Reflection on Driving and Community Mobility Lecture

This past week in OCP Older Adults, we had the chance to hear Cody Stovall, MOT, OTR/L, CDRS lecture on his experience and certification in driving and community mobility. There were several takeaway points from this lecture:
  • A driving program involves a thorough assessment of a person’s performance skills/client factors needed to drive a vehicle.
  • An adaptive driving program has 3 purposes: 
              1. Assess individuals for safety and potential to drive
              2. Evaluate persons with physical disabilities for appropriate AE 
              3. Train individuals in the use of AE and/or compensation techniques for driving
  • If a person has any additional/modified equipment that did not come with his/her original vehicle, that person must have a restriction placed on his or her license for that. This ensures safety in using that modification while driving.
  • Common diagnoses served through adaptive driving programs include stroke, TBI, SCI, amputations, AD, Muscular Dystrophy, CP, visual processing impairments, and intellectual disabilities. 
  • Functional deficits of a stroke with driving could include spasticity (could only be driving with one hand), left or right neglect, and cognitive deficits. 
  • Functional deficits in driving that could be involved with a TBI include: irregular tone and/or coordination, attention/maintaining focus, impulsivity, involuntary movements/reflexes, alternative sense of reality/hallucinations, and difficulty regulating emotions/frustrations.
  • Functional deficits in driving with a SCI could include paralysis (must be able to get in car, hold steering wheel, press pedals with feet), problems with pressure relief, and impaired sensation. 
  • Functional deficits in driving that could be involved with an amputation could include inability to press brake/gas pedal with corresponding leg, inability to trigger blinker/other controls with corresponding hand, and inability to pick up ankle to move it to pedals (if it is AKA).
  • Functional deficits in driving that could be involved with Alzheimer’s disease include decreased cognition/metacognition, orientation, insight, procedural memory, and a progressive decrease in physical/cognitive abilities as disease progresses. 
  • Functional deficits in driving involved with muscular dystrophy could include fluctuating muscle weakness/energy.
  • Functional deficits in driving involved with cerebral palsy could include tone (spasticity/flaccidity) and the startle reflex still being present. 
  • During an initial assessment of a driving program with an individual who presents with symptoms or a diagnosis of dementia, the OT should ask the date, month, year, location, what places the client commonly drives to/from, if the person commonly forgets where they are when they are driving, and what their highest level of education is.
  • In the state of TN, a person must be seizure-free for 6 months before he or she can drive again.
  • Approximately 3 months is a good window to wait out the effects of a stroke before beginning rehab to seek full potential/recovery to walk, drive, etc. 
  • Most individuals outlive their driving ability by 6-8 years. It’s hard for people to admit that they cannot drive and will lose independence. 
  • A driving program evaluation has 2 components: a clinical evaluation and a behind-the-wheel assessment.
  • The clinical evaluation includes a vision screening (which should come first), visual perception test (uses MVPT to look at visual closure, visual memory, figure-ground, visual discrimination, spatial relationships, etc.), a cognitive assessment, AROM (UE, LE, cervical), sensation testing of UE and LE (light touch, sharp/dull, proprioception, kinesthesia), rules of the road test, insight/awareness test, and grip testing via dynamometer. The Trail Making A and B tests are also both used during this evaluation. 
  • Trail Making A works with sustained and divided attention (connecting dots 1-25 and time that ability), and theTrail making B looks at how well can you divide your attention between letters and numbers. 
  • During the clinical evaluation, it is important for the client to SHOW you that you they can do something and not just tell you that they can.
  • The behind-the-wheel assessment of a driving program includes getting into the vehicle, familiarizing with the car, and then navigating the parking lot/light traffic/moderate traffic/heavy traffic/little to no traffic with stop signs/traffic light/school zones/4 way stops/unusual traffic lights and road patterns. 
  • During the behind-the-wheel assessment, the OT should be assessing if the client reacts to changing conditions or cars/people on the side of road? 
  • Driving is a multi-task, multi-stimulus ADL. Therefore, an individual must be able to shift their attention from one task to another and be able to come back to the correct point of sequence in the task.
  • During the behind-the-wheel assessment, the OT should also consider: does he/she acclimate to vehicle or assign blame? Does he/she judge time and distance safely? As intensity and stimulus increases, can they maintain safety? Can they stay in their lane? Do they scan the environment and use mirrors? 
  • A Certified Driving Rehab Specialist should must be trained under CDRS for 2 years, has to pass a national exam, and must maintain continuing education.
  • Telling a client they cannot drive can be tough news to deliver, but their safety and others’ safety is priority. 
  • Safety from the driver’s seat includes: distance from the airbag should be 10 inches or greater, line of sight should be 3 inches above steering wheel, the seat should be adjusted, then the seatbelt (should be over clavicle), then the mirrors.
  • Adaptive hand controls include push/rock, push/right angle, push/twist (smallest space needed), and push/pull.
  • Screening tools used in a driving program can include: SIMARD MD Screen for the Identification of the Cognitively Impaired Medically At-Risk Driver:A Modification of the DemTect, the MOCA, the Trailmaking Test A and B, and MMT/ROM. 
OT interventions to address driving/community mobility:
  • Individual/1:1 OT session: Client can complete graded clothespin activity in order to increase grip strength needed for maintaining hold on steering wheel and for turning steering wheel different directions during driving. 
  • Group OT session: Individuals involved in driving program could engage in OT group session(s) in which they talk through case scenarios involving problem-solving during driving and discuss possible solutions to those scenarios among one another. (Example: You are driving down the interstate and there is a person on the side of the road changing their tire. How should you respond as a driver?) 

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