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I.C. DEVELOP TOOLS NEEDED TO IMPLEMENT MODEL PROGRAMS


I.C.3. Rehabilitation Procedures

(a) Elderly population without chronic conditions (includes post-trauma recovery)

(b) Elderly population with chronic conditions -- intervention required


1C3(a)i. Rehabilitation Procedures - Elderly Population Without Chronic Conditions: Education


AARP: 55-Alive/Mature Driving Course

The American Association of Retired Persons (AARP) 55-Alive/Mature Driving course is an eight-hour driver improvement/classroom refresher designed to provide drivers age 50 and older with information about the effects of aging on driving, compensation techniques, rules of the road, and defensive driving techniques. The curriculum consists of nine chapters and is conducted over a two-day period, with each session lasting four hours. It is taught, promoted, and administered by volunteers (approximately 7,000 nationwide) utilizing the peer concept, who are recruited and trained by AARP, and serve as Area, State, Associate or Assistant State Coordinators, Chief Trainers, or Instructors. The volunteers receive a 3-phase training process. In the first phase, an instructor training session provides the overall training to conduct educational discussion groups and review educational learning skills. In the second phase, the Instructor's first course is conducted as a practice teaching session (it is monitored by the trainer). The last phase is an on-going supervision process supplemented by in-service training workshops held regularly. Participants are charged a minimal fee ($8.00) to help offset overall program costs (Instructor recruitment and training, Instructor out-of-pocket expenses, ongoing supervisory training nationwide, and program materials and distribution). AARP subsidizes the remaining expenses. Each Instructor volunteers his/her own time.

Legislation has been enacted in 33 States and the District of Columbia that requires all automobile insurance companies conducting business in those States to provide a multi-year premium discount to graduates of State-approved classroom driver improvement courses. 55-Alive is approved in every state. Several automobile insurance companies in selected States voluntarily provide premium reductions to graduates of 55-Alive.

Several evaluations have been conducted on program effectiveness. McKnight, Simone, and Weidman (1982) found that drivers who took the course had a significantly higher knowledge score than a control group (not taking the course) and that it was retained during the entire evaluation period (14 months). Drivers taking the course also showed a trend in violation reduction. Evaluations by CA DMV, NY DMV, and NY Department of Insurance demonstrated fatal injury crash and violation reductions among program participants (AARP "55 Alive" Fact Sheet).

AAA: Safe Driving for Mature Operators Course

This driver improvement course is conducted in a classroom, generally in two four-hour sessions, for drivers age 55+. According to American Automobile Association (AAA) Driver Safety Services in Heathrow, FL, presenting the material across two sessions is preferable to scheduling a one-day session that lasts 6 to 8 hours. The half-day format allows drivers to travel during non-rush periods (e.g., late morning to early afternoon), and is also better for information retention. Some areas schedule a full-day session on Saturdays, to avoid requiring their drivers to drive in busy traffic.

The cost to the participant ranges nationwide from $5.00 to $40.00. For example, it is offered by AAA clubs in Kansas for $5.00; Northern California clubs charge $10.00, and in the Lehigh Valley (PA), the cost is $20.00 per AAA member and $30.00 for non-members. There are no tests.

Insurance discounts vary across the nation, and therefore, individuals must obtain information about insurance discounts in their State by contacting their local AAA office. Selected examples follow. AAA's Safe Driving For Mature Operators course has been approved by the Pennsylvania Department of Transportation for a minimum 5 percent premium reduction for each motor vehicle on a policy under which all named insureds are age 55 or older and have successfully completed a driver improvement course. To retain the discount, insureds must take the course every three years. Connecticut statutes require a minimum discount of 5 percent for drivers over the age of 62, for a minimum of 24 months. Many companies have exceeded these minimums. In California, drivers over age 55 who complete the course are entitled to a 5 percent reduction on bodily injury and a 5 percent reduction on property damage. This premium reduction averages approximately $13 to $18 annually.

The course covers aging effects on driving, and reviews safe driving practices (looking far ahead; signaling; leaving a safety margin; a review of signs, signals and pavement markings; use of safety belts; and effects of medicines and alcohol on driving).

Instructors are required to complete a 40-hour certification course every three years. During two of the days, instructors learn the course content. On an additional day, they receive hands-on training on the road, to practice some of the emergency skills they will teach in the course. During two more days, they are back in the classroom, giving a 1-segment presentation from the course to the other students, and critiquing other students' presentations.

In certain AAA motorclubs there are additional optional components of the Mature Driver Program. In addition to the classroom segments (scheduled in 2, 4-hour sessions in the afternoons, and also in 4, 2-hour evening sessions), AAA of Hartford, CT offers a physical testing and vision screening component as well as a driver evaluation component. The first component includes vision screening with the Optec 1000 Vision Tester (acuity, road sign recognition, depth perception, color vision, and peripheral vision), and the AAA Night Sight Meter (measures vision in darkness under headlight glare and no glare conditions), as well as brake reaction time testing, using the AAA Brake Reaction Timer. The cost for this component alone is $27.00 for AAA members. AAA Hartford also offers an on-road driving evaluation, either in combination with the classroom lectures, or separately. The cost for classroom instruction alone is $15.00, and for an in-car evaluation alone, the cost is $60.00. AAA Hartford offers a package deal (classroom plus on-road driving evaluation) for $45.00. The 90 minute in-car evaluation is conducted by an AAA instructor in a dual brake-controlled training vehicle. For approximately 60 minutes, the individual drives over a pre-determined route while the instructor observes the driver's ability to follow simple directions, control the vehicle's movement, and make sound judgments and safe operating decisions. The remaining time is used to complete a written evaluation, discuss the results, and plan a strategy for appropriate corrective measures. Approximately 50 older drivers participate in both segments each year. This program has been in existence for over 20 years. Many older drivers are referred to AAA for on-road evaluation by their families, physicians, and even the DMV. AAA provides the driver with a "report card," but the results are confidential. A driver may share the evaluation results with the physician or family, but AAA will not report results to anyone but the person who was evaluated.

Mature Driver Retraining Workshop (Traffic Improvement Association [TIA], St. Joseph's Mercy Hospital, and AAA Michigan)

The Mature Driver Retraining Workshops are voluntary, and are designed to help drivers age 55 and older evaluate their driving skills (a self-assessment). Each Workshop consists of two, four-hour sessions, held on consecutive days, and an optional half-hour on-road evaluation with a certified instructor. The Workshop is advertised through Senior Centers and Area Agencies on Aging. The instructors are AAA-certified, and are retired law enforcement officers. The first four hours consists of a classroom review using AAA "Safe Driving for Mature Operators" course materials. The second classroom session incorporates psychophysical testing to allow an individual to evaluate his or her own abilities (the results are confidential). The psychophysical tests include simple reaction time; visual capabilities (acuity and depth perception) and visual attention (Visual Attention Analyzer/UFOV). The driving course is laid out by the University of Michigan Traffic Engineering Department. The instructor provides feedback on possible problem areas in an individual's driving behavior and will offer suggestions for improvement.

The cost is $41.00 per driver, but generally, only $20.00 is charged to an individual. The balance is funded by AAA Michigan, St. Joseph's Mercy Hospital, and TIA. They are looking forward to a larger grant to help fund the course this year, as it is important to keep the price low. One community received funding from their police department, allowing students to participate at no cost. Another community offered the workshop at $5.00 per participant, as a result of funding provided by a local insurance agency.

Fourteen workshop were conducted in Oakland, Wayne, Macomb, and Washtenaw Counties between May 1998 and October 1998 (Stuart Packard and Associates, 1998). One hundred eighty-five older persons participated in the workshops. One hundred four participants completed follow up evaluations of the Program; 66 percent were female, and 33 percent were male. Sixty-six percent of the respondents rated their driving ability as good or excellent. Seventy-seven percent stated that they drive 5 or more days per week on average. Eighty-five percent indicated that they had not been stopped by police in the past three years, and 86 percent indicated they had not been involved in a crash in the past three years. Sixty percent indicated that they do not voluntarily restrict their driving. Of the 64 respondents who evaluated the on-road portion of the class, 84 percent stated that they were given information that will change some of their driving practices. This included use of turn signals, coming to a complete stop at stop signs, correct yielding procedures, maintaining reasonable speed, and maintaining 3 seconds of space between vehicles. Ninety-six percent of the respondents stated that they would recommend the workshop to others.

National Safety Council Defensive Driving Course: Coaching the Mature Driver

This course is designed for senior drivers, (age 55 and older) to review the effects of aging on driving and how to compensate for the physical and mental changes, to promote defensive driving. This is a State of Florida-approved course for insurance discounts (5 to 10 percent). The goal is to help older drivers maintain their safe and defensive driving abilities. The course covers adjusting to certain driving habits and limitations; backing, parking and multiple lane driving; how seniors are perceived by other motorists; urban, rural and highway driving; road sign recognition; and physical effects of aging. The class is taught in two 3-hour classroom segments in an interactive format including lecture, slides, films and a workbook. Tuition is approximately $10.00 (Note: It is free from the Indiana Bureau of Motor Vehicles). Instructors require certification through the National Safety Council; they must complete an Instructor Development Course and be associated with a registered training agency.

Driving School Association of the Americas: E-VAL for Mature Drivers

The Driving School Association of the Americas is a national association of driving school owners, that includes approximately 2,500 driving schools in the U.S. They are in the process of developing a curriculum for drivers age 50 and older. The curriculum will consist of three components: (1) a 90-minute on-road driving evaluation; (2) a 2-hour classroom segment; and (3) a follow-up 60-minute on-road driving evaluation.

The first on-road evaluation will begin at the driver's home. The instructor/evaluator will employ a 32-point checklist to evaluate driving performance (e.g., visual search behavior; stopping, left-turn, and right-turn techniques). Drivers will be instructed where to drive during this portion. After the checklist has been completed, drivers will then be evaluated during a "Freedom Drive." During this portion of the evaluation, drivers choose their own routes; this portion demonstrates how well a person can negotiate a (probably) familiar area, without the assistance/instruction of a passenger.

The classroom segment is taught in a group setting. The content includes a discussion of new laws, new traffic control devices, and new highway design elements. In addition, a critique of driving performance during the evaluations is provided, and corrections to poor performance are provided.

During the last segment, drivers undergo a second on-road performance evaluation. An evaluation report will be provided to the driver that contains an in-depth description of driving skill, outlines corrective behaviors, and may recommend additional behind-the-wheel lessons. The evaluation report will remain confidential (e.g., drivers will not be reported to the DMV for unsafe performance).

Once the E-VAL for Mature Drivers curriculum is established, the Driving Schools Association will provide a Train-the-Trainer course at each of their professional regional and annual conferences. The program may be ready to implement by Spring 1999 (pers. comm., Jack Sousa, 10/6/98). The instructors will initially be credentialed by the Driving School Association of the Americas to evaluate "well" elderly clients; however, Mr. Sousa indicated that ADED will be asked for input in certification requirements for evaluating drivers with disabilities.

The program will be marketed through high school adult education programs and community colleges. The plan is to make the program as community-based as possible, to make it easily accessible to older drivers. The cost of this program has not been determined; however, it is probable that it will vary from State to State.

Bogdonoff Enterprises, Inc (The BEI Group): The Driver Skill Enhancement Program (D-SEP)

BEI has developed the Driver Skill Enhancement Program, aimed at improving the driving skills of persons age 55 and older. The proposed program includes screening, testing, and counseling, combined with classroom instruction, and simulator-based and on-road training and practice. D-SEP will be a 5-day program, that starts with screening to determine a driver's present capability; this is used as the basis for tailoring a plan for training and practice. The screening procedure will require approximately 1.5 hours to complete, and includes simple tests of vision, cognition, perception, and physical ability, in addition to the completion of a health, medication-use, and driving history questionnaire. Lectures will be used to increase drivers' knowledge of issues ranging from vision skills to complex driving situations. Classroom sessions will focus on strategic driving issues, including recognizing and managing dangerous driving situations; developing effective visual scanning techniques; and awareness of following and stopping distances for reducing driving risks. Additional class time will be devoted to the program philosophy, specific older driver issues, and suggested physical exercises for maintenance of mobility and strength. Simulators will be used to provide training and practice in key elements of driving. The simulator training will not use vehicle simulators, but will use small simulators that evaluate visual and attentional performance, and reaction time. In-vehicle training will integrate all skills in actual driving situations in the client's own car; however, this will not occur on public roads. Activities will include training in panic braking techniques; skidpad exercises; rapid and controlled lane changes; backing; and parking. These exercises are designed to improve participants' vehicle control skills and response to emergency situations (Bogdonoff, 1997).

The kinds of people who will be recruited to be trainers include teaching assistants, social workers, and occupational therapists. A 1-week training program will be delivered to the trainers.

Participants will be encouraged to return at intervals for testing to determine skill retention and further needs for practice. According to Bogdonoff (1998), BEI is discussing plans with a consortium of State agencies and insurance providers to set up a demonstration of the D-SEP in central New Jersey. The demonstration would serve to provide training for older drivers in New Jersey, as well as promote the establishment of similar training programs elsewhere. The estimated cost per driver ranges from $500 to $1,500, and will depend on whether it becomes a non-profit, government, or private program. Dr. Bogdonoff hopes to find an insurance company in New Jersey that would provide an insurance premium discount of 25 percent, to drivers who complete the program (pers. comm., Dr. Seymour Bogdonoff, October 9, 1998).

References:

• AAA "Safe Driving for Mature Operators"

• AARP "55 Alive" Fact Sheet

• Bogdonoff (1997, 1998)

• McKnight, Simone, and Weidman (1982)

• Michigan "Mature Driver Workshop" ( pers. comm., Frank Cardimen, President, Traffic Improvement Association 1/22/98);

• Stuart Packard and Associates (1998)

• National Safety Council/Defensive Driving Course: "Coaching the Mature Driver"

• pers. comm., Rosa Fix, Supervisor, AAA Program in Hartford, CT

• pers. comm., Jack Sousa, Driving School Association of the Americas, Waterbury, CT

• pers. comm., Seymour Bogdonoff, Chairman, BEI, Princeton, NJ

 

1C3(a)ii. Rehabilitation Procedures - Elderly Population Without Chronic Conditions: Perceptual Skills Training


Visual Attention Analyzer/Useful Field of View

UFOV training is available on a turnkey computer system through Visual Resources, Inc., including a 17-inch interactive touch screen monitor, a Pentium computer system, a printer, and a User's Manual. The Visual Attention Analyzer (see Notebook Section IC2(a)iv: Supplemental tests specialized for attentional and informational processing skills) is currently being evaluated as a rehabilitation tool to increase the size of a driver's useful field of view. In a study by Roenker, Cissell, and Ball (submitted) 71 subjects with UFOV restrictions of 35 percent or more were divided into one of two training groups: UFOV Training or Doron Driving Simulator Training. The UFOV training (n=49 subjects, mean age = 72.1 years) consisted of four, 1-hour blocks on UFOV, customized to the needs of the individual (processing speed, divided attention training, and/or selective attention training). The size of UFOV was assessed, and training continued until a mastery level of 75 percent correct performance was achieved (average training time = 4.5 hours). The Doron Driving Simulator Training (n=22 subjects, mean age = 72.4 years) consisted of two educational sessions of 2 hours each. It included 3 hours of instruction in driver safety and a 1-hour, on-the-road demonstration of these driving skills (e.g., safe following distance, use of turn signals). A Control group (n=25, mean age = 69.4 years) consisted of individuals with less than 30 percent UFOV reduction. Participants were assessed on several visual, attentional, and driving tasks; then training proceeded, and subjects were re-assessed on the same measures. These included UFOV; simple RT to simulated brake lights (Doron L-225 Driving Simulator); complex RT to Doron simulator stimuli; and a 15-mile open road driving evaluation (1-mile warm up, plus 2 loops of a 7-mile urban/suburban route).

The Driving evaluation proceeded as follows. Two independent evaluators in the back seat rated each driver on a checklist of 455 driving skills. Behaviors were rated on a 3-point scale: 0=very unsafe or inappropriate; 1=somewhat unsafe; 2=safe or appropriate. Also, a global rating of driving skill was indicated, ranging from 1 (drive aborted/very unsafe) to 6 (very competent driver). Eleven composite behaviors were formed from the 455 individual items: (1) acceleration; (2) gap selection; (3) position in traffic; (4) signals; (5) speed; (6) stop position; (7) deceleration; (8) tracking; (9) turning; (10) right of way; and (11) changing lanes. A visual search composite had to be dropped from analyses due to difficulty in assessing behavior. A dangerous maneuver composite was created from 17 high-traffic roadways, consisting of 6 left unprotected turns, 9 entrances to high-traffic roads from a stop sign, and 2 opportunities for inappropriate stopping in traffic to turn right.

