Side-Lying to Sit Up at the Edge of the Bed:

1. Bring the client’s feet off the edge of the bed.

2. Stabilize the client’s lower extremities with your knees.

3. Shift the client’s body to an upright sitting position.

4. Place the client’s hands on the bed at the sides of his or her body to help maintain balance.

Scooting to the Edge of the Bed: When working with a client who has sustained a stroke or a traumatic brain injury, walk the client’s hips toward the edge of the bed. Shift the client’s weight to the less affected or unaffected side, position your hand behind the opposite buttock, and guide the client forward. Then shift the client’s weight to the more affected side, and repeat the procedure if necessary. Move forward until the client’s feet are flat on the floor.

In the case of an individual with spinal cord injury, grasp the client’s legs from behind the knees and gently pull the client forward, placing the client’s feet firmly on the floor and making sure that the ankles are in a neutral position.

Stand Pivot Transfers

The standing pivot transfer requires the client to be able to come to a standing position and pivot on both feet. It is most commonly used with clients who have hemiplegia, hemiparesis, or general loss of strength or balance. If the client has significant hemiparesis, stand pivot transfers encourage the less affected or the unaffected side to accommodate most of the body weight and may put the more affected limb (ankle) at risk while pivoting.

Wheelchair-to-Bed or -Mat Transfer

1. Facilitate the client’s scoot to the edge of the surface, and put his or her feet flat on the floor. The client’s heels should be pointed toward the surface to which the client is transferring. The feet should not be perpendicular to the transfer surface, but the heel should be angled toward the surface.

2. Stand on the client’s affected side with your hands on the client’s scapulae or around the client’s trunk, waist, or hips. Stabilize the client’s involved foot and knee with your own foot and knee. Provide assistance by guiding the client forward as the buttocks are lifted up from the present surface and toward the transfer surface (Figure 11-9, A).

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FIGURE 11-9 Standing pivot transfer; wheelchair to bed, assisted. A, Therapist stands on client’s affected side and stabilizes client’s foot and knee. She assists by guiding client forward and initiates lifting the buttocks up. B, Client reaches toward transfer surface. C, Therapist guides the client toward transfer surface. (Courtesy Luis Gonzalez.)

3. The client may reach toward the surface to which he or she is transferring or may push off the surface from which he or she is transferring (Figure 11-9, B).

4. Guide the client toward the transfer surface, and gently help him or her down to a sitting position (Figure 11-9, C).

Variations: Stand Pivot and/or Stand/Step Transfer

A stand pivot and/or stand/step transfer is generally used when a client can take small steps toward the surface goal and not just pivot toward the transfer surface. The therapist’s intervention may range from physical assistance to accommodation for potential loss of balance to facilitation of near normal movement, equal weight bearing, and maintenance of appropriate posture for clients with hemiplegia or hemiparesis. If a client demonstrates impaired cognition or a behavior deficit, including impulsiveness and poor safety judgment, the therapist may need to provide verbal cues or physical guidance.

Sliding Board Transfers

Sliding board transfers are best used with those who cannot bear weight on the lower extremities and who have paralysis, weakness, or poor endurance in their upper extremities. If the client is going to assist the caregiver in this transfer, the client should have good upper extremity strength. This transfer is most often employed with persons who have lower extremity amputations, individuals with spinal cord injuries, and bariatric clients.

Method

See Figure 11-10.

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FIGURE 11-10 Positioning sliding board. Lift leg closest to transfer surface. Place board midthigh between buttocks and knee, angled toward opposite hip. (Courtesy Luis Gonzalez.)

1. Position and set up the wheelchair as previously outlined.

2. Lift the leg closer to the transfer surface and place the board under this leg, at midthigh between the buttocks and the knee, angled toward the opposite hip. The board must be firmly under the thigh and firmly on the surface to which the client is transferring.

3. Block the client’s knees with your own knees.

4. Instruct the client to place one hand toward the edge of the board and the other hand on the wheelchair seat.

5. Instruct the client to lean forward and slightly away from the transferring surface.

6. The client should transfer his or her upper body weight in the direction opposite to which he or she is going. The client should use both arms to lift or slide the buttocks along the board.

7. Assist the client where needed to shift weight and support the trunk while moving to the intended surface.

Bent Pivot Transfer: Bed to Wheelchair

The bent pivot transfer is used when the client cannot initiate or maintain a standing position. A therapist often prefers to keep a client in the bent knee position to maintain equal weight bearing, provide optimal trunk and lower extremity support, and perform a safer and easier therapist-assisted transfer.

Procedure

1. Assist the client to scoot to the edge of the bed until both of the client’s feet are flat on the floor. Grasp the client around the waist, trunk, or hips, or even under the buttocks, if a moderate or maximal amount of assistance is required.

2. Facilitate the client’s trunk into a midline position.

3. Shift the weight forward from the buttocks toward and over the client’s feet (Figure 11-11, A).

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FIGURE 11-11 Bent pivot transfer; bed to wheelchair. A, Therapist grasps client around trunk and assists in shifting client’s weight forward over feet. B, Client reaches toward wheelchair. C, Therapist assists client down toward sitting position. (Courtesy Luis Gonzalez.)

4. Have the client reach toward the surface he or she is transferring to or push from the surface he or she is transferring from (Figure 11-11, B).

5. Provide assistance by guiding and pivoting the client around toward the transfer surface (Figure 11-11, C).

Depending on the amount of assistance required, the pivoting portion can be done in two or three steps, with the therapist repositioning himself or herself and the client’s lower extremities between steps. The therapist has a variety of choices regarding where to hold or grasp the client during the bent pivot transfer, depending on the weight and height of the client in relation to the therapist and the client’s ability to assist in the transfer. Variations include using both hands and arms at the waist or trunk, or one or both hands under the buttocks. The therapist never grasps under the client’s weak arm or grasps the weak arm—an action that could cause significant injury because of weak musculature and poor stability around the shoulder girdle. The choice is made with consideration of proper body mechanics. Trial and error in technique is advised to allow for optimal facilitation of client independence and safety, and the therapist’s proper body mechanics.

