Occupational Therapy In Health Care, 28(2):148–153, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.899415
ARTICLE
Driving for Adults with Acquired Physical Disabilities Donna Stressel1 , Anne Hegberg2 , & Anne E. Dickerson3 1
Sunnyview Rehabilitation Hospital, Schenectady, NY, USA, 2 Marianjoy Rehabilitation Hospital, Wheaton, IL, USA, 3 Occupational Therapy, East Carolina University, Greenville, SC, USA
ABSTRACT. The purpose of this paper is to document and give context to consensus statements for drivers with physical disabilities, and specifically chronic obstructive pulmonary disease, by expert clinicians in driver rehabilitation and researchers in the area of driver assessment. A brief introduction to the profession of driver rehabilitation sets the context for how individuals with physically based impairments have facilitated the development of the specialty area. KEYWORDS. Consensus statements, evidence, physical disabilities
BACKGROUND The driver rehabilitation field developed soon after the proliferation of the automobile on America’s roads and highways with the pioneers in the field using creative problem solving approaches (Pellerito, 2006). As early as 1920s, adaptations to vehicles were created to allow individuals to continue to drive despite physical impairments (e.g., Judge Quentin Corley in 1918) (Hyde, 2006). Occupational therapists, driver educators, and after-market vendors worked together to provide driver rehabilitation services paving the way for the development of the Association for Driver Rehabilitation Specialists (ADED), formerly known as the Association of Driver Educators for the Disabled (Pellerito, 2006). Historically, ADED’s growth was based on the medical model and the vocational rehabilitation model. Under these models, the focus was evaluation and rehabilitation to achieve successful driving by incorporating vehicle modification and adaptive equipment for individuals with physically disabilities. It has only been in recent years that the programs have been expanding with the need to determine older adults’ fitness to drive due solely to cognitive deficits. This is due to the emergence of the aging baby boomers and the increasing numbers of older adults living longer with accompanying rise in individuals with cognitive impairment. In fact, the first National Highway Address correspondence to: Anne Dickerson, PhD, OTR, FAOTA, Occupational Therapy, East Carolina University, Greenville, SC 27858, USA (E-mail: [email protected]). (Received 11 February 2014; accepted 25 February 2014)
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Traffic Safety Administration (NHSTA) collaborative agreement with the American Occupational Therapy Association (AOTA) was initiated in 2003 with the recognition that expansion of driver rehabilitation services programs, policies, and strategies was required to meet the need. A driver rehabilitation specialist (DRS) typically performs a comprehensive driving evaluation to determine an individual’s driving knowledge, skills, and abilities that includes: 1) medical and driving history, 2) clinical assessment of physical, cognitive, vision, and/or perception abilities, 2) on road assessment, as appropriate, 3) an outcome summary, and 4) goals and recommendations for inclusive mobility plan including transportation options. Specifically for older adults with medical conditions, the individualized plans may include recommendations for rehabilitation of skills (e.g., increase scanning skills through designed intervention), compensation through training (e.g., learn to drive a roundabout, learn to use hand controls), compensation through adaptation of the vehicle (e.g., changing to a wide angle mirror), cessation of driving, or a combination of these. A wide range of options and innovations make it possible to compensate for physical disabilities through technology. For example, bioptic telescope systems for individuals with low vision, hand controls for individuals with lower limb amputations or joystick steering for the individual with high-level spinal cord injury are technological advances for many individuals with significant physical impairments. However, although rehabilitation or compensation through training or adaptation is the ideal goal, the individual must have the capacities for new learning and skill development. Technology advances are not yet able to compensate for executive functioning skills, a key determinate of driver strategies, tactics, and safety (Rizzo & Kellison, 2010). Additionally, individuals with decreased insight (Anstey et al., 2005) or poor cognitive abilities (Carr et al., 2006) in addition to their physical impairment no longer have the ability to voluntary limit or adapt their behaviors to deemed fit to drive. There are many decisions to be made as clients and their families make plans for returning home after recovery from a major physical impairment. With driving being one of the most valued IADL for rehabilitation clients (Dickerson et al., 2013), it is critical to understand that advanced technologies and vehicle adaptations are highly individualized. Thus, it is very important to offer education and referral early in the process of rehabilitation. Factors such as the type and size of the wheelchair impact the choice of vehicle that might need to be purchased for transport of the client and/or driving potential (Hegberg, 2012). For example, a family may purchase a large SVU assuming that it would made it easy to store a wheelchair, when, in fact, another type of vehicle (e.g., a minivan) would be much cheaper and easier to convert for a wheelchair driver. It is essential for the occupational therapist in general practice to recognize the possible need for adaptive equipment and ensure that the client is referred to the right professional (e.g., occupational therapist who is a DRS) who has experience and skill to evaluate the physical strengths and limitations, can evaluate the client within the context of an adaptive vehicle, and offer choices of various equipment to try before the client makes a decision about purchasing a modified vehicle or a vehicle to be modified. Clinicians and physicians seek criteria on which to base their decisions, and many struggle to determine when referral to a driving rehabilitation program is justified.