Results were as follows. UFOV scores significantly improved across testing sessions for only the UFOV-trained subjects (average = 24.44 point improvement). No significant differences were found across testing sessions for Simple Reaction Time. For Complex RT, only the UFOV-trained group significantly improved their scores (average improvement = 0.287 seconds, or 23 feet). On the on-road driving evaluation, both the Simulator and UFOV-trained group improved their global ratings across test sessions; there was no change in the control groups' global rating. For turning (turning into the correct lane) and signals (signaling 100-150 ft in advance of a turn) composites, only the Simulator-trained group significantly improved from the pre- to post-training test. For the stop position (positioning vehicle at stops in order to see clearly but not obstructing traffic flow) measure, both the Simulator- and UFOV-trained groups performed significantly better than the Control group. The gap selection composite and the tracking composite were significantly correlated to UFOV performance. No group by pre/post interactions were found for the other composites, but general improvement was found for all groups from pre- to post-test. This reflects comfort and familiarity on the second drive through the route.

For the dangerous maneuvers composite, only the UFOV-trained group demonstrated a significant reduction in the number of dangerous maneuvers from pre- to post-test. Simulator training was effective in some areas of specific instruction and demonstration; UFOV training did not transfer to driving skills that reflect the mechanical operation of the vehicle, but improved items that measured critical search and judgment abilities in visually cluttered and cognitively demanding situations.

Other clinical trials utilizing the UFOV for training are still active.

Vision Aerobics

Vision Aerobics, Inc., 12 Doughty Lane, Fair Haven, NJ 07704, phone: 732-219-1916;

fax: 732-219-9797. Software distributed by Dual Control Safety Centers, Inc. 9 Delaware Ave., Cherry Hill, NJ 08002.

This product includes software installation/usage instruction booklet; diskette (CD-ROM if multi-user/commercial package) containing Vision Aerobics software; dura-lens, high impact polymer 3-D viewer glasses; registration card to receive updates/upgrades of software and technical support. The software requires an IBM-compatible computer and a VGA color monitor.

Vision Aerobics is a computer software program that contains three sets of eye exercises designed to improve peripheral vision, static and dynamic acuity, scanning field of vision, depth perception, eye-hand coordination, and speed of reaction. The premise is that people have "flabby eye muscles" which can become more efficient and better conditioned through aerobic exercising, just as the heart and legs benefit from regular exercise. Vision Aerobics is based on eye exercise techniques used and recommended by eye doctors and vision specialists for over 40 years. The "Eyes in Motion" component is an arcade-type exercise that helps improve ability to make rapid and accurate eye movements. It exercises all eye muscles and can improve visual acuity, peripheral vision, and reading skills. The "Images" component is a 3-D exercise to condition the muscles that align the eyes for depth perception. It helps to gradually condition eye muscles to focus at varying distances and to perceive depth better. The "Relaxation" component (in full color) helps relieve the stress of work and (in 3-D) relaxes the eyes. Using over 40 game-like exercises scientifically designed to condition the eye, users have reported improvement in both their static and dynamic vision, with 10 minutes' daily exercise. The software automatically records a user's score after each exercise. In the "Images" component, for example, the more difficult the exercise, the more points a user can accumulate. The scores are a reflection of the ability to keep the two images "together" (fused) even though they are actually moving apart. As the difficulty level increases, the images move farther apart at increasingly greater speed.

Preliminary, unpublished research suggests a significant improvement in visual skills among subjects ages 9 to 86 who have used the eye exercises 3 to 5 times per week for four consecutive weeks. (Note: These clinical and field studies have been conducted at: Continental Insurance Company, NJ; Community Medical Center, NJ; NJ Division of Highway Traffic Safety using senior drivers; Laidlaw Transit using school bus drivers; Montgomery County, MD using school children). In 1993, a pilot study of the effects of visual training among senior drivers was jointly conducted by the NJ Division of Highway Traffic Safety, The Lighthouse Senior Health Center of Community Medical Centers, and Vision Aerobics, Inc. Thirty-five subjects ages 65 to 86 participated in a 4-week program that required them to exercise their eyes with Vision Aerobics five times per week for 10 minutes per day. The following results were obtained: visual skills (unspecified in the report) increased by an average of 52 percent; 81 percent of the subjects reported an increased awareness of their driving environment and were more alert when driving; 25 percent reported improvements in day and/or night vision including peripheral vision; and 19 percent reported improvement in reading vision. According to the developer (Richard Cheu) Vision Aerobics can help prevent traffic crashes, particularly among seniors, by improving dynamic vision and reaction times. (Note: No published studies using crashes or violations as a measure of effectiveness for Vision Aerobics treatment groups, nor any objective measure of visual performance before and after training could be identified in the technical literature).

Vision Aerobics is currently available at no cost to older drivers at 14 sites in Ocean, Atlantic, Camden, and Cape May Counties in New Jersey, under a program operated by the International Association of Lions Clubs.

Dynavision

Distributed through Performance Enterprises, 76 Major Button's Drive, Markham, Ontario, Canada, L3P 3G7; phone: (905) 472-9074; fax: (905) 294-6327.

Dynavision was originally developed as a device to improve the visuomotor skills of athletes competing in sports such as hockey, basketball, football, and tennis, and has been adapted to provide the same training benefits to people whose visual and motor function has been compromised by injury or disease. The apparatus can be used to: increase active upper extremity range of motion and coordination; train compensatory scanning strategies for visual inattention and visual field deficit; and improve oculomotor control, eye-hand coordination, and muscular and physical endurance.

The training area measures 47 in by 47 in (120 cm by 120 cm) in length and width, and weighs 287 pounds (130 kg). The apparatus must be wall mounted. The board is vertically adjustable to accommodate users of different heights, as well as users who are seated and those in wheelchairs. The training surface houses 64 small square buttons, each illuminated by a small light bulb. The bulbs are arranged in a pattern of 5 rings (concentric circles). Clients are required to locate an illuminated button and strike it with their hand as quickly as possible. After each hit, another button will randomly light up; this sequence continues for the duration of the exercise. A successful hit is acknowledged by a beeping signal. The average time to strike the buttons and the total number of successful hits during a given exercise (the main performance variable) are recorded by the apparatus.

Tasks or exercises last either 30, 60, or 240 seconds. A computerized display panel and a printer are built into the side of the apparatus and provide immediate performance feedback. A LED display is positioned just above the center of the training surface. It can display up to seven computer-selected, random numbers every five seconds for preselected exposure periods ranging from 0.01 to 1.0 second. The client can be instructed to call out the digits displayed, as well as use them to perform various computations while performing the button-striking tasks. Exercises are either self-paced (Mode A) or apparatus-paced (Mode B). In the self-paced mode, the target button remains illuminated until struck. It then moves to another random location on the board. In the more challenging apparatus-paced tasks, a target button that is not struck within a preset time period, extinguishes automatically, and a new target immediately appears elsewhere on the board. The most challenging tasks combine the striking of buttons within the apparatus-pace tasks with the calling out of digits displayed on the LED panel.

The size and location of the area on the board in which buttons are illuminated can be manipulated in order to train specific abilities. The buttons are arranged in five concentric rings, thus tasks involving use of all five rings represent the largest board size. Tasks can also be selected using only four rings or three rings, which decreases the working area in which the lighted buttons appear. The board can also be divided into four quadrants: upper right, upper left, lower right, and lower left. Tasks can be restricted to any combination of quadrants.

There are approximately 90 units in use in the U.S., in physical therapy departments; and, according to Mary Warren, an occupational therapist experienced with this apparatus, Dynavision is the only standardized reproducible instrument that is large enough for retraining driving-related skills. It can be used to train people to search a visual field where they have a deficit (usually left neglect), but they must have good attentional abilities. Ms. Warren doesn't recommend retraining for people with visual inattention from brain damage. Retraining works best for people with blindness in a visual field but intact attentional mechanisms. It is possible to train drivers to "look where they can't see" and to use license restrictions for drivers who will be compliant. There is a need to look at the demand in the area in which a driver needs to be mobile, when restricting to time of day and radius from home.

There are several published studies on the effectiveness of Dynavision rehabilitation programs for people who had sustained CVAs (cerebral vascular accidents). The first study (Klavora et al., 1995a) examined the effects of Dynavision training on a variety of psychomotor skills in one 71-year old post-stroke male driver whose license was suspended. The subject had limited mobility in his left arm and leg, and some peripheral visual impairment. Dynavision training occurred over a course of 4 weeks, with 4 sessions per week, at approximately 60 minutes per session. A battery of four tests were all administered on each of six days before the treatment period and each of three days after the treatment period to establish a reliable baseline for comparison. The four tests were also administered once each week during training to track change in test performance. Performance improvements began to occur after the start of treatment. Following Dynavision training, the subject had improved on all four measures: he showed a 40 percent increase in the number of hits on a 4-minute Dynavision task; a 6.95 percent decrease (faster) in simple reaction time; a 12.2 percent decrease (faster) in choice reaction time; a 21 percent decrease (faster) in the amount of time to scan a string of letters in a search for two target letters; and a 67 percent increase in the amount of time he could successfully perform a visuomotor coordination task. Even though the subject did not pass an on-road driving test, his posttraining on-the-road driving performance was evaluated as significantly improved from the baseline performance test and a recommendation was made that he receive 4 to 6 hours of additional behind-the-wheel training before attempting another on-road driving test.

In the second study (Klavora et al., 1995b), the usefulness of the Dynavision apparatus for driving-related rehabilitation and the benefits of Dynavision training on the motor, perceptual, and cognitive abilities of 10 older (age 46-73) post-CVA individuals were evaluated. Most of the subjects in the study experienced multiple deficits, including hemiplegia, hemiparesis, reduced peripheral visual field, loss of energy, emotional liability, and reduced attentional capacity. All subjects had failed behind-the-wheel assessments. Training involved three 40-minute Dynavision Training sessions per week for 6 weeks. Comparisons between performance levels before and after the program on several Dynavision, response, and reaction time variables showed significant improvements. Dynavision training resulted in significantly improved behind-the-wheel driving performance when compared with expected outcomes. On the second BTW assessment, 6 of the 10 subjects earned a "safe to resume driving and/or receive on-road driving lessons," and 4 subjects were assessed as "unsafe to drive at this time." The expected frequency for safe assessments on a second attempt was 24 percent during the period of study; the safe rate for study subjects was 60 percent. Furthermore, there was a correlation between Dynavision performance and between "safe" and "unsafe" drivers. The safe drivers scored a significantly greater number of hits than unsafe drivers on the Dynavision endurance and speed tasks.

In a study by Klavora et al. (1997), 56 post-stroke patients whose driving licenses were under suspension completed a Dynavision Performance Assessment Battery of four tests, plus the Cognitive Behavioral Driver's Inventory, in conjunction with an on-road driving test. An analysis showed that each test yielded reasonable prediction of the on-road driving fitness of elderly post-stroke drivers; however, when the scores on the two tests were combined, they explained a greater proportion of the variance in on-road testing than either task alone. All patients who passed the CBDI and the endurance task on the Dynavision test battery were successful in the on-road tests.

References:

• pers. comm., Kristi Berg, President, Visual Resources, Inc.

• Roenker, Cissell, and Ball (submitted)

• 3 on-going studies funded by NIH through Roybal Center (Principal Investigators: Christie Rom, Tom Kalina, and Linda Hunt)

• Vision Aerobics Website; Letter to L. Decina from R. Cheu, 1996

• pers. comm., Peter Klavora, Univ. of Toronto; Mary Warren, Eye Foundation of Kansas City, MO; and Phil Jones, Performance Enterprises, Ontario, Canada

• Klavora, Warren, and Leung (undated). Dynavision for Rehabilitation of Visual and Motor Deficits: A User's Guide

• Klavora et al. (1995a, 1995b, 1997)

• Klavora and Warren (1998)

1C3(a)iii. Rehabilitation Procedures - Elderly Population Without Chronic Conditions: Vehicle Modification


Equipment that comes standard on many vehicles or may be added without the requirement for training by an occupational therapist is described in this section of the Notebook. Special adaptive equipment is described in Section IC3(b)iii.

Many vehicle design characteristics are of special importance to disabled and elderly drivers. Automatic transmission may be a necessity for many drivers with disabilities, and in most cases, it is highly desirable. In addition, power steering and braking reduce the exertion required to drive. Power steering is a must for any driver using one hand to steer, and for drivers with poor endurance, general muscle weakness, and poor muscle control. Other features include power windows, power seats with adjustable seat height, lumbar support, adjustable steering wheel, cruise control, air conditioning (a must for those who have lost capability to regulate body temperature), trunk release, power door locks, rear window defroster, and remote adjustable right and left outside mirrors.

After-market equipment available for use by intact elderly drivers with age-related functional impairments include seat cushions, back rests, pedal extenders, wide angle (convex) stick-on mirrors for side-view mirrors, and a rear-view mirror available from AAA (Panamirror) that expands vision to the left and right rear to reduce the blind spot. The Panamirror consists of three mirrored segments. The central mirror, which comprises a large-radius convex sphere, covers a rearward field approximately the width of the rear window. This treatment minimizes the distance distortion normally associated with convex mirrors. Mirror segments to the left and right sides are designed for the detection of vehicles to the sides, with continually reducing radii to provide maximum visibility of objects in the blind spot. The mirror is attached over the existing rear-view mirror.

Regarding the availability of pedal extenders through AAA, Bill When (AAA Safety Services) advised that pedal extenders were available in the past from AAA for $25.00-30.00; however, many organizations will not supply this equipment without a prescription from a physician or OT, and the price has escalated to near $150.00. Additionally, there was not much demand for the Panamirror, so AAA has discontinued its sale, and provides a list of vendors where Panamirror-type mirrors can be purchased.

The following table lists common disabilities, their effects on driving, and suggested adaptive aids.

Common Disabilities, Their Effects on Driving, and Suggested Adaptive Aids.

 

Disability Effects on Driving Suggested Driving Aids
Lack of Range of Motion - Neck • Limited ability to see the full field of traffic • Convex or 48 rear- and side- view mirrors
General Muscle Weakness • Difficulty turning steering wheel and applying pressure to brake and clutch

• Difficulty applying and releasing brake

• Power steering, power brakes, and automatic transmission

• Adaptation of parking brake (for the stronger limb)

Poor Endurance, Fatigue • Inability to drive for long periods of time without rest • Power steering, power brakes, cruise control
Small Body Size • Insufficient height to see out of windows

• Inability to reach brake, accelerator, dimmer switch, and parking brake

• Specially constructed seat to raise driver (some vehicles have seat height adjustments)

• Extensions on brake, accelerator, dimmer switch, and parking brake or hand operated controls.

Short Legs • Inability to reach brake and accelerator

• Inability to operate dimmer switch and parking brake

• Extension of the brake and accelerator pedals of up to 2 in (5 cm)

• Back cushion

• Seat cushion

• Hand-operated dimmer switch and parking brake

Short Arms • Inability to reach dashboard controls and ignition

• Possible inability to reach gear shift and turn signal

• Difficulty using conventional steering wheel

• Difficulty performing many hand-over-hand steering maneuvers

• Back cushion; extensions for dashboard controls and ignition key

• Extensions on gear shift lever and turn signal lever

• Steering column extension on adjustable steering wheel

• Small steering wheel (requiring fewer revolutions to turn the wheel).

 

References:

• AAA Driver Test and Training Equipment Brochure

• pers. comm., Bill When, AAA Driver Safety Services, Heathrow, FL, 7/98

• Transport Canada (1986)

• Vehicle Selection Guidelines, Milton S. Hershey Medical Center Brochure

 

1C3(a)iv. Rehabilitation Procedures - Elderly Population Without Chronic Conditions: Fitness and Nutrition


Fitness

Joint flexibility is an essential component of driving skill. If upper extremity range of movement is impaired in the older driver, mobility and coordination may be seriously weakened. Older drivers with some upper extremity dysfunction may not be able to steer effectively with both hands gripping the steering wheel rim. Upper extremity movements required for hand control and steering control operation include shoulder abduction, flexion, extension, internal rotation, external rotation, circumduction, and forearm flexion, extension, supination, and pronation (Gurgold and Harden, 1978).

Also with advancing age there is decreased head and neck mobility that adversely affects the older person's ability to complete driving tasks. A restricted range of motion can reduce an older driver's ability to operate an automobile, especially for effectively scanning directly and indirectly (mirrors) to the rear and sides of his/her vehicle to observe blind spots, as well as hindering timely recognition of conflicts during turning and merging maneuvers at intersections (Ostrow, Shaffron, and McPherson, 1992).

