Driver Rehabilitation Services to Support Persons after a Traumatic Brain Injury Teresa Valois, OTR/L, ATP, CDRS.

Driver Rehabilitation Driver Rehabilitation Services to Support Services to Support

Persons after a Persons after a Traumatic Brain InjuryTraumatic Brain Injury

Teresa Valois, OTR/L, ATP, Teresa Valois, OTR/L, ATP, CDRSCDRS

What Happened?What Happened?

Traumatic Brain Injury?Traumatic Brain Injury?

An injured person may safely return to An injured person may safely return to driving and this should be addressed early driving and this should be addressed early in recovery. in recovery.

The injured person, family members, The injured person, family members, caregivers and health professionals should caregivers and health professionals should all be included in this important decision.all be included in this important decision.

If anyone has concerns that that driving If anyone has concerns that that driving may put the injured person or others in may put the injured person or others in danger, health professionals may danger, health professionals may recommend pre-driving testing.recommend pre-driving testing.

Driving safely is even Driving safely is even important for your important for your

doggie!doggie!

The Goal: To Drive!The Goal: To Drive!Knowledge Enhances Your Knowledge Enhances Your

Safety= KEYSSafety= KEYS

Dignity Responsibility

Safety,

route planningexecution and return

Independence Freedom

Choice

The presentation goals:The presentation goals:

Learn the details of a Driver Rehabilitation Learn the details of a Driver Rehabilitation assessment assessment

Vehicle modifications will be demonstratedVehicle modifications will be demonstrated Brake reaction time testing will be Brake reaction time testing will be

demonstrateddemonstrated Department of Licensing guidelines will be Department of Licensing guidelines will be

providedprovided Learn about legal issues of returning to Learn about legal issues of returning to

driving and possible unsafe driving reportingdriving and possible unsafe driving reporting

Physician's Legal and Physician's Legal and Ethical DutiesEthical Duties

Document thoroughly and reiterate Document thoroughly and reiterate safetysafety

Protect the patient/clientProtect the patient/client

Protecting the safety of the publicProtecting the safety of the public

Be aware that the physician-patient Be aware that the physician-patient privilege does not prevent you from privilege does not prevent you from reporting to the DMVreporting to the DMV

Ethics and Legal Ethics and Legal continuedcontinued

Commit to breaching the patient’s Commit to breaching the patient’s confidentiality vs. allowing a potential confidentiality vs. allowing a potential injury to himself and third partyinjury to himself and third party

Know, advise and adhere to State Know, advise and adhere to State Reporting LawsReporting Laws

Counsel your patient- recommend Counsel your patient- recommend driving retirement as neededdriving retirement as needed

Suggest a second opinion Suggest a second opinion

Seizures?Seizures?

Having experienced a seizure after Having experienced a seizure after the TBI may be a barrier to driving.the TBI may be a barrier to driving.

States often require that a person States often require that a person be free of seizures for a period of be free of seizures for a period of time, such as 6 months, before time, such as 6 months, before resuming driving.resuming driving.

People who want to return to People who want to return to driving need to check with the laws driving need to check with the laws in their state.in their state.

Initial Screening:Initial Screening:

Medical Clearance by PhysicianMedical Clearance by Physician Seizures/medications/stable conditionSeizures/medications/stable condition Understand if there is support of familyUnderstand if there is support of family Ask about the availability of Ask about the availability of

vehicle/insurance/how to manage vehicle/insurance/how to manage emergency situationsemergency situations

Ask to see the Driver License statusAsk to see the Driver License status Inquire about driving Inquire about driving

history/restrictionshistory/restrictions

Observe!Observe!

Poor hygiene and groomingPoor hygiene and grooming Difficulty with walking, getting into/out Difficulty with walking, getting into/out

of chairsof chairs Difficulty with visual trackingDifficulty with visual tracking Difficulty with attention, memory, Difficulty with attention, memory,

comprehensioncomprehension Impulsivity, willingness to participate in Impulsivity, willingness to participate in

evaluationevaluation

Questions/discussionQuestions/discussion

Patient’s or family member concern Patient’s or family member concern (example: recent crashes)(example: recent crashes)

Medical history: Chronic medical Medical history: Chronic medical conditions?conditions?