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This may include what level of impairment and what clinical factors warrant questioning of driving privileges and referral to an advanced level of practice that requires additional time and expense. The following consensus statements were developed by experts to offer criteria and guidance for clinicians to consider when developing an individualized plan of care for individuals with physical disabilities to include driving and community mobility.
• An individual with a nonfunctional lower limb, lower extremity prosthesis, or an orthotic on a lower limb used for the operation of a motor vehicle should be referred for a driving evaluation. • An individual with a nonfunctional upper limb or upper extremity prosthesis should be referred for a driving evaluation. • An individual with a spinal cord injury at any level should be referred early in the rehabilitation process for consultation with a DRS. Although the time frame may vary with each individual, it is important to discuss how a particular client’s mobility device (i.e., wheelchair) and functional skill set will interface with transportation options before purchasing or modifying a vehicle. • A client with a progressive condition that affects primarily sensation and/or motor function with the potential to impact driving (i.e., multiple sclerosis, postpolio syndrome) should be referred to a DRS to determine a baseline need for adaptive equipment for their motor vehicle. The DRS can assist with planning for future needs and reevaluation based on the progression of the condition. • A client with a nonprogressive condition that affects primarily sensation and/or motor function (i.e., cerebral palsy, spina bifida) should be referred to a DRS to determine adaptive equipment needed as well as their potential to drive in the future. Since wheelchair, vehicle, and funding decisions made early in the process impact the potential for driving independence, involving the specialist early in the process will ensure comprehensive planning for community mobility for the client and family. • Community mobility should be addressed with every occupational therapy client as part of the initial evaluation and most importantly as part of the discharge planning. Unlike some of the other consensus statements (e.g., on dementia, screening, and assessment), none of the above statements have research evidence to support the statement. However, clinical decisions are made every day and these recommendations were developed as guidance based on expert clinical judgment by a team of expert clinicians and researchers. Certainly, a call to build the evidence to support these statements and criteria for intervention is needed and should be forthcoming. CLIENT GROUP CONSENSUS STATEMENTS In addition to the general consensus statements about clients with specific physical disabilities, common diagnostic groups were selected for a literature review because research evidence is available (e.g., dementia and Parkinson’s Disease) and development of specific statements were developed (see Classen and Wheatley, Carr, & Marottoli, this issue). In addition, due to fact that there is limited research on
Physical Disabilities
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the specific diagnosis of chronic obstructive pulmonary disease (COPD), was also reviewed and discussed with resulting consensus statements. Chronic Obstructive Pulmonary Disease COPD refers to diseases involving obstructed airflow such as peripheral airway disease, emphysema, and chronic bronchitis. In 2008, the Centers for Disease Control and Prevention reported that COPD is the primary contributor to mortality caused by chronic lower respiratory diseases, the third leading cause of death in the United States (CDC, 2012). Symptoms include chronic cough, sputum production, and dyspnea that increase with exertion, exposure to extreme temperature, and with severe airway obstruction, some individuals may experience cough syncope. There are few studies examining the relationship between COPD and motor vehicle crashes, two studies suggest individuals with COPD are at higher risk of cognitive impairment resulting from chronic hypoxemia, placing the individual at-risk for motor vehicle crashes (Dobbs, 2005). One study found that patients with COPD demonstrated significantly