Decreased flexibility with age is probably the result of combined histological and morphological changes in the components of the joint, including cartilage, ligaments, and tendons (Adrian, 1981; Serfass, 1980). The greater calcification of cartilage and surrounding tissue, the shortening of muscles, increased tension and anxiety, and the prevalence of arthritic and other orthopedic conditions all contribute to reduced flexibility (Piscopo, 1981). Changes in joints and tendons may adversely affect the flexibility and stability of joints. Studies that have made assessments of flexibility in older persons generally support the conclusion of a decline in flexibility in the middle and later years. Motion perception in the lower extremities, metatarsophalangeal joints (those between the toe and ankle bones), decline with age as well (Kokmen, Bossemeyer, and Williams, 1978). It has also been reported that over 50 percent of people over the age of 65 have osteoarthritis in at least one joint.

One encouraging note is that many of the movement execution problems associated with losses in flexibility pervasive among older road users may stem simply from an overall decline in physical fitness among this group, and is thus amenable to remediation. One research study involving 63 older drivers found that drivers ages 60 to 75 demonstrated less shoulder flexibility and torso/neck rotation than a comparison group including 43 younger drivers (McPherson, Ostrow, and Shaffron, 1988). However, an exercise program conducted by Ostrow et al. (1992) was shown to be an effective intervention for older drivers for enhancing driving skills that accentuate demands on the range of motion, such as observing to the rear and parallel parking. The exercises consisted of chin flexion/extension, neck rotations, head side bending, chin tucks, rotating the shoulders backward, and trunk rotations. After participating in the program, older drivers showed improvements using a field-based assessment of automotive driving skill. Subjects in the experimental group who received the range-of-motion training looked more frequently to the sides and rear of their vehicle than drivers in a control group who did not participate in the exercise program.

Meister (1998) reports that exercise can significantly benefit even people above the age of 80. In a study of nursing-home residents whose average age was 87, ten weeks of progressive resistance exercise led to significant increases in muscular strength, walking speed, and stair-climbing ability.

As described in section IA2(a) of this Notebook, older drivers who have diminished physical performance ability are more likely to be involved in automobile crashes, than older drivers who are physically fit. Information about the benefits of exercise for older adults is ubiquitous. Brochures with activity tips for older adults may be found in grocery stores; articles are written in the magazine sections of Sunday newspapers (e.g., Parade Magazine); the internet has hundreds of advertisements for fitness videos and programs for older adults; and video rental centers, retailers and discount stores offer exercise videotapes geared to seniors. Examples are provided at the end of this section. As noted throughout various sections of this Notebook, health and social service providers are aware of the benefits of exercise for older persons, and have developed exercise programs that are presented in senior centers, local health and fitness centers, and hospital wellness centers. Other sources that may reference the benefits of fitness and include simple exercises are identified in Notebook Section IB3.

According to Dr. Nicholas DiNubile, an orthopedic consultant to the Philadelphia 76'ers basketball team and the Pennsylvania Ballet, fitness strengthens bones, improves balance, and makes falls less likely to occur; if people are in better shape and have better muscle tone, they are less likely to sustain a severe fracture if they do fall (O'Shea, Parade Magazine, September 6, 1998). O'Shea states that falls are the leading cause of death and injury in the U.S. for persons over age 65. Across America, nearly 1,000 people fracture their hips in falls every day. Falling has been associated with increased crash risk; some of the same factors that are associated with falling are associated with automobile crashes.

Seniors need to do exercises that will increase muscle strength, aerobic endurance, and flexibility. Weight-bearing exercises that put stress on bones helps to prevent calcium loss; this will help to strengthen bones and help them to absorb vital minerals. Weight training with light dumbbells, weight machines, or calisthenics (push ups, dips, chins) are all good for the upper body. It is not necessary to go to a gym for this kind of exercise; several resources note that weight training can be accomplished at home using 2.5 pound weights (soup cans, water bottles). A position stand on "Exercise and Physical Activity for Older Adults" by the American College of Sports (summarized by Bowerman, 1998) states that "when the intensity of exercise is low, only modest increases in strength are achieved by older subjects." They state that a number of studies have demonstrated that, given an adequate training stimulus, older men and women show similar or greater strength gains compared with young individuals as a result of resistance training. Two- to threefold increases in muscle strength can be accomplished in a 3- to 4-month timeframe in older adults. They further state that the effects of a heavy-resistance strength-training program on bone density in older adults can offset the typical age-associated declines in bone health by maintaining or increasing bone mineral density and total body mineral content. However, in addition to its effect on bone, strength training also increases muscle mass and strength, dynamic balance, and overall levels of physical activity. All of these outcomes may result in a reduction in the risk of osteoporotic fractures.

Next is aerobic endurance. Aerobic activities are those which increase the heart rate and make a person breathe more quickly, such as bicycling, swimming, and brisk walking while swinging one's arms. Bowerman (1998) says that endurance training appears to lower blood pressure to the same degree in young and older hypertensive adults. He states that the contraindications to exercise testing and exercise training for older men and women are the same as for young adults. The major absolute contraindications precluding exercise testing are:

• Recent ECG changes or myocardial infarction

• Third degree heart block

• Unstable angina

• Acute congestive heart failure

• Uncontrolled arrhythmias

The major relative contraindications for exercise testing include:

• Elevated blood pressure

• Complex ventricular ectopy

• Cardiomyopathies

• Uncontrolled metabolic diseases

• Valvular heart disease

Regular aerobic exercise can increase oxygen uptake, which brings greater endurance for the heart, lungs, and skeletal muscles, and improved ability to burn fat. One workout program geared to seniors is Geri-Fit (see ad at the end of this section). It was developed by a geriatrician and has been medically reviewed and approved by doctors, physical therapists, exercise physiologists, and other health care professionals. It is a 45-minute strength training exercise program for older adults. The exercises are performed seated in a chair, and classes are guided by a trained and certified instructor. Participants bring their own set of 2-pound dumbbells to class. Their website lists several agencies that have purchased their exercise program, which include two senior centers in Ohio. There are dozens of aerobic exercise videotapes on the market, many of which are geared to seniors. Jodi Stolove, a fitness instructor, has three videotapes ranging from 20 to 45 minutes on chair dancing (O'Shea, Parade Magazine, May 17, 1998). She states that they provide a balanced workout that includes a warm-up, toning, aerobic conditioning, stomach crunches, and gentle stretching, all from a chair. The seated workouts are ideal for individuals with a bad knee, arthritis, or poor balance. One videotape exercise program found on the internet is called "More Gain, Less Pain: A Low-Stress Exercise Program for Seniors" (www.fitnesslink.com/moregain.htm). It features Charles Manning, a Certified Personal Trainer, Certified Aerobic Instructor and Corporate Fitness Director. The tapes feature a warm-up, aerobic training, muscle strengthening and toning, and a final stretch. The cost is $19.95. Of course, individuals can contact their local health and fitness club, YMCA, hospital wellness center, or senior center to find out what programs are available in weight training and aerobics for seniors. For example, Howard County (Maryland) Office on Aging provides: seated exercise classes; American Arthritis Foundation-approved exercise classes; Tai Chi; low-impact aerobics; and country line dancing in their senior centers. Classes are twice weekly for 8 to 12 weeks, and cost approximately $25.00.

The last area is flexibility. Staying flexible is important for reaching, bending, keeping balance, and lowers the risk of serious injury in the event of a fall. Simple exercises can be done at home, and most of the videotape exercise programs and regular programming of exercise shows on TV include stretching. Yoga classes at the local YMCA or senior center are another option. Other home activities such as raking leaves and sweeping provide a benefit. Simple exercises are shown at the end of this section, from a pamphlet distributed by the Central Plains (Kansas) Area Agency on Aging.

The National Institute on Aging is currently funding a study to determine whether a multicomponent physical conditioning program can enhance driving performance and improve physical ability among active drivers age 70 and older who have physical impairments, but who are free of severe visual and cognitive impairments (TRB Committee A3B13: Safe Mobility of Older Persons, Newsletter, November 1998).

Nutrition

The material in this section is largely reproduced from an article by Kathleen A. Meister (1998) posted on the American Council on Science and Health's Internet Website (www.asch.org) and by Paula Kurtzweil (1996) originally appearing in the March 1996 FDA Consumer reprinted on the American Dietetic Association Website (www.eatright.org/olderamericans). Sections are also cited from The American Dietetic Association Position Paper on Nutrition, Aging, and the Continuum of Care.

Kurtzweil states that nutrition remains important throughout life; many chronic diseases that develop late in life, such as osteoporosis, can be influenced by earlier poor habits. Insufficient exercise and calcium intake, especially during adolescence and early adulthood, can significantly increase the risk of osteoporosis, a disease that causes bones to become brittle and crack or break. She goes on to say that good nutrition in the later years still can help lessen the effects of diseases prevalent among older Americans or improve the quality of life in people who have such diseases. They include osteoporosis, obesity, high blood pressure, heart disease, certain cancers, gastrointestinal problems, and chronic undernutrition. Studies show that a good diet in later years helps both in reducing the risk of these diseases and in managing the diseases' signs and symptoms. This contributes to a higher quality of life, enabling older people to maintain their independence by continuing to perform basic daily activities, such as bathing, dressing and eating (and driving). Poor nutrition, on the other hand, can prolong recovery from illnesses, increase the costs and incidence of institutionalization, and lead to a poorer quality of life.

Meister (1998) reports that in a 1997 national survey conducted by the American Dietetic Association, 55 percent of respondents age 55 and older reported that they make a conscientious effort to eat healthfully; only 28 percent of respondents aged 25 to 34 reported the same. People age 60 and older do about as well as younger people in terms of fulfilling recognized guidelines concerning intake of fat, saturated fat, and cholesterol. In addition, the proportion of seniors whose intakes of various nutrients are at Recommended Dietary Allowance (RDA) levels is only slightly lower than the proportion of younger adults with such intakes. Nevertheless, some senior citizens do develop significant nutritional problems.

Many things contribute to the risk of malnutrition in older adults. These include:

• Chronic diseases that may lead to physical limitations, making shopping for, preparing, and consuming food difficult without assistance.

• Dental problems that may incline some seniors to avoid eating foods that must be chewed well.

• Depression is relatively common among older people, and it can lead to severe weight loss.

• Changes in the senses of smell and taste, which can result from aging itself or from drug therapy, can cause decreases in food consumption or disinterest in, even aversion to, formerly preferred foods.

• The gastrointestinal side effects of some medications, which can interfere with the desire to eat. Some medicines also affect the absorption or metabolism of nutrients: laxatives that contain mineral oil can decrease the absorption of certain vitamins, for example.

• People often become less active as they age, and consequently, their appetites may decrease. Increasing physical activity, by following an exercise regimen, may stimulate seniors' appetites. It may also help older adults to maintain physical abilities necessary for routine actions, to slow the development of osteoporosis, and to improve their cardiovascular fitness and immune-system functioning.

• Isolation, which is a major risk factor for poor nutrition among seniors, and especially among those seniors who have recently lost a spouse. Someone who is suddenly alone after many years of living with another person may lose interest in eating or, if the housemate was the sole food preparer, may not be accustomed to or even marginally skilled at designing healthful meals and preparing food.

• Lack of money may lead older people to scrimp on important food purchases--for example, perishable items like fresh fruits, vegetables and meat--because of higher costs and fear of waste. They may avoid cooking or baking foods like meats, stews and casseroles because recipes for these foods usually yield large quantities. Financial problems also may cause older people to delay medical and dental treatments that could correct problems that interfere with good nutrition.

An evaluation of the Elderly Nutrition Program of the Older Americans Act indicates that 67 percent to 88 percent of participants are at moderate to high nutritional risk (Ponza, Ohls, and Millen, 1996). These community-based programs are finding serious nutrition-related problems among older adults, especially among the frail homebound. Many older adults have two to three diagnosed chronic health conditions; 26 percent of participants in congregate meal programs and 43 percent of those who receive home-delivered meals had a hospital or nursing facility stay in the previous year. One survey found that almost two-thirds of respondents had a weight outside the healthful range and that 18 percent to 32 percent had involuntarily gained or lost 10 pounds within the 6 months before the survey (Ponza et al., 1996). As pointed out in Section IC2(b)v of this Notebook, Consumer Report's (1998) analysis of data on 35,000 patients found that dietary counseling is given only to 1 in 5 patients during their physical examination appointment with their physician.

The nutritional needs and priorities of the frail elderly differ considerably from those of their active peers (Meister, 1998). Healthy older adults may benefit from following recognized dietary recommendations applicable to most younger adults in the U.S., such as limiting fat intake; but the frail elderly may need to disregard some of those recommendations. For example, to prevent weight loss they may need to ingest fat at levels above those generally recommended.

Meister (1998) states that in older adults, poor health and poor nutrition often interact in a

vicious circle: inadequate food intake promotes illness, and illness diminishes food intake. She cites several research studies that have shown that improving nutrition can contribute to improvements in both health and functioning in older adults. These are presented below.

In one of the studies conducted by F. Michael Gloth III, M.D. and his colleagues at Johns Hopkins University, correction of vitamin D deficiency in frail elders led to improvements on a standard test of their ability to function independently. The improvements may have been due to the relief of symptoms such as muscle weakness and bone pain that often occur in people deficient in vitamin D. In a study conducted in the Netherlands, administration of B-complex and vitamin-C supplements to poorly nourished, elderly nursing home residents led to desirable increases in body weight. Although vitamins are not weight-gain agents, in this case an improvement in vitamin nutrition may have beneficially affected the elders' appetite and disposition, and this may have led to increases in food intake. The improvement in vitamin nutrition may also have increased the seniors' ability to use the nutrients they consumed.

At least two studies have shown that the administration of liquid supplements of protein and other nutrients can improve clinical outcomes in elderly patients whose hips have fractured. In these two studies the patients who received the supplements spent fewer days in a hospital, and had fewer fatal complications from their fractures, than those patients who did not.

In a study conducted in Ireland, correction of marginal thiamin deficiencies in senior citizens led to increases in appetite and subjective well-being and to a decrease in fatigue.

In two double-blind studies, modest vitamin and mineral supplementation improved immune-system functioning in older adults. In one of these studies the subjects who received the supplements had fewer "sick days" from infection than those who instead received a placebo (23 versus 48 days). Meister cautions that taking an overdose of vitamin D can cause serious problems, including bone loss--the very condition that most users of vitamin D supplements want to prevent. Physicians in Los Angeles reported in 1997 on four people who had unintentionally worsened their osteoporosis by taking too much supplemental vitamin D. Supplement users should avoid taking more than one product that contains vitamin D. If an individual takes both a multivitamin that contains vitamin D and a calcium supplement that contains it, one's vitamin D intake might be excessive.

Regarding dietary supplements, Meister states that two kinds of dietary supplements, vitamin-mineral pills and supplementary beverages (e.g., Ensure), are heavily marketed to senior citizens. Both kinds of supplements can contribute to adequate nourishment in some seniors, but they are far from nutritional panaceas. Supplementary beverages were introduced for consumption not by healthy, active people, but by persons with medical conditions that interfere with eating. Such supplements may be appropriate for patients recovering from serious illnesses, for frail elders who need to put on weight, and for persons with medical or dental problems that make chewing or swallowing difficult. Healthy people do not need such products; they would benefit far more from eating a balanced, nutritionally adequate diet that includes diverse foods. Vitamin-mineral pills can be beneficial in some situations, to decrease the risk of vitamin deficiency in frail elders, for example, but such supplements cannot offset an unhealthy diet and should not be used instead of strategies to relieve problems, depression, poor dentition, and medication side effects, for example, that interfere with food consumption. Healthy, active older adults who consume ample food from all the major food groups (grains, vegetables, fruits, dairy products, and meat/meat alternatives) may not need vitamin or mineral supplements at all. Older adults with low calorie intakes, however, may benefit from taking a multivitamin with minerals, because maintaining an adequate intake of such nutrients becomes increasingly difficult as the caloric value of one's diet decreases. Also, it is advisable for older adults who do not drink milk, the main source of calcium and vitamin D in the U.S. diet, to take supplements that provide the Daily Value of those nutrients, especially if the non-milk-drinking seniors are seldom exposed to sunlight.

The current Recommended Dietary Allowances (RDAs) do not provide separate recommendations for persons older than 51 years and, thus, do not take into account that older adults have special nutrition needs (Food and Nutrition Board, 1989). In 1996, the American Dietetic Association developed a "Nutrition and Health For Older Americans Campaign" and posted fact sheets about eating healthy geared to older adults on their internet website (www.eatright.org/older americans/foodneeds.html). This site includes a food guide pyramid for older Americans that illustrates some of the nutritional needs and differences. They indicate that persons who want help in interpreting the pyramid should ask their doctor to recommend a registered dietitian, or call The American Dietetic Association's

Consumer Nutrition Hot Line (1-800-366-1655) for a referral. Some of these are discussed below.

