Driver Rehabilitation Services to Support Persons after a Traumatic Brain Injury

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

2. What Happened?

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

4. Driving safely is even important for your doggie!

5. The Goal: To Drive!Knowledge Enhances Your Safety= KEYS

6. The presentation goals: Learn the details of a Driver Rehabilitation assessment Vehicle modifications will be demonstrated Brake reaction time testing will be demonstrated Department of Licensing guidelines will be provided Learn about legal issues of returning to driving and possible unsafe driving reporting

7. 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

8. 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

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

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

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

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

13. Medications? • Prescription • Non-prescription • Combination of drugs Discussion of each medication class, dosage, schedule and side affects

14. My goal is to drive in Seattle. How do we decide if I am safe?

15. What are the medical concerns? Partial loss of the visual field from traumatic brain injury Problems with heart rhythm Seizures Low or high bloodpressure Alcoholic intoxication Fatigue

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

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

18. Warning signs of unsafe drivers after Traumatic Brain Injury • Drives too fast or too slow for road conditions or posted speeds • Needs help or instructions from passengers • Doesn’t observe signs or signals • Makes slow or poor distance decisions • Gets easily frustrated or confused • Often gets lost, even in familiar areas • Has accidents or near misses • Drifts across lane markings into other lanes

19. 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

20. Answer is B b. applying the left indicator and applying the brake hard Which of the following is inappropriate when attempting a left lane change?

21. What are common driving errors? Incorrectly making a left-hand turn Driving too fast or tooslowly for the road conditions Making sudden turns Not usingthe turn indicator or forgetting to turn it off Getting lostor seeming disoriented

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

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

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

25. Trail Making B sample

26. Trail B sample

27. Short Blessed Test Sample • 1. What year is it now? • 2. What month is it now? • 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

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

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

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

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

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

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

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

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

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

37. Visual Perception • Visual closure- The ability to identify incomplete figures when only fragments are presented

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

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

40. Reaction time testing machines

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

42. Cognitive continued • Understands and appreciates levels of acceptable risks • Consistency in behavior • Self regulation for accuracy • Memory • Path finding • Endurance and fatigue • Recognition of error/correction • Judgment and recognition of skills and limitations

43. Planning a route Path finding without a GPS system?

44. Simulator and monitors with driving views

45. Hand Controls and Spinner Knob

47. Who does the Behind-the-Wheel Driving Assessment?

48. Behind-The-Wheel Evaluation • A clinical evaluation prior to a BTW evaluation • 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

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

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