By: Jami Dalchow, OTD, OTR/L, SCDCM
Recently, I was working with a patient who was only several days out from having had a stroke. While trying to engage him in conversation I asked what he did for a living. He replied “I drive truck. Well…I did. I won’t be able to anymore.” This is a common thought for individuals who have had a CVA and are now dealing with a loss and/or change in their independence. The ability to drive is so central to our lives that a sudden change in ability leaves individuals wondering what lies ahead. This can especially be true for working-age adults who equate the necessity of driving with the ability to work and be productive, in turn, making an income. Driving is often seen as a sign of independence and freedom regardless of age or disability. Any occupational therapy clinician that has ever had a conversation with a patient about driving or the potential for inability to drive can attest that is it not an easy topic to discuss.
Not all individuals who have had a stroke will be able to go back to driving. In one study, approximately 31% of patients who underwent inpatient rehabilitation following stroke returned to driving within 6 months (Aufman, Marghuretta, Barco, Carr, & Lang, 2013). A larger sample from a recent meta-analysis and systematic review found that 54% of participants with a stroke passed an on-road evaluation at an average time of 8.8 months following insult (Devos, Akinwuntan, Nieuwboer, Truijen, Tant, & De Weerdt, 2011). Driving is considered an instrumental activity of daily living (IADL) and is, therefore, our responsibility to address regardless of practice setting.
Driving is an incredibly complex task that requires many functional abilities, mainly grouped into motor, visual-perceptual, sensory and cognitive components. Depending on the type and severity of the stroke, one or more of these components can be impacted at varying degrees. Because there can be such a wide range of deficits following a stroke, driving evaluation should be a key component of any rehabilitation program. Some programs may have the capacity to evaluate patients close to discharge if appropriate. Other facilities may wish to evaluate the patient once outpatient therapy services have been concluded. Some facilities have taken the approach that driving will not be addressed until a follow-up neurologist appointment 2-3 months after discharge from the acute hospital setting as this allows optimal neurological improvement before formally evaluating any remaining deficit areas (Smith-Arena, Edelstein, & Rabadi, 2006). At one time, it was estimated that 87% of people who returned to driving after a stroke did not have any type of formal driving assessment (Fisk, Owsley, & Pulley, 1997). Although access to driving rehabilitation programs has increased since that time, there is still a large majority of patients who are not evaluated. The question should not ask if a driving evaluation is necessary, but rather when.
In recent years, physicians have been given educational material of how to assess older drivers and refer for further evaluation when appropriate (American Medical Association, 2010). This comprehensive manual includes topics on medical impairments, assessing physical function, assessing cognitive function, interventions, driving rehabilitation specialists, counseling, ethical responsibilities, state licensure laws, and medical conditions that affect driving. Although this resource is directed specifically at the medical physician it is a valuable resource for any professional working with older adults or any individuals who continue to drive.
If physicians are unsure about an individual’s fitness-to-drive they will often refer to a driving rehabilitation program for further assessment. Driving rehabilitation specialists, typically occupational therapists or occupational therapy assistants are experienced in assessment and/or management of a wide range of diagnoses including stroke. Just as all rehabilitation programs vary in their intervention strategies, all driving rehabilitation programs vary in their approach to assessment batteries. Some programs rely heavily on clinic based paper and pencil tests to predict on-road performance after stroke. While others, consider the on-road evaluation the gold standard for medical fitness to drive (Kay, Bundy, Clemson, & Jolly, 2008). A combination of the two approaches is often used for a comprehensive evaluation. The clinical evaluation can identify deficit areas that the occupational therapist needs to be watch for during the on-road evaluation. Without the clinical evaluation, the therapist may miss key information that is essential for safe driving. Often, the clinical evaluation will help to discover a field cut, memory impairment, decreased cervical range of motion, or slowed processing speed.
There are many assessments and intervention strategies that you, as an occupational therapy generalist clinician, can use to address driving with your patients regardless of what type of assessment the driving rehabilitation program near your facility uses. If you are questioning whether your patient who has had a stroke is ready to start driving again you can do a quick clinical screening to determine if they should be referred for further evaluation. Often times, if a patient has “passed” the screening with an occupational therapy generalist, it would not need to be completed again, although this varies by facility.
