1/29/2010
Driver Rehabilitation Following
Brain Injury:
Brain Injury
A Collaborative Effort
• Definition: Brain injury refers to damage or destruction of
brain tissue due to trauma or a wide range of medical
conditions, e.g. anoxia, stroke, encephalitis, brain tumors,
poisoning, brain toxins, or aneurysms.
• Incidence is estimated between 5-7 % of the U.S. Population
have been treated for traumatic brain injury.
• Prevalence the Centers for Disease Control estimates that 5.2
million Americans are living with some degree of disability
caused by TBI.
Presented by: Lee Hirsch, OTR/L, DRS, LDI
Mobility Quest
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Brain Injury
Brain Injury
• What is the Impact of a Brain Injury on the
Person’s Life?
A wide range of cognitive, physical, perceptual,
emotional and behavioral impairments may follow
brain injury
injury. Physical
Physical, i.e.
i e motor,
motor and basic
sensory functions can be affected, as well as the
functioning of multiple (e.g. hormonal, endocrine)
body systems. Cognitively, individuals with brain
injury may have subtle to significant impairments
in their perception, language, attention,
concentration, information processing, learning
and/or memory.
• Executive function include: insight into
strengths and limitations, goal setting,
planning and organizing, initiating tasks,
self control or self-inhibiting
self-control
self inhibiting behavior,
behavior
monitoring and evaluating performance,
problem-solving, transferring newly
acquired skills to alternate settings or
situations.
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Driving - Who is Responsible?
Brain Injury
• Perception and visual disturbances are common
occurrences with brain injury and may include
impairment in one or more of the following areas:
spatial orientation, figure ground, depth
perception, form constancy, contrast sensitivity,
ocular pursuits, fixation, accommodation, and/or
convergence/divergence. Resulting in diploplia,
impaired vision and motor processing, midline
orientation and/or unstable ambient vision.
Mandated Physician Reporting California Department of Motor
Vehicles:
CA Health and Safety Code Reporting Disorders Characterized by
Lapses of consciousness 103900
(f) A physician and surgeon who report a patient diagnosed as a
case of a disorder characterized by lapses of consciousness
pursuant to this section shall not be civilly or criminally liable to
any patient for making any report required or authorized by this
section.
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http://www.dmv.ca.gov/pubs/vctop/vc/vc.htm
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1/29/2010
STATE OF CALIFORNIA DEPARTMENT OF MOTOR VEHICLES MEDICAL
CONDITIONS AND OTHER FACTORS IN DRIVER RISK
REPORT TO THE LEGISLATURE OF THE STATE OF CALIFORNIA IN
ACCORD WITH SENATE BILL 335 CHAPTER 985, 2000 LEGISLATIVE
SESSION - MAY 2001
Grounds Permitting Refusal of License
California Vehicle Code 1806
“Also discussed were various relatively common disorders, mandatorily not
reportable, which have the potential to affect driving safety. The
information presented on specific disorders comes from previously published
departmental reviews of the scientific literature in this area, and from a review of
recently published studies identified through a search in Medline, a medical
information referencing system on the Internet.
These Orders Include:
• Poorly controlled DM with
diabetic hypoglycemia
• MI
• Uncontrolled Epilepsy
• CVA
• Brain Tumor
• Syncope
• Alcohol/Drug dependency
• Narcolepsy
•
•
•
•
•
•
•
Vision disorders impairing
contrast sensitivity
Hemianopsia
Trauma
Concussion
Dizziness/Vertigo
Cardiac Arrhythmias
Sleep Apnea
• The department may refuse to issue to, or renew a
driver’s license of, any person:
(c) . . . . Who has any physical or mental disability,
disease, or disorder which could affect the safe
operation of a motor vehicle unless the department
has medical information which indicates the
person may safely operate a motor vehicle. In
making it’s determination, the department may rely
on any relevant information available to the
department.
http://www.dmv.ca.gov/pubs/vctop/d06/vc12806.htm
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Vision Requirement for Class “C” Driver’s License
The CA DMV, under the Physical and Mental Disabilities Guidelines:
Section 5, has a “Guidelines Document” which provides matrices for
visual conditions, definitions, range of severity, whether a drive
test/special drive test should be administered, and types of
restrictions (e.g. corrective lens, sunrise to sunset driving only, no
freeway driving, area restrictions, additional mirrors (right side, wide
angle, panoramic, right or left fender mounted mirrors). An
immediate revocation may be imposed if an individual performs
dangerously and the condition renders the person unsafe to drive.
Vision Requirement for Class “C” Driver’s License
Visual Acuity Screening– Minimum of 20/40 or better with both eyes
together, and no worse than 20/70 in the poorer eye.
If Screening failed DMV refers to vision specialist with a form to
complete the Report of Vision Examination form number DL62.