Dependent Transfers

The dependent transfer is designed for use with the client who has minimal to no functional ability. If this transfer is performed incorrectly, it is potentially hazardous for therapist and client. This transfer should be practiced with able-bodied persons and should be used first with the client only when another person is available to assist.4

The purpose of the dependent transfer is to move the client from surface to surface. The requirements are that the client be cooperative and willing to follow instructions. The therapist should be keenly aware of correct body mechanics and his or her own physical limitations. With heavy clients, it is always best to use the two-person transfer, or at least to have a second person available to spot the transfer.

One-Person Dependent Sliding Board Transfer

See Figure 11-12.

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FIGURE 11-12 One-person dependent sliding board transfer. A, Therapist positions wheelchair and client and pulls client forward in chair. B, Therapist stabilizes client’s knees and feet after placing sliding board. C, Therapist grasps client’s pants at lowest point of buttocks. D, Therapist rocks with client and shifts client’s weight over client’s feet, making sure client’s back remains straight. E, Therapist pivots with client and moves client onto sliding board. F, Client is stabilized on the bed. (Courtesy Luis Gonzales.)

The procedure for transferring the client from wheelchair to bed is as follows:

1. Set up the wheelchair and bed as described previously.

2. Position the client’s feet together on the floor, directly under the knees, and swing the outside footrest away. Grasp the client’s legs from behind the knees, and pull the client slightly forward in the wheelchair, so the buttocks will clear the large wheel when the transfer is made (Figure 11-12, A).

3. Place a sliding board under the client’s inside thigh, midway between the buttocks and the knee, to form a bridge from the bed to the wheelchair. The sliding board is angled toward the client’s opposite hip.

4. Stabilize the client’s feet by placing your feet laterally around the client’s feet.

5. Stabilize the client’s knees by placing your own knees firmly against the anterolateral aspect of the client’s knees (Figure 11-12, B).

6. Facilitate the client’s lean over the knees by guiding him or her forward from the shoulders. The client’s head and trunk should lean opposite the direction of the transfer. The client’s hands can rest on the lap.

7. Reach under the client’s outside arm and grasp the waistband of the trousers or under the buttock. On the other side, reach over the client’s back and grasp the waistband or under the buttock (Figure 11-12, C).

8. After your arms are positioned correctly, lock them to stabilize the client’s trunk. Keep your knees slightly bent and brace them firmly against the client’s knees.

9. Gently rock with the client to gain some momentum, and prepare to move after the count of three. Count to three aloud with the client. On three, holding your knees tightly against the client’s knees, transfer the client’s weight over his or her feet. You must keep your back straight and your knees bent to maintain good body mechanics (Figure 11-12, D).

10. Pivot with the client and move him or her onto the sliding board (Figure 11-12, E). Reposition yourself and the client’s feet and repeat the pivot until the client is firmly seated on the bed surface, perpendicular to the edge of the mattress and as far back as possible. This step usually can be achieved in two or three stages (Figure 11-12, F).

11. You can secure the client onto the bed by easing him or her against the back of an elevated bed or onto the mattress in a side-lying position, then by lifting the legs onto the bed.

The one-person dependent sliding board transfer can be adapted to move the client to other surfaces. It should be attempted only when therapist and client feel secure with the wheelchair-to-bed transfer.

Two-Person Dependent Transfers

Bent Pivot: With or Without a Sliding Board Bed to Wheelchair: A bent pivot transfer is used to allow increased therapist interaction and support. It provides the therapist with greater control of the client’s trunk and buttocks during the transfer. This technique can also be employed during a two-person dependent transfer. It is often used with neurologically involved clients because trunk flexion and equal weight bearing are often desirable with this diagnosis. The steps in this two-person procedure are as follows:

1. Set up the wheelchair and bed as described previously.

2. One therapist assumes a position in front of the client and the other in back.

3. The therapist in front assists in walking the client’s hips forward until the feet are flat on the floor.

4. The same therapist stabilizes the client’s knees and feet by placing his or her knees and feet lateral to each of the client’s.

5. The therapist in back positions himself or herself squarely behind the client’s buttocks, grasping the client’s waistband, grasping the sides of the client’s pants, or placing his or her hands under the buttocks. Maintain proper body mechanics (Figure 11-13, A).

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FIGURE 11-13 Two-person dependent transfer, bed to wheelchair. A, One therapist positions self in front of client, blocking feet and knees. The therapist in back positions self behind client’s buttocks and assists by lifting. B, Person in front rocks client forward and unweights buttocks as the back therapist shifts buttocks toward wheelchair. C, Both therapists position client in upright, midline position in wheelchair. Seat belt is secured and positioning devices are added. (Courtesy Luis Gonzales.)

6. The therapist in front moves the client’s trunk into a midline position, grasps the client around the back of the shoulders, waist, or hips, and guides the client to lean forward and shift his or her weight forward, over the feet and off the buttocks. The client’s head and trunk should lean in the direction opposite the transfer. The client’s hands can rest on the lap (Figure 11-13, B).

7. As the therapist in front shifts the client’s weight forward, the therapist in back shifts the client’s buttocks in the direction of the transfer. This can be done in two or three steps, making sure the client’s buttocks land on a safe, solid surface. The therapists reposition themselves and the client to maintain safe and proper body mechanics (Figure 11-13, C).

8. The therapists should be sure they coordinate the time of the transfer with the client and one another by counting to three aloud and instructing the team to initiate the transfer on three.

