Transcript The following slides are adapted from original work by

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.
•
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…
•
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
Defining OT Roles…
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.
Occupational Therapy
Generalist…
•
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
In order to Drive…
•
•
•
•
•
•
•
•
•
•
Physical Abilities
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
Assessments Currently
Employed…
•
•
•
•
•
•
Trail Making Test (Part A)
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
Where to Focus…
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…
•
An estimated 90% of informational input received during
driving is visual
•
Necessary to evaluate basic visual skills first…
Vision…
Adaptation
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…
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
Perceptual Skills…
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
Perceptual Skills…
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
Cognitive Skills…
•
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
Additional Off-Road Tests…
•
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…
•
Cost Effective
•
Less intimidating to client
•
Safer form of evaluation
•
Allow for task break down, assessing performance of driving
sub-skills
In Summary…
•
•
•
•
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…
Fisk, G. D., Owsley, C., & Mennemeier, M. (2002). Vision, attention, and selfreported 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.