DL62
The Vision Conditions and Actions Chart lists seven vision functions
that may impair driving:
Drivers with visual acuity of 20/200 or worse may not be licensed to
drive. Drivers may use Bioptics for driving, but may not use them to
meet the vision Standard.
Central Vision
Peripheral Vision (no degree of loss field is identified)
Night Vision (includes glare recovery and glare resistance)
Judgment of Distance
Eye Movement
Visual Perception
Following review of the Report of Vision Examination the client may
be schedule for a drive test or a special drive test to determine
whether the vision condition impairs the ability to drive.
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The AMA’s Opinion
• It is the physician’s duty to report if: State
Integrated Heath Care Team
mandates reporting, or there are clear signs of
impairment, or the patient is unlikely to stop
• To Report: The physician should advise the patient
of their intent, they should send ONLY key
information, The Clinician (physician) can
recommend further evaluation or license
revocation, Driver licensing is revoked by the
state NOT the physician.
• Consists of: Physicians and Optometrists, Physician
Extenders: Physician Assistants,
Assistants Occupational Therapists,
Therapists
Physical Therapists, Speech Pathologists, Nurse
Practitioners…
• These professionals have comprehensive knowledge and skills
that help increase access to care and reduce costs. Their
teamwork is appropriate and protects the public.
Taken from physician presentation by G. Odenheimer, MD, K. Johnson, D.O., C. Robinson, OT, J. Walls (DPS)
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Per Alexander Lopez, JD, OTR, September 2007
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1/29/2010
Know how you can address driving
within your Scope of Practice
What is Your role when asked,
“Red Flags”
•
Driving Screening tool for health care professionals
Neuro-optometrist Exam
“Can I Drive?”
•
•
•
•
•
•
•
•
•
General History
y – Behavioral observations client walking/wheeling
g/
g
to room, note functional problems
Ocular history
Visual fields
Visual acuity (distance and near)
Refraction
Binocular Vision Testing (distance and near) – aided/unaided
Accommodative evaluation
Sensory motor analysis
Ocular Motility
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Know how you can address driving
within your Scope of Practice
Know how you can address driving
within your Scope of Practice
Neuro-optometrist Exam (cont.)
•
•
•
•
•
•
Pursuits - were eyes yoked Y/N
Saccades
Near Point convergence
Stereopsis
Cover Test
Midline Evaluation
Pupil Testing
Glare Recovery
Color Vision
Contrast Sensitivity
Light Sensitivity
Useful Field of Vision
Visual Evoked Potential – for those who demonstrate characteristics
of Post Trauma Vision Syndrome
Neuro-optometrist Exam (cont.)
•
Observations and Subjective Comment of Client
– discomfort, e.g. neck and shoulders
– decreased ability to follow verbal direction
– client asks examiner to repeat questions
– posture of client: head and neck, asymmetry
Neuro-optometrist Exam Results
•
•
•
Prescribe and fit with appropriate lenses
Refer for vision therapy PRN
And/or refer to driving rehab specialist with approval for behind the
wheel evaluation and training
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Know how you can address driving
within your Scope of Practice
Know how you can address driving
within your Scope of Practice
Occupational Therapists (the generalist)
•
•
•
•
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“…practitioners must recognize driving and community mobility as
part of every OT evaluation…
…whether the client was driving and has deficits may be all you
need to know – but what you do with the information is important…
…Intervene as appropriate, then refer…”
- Per AOTA OT Practice July 2005
Addresses the patient’s needs e.g. vision, as prescribed by OD
(scanning, pursuits, saccades, etc.), in addition, the OT also
addresses the physician prescribed: safety, cognition, perception
(depth of field, spatial, figure ground, visual closure, right/left
discrimination, etc.), UE range of motion, strength, coordination,
sensation, and general ADL’s. Is the client ready for a driving
evaluation? Refer to the driving specialist. For those client’s that
cannot return to driving, be prepared to do community mobility
retraining, or refer.
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Occupational Therapists
(the specialist)
• The Driver Rehab Specialist
has a specialty in driving
that
h is
i obtained
b i d with
ih
additional course work. The
Association of Rehab
Specialist (ADED) is an
international organization
that has guidelines for best
practices that are followed
in this arena.
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1/29/2010
Driver Rehabilitation
Driver Rehabilitation
Clinical Assessment may include the following:
COMPREHENSIVE DRIVING EVALUATION
Occupational Profile includes:
Diagnosis w/ onset, PMH, clients needs, problems, and concerns
regarding driving
driving, identified roles
roles, priorities
priorities, and values
values, patterns of
driving, obtain an understanding of the client’s perspective and
background.