Medical conditions with Medical conditions with unpredictable/episodic events- unpredictable/episodic events- (example: sleep apnea)(example: sleep apnea)

Medications?Medications?

PrescriptionPrescription Non-prescriptionNon-prescription Combination of drugsCombination of drugs

Discussion of each medication class, Discussion of each medication class, dosage, schedule and side affectsdosage, schedule and side affects

My goal is to drive in My goal is to drive in Seattle. How do we decide if Seattle. How do we decide if

I am safe?I am safe?

What are the medical What are the medical concerns?concerns?

Partial loss of the visual field from Partial loss of the visual field from traumatic brain injurytraumatic brain injury

Problems with heart rhythmProblems with heart rhythm SeizuresSeizures Low or high bloodLow or high blood pressurepressure Alcoholic intoxicationAlcoholic intoxication FatigueFatigue

What can cause unsafe What can cause unsafe driving?driving?

Loss of feeling in the feet Loss of feeling in the feet Loss of muscle power, or weakness Loss of muscle power, or weakness

and coordinationand coordination Loss of judgmentLoss of judgment Loss of coordinationLoss of coordination Loss of sleepLoss of sleep

Limitations in left side Limitations in left side visual and depth perception visual and depth perception

can cause a crashcan cause a crash

Warning signs of unsafe Warning signs of unsafe drivers after Traumatic drivers after Traumatic

Brain InjuryBrain Injury• Drives too fast or too slow for road Drives too fast or too slow for road

conditions or posted speedsconditions or posted speeds• Needs help or instructions from passengersNeeds help or instructions from passengers• Doesn’t observe signs or signalsDoesn’t observe signs or signals• Makes slow or poor distance decisionsMakes slow or poor distance decisions• Gets easily frustrated or confusedGets easily frustrated or confused• Often gets lost, even in familiar areasOften gets lost, even in familiar areas• Has accidents or near missesHas accidents or near misses• Drifts across lane markings into other lanesDrifts across lane markings into other lanes

CDRS test question:CDRS test question:

Which of the following is Which of the following is inappropriate when attempting a inappropriate when attempting a left lane change?left lane change?

a. scanning rear-view mirror and left side-view a. scanning rear-view mirror and left side-view mirrormirror

b. applying the left indicator and applying the b. applying the left indicator and applying the brakebrake

hardhard

c. checking the blind spot over the left shoulderc. checking the blind spot over the left shoulder

d. gradually guiding the vehicle into the left laned. gradually guiding the vehicle into the left lane

Answer is BAnswer is B

Which of the following is Which of the following is inappropriate when attempting a inappropriate when attempting a left lane change?left lane change?

b. applying the left indicator and applying the brakehard

What are common What are common driving errors?driving errors?

Incorrectly making a left-hand turnIncorrectly making a left-hand turn

Driving too fast or tooDriving too fast or too slowly for the slowly for the road conditionsroad conditions

Making sudden turnsMaking sudden turns

Not usingNot using the turn indicator or the turn indicator or forgetting to turn it offforgetting to turn it off

Getting lostGetting lost or seeming disorientedor seeming disoriented

Review of SystemsReview of Systems

GeneralGeneral-- weakness, fatigue weakness, fatigue HEENTHEENT-- headache, head trauma headache, head trauma RespiratoryRespiratory-shortness of breathe-shortness of breathe CardiacCardiac-palpitations, loss of consciousness-palpitations, loss of consciousness MusculoskeletalMusculoskeletal- muscle pain, joint - muscle pain, joint

stiffness, decreased range of motionstiffness, decreased range of motion NeurologicalNeurological-paralysis, tremors, loss of -paralysis, tremors, loss of

sensationsensation PsychiatricPsychiatric- depression, anxiety, memory - depression, anxiety, memory

loss, confusion, manialoss, confusion, mania

Assessment and PlanAssessment and Plan

Formulate diagnosis and treatment Formulate diagnosis and treatment plan for medical conditionplan for medical condition

Prescribe or change medicationsPrescribe or change medications Work-up new-onset disease or treat Work-up new-onset disease or treat

unstable conditionunstable condition Referral for objective tests- Referral for objective tests-

OT/PT/Speech, Neuropsych and OT/PT/Speech, Neuropsych and Driver Rehabilitation AssessmentDriver Rehabilitation Assessment

Tests:Tests:

Snellen E chartSnellen E chart Visual FieldsVisual Fields Trail-Making Tests A and BTrail-Making Tests A and B Clock Drawing testClock Drawing test Rapid Pace WalkRapid Pace Walk Manual test of range of motionManual test of range of motion Manual test of motor strength, balanceManual test of motor strength, balance Auditory Auditory SensorySensory

Trail Making B sampleTrail Making B sample

Trail Trail B sampleB sample

Short Blessed Test Short Blessed Test SampleSample

• 1. What year is it now?1. What year is it now?