9. Transfer or gait belts may be employed to offer a place to grasp while assisting the client in a transfer. The belt is placed securely around the waist and often is utilized instead of the client’s waistband. The belt should not be allowed to slide up the client’s trunk because leverage will be compromised.

Mechanical Lift Transfers

Some clients, because of body size, degree of disability, or the health and well-being of the caregiver, require the use of a mechanical lift. A variety of mechanical lifting devices can be used to transfer clients of any weight (Figure 11-14). A properly trained caregiver, even one who is considerably smaller than the client, can learn to use the mechanical lift safely and independently.161 The client’s physical size, the environment in which the lift will be used, and the uses to which the lift will be put must be considered to order the appropriate mechanical lift. The client and caregiver should demonstrate safe use of the lift for the therapist before the therapist prescribes it.

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FIGURE 11-14 A, Traditional boom-style mechanical lift. B, Client lift useful in transferring individuals with spinal cord injury. (A, Courtesy Trans-Aid Lifts, Sunrise Medical; B, courtesy EZ-Pivot, Rand-Scott.)

Transfers to Household Surfaces

Sofa or Chair

See Figure 11-15.

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FIGURE 11-15 Client who sustained a stroke in midtransfer reaches for seat of chair, pivots, and lowers body to sitting. (Courtesy Luis Gonzales.)

Wheelchair-to-sofa and wheelchair-to-chair transfers are similar to wheelchair-to-bed transfers; however, a few unique concerns should be assessed. The therapist and the client need to be aware that the chair may be light and not as stable as a bed or wheelchair. When transferring to the chair, the client must be instructed to reach for the seat of the chair. The client should not reach for the armrest or the back of the chair because this action may cause the chair to tip over. When moving from a chair to the wheelchair, the client should use a hand to push off from the seat of the chair as he or she begins to stand. Standing from a chair is often more difficult if the chair is low or the seat cushions are soft. Dense cushions may be added to increase height and provide a firm surface to which to transfer.

Toilet

In general, wheelchair-to-toilet transfers are difficult because of the confined space in most bathrooms, the height of the toilet, and the instability and lack of support of a toilet seat. The therapist and client should attempt to position the wheelchair next to or at an appropriate angle to the toilet. The therapist should analyze the space around the toilet and wheelchair to ensure that no obstacles are present. Adaptive devices such as grab bars and raised toilet seats can be added to enhance the client’s independence during this transfer. (Raised toilet seats are poorly secured to toilets and may be unsafe for some clients.) The client can use these devices for support during transfers and to maintain a level surface to which to transfer.

Bathtub

The OT should be cautious when assessing or teaching bathtub transfers because the bathtub is considered one of the most hazardous areas of the home. Transfers from the wheelchair to the bottom of the bathtub are extremely difficult and are used with clients who have good bilateral strength and motor control of the upper extremities (e.g., clients with paraplegia and lower extremity amputation). A commercially produced bath bench or bath chair or a well-secured straight-back chair is commonly used by therapists for seated bathing. Therefore, whether a standing pivot, bent pivot, or sliding board transfer is performed, the technique is similar to a wheelchair-to-chair transfer. However, the transfer may be complicated by the confined space, the slick bathtub surfaces, and the bathtub wall between the wheelchair and the bathtub seat.

If a standing pivot transfer is employed, it is recommended that the locked wheelchair be placed at a 45-degree angle to the bathtub if possible. The client should stand, pivot, sit on the bathtub chair, and then place the lower extremities into the bathtub.

If a bent pivot or sliding board transfer is used, the wheelchair is placed next to the bathtub with the armrest removed. The transfer tub bench may be used and removes the need for a sliding board. This approach allows the wheelchair to be placed right next to the bench, which permits safe and easy transfer of the buttocks to the seat. Then the lower extremities can be assisted into the bathtub.

In general, the client may exit by first placing one foot securely outside the bathtub on a nonskid floor surface and then performing a standing or seated transfer back to the wheelchair. Often the client’s buttocks may be bare; therefore a pillowcase may be placed over the sliding board, or a Safety Sure Transfer Sling (The Wright Stuff Inc., Crystal Springs, Miss) (Figure 11-16) may be utilized for safe transfers for bathing.

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FIGURE 11-16 Safety Sure Transfer Sling fastened around the client’s waist and lower back for support. (Courtesy Mobility Transfer Systems, Inc.)

Car Transfers

A car transfer is often the most challenging for therapists because it involves trial-and-error methods to develop a technique that is safe and easy for the client and caregiver to carry out. The therapist often uses the client’s existing transfer technique. The client’s size, degree of disability, and vehicle style (two-door vs. four-door) must be considered. These factors will affect level of independence and may necessitate a change in the usual technique to allow a safe and easy transfer.

In general, it is difficult to get a wheelchair close enough to the car seat, especially with four-door vehicles. The following are some additional considerations when making wheelchair-to-car transfers:

1. Car seats are often much lower than the standard wheelchair seat height, which makes the uneven transfer much more difficult, especially from the car seat to the wheelchair.

2. Occasionally, clients have orthopedic injuries that necessitate the use of a brace such as a halo body jacket or a lower extremity cast or splint. The therapist often must alter the technique (e.g., recline the car seat) to accommodate these devices.

3. The therapist may suggest the use of an extra-long sliding board for this transfer to compensate for the large gap between transfer surfaces.

4. Because uphill transfers are difficult and the level of assistance may increase for this transfer, the therapist may choose a two-person assist instead of a one-person assist transfer to ensure a safe and smooth technique.