•
VISUAL ASSESSMENT: Distant Visual Acuity, Visual Fields, Oculomotor
Range of Motion, Pursuits, Convergence/Divergence, Visual Midline Shift,
Saccades, Fixation, Contrast Sensitivity, Glare Recovery, Screen for
Stereopsis
•
VISUAL PERCEPTION: Visual Closure, Visual Discrimination, Design Copy,
Figure Ground, Spatial, Right/Left Discrimination, Neglect
•
PHYSICAL ASSESSMENT: Means of Mobility/Transfers, Balance
(Sitting/Standing), Head and Trunk Control, Active Range of Motion,
Strength, Motor Control (e.g. ataxia, tremors, tone), Sensation, Endurance,
Reaction Time, Rapid Pace Walk, Reflexes
•
COGNITIVE ASSESSMENT: Attention (Visual, Selective, Divided, Sustained),
Memory (STM, LTM, Working Memory, Procedural, Visual), Planning,
Organization Skills, Decision Making, Task Execution, Safety, Mental
Flexibility, Self-Monitoring
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Driver Rehabilitation
Driver Rehabilitation
•
COMMUNICATION: Language/Communication, Reading Comprehension,
Confrontation Naming, Generative Naming, General Word Search and
Retrieval, Road Sign Knowledge and Recognition
•
INITIAL CAR MOVEMENT: Applies Brake, Selects appropriate gear,
Releases parking brake, Checks mirrors and over shoulder (blind
spots), Signals, Enters traffic safely
•
BEHAVIORAL/EMOTIONAL: Frustration Tolerance, Irritability, Maturity,
Apathy, Loss of emotional control, Self Control/Self Perceptiveness, Self
Centered Behavior (does not see consequences for others), Mental Fatigue
•
STEERING: Hand placement, demonstrates smooth steering and
recovery, lane maintenance and position, straight a-ways vs curves
•
SPEED CONTROL: Proper speed for conditions and road surfaces,
appropriately uses acceleration/deceleration
•
TRAFFIC: Lane position is appropriate, following distance/gap,
checks traffic, judges the speed of others appropriately, passing,
stops, yields right-of-way, avoids position in blind spot, enters/exits
traffic safely, anticipates the actions of other drivers, backs car out
of driveway/parking space
•
TURNS: Right, Left, U Turns, 3 point turn (appropriately signals,
checks mirrors and over shoulder, width and control of turn,
appropriate speed), takes turn appropriately, do not impede traffic
On-The-Road Assessment may include:
•
VEHICLE ENTRY (includes safely unlocking and opening/closing door(s),
loading/unloading devices, and transfers in/out of car)
•
PRE-TRIP INSPECTION: Parking Brake Checked, Seat Adjustments, Mirrors
Adjusted, Seatbelt (donned properly), knows functions of the dash board
gauges and indicators
•
STARTS THE VEHICLE: Key insertion, starts the vehicle
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Driver Rehabilitation
Driver Rehabilitation
•
COGNITIVE ASPECTS: Attention (Visual, Selective, Divided,
Sustained), Anticipates (light changes, hazards, actions of other
drivers), Concentration, Confidence, Memory (procedural, working,
STM, LTM, Visual, Selective, Divided, Sustained), Planning,
Organization Skills, Decision Making, Task Execution, Safety,
Mental Flexibility, Self-Monitoring
FREEWAY DRIVING: Signals entry/exit, speed control/adjusts
accordingly, checks traffic, judges the speed of others appropriately,
merges safely, steering control, uses proper lane for exit,
anticipation of others, and cognitive execution
•
BEHAVIORAL/EMOTIONAL: Frustration Tolerance, Irritability,
Maturity, Apathy, Loss of emotional control, Self Control/Self
Perceptiveness, Self Centered Behavior (does not see consequences
for others), Mental Fatigue
COMMUNICATES: Observes and follows flow of traffic
lights/warning signs, appropriate use of auxiliary controls
(headlights, emergency flashers, horn), Cooperates with other
drivers, takes turn appropriately
•
RECOMMENDATIONS TO RESUME DRIVING: Based on outcome
of the evaluation, resume driving with physician clearance or
complete adaptive driver’s training with an individualized plan of
care.
•
INTERSECTIONS: Approach (too slow/fast, stops at limit line),
following distance/gap, limit line (cross walk) adherence, checks
traffic, judges the speed of others appropriately, correct lane
position and use
•
PARKING: Stall (right/Left approach, 90 degree, and/or diagonal),
Parallel parking
•
•
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1/29/2010
Driver Rehabilitation
Adaptive Equipment
Driver Rehabilitation
Allview (aka Smartview) Panoramic Mirror
Adaptive Drivers Training and Recommendations
• Adaptive drivers training following plan of care based on
comprehensive driving evaluation
• adaptive equipment in vehicle training, provision of
prescription for appropriate vehicle and/or adaptive
equipment
• driver training, driver education, and driver refresher
Fender Mount Mirrors
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Driver Rehabilitation
Adaptive Equipment
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Driver Rehabilitation
Adaptive Equipment
Left footed accelerator
Smart View Mirrors
Hand Controls
Left footed accelerator
installed
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Driver Rehabilitation
Adaptive Equipment
Standard Spinner Knob
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Drive Safely
Tri Pin Spinner knob
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