auto&mobility: driving with a visual impairment in the netherlands dr. bart melis-dankers phd...
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AutO&Mobility: driving with a visual impairment in the Netherlands
dr. Bart Melis-Dankers PhD
Royal Dutch VisioCentre of expertise for blind and partially sighted people
SMS-conferenceDecember 5, 2012København
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16.7 million inhabitants 316,000 visually impaired people [1.9%]
primary care: 700 optometrists and 2,500 opticians. secondary care: 707 ophthalmologists [1:23,600]. tertiary care: visual rehabilitation centres:
-- Royal Dutch Visio: 3,200 employees
-- Bartiméus: 2,200 employees
The Netherlands
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Optimization of independent mobility is important for
social participation. Driving is the main form of transport in NL.
7.7 million passenger cars. Driving itself is not the goal.
Independent mobility is! Safety first.
Rehabilitation programme AutO-Mobility:
Individual advice and training programme to optimize
independent mobility, if possible in motorised vehicles.
AutO-Mobility
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fitness to drive: NL in 1998
medical visual acuity: 0.5 in best eye [6/12, 20/40] visual field: ≥ 140°
practical the ability to drive safely and smoothly despite
one’s visual impairment. on road driving test by the Netherlands Bureau of
Driving Skills Certificates [CBR].
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VA = 0.2
visual acuity 0.5 : reading licence plate at 35m
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Step 1: Coeckelbergh & Kooijman
1998 – 2002
N = 67 participants. Visual acuity loss and/or visual field defect. All had insufficient medical fitness to drive. Practical fitness to drive test [CBR].
[Human Factors, 2004, 46(4): 748-760]
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central peripheral central and peripheral
VA Snellen
horizontal fielddiameter (degrees)
(n=24)
0.23
142
(n=36)
0.74
84
(n=7)
0.19
91
Visual Field Defect
passed
failed
practical fitness to drive:
6(25%)
15(42%)
2(14%)
21(58%)
5(86%)
18(75%)
N = 67 participants
Step 1: Coeckelbergh & Kooijman
1998 – 2002: data
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Step 1: Coeckelbergh & Kooijman
1998 – 2002: conclusion
N = 67 All had insufficient medical fitness to drive. 34% passed practical fitness to drive test [CBR]
The medical fitness to drive (visual acuity and visual
field) provides not sufficient information to decide about
the practical fitness to drive.
[Human Factors, 2004, 46(4): 748-760]
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Netherlands Bureau of Driving Skills Certificates [CBR] Ministery of Transport 2 driving schools University Medical Center Opthalmology Univeristy Medical Center Traffic Medicine Royal Dutch Visio: clinical physicist
optometrist
occupational therapist
neuro-psychologist
Step 2: build a consortium
2000 - 2004
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Impaired visual acuity:
Bioptic Telescope System [BTS]
Visual field defect: homonymous hemianopia
Scanning Compensatory Therapy [SCT]
Step 3: development of training
2004 - 2007
Road design Traffic signs / traffic lights Route signs
Other road users
VA = 0.16 = 20/125
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Bioptic telescope system [BTS]
monocular 2x - 3x magnification field of view: 15° weight: 12 gr.
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Correct BTS use
driving road signs crossings / traffic lights pedestrians / cyclists overtaking
safety first right moments short goal directed in time (not too early)
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Step 3a: pilot project BTS
2004 - 2007
inclusion: 0.16 <= BBCVA < 0.5 BTS-programme:
assessment day fitting BTS [optometrist] O&M-training 4 x 3 hours [O&M-trainer] driving lessons [driving
instructor] practical fitness to drive test [CBR]
9 subjects passed fitness to drive test with BTS
[Visual Impairment Research, 2008, 10: 1-6][Visual Impairment Research, 2008, 10: 7-22]
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The Effects of Compensatory The Effects of Compensatory Scanning Training on Driving for Scanning Training on Driving for Hemianopia PatientsHemianopia Patients
Gera de Haan MSc.University of Groningen, The NetherlandsClinical and Developmental Neuropsychology
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Current studyCurrent study
Aim:Examining the effect of compensatory scanning training on mobility for homonymous hemianopia.
Compensatory Scanning Training:1. Increase of awareness2. Systematic scanning strategy3. Transfer to mobility in daily life
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Systematic scanning Systematic scanning strategystrategyBased on training Pizzamiglio (1992) and Tant (2002) Scanning strategy:
◦ Fixate straight ahead◦ Large saccade towards blind hemifield◦ Saccade back to seeing hemifield◦ Fixate straight ahead◦ . . .