worse results in terms of accident frequency in a simulated driving situation; however, no correlations existed between the severity of the disease and driving performance (Orth et al., 2008). Another study concluded that oxygen therapy does not improve the simulated driving performance or neurocognitive function in patients with hypoxemic COPD (Pretto & McDonald, 2008). Although declines in cognitive functions affecting attention, reaction time, memory, abstract reasoning skills, and complex visual motor processes would be the primary concern for driving competency, due the diverse nature of COPD, decisions regarding fitness-to-drive should be made on an individual basis after evaluation of cognitive function and on-road performance. Guidelines for physicians’ counseling patient’s driving with COPD and reporting to State Department of Motor Vehicles are limited. The American Medical Association (Carr et al., 2010) recommends no restrictions if symptoms are well controlled, and the patient does not experience significant side effects from the condition or the medications. Driving is not advised if the patient suffers from: 1) dyspnea at rest or while behind the wheel, 2) excessive fatigue, or 3) significant cognitive impairment. If the patient requires supplemental oxygen to maintain hemoglobin saturation of 90% or greater they should be counseled to use the oxygen at all times while driving, and to avoid driving when they have other respiratory symptoms (e.g., infection, exacerbation of symptoms, and increased sputum production). If the physician is concerned that the patient’s symptoms compromise driving safety, referral to a DRS is recommended with periodic reevaluation due to the progressive nature of the disease (Carr et al., 2010). The state of Maine utilizes a Functional Ability Profile identifying impairment levels, which often precludes driving. These circumstances include concerns with moderate to severe dyspnea on exertion, dyspnea at rest, and O2 saturation
ARTICLE
Driving for Adults with Acquired Physical Disabilities Donna Stressel1 , Anne Hegberg2 , & Anne E. Dickerson3 1
Sunnyview Rehabilitation Hospital, Schenectady, NY, USA, 2 Marianjoy Rehabilitation Hospital, Wheaton, IL, USA, 3 Occupational Therapy, East Carolina University, Greenville, SC, USA
ABSTRACT. The purpose of this paper is to document and give context to consensus statements for drivers with physical disabilities, and specifically chronic obstructive pulmonary disease, by expert clinicians in driver rehabilitation and researchers in the area of driver assessment. A brief introduction to the profession of driver rehabilitation sets the context for how individuals with physically based impairments have facilitated the development of the specialty area. KEYWORDS. Consensus statements, evidence, physical disabilities
BACKGROUND The driver rehabilitation field developed soon after the proliferation of the automobile on America’s roads and highways with the pioneers in the field using creative problem solving approaches (Pellerito, 2006). As early as 1920s, adaptations to vehicles were created to allow individuals to continue to drive despite physical impairments (e.g., Judge Quentin Corley in 1918) (Hyde, 2006). Occupational therapists, driver educators, and after-market vendors worked together to provide driver rehabilitation services paving the way for the development of the Association for Driver Rehabilitation Specialists (ADED), formerly known as the Association of Driver Educators for the Disabled (Pellerito, 2006). Historically, ADED’s growth was based on the medical model and the vocational rehabilitation model. Under these models, the focus was evaluation and rehabilitation to achieve successful driving by incorporating vehicle modification and adaptive equipment for individuals with physically disabilities. It has only been in recent years that the programs have been expanding with the need to determine older adults’ fitness to drive due solely to cognitive deficits. This is due to the emergence of the aging baby boomers and the increasing numbers of older adults living longer with accompanying rise in individuals with cognitive impairment. In fact, the first National Highway Address correspondence to: Anne Dickerson, PhD, OTR, FAOTA, Occupational Therapy, East Carolina University, Greenville, SC 27858, USA (E-mail: [email protected]). (Received 11 February 2014; accepted 25 February 2014)
