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
To receive articles from Occupational Therapy Cafe, please subscribe by clicking here
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.
Using the Motor Assessment Scale: Updates to assessing hand function, as a quick and comprehensive evaluation of motor function in stroke survivors
By: Joyce Sabari, Ph.D, OTR, FAOTA
UPDATE: The Motor Assessment Scale Resources Web Site is NOW Live
Current evidence-based practice for motor rehabilitation after stroke is influenced by task-oriented approaches that aim to improve overall function related to balance, gross mobility, and use of the paretic limbs. Therapists are encouraged to use standardized assessment tools for objective measurement of client progress, communication about client status between different treatment sites within the continuum of care, and research investigating the efficacy of selected interventions.
The Motor Assessment Scale (MAS) is a standardized assessment devised by Carr, Shepherd, Nordholm & Lynne (1985) to assess motor function in stroke survivors and to correspond with the motor relearning approach to recovery after stroke (Carr & Shepherd, 1998; 2007). The MAS is a well-studied assessment with properties that make it useful for rehabilitation therapists, and is specifically recommended as a measure of post-stroke motor function in the American Heart Association’s Clinical Practice Guideline for Stroke Rehabilitation (Duncan, Zorowitz, et al, 2005) and the Canadian health system’s Evidence-Based Review of Stroke Rehabilitation (Salter et al, 2012). Objective reviews of stroke assessments typically commend the MAS for reliability and ease of administration (Poole & Whitney, 2001; Fasoli, 2003). The MAS continues to be used extensively as an outcome measure in studies of rehabilitation interventions for stroke survivors (Langhammer, Stanghelle, Lindmark, 2009; Hayward et al, 2013, Colomer, et al, 2013; Katrak, Black & Peeva, 2011, Kwah, et al, 2013).
The MAS provides a standardized scoring system for assessing eight categories of motor behavior:
- Supine to Side-lying
- Supine to Sit
- Balanced Sitting
- Sit to Stand
- Upper Arm Function
- Hand Movements
- Hand Activities
The full protocol is available at: http://www.rehabmeasures.org/pdf%20library/motor%20assessment%20scale%20testing%20form.pdf
Each category is scored on a 7 point scale (0-6), based on a person’s ability to perform specific tasks. The tasks in each category are intended to be hierarchical; that is, the ability to accomplish task 6 implies the ability to accomplish tasks 1 through 5. This arrangement reduces administration time and increases its appeal to clinicians.
Two of the 8 items on the MAS assess hand function. A third item on the MAS assesses upper arm function (defined as a person’s ability to functionally use the shoulder and elbow). In response to concerns raised in a previous study (Poole & Whitney, 1988) about the hierarchies used to assign scores on the hand items, Sabari et al. (2005) used Rasch analysis to evaluate the validity of the scoring hierarchy of the 3 upper limb items This Rasch analysis of a sample of 100 stroke rehabilitation patients provided support for the hierarchical scoring criteria proposed by the MAS developers for upper-arm function. However, the analysis showed significant problems with the scoring hierarchies for the hand movements and the advanced hand activities items. Specifically, several criteria were not in order of performance difficulty, significant gaps in difficulty were found between adjacent criteria, and some criteria were redundant with one another in their levels of difficulty. Subsequent studies by independent authors (Aamodt, Kjendahl & Jahnsen, 2006; Pickering et al, 2010) corroborated these findings.
Though many evaluations of motor function in stroke survivors have been developed and piloted, very few provide clinicians with a single tool that provides holistic information about the multiple aspects of motor performance that are critical components to neurorehabilitation interventions. Aside from its original problems in the hand items, the Motor Assessment Scale provides a quick, comprehensive assessment of motor function in stroke survivors. Therefore, I worked with colleagues to redesign the two hand items on the MAS, following a multi-step process of scale development, refinement and Rasch analysis (Sabari, Woodbury & Velozo, 2014). The published report is available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142312/
Data collectors at eight clinical sites were enthusiastic about the utility of the newly developed hand items, and it is my sincere hope that, with these suggested improvement, occupational therapy clinicians will consider adopting the MAS as a clinical assessment tool. I am currently working with colleagues at SUNY Downstate Medical Center to develop a resource web page, which will provide therapists with the complete test protocol, training videos and other materials to help them use the tool with confidence. We hope the webpage will be accessible by January 1, 2016. I invite you to send me an email if you would like to receive notification, with the link, when this webpage becomes available.
To read more from Occupational Therapy Cafe on task-oriented approaches click here
About the Author
Joyce Sabari, PhD, OTR, FAOTA is Associate Professor and Chair of the Occupational Therapy Program at SUNY Downstate Medical Center. In addition to her published work related to the Motor Assessment Scale, she has written several textbook chapters about neurorehabilitation and task-based approaches to improving motor function in stroke survivors. She is also the author of the 2008 edition of Occupational Therapy Practice Guidelines for Adults with Stroke, published by AOTA Press.
