Vol. 22 Issue 14
Getting Into the Driver's Seat
Occupational therapists play a crucial role in adapted driving and driver rehabilitation
Whether you started driving in your teenage years or later in life, driving in many ways represents the very essence of freedom. The benefits of this freedom promote community accessibilitygetting to and from a job, staying in touch with family and friends, and providing access to the necessities of life, such as grocery shopping or obtaining health care needs.
To lose or be unable to attain this freedomor as my father used to say, this "privilege"ranges from an inconvenience to isolation from people and activities. The American Occupational Therapy Association (AOTA) promotes driver rehabilitation and adapted driving as a domain of instrumental ADL pertinent to the skills of the occupational therapist. The duty of the occupational therapist is to assist drivers with disabilities in identifying deficits in order to restore function and compensate for limitations.2
Occupational therapists may participate on the driver rehabilitation team as generalists, driver rehabilitation specialists or CDRSes (certified driver rehabilitation specialists). Specialists using the CDRS credential may also have backgrounds in professions other than OT, such as physical therapy, driving education or other health care professions. Training may involve self study and seminars but one may not use the CDRS credential until completion of the certification process with the Association of Driver Rehabilitation Specialists (ADED). Currently AOTA is making preparations to offer their own credentialing process, but all forms of driver rehabilitation credentialing are voluntary at this time.2,4
Identifying the Risks
The need for driver rehabilitation over the next few decades is projected to increase dramatically: there are 60 million adults and children with disabilities in the United States, and the older population is expected to sharply increase as well. The American Automobile Association (AAA) reports that 25 percent of drivers are 55 and older, with an anticipated 22-30 percent increase in that demographic by the year 2020.
Numerous factors can place a driver at risk for unsafe driving, the consequences of which can end sadly in tragedy. Certain conditions may lead to unresolved deficits or poorly controlled symptoms, or may require medications or other aids to treat the patient. For example, persons afflicted with a seizure disorder must be careful to obtain proper medical management and monitoring for a time sufficient to assure that they are safe to drive. The period of time between being diagnosed with a seizure disorder and permitted resumption of driving varies from state to state.
Often the assumption is that the older driver is unsafe; however, drivers 65-74 years old are statistically the cause of fewer accidents than their younger counterparts. It is not until 75 years of age and older that the risk for causing a motor vehicle accident increases, especially in the presence of chronic illness.
It does, however, behoove the older driver to assess his own skills and act responsibly as progressive changes in his abilities may preclude him from driving safely. On its Web site, AAA provides drivers with the opportunity to take a 15-question inventory that poses questions about driving habits and gives a score in the privacy of their own homes. This tool provides information which may suggest that the driver take further action, such as a pre-driving assessment with an occupational therapist.4,7
Types of Evaluation
Driving can be evaluated formally in several different ways. Drivers often make their own arrangements for occupational therapy after referral by a physician for a pre-driving assessment, or to see a driver specialist for an on-road driving evaluation.
The pre-driving assessment is an in-clinic test which can be administered as part of an occupational therapy program. The assessment generally examines performance components that affect driving: overall vision and scanning, coordination, judgment, memory, range of motion, strength, sensation, participation in ADL, reaction time, and general awareness of the "rules of the road," including differentiating the colors of a traffic light.4
Patients may present to occupational therapy for a pre-driving assessment to identify deficits after diagnoses such as status post-CVA, amputation, paralysis, brain injury, post-operative conditions, rheumatoid arthritis, congenital birth defects, multiple sclerosis, muscular dystrophy, or in the presence of an overall decline in function due to age, or other factors.
Also, any treatments that limit the driver's ability to control his body should be taken into consideration. Prosthetics and orthotics Ð even slings and hand splints Ð alter the way a driver is able to manipulate the vehicle controls. Medications with side effects such as dizziness, drowsiness or visual changes may also raise a red flag.4,6 The decision must be made whether it is safe for the patient to drive and whether special training and compensatory techniques would allow for safe operation of the vehicle.
The pre-driving assessment, performed as part of an occupational therapy program, has the unique capacity to identify specific limitations so that a plan of care can be initiated to correct them and restore function.4
The on-road evaluation is performed in a vehicle and can be initiated once the patient has been screened over the phone or, preferably, after the patient has taken the OT pre-driving assessment. It is generally recommended that persons take the on-road evaluation even if they "fail" the pre-driving assessment, due to the fact that some people work better in real-life situations than in the theoretical context of the in-clinic portion of the evaluation process. Evaluators may initially conduct the on-road testing in an isolated parking lot, away from the challenges of traffic.
The on-road driving evaluation will test the driver's abilities in a specially equipped car and identify what skills may be enhanced by subsequent driver training sessions, or what types of adaptive equipment may be useful to the patient. The evaluator can identify motor or behavioral patterns that may contribute to unsafe driving and develop strategies to correct them.
For example, persons requiring a walker for ambulation often have the habit of looking toward the ground to avoid obstacles and assess the terrain they are walking on. This habit needs to be modified when driving to allow for more scanning in the upper visual quadrants to observe traffic and pedestrians.
