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

What Happened?

Traumatic Brain Injury? An injured person may safely return to driving and this should be addressed early in recovery. 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. 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 pre- driving testing. If anyone has concerns that that driving may put the injured person or others in danger, health professionals may recommend pre- driving 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: Learn the details of a Driver Rehabilitation assessment Learn the details of a Driver Rehabilitation assessment Vehicle modifications will be demonstrated Vehicle modifications will be demonstrated Brake reaction time testing will be demonstrated Brake reaction time testing will be demonstrated Department of Licensing guidelines will be provided Department of Licensing guidelines will be provided Learn about legal issues of returning to driving and possible unsafe driving reporting 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? Having experienced a seizure after the TBI may be a barrier to driving. 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. 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. People who want to return to driving need to check with the laws in their state.

Initial Screening: Medical Clearance by Physician Medical Clearance by Physician Seizures/medications/stable condition Seizures/medications/stable condition Understand if there is support of family Understand if there is support of family Ask about the availability of vehicle/insurance/how to manage emergency situations Ask about the availability of vehicle/insurance/how to manage emergency situations Ask to see the Driver License status Ask to see the Driver License status Inquire about driving history/restrictions Inquire about driving history/restrictions

Observe! Poor hygiene and grooming Poor hygiene and grooming Difficulty with walking, getting into/out of chairs Difficulty with walking, getting into/out of chairs Difficulty with visual tracking Difficulty with visual tracking Difficulty with attention, memory, comprehension Difficulty with attention, memory, comprehension Impulsivity, willingness to participate in evaluation Impulsivity, willingness to participate in evaluation

Questions/discussion Patient’s or family member concern (example: recent crashes) Patient’s or family member concern (example: recent crashes) Medical history: Chronic medical conditions? Medical history: Chronic medical conditions? Medical conditions with unpredictable/episodic events- (example: sleep apnea) Medical conditions with unpredictable/episodic events- (example: sleep apnea)

Medications? Prescription Prescription Non-prescription Non-prescription Combination of drugs 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? Partial loss of the visual field from traumatic brain injury Partial loss of the visual field from traumatic brain injury Problems with heart rhythm Problems with heart rhythm Seizures Seizures Low or high blood pressure Low or high blood pressure Alcoholic intoxication Alcoholic intoxication Fatigue Fatigue

What can cause unsafe driving? Loss of feeling in the feet Loss of feeling in the feet Loss of muscle power, or weakness and coordination Loss of muscle power, or weakness and coordination Loss of judgment Loss of judgment Loss of coordination Loss of coordination Loss of sleep Loss of sleep

Limitations in left side visual and depth perception can cause a crash

Warning signs of unsafe drivers after Traumatic Brain Injury Drives too fast or too slow for road conditions or posted speeds Drives too fast or too slow for road conditions or posted speeds Needs help or instructions from passengers Needs help or instructions from passengers Doesn’t observe signs or signals Doesn’t observe signs or signals Makes slow or poor distance decisions Makes slow or poor distance decisions Gets easily frustrated or confused Gets easily frustrated or confused Often gets lost, even in familiar areas Often gets lost, even in familiar areas Has accidents or near misses Has accidents or near misses Drifts across lane markings into other lanes 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? Incorrectly making a left-hand turn Incorrectly making a left-hand turn Driving too fast or too slowly for the road conditions Driving too fast or too slowly for the road conditions Making sudden turns Making sudden turns Not using the turn indicator or forgetting to turn it off Not using the turn indicator or forgetting to turn it off Getting lost or seeming disoriented Getting lost or seeming disoriented

Review of Systems General- weakness, fatigue General- weakness, fatigue HEENT- headache, head trauma HEENT- headache, head trauma Respiratory -shortness of breathe Respiratory -shortness of breathe Cardiac -palpitations, loss of consciousness Cardiac -palpitations, loss of consciousness Musculoskeletal - muscle pain, joint stiffness, decreased range of motion Musculoskeletal - muscle pain, joint stiffness, decreased range of motion Neurological -paralysis, tremors, loss of sensation Neurological -paralysis, tremors, loss of sensation Psychiatric - depression, anxiety, memory loss, confusion, mania Psychiatric - depression, anxiety, memory loss, confusion, mania

