Brain Injury Brain Injury: Definition: Brain injury refers to - - PDF document

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Driver Rehabilitation Following Brain Injury: A Collaborative Effort

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Presented by:Lee Hirsch, OTR/L, DRS, LDI Mobility Quest

Brain Injury

• Definition: Brain injury refers to damage or destruction of

brain tissue due to trauma or a wide range of medical conditions, e.g. anoxia, stroke, encephalitis, brain tumors, poisoning, brain toxins, or aneurysms.

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• Incidence is estimated between 5-7 % of the U.S. Population

have been treated for traumatic brain injury.

• Prevalence the Centers for Disease Control estimates that 5.2

million Americans are living with some degree of disability caused by TBI.

Brain Injury

• What is the Impact of a Brain Injury on the

Person’s Life? A wide range of cognitive, physical, perceptual, emotional and behavioral impairments may follow brain injury Physical i e motor and basic

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brain injury. Physical, i.e. motor, and basic sensory functions can be affected, as well as the functioning of multiple (e.g. hormonal, endocrine) body systems. Cognitively, individuals with brain injury may have subtle to significant impairments in their perception, language, attention, concentration, information processing, learning and/or memory.

Brain Injury

• Executive function include: insight into

strengths and limitations, goal setting, planning and organizing, initiating tasks, self control or self inhibiting behavior

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self-control or self-inhibiting behavior, monitoring and evaluating performance, problem-solving, transferring newly acquired skills to alternate settings or situations.

Brain Injury

• Perception and visual disturbances are common
• ccurrences with brain injury and may include

impairment in one or more of the following areas: spatial orientation, figure ground, depth

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perception, form constancy, contrast sensitivity,

• cular pursuits, fixation, accommodation, and/or

convergence/divergence. Resulting in diploplia, impaired vision and motor processing, midline

• rientation and/or unstable ambient vision.

Driving - Who is Responsible?

Mandated Physician Reporting California Department of Motor Vehicles:

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CA Health and Safety Code Reporting Disorders Characterized by Lapses of consciousness 103900 (f) A physician and surgeon who report a patient diagnosed as a case of a disorder characterized by lapses of consciousness pursuant to this section shall not be civilly or criminally liable to any patient for making any report required or authorized by this section.

http://www.dmv.ca.gov/pubs/vctop/vc/vc.htm

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STATE OF CALIFORNIA DEPARTMENT OF MOTOR VEHICLES MEDICAL CONDITIONS AND OTHER FACTORS IN DRIVER RISK REPORT TO THE LEGISLATURE OF THE STATE OF CALIFORNIA IN ACCORD WITH SENATE BILL 335 CHAPTER 985, 2000 LEGISLATIVE SESSION - MAY 2001 “Also discussed were various relatively common disorders, mandatorily not reportable, which have the potential to affect driving safety. The information presented on specific disorders comes from previously published departmental reviews of the scientific literature in this area, and from a review of recently published studies identified through a search in Medline, a medical information referencing system on the Internet. These Orders Include:

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• Poorly controlled DM with

diabetic hypoglycemia

• MI
• Uncontrolled Epilepsy
• CVA
• Brain Tumor
• Syncope
• Alcohol/Drug dependency
• Narcolepsy
• Vision disorders impairing

contrast sensitivity

• Hemianopsia
• Trauma
• Concussion
• Dizziness/Vertigo
• Cardiac Arrhythmias
• Sleep Apnea

Grounds Permitting Refusal of License California Vehicle Code 1806

• The department may refuse to issue to, or renew a

driver’s license of, any person: (c) . . . . Who has any physical or mental disability, disease, or disorder which could affect the safe

• peration of a motor vehicle unless the department

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• peration of a motor vehicle unless the department

has medical information which indicates the person may safely operate a motor vehicle. In making it’s determination, the department may rely

• n any relevant information available to the

department.

http://www.dmv.ca.gov/pubs/vctop/d06/vc12806.htm

Vision Requirement for Class “C” Driver’s License

Visual Acuity Screening– Minimum of 20/40 or better with both eyes together, and no worse than 20/70 in the poorer eye. If Screening failed DMV refers to vision specialist with a form to complete the Report of Vision Examination form number DL62

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complete the Report of Vision Examination form number DL62. Drivers with visual acuity of 20/200 or worse may not be licensed to

• drive. Drivers may use Bioptics for driving, but may not use them to

meet the vision Standard. Following review of the Report of Vision Examination the client may be schedule for a drive test or a special drive test to determine whether the vision condition impairs the ability to drive.

Vision Requirement for Class “C” Driver’s License

The CA DMV, under the Physical and Mental Disabilities Guidelines: Section 5, has a “Guidelines Document” which provides matrices for visual conditions, definitions, range of severity, whether a drive test/special drive test should be administered, and types of restrictions (e.g. corrective lens, sunrise to sunset driving only, no freeway driving, area restrictions, additional mirrors (right side, wide angle, panoramic, right or left fender mounted mirrors). An immediate revocation may be imposed if an individual performs dangerously and the condition renders the person unsafe to drive.