• Calorie Needs. While vitamin and mineral requirements don't decline, the need for calories decreases by 25 percent as we age.

• Convenience. Healthy, balanced intake of nutrients will increase if foods, both convenient to obtain and prepare, are emphasized in meal planning.

• Thirst and Fluid Requirements. As they age, many people experience a decreased sensitivity to thirst. In addition, many older adults may have difficulty in moving around the house to get something to drink, or may restrict their fluid intake due to an incontinence problem.

Kurtzweil (1996) reports that many older people may find help under the Older Americans Act, which provides nutrition and other services that target older people who are in greatest social and economic need, with particular attention on low-income minorities. According to the U.S. Administration on Aging, which administers the Older Americans Act, the nutrition programs were set up to address the dietary inadequacy and social isolation among older people. Home-delivered meals and congregate nutrition services are the primary nutrition programs. The congregate meal program allows seniors to gather at a local site, often the local senior citizen center, school or other public building or a restaurant, for a meal and other activities, such as games and lectures on nutrition and other topics of interest to older people. Available since 1972, these programs, funded by the federal, state and local governments, ensure that senior citizens get at least one nutritious meal five to seven days a week. Under current standards, that meal must comply with the Dietary Guidelines for Americans and provide at least one-third of the Recommended Dietary Allowances for an older person. Often, people receive foods that correspond with their special dietary needs, such as no-added-salt foods for those who need to restrict their sodium intake or ground meat for those who have trouble chewing.

Other nutrition services provided under the Older Americans Act are nutrition education, screening and counseling. Kurtzweil cites Jean Lloyd, a registered dietitian and nutrition officer with the Administration on Aging, who states that while these nutrition programs target poor people, they are available to other older people regardless of income. Although no one is charged for the meals, older people can voluntarily and confidentially donate money, she said. The meals provide not only good nutrition, but they also give older people a chance to socialize--a key factor in preventing the adverse nutritional effects of social isolation. For those who qualify, food stamps are another aid for improving nutrition. Under this program, a one-person household can receive up to $115 a month in food stamps to buy most grocery items. For the homebound, grocery-shopping assistance is available in many areas. Usually provided by nongovernment organizations, this service shops for and delivers groceries to people at their request. The recipient pays for the groceries and sometimes a service fee.

However, in their position paper on "Nutrition, Aging, and the Continuum of Care" the American Dietetic Association cites Poza et al. (1996) and Burt (1993), who indicate that Federal programs to combat hunger and food insecurity reach only one-third of needy older adults (Burt, 1993). The Older Americans Act's congregate and home-delivered meal programs and the US Department of Agriculture's Food Stamp Program reach those with the highest rates of food insecurity, but fail to reach many who do not meet the income guidelines for food stamps or who will not accept aid because of its connotation as welfare. Many may be unaware of, are unable to get to, or are uncomfortable attending a congregate meal program, or no programs exist in their area. Additionally, they may fail to qualify or be placed on long waiting lists for home-delivered meals (Poza et al, 1996; Burt, 1993). To date, older adults have not been a primary focus of hunger advocacy groups, food banks, food pantries, and soup kitchens. (American Dietetic Association).

Kurtzweil suggests that family members and friends can help ensure that older people take advantage of food programs by putting them in touch with the appropriate agencies or organizations and helping them fill out the necessary forms. In some communities, private organizations sell home-delivered meals. Other steps include: looking in occasionally to ensure that the older person is eating adequately; preparing foods for and making them available to the older person; and joining the older person for meals. In some cases, they may help see that the older person is moved to an environment, such as their home, an assisted-living facility, or a nursing home, that can help ensure that the older person gets proper nutrition. Whatever an older person's living situation, proper medical and dental treatment is important for treating medical problems, such as gastrointestinal distress and chewing difficulties, that interfere with good nutrition. If a medication seems to ruin an older person's taste and appetite, a switch to another drug may help.

A review of basic diet principles may help improve nutrition. Explaining to older people the importance of good nutrition in the later years may motivate them to make a greater effort to select nutritious foods. Health and wellness programs sponsored by Hospitals, YMCA's, and senior centers often provide information about nutrition in seminars or classes. The "Eat Well" brochure contained at the end of this section was found at a local grocery store.

The American Dietetic Association states that "Nutritional well-being is integral to successful aging. Successful aging, in turn, results from a broadly defined continuum of care that promotes quality of life, independence, and health. Medical and other supportive services, including food and nutrition services, that are appropriate to levels of dependency, diseases, conditions, and functional ability are key components of the continuum of care. The burgeoning elder population, changing concepts of aging itself, and dramatic changes in the delivery of health care accentuate the importance of food and nutrition as sustenance as well as in disease prevention and therapy." They further state that "Good nutritional status in older adults benefits both the individual and society: health is improved, dependence is decreased, time required to recuperate from illness is reduced, and utilization of health care resources is contained."

In development of the Model Driver Screening and Evaluation Program, it appears that a dietetics professional is an important referral source in the case management of persons who cease driving. Administrators of the Ohio Older Driver Program have found that stopping driving has an incredibly negative impact on health. For example, a person's vitamin B level is likely to fall off when they "stop driving to restaurants for lunch (for a fish sandwich) and stay home and eat cookies." (pers. comm., Bonnie Kantor, 1/20/98).

References

• Chair Dancing, Department P., 2658 Del Mar Heights Road, Del Mar, California 92014; 1-800-551-4386; www.chairdancing.com.

• "Helping You Drive Safely Longer" (Pamphlet: Central Plains Area Agency on Aging)

• Michael O'Shea (in Parade Magazine, 5/17/98 and 9/6/98)

• Gurgold and Harden (1978).

• Daniel Bowerman, D.C. (in Health and Fitness Magazine, November, 1998)

• Brochures distributed at local grocery stores, "Stay Active: Activity Tips for Older Adults" and "Eat Well: Food Tips for Older Adults." (developed as part of "To Your Health! Food and Activity Tips For Older Adults," an information and education campaign to promote healthful food choices and physical activity for healthy adults age 55+. "To Your Health" is a cooperative effort by the National Council on the Aging, the National Institute on Aging, the President's Council on Physical Fitness and Sports, and the Food Marketing Institute.

• Jean-Noel Bassior (in Parade Magazine, November 22, 1998)

• Geri-Fit Co. Ltd. P.O. Box 444, Hudson, OH 44236; phone: 330-655-9306; 1-888-GERIFIT; fax: 330-655-9347; www.gerifit.com

• "More Gain, Less Pain: A Low-Stress Exercise Program for Seniors;" (www.fitnesslink.com/moregain.htm)

• Ostrow, Shaffron, and McPherson (1992).

• Adrian (1981).

• Serfass (1980).

• Piscopo (1981).

• Kokmen, Bossemeyer, and Williams (1978).

• McPherson, Ostrow, and Shaffron (1988).

• Ponza, Ohls, and Millen (1996).

• Burt (1993).

• ADA Position adopted by the House of Delegates on October 26, 1986, and reaffirmed on October 24, 1991 and September 15, 1995. This position will be in effect until December 31, 1999.

[ Stay Active (front) ]

[ Stay Active (back) ]

[ Eat Well (front) ]

[ Eat Well (back) ]

[ Helping You Drive Safely Longer (front) ]

[ Helping You Drive Safely Longer (back) ]

[ Weight Lifter ]

[ Geri-fit ]

[ More Gain/Less Pain ]

 

1C3(b)i. Rehabilitation Procedures - Elderly Population With Chronic Conditions Requiring Intervention: Physician and/or Occupational Therapist Review


Loss of the ability to drive is often a major obstacle to being able to live independently and return to employment following a disability. Hunt (1993) reports that many health professionals are unaware that automobiles can be adapted to enable independent transportation for the physically disabled. The objective of occupational therapy treatment is to make changes in performance components (e.g., strength, fine motor ability, problem solving ability) and or contexts (e.g., environmental factors) so that a person can function in a specific activity (AOTA, 1994a). When these changes cannot be made, the occupational therapist teaches the individual compensatory techniques to allow success in performance areas in spite of continued impairment. Occupational therapists may be certified by AOTA in neurorehabilitation, pediatrics, and geriatrics (certification under development). Other certification that OTs may obtain from external associations include: hand therapy, driver rehabilitation specialty, aquatic therapy, and as an assistive technology provider.

Driver rehabilitation services are established to assist individuals with a variety of disabilities to achieve independent, low-risk driving. Driver rehabilitation may be of benefit whenever a disabling condition affects a person's driving ability. Disabilities may be neurological, orthopedic, or developmental in nature, or may occur as a result of age-associated changes. A table is presented at the end of this section that lists the following: specific diagnoses; their effects on driving; what can be done to remediate a person to allow him or her to continue to drive safely; and a generic list of referral resources. This information was largely taken from a report by Sabo and Shipp (1989) and Harvard and Shipp (1998), with input using Fact Sheets produced by ADED. This matrix will be of particular use to health care specialists who may not have undergone any inservice training about the effects of medical conditions on driving ability, and can help point professionals in the right direction when referring a driver for further evaluation/remediation of their ability to drive safely. A similar table is presented in Section IC3(b)iii, for drivers with physical impairments (e.g., missing or non-functional limbs) who may benefit from adaptive equipment.

Whether a disabled/impaired individual can be remediated to drive is governed by the following:

• Can the person handle the mental and physical demands of driving?

• Will he or she be able to transfer to a driver seat or will the individual need to drive from a wheelchair?

• Will the person need special modifications to operate the vehicle?

Acquiring the correct information to answer these questions requires the assistance of professionals. An individual's physician and health care team will have input, but the expertise and assistance of a driver rehabilitation specialist is recommended. Driver rehabilitation specialists can be contacted through a rehabilitation center, the Association for Driver Rehabilitation Specialists/ADED, or the American Occupational Therapy Association (AOTA). Driving rehabilitation specialists come from a variety of disciplines including driver education and occupational, physical, recreational, and kinesio therapies. The primary discipline providing these services is occupational therapy. It is important to note that no discipline is able to provide these specialized services solely on the basis of their degree or credential--all disciplines require additional training. Training programs to provide driver rehabilitation specialists are scarce. ADED is working on a Professional Development series to provide training workshops. The target date for the first workshop is August 2000. AOTA is developing a driver rehabilitation soft-bound book in response to requests from their membership for training materials. ADED is working in partnership with AOTA on this project.

ADED began the certification process for driver rehabilitation specialists in 1992. The exam was developed in 1994-95. To take the exam, the applicant must either hold an undergraduate degree in rehabilitation, education, health, safety, therapy or a related profession; or have eight years of full-time experience working in the field of Driver Rehabilitation. There are too few CDRS's to perform assessments on all who need them. To increase the number of CDRS's, at least two things must happen: (1) an educational core curriculum must be established; and (2) a curriculum must be developed. AOTA is informally assessing current university-level driver rehabilitation instruction within OT coursework. Driver rehabilitation content is not required, although many universities provide a one-hour, non-standardized introductory session. ADED is currently convening an education committee to develop educational standards that will serve as the foundation for training curriculums.

The Association of Driver Educators for the Disabled has a fact sheet called "Recommended Practices for Driver Rehabilitation Services." It states that a driver rehabilitation program must have a qualified driver rehabilitation specialist and the appropriate vehicle(s) and equipment to provide comprehensive services in the following areas:

1. Clinical Evaluation: Applicable testing in the areas of physical functioning, visual/perceptual/cognitive screening. Where applicable, a wheelchair/seating assessment shall be conducted.

2. Driving Evaluation: Shall include an on-the-road performance assessment of the client in an actual driving environment using equipment similar to that which is being prescribed.

3. Vehicle Modification/Prescription: All prescriptions shall be based on the client's demonstrated performance in an actual driving experience with equipment similar to that which is being prescribed. The prescription should include appropriate description and dimensions of the client's vehicle and wheelchair.

4. Driver Education: Shall include sufficient practice and training to enable the client to operate a motor vehicle with the prescribed equipment at a level that meets the client's needs for a driver's license.

5. Final Fitting: The client shall receive a final fitting and operational assessment in his/her modified vehicle.

Many major rehabilitation centers conduct complete driver evaluation programs which are certified by their State's department of motor vehicles. This includes a pre-driver evaluation, behind-the-wheel lessons, and assistance in licensing. Pre-driver evaluation includes testing eyesight, motor control, judgment, and reaction time. Hunt (1993) states that poor judgment may be the only limiting factor that revokes a driver's license. Judgment and attentional deficits require serious consideration because these cannot be remediated with compensatory techniques or equipment.

For example, at Bryn Mawr Rehabilitation Hospital's Adapted Driver Education Program, which has a State license and speciality certification, approximately 250 individuals are evaluated and trained each year. Tom Kalina, the program coordinator, stated that "success depends on the situation; if someone fails, it can still be a successful evaluation because it helps the person see that he or she is not able to drive anymore."

Another example is the Cleveland Clinic Foundation Driver Rehabilitation service. The primary goal of the service is to enable their clients to attain low-risk independent mobility in the community using the least amount of adaptive technology possible. Services are provided by a Registered Occupational Therapist, who is a also a Certified Driver Rehabilitation Specialist - a health care professional specifically trained in the evaluation and treatment of visual, physical, sensory, and cognitive/perceptual dysfunction within the driving task. The program features a specially-modified evaluation sedan which can be fitted with several types of hand controls, adapted steering devices, a

left-side accelerator pedal, devices to activate secondary controls, and other adaptive driving aids.

One of the services offered at the Clinic includes Occupational Therapy Driving Education. Most clients entering the program undergo a three hour OT Driving Evaluation. It consists of a two hour clinical assessment which screens visual, cognitive/perceptual, and physical capabilities as they relate

to the driving task, followed by a one hour behind-the-wheel assessment in their evaluation sedan using necessary adaptations. If concerns are identified during the Driving Evaluation, or if the person needs to learn safe use of adaptive driving aids, a systematic program of therapy designed to decrease a client's driving risk may be recommended. This form of occupational therapy treatment is called "driver rehabilitation" and is individualized to the client's particular needs. Obtaining proper license restrictions for adapted equipment is also included under this service.

Vehicle Modification Consultation service is provided by Cleveland Clinic Foundation primarily to those who have successfully completed driver rehabilitation using adapted equipment, or to individuals who require modifications to a vehicle in order to be transported safely as passengers. The detailed report generated by this service describes what equipment and vehicle modifications an individual requires. The report may be submitted to equipment vendors/van modifiers for competitive bid.

Driving programs stress that a consultation with the individual's physician is necessary to make sure that he or she is physically and psychologically prepared for the driving experience. If an individual is evaluated too soon after an injury, there is the danger of recommending too much equipment and, consequently, spending money on adaptive equipment he or she will not need in the future. After a traumatic experience, such as a spinal cord injury, there is a great deal to re-learn. A person should be cautioned not to put too much pressure on himself or herself too soon.

Most driver evaluation programs utilize vehicles with hand controls and steering devices to instruct their clients. Some cars have a Chair Topper mounted on the roof which mechanically loads and stores the wheelchair for the driver or passenger. Most programs also operate a fully modified van for people who drive from their wheelchairs. This van may have a raised top as well as a lowered floor. It may also have a Lift-A-Way or Swing-a-Way wheelchair lift with power doors on the side cargo door and a remote control entry device. Some driving programs are even including the lowered-floor minivan conversion such as the Braun Entervan.

After entering the vehicle, the evaluator can determine if the client will drive from a wheelchair or from a power seat. The power seat base moves electrically into position next to the client so that the transfer may be comfortable and safe. Generally, if a person can transfer, he or she should drive from the van seat which is bolted to the floor. If the client cannot transfer, an electric wheelchair tiedown can be added along with special stabilizing belts to secure the client and the wheelchair behind the steering wheel.

There are many different types of driving controls and assistive driving devices. These include hand controls for throttle and brake, extended steering columns to position the wheel at the proper height, lower effort steering and braking, and modified vehicle switches. In a driver training vehicle, it may take a few sessions to fit this equipment. Once the client is evaluated by the instructor, he or she can begin to shop for a vehicle. Hunt (1993) reports that adaptive devices have been referred to as "gadgets" that can be recommended by physicians. She states that this suggestion is erroneous because physicians are generally not familiar with the variety of adaptive devices or the functional performance skills necessary to use these devices. In addition, selection of appropriate devices requires trial usage, followed by the modification or selection of a different device. Because people are generally unable to spontaneously adjust to driving with these devices, they require training; OTs can provide training and practice in a nonthreatening, nonjudgmental environment.

