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Driving After Stroke Jennifer Milsovic, OTR/L
Adventist Rehabilitation Hospital of Maryland
Objectives
Discuss appropriate candidates for return to driving
after stroke
List all of the steps in the process of returning to driving
after stroke
Name at least 3 types of adaptive driving equipment
that may be used for persons following stroke
Who of the Following is a
Candidate to Drive?
A person with mild memory and mild attention deficits
A person with flaccid hemiplegia in the right upper and
lower extremities
A person with severe receptive and severe expressive
aphasia
A person with homonymous hemianopsia
Skills Required for
Safe Driving Visual (acuity, contrast sensitivity, visual fields, binocular
vision, fixation, scanning, visual perception)
Cognitive (orientation, alertness, processing speed,
immediate memory, short-term memory, sustained attention,
divided attention, selective attention, problem solving,
judgment/reasoning, planning)
Physical (right lower extremity and bilateral upper extremity
ROM, strength, coordination, reaction time,
sensation/proprioception; trunk control, cervical ROM)
Emotional/Behavioral
Can My Patient Drive
Following a Stroke?
Maybe, but he/she needs clearance first
Why does my patient need to be cleared?
Liability Issues
Maryland Motor Vehicle Administration (MVA) requires
that a person who has had a stroke must self-report
his/her condition
What Steps Should My Patient
Take Before Resuming Driving?
Obtain clearance from his/her physician
AND/OR
Report his/her condition to the MVA
Online
By phone
By mail
AND/OR
Obtain a driving evaluation
The Driving Evaluation
Part One: Clinical Evaluation Done in the clinic
Purpose is to identify any potential barriers to safe driving and identify any potential adaptive equipment needs
Components include:
An extensive interview to determine medical and social history, driving history, ADL/IADL status
An assessment of vision and visual perception
An assessment of cognition
An assessment of physical functioning
Part One: Clinical Evaluation
(Continued) After the evaluation, a recommendation is made
If all areas of functioning are grossly intact, recommend proceeding to behind-the-wheel evaluation
If deficit areas are present that would preclude safe driving, recommend service(s) to further evaluate and remediate deficits (i.e. neuro-optometry, OT, PT, speech therapy, neuro-psychology, etc.)
If deficits are severe or co-morbidities (such as dementia) are present, recommend retirement from driving and counsel client on alternative transportation
If deficits are mostly physical in nature (i.e. hemiparesis) with little to no visual or cognitive impairment, recommend proceeding to training with adaptive equipment
Note: aphasia alone does not preclude safe driving
The Driving Evaluation Part Two: Behind-the-Wheel Evaluation
Evaluation is done in a car with an instructor brake
Client is usually taken on a standard route that includes all traffic environments and cognitively taxing situations
In some cases, for clients with mild memory or attention impairments, evaluation may be done in familiar areas
Evaluator assesses the occurrence of critical errors (i.e. not stopping at a stop sign, hitting a curb, drifting into another lane)
Evaluator assesses the repeated occurrence of smaller errors (i.e. repeatedly not signaling for turns, repeatedly drifting within the lane, repeatedly not noticing signs until the last minute)
Part Two: Behind-the-Wheel Evaluation
(Continued)
After the evaluation, a recommendation is made
Continue driving in the same capacity that client was prior
to stroke
Continue driving, but with restrictions (i.e. radius
restriction, daytime-only restriction, etc.)
If deficit areas emerge during behind-the-wheel
evaluation, recommend service(s) to further evaluate and
remediate deficits (i.e. neuro-optometry, OT, PT, speech
therapy, neuro-psychology, etc.)
