Prediction of return to driving post cva an evidence based review
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Prediction of Return to Driving Post-CVA: An Evidence-Based Review. Presented by Melissa Arakelian. Introduction…. Currently CVA is the most frequently encountered diagnosis by occupational therapists in the adult setting Leading cause of disability in the U.S.

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Presentation Transcript

Introduction l.jpg
Introduction… Review

  • Currently CVA is the most frequently encountered diagnosis by occupational therapists in the adult setting

  • Leading cause of disability in the U.S.

  • Driving is relatively new problem faced by clinicians

  • Identified as one of top 10 emerging practice areas by The American Occupational Therapy Association (AOTA)


Impact of driving l.jpg
Impact of Driving… Review

  • Clients often identify driving as the most important IADL

  • Viewed, within our culture, as a symbol of independence and adulthood

  • Greater incidence of depression noted in non-drivers

  • Decreased participation in social activities


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Defining OT Roles… Review

Occupational Therapy Generalist: Possess general knowledge and understanding of performance and processing skills related to driving.

Occupational Therapist with Advanced Training: Further educated to evaluate the integration of sub-skills associated with driving, and provide specific sub-skill training.

Occupational Therapist with Specialized Training:Received specialized education, examination, and/or certification.


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Occupational Therapy Generalist… Review

  • Expected to have greatest knowledge of expertise among team members

  • Responsible for clinical evaluation of sub-skills necessary for driving

  • Knowledgeable of driving programs and resources available


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Physical Abilities Review

Perceptual skills

Cognitive abilities

Vision

Attention

Emotion

Reaction Time

Mobility

Hearing

Visual Attention

Planning/Problem Solving

Physical and Mental Endurance

Information Processing Speed

Visual Memory

Visuocognitive abilities

Visual Attention

Visuomotor coordination

In order to Drive…


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Trail Making Test (Part A) Review

Visual Form Recognition Test

Single and Double-Letter Cancellation

Cognitive Behavioral Driver’s Inventory (CBDI)

Dynavision Assessment Battery (DPAB)

Bells Test

Motor-Free Visual Perception Test

TMT-A and TMT-B

UFOV (useful field of vision)

Complex Reaction Timer

Money Road Map of Direction Test

Charron Test

Assessments Currently Employed…


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Where to Focus… Review

Currently there are no universally accepted clinical guidelines defining what constitutes a complete assessment battery for determining the ability to return to driving

General clinical evaluation should consist of

  • Vision

  • Perceptual skills

  • Cognitive skills


Vision l.jpg
Vision… Review

  • An estimated 90% of informational input received during driving is visual

  • Necessary to evaluate basic visual skills first…


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Adaptation Review

Through Vision

Visuocognition

Visual Memory

Pattern Recognition

S c a n n i n g

Attention: Alertness and Attending

Oculomotor Control Visual Fields Visual Acuity

*Adapted from original work by Margaret Horger, OTR

Vision…


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Vision… Review

In a study by Fisk, G. D., Owsely, C., & Mennemeier, M. (2002), impairment of visual attention measured by the UFOV indicated greater impairment among post-stroke non-drivers versus post-stroke drivers

Useful Field of Vision (UFOV) : Test of visual attention, measuring information processing, ability to divide attention, and the speed of processing


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Perceptual Skills… Review

Mazer, B., Korner-Bitensky, N. A. & Sofer, S. (1998) assessed the ability of the following perceptual tests to predict on-road driving outcomes:

  • The Complex-Reaction Timer

  • Motor-Free Visual Perception Test (MVPT)

  • Single & Double Letter Cancellation Tests

  • Money Road Map Test of Direction Sense

  • Trail Making Test A and B

  • Bells Test

  • Charron Test


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Perceptual Skills… Review

Findings by Mazer, B., Korner-Bitensky, N. A. & Sofer, S. (1998):

  • MVPT found to have the highest positive and negative predictive ability

  • Logistic model found best at predicting on-road driving outcomes included use of the MVPT and Trail Making B tests

  • Reaction time noted as near significance in prediction


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Cognitive Skills… Review

  • Research indicates neuropsychological testing of executive functions should be included in pre-driving assessment

  • Klavora, P., Heslegrave, R. J., & Young, M. (2000) compared the effectiveness of Cognitive Behavioral Driver’s Inventory (CBDI) and the Dynavision Performance Assessment Battery (DPAB)

  • Only the Endurance Dynavision Task (EDT) and the CBDI were found significant in predicting on-road outcomes


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Additional Off-Road Tests… Review

  • Implementation of simulators in clinical evaluation

  • Able to provide face-valid context for observing driving behaviors

  • Study by Lee, H. C., Lee, A. H., & Cameron, D. (2003) validated the use of the STISIM Driving Simulator for assessing visual attention


Impact of off road tests l.jpg
Impact of Off-Road Tests… Review

  • Cost Effective

  • Less intimidating to client

  • Safer form of evaluation

  • Allow for task break down, assessing performance of driving sub-skills


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In Summary… Review

  • Driving is an IADL, and within the scope of practice for occupational therapists

  • General clinical evaluations of driving should include standardized assessment of visual, perceptual, and cognitive skills

  • Impossible to determine ability to return to driving using one assessment tool

  • Clinical evaluation should be followed by on-road testing prior to judgment of driving ability


References l.jpg
References… Review

Fisk, G. D., Owsley, C., & Mennemeier, M. (2002). Vision, attention, and self-reported driving behaviors in community-dwelling stroke survivors. Archives of Physical Medicine and Rehabilitation, 83, 469-477.

Hopewell, A. C. (2002). Driving assessment issues for practicing clinicians. Journal of Head Trauma and Rehabilitation, 17, 48-61.

Klavora, P., Heslegrave, R. J., & Young, M. (2000). Driving skills in elderly persons with stroke: Comparison of two new assessment options. Archives of Physical Medicine and Rehabilitation, 81, 701-705.

Korner-Bitensky, N. A., Sofer, S., Gelinas, I., & Mazer, B. (1998). Evaluating driving potential in persons with stroke: A survey of occupational therapy practices. American Journal of Occupational Therapy, 52, 916-919.

Lee, H. C., Lee, A. H., & Cameron, D. (2003). Validation of a driving simulator by measuring the visual attention skill of older adult drivers. American Journal of Occupational Therapy, 57, 324-328.

Mazer, B., Korner-Bitensky, N. A., & Sofer, S. (1998). Predicting ability to drive after stroke. Archives of Physical Medicine and Rehabilitation, 79, 743-749.