Assessment and Plan Formulate diagnosis and treatment plan for medical condition Formulate diagnosis and treatment plan for medical condition Prescribe or change medications Prescribe or change medications Work-up new-onset disease or treat unstable condition Work-up new-onset disease or treat unstable condition Referral for objective tests- OT/PT/Speech, Neuropsych and Driver Rehabilitation Assessment Referral for objective tests- OT/PT/Speech, Neuropsych and Driver Rehabilitation Assessment

Tests: Snellen E chart Snellen E chart Visual Fields Visual Fields Trail-Making Tests A and B Trail-Making Tests A and B Clock Drawing test Clock Drawing test Rapid Pace Walk Rapid Pace Walk Manual test of range of motion Manual test of range of motion Manual test of motor strength, balance Manual test of motor strength, balance Auditory Auditory Sensory Sensory

Trail Making B sample

Trail B sample

Short Blessed Test Sample 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 order 3. Say the months of the year in reverse order 4. Please repeat this name and address after me: John Brown, 42 Market Street, Chicago-remember this 4. Please repeat this name and address after me: John Brown, 42 Market Street, Chicago-remember this

Clinical Driver Assessments: Vision Vision Visual Perception Visual Perception Physical Functioning Physical Functioning Cognitive skills Cognitive skills BRAKE REACTION TIME BRAKE REACTION TIME

Tests done by Driver Rehabilitation Specialist Optec Vision Tester Optec Vision Tester Motor Free Visual Perception Test Motor Free Visual Perception Test Block Design- Constructional Apraxia, Spatial Relations, Depth Perception Block Design- Constructional Apraxia, Spatial Relations, Depth Perception Symbol Digit Modalities Test Symbol Digit Modalities Test

Vision screening: Visual acuity Visual acuity Night vision/glare recovery Night vision/glare recovery Far and Near vision Far and Near vision Peripheral vision Peripheral vision Color perception Color perception Depth perception Depth perception Road sign recognition Road sign recognition Visual tracking Visual tracking

Visual Perception: Form constancy- the ability to recognize the same shape among a variety of shapes 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 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. 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 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 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 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 memory- the ability to recall dominant features on one stimulus item or to remember the sequences of several items

Visual Perception  Form constancy- the ability to recognize the same shape among a variety of shapes

Visual Perception  Figure ground- the ability to identify one object or design from a series of superimposed objects or designs

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

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

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

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

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

Physical Functioning Range of motion/strength/coordination/sensation Range of motion/strength/coordination/sensation Use of mobility devices Use of mobility devices Potential skills for transfers in and out of car Potential skills for transfers in and out of car Balance Balance Fine motor skills- use of keys, secondary switches Fine motor skills- use of keys, secondary switches Reaction time/right foot/left foot/need for hand controls or other modifications Reaction time/right foot/left foot/need for hand controls or other modifications

Reaction time testing machines

Cognitive skills Mental status Mental status Information processing Information processing Decision making Decision making Divided attention Divided attention Multiple task sequencing Multiple task sequencing Distractibility and the ability to focus Distractibility and the ability to focus Recognizes abilities/limitations Recognizes abilities/limitations

Cognitive continued Understands and appreciates levels of acceptable risks Understands and appreciates levels of acceptable risks Consistency in behavior Consistency in behavior Self regulation for accuracy Self regulation for accuracy Memory Memory Path finding Path finding Endurance and fatigue Endurance and fatigue Recognition of error/correction Recognition of error/correction Judgment and recognition of skills and limitations 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 A clinical evaluation prior to a BTW evaluation A clinical evaluation prior to a BTW evaluation BTW evaluations should include a number of driving maneuvers and a variety of settings BTW evaluations should include a number of driving maneuvers and a variety of settings Progress the driving evaluation/experience to meet the person’s physical and cognitive skills