148
Physical Disabilities
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Traffic Safety Administration (NHSTA) collaborative agreement with the American Occupational Therapy Association (AOTA) was initiated in 2003 with the recognition that expansion of driver rehabilitation services programs, policies, and strategies was required to meet the need. A driver rehabilitation specialist (DRS) typically performs a comprehensive driving evaluation to determine an individual’s driving knowledge, skills, and abilities that includes: 1) medical and driving history, 2) clinical assessment of physical, cognitive, vision, and/or perception abilities, 2) on road assessment, as appropriate, 3) an outcome summary, and 4) goals and recommendations for inclusive mobility plan including transportation options. Specifically for older adults with medical conditions, the individualized plans may include recommendations for rehabilitation of skills (e.g., increase scanning skills through designed intervention), compensation through training (e.g., learn to drive a roundabout, learn to use hand controls), compensation through adaptation of the vehicle (e.g., changing to a wide angle mirror), cessation of driving, or a combination of these. A wide range of options and innovations make it possible to compensate for physical disabilities through technology. For example, bioptic telescope systems for individuals with low vision, hand controls for individuals with lower limb amputations or joystick steering for the individual with high-level spinal cord injury are technological advances for many individuals with significant physical impairments. However, although rehabilitation or compensation through training or adaptation is the ideal goal, the individual must have the capacities for new learning and skill development. Technology advances are not yet able to compensate for executive functioning skills, a key determinate of driver strategies, tactics, and safety (Rizzo & Kellison, 2010). Additionally, individuals with decreased insight (Anstey et al., 2005) or poor cognitive abilities (Carr et al., 2006) in addition to their physical impairment no longer have the ability to voluntary limit or adapt their behaviors to deemed fit to drive. There are many decisions to be made as clients and their families make plans for returning home after recovery from a major physical impairment. With driving being one of the most valued IADL for rehabilitation clients (Dickerson et al., 2013), it is critical to understand that advanced technologies and vehicle adaptations are highly individualized. Thus, it is very important to offer education and referral early in the process of rehabilitation. Factors such as the type and size of the wheelchair impact the choice of vehicle that might need to be purchased for transport of the client and/or driving potential (Hegberg, 2012). For example, a family may purchase a large SVU assuming that it would made it easy to store a wheelchair, when, in fact, another type of vehicle (e.g., a minivan) would be much cheaper and easier to convert for a wheelchair driver. It is essential for the occupational therapist in general practice to recognize the possible need for adaptive equipment and ensure that the client is referred to the right professional (e.g., occupational therapist who is a DRS) who has experience and skill to evaluate the physical strengths and limitations, can evaluate the client within the context of an adaptive vehicle, and offer choices of various equipment to try before the client makes a decision about purchasing a modified vehicle or a vehicle to be modified. Clinicians and physicians seek criteria on which to base their decisions, and many struggle to determine when referral to a driving rehabilitation program is justified.
150
Stressel et al.
This may include what level of impairment and what clinical factors warrant questioning of driving privileges and referral to an advanced level of practice that requires additional time and expense. The following consensus statements were developed by experts to offer criteria and guidance for clinicians to consider when developing an individualized plan of care for individuals with physical disabilities to include driving and community mobility.