• 2. What month is it now?2. What month is it now?

• 3. Say the months of the year in reverse 3. Say the months of the year in reverse orderorder

• 4. Please repeat this name and address 4. Please repeat this name and address after me: John Brown, 42 Market after me: John Brown, 42 Market Street, Chicago-Street, Chicago-remember thisremember this

Clinical Driver Clinical Driver Assessments:Assessments:

VisionVision Visual Visual

PerceptionPerception Physical Physical

FunctioningFunctioning Cognitive skillsCognitive skills BRAKE BRAKE

REACTION TIMEREACTION TIME

Tests done by Driver Tests done by Driver Rehabilitation SpecialistRehabilitation Specialist

Optec Vision TesterOptec Vision Tester Motor Free Visual Perception TestMotor Free Visual Perception Test Block Design- Constructional Block Design- Constructional

Apraxia, Spatial Relations, Depth Apraxia, Spatial Relations, Depth PerceptionPerception

Symbol Digit Modalities TestSymbol Digit Modalities Test

Vision screening:Vision screening:

Visual acuityVisual acuity Night vision/glare recoveryNight vision/glare recovery Far and Near visionFar and Near vision Peripheral visionPeripheral vision Color perceptionColor perception Depth perceptionDepth perception Road sign recognitionRoad sign recognition Visual trackingVisual tracking

Visual Perception:Visual Perception:

Form constancy-Form constancy- the ability to recognize the same shape the ability to recognize the same shape among a variety of shapesamong a variety of shapes

Figure groundFigure ground- the ability to identify one object or design - the ability to identify one object or design from a series of superimposed objects or designsfrom a series of superimposed objects or designs

Position in space-Position in space- the ability to understand the spatial the ability to understand the spatial concept of positioning such as differentiating the same concept of positioning such as differentiating the same form in various orientations.form in various orientations.

Depth Perception-Depth Perception- the ability to judge distances as in the ability to judge distances as in differentiating close and farthest from oneselfdifferentiating close and farthest from oneself

Spatial Relations-Spatial Relations- the ability to perceive the relationship the ability to perceive the relationship between two or more objects to each other and to oneselfbetween two or more objects to each other and to oneself

Visual closure-Visual closure- The ability to identify incomplete figures The ability to identify incomplete figures when only fragments are presentedwhen only fragments are presented

Visual memory-Visual memory- the ability to recall dominant features on the ability to recall dominant features on one stimulus item or to remember the sequences of several one stimulus item or to remember the sequences of several itemsitems

Visual PerceptionVisual Perception

Form constancy-Form constancy- the ability to the ability to recognize the same shape among a recognize the same shape among a variety of shapesvariety of shapes

Visual PerceptionVisual Perception

Figure groundFigure ground- the ability to - the ability to identify one object or design from a identify one object or design from a series of superimposed objects or series of superimposed objects or designsdesigns

Visual PerceptionVisual Perception

Position in space-Position in space- the ability to the ability to understand the spatial concept of understand the spatial concept of positioning such as differentiating positioning such as differentiating the same form in various the same form in various orientations.orientations.