Credentials for Occupational Therapists:

Occupational therapy services include, but are not limited to:

• Assessing and providing treatment in consultation with the individual, family, or other appropriate persons;

• Designing interventions directed toward developing, improving, sustaining, or restoring daily living skills, including self-care skills and activities that involve interactions with others and the environment, work readiness or performance, play skills or leisure capacities, or enhancing educational performance skills;

• Developing, improving, sustaining, or restoring sensorimotor, oral-motor, perceptual, or neuromuscular functioning, or emotional, motivational, cognitive, or psychosocial components of performance;

• Educating the individual, family, or other appropriate persons in carrying out appropriate interventions.

These services may encompass assessing the need and design, development, adaption, application, or training in the use of assistive technology devices; designing, fabricating, or applying rehabilitative technology; training in the use of orthotic or prosthetic devices; applying physical agent modalities as an adjunct to or in preparation for purposeful activity; applying ergonomic principles; adapting environments and processes to enhance functional performance; or promoting health and wellness (AOTA, 1994b).

Accreditation of educational programs for the occupational therapist and the occupational therapy assistant is granted by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association (AOTA). The ACOTE is recognized as the accrediting agency for occupational therapy education by the United States Department of Education (USDE) and the Council on Higher Education Accreditation (CHEA).

An occupational therapist is a "professional-level" practitioner who has, at a minimum, a Bachelor's Degree in occupational therapy (or a Master's degree in OT, after receiving a BA in another field), has completed 6 months of field work, and has passed the national certification examination. An Occupational Therapy Assistant (COTA) is also a practitioner, for whom standards are provided by AOTA. The COTA is a "technical-level" practitioner who has completed an Associate's Degree Program in occupational therapy (2 years post-secondary education), has completed 3 months of field work, and has passed the national certification examination. All COTAs require more than a minimal level of supervision by an OT when providing services (AOTA, 1993). The major function of a COTA is to provide quality occupational therapy services to assigned individuals under the supervision of an OT, such as assisting with data collection and evaluation; developing treatment goals; implementing and coordinating intervention plans; providing direct service; adapting intervention equipment; administering standardized tests; etc.

Occupational therapists who treat for strokes, spinal cord injuries, amyotrophic lateral sclerosis, Alzheimer's Disease, brain injury, Multiple Sclerosis, or Parkinson's Disease may become Board Certified in Neurorehabilitation (BCN). Neurorehabilitation encompasses the treatment of sensory, motor, cognitive, and behavioral processes which impact on functional performance in persons with central nervous system disorders. Requirements for board certification include: (1) 5 years of experience in neurorehabilitation since initial certification/licensure including direct treatment, supervision, teaching, etc; and at least 2 years of direct treatment in neurorehabilitation practice; (2) demonstrated professional development; and (3) a qualifying score on the written exam.

Excerpts From: STANDARDS FOR AN ACCREDITED EDUCATIONAL PROGRAM FOR THE OCCUPATIONAL THERAPIST (American Occupational Therapy Association, 1998) are provided in the pages that follow, to promote an awareness of the depth and breadth of the training to become an OT, the skill level of OT for providing assessment and rehabilitation, and how OTs fit into the health care delivery system.

STANDARDS FOR AN ACCREDITED EDUCATIONAL PROGRAM FOR THE OCCUPATIONAL THERAPIST

Basic Tenets of Occupational Therapy

• Acknowledge and understand the importance of the history and philosophical base of the profession of occupational therapy.

• Understand the meaning and dynamics of occupation and purposeful activity including the interaction of performance areas, performance components and performance contexts.

• Be able to articulate to the consumer, potential employers, and general public the unique nature of occupation as viewed by the profession of occupational therapy and communicate the value of occupation for the client.

• Acknowledge and understand the importance of the balance of performance areas to the achievement of mental and physical health.

• Understand and appreciate the role of occupation in the promotion of health and the prevention of disease and disability for the individual, family, and society.

• Understand the effects of health, disability, disease processes, and traumatic injury to the individual within the context of family and society.

• Exhibit the ability to analyze tasks relative to performance areas, performance components, and performance contexts.

• Appreciate the individual's perception of quality of life, well being, and occupation to promote health and prevention of injury and disease.

• Understand the need for compensatory strategies when desired life tasks cannot be performed.

Screening and Evaluation

• Use standardized and non-standardized screening tools to determine the need for occupational therapy intervention. These include, but are not limited to, specified screening assessments, skilled observation, checklists, histories, interviews with the client/family/significant others, and consultations with other professionals.

• Select appropriate assessment tools based on client need, contextual factors, and psychometric properties of tests.

• Use appropriate procedures and protocols, including standardized formats, when administering assessments.

• Understand and appreciate the participation of the certified occupational therapy assistant as a data gatherer and contributor to the screening and evaluation process.

• Exhibit the ability to interpret criterion referenced and norm referenced standardized tests scores based on an understanding of sampling, normative data, standard and criterion scores, reliability, and validity.

• Consider factors that might bias assessment results, such as culture, disability status, and situational variables related to the individual and context.

• Interpret the evaluation data in relation to uniform terminology of the profession and relevant theoretical frameworks.

• Demonstrate the ability to use safety precautions with the client during the evaluation and screening process. These include, but are not limited to, standards for infection control that include universal precautions.

• Understand the need when indicated for referral to specialists both internal and external to the profession for additional evaluation.

• Document occupational therapy services to ensure accountability of service provision and meet standards for reimbursement of services. Documentation shall effectively communicate the need and rationale for occupational therapy services. Documentation must be appropriate to the system in which the service is delivered.

• Adhere to the Standards for Educational and Psychological Testing by the American Psychological Association.

Intervention Plan: Formulation and Implementation

• Identify appropriate models of practice, theoretical approaches, and frames of reference based on the interpretation of evaluation findings.

• Develop occupational intervention plans and strategies, based on the stated needs of the client and data gathered during the evaluation process, including goals and methods to achieve them.

• Provide evidence-based effective therapeutic intervention related to performance areas, performance components, and performance contexts directly and in collaboration with the client and others.

• Employ relevant occupations and purposeful activities that support the intervention goals and are meaningful to the client.

• Use individual and group interaction as a means of achieving therapeutic goals.

• Develop and promote use of appropriate home and community programming to support performance in the client's natural environment.

• Foster education of client/family/significant others, including prevention, health maintenance, and safety, which facilitate skills in performance areas.

• Exhibit the ability to use the teaching-learning process with client/family/significant others, colleagues, other health providers, and the public. This includes assisting learners to identify their needs and objectives, and using educational methods that will support those needs and objectives.

• Demonstrate the ability to collaborate through written, oral, and nonverbal communication with client/family/significant others, colleagues, other health providers, and the public.

• Use therapeutic adaptation with occupations pertinent to the need of the client. This shall include, but not be limited to, family/careprovider training, environmental and behavioral modifications, orthotics, prosthetics, assistive devices, and equipment.

• Demonstrate the ability to grade and adapt tasks related to performance areas and performance components for therapeutic intervention.

• Demonstrate the ability to teach compensatory strategies such as use of technology, adaptations to the environment, involving others and animals in the completion of tasks.

• Demonstrate the ability to use safety precautions with the client during therapeutic intervention, including but not limited to, contraindications and use of infection control standards that include universal precautions.

• Supervise and collaborate with certified occupational therapy assistants on therapeutic interventions.

• Supervise and instruct non-occupational therapy personnel regarding therapeutic interventions.

• Demonstrate when necessary the ability to refer to specialists both internal and external to the profession for consultation and intervention.

• Monitor and reassess, in collaboration with the client, the effect of occupational therapy intervention and the need for continued and/or modified intervention.

• Employ, in collaboration with the client, discharge planning, such as reviewing needs of client/family/significant others, resources, and discharge environment. This includes, but is not limited to, identification of community resources, identification of human and fiscal resources, recommendations of environmental adaptations, home programming, and other needed areas.

• Organize, collect, and analyze data in a systematic manner for evaluation of practice outcomes.

• Terminate occupational therapy services when stated outcomes have been achieved or determined that they cannot be achieved, including summary of occupational therapy outcomes, appropriate recommendations and referrals, and discussion with the client of post discharge needs.

• Document occupational therapy services to ensure accountability of service provision and meeting standards for reimbursement of services. Documentation shall effectively communicate the need and rationale for occupational therapy services. Documentation must be appropriate to the system in which the service is delivered.

Context of Service Delivery

• Understand the system models of health care, education, community, and social systems as they relate to the practice of occupational therapy.

• Understand the current policy issues in the above mentioned systems that effect the practice of occupational therapy.

• Understand the current social, economic, political, geographic, and demographic factors that effect policy development and the provision of occupational therapy services.

• Understand the role and responsibility of the practitioner to address changes in service delivery policies and to effect changes in the system.

• Understand the trends in models of service delivery and their effect on the practice of occupational therapy, including but not limited to medical, educational, community, and social models.

• Appreciate the influence of international occupational therapy contributions to education, research, and practice.

Management of Occupational Therapy Services

• Understand a variety of systems and service models, including, but not limited to, health care, education, community and social models, and how these models effect service provision.

• Demonstrate knowledge of the social, economic, political, and demographic factors that influence the delivery of health care in the U.S.

• Understand the implications and effects of federal and state regulatory and legislative bodies on practice.

• Understand the systemic and policy issues, including knowledge and implication of current statutes and regulations that effect the provision of occupational therapy services.

• Demonstrate knowledge of and ability to comply with the various reimbursement mechanisms that effect the practice of occupational therapy, including, but not limited to federal, and state reimbursement practices, third party and private payers.

• Advocate for the profession and the consumer, to include an understanding of the due process and appeals systems when reimbursement is not approved for occupational therapy services or for specific services for the consumer.

• Demonstrate an understanding of the resources and mechanisms that a practitioner can use to respond to changes in the marketplace.

• Demonstrate knowledge of applicable national and state requirements for credentialing.

• Use principles of time management, including being able to schedule and prioritize workloads.

• Maintain and organize treatment areas, equipment, and supply inventory.

• Maintain records as required in practice setting, third party payers, and regulatory agencies.

• Demonstrate the ability to design and implement program improvement measures and ongoing service delivery assessment using predetermined criteria.

• Plan, develop, and organize the delivery of services to include the determination of programmatic needs such as staffing and service delivery options.

• Demonstrate the ability to supervise professional, technical, and non-occupational therapy personnel.

• Understand the responsibility for fieldwork education and supervision.

• Develop strategies for effective use of professional and non-professional staff.

• Formulate and manage teams for effective service provision.

• Use analysis of outcome studies to direct administrative changes.

• Develop entry-level marketing skills to advance the profession.

Use of Research

The ability to read and understand current research that affects practice and the provision of occupational therapy services.

Fieldwork Education

Fieldwork education is a crucial part of professional preparation and is best integrated as a component of the curriculum design. Fieldwork experiences should be implemented and evaluated for their effectiveness by the educational institution. The experience should provide the student with the opportunity for carrying out professional responsibilities, under supervision, and for professional role modeling.

Level I fieldwork shall be integral to the program's curriculum design and include experiences designed to enrich didactic coursework through directed observation and participation in selected aspects of the occupational therapy process. The focus of these experiences is not intended to be independent performance. Supervised Level I fieldwork with qualified personnel, includes, but is not limited to, initially certified nationally occupational therapy practitioners, psychologists, physicians assistant, teachers, social workers, nurses, and physical therapists. The goal of Level I Fieldwork is to introduce students to the fieldwork experience, develop a basic comfort level with and understanding of the needs of clients.

Level II fieldwork shall be integral to the program's curriculum design and shall include an in-depth experience in delivering occupational therapy services to clients, focusing on the application of purposeful and meaningful occupation. It is recommended that the student be exposed to a variety of clients across the life span and to a variety of settings. The fieldwork experience shall be designed to promote clinical reasoning and reflective practice, to transmit the values and beliefs that enable ethical practice, and to develop professionalism and competence as career responsibilities. The goal of Level II fieldwork is to develop competent, entry-level, generalist occupational therapists. The student can complete Level II fieldwork in a minimum of one setting and maximum of four different settings. It Requires a minimum of the equivalent of 24 weeks full time of Level II fieldwork. This may be completed on a full-time or part-time basis, but not less than half-time relative to the fieldwork site. A maximum of 12 weeks of Level II fieldwork can be completed under the supervision of an occupational therapist in a setting without an occupational therapist on site, in keeping with state credentialing requirements.

References:

• American Occupational Therapy Association, Inc. (AOTA), 4720 Montgomery Lane, P.O. Box 31220, Bethesda, MD 20824-1220. Phone: (301) 652-2682, Fax: (301) 652-7711. www.aota.org.

• American Occupational Therapy Association (1993, 1994a, 1994b, 1998)

• Association of Driver Educators for the Disabled (ADED), P.O. Box 49, Edgerton, WI 53534. Phone: (608) 884-8833; Fax: (608) 884-4851

• B R A U N Guidelines for Choosing the Right Mobility Equipment, Automotive Innovations, Inc Website (www.ai1.com) Automotive Innovations, Inc. 4 First Street, Bridgewater, MA 02324, (508) 697-8324.

• Bryn Mawr Adapted Driver Education Program. "Steering Toward Independence," Daily Local News, Chester County, PA Newspaper; November 6, 1995

• Cleveland Clinic Foundation, Driver Rehabilitation Services, 9500 Euclid Avenue, Cleveland, OH, 44195 (216) 444-2200 (Website:www.ccf.org)

• Hunt (1993)

• Association of Driver Educators for the Disabled. (undated). Driving and Alzheimer's/Dementia.

• Association of Driver Educators for the Disabled. (undated). Driving After a Stroke.

• Association of Driver Educators for the Disabled. (undated). Driving After a Spinal Cord Injury.

• Benner, L., Bytof, J., and Gallop, S. (undated). Functional Vision and Driving.

• Sabo, S. and Shipp, M. (1989). Disabilities and Their Implications for Driving. Louisiana Tech University, Center for Rehabilitation Science and Biomedical Engineering.

 
Diagnoses
Diagnosis Effects on Driving Remediation Resources
Alzheimer's Disease/Dementia Compromises in:

• attention

• processing speed

• visuospatial functioning

• decision making

• judgment

• planning

• memory

• behavior

• awareness of problem areas

Warning signs:

• driving too slowly

• failure to observe signs or signals

• difficulty interpreting traffic situations and predicting changes

• failure to yield

• easily frustrated or confused

• frequently gets lost

• needs instructions from passengers

• poor road position or driving the wrong way down streets

• Comprehensive evaluation by driver rehabilitation specialist (clinical plus driving) to determine extent of impairments, and level of hazard posed by driver

• Counseling (during early stages) re: compensatory strategies (where and when to drive; taking a passenger, etc.), planning for retirement from driving

• Due to progressive nature of the disease, periodic re-evaluation of driving safety should be conducted in response to changes with the individual's level of functioning.

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Parkinson's Disease

A disorder of the central nervous system that is slowly progressive

• difficulty and slowness in initiating movement

• resting tremors in forearms and elbow, w/ pill-rolling movements of the fingers

• rigidity in muscles of the neck, trunk, and forearm

• difficulty with fine and gross motor skills

While there is no loss in sensory function, there may be dementia and memory loss. The person may not know where he or she is in relation to the space around them.

• Usually no adaptive equipment is needed; the focus of training should be to teach compensatory techniques for decreased physical functioning

• An evaluation of the person's active range of motion should be done to ensure the necessary range to reach controls

• Reaction time and fine and gross motor coordination should be evaluated

• A cognitive assessment should be conducted to assess the thought processes involved in driving

• Reevaluation should be conducted in response to significant changes in the person's level of functioning

•Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

Stroke

(Syndrome that involves damage to brain tissue caused by a disruption of the blood supply to the brain. The affected areas will in part determine whether the effects of stroke are severe, moderate, or minimal, and whether they are temporary or permanent)

May affect vision perception, physical functionality, and reaction time, including:

• All or partial loss of muscle strength on 1 side of the body, & involuntary muscle movements may interfere with the ability to use the involved limbs for operating primary & secondary controls. Sitting balance may also be a problem.

• Possible partial loss of vision and/or perceptual changes including visual field defects, inability to recognize & understand signs, signals, & markings.

• Impaired cognitive skills: decision making & judgment.

• Reaction time may be impaired for responding to events on the roadway that require an immediate response (evasive maneuvers or immediate stops)

Warning signs:

• inappropriate driving speeds

• needs help from passengers

• failure to observe signs or signals

• slow or poor decisions (poor judge of distances, too close to other cars)

• easily frustrated or confused

• pattern of getting lost, even in familiar areas

• accidents or near misses

• drifting across lane markings & into other lanes

• Comprehensive evaluation by driver rehabilitation specialist (clinical plus driving) to determine extent of impairments

• Adaptive equipment for physical problems:

• spinner knob

• left foot accelerator

• right-side mounted turn signal lever

• parking brake extension

• chest harness for balance

• hand operated dimmer switch

• Physical therapy and occupational therapy (strength building exercises)

• Compensatory scanning techniques may need to be taught if there is a visual field deficit

• If the person experiences difficulty in navigation skills, training may need to be focused on this area

• Speech therapy for language skills; both verbal and written info.