Right hemianopia:
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Participants in driving Participants in driving studystudy RCT of 60 hemianopic patients with mobility problems
Effect of Scanning Compensatory Training on mobility and Quality of Life
------------------------------------------------------------------------------- N = 27 adults reporting mobility problems because of a
homonymous hemianopia, the hemianopia existing for at least 6 months
N = 21 left-sided hemianopia, N = 6 right-sided hemianopia
N = 18 male, N = 9 female M(age) = [27-71] M(TimeSinceLesion) = 24 months [6.5-122]
No severe motor, neuropsychologic or hearing impairments
No ophthalmologic dysfunctioning and binocular visual acuity > 0.5
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Training group
T1 T2Control group T3Training
T1 T2Training
pre
post
-3mth
DesignDesign
Tests on T1, T2 and T3: Impaired Mobility Questionnaire (IMQ; Turano, 1999) Tracking Task Obstacle course (with dual task) Hazard perception (Vlakveld, 2011)
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Training group
T1 T2Control group T3Training
T1 T2Training
pre
post
-3mth
DesignDesign
Tests on T1, T2 and T3: Impaired Mobility Questionnaire (IMQ; Turano, 1999) Tracking Task Obstacle course (with dual task) Hazard perception (Vlakveld, 2011) Driving simulator Fitness to drive
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inclusion: homonymous hemianopia SCT-programme:
assessment day optimizing optics [optometrist] SCT-training 10 x 1.5 hours [O&M-trainer] driving lessons [driving
instructor] practical fitness to drive test [CBR]
Step 3b: scanning compensatory therapy
2007 - 2012
Result
Result
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Practical Fitness to drive: Practical Fitness to drive: TRIPTRIP
Test Ride for Investigating Practical fitness to drive
57 items: insufficient, doubtful, sufficientDriving test taken by ‘blind’ CBR-expertFactors:
◦ VIS: visual factor◦ OPER: operational factor◦ TACT: tactical factor
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Fitness to driveFitness to drive N = 27 Hemianopia patients (total N = 57) N = 21 left-sided, N = 6 right-sided hemianopia N = 18 male, N = 9 female M(Age) = 52 [27-71]
CBR (Dutch department of motor vehicles) 2 on-road driving assessments:
Before onset of training (N=27) 15 passed (56%)
12 failed (44%)
After training (N=10) 6 failed 4 passed
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Fitness to drive: TRIPFitness to drive: TRIPTRIP-factors improve after training
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ConclusionConclusion
Self-reported mobility in daily life improved (IMQ) Faster responses to stimuli in the blind periphery (Tracking
Task) Higher walking speed in obstacle course with cognitive dual
task Part of patients with hemianopiae is practical fit to drive,
even without training. Visual aspects of driving are most problematic. Negative judgement due to insufficient viewing strategy, but
also due to operational and tactical driving. Training improves visual and tactical aspects. No age-related effect found.
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Hemianopia does not necessarily impair fitness to drive
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report to the minister of Transport
decisions: May 2009 and February 2010
visual acuity impairment: VA >= 0.50 : unrestricted driving
license 0.40 <= VA < 0.50 : CBR-test without BTS 0.16 <= VA < 0.40 : CBR-test with BTS
visual field defect: HVF >= 120° : unrestricted driving
license 90° <= HVF < 120° : CBR-test
Step 4: lobby to change regulations
2007 - 2010
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South
NWNorth
SW
Step 5: extending consortium
2009 - 2010
°
°
4 regions: 12 locations education of:
9 information officers 31 optometrists 25 O&M trainers 6 clinical physicists 5 neuro-psychologists 23 driving instructors 8 CBR experts on practical fitness to drive 12 CBR driving examiners
September 2010: AutO-Mobility nationally available
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BTS: SCT: driving licenses issued: 70 19 not fit to drive: >250 >80
Remember:
AutO&Mobility is about mobility (and not driving per se).
------------------------------------------------------------
2012: BTS-program for nystagmus patients
Current situation
December 2012
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New programmes for: mobility scooter [16 km/h = 10 miles/h] microcars [45 km/h = 30 miles/h] patients with combined acuity and field impairment patients with visual and neurological impairment
Step 6: future developments
2012 - 2015
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ITMA 2012: May 19-22
International Traffic Medicine Association
Hamburg
www.trafficmedicine.org
-----------------------------------------------------------------
ESLRR 2012: September 13-15
European Society for Low Vision Research and Rehabilitation
Oxford
www.eslrr.eu
Interesting congresses
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Royal Dutch Visio
www.auto-mobiliteit.org
Please contact
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Practical fitness to drive: Practical fitness to drive: TRIPTRIPMain reason for negative judgement
VIS OPER TACT GLOB TOT Mean (SD)Drive1
(N=27) 2.60
(0.51)2.70
(0.48)2.67
(0.41)2.52
(0.64)2.66
(0.43)Failed
(N=12) 2.20
(0.53)2.40
(0.58)2.36
(0.44)1.92
(0.52)2.32
(0.45)Passes
(N=15) 2.92
(0.10)2.95
(0.10)2.92
(0.10)3.00
(0.00)2.93
(0.06)p-value .001 .007 .001 <.001 .001LHH (N=21) 2.50
(0.54)2.64
(0.52)2.61
(0.45)2.38
(0.67)2.58
(0.46)RHH (N=6) 2.94
(0.10)2.93
(0.13)2.88
(0.10)3.00
(0.00)2.93
(0.07)p-value .002 .032 .019 <.001 .003Men (N=18) 2.61
(0.41)2.73
(0.41)2.71
(0.35)2.56
(0.57)2.69
(0.31)Women
(N=9) 2.58
(0.70)2.64
(0.61)2.58
(0.52)2.44
(0.80)2.60
(0.62)p-value .896 .643 .451 .667 .609
ratings on the individual TRIP-items, split by factor (N=27)