Prior to continuing to drive, take a refresher course to
remediate premorbid bad driving habits
If Adaptive Equipment
is Needed… Steps in process to drive with adaptive equipment
1. Driver training with adaptive equipment
a. Done in a vehicle with an instructor brake
b. Initiated in an empty parking lot and progresses through increasingly complex traffic environments
2. Client is given prescription to have equipment installed in his/her vehicle
3. Client is encouraged to use a NMEDA-certified equipment dealer to have equipment installed
4. Client returns to driving program to have equipment inspected to ensure that it was installed according to prescription
5. Client takes driving test at MVA with adaptive equipment and, upon passing, receives license that denotes adaptive equipment
Types of Adaptive
Equipment Commonly Used
Following Stroke
Left Foot
Accelerator
• Used when right lower extremity is
too weak or uncoordinated to
operate gas/brake
• Must be used when AFO is worn on
right lower extremity
• Includes pedal guard to ensure that
right foot doesn’t accidentally kick
OEM pedal
• Removable
Spinner Knob
• Used when one arm is too weak or
uncoordinated to assist with
steering functions
• In Maryland, must be used for
“one-handed” driving
• Can be placed at any position on
steering wheel
• Removable
Crossover
Turn Signal
• Used when left hand is too weak or
uncoordinated to operate existing
turn signal
• Attaches directly to existing turn
signal
Additional Adaptive Equipment
Adapted mirrors (to expand visual field in client with visual deficits)
Remote turn signals and secondary controls (if client has difficulty
with existing turn signal and crossover turn signal)
Reduced-effort steering (if arm used for steering is weak or has
decreased ROM)
Parking brake extension (if parking brake is on left side of floor and
client has left hemiparesis)
Key extender (if patient has right hemiparesis and has difficulty
reaching/turning key on left)
Additional Adaptive Equipment
(Continued)
Transfer assists (to assist client with lower extremity
weakness to get in and out of vehicle)
Wheelchair lifts/hitches/car toppers (to stow wheelchair
while client is driving)
Chest straps (worn in addition to seatbelt for clients
with decreased trunk control)
Miscellaneous Information Driving evaluations are not covered by insurance,
except for Workman’s Compensation and Division of
Rehabilitation Services
A doctor’s prescription is required prior to participating
in a driving evaluation
Adaptive equipment is not covered by insurance,
except for above payers
After having adaptive equipment installed, client should
notify insurance company
To Review: Steps in Return
to Driving Process If no adaptive equipment is needed:
1. Discuss return to driving with physician
2. Participate in a comprehensive driving evaluation (clinical and behind-the-wheel evaluations)
3. Report condition to MVA
If adaptive equipment is needed:
1. Discuss return to driving with physician
2. Participate in a clinical evaluation
3. Participate in training with adaptive equipment
4. Have adaptive equipment installed in personal vehicle
5. Return to driving program to have equipment inspected to ensure that it was installed according to prescription
6. Report condition to MVA
7. Take driving test at MVA
How Can the Clinician Facilitate
the Client’s Return to Driving?
1. Educate the client regarding:
a. Self-reporting regulations
b. The driving evaluation process
c. The process for obtaining adaptive equipment if applicable
2. Advise client to speak with physician regarding return to driving
3. Assess visual, cognitive and physical skills needed for return to driving
4. Treat any visual, cognitive or physical skills needed for return to driving
Who of the Following is a
Candidate to Drive?
A person with mild memory and mild attention deficits
A person with flaccid hemiplegia in the right upper and
lower extremities
A person with severe receptive and severe expressive
aphasia
A person with homonymous hemianopsia
Questions?
References Customer Self-Report of a Medical Condition. (2012). Retrieved
April 11, 2012, from http://www.mva.maryland.gov/About-MVA/INFO/26200/26200-11T.htm
Pierce, S., Blackburn, S. (2007, June). Building Blocks for Becoming a Driver Rehabilitation Therapist. Course conducted from Adaptive Mobility Services, Orlando, FL.
Redpenning, S. (2006). Driver Rehabilitation Across Age and Disability: An Occupational Therapy Guide. Bethesda, MD: AOTA Press.
Stav, W., Hunt, L., & Arbesman, M. (2006). Occupational Therapy Practice Guidelines for Driving and Community Mobility for Older Adults. Bethesda, MD: AOTA Press.
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