Summary

A wheelchair that fits well and can be managed safely and easily by its user and caregiver is one of the most important factors in the client’s ability to perform ADLs with maximal independence.159 All wheelchair users must learn the capabilities and limitations of the wheelchair and safe methods of performing all self-care and mobility skills. If a caregiver is available, he or she needs to be thoroughly familiar with safe and correct techniques of handling the wheelchair, the positioning equipment, and the client.

Transfer skills are among the most important activities that must be mastered by the wheelchair user. The ability to transfer increases the possibility of mobility and travel. However, transfers can be hazardous. Safe methods must be learned and followed.161 Several basic transfer techniques are outlined in this chapter. Additional methods and more detailed training and instructions are available, as discussed previously.

Many wheelchair users with exceptional abilities have developed unique methods of wheelchair management. Although such innovative approaches may work well for the person who has devised and mastered them, they cannot be considered basic procedures that everyone can learn.61

Section 3 Transportation, Community Mobility, and Driving Assessment

ANA VERRAN with contributions from SUSAN M. LILLIE

image Threaded Case Study

Jacqueline, Part 1

Jacqueline is a 67-year-old retiree who has had increased difficulty in her ADLs because of painful arthritis in her neck, hands, back, hips, knees, and ankles. She is 5 feet, 6 inches tall, weighs 138 lb, and drives a 20-year-old sedan, which is meticulously maintained. Her husband has diabetes and no longer drives because of peripheral neuropathies in his legs. He is 6 feet tall and weighs 220 lb. Her role has dramatically changed; she was primarily the passenger and navigator until 1 year ago, when her husband ceased driving at the direction of his physician. She then assumed the primary role for transportation and driving, including assisting her husband with his wheelchair and car transfers.

Her doctor referred her to OT to increase independence with ADLs. She completed four visits on an outpatient basis. The therapist worked with her in the kitchen and recommended larger grip kitchen utensils to facilitate performance in meal preparation. One day, she escorted Jacqueline to her car to assess car transfers and noted difficulty in several areas: she had difficulty loading her husband’s manual wheelchair, managing the key in the door, and opening the car door. Jacqueline doesn’t mind driving, “although it can be painful,” she told her therapist. On bad days, she doesn’t drive at all.

Jacqueline is in fine health, other than the limitations posed by her arthritis. During therapy sessions, she mentioned that she feels fatigued from so much driving. She takes herself and her husband to all doctor appointments, to the pharmacy for medicines, and to church, and she maintains their home and cares for her disabled husband. She stated that she rarely participates in her hobby of scrapbooking anymore because of fatigue and lack of time. She is worried about what the future will bring because their two adult children live out-of-state, 500 miles away.

Critical Thinking Questions

1. What areas of Jacqueline’s community mobility are appropriate for OT intervention?

2. Upon analysis of the task of driving relative to her diagnosis, what client factors can be predicted as needing assessment and intervention?

3. What adaptations or recommendations can Jacqueline and her therapist consider to improve mobility for her and her husband?

Competence in community mobility is an important component of quality of life throughout the lifespan.21,40 Community mobility can be accomplished in many ways, including walking, using a bicycle or a powered mobility device, riding as a passenger, driving oneself, or using public transportation.164 It is an area of occupation that affects all areas of practice and is considered an instrumental ADL under the Occupational Therapy Practice Framework, 2nd edition (OTPF-2).13 Community mobility can be a means to an occupation (walking or driving to work) or an occupation in and of itself (a leisurely stroll or scenic drive).

The potential for engagement in areas of occupation and community mobility are closely linked.54 OTs understand that community mobility is critical for accomplishing necessary activities and enabling those that maintain social connectedness.164 In the United States, community mobility, and the subset of driving in particular, is often viewed as synonymous with independence.67 Conversely, limitations in community mobility and loss of a driver’s license can negatively impact autonomy and feelings of well-being. Lack of transportation to engage in occupations such as grocery shopping, going to medical appointments, and attending religious and/or recreation events can result in diminished social participation.79 Transportation problems are often cited as a primary barrier among individuals with disabilities.100 Also, older adults faced with driving cessation risk depression125 and entry into long-term care,76 and have increased self-perceptions of disability.91

The Role of Occupational Therapy

The OT is ideally suited to identify when community mobility occupations require assessment and intervention.89,95 OT practitioners understand the interplay between engagement in occupation, the existence or lack of mobility options, and physical and mental health. Knowledge in this area makes the profession relevant to clients, the community, and public and private entities.15 To develop treatment plans, therapists analyze performance skills and patterns, contexts, activity demands, and client body functions and structures involved in driving and community mobility13 (Figure 11-17). Under this framework, OTs are concerned with the community mobility needs of clients with varying disabilities at all stages of life. Service recipients could be as diverse as a toddler with cerebral palsy, an adolescent with Asperger’s syndrome, a young adult with a spinal cord injury, and a senior citizen with dementia.15

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FIGURE 11-17 Community mobility in this context includes pedestrian and driver issues. The “Senior Citizen X-ing” sign reflects growing awareness of the needs of the aging population.

OT services are directly related to a client’s mobility concerns and are as varied as clients and the occupations in which they engage. They can address various aspects of passenger safety, walking, biking, and use of mass transit. Interventions may also involve training in preparation to acquire a first driver’s license, evaluation of experienced drivers with age-related changes that interfere with driving, and exploration of alternative transportation options for those people who must temporarily discontinue driving.15 Although clients are often individual persons, organizations or populations may also benefit from OT services.15 Examples of services that might be provided to organizations include modification of the paratransit eligibility evaluation for a transit company seeking to increase ridership of disabled persons, and training of drivers and bus aides for a school system seeking to improve the safety of student passengers with special needs. Services to populations may include collaboration with municipal planning organizations to promote roadway design, bike lanes, and pedestrian paths to support older drivers and persons using other modes of transportation.15,16