Clinical assessments that have been shown to predict driving ability include:
National Institutes of Health Stroke Scale (NIHSS)
Short Blessed Test
Mini Mental Status Examination (MMSE)
Functional Independence Measure (FIM)
Road Sign Recognition
Trail Making Test Part B (TMT B)
Useful Field of View (UFOV)
The Motricity Index
Visual fields testing
If a patient is referred for a formal driving evaluation, they can expect the assessment to take between 2-3 hours. The clinical screening/assessment typically lasts for 45 minutes – 1. 5 hours while the on-road evaluation lasts for 1-1.5 hours. Upon completion, the driving rehabilitation specialist will make a recommendation immediately and discuss the findings with the patient and family members. If it is determined that the patient is not ready to resume driving yet at that time, further recommendations will be made. Sometimes, an individual simply needs further occupational, physical, and speech therapy to continue working on neurological deficits.
Regarding intervention and driving preparedness for cognitive-perceptual training, a review by Golisz (2014) reported that cognitive-perceptual training with use of programs similar to the UFOV result in positive changes in driving performance. Speed-of-processing and reasoning training decreased the rate of driver at-fault motor vehicle accidents per year (by 50%). Computer based interventions are common and involve visual attention skills targeting UFOV – participants quickly identify and locate visual targets while the visual displays become progressively more challenging.
In terms of physical fitness, coordination, flexibility, and speed of movement have been associated with on-road performance. Golisz (2014) found moderate evidence supporting improved driving performance through use of physical tasks that require simultaneous cognitive-perceptual skills. Examples of noted activities include: use of peripheral vision to maintain several balloons in the air – could include an auditory cue to interact with a specific color of balloon; and responding to different auditory or visual signs while walking in order to target processing speed. Simulated driving activities with use of props appeared to improve self-reported driving skills and confidence. Task examples include head/neck/torso rotation to locate signs; and imitation of checking the rearview mirror, braking, or steering during an audiotape of roadway sounds.
A generalist OT practitioner has the knowledge and the ability to initiate screening, assessment, and intervention for individuals post-stroke in order to document on and promote the possibility of a return to driving. Targeting of driving related performance skills along the care continuum can contribute to the assessment completed at a driving rehabilitation facility as well as is invaluable to the patient during the journey of recovery.
Valuable Resources for Occupational Therapists regarding Driving
AMA Physicians Guide to Assessing and Counseling Older Drivers
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About the Author
Dr. Jami Dalchow received her Bachelor of Science from South Dakota State University (SDSU) before obtaining her OTD from Washington University in St. Louis. It was at Washington University that she developed a love for all things driving and occupational therapy. She received a majority of her training regarding clinical assessments and on-road evaluations during her graduate work. She was fortunate enough to be able to start practicing with her area of passion after she became employed at Sanford Health in Sioux Falls, SD. Jami holds the Specialty Certification in Driving and Community Mobility (SCDCM) from AOTA.
She enjoys spending her days evaluating medical fitness-to-drive and completing driver training after a disability.
American Medical Association. (2010). Physicians Guide to Assessing and Counseling Older Drivers. http://www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers.pdf.
Aufman, E., Bland, M., Barco, P., Carr, D., & Lang, C. (2013). Predictors of Return to Driving After Stroke. American Journal of Physical Medicine and Rehabilitation, 92(7). 627-634.
Devos, H., Akinwuntan, A.E., Nieuwboer, A., Truijen, S., Tant, M., & De Weerdt, W. (2011). Screening for Fitness to Drive after Stroke. Neurology. 76. 747-756.
Fisk, G., Owsley, C., & Pulley, V. (1997). Driving After Stroke: Driving exposure, advice, and evaluations. Archives of Physical Medicine and Rehabilitation. 78. 1338-1345.
Golisz, K. (2014). Occupational Therapy Interventions to Improve Diving Performance in Older Adults: A Systematic Review. American Journal of Occupational Therapy, 68(6), 662-669.
Kay, L., Bundy, A., Clemson, L., Jolly, N. (2008). Validity and Reliability of the On-road Driving Assessment with Senior Drivers. Accident Analysis & Prevention. 40 (2). 751–759
Smith, L., Edelstein, L., & Rabadi, M. (2006). Predictors of a Successful Driver Evaluation in Stroke Patients After Discharge Based on an Acute Rehabilitation Hospital Evaluation. American Journal of Physical Medicine and Rehabilitation. 85(1). 44-52.