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The Vision Conditions and Actions Chart lists seven vision functions that may impair driving: Central Vision Peripheral Vision (no degree of loss field is identified) Night Vision (includes glare recovery and glare resistance) Judgment of Distance Eye Movement Visual Perception

The AMA’s Opinion

• It is the physician’s duty to report if: State

mandates reporting, or there are clear signs of impairment, or the patient is unlikely to stop

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• To Report: The physician should advise the patient
• f their intent, they should send ONLY key

information, The Clinician (physician) can recommend further evaluation or license revocation, Driver licensing is revoked by the state NOT the physician.

Taken from physician presentation by G. Odenheimer, MD, K. Johnson, D.O., C. Robinson, OT, J. Walls (DPS)

Integrated Heath Care Team

• Consists of: Physicians and Optometrists, Physician

Extenders: Physician Assistants Occupational Therapists

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Extenders: Physician Assistants, Occupational Therapists, Physical Therapists, Speech Pathologists, Nurse Practitioners…

• These professionals have comprehensive knowledge and skills

that help increase access to care and reduce costs. Their teamwork is appropriate and protects the public.

Per Alexander Lopez, JD, OTR, September 2007

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What is Your role when asked, “Can I Drive?”

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Know how you can address driving within your Scope of Practice

“Red Flags”

• Driving Screening tool for health care professionals

Neuro-optometrist Exam

• General History – Behavioral observations client walking/wheeling

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y g/ g to room, note functional problems

• Ocular history
• Visual fields
• Visual acuity (distance and near)
• Refraction
• Binocular Vision Testing (distance and near) – aided/unaided
• Accommodative evaluation
• Sensory motor analysis
• Ocular Motility

Know how you can address driving within your Scope of Practice

Neuro-optometrist Exam (cont.)

• Pursuits - were eyes yoked Y/N

Saccades Near Point convergence Stereopsis

• Cover Test
• Midline Evaluation

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• Pupil Testing

Glare Recovery Color Vision Contrast Sensitivity Light Sensitivity

• Useful Field of Vision
• Visual Evoked Potential – for those who demonstrate characteristics
• f Post Trauma Vision Syndrome

Know how you can address driving within your Scope of Practice

Neuro-optometrist Exam (cont.)

• Observations and Subjective Comment of Client

– discomfort, e.g. neck and shoulders – decreased ability to follow verbal direction – client asks examiner to repeat questions

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– posture of client: head and neck, asymmetry

Neuro-optometrist Exam Results

• Prescribe and fit with appropriate lenses
• Refer for vision therapy PRN
• And/or refer to driving rehab specialist with approval for behind the

wheel evaluation and training

Know how you can address driving within your Scope of Practice

Occupational Therapists (the generalist)

• “…practitioners must recognize driving and community mobility as

part of every OT evaluation…

• …whether the client was driving and has deficits may be all you

need to know – but what you do with the information is important…

• …Intervene as appropriate, then refer…”

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• Per AOTA OT Practice July 2005
• Addresses the patient’s needs e.g. vision, as prescribed by OD

(scanning, pursuits, saccades, etc.), in addition, the OT also addresses the physician prescribed: safety, cognition, perception (depth of field, spatial, figure ground, visual closure, right/left discrimination, etc.), UE range of motion, strength, coordination, sensation, and general ADL’s. Is the client ready for a driving evaluation? Refer to the driving specialist. For those client’s that cannot return to driving, be prepared to do community mobility retraining, or refer.

Know how you can address driving within your Scope of Practice

Occupational Therapists (the specialist)

• The Driver Rehab Specialist

has a specialty in driving h i b i d i h

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that is obtained with additional course work. The Association of Rehab Specialist (ADED) is an international organization that has guidelines for best practices that are followed in this arena.

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Driver Rehabilitation

COMPREHENSIVE DRIVING EVALUATION

Occupational Profile includes: Diagnosis w/ onset, PMH, clients needs, problems, and concerns regarding driving identified roles priorities and values patterns of

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regarding driving, identified roles, priorities, and values, patterns of driving, obtain an understanding of the client’s perspective and background.

