driver rehabilitation services to support persons after a traumatic brain injury teresa valois,...
TRANSCRIPT
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
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.
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
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
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
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
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
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
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