• Need to monitor side effects of medications and effects on driving (side effects of coumadin and heparin--anti-coagulant medications--include possible bleeding from the body orifices).

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Note: Harvard and Shipp (1998) state that a person with left-sided neglect should not drive.

Spinal Cord Injury • Loss of strength and/or range of motion. Depending on location of injury, may affect breathing, use of arms, shoulders, hands, and legs. (see specific functional deficit in matrix of physical deficits).

• May also include compromised visual perception and reaction time.

• Comprehensive evaluation by driver rehabilitation specialist (clinical plus driving) to determine extent of impairments

• The level and extent of spinal cord involvement will determine the need for vehicle modifications and adaptive driving equipment. Adaptive equipment for physical problems:

• reduced effort steering systems

• servo brake and accelerator control

• joystick driving systems

• mirror system for person who can't turn head

• adaptive equipment/vehicle modifications for wheelchair access

• Dynavision

• Need to monitor side effects of medications and effects on driving (Anti-spasmodic medication may be prescribed for a person with a high level spinal cord injury. Drowsiness, weakness, and fatigue are possible side effects of Valium, Dantrium, and Lioresal).

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Traumatic Brain Injury • Impairments in muscle function and joint mobility. Ranges from extensive loss of strength, range of motion, coordination, reaction abilities, and/or balance to little to no physical limitations.

• Loss of sensation in various parts of the body.

• Impaired problem-solving ability, judgment, memory, and attention span.

• Impairments in ability to recognize road signs, signals, markings.

• Impaired perceptual motor skills (spatial relationships and reaction time).

• Visual field deficits, resulting in person not being able to see whole roadway.

• The extent of physical limitations will determine the type of vehicle that is needed and how the vehicle should be modified and equipped. It is impossible to generalize adaptive equipment needs of people with traumatic brain injuries due to the uniqueness of the symptoms in each person's case.

• The ability to exercise sound judgment and carry out needed decision-making and problem- solving skills may be impaired to the point that reaching the goal of becoming a safe driver is unattainable.

• Dynavision

• Need to monitor side effects of medications and effects on driving (weakness and fatigue are possible side effects of anti-convulsant medications, such as Dilantin, Clonopin, Tegretol, or Phenobarbital).

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Cerebral Palsy Depending upon location of brain damage:

• Sensory and perceptual problems

• Intellectual impairment

• Seizure disorders and emotional problems

• Involuntary muscle movements, imbalance in muscle tone and strength

The presence of spasticity may make it difficult to execute the fine motor movements needed to operate the primary and secondary driving controls. Involuntary movements may lead to inadvertent activation of the driving controls.

• The extent of visual-perceptual impairment, cognitive impairment, and quality of muscle tone and movements will determine the potential of a person with cerebral palsy to drive.

• The ability to independently get into, get properly seated in, and get out of a standard-size sedan may be impaired. A van equipped with the necessary adaptive driving equipment and modified to accept a wheelchair in the driver's station, may be the vehicle of choice.

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

Friedreich's Ataxia

(Spinal cord and cerebellar degeneration)

• Diminished muscle control

• Diminished ability to coordinate arms and hands due to severe tremors

• Visual and perceptual limitations

• Mental deterioration

• Slowed reaction time

• Difficulty getting into and out of a standard-sized sedan

• The ability to coordinate the various arm and leg movements required to operate primary and secondary controls may be so impaired that attaining the goal of safe driving is impossible even with adaptive driving equipment.

• Due to the progressive nature of the disease, periodic re-evaluation of driving ability and equipment should be conducted in response to changes with the individual's level of function.

• Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

Multiple Sclerosis

(Chronic disabling disease of the central nervous system)

• Symptoms begin as a vague feeling of tingling or numbness in one area of the body that lasts less than 24 hours. As disease progresses, symptoms become more severe and may include weakness; inability to coordinate voluntary muscular movements; losses in sensation; blurred or double vision; loss of balance; and impairments in conceptual thinking, memory, attention span, and judgment.

• Effects on driving range from few (if any) to cognitive, perceptual or sensory problems that are so severe that it is impossible for the person to drive safely.

• The disease is unpredictable and not all people with MS experience the same symptoms; this makes it difficult to generalize adaptive equipment or training needs.

• Periodic re-evaluation of driving ability and equipment needs is required to track changes in level of function.

A complete vision exam is essential, due to changing visual deficits. Driving could be ruled out, solely on the basis of vision.

• Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

Muscular Dystrophy

(a group of chronic, progressive diseases that result in degeneration of skeletal or voluntary musculature).

The age of onset and rate of progression vary according to the type of dystrophy involved. Effects include:

• Weakening of the respiratory muscle leading to endurance problems.

• Muscle weakness in the arms, legs, and trunk leading to the need for a wheelchair for mobility.

• Weakening of face and eye muscles impairing the ability to swallow food or talk.

• Weakening of heart muscle leading to fatigue and impairments in the ability to independently carry out abilities of daily living.

• Losses in strength and flexibility may limit the persons ability to reach, grasp, and operate driving controls; turn a standard steering wheel through its full circular motion; and accurately view and interpret the roadway and surroundings.

• Impairments in the ability to get into and out of a standard size sedan.

• May range from a standard sedan with minimal adaptive driving equipment to an extensively modified van with adaptive driving equipment and modified to accept a wheelchair in the driver's station.

• Periodic re-evaluation of driving ability and equipment needs should be conducted, due to the progressive nature of the disease

• Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

Poliomyelitis

(a viral infectious disease of the nervous system that causes degenerative changes resulting in muscular paralysis or weakness, primarily in the legs and trunk.)

• Weakening or paralysis of muscles associated with trunk, pelvis, shoulder, arm, and leg functions may impair the ability to operate standard primary and secondary controls.

• Weakening or paralysis of muscles associated with breathing

• Major deficits in the lower extremities may impair ambulation and transfer, and necessitate the use of orthotics, ambulation aids, or wheelchairs. This may impair ability to get into and out of a standard sedan independently.

• Deformities such as curvature of the spine or partial dislocation of the spine may occur.

• In cases where the legs alone are affected, a vehicle equipped with hand operated brake and accelerator controls, a spinner knob, an extension on the parking brake, and a dimmer switch relocated for hand activation, may be all that is required to maintain safe driving performance.

• If the arms and legs are weakened, more extensive adaptive driving equipment and/or vehicle modifications will be needed.

• Periodic re-evaluation for equipment needs may be necessary over the course of time, if the person becomes significantly weaker.

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

Rheumatic Disease

(includes 100 different conditions that cause aching and pain in the joints and connective tissues throughout the body; results in heat, swelling, redness, stiffness, and pain. Three prevalent forms are rheumatoid arthritis, ankylosing spondylitis, and degenerative joint disease.)

• Loss of joint mobility resulting in diminished ability to reach, grasp, manipulate, and release standard and primary and secondary driving controls.

• Diminished strength and endurance making long distance driving difficult.

• The need for adaptive equipment will depend on the parts of the body affected by the disease.

• Driving equipment and adaptive aids may include extended gear lever, extended parking brake, tilt steering, power seats, power windows, power steering, and power brakes.

• Additional mirrors may be needed for drivers with limited ability to turn their heads.

• More extensive adaptive equipment /vehicle modifications may be necessary for the person whose ability to use legs and/or arms is severely affected by the disease.

• Need to monitor side effects of medications and effects on driving (People with arthritis may be taking anti-inflammatory or pain relieving medications such as Decadron, Aspirin, Anaprox, Butazolidin, Clinoril, or Motrin. Potential side effects vary depending on the prescribed medication).

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

Spina Bifida

(a birth defect resulting from the failure of the vertebral canal to close normally around the posterior end of the spinal cord.)

• Weakness or paralysis of the leg and feet muscles may result in the inability to reach and operate brake & accelerator pedals, floor-mounted parking brake, or floor-mounted dimmer switch.

• Abnormal (or absent) sensation in the lower back & legs, making it difficult to independently get into or out of a car.

• Impairment in visual-perceptual functioning resulting in impairment in the ability to accurately perceive the roadway & its surroundings. Perceptual problem that may occur in persons with unarrested or poorly arrested hydrocephalus include: visual discrimination (color, size, shape, position, same & different); visual closure (part-whole); figure-ground; form constancy; depth perception; visual orientation in space.

• Auditory impairments (localization, discrimination, and identification)

• Impairment in proprioceptive abilities (body scheme, right-left discrimination, spatial relationships) & kinesthetic abilities (position in space).

• If hydrocephalus is not arrested early, mental redardation & other cognitive disorders usually occur. (poor attending behavior, short attention span, memory deficits).

• A visual examination should be performed, due to possible deficits in eye movement

• A visual perceptual assessment should be performed

• The need for vehicle modifications or adaptive equipment will depend on the parts of the body affected, and the loss in strength/joint mobility.

• Examples of adaptive equipment that may be helpful include: hand controls for brake and accelerator, spinner knob, hand-operated dimmer switch, and transfer board.

• An extensively modified van is necessary for the person who needs to drive from a wheelchair.

• Ophthalmologist/Optometrist

• Physiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• May require van modification + training)

 

Visual Impairments
Visual/Perceptual Impairment (Deficit) Effects on Driving Remediation Resources
Depth Perception

(Ability to judge distances. Dependent on stereopsis which is binocular appreciation of three dimensional space. Most so-called depth perception tests assess stereopsis.)

• Timing of turns

• Stopping distance

• Timing of pulling out into traffic

• Lane position

• Difficulty in merging or in blending with traffic

• Distance judgment

• Stops too soon or goes over line at intersections

• Difficulty in parking lots

• Cuing: "Stop so you can see the wheel of the car in front of you and some of the pavement."

" If a car fills your rearview mirror, it is too close."

• Vision Aerobics

• Ophthalmologist/Optometrist

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Acuity • Delay in responding to environment (due to difficulty in anticipating and detecting hazards)

• Can't read street/highway signs and other info.

• Increased difficulties in low light conditions

• New lens prescription

• Specialized driver training

• Ophthalmologist/Optometrist

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• MVA regarding low vision driving program

Blurred or Double Vision

(May be a result of the following eye diseases: Diabetic Retinopathy, Cataracts, Macular Degeneration)

• Delay in ability to recognize threats

• Slow to recognize signs

• Difficulty staying in lane

• Eyes may be more sensitive to light and glare making night driving difficult.

Diabetic Retinopathy:

ophthalmologic laser surgery or vitrectomy

Macular Degeneration:

Low vision optical aids

Cataracts:

eye surgery

• Ophthalmologist/Optometrist

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• MVA regarding low vision driving program

Visual Attention/Fixation

(The act of keeping one or both eyes pointed directly at an object of regard for as long as needed or requested.)

• Distractibility

• Difficulty maintaining lane position

• Staying at traffic signals too long

• Dynavision

• Visual Attention Analyzer

• Evaluation required

NOTE: Individuals with visual inattention are generally poor candidates to resume driving, and training with Dynavision should be considered carefully before being undertaken (Dynavision Users Guide)

• Family Physician

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Visual Field Cut

(May be seen with spatial body neglect and is associated with frontal lobe damage and left or right occuloparietal and parietal damage. Client fails to "see" all relevant information or is missing a particular zone in his/her peripheral field.)

• Missing streets or stimuli on neglected side

• Difficulty maintaining lane position

• Following the edge of the road

• May not see vehicles during quick glances for lane changes

• Denial

see also peripheral vision

Persons with visual field defects with intact visual attentional capabilities will attempt to compensate for the loss by engaging visual attention; they will direct eye movements toward the side of vision loss in an attempt to gather visual information from that side.

• Dynavision training

• Extra head turns and mirrors

• Evaluation required

NOTE: Persons with visual field cuts combined with visual inattention should not resume driving (client will likely be a hazard), as remediation is not possible with denial.

• Family Physician

• Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• MVA referral for low vision program

Color Discrimination Diminished ability to perceive differences in color, usually for red and green. • Education: client must learn sequence for traffic signals and sign shapes. • Ophthalmologist/Optometrist

• State Licensed Driving Instructors/Schools

Accommodation and Focusing

(The ability to automatically and without strain, bring near objects into clear focus. Relaxation of accommodation allows distant objects to become clear.)

Also:

Convergence and Divergence

(The ability to smoothly and automatically bring the eyes together to look at things closely, or move them apart)

Driving requires a flexible accommodation system, to allow the driver to shift from far (intended path of travel) to near (speedometer, rear-view mirrors).

Deficit may result in difficulty:

• reading street signs

• interpreting speed from speedometer

• using information seen in mirrors

• positioning vehicle in turns and curves

Client is likely to drive slow in order to have the time to figure out what is happening

• Vision Aerobics • Ophthalmologist/Optometrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

Ocular Motility/Range of Motion/Pursuit Movements

(The ability to coordinate and move the eyes smoothly through all planes)

• Diminished ability to attend to all stimuli in the environment; will likely miss the most important information

• Difficulty maintaining lane position

• May be slow in pulling out into traffic

• May miss stimuli in the environment (signs, pedestrians, bicyclists)

• Usually poor at dealing with intersections or cross traffic.

• May stare at road scene

• May move eyes randomly and be distracted by any movement

Practitioner may observe clumsiness or lack of balance

• Level of impairment will impact client's ability to be trained/remediated.

• Evaluation and training required.

• Ophthalmologist/Optometrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

Peripheral Vision • Misses stimuli in the environment

• Timing of turns may be off

• May not see cross) traffic

• Wide-angle rear-view mirrors

• Training to make more head movements

Note: if the jurisdiction has a specific requirement for peripheral vision, a license may not be granted to individuals who do not meet the minimum requirement.

• Ophthalmologist/Optometrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• MVA low vision program

Impaired Figure-Ground Discrimination • Unable to distinguish foreground from background

• Difficulty finding STOP sign among other stimuli in environment

• Difficulty as traffic increases and/or road scene increases in complexity

• Difficulty finding controls or dashboard information quickly

• Recommendation to drive only in familiar areas, during non-rush hours

• Evaluation and training required

• Ophthalmologist/Optometrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• State Licensed Driving Instructors/Schools

Parts-To-Whole Deficits • Can "see" individual items in road scene but may not realize what's happening in the whole environment

• Unable to look ahead in anticipation of potential threats (e.g., may see stopped cars, police cars, and ambulances, but not recognize that there has been an accident).

• Level of impairment will effect prognosis for remediation.

• Evaluation and training required.

• Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• State Licensed Driving Instructors/Schools

Position in Space Deficits • Unsure of position as related to another object

• Problems particularly when close to other objects, such as in parking lots

• Will often go past limit line or stop too early

• Trouble orienting vehicle when in curves or coming out of turns

NOTE: problem does not usually improve significantly with cues or practice • Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• State Licensed Driving Instructors/Schools

Impaired Right/Left Discrimination • Confused right and left

• Ends up on wrong side of road

• Puts turn signal on for opposite direction of intended turn

• Evaluation and training required.

• Driving may be appropriate only in familiar and routine driving areas.

• Ophthalmologist/Optometrist

• Neurologist/Neuropsychologist/

Psychologist/Psychiatrist

• General Rehab Facility (PT, OT, Psychologist, Speech-Language)

• Rehab Facility with Driving Program (clinical eval + BTW+training)

• State Licensed Driving Instructors/Schools

1C3(b)ii. Rehabilitation Procedures - Elderly Population With Chronic Conditions Requiring Intervention: Physical Rehabilitation


A physical therapist (PT) can assist individuals in understanding normal age-related changes, and can develop exercise programs to assist an individual in regaining lost abilities or developing new ones. Some age-related bodily changes may be misunderstood and unnecessarily limit daily activities. Normal aging need not result in pain and a decrease in physical mobility. More than 90,000 physical therapists practice in the U.S. (APTA Fact Sheet, 1997), and treat nearly one million people every day. Although many physical therapists practice in hospitals, more than 70 percent practice in private physical therapy offices, community health centers, industrial health centers, sports facilities, rehabilitation centers, nursing homes, home health agencies, schools or pediatric centers, work in research institutions, or teach in colleges and universities.

Physical Therapy Services

A physical therapist, working with the older adult, understands the anatomical and physiological changes that occur with normal aging. The PT will evaluate and develop a specially designed therapeutic exercise program. Physical therapy intervention may prevent life long disability and restore the highest level of functioning. Through the use of tests, evaluations, exercises, treatments with modalities, screening programs, as well as educational information, physical therapists:

• increase, restore or maintain range of motion, physical strength, flexibility, coordination, balance and endurance;

• recommend adaptations to make the home accessible and safe;

• teach positioning, transfers, and walking skills promote maximum function and independence within an individual's capability;

• increase overall fitness through exercise programs;

• prevent further decline in functional abilities through education, energy conservation techniques, joint protection, and use of assistive devices to promote independence;

• improve sensation, joint proprioception;

• reduce pain.