The skills and training necessary to ask basic questions about community mobility issues are possessed by all OT practitioners.15 They have in common the goals of supporting participation in the community; optimizing independence in community mobility; and reducing crashes, injuries, and fatalities. However, the depth at which the individual therapist addresses community mobility issues with clients depends on his or her level of experience and the specialized training that he or she has received.40,59,121 Occupational therapy practitioners with specialty training and advanced certification may offer a focused approach in which driving or community mobility is the primary goal.139 A generalist OT practitioner may address driving and community mobility as part of a larger agenda to optimize occupational engagement.15

The case study at the beginning of this section illustrates how the therapist identified several areas in the client’s situation that required intervention and were within her expertise and competence of training. The therapist understood that as older drivers begin to sustain more health problems, they are more likely to interact with OTs, regardless of whether the therapist specializes in driver rehabilitation.102 Although the OT working with Jacqueline did not specialize in driving, she was able to provide intervention by focusing on community mobility in a wider fashion. To elicit additional information, she explored the report that Jacqueline was sometimes unable to drive because of arthritic flare-ups. She kept in mind that early discussions about alternative transportation modes enable individuals and their families to initiate the process of considering appropriate resources and to begin contingency planning before a transportation crisis occurs.7 An intervention for alternative transportation was developed as a result of this conversation. As it turned out, Jacqueline qualified for alternate transportation systems but was unaware of it. The therapist was able to direct her to the appropriate resource and to assist in developing a comprehensive transportation plan. After completing the application process and becoming an established member of the system, Jacqueline was relieved that a safety net was in place for her and her husband.

Historical Context

In 1938 President Franklin Delano Roosevelt utilized the first documented gas/brake hand control to accommodate for polio-related lower extremity weakness.82,124 OTs, along with driver educators and installers of mobility equipment, have shaped the practice of driving rehabilitation since that time.141 The Association for Driver Rehabilitation Specialists (ADED) was founded in 1977 to provide professional education and support to practitioners in various disciplines involved in driver rehabilitation.26,28 Certification in driver rehabilitation for individuals from allied health or other multidisciplinary backgrounds was offered by ADED beginning in 1995. Practitioners with this credential are known as certified driver rehabilitation specialists (CDRSs). As an understanding of driving as both an occupation and an occupational enabler141 grew, the American Occupational Therapy Association (AOTA) implemented a Specialty Certification in Driving and Community Mobility9 with the intent of establishing a professional identity and an occupation-based focus for this specialty practice area.141

Expansion of the driver rehabilitation field resulted in mobilization of trade and government agencies to address safety issues. A quality certification program was established by the National Mobility Equipment Dealers Association (NMEDA) for dealers who modify vehicles for persons with disabilities. The National Highway Traffic Safety Administration (NHTSA), a government agency under the Department of Transportation (DOT) umbrella, also became involved in driver rehabilitation by ensuring that vehicle modifications for persons with disabilities met federal motor vehicle standards. As American demographics changed, NHTSA also provided funding for projects aimed at addressing older driver safety and increasing the capacity of health professionals to meet older driver needs.103,105 One of the funded projects was the Older Driver Initiative, launched in 2003 by AOTA.33

The expectation that more than 71 million senior citizens will be included in the U.S. population by 203049 has brought attention to the issues of fitness to drive, driving cessation, and transportation problems faced by older adults.11,45 Collaboration between agencies has been critical for improving the quality and availability of service providers and for developing alternative transportation systems to accommodate nondrivers. The NHTSA has encouraged creation of services by other agencies to extend the period of safe driving and the development of alternative transportation for individuals faced with driving cessation.6,102 The Physician’s Guide to Assessing and Counseling Older Drivers7 was developed by the American Medical Association in cooperation with the NHTSA to address the driving safety of older patients and to foster understanding of the public health issues involved. The American Society on Aging (ASA) has also utilized funding from NHTSA to develop educational programs19,20 to help professionals better face the challenges of keeping older adults mobile and engaged in their communities.35,66

Other agencies have collaborated to improve driving and transportation alternatives. Project ACTION (an acronym for Accessible Community Transportation in Our Nation) was funded through an agreement with the DOT, the Federal Transit Authority (FTA),71 and Easter Seals. This program seeks to promote cooperation within the transportation industry to increase mobility for persons with disabilities under the Americans With Disabilities Act (ADA) and beyond.63,80,145 The American Automobile Association Foundation for Traffic Safety (AAAFTS)1 sponsors research that uncovers critical traffic safety problems and identifies the most effective solutions to them. A multiagency effort by this agency, the AOTA, the ASA, and the American Association of Retired Persons (AARP) resulted in CarFit, a campaign to help seniors ensure that they have a good fit with their vehicles.4,46a,143

In 1998, AOTA President Karen Jacobs noted that OT had only just begun to identify and reach markets for service.87 Since that time, Centennial Vision, provided by AOTA, has been instrumental in shaping the direction of practice in the areas of driving and community mobility. Endorsed by the Board of Directors in 2003, Centennial Vision serves as a roadmap for the future of the profession8 and identifies opportunities to expand OT practice to serve individuals, organizations, and communities. Recognition of the societal needs posed by an aging population has focused attention on driver training and rehabilitation, resulting in the designation of this specialty as one of the top six emerging areas of OT practice.50,87,139,158 The Centennial Vision strategy of linking education, research, and practice has been implemented by increased scholarly research in the driving and community mobility specialty areas. Evidence-based literature reviews related to OT and driving and community mobility for older adults were published in the American Journal of Occupational Therapy in 2008 and 2010.51,141