Driver Rehabilitation

Clinical Assessment may include the following:

• VISUAL ASSESSMENT: Distant Visual Acuity, Visual Fields, Oculomotor

Range of Motion, Pursuits, Convergence/Divergence, Visual Midline Shift, Saccades, Fixation, Contrast Sensitivity, Glare Recovery, Screen for Stereopsis

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• VISUAL PERCEPTION: Visual Closure, Visual Discrimination, Design Copy,

Figure Ground, Spatial, Right/Left Discrimination, Neglect

• PHYSICAL ASSESSMENT: Means of Mobility/Transfers, Balance

(Sitting/Standing), Head and Trunk Control, Active Range of Motion, Strength, Motor Control (e.g. ataxia, tremors, tone), Sensation, Endurance, Reaction Time, Rapid Pace Walk, Reflexes

• COGNITIVE ASSESSMENT: Attention (Visual, Selective, Divided, Sustained),

Memory (STM, LTM, Working Memory, Procedural, Visual), Planning, Organization Skills, Decision Making, Task Execution, Safety, Mental Flexibility, Self-Monitoring

Driver Rehabilitation

• COMMUNICATION: Language/Communication, Reading Comprehension,

Confrontation Naming, Generative Naming, General Word Search and Retrieval, Road Sign Knowledge and Recognition

• BEHAVIORAL/EMOTIONAL: Frustration Tolerance, Irritability, Maturity,

Apathy, Loss of emotional control, Self Control/Self Perceptiveness, Self Centered Behavior (does not see consequences for others), Mental Fatigue

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On-The-Road Assessment may include:

• VEHICLE ENTRY (includes safely unlocking and opening/closing door(s),

loading/unloading devices, and transfers in/out of car)

• PRE-TRIP INSPECTION: Parking Brake Checked, Seat Adjustments, Mirrors

Adjusted, Seatbelt (donned properly), knows functions of the dash board gauges and indicators

• STARTS THE VEHICLE: Key insertion, starts the vehicle

Driver Rehabilitation

• INITIAL CAR MOVEMENT: Applies Brake, Selects appropriate gear,

Releases parking brake, Checks mirrors and over shoulder (blind spots), Signals, Enters traffic safely

• STEERING: Hand placement, demonstrates smooth steering and

recovery, lane maintenance and position, straight a-ways vs curves

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• SPEED CONTROL: Proper speed for conditions and road surfaces,

appropriately uses acceleration/deceleration

• TRAFFIC: Lane position is appropriate, following distance/gap,

checks traffic, judges the speed of others appropriately, passing, stops, yields right-of-way, avoids position in blind spot, enters/exits traffic safely, anticipates the actions of other drivers, backs car out

• f driveway/parking space
• TURNS: Right, Left, U Turns, 3 point turn (appropriately signals,

checks mirrors and over shoulder, width and control of turn, appropriate speed), takes turn appropriately, do not impede traffic

Driver Rehabilitation

• INTERSECTIONS: Approach (too slow/fast, stops at limit line),

following distance/gap, limit line (cross walk) adherence, checks traffic, judges the speed of others appropriately, correct lane position and use

• PARKING: Stall (right/Left approach, 90 degree, and/or diagonal),

Parallel parking

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Parallel parking

• FREEWAY DRIVING: Signals entry/exit, speed control/adjusts

accordingly, checks traffic, judges the speed of others appropriately, merges safely, steering control, uses proper lane for exit, anticipation of others, and cognitive execution

• COMMUNICATES: Observes and follows flow of traffic

lights/warning signs, appropriate use of auxiliary controls (headlights, emergency flashers, horn), Cooperates with other drivers, takes turn appropriately

Driver Rehabilitation

• COGNITIVE ASPECTS: Attention (Visual, Selective, Divided,

Sustained), Anticipates (light changes, hazards, actions of other drivers), Concentration, Confidence, Memory (procedural, working, STM, LTM, Visual, Selective, Divided, Sustained), Planning, Organization Skills, Decision Making, Task Execution, Safety, Mental Flexibility, Self-Monitoring

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• BEHAVIORAL/EMOTIONAL: Frustration Tolerance, Irritability,

Maturity, Apathy, Loss of emotional control, Self Control/Self Perceptiveness, Self Centered Behavior (does not see consequences for others), Mental Fatigue

• RECOMMENDATIONS TO RESUME DRIVING: Based on outcome
• f the evaluation, resume driving with physician clearance or

complete adaptive driver’s training with an individualized plan of care.

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Driver Rehabilitation

Adaptive Drivers Training and Recommendations

• Adaptive drivers training following plan of care based on

comprehensive driving evaluation

• adaptive equipment in vehicle training, provision of

prescription for appropriate vehicle and/or adaptive

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prescription for appropriate vehicle and/or adaptive equipment

• driver training, driver education, and driver refresher

Driver Rehabilitation Adaptive Equipment

Allview (aka Smartview) Panoramic Mirror

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Fender Mount Mirrors

Driver Rehabilitation Adaptive Equipment

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Smart View Mirrors Hand Controls

Driver Rehabilitation Adaptive Equipment

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Left footed accelerator Left footed accelerator installed

Driver Rehabilitation Adaptive Equipment

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Standard Spinner Knob Tri Pin Spinner knob

Drive Safely

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