Behind-the-wheel evaluation Clinical evaluation before a behind-the-wheel evaluation Clinical evaluation before a behind-the-wheel evaluation Orientation in the vehicle- mirrors, seat belt Orientation in the vehicle- mirrors, seat belt Established driving route in residential, commercial traffic Established driving route in residential, commercial traffic Perform numerous driving maneuvers such as lane changes and merging Perform numerous driving maneuvers such as lane changes and merging

Assessment of driving skills Beginner/previous driver skill knowledge Beginner/previous driver skill knowledge Steering of the vehicle- speed and consistency Steering of the vehicle- speed and consistency Gas/brake functions- reaction time Gas/brake functions- reaction time Secondary functions – use of turn signals, wipers, parking brake Secondary functions – use of turn signals, wipers, parking brake Visual scanning skills Visual scanning skills Motor planning-repetitive, fatigue Motor planning-repetitive, fatigue Sequencing- secured parking Sequencing- secured parking Problem solving- impulse control Problem solving- impulse control Driving behavior- aggressive, indecisive Driving behavior- aggressive, indecisive Following rules and regulations of the road Following rules and regulations of the road Route planning Route planning

Vehicle Modifications needed? Clinical evaluation and hands on assessment to trial and match the appropriate equipment with the client’s needs 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 Collaboration with vendor (equipment installer), therapist and client Vehicle fittings with client and vendor Vehicle fittings with client and vendor

Types of modifications Mirrors, wide angle and spot mirrors Mirrors, wide angle and spot mirrors Seating, positioning, seat belt Seating, positioning, seat belt Transfer/wheelchair loading Transfer/wheelchair loading Hand controls, steering devices Hand controls, steering devices Left foot accelerator Left foot accelerator Entry systems, lifts, ramps Entry systems, lifts, ramps Secondary Switches for electronics Secondary Switches for electronics Voice control of switches Voice control of switches Back up sensors, rain tracker for wipers 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 Push forward for braking, downward for acceleration. Push forward for braking, downward for acceleration.

Left foot accelerator Move left foot from pedal to the brake Needs to have a right side guard too 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 Side entry with power door, ramp and lowered flooring- Honda Odyssey conversion by Vantage Side entry with power door, ramp and lowered flooring- Honda Odyssey conversion by Vantage

Vehicle Selection Assessing the person’s needs and the vehicle 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 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? Can the individual use their own vehicle?

Fitting and Training New skill development with modifications New skill development with modifications Understanding of limitations Understanding of limitations Training in adaptive techniques Training in adaptive techniques Memory/orientation/behavioral management Memory/orientation/behavioral management Preparation for re-licensing Preparation for re-licensing

Interpretation of the evaluation Combined feedback Combined feedback of clinical and behind-the-wheel evaluation using clinical reasoning

Documentation Notifying physician- copy of report to client/patient family Notifying physician- copy of report to client/patient family Reporting to the Department of Motor Vehicles/Licensing Reporting to the Department of Motor Vehicles/Licensing

Summary Recommendations with a plan to not drive Recommendations with a plan to not drive Explore alternative to driving Explore alternative to driving Monitor for depression and social isolation Monitor for depression and social isolation Vehicle Modifications, fitting Vehicle Modifications, fitting Behind-the-wheel driver’s training Behind-the-wheel driver’s training Licensure/restrictions/re-examination Licensure/restrictions/re-examination Follow up re- assessment as needed- 6 months Follow up re- assessment as needed- 6 months

The Road Ahead

Resources: ADED- Association for Driver Rehabilitation Specialists (Model Practices for Driver Rehabilitation for Individuals with Disabilities) ADED- Association for Driver Rehabilitation Specialists (Model Practices for Driver Rehabilitation for Individuals with Disabilities) AOTA-American Occupational Therapy Association (Driving Evaluations by Occupational Therapists) www. aota.olderdriver 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 org RESNA-an interdisciplinary association of people with a common interest in technology and disability org AARP- (AARP Driver Safety Online Course) AARP- (AARP Driver Safety Online Course) AAA -(AAA Driver Improvement Classes) Com AAA -(AAA Driver Improvement Classes) Com