The benefit of OT in meeting the concerns of older adult clients is demonstrated on an individual basis by programs targeting assessment of driver competency and planning for transition from driving. Additionally, the value of the profession in this area is recognized by other professionals and organizations, including the NHTSA102 and the American Medical Association (AMA).7 Public transit authorities also acknowledge OT expertise in community mobility and often contract with practitioners to perform functional assessments to determine paratransit ridership eligibility.157 On a national level, the visibility of OT contributions to driving and community mobility has been enhanced through professional contributions to CarFit programs. The Older Driver Website of the AOTA provides resources for practitioners and for consumers, physicians, and others who refer clients to OT services available for older adult drivers.14

Public Transportation

Community mobility within public transportation includes the use and navigation of transportation systems offered by public and private entities. Public transportation refers to services operated by public agencies or supported by public funds.155 It utilizes buses, trolleys and light rail, subways, commuter trains, street cars, cable cars, van pool services, paratransit services, ferries and water taxis, and monorails and tramways.17,18 The two categories of public transportation are fixed route and paratransit systems. Fixed route systems use defined routes with predetermined stops and run on a published schedule.155 Trains, city buses, and shuttles are types of fixed route transportation. The paratransit system provides demand-response service within a prescribed geographic area; vehicle dispatch occurs only in response to the request of a qualified rider.73

Jacqueline’s OT understood that driving an automobile is the preferred form of transportation for older adults.36 She also knew that inconvenience and fear for personal safety are frequently cited as barriers to the use of fixed and demand-response public transit.134 She explored Jacqueline’s feelings about using public transportation and pointed out the pros and cons of using this mode of transportation. Armed with information provided to her as a result of the OT intervention, Jacqueline made an informed decision that public transit could meet her needs and qualified herself and her husband to use their local paratransit system.

Americans With Disabilities Act

The Americans With Disabilities Act of 1990 (ADA)1 was landmark civil rights legislation for persons with disabilities. Twenty years after it became law, its impact is most apparent in gains in accessibility and transportation. Buses with lifts and sidewalks with curb cuts are common examples of changes accomplished through this Act. In fact, the FTA estimates that by 2006, 98% of bus service was ADA accessible.72 Title II of the ADA prohibits discrimination on the basis of disability by all public entities that provide transportation at the local (school district, municipal, city, and county) and state levels. Title III extends coverage to private entities that provide public transportation services.80 Most modes of transportation have jurisdiction under the ADA, but transportation that is specifically covered through other laws is excluded. For example, discrimination on the basis of disability in air travel is prohibited by the Air Carrier Access Act of 1986 (ACAA).149

The ADA regulates buses, trains, ships, and other means of transportation that use fixed and demand-response systems.147 This legislation establishes accessibility guidelines for buses, trains, and light rail systems, specifying the need for wheelchair lifts and ramps and for securement of mobility aids.2 ADA guidelines also provide for priority seating, handrails to facilitate interior circulation, public address systems to announce stops, stop request controls, clearly marked destination and route signs, and various other features intended to ease navigation by persons with disabilities.

Complementary paratransit service is mandated by the ADA, but individuals must meet eligibility requirements to qualify for this demand-response service.148 Service is available to persons with physical or mental impairments who cannot board and ride accessible fixed route transit systems, whose fixed route system lacks accessible vehicles, or who have specific impairments that prevent getting to and from a stop. Eligible persons who require personal assistance when using paratransit service may have one attendant travel with them at no charge.

Intervention Implications for Fixed Transit

Fixed route transportation using buses or train services creates links among home, school, work, recreation areas, and other important destinations. The FTA estimates that the size of the nation’s transit bus fleet grew by more than 25% since 1984, extending fixed transit transportation options to many communities.72 Many of these buses are fully accessible. Fixed route systems are more economical and offer greater autonomy and flexibility than demand-response systems; consequently, they present a good transportation alternative for many persons with disabilities and older adults. Another advantage is that fixed route transit is available to everyone and does not have a qualification process. Consequently, when it is possible to use fixed route services, the role of the OT practitioner is to inform, educate, and encourage the client to do so.164

Trepidation about traveling alone can make an older adult or a person with a disability reluctant to use the fixed route system.155 To achieve increased ridership, OTs must match the task demands of the local fixed transit environment with client factors and performance skills.18 The client’s proficiency as a fixed transit user should be evaluated in the actual setting where the individual will be using bus or rail services. It will be necessary to examine whether the client can efficiently get to a bus stop, if bus stops at origin and destination points are safe, whether the individual is safe in boarding and exiting the bus, and if the time at which travel will occur is optimal. Determination of the client’s ability to manage the system (handle money, understand transfers, find a seat) and to plan for contingencies such as missing a stop is also important.

If the OT identifies barriers to successful use of fixed transit, a focused intervention plan may be required to remediate or compensate for limited subskills. Strengthening, balance, and endurance programs to enhance ambulation or efficiency in using a mobility device can be carried out in the clinic. Clients can also practice skills such as reading a schedule and managing money in a clinic setting. Additionally, evidence suggests that some mobility device skills practiced in controlled environments can transfer to community settings.156 However, the natural environment poses limitations that cannot be duplicated or foreseen in the clinic. It is thus very important to practice skills within the context of where they will occur. The environment appears to have a larger impact on processing ability than on individual motor skills116; therefore, performance of bus riding tasks in the clinic may not translate to ability to use the bus.

Similarly, if a recommendation for a scooter wheelchair is to be made, it should first be determined whether the device will actually fit on the platform lift of the bus. Accessibility on an ADA compliant lift is a function of the height of the end flap (ranging from 3 to 8 inches) and the footrest clearance of a given wheelchair. Lower footrests tend to make a wheelchair functionally longer and potentially incompatible with transit lifts. Lifts are located differently and can vary in style from bus to bus. The unique characteristics of each lift will need to be considered in determining boarding techniques. Finally, although a scooter or a wheelchair might actually fit on a lift, its turning radius may exceed the physical environment available on the bus or light rail system.