Driving simulators assess driving abilities but are generally not used as the only means of evaluation, due to the limitations in the technology available at this time, as well as the common problem of "simulator sickness," which presents as motion sickness. Simulators can be used as a valuable tool to facilitate the assessment process, but further research is required.4
Treatment and Compensation
Whatever the cause of a driver's limitations, it is imperative to identify problem areas and develop a plan, which may involve visual re-training or exercises geared toward improving function. Sometimes the "cure" is relatively simple Ð a physician referral to an ophthalmologist for new prescription glasses or exercises to strengthen extrinsic hand muscles. Unfortunately, for some patients with physical deficits that cannot be corrected, and purchasing a new vehicle equipped with adaptive equipment can cost as much as $20,000 to $80,000. It is also important to remember that therapeutic intervention cannot compensate for or restore some limitations, such as decreased response time on the part of the patient.4
With physician approval, the occupational therapist may develop an exercise program to restore upper-body function or improve visual scanning and performance. Upper-body exercises may be needed for sufficient flexibility, endurance, coordination and strength required to enter and exit the vehicle; fasten the seatbelt; turn the key in the ignition and use necessary controls; turn the head to observe other cars, the course of the road and traffic signals; and maintain shoulder flexion/abduction, elbow flexion, pronation, supination and finger flexion to utilize the steering wheel. Physical therapy may receive a referral to address lower-body weakness and control, and limited endurance.
It is important, also, to assess the need for adaptive driving equipment, which may assist in compensating for limitations in function. If prescribed, the driver should receive training in the use of any adaptive devices. The equipment can be costly, but the state's department of vocational rehabilitation and department of veteran's affairs may aid in defraying the cost, in some cases. Some of the major vehicle manufacturers also offer a $1,000 incentive and will finance the adaptive equipment, along with the vehicle.1
Adaptive equipment may be added to aid in ingress/egress, posture, use of the controls and visibility:
Running boards, swivel seats or hydraulic lifts assist the driver in getting into and out of the vehicle.
Special seating systems and chest restraints help in maintaining proper posture.
Controls can be augmented by putting an extension on the parking brake, switching the side of the controls on the steering column, switching the gas/brake to the left side, adding hand controls in the absence of foot controls altogether, or adding a swivel ball or a hook on the steering wheel to allow for safe one-handed steering.
Visibility can be enhanced by adding extra wide mirrors or the use of bioptic telescope lenses to compensate for limited vision. Each state has laws governing the use of this type of powerful telescopic lens, which is attached to the user's glasses.3
Parking space should also be addressed to assure there is enough room to load/unload a wheelchair and accommodate the presence of a lift.1
The overall process of assessing one's ability to drive in the presence of illness or injury requires extensive documentation and places a large responsibility on the part of the occupational therapist and other members of the driver rehabilitation team.
Carol A. Chin, OTR, reports that as a generalist performing pre-driving assessments, "It is one of the most emotional things that I have to do Ð making the recommendation that the patient not drive until they complete the on-road driving evaluation." She feels it is especially difficult when the findings of the pre-driving assessment make failure of the on-road driving evaluation seem imminent. Chin states that, "It is important to realize the implications of driving on someone's life to support themselves and be independent."
The potential loss of that ability can be devastating, with social, economic and emotional ramifications. For some, the loss of their license feels like an overall loss of their identity, considering that driver's licenses are also used as a way to identify oneself, prove age or to provide verification when using credit cards.
If the decision has been made to cease driving, it is important to offer counsel regarding alternative forms of transportation to facilitate community mobility. For some, family is readily available to assist, while others must rely on public transportation, which is available to varying degrees throughout the country. Some states also allow restricted driving, rather than revoke the driver's license altogether, which may allow for daytime driving only.6
At times, family is put in the awkward position of intervening as concerns over safety develop. Persons afflicted with degenerative illnesses, such as the early stages of dementia, may present with limited insight, and when behind the wheel may place not only themselves but others in jeopardy. Family may choose to contact the patient's primary care physician; however, the potential for legal recourse on the part of the patient and the concern over violating physician/patient confidentiality often complicate the process of pursuing evaluation of driving abilities or revocation of a driver's license.
Massachusetts, for instance, is a self-reporting state it is the responsibility of the patient to contact the Registry of Motor Vehicles with concerns over their own driving. Physicians are encouraged to report any patient they feel is an "immediate threat," but there are no laws in Massachusetts to protect the physician from a lawsuit.6
What the Future Holds
Vehicles continue to evolve. Car manufacturers are utilizing design concepts such as universal design to create efficient use of space and controls. This effort is intended to facilitate ease of use and provide comfort for all persons. Features in concept cars include removing the center pillar between the front and rear doors, and seats that swivel out (with the car in park) to aid in ingress/egress.4
Driver rehabilitation will eventually be affected by the more futuristic application of cars that "drive themselves," working off a computerized guidance system that propels the car on the road and measures and stays a certain distance away from other cars and obstacles. Currently, prototypes are in development for this option on highways, but they still require that the driver rest their hands on the wheel to keep the system activated.
For the time being, however, it appears that drivers will continue to solely be the master of their destination, as there are still numerous factors for the car manufacturers to work out, such as legal considerations and the public's reception to having less perceived control over their own driving.5
Driving, referred to in an AOTA-sponsored seminar as "the ADL that kills," requires careful examination, considering all that is at stake. The involvement of the occupational therapist in the specialty of driver rehabilitation is crucial and consistent with our role as the guardians of independence in activities of daily living. This role has expanded to secure public safety on the roadways by helping drivers with limitations to drive safely. The concern of the driver rehabilitation team must extend to not only those drivers requiring their assistance, but also to those whom could be affected adversely by their driving.
References available at www.advance web.com/OT or upon request.
Amy Roux, OTR/L, CHT, has been an occupational therapist at University of Massachusetts-Leominster Hospital since 1993 and a certified hand therapist since 2001. She has worked with patients ranging in age from 3 months to 104.