Common Conditions

A vast number of conditions are treated effectively with physical therapy intervention. Examples of specific diseases and conditions that may affect older people and be improved with physical therapy include:

• Arthritis

• Osteoporosis

• Cerebral Vascular Accident (Stroke)

• Cancer

• Parkinson's Disease

• Urinary and Fecal Incontinence

• Amputations

• Cardiac and Pulmonary Diseases

• Dementias

• Alzheimer's Disease

• Coordination and Balance Disorders

• Functional Limitations related to mobility

• Sports/Orthopedic Injuries

• Joint Replacements

• Hip Fractures

Reimbursement

Physical therapy evaluation and treatment is covered fully or in some percentage by:

• Medicare

• Medicaid

• Private Insurance Companies

• Options under the Federal Employee Health

• Benefit Programs

• Workers' Compensation Programs

• Private Pay

• HMO (Health Maintenance Organizations)

• PPO (Preferred Provider Organizations)

Credentials

Physical Therapists (P.T.):

• Have completed coursework in the medical, biological, physical and psychological sciences;

• Graduate from an accredited education program;

• Complete bachelors, masters or doctoral degrees with special clinical experiences in physical therapy;

• May opt to gain further expertise and seek a clinical speciality in geriatrics;

• Meet licensure requirements required in all states for PT's.

Physical Therapist Assistants (P.T.A.):

• Must have an associates degree from an accredited PT assistant program;

• Work under the direct supervision of a Physical Therapist;

• Meet licensure requirements in states where it's required.

Geriatric Certified Specialists (GCS) are physical therapists who have demonstrated expertise in working with geriatric patients by attaining additional licensure. As of 6/97 (latest Webpage update), there were 56 Geriatric Certified Specialists across 26 States in the U.S.

GCS certification requires the following. Applicants must submit evidence of 8,000 hours (approximately 4 full-time years with normal annual leave) of general physical therapy practice accrued after successful completion of professional physical therapy education. These hours do not have to be in the specialty area. Applicants must submit evidence of 6,000 hours (approximately 3 full-time years with normal annual leave) of clinical practice in geriatric physical therapy completed within the last 10 years (from August 1, 1988). These hours may be concurrent with general physical

therapy practice. Clinical practice in the specialty area includes any aspect of physical therapy practice such as teaching, research, consultation, and administrative duties beyond patient care. At least 4,000 hours (approximately 2 full-time years with normal annual leave) of clinical practice experience in geriatric physical therapy must be in direct patient care (such as patient evaluation and treatment, patient documentation, travel en route to patient care, patient education, rounds/discharge planning conferences). Direct patient care hours in geriatrics must have been completed within the last 6 years. Direct patient care experience must be gained in at least 2 different areas of practice (such as acute care, outpatient, long-term care, home health care, subacute rehabilitation, short-term rehabilitation, wellness center). The Geriatric Specialty Council recommends that specialty area experience be obtained in more than two areas of practice.

References:

• American Physical Therapy Association (APTA) Website, Section on Geriatrics; 1111 N. Fairfax Street, Alexandria, VA 22314-1488. Phone 1-800-999-APTA

1C3(b)iii. Rehabilitation Procedures - Elderly Population With Chronic Conditions Requiring Intervention: Vehicle Modification


Modifying a vehicle for a person with a disability can be as simple as installing a spinner knob on the steering wheel or as complex as a van renovation. Information about a 1987 Ford van conversion was described in a newspaper article "Steering Toward Independence," and is provided here. The client drives from a wheelchair, and therefore, extensive changes were made to the van's interior to accommodate the chair, in addition to the adaptive devices which included special controls for steering, braking, acceleration, and things like windshield wipers. The client was eligible for financial assistance from the state Department of Labor and Industry's Office of Vocational Rehabilitation (OVR), since he needed the van to continue working; acquiring the vehicle, however, was his responsibility. A program such as Bryn Mawr Rehabilitation Hospital's Adapted Driving Program will make recommendations as to what modifications are absolutely needed, and the recommendations are presented to the OVR. This process is required, because, according to an OVR supervisor, sometimes there are items that a person wants that have nothing to do with his or her driving, and shouldn't be reimbursed. The average adaptation for a van is approximately $15,500 (in 1995), but can cost up to $50,000. Equipping a car with basic hand controls, spinner knob, and parking brake extension averages approximately $500.00 (in 1995). In one year (1994-1995), the Office of Vocational Rehabilitation in Rosemont (Chester County, PA) spent approximately $300,000 working with 29 individuals on van modifications, and $100,000 working with 33 people on car adaptations.

To be eligible for State assistance, the changes must have a work-related purpose; the person must pass the State driver's test and have a properly coded license to drive with the adaptations, and must be able to insure the vehicle. The Bryn Mawr Adapted Driving Program Director, Tom Kalina, stated that if there is no impairment in vision, knowledge, and reaction time, a person can learn to drive with the controls in 3 to 15 hours. Once an individual meets Bryn Mawr's performance requirements, he or she must then take and pass the State driver's test. Mr. Kalina reported that the State test is a legal requirement, however, Bryn Mawr bases their findings on much more extensive driving compared to what is contained in the 10-minute State test. The Bryn Mawr adapted driving instructors will not take a client to the State for testing until they have proven their competency to the instructors.

An inventory of the kinds of adaptive equipment for the following five categories is provided below (taken from Transport Canada, 1986): entry and exit aids; seating aids and restraints; steering aids; accelerating and braking aids; and control levers.

Entry and Exit

Adapted Key Holder: A variety of key holders for various limitations of hand use are available for the outside door and for the ignition; the rigid holder provides for easier grasp.

Wheelchair Lift: Several types of lifts are available; electric, gravity, or hydraulic. They are either automatic or semiautomatic, and operate using rotary or swing-down mechanisms. Size and weight of the wheelchair are important considerations when selecting a lift.

Cartop Wheelchair Loader: This loader features push-button operation to automatically fold and store a conventional wheelchair on top of the car under a weather-resistant cover.

Wheelchair Loader (in-car): The lift is installed on either the passenger or driver side of any full-sized two-door automobile. A switch activates the loader, which lifts and stores the chair behind the driver's seat.

Trunk Loader: This consists of an electric hoist attached to the car bumper. It can be used to load a powered scooter or a wheelchair. Manual loaders are also available.

Bumper Rack Loader: This wheelchair loader fits onto the rear of the trunk and can be either hand or power operated. To make use of these loaders, a driver must be able to walk from the rear of the car to the car door, or have someone with them for assistance.

Automatic Door Openers: These are available for vans with sliding or swing doors and consist of separate switches in a control box (or a single key holder for sequential operations.) For those unable to manipulate keys, remote control or magnetically activated switches are available.

Transfer Assists: For those persons unable to transfer in and out of the car easily on their own, a variety of transfer assists are available (transfer boards, overhead handle above the doorway, etc.)

Wheelchair Ramps: These are movable ramps for use with vans or any object with two or three steps.

Seating Aids and Restraints

Torso Restraints: When driving a van from a wheelchair, chest harness and/or lateral trunk supports may be used, together with lap belts and wheelchair restraints, for those with diminished trunk musculature and balance.

Power Driver Seat: A four- or six-way power seat base (front to rear travel, vertical travel for height adjustment and swivel) facilitates a driver's self-transfer from wheelchair to driver's seat and allows for optimal positioning for driving.

Power Pan: A power pan is designed to accommodate the driver with disabilities who cannot transfer from wheelchair to seat without assistance and must drive from a wheelchair. It allows the driver who sits high in his or her wheelchair to lower the line of vision 2.5 to 6 inches (6 to 15 cm), by automatically lowering the vehicle floor in the driver's station.

Power Wheelchair Restraint: This quick lock and release system for the wheelchair enables the driver with disabilities to quickly and easily secure his or her chair in the proper driving position.

Manual Wheelchair Restraint: This model can be used by a wheelchair driver who can physically operate a restraint without power controls, or by a wheelchair passenger.

Wheel Wells: These channels are installed in a vehicle floor to lower the wheelchair driver, thereby correcting visibility problems caused by height.

Removable Seat Base: This is a detachable seat, usually mounted on casters. It allows for easy conversion of the driver's station for a wheelchair driver. It stores in the rear of the van when not in use.

Steering Aids

Steering Column Extension: This extension brings the steering wheel 2 to 6 inches (5 to 15 cm) closer to the wheelchair driver. It provides extra leg room and compensates for reduced range of motion.

Foot Steering Control: This device transfers control of hand-operated driving functions to foot operation. Auxiliary and secondary vehicle controls are also adapted to foot operation.

Low-Effort Steering: This feature reduces the effort to steer the vehicle by approximately 40 percent.

Zero-Effort Steering: This reduces the effort required to steer the vehicle by approximately 70 percent; a back-up steering system is usually recommended. It is available for cars or vans with power steering.

Horizontal Steering Column: This motorized, telescoping steering column allows for adjustment of steering in a variety of planes and positions. It adapts to the reach limitations of a driver, and can be positioned for right- or left-hand use.

Deep-Dish Steering Wheel: This device brings the steering wheel rim approximately 4 inches (10 cm) closer to the wheelchair driver and is normally used with a low-effort steering system. It improves wheelchair accessibility to the steering wheel, and lessens the range of steering motion.

One-Hand Drive Control System: This steering system is designed for persons with limited or no use of lower extremities, but good strength in one arm and hand. Its main component is a knob through which steering, brake, and throttle are activated. Auxiliary switches can be located adjacent to the knob, with toggle switches for convenience.

Steering Spinners: Spinner knobs permit safe operation of the steering wheel by drivers who must steer with one hand, allowing them to remain in contact with the steering wheel at all times. The come in a variety of configurations including an amputee ring, knob, so-called "quad steering cuff," palm grip, tri-pin, and V-grip.

Acceleration/Braking Aids

Hand Controls: There are 3 types of hand controls: push-pull, twist-push, and right angle push (also known as the universal control because it can be used for most disabilities). Recommended for use in vehicles with power brakes and steering, they do not interfere with operation of the vehicle by able-bodied drivers.

Quad Hand Control: This consists of an extra L-shaped attachment for hand control. It is designed for quadriplegic drivers with little wrist or hand strength. It is used with a dimmer switch and horn button.

Hand Clutch Control: The hand clutch is for vehicles with standard transmission. It is recommended for drivers with weakness or loss of use in the left leg only.

Left-Foot Accelerator Pedal: With this pedal, accelerator functions of the vehicle are converted to left-foot use for those with limited or no use of the right foot.

Pedal Extensions: Pedal extensions are used when a driver's legs are too short to reach the gas and brake pedals. These extensions must be light enough not to depress the pedals unless activated, and secure enough not to slip off while the car is being driven. They are often used together with a false floor in order to rest the heels.

Parking-Brake Extension Lever: This lever attaches to a foot-operated parking brake in order to adapt it to hand use. With the lever, the driver still needs a grip sufficient to operate the regular brake and lever.

Servo Controls: These consist of touch controls that provide reduced effort acceleration and/or braking control. Two levels of assistance are available--low effort or zero effort. Emergency back-up systems are available to provide additional safety in case of control failure.

Electric Parking Brake: An electric parking brake offers complete control of the power brake by manipulation of a toggle switch. It is available for cars, vans, and trucks. This unit is usually prescribed for individuals who drive a van from their wheelchair.

Portable Hand Controls: These are to be used on a temporary basis only: very strong arms are required. They are persons traveling with rental cars on which hand controls are not available.

Control Levers

Right-Hand Directional-Signal Extension Lever: This extension lever attaches to the turn signal lever and crosses to the right side of the steering column for persons unable to use their left hand.

Left-Hand Gear-Selector Extension Lever: This extension lever attaches to the gear shift lever and crosses to the left side of the steering column. It is for use only on vehicles with automatic transmission.

Gear-Selector Extension Lever: This extension lever provides more leverage for shifting gears, for persons with disabilities. It can be used with automatic transmission only.

Powered Gear Selector: This allows a driver with an upper extremity dysfunction to shift gears with a toggle switch positioned where most convenient for the driver (usually on the console).

Remote Wiper/Washer, Horn, Dimmer Switch, Directional Signals, and Headlights Control: This control relocates these functions to an easily reached location. It allows the driver to use a switch with the hand, elbow, head, or knee, whichever is most convenient.

Quad Control: This control provides a handy location for all accessory controls and out-of-reach switches normally found on the dash.

Keyless Ignition: A toggle switch provides remote control of ignition for those drivers unable to manipulate an ignition key.

The following table lists specific disabilities, their effects on driving, and driving aids/adaptive equipment to accommodate the disability.

Physical Disabilities (Missing or Non-Functional Body Parts), their Effects on Driving, and Suggested Driving Aids.
Disability Effects on Driving Suggested Driving Aids
Left Leg Missing or Non-Functional • Inability to use left foot on dimmer switch and parking brake

• Possible inability to maintain body balance

• Inability to use clutch

• Possible interference of leg or foot with driving mechanisms

• Hand-operated dimmer switch and parking brake (or center console parking brake)

• Shoulder or chest safety belts; arm rests

• Automatic transmission

• A restraint (e.g., belt, loop, or barrier of some type) to keep the disabled leg or foot from lodging against brake or accelerator

Right Leg Missing or Non-Functional • Inability to use standard accelerator

• Possible inability to maintain body balance

• Awkwardness in using left foot dimmer switch (because left foot occupied w/brake and accelerator)

• Inability to use clutch

• Possible interference of leg or foot with driving mechanisms

• Left-foot accelerator

• Shoulder or chest safety belts; arm rests

• Hand-operated dimmer switch

• Automatic transmission

• A restraint (e.g., belt, loop, or barrier of some type) to keep the disabled leg or foot from lodging against brake or accelerator

Both Legs Missing or Non-Functional • Inability to use brake and accelerator

• Inability to use dimmer switch or foot-operated parking brake

• Possible difficulty maintaining body balance

• Possible interference of legs with driving controls

• Possible difficulty entering car

• Hand-operated brake and accelerator, necessitating automatic transmission

• Hand-operated dimmer switch and parking brake

• Special seat structure, cushions, arm rests, or chest/shoulder safety belts

• A restraint (e.g., belt, loop, or barrier) to keep legs clear of brake and accelerator

• A grab bar or strap; transfer board. A swivel seat may be helpful

Left Arm Below Elbow Missing or Non-Functional • Difficulty performing hand-over-hand steering maneuvers

• Inability to shift gears while steering

• Difficulty grasping and pulling left-hand dash controls

• Inability to use turn signal and other controls mounted on lever (wipers, cruise control)

• Power steering and spinner knob attached to steering wheel, mounted at 3 or 4 o'clock position, for the sound hand

• Automatic transmission

• Rings attached to left-hand dash controls

• Right side turn signal modification or electronic signals

Right Arm Below Elbow Missing or Non-Functional • Difficulty performing hand-over-hand steering maneuvers

• Inability to shift gears while steering

• Difficulty grasping and pulling right-hand dash controls

• Power steering and spinner knob attached to steering wheel, mounted at 8 or 9 o'clock position, for the sound hand

• Rings attached to right-hand dash controls

• Although a driver with a right-hand hook should be able to operate either a standard or an automatic shift lever, automatic transmission is easier

• Presetting auxiliary controls prior to driving

Both Arms Below Elbow Missing or Non-Functional • Inability to grasp and turn regular steering wheel

• Difficulty grasping and pulling dashboard controls

• Difficulty grasping and pulling or turning other small devices or control in the car (door locks and handles, window cranks, ashtray, glove compartment, radio knobs, etc.)