Some transit systems offer individualized training programs, known as travel training, to assist persons who cannot negotiate the fixed route system to travel safely and independently to a regularly visited destination such as work or school. The unique blend of skills and understanding of client and contextual factors demonstrated by OTs make them perfectly suited to provide travel training to clients who need assistance in using fixed transit. Specialized training in this area is available at no cost through Easter Seals Project ACTION.65

Under Centennial Vision, OTs have a role in providing services to communities and organizations. They advise transit agencies about starting travel training programs and confer with city planners and local governments about environmental challenges such as lack of benches and shelters to provide rest areas, less than optimal lighting at a bus stop, inadequately timed crossing lights, and the need to add or modify a curb cut.157

Intervention Implications for Paratransit

Paratransit offers a viable transportation alternative for many persons with disabilities. OTs can play a critical role in helping clients determine whether paratransit service best meets their community transportation needs. To do this, the practitioner must become familiar with the policies of the local transit company and must clearly understand the client’s passenger assistance level. Under the ADA, transit providers have an obligation to provide origin-to-destination services to qualifying individuals.151 The law allows transit companies to determine whether the service provided will be door-to-door or curb-to-curb. In door-to-door service, the driver offers help from the door at the origin point of the trip to the vehicle. Comparable assistance is provided at the destination point. In curb-to-curb, help is not provided until the person actually reaches the curb. Recent guidance from the DOT to transit agencies clarifies that transit agencies with curb-to-curb service must provide assistance to riders who need it because of a disability; however, door-to-door service may be provided only as needed, not necessarily for all rides.61 The activity demands of curb-to-curb service are much greater than those of door-to-door service. The OT should prepare the client to advocate for door-to-door service if the person’s functional limitations require it.

ADA regulations require that the transit system must have a process in place to determine eligibility for complementary paratransit.64,151 This process is developed by the transit system in consultation with the local community. Eligibility may be conditional if the person is able to ride fixed transit for some trips but not for others. Examples of situations that might prevent an individual’s use of a fixed route service for some trips include weather conditions for a person with temperature sensitivity, presence of a variable medical condition, and environmental barriers at certain locations. An application is usually required to qualify, but some transit systems also ask for supporting documentation, an in-person interview, and/or an in-person assessment of the applicant’s ability to use fixed route service. The focus of the in-person assessment used to enforce conditional eligibility is to determine the person’s ability to use public transportation, not the extent of their disability.

ADA paratransit ridership increased from 20 million to 45 million annual trips in the 5 years after the ADA was signed into law.75 This statistic reflects the demand for this transportation service. Unfortunately, the costs of providing a paratransit trip are significantly higher than for a fixed transit trip—often 10 times more expensive.75 The high expense of providing paratransit service has caused some transit providers to implement a stringent eligibility certification process as a way to contain costs.75 OTs have a potential role in all aspects of eligibility certification.157 To ensure appropriate categorization of a disability, assistance can be provided during the application process. Clients can be encouraged to accurately report all significant disabling conditions that interfere with using fixed route service. Assistance during the interview process could involve educating the person to provide necessary documentation of these problems and helping him or her to articulate the difficulties encountered when using fixed route service, for example, by describing an inability to wait at a bus stop. OT services are also needed by transit authorities to determine whether a person’s wheelchair conforms to the common wheelchair ADA requirements, to prescreen an applicant for balance and motor capabilities, and to conduct an assessment of the person’s skills during an actual transit trip.81

OT interventions may include orientation to the local system, training in making a reservation, and education related to service limitations. Paratransit ridership combines trips of several individuals to meet the capacity of the vehicles; consequently, travel often takes longer than private transportation. It can, in some cases, exceed fixed route timelines. Long trips can pose hardship to those whose medical conditions or symptoms include urinary urgency and frequency, pain with prolonged immobility, insensate skin, or decreased endurance. OT intervention in such cases may call for cushioning and positioning devices to decrease discomfort and fatigue during the trip. Clients who are reluctant to travel alone gain confidence in their abilities when accompanied on a trip to a destination and back.

Clients may also benefit from instruction on planning a trip and discussing contingency and safety preparations. Food, water, and shelter may not be available at drop-off points. On some occasions, miscommunications or errors cause a delay in or outright cancellation of a ride. As with fixed transit, the unaccompanied rider needs a certain degree of resourcefulness and problem-solving skill to navigate the system safely and efficiently. Jacqueline became a paratransit rider to provide herself with transportation and to accompany her husband to appointments. She was concerned about the long ride because her doctor’s office was an hour from her home. With travel time, waiting, and the doctor visit factored in, they could potentially be away from home for 3 to 5 hours. Her therapist recommended that she pack appropriate diabetic snacks to properly maintain her husband’s blood sugar level and avoid low blood sugar problems during their journey.

Private Transportation

Private transportation relies on consumer vehicles that are privately owned, either individually or by an entity collectively. The primary advantage of private transportation is the on-demand, 24-hour availability of origin-to-destination travel, the flexibility to modify travel plans, and the strong sense of control over one’s life. Individuals in rural areas that are not served by fixed transit routes may have no alternative but to utilize private transportation. The primary disadvantage of private transportation is cost: the individual is responsible for access needs, for fuel, and for keeping the vehicle and any driving modifications mechanically sound. Nondrivers who own vehicles face additional costs of hiring drivers; this limits on-demand transportation.

Persons who prefer the convenience of private transportation must plan for replacement costs of the vehicle to retain independence. Future expenditures can also be expected for compensatory adaptations necessitated by aging and long-term disability.34,94 An emerging trend may result in additional costs, as mobility equipment dealers begin to require a driver assessment before adapting a vehicle. Costs and vehicle responsibilities prohibit many from private transportation options.