Aamodt, G., Kjendahl, A., Jahnsen, R. (2006). Dimensionality and scalability of the Motor Assessment Scale (MAS). Disability and Rehabilitation, 28, 1007-1013.
Barker, R.N., Brauer, S.G., Carson, R.G. (2008). Training of reaching in stroke survivors with severe and chronic upper limb paresis using a novel nonrobotic device: a randomized clinical trial, Stroke, 39(6), 1800-1807.
Brauer, S.G., Bew, P.G., Kuys, S.S., Lynch, M.R., Morrison, G. (2008). Prediction of discharge destination after stroke using the Motor Assessment Scale on admission: A prospective, multisite study, Archives of Physical Medicine and Rehabilitation, 89(6), 1061-2065.
Carr, J.H. & Shepherd, R.B. (2003). Stroke rehabilitation: Guidelines for exercise and training to optimize motor skill, London: Butterworth Heinemann.
Carr, J.H. & Shepherd, R.B. (1998). Neurological rehabilitation: Optimizing motor performance, London: Carr, J.H. & Shepherd, R.B.
Carr, J.H., Shepherd, R.B. & Nordholm, L. (1985). Investigation of a new motor assessment scale for stroke patients. Physical Therapy, 65, 175-180.
Colomer, C., Baldovi, A., Torrome, S, et al. (2013) Efficacy of Armeo Spring during the chronic phase of stroke: Study in mild to moderate cases of hemiparesis, Neurologia, 28, 261-267.
Duncan, P.W., Zorowitz, R., Bates, B., Choi, J.Y., Glasberg, J.J., Graham, G.D., Katz, R.C., Lamberty, K. & Reker, D. (2005). Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline – Appendix D, Stroke, 36, 100-143.
English, C.K., Hillier, S.L., Stiller, K.R., Warden-Flood, A. (2007). Circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: A controlled trial, Archives of Physical Medicine and Rehabilitation, 88, 955-963.
Fasoli, S. (2003). Assessing Upper-Limb Motor Function in Clients with Stroke. American Occupational Therapy Association Physical Disability Special Interest Section Quarterly. 26(2), 1-4.
Hayward, K.S., Barker, S.G., Brauer, D., Lloyd, S., Horsley, A., Carson, R.G. (2013). SMART arm with outcome-triggered electrical stimulation: a pilot randomized clinical trial, Topics in Stroke Rehabilitation, 20, 289-298.
Katrak, P.H., Black, D., Peeva, V. (2011). Stroke rehabilitation is Australia in a freestanding inpatient rehabilitation unit compared with a unit located in an acute care hospital, Physical Medicine & Rehabilitation, 3, 716-722.
Kwah, L.K., Harvey, A., Diong, J., Herbert, R.D. (2013). Models containing age and NIHSS predict recovery of ambulation and upper limb function six months after stroke: An observational study, Journal of Physiotherapy, 59, 189-197.
Langhammer, B., Stanghelle, J.K., Lindmark, B. (2009). An evaluation of two different exercise regimes during the first year following stroke: A randomized controlled trial, Physiotherapy Theory and Practice, 25(2), 55-68.
Pickering, R.L., Hubbard, I.J., Baker, K.G., Parsons, M.W. (2010). Assessment of the upper limb in acute stroke: the validity of hierarchical scoring for the Motor Assessment Scale, Australian Occupational Therapy Journal, 57, 174-182.
Poole J, Whitney S. Motor Assessment Scale for stroke patients: Concurrent validity and interrater reliability. (1988). Archives of Physical Medicine and Rehabilitation, 69, 195-197.
Sabari, J.S., Lim, A.L., Velozo, C.A., Lehman, L., Kieran, O. & Lai, J.S. (2005). Assessing arm and hand function after stroke: a validity test of the hierarchical scoring system used in the motor assessment scales for stroke. Archives of Physical Medical Rehabilitation, 86, 1609-15.
Sabari, J.S., Woodbury, M., Velozo, C.A. (2014). Rasch analysis of a new hierarchical scoring system for evaluating hand function on the Motor Assessment Scale for Stroke, Stroke Research and Treatment, Volume 2014, Article ID 730298.
Salter, K., Campbell, N., Richardson, M., Mehta, S., Jutai, J., Zettler, L., Moses, M., McClure, A., Mays, R., Foley, N., Teasell, R. (2012). Outcome measures in stroke rehabilitation, in The Evidence-Based Review of Stroke Rehabilitation (EBRSR), R. Teasell, Ed., Chapter 21.