With a Prosthesis:

• Driving ring or steering knob attached to the steering wheel, on the side of the dominant arm

• Rings attached to the dashboard controls

• Ring attachments for any small device or controls difficult to operate; electric door locks and power windows

No Prothesis:

• The driver should be able to maneuver the steering wheel using two arms; if not, an extended/telescopic steering column is recommended

• Dashboard extensions

• Power door locks and power windows; keyless ignition

Left Arm Above Elbow Missing or Non-Functional • Inability to perform hand-over-hand steering maneuvers

• Inability to use left-hand turn signal

• Difficulty reaching left-hand dashboard controls

• Difficulty releasing left-hand parking brake

• Inability to shift gears on standard transmission while right arm is occupied

• Difficulty activating horn while right hand is occupied

• Steering knob or other steering aid mounted on the right

• Right-hand extension turn signal lever or electrical signal

• Right-hand extensions on left-hand dashboard controls, or dashboard models with right-hand controls

• Parking brake release adapted for use by the left foot or the right hand

• Automatic transmission

• Horn ring that can be reached without letting go of the steering knob

Right Arm Above Elbow Missing or Non-Functional • Inability to perform hand-over-hand steering maneuvers

• Difficulty reaching right-hand dashboard controls

• Possible difficulty turning ignition key

• Inability to use right-hand automatic gear shift

• Inability to shift gears on standard transmission

• Steering knob or other device mounted on the left

• Left-hand extensions for dashboard controls and/or dashboard model with some left-hand controls

• Ignition key reachable with the left hand while parked, or adapted for the left hand

• Left-hand extension of gear shift lever

• Automatic transmission

Both Arms Above Elbow Missing or Non-Functional • Inability to use conventional steering wheel

• Inability to operate standard transmission

• Inability to operate turn signal, ignition key, gear selector, dash controls, horn, parking brake release

• Foot steering controls: a metal boot mounted on a circular disk in the floor-board, by the left foot

• Automatic transmission

• Gear selector on the floor, by the right foot; horn and turn signal on the floor, or remote controls for knee operation; ignition, lights, windshield wipers, and emergency brake underneath and behind instrument panel

Lack of Manual Dexterity • Limited ability to grasp and turn steering wheel

• Limited ability to grasp and operate ignition key and dashboard controls

• Difficulty releasing hand-operated parking brake

• Tri-post, "V," of cuff-type steering wheel spinner

• Ignition key holder; rings or other adaptations on dashboard controls

• Foot-operated parking brake, or extension loop on the parking brake handle

Both Arms and Both Legs Disabled (Quadriplegia)

Low Level Quadriplegia - Able to Transfer Into Car

• Inability to use brake, accelerator, dimmer switch, foot-operated parking brake, and clutch

• Limited ability to grasp and turn steering wheel

• Limited ability to maintain body balance

• Possible limited ability to see full field of traffic

• Difficulty entering car and storing wheelchair

• Possible fatigue

• Difficulty using dashboard controls, ignition key, and seat belt fixture

• Hand-operated brake, accelerator, dimmer switch (may be combined with horn switch); extension and loop on parking brake; automatic transmission and parking brake

• "Quad" steering device ("V" shaped grip, semicircle, steering pin, or tripost, as necessary); wrist cuff; wrist splint or elbow support

• Chest harness safety belt, arm rests, cushions

• Side view mirrors and full-range rear-view mirrors if neck rotation is limited

• Two-door car; grab bar or strap; transfer board; wheelchair hoist

• Instruction in avoiding and dealing with fatigue; driving lessons planned with awareness of student's stamina range

• Ignition key holder and adaptations of seat belt fixtures and other small devices

Both Arms and Both Legs Disabled (Quadriplegia)

High Level Quadriplegia - Driving in Van From Wheel Chair

• Inability to use brake, accelerator, dimmer switch, foot-operated parking brake, and clutch

• Limited ability to grasp and turn steering wheel

• Limited ability to maintain body balance

• Possible limited ability to see full field of traffic

• Difficulty entering car and storing wheelchair

• Possible fatigue

• Difficulty using dashboard controls, ignition key, and seat belt fixture

• Quad hand controls, which may have dimmer-plus-horn and signals incorporated or servo controls. The dimmer switch can be controlled by the elbow; electric parking brake; automatic transmission

• "Quad" steering device, if necessary; adjustable height, position, and diameter of steering wheel, as well as adjustable steering column position; "low" or "zero" effort steering with emergency back up

• Wheelchair restraint-a safety locking device to prevent the wheelchair from moving; passenger restraint could include a lap belt, chest harness, lateral supports attached to the wheelchair, and a special quad seat belt

• Power pan or wheel channels; special mirrors

• Automatic wheelchair lift; wheelchair restraint

• Instruction in avoiding and dealing with fatigue; air conditioning, cruise control, easy/zero effort controls

• Keyless ignition, or ignition relocated to an accessible area; dashboard controls converted to a special quad console with toggle switches and/or dashboard control extensions

Lack of Range of Motion - Arms • Limited ability to turn steering wheel

• Possible difficulty operating dashboard controls, gear shift, turn signal, and/or parking brake release

• Extension of the steering column and a small steering wheel complete with a spinner knob

• Extensions on or adaptations of dashboard controls, gear shift lever, turn signal, and parking brake release

Lack of Range of Motion - Shoulders • Limited ability to turn steering wheel

• Possible difficulty operating dashboard controls, gear shift, ignition key, and parking brake release

• Limited ability to see the full field of traffic

• Extension of steering wheel column and small wheel with spinner knob; or, foot-operated steering if limitation is severe

• Extensions or adaptations of dashboard controls, gear shift lever, turn switch and ignition switch, and foot-operated parking brake

• Convex or 48 rear and side view mirrors

Lack of Range of Motion - Hips • Difficulty using brake and accelerator

• Difficulty using dimmer switch and parking brake

• Difficulty using clutch

• Possible difficulty turning to watch rear view while backing up

• Possible difficulty entering and leaving car

• Hand-operated brake and accelerator

• Hand-operated dimmer switch and parking brake

• Automatic transmission

• Convex or 48 rear view mirror

• Grab bar or strap (swivel seats are also helpful); power seats

Lack of Body Balance • Danger of falling to one side in turns or sudden motions • Specially constructed seat for balance; arm rests; cushions and or shoulder or chest safety belts
Poor Muscle Control • Difficulty controlling steering wheel

• Uncontrolled involuntary movement, or spasms of rigidity may present too great a danger for driving

• Tri-post, "V," or cuff-type steering wheel spinner

• Persons suffering from uncontrolled muscle activity that is potentially dangerous for driving should consult a driver education specialist before going on the road. If spasms occur in the legs only and hand controls are used, the legs can be secured close to the seat.

The Disabled Driver's Mobility Guide (AAA, 1997) states that in-vehicle and medical evaluations are the best way to determine the most suitable adaptive equipment. Physicians, occupational therapists, and physical therapists may be able to recommend specific vehicle equipment. In addition, State Departments of Vocational Rehabilitation, the local Veteran's Administration health care facility, and rehabilitation hospitals and clinics may offer driver education for the disabled and have direct experience with adaptive equipment.

Adaptive equipment manufacturers may be able to recommend appropriate equipment. AAA (1997) provides listings of VA-approved automobile and van adaptive equipment manufacturers. VA-approved equipment has been tested and meets minimum safety and quality standards.

References:

• Bryn Mawr Adapted Driver Education Program. "Steering Toward Independence," Daily Local News, Chester County, PA Newspaper; November 6, 1995

• Transport Canada (1986)

• AAA (1997)

1C3(b)iv. Rehabilitation Procedures - Elderly Population With Chronic Conditions Requiring Intervention: Functional Status Review Leading to License Restriction


Petrucelli and Malinowski (1992) reported that all jurisdictions issue one or more types of restricted license, the most common restriction being a requirement to wear corrective lenses. A range of other restricted licenses are available including: time of day (daylight only, no late-night to early morning hours driving for novice young drivers); geographic boundaries (certain radius from home, no interstate, no one-way streets, no two-lane streets, to/from doctor's office/shopping/church); class of vehicle; speed limit; special equipment (hand controls, right and left outside rearview mirrors, automatic transmission); licensed drivers over age 21 must be present; and occupational needs (to/from work, only during certain hours).

Drivers may come to the attention of a licensing agency in a number of ways (see Notebook Section IC1). Physicians are required to report drivers with specific disorders that may impair driving ability to driver licensing bureaus in a minority of U.S. States/Canadian provinces. Although in many jurisdictions physicians may report drivers to a licensing agency (e.g., the State will provide immunity), many consider reporting to be a breech of confidentiality, or fear that the patient will search out a new physician. Hunt (1994) states that a useful strategy is for a physician to refer an individual to a driving program, which will utilize OTs and driving instructors to objectively determine driving ability. After the assessment, the OT will explain performance outcomes to the patient and family, and will provide a written report to the individual's physician. In this way, the family and physician have an objective determination of driving ability to back up any recommendations for driving restriction or driving cessation. The OT may also send a report to the State licensing bureau indicating that the individual's current license to drive should be reevaluated. Hunt (1996) notes that it is important for therapists to report patient road test results to a licensing agency for further testing, because physically and mentally unfit license holders often continue to drive despite medical advice against driving.

In some states, there is a Medical Review Board that assists with licensing decisions. In Maryland, for example, when the licensing agency has reason to believe conditions exist that might impair a person's driving ability, the applicant is required to submit certain medical information, as well as an authorization for release of records and information from physicians or hospitals that have treated the applicant for that medical condition (Petrucelli and Malinowski, 1992). The MVA's administrative staff then summarizes the information and sends a report to the Medical Advisory Board for its review, along with the applicant's case history. The board has the authority not only to interview the applicant, but also to conduct certain tests (e.g., reaction time) to evaluate more effectively the driver's functional capability. Most drivers under review must appear in person before the Medical Advisory Board. The board also has access to the driver's crash and violation records.

In Pennsylvania (where reporting is mandatory), when a report is made to the DMV, restrictions to the person's driving privilege may be added or deleted, the person's license may be recalled or restored, the person may be required to provide more specific medical information or to complete a driver's examination, or no action may be taken. See Notebook Sections IC1bix and IC1aiv for descriptions of PA's physician reporting law and PA's re-examination program, respectively. Freedman, Decina, and Knoebel (1986) reported that vision problems are the most frequent reasons for new restrictions and re-exam failures. Fifty-three percent of corrective lens restrictions, 88 percent of outside mirror requirements, and 92 percent of daylight driving only restrictions were instigated by the re-examination program. The proportion of drivers requiring new corrective lens restrictions diminished considerably as a function of increasing age beyond age 70, but the proportion requiring outside mirrors increased with age, from approximately 10 percent of drivers age 60, to more than 40 percent of drivers age 80 and older. A new restriction to daylight driving was rare for drivers younger than age 70, but was imposed on almost 20 percent of the drivers age 80 and older, and 40 percent of newly restricted drivers age 90 and older.

The Florida Examiner's Manual provides a chapter to help the examiner identify a physical impairment, understand what physical skills are affected, and what license restrictions and/or adaptive equipment are appropriate. Examiners are authorized to place restrictions of cushions or pads for small people, outside mirrors to deaf people, and mechanical equipment to drivers with physical impairments, unless the applicant requests a road test to prove that mechanical equipment is not necessary. The Manual describes physical impairments and limitations, and suggests adaptive equipment for disorders affecting coordination, range of motion, and strength of motion. This information is provided in the table below.

 
Physical Skill Affected Disorders Adaptive Equipment/Restrictions
Coordination

Includes all disorders that limit the driver's ability to coordinate motion of bodily members. All body members are present, but cannot be adequately controlled.

• Paraplegia

• Quadriplegia

• Hemiplegia

• Cerebral palsy

• Polio

• Hand-operated controls (brake and accelerator)

• Low effort power steering

• Spinner knobs of cuffs (grip on steering wheel)

• Left foot accelerator

• Steering column mounted dimmer and horn

• Right side turn indicator

• Electrical lifts and transfer boards

• Automatic transmission

• Pedal extensions

Range of Motion

Disorders that limit the ability to reach and operate various components of the automobile

• Congenital deformity

• Amputation

• Dwarfism

• Hand-operated controls (brake and accelerator)

• Low effort power steering

• Spinner knobs of cuffs (grip on steering wheel)

• Left foot accelerator

• Steering column mounted dimmer and horn

• Right side turn indicator

• Automatic transmission

• Pedal extensions

• Seat cushions

• Prosthetic restrictions

Strength of Motion

Disorders that limit the strength and endurance of the driver.

• Arthritis, plus a variety of physical problems • Special mirrors

• Mechanical directional signals

• Power or low effort steering

• Automatic transmission

• Spinner knobs

• Power brakes

The final test of an applicant's ability to handle the vehicle is a driving demonstration. If any special mechanical devices are required for the driver to maintain safe driving performance, then the applicant must be restricted to driving a vehicle that is so equipped, and an equipment restriction is placed on the applicant's license. Florida's restriction codes and definitions follow:

 
Restriction Code Description
A: Corrective Lenses Corrective lenses must be worn while driving. This includes contact lenses, as there is no special restriction for contacts.
B: Outside Rearview Mirror Mandatory for all deaf drivers and those who are blind in one eye.
C: Business Purposes Only This permits any driving necessary to maintain livelihood, including driving to and from work, necessary on-the-job driving, driving for educational purposes, and driving for church and for medical purposes. No pleasure or nonessential driving is permitted.
D: Employment Purposes Only This restriction permits driving to and from work and any necessary on-the-job driving required by an employer or occupation. No driving for any other purpose is permitted.
E: Daylight Driving Only This restriction is placed on a license only upon recommendation of a doctor.
F: Automatic Transmission This restriction is placed on the license when the driver cannot qualify with a standard transmission because of a physical disability.
G: Power Steering This restriction is placed on the license when a driver exhibits limited strength.
I: Directional Signals This restriction is placed on the license when the driver cannot give arm signals due to a physical disability.
J: Grip on Steering Wheel This restriction is placed on the license if one hand is missing or useless, or if the driver's strength is inadequate to control the vehicle without the grip or knob on the wheel.
K: Hearing Aid This restriction is placed on the license when an applicant is currently wearing a hearing aid.
L: Seat Cushion This restriction is placed on the license due to short stature of the driver.
M: Hand Control or Pedal Extension This restriction is placed on the license when the driver cannot otherwise qualify due to a physical disability.
N: Left Foot Accelerator This restriction is placed on the license when the driver cannot otherwise qualify due to a physical disability (authority of Driver Improvement Hearing Officer).
P: Probation Interlock Device This restriction mans the vehicle driven must be equipped with an ignition interlock device. The Department will impose this restriction upon recommendation of any court as a rule of probation, or by the Department as a requirement to reinstate a hardship.
S: Other Restrictions Could include artificial arm, three-wheeled golf-cart type of vehicle, time of day, days of week, driving routes or radius, size of vehicle, etc
X: Medical Alert Bracelet This restriction means that the driver is required to wear a medical alert bracelet at all times while operating a motor vehicle.

In Wisconsin, restrictions may be added to a license as a result of a physician's recommendation, the recommendation of an optometrist completing a vision report, or a driving evaluation by the personnel (examiners) in the DMV Customer Service Center. Restrictions are used to allow a driver privileges which are limited to some degree. Restrictions must be enforceable (i.e., a law enforcement officer must be able to determine if the restriction on the license is being observed). An example of an unenforceable restriction that is often received on medical forms but cannot be applied is "must take medication (or check blood sugar, eat, etc.) prior to driving." Examiners may only add equipment restrictions if the equipment is in place at the time of the driving examination or evaluation. Upon successful completion of driving examination or evaluation, appropriate restrictions are applied. Restriction codes include:

Code 1 Corrective glasses or contact lenses

Code 2 Hearing aid or vehicle equipped with outside rearview mirror

Code 3 Automatic transmission

Code 4 Automatic turn signals

Code 5 Daylight driving only doctor's recommendation required or based on driving evaluation given at night

Code 7 Proof of financial responsibility

Code 9 Complete hand controls

Code 10 Left outside mirror

Code 11 Right outside mirror

Code 12 Adequate seat adjustment

Code 14 Under 10,000 lbs.

Code 99 Special restriction card

Area and Speed Restrictions

•Radius of home area:

The residence address must be part of a radius restriction (e.g., 20 mile radius of home at 140 Merry St., Madison, WI). If a doctor recommends a radius restriction, licensing personnel may shorten the radius as a result of a driving examination, but may not increase radius beyond doctor's recommendation.

•No freeway or interstate highway driving (wording must be exact)

•County or town roads: e.g., no driving on Main St. in the city of Sparta

•Not in city (name the city)

•Within city or village limits only

•Highways posted ___mph or less

•Between residence and work

Time of Day

•Daylight driving only

•Certain hours only (e.g., between 9:00 a.m. and 3:00 p.m.)

Special Equipment

•steering knob or power steering; steering cuff

•hand-operated dimmer switch

•power assisted brakes

•re-arrangement of pedals or controls

•artificial arm, hand, or foot

•foot brake extension

•accelerator extension

•Specially equipped van or automobile (specify vehicle make, year, and VIN)

References:

• Florida Examiner's Manual (Ch 11: Restrictions/Adaptive Equipment, 3/1/87, 8/1/91, 6/1/93);

• Freedman, Decina, and Knoebel (1986)

• Hunt (1994, 1996)

• Petrucelli and Malinowski (1992)

• Wisconsin Examiner's Manual, Section 350: Restrictions for Physical Disabilities, 8/90


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