• An individual with a nonfunctional lower limb, lower extremity prosthesis, or an orthotic on a lower limb used for the operation of a motor vehicle should be referred for a driving evaluation. • An individual with a nonfunctional upper limb or upper extremity prosthesis should be referred for a driving evaluation. • An individual with a spinal cord injury at any level should be referred early in the rehabilitation process for consultation with a DRS. Although the time frame may vary with each individual, it is important to discuss how a particular client’s mobility device (i.e., wheelchair) and functional skill set will interface with transportation options before purchasing or modifying a vehicle. • A client with a progressive condition that affects primarily sensation and/or motor function with the potential to impact driving (i.e., multiple sclerosis, postpolio syndrome) should be referred to a DRS to determine a baseline need for adaptive equipment for their motor vehicle. The DRS can assist with planning for future needs and reevaluation based on the progression of the condition. • A client with a nonprogressive condition that affects primarily sensation and/or motor function (i.e., cerebral palsy, spina bifida) should be referred to a DRS to determine adaptive equipment needed as well as their potential to drive in the future. Since wheelchair, vehicle, and funding decisions made early in the process impact the potential for driving independence, involving the specialist early in the process will ensure comprehensive planning for community mobility for the client and family. • Community mobility should be addressed with every occupational therapy client as part of the initial evaluation and most importantly as part of the discharge planning. Unlike some of the other consensus statements (e.g., on dementia, screening, and assessment), none of the above statements have research evidence to support the statement. However, clinical decisions are made every day and these recommendations were developed as guidance based on expert clinical judgment by a team of expert clinicians and researchers. Certainly, a call to build the evidence to support these statements and criteria for intervention is needed and should be forthcoming. CLIENT GROUP CONSENSUS STATEMENTS In addition to the general consensus statements about clients with specific physical disabilities, common diagnostic groups were selected for a literature review because research evidence is available (e.g., dementia and Parkinson’s Disease) and development of specific statements were developed (see Classen and Wheatley, Carr, & Marottoli, this issue). In addition, due to fact that there is limited research on
Physical Disabilities
151
the specific diagnosis of chronic obstructive pulmonary disease (COPD), was also reviewed and discussed with resulting consensus statements. Chronic Obstructive Pulmonary Disease COPD refers to diseases involving obstructed airflow such as peripheral airway disease, emphysema, and chronic bronchitis. In 2008, the Centers for Disease Control and Prevention reported that COPD is the primary contributor to mortality caused by chronic lower respiratory diseases, the third leading cause of death in the United States (CDC, 2012). Symptoms include chronic cough, sputum production, and dyspnea that increase with exertion, exposure to extreme temperature, and with severe airway obstruction, some individuals may experience cough syncope. There are few studies examining the relationship between COPD and motor vehicle crashes, two studies suggest individuals with COPD are at higher risk of cognitive impairment resulting from chronic hypoxemia, placing the individual at-risk for motor vehicle crashes (Dobbs, 2005). One study found that patients with COPD demonstrated significantly worse results in terms of accident frequency in a simulated driving situation; however, no correlations existed between the severity of the disease and driving performance (Orth et al., 2008). Another study concluded that oxygen therapy does not improve the simulated driving performance or neurocognitive function in patients with hypoxemic COPD (Pretto & McDonald, 2008). Although declines in cognitive functions affecting attention, reaction time, memory, abstract reasoning skills, and complex visual motor processes would be the primary concern for driving competency, due the diverse nature of COPD, decisions regarding fitness-to-drive should be made on an individual basis after evaluation of cognitive function and on-road performance. Guidelines for physicians’ counseling patient’s driving with COPD and reporting to State Department of Motor Vehicles are limited. The American Medical Association (Carr et al., 2010) recommends no restrictions if symptoms are well controlled, and the patient does not experience significant side effects from the condition or the medications. Driving is not advised if the patient suffers from: 1) dyspnea at rest or while behind the wheel, 2) excessive fatigue, or 3) significant cognitive impairment. If the patient requires supplemental oxygen to maintain hemoglobin saturation of 90% or greater they should be counseled to use the oxygen at all times while driving, and to avoid driving when they have other respiratory symptoms (e.g., infection, exacerbation of symptoms, and increased sputum production). If the physician is concerned that the patient’s symptoms compromise driving safety, referral to a DRS is recommended with periodic reevaluation due to the progressive nature of the disease (Carr et al., 2010). The state of Maine utilizes a Functional Ability Profile identifying impairment levels, which often precludes driving. These circumstances include concerns with moderate to severe dyspnea on exertion, dyspnea at rest, and O2 saturation