Visual PerceptionVisual Perception

Depth Perception-Depth Perception-

the ability to judgethe ability to judge

distances as distances as

in differentiatingin differentiating

close and farthestclose and farthest

from oneselffrom oneself

Visual PerceptionVisual Perception

Spatial Relations-Spatial Relations- the ability to the ability to perceive the relationship between perceive the relationship between two or more objects to each other two or more objects to each other and to oneselfand to oneself

Visual PerceptionVisual Perception

Visual closure-Visual closure- The ability to The ability to identify incomplete figures when identify incomplete figures when only fragments are presentedonly fragments are presented

Visual PerceptionVisual Perception

Visual memory-Visual memory- the ability to recall the ability to recall dominant features on one stimulus dominant features on one stimulus item or to remember the sequences item or to remember the sequences of several itemsof several items

Physical FunctioningPhysical Functioning

Range of Range of motion/strength/coordination/sensationmotion/strength/coordination/sensation

Use of mobility devicesUse of mobility devices Potential skills for transfers in and out of Potential skills for transfers in and out of

carcar BalanceBalance Fine motor skills- use of keys, secondary Fine motor skills- use of keys, secondary

switchesswitches Reaction time/right foot/left foot/need Reaction time/right foot/left foot/need

for hand controls or other modificationsfor hand controls or other modifications

Reaction time testing Reaction time testing machinesmachines

Cognitive skillsCognitive skills

Mental statusMental status Information processingInformation processing Decision makingDecision making Divided attentionDivided attention Multiple task sequencingMultiple task sequencing Distractibility and the ability to focusDistractibility and the ability to focus Recognizes abilities/limitationsRecognizes abilities/limitations

Cognitive Cognitive continuedcontinued

Understands and appreciates levels of Understands and appreciates levels of acceptable risksacceptable risks

Consistency in behaviorConsistency in behavior Self regulation for accuracySelf regulation for accuracy MemoryMemory Path findingPath finding Endurance and fatigueEndurance and fatigue Recognition of error/correctionRecognition of error/correction Judgment and recognition of skills and Judgment and recognition of skills and

limitationslimitations

Planning a routePlanning a route

Path finding without a GPS system?

Simulator and monitors Simulator and monitors with driving viewswith driving views

Hand Controls and Hand Controls and Spinner KnobSpinner Knob

Who does the Behind-Who does the Behind-the-Wheel Driving the-Wheel Driving

Assessment?Assessment?

Behind-The-Wheel Behind-The-Wheel Evaluation Evaluation

A clinical evaluation prior A clinical evaluation prior to a BTW evaluation to a BTW evaluation

BTW evaluations should BTW evaluations should include a number of driving include a number of driving maneuvers and a variety of maneuvers and a variety of settingssettings

Progress the driving Progress the driving evaluation/experience to evaluation/experience to meet the person’s meet the person’s physical and cognitive physical and cognitive skillsskills

Behind-the-wheel evaluationBehind-the-wheel evaluation

Clinical evaluation before a behind-Clinical evaluation before a behind-the-wheel evaluationthe-wheel evaluation

Orientation in the vehicle- mirrors, Orientation in the vehicle- mirrors, seat beltseat belt

Established driving route in Established driving route in residential, commercial trafficresidential, commercial traffic

Perform numerous driving maneuvers Perform numerous driving maneuvers such as lane changes and mergingsuch as lane changes and merging

Assessment of driving skills Assessment of driving skills

Beginner/previous driver skill knowledgeBeginner/previous driver skill knowledge Steering of the vehicle- speed and consistencySteering of the vehicle- speed and consistency Gas/brake functions- reaction time Gas/brake functions- reaction time Secondary functions – use of turn signals, wipers, Secondary functions – use of turn signals, wipers,

parking brakeparking brake Visual scanning skillsVisual scanning skills Motor planning-repetitive, fatigue Motor planning-repetitive, fatigue Sequencing- secured parkingSequencing- secured parking Problem solving- impulse controlProblem solving- impulse control Driving behavior- aggressive, indecisiveDriving behavior- aggressive, indecisive Following rules and regulations of the roadFollowing rules and regulations of the road Route planningRoute planning

Vehicle Modifications needed? Vehicle Modifications needed?

