impaired horizontal fixation to right
• Bells Test: 1:54, 3 errors
• Rapid pace walk- 6 seconds
• Scored 14 on the Short Blessed
• Trials Making B Test 194 seconds
• Intact visual closure, visual processing speed showed mild deficit
Case Study 5: Recommendations
• Driving should be restricted at best to her immediate neighborhood,
however without being able to control what happens such as
weather conditions, and changes in traffic volumes driving cessation
may need to be considered. If family insist on pt. continuing to drive
a referral to CDRS for BWT should be completed.
I am not the decider!
QUESTIONS?????