Clinical evaluation and hands on Clinical evaluation and hands on assessment to trial and match the assessment to trial and match the appropriate equipment with the appropriate equipment with the client’s needsclient’s needs

Collaboration with vendor Collaboration with vendor (equipment installer), therapist and (equipment installer), therapist and clientclient

Vehicle fittings with client and Vehicle fittings with client and vendor vendor

Types of modificationsTypes of modifications Mirrors, wide angle and spot mirrorsMirrors, wide angle and spot mirrors Seating, positioning, seat beltSeating, positioning, seat belt Transfer/wheelchair loadingTransfer/wheelchair loading Hand controls, steering devicesHand controls, steering devices Left foot acceleratorLeft foot accelerator Entry systems, lifts, rampsEntry systems, lifts, ramps Secondary Switches for electronicsSecondary Switches for electronics Voice control of switchesVoice control of switches Back up sensors, rain tracker for wipersBack up sensors, rain tracker for wipers

Turn signal cross over to Turn signal cross over to right sideright side

Spinner Knob for Spinner Knob for steering with one steering with one

handhand

Steering device and Steering device and electronic secondary electronic secondary

switchesswitches

Mechanical Hand Mechanical Hand ControlsControls

Push forward for braking, downward Push forward for braking, downward for acceleration.for acceleration.

Left foot acceleratorLeft foot acceleratorMove left foot from pedal to the brakeMove left foot from pedal to the brake

Needs to have a right side guard tooNeeds to have a right side guard too

Pedal guard is required Pedal guard is required for safetyfor safety

LiftsLifts

Rear and loading liftsRear and loading lifts

Vehicle Entry OptionsVehicle Entry Options

Passenger side door entry with ramp

Full size van with under vehicle lift Rear door entry mini van

Ramp vansRamp vans

Side entry with power door, ramp Side entry with power door, ramp and lowered flooring- Honda and lowered flooring- Honda Odyssey conversion by Vantage Odyssey conversion by Vantage

Vehicle SelectionVehicle Selection

Assessing the person’s Assessing the person’s needs and the vehicle needs and the vehicle

What is the What is the appropriate seating? appropriate seating? WC 19 standards for WC 19 standards for safe use of wheelchair safe use of wheelchair as seating in the as seating in the vehiclevehicle

Can the individual use Can the individual use their own vehicle?their own vehicle?

Fitting and TrainingFitting and Training

New skill development with New skill development with modificationsmodifications

Understanding of limitationsUnderstanding of limitations Training in adaptive techniquesTraining in adaptive techniques Memory/orientation/behavioral Memory/orientation/behavioral

managementmanagement Preparation for re-licensingPreparation for re-licensing

Interpretation of the Interpretation of the evaluationevaluation

Combined feedbackCombined feedback

of clinical of clinical

and behind-the-wheel and behind-the-wheel

evaluation evaluation

using clinical reasoning using clinical reasoning

DocumentationDocumentation

Notifying physician- copy of report Notifying physician- copy of report to client/patient familyto client/patient family

Reporting to the Department ofReporting to the Department of Motor Vehicles/LicensingMotor Vehicles/Licensing

SummarySummary Recommendations with a plan to not Recommendations with a plan to not

drivedrive Explore alternative to drivingExplore alternative to driving Monitor for depression and social Monitor for depression and social

isolationisolation Vehicle Modifications, fittingVehicle Modifications, fitting Behind-the-wheel driver’s trainingBehind-the-wheel driver’s training Licensure/restrictions/re-examinationLicensure/restrictions/re-examination Follow up re- assessment as needed- 6 Follow up re- assessment as needed- 6

monthsmonths

The The RoadRoad

Ahead Ahead

Resources:Resources:

ADED-ADED- Association for Driver Rehabilitation Association for Driver Rehabilitation Specialists (Model Practices for Driver Rehabilitation Specialists (Model Practices for Driver Rehabilitation for Individuals with Disabilities) for Individuals with Disabilities) www.aded.netwww.aded.net

AOTAAOTA-American Occupational Therapy Association -American Occupational Therapy Association (Driving Evaluations by Occupational Therapists) (Driving Evaluations by Occupational Therapists) www. aota.olderdriver www. aota.olderdriver

RESNA-RESNA-an interdisciplinary association of people an interdisciplinary association of people with a common interest in technology and disability with a common interest in technology and disability www.resna. orgwww.resna. org

AARPAARP- (AARP Driver Safety Online Course) - (AARP Driver Safety Online Course) www.aarp.org/drivewww.aarp.org/drive

AAAAAA -(AAA Driver Improvement Classes) -(AAA Driver Improvement Classes) www.AAA. www.AAA. ComCom

www.oregon.gov.ODOT/DMVwww.oregon.gov.ODOT/DMV www.dol.wa.gov/driverlicensewww.dol.wa.gov/driverlicense