Supplemental Transportation Programs for Seniors

The aging of America has resulted in a focused effort to develop supplemental transportation programs for seniors, also known as STPs.36 Their primary purpose is to support the gap in transportation services for older adults, particularly those over age 85, who most likely do not drive. They may also serve people with disabilities, however. Key to these programs is that they offer assistance that is unavailable through public transit and ADA paratransit. STPs may be sponsored through senior centers, hospitals, city councils, paratransit, places of worship, or a city office on aging and door-to-door, door-through-door assistance at the destination and escort service may be provided. Services are available at a variety of times, often permit multiple stops, and may allow jurisdictional boundaries to be crossed. Volunteer drivers, paid drivers, or a combination of both may be used. Some STPs have their own vehicles purchased through public funding. Others, such as volunteer driver programs, rely on the vehicles of their volunteer drivers. The Beverly Foundation, a technical assistance program that encourages senior mobility and transportation,34,35 has defined the factors necessary for senior-friendly transportation: availability, accessibility, acceptability, affordability, and adaptability. By being involved in senior mobility issues in the community, OT practitioners can learn about appropriate transportation alternatives to driving and can help disseminate information about these alternatives, adding their unique expertise to the process.

Intervention Implications

Some clients who are considering driving will request OT consultations to explore the process involved and to identify costs for private transportation based on their diagnosis and function. In one such case, a client with a C5 spinal cord injury discovered that the level of technology he was likely to need to be able to drive was expensive. If he proved to be a successful driver candidate, the vehicle and adaptations alone would cost more than $100,000. This figure does not reflect the cost of the comprehensive evaluation or the extensive driver’s training. The client appreciated learning the assistive technology required for his injury because it provided pivotal information for his transportation planning. Some people value driving so highly that they would gladly pay such costs out of settlement or other funds. However, this client decided not to drive, stating, “That sure would buy a lot of taxi rides!” By providing a “mini” evaluation or consultation, the client was given the critical information he required to plan his future optimally. He learned that he probably had the ability to drive but made an educated decision to use his resources for a different transportation plan.

Driving is but one aspect of private transportation within the practice area of community mobility. Passenger evaluations, which can significantly improve the safety of the caregiver and the rider, are too often overlooked as a focus of intervention. If the person to be transported uses a wheelchair and cannot transfer to a vehicle seat, the OT can be an important source of information about how the wheelchair can be safely transported. In a school setting, OTs are responsible for students who use wheelchairs, including their safe transport to and from school.136

The basic elements for protecting passengers seated in wheelchairs within motor vehicles are (1) a safe vehicle, (2) a forward facing vehicle, (3) a crash worthy wheelchair, (4) effective wheelchair securement, and (5) effective occupant restraint.77 The voluntary ANSI/RESNA WC19 compliance standard describes the type of wheelchair that can be used as a seat in a motor vehicle. Such a wheelchair has a frame and transit components that have been crash tested, four securement points, specific securement point geometry, a clear path of travel for proper placement of vehicle-mounted occupant safety belts, and anchor points for an optional wheelchair-anchored pelvic safety belt.127 OTs can help clients advocate for a WC19 wheelchair by providing justification and documentation of need.77 School-based therapists can collaborate with other therapists in ordering a wheelchair to make sure that it can be safely used to transport a child.136 Practitioners will find a list of wheelchairs that comply with the WC19 standard available on The Rehabilitation and Engineering Research Center on Wheelchair Transportation Safety (RERCWTS).128

A complete wheelchair tie-down and occupant restraint system (WTORS) must be used to safely transport a person in a wheelchair. A WTORS attaches the wheelchair to the vehicle with a four-point strap-type tie-down. Wheelchairs can also be secured with an SAE J2249 or ISO 10542 compliant docking tie-down device.77 Adaptor hardware attached to the wheelchair frame engages with the docking tie-down device installed in the vehicle.129 To protect the rider, a seat belt system with pelvic and upper torso belts must be used.129 OTs should recommend that WTORS be installed by vehicle manufacturers or accredited members of NMEDA. The WTORS must be manufactured by a single supplier, labeled as meeting crash standards, and installed according to manufacturer’s specifications.77 Knowledge of these standards will ensure that safety is not compromised.

A skilled therapist can identify and recommend the secondary postural supports (head supports, lateral pads, butterfly vests, and pommels) needed to help a passenger sit with good posture.136 OTs should keep in mind the caregiver’s physical capacities in making recommendations for equipment. Because the tight confines of a bus, car, or van pose challenges to ease of movement, educating and training caregivers in body mechanics and joint protection is essential for safety and injury prevention.32,136

OTs can be instrumental in educating attendants and transporters in safe loading of a wheelchair onto a lift (passenger facing away from the vehicle and wheel locks applied) and in deciding whether an individual with a power wheelchair can safely drive onto the lift.136 School-based therapists have opportunities to work with transporters in developing a bus evacuation plan for disabled students.136

Specialized Needs

When life support devices are required in a vehicle, safety dictates provision of a backup energy source in the vehicle through a device known as an inverter. An inverter converts a 12-volt DC battery source to common 110-volt AC power and provides an instantaneous plug-in source of power if the life support device battery fails.

Safe transport of infants and children with medical needs or disabilities is another area of practice that should not be overlooked. Car seats should not be modified unless the person performing the modification is certified to do so. Inappropriate car seat adaptations recommended or made with good intentions can have life-threatening implications.33

Assessment for children and teenagers must take into account future physical growth. For example, a 6-year-old riding in a van seated in a wheelchair may no longer fit in the vehicle by age 15 because of increased height. Also, activity demands associated with caregiving will be greater for a 15-year-old than for a 6-year-old. Alternative mechanical or power lifts or adaptations may become necessary for children or adults when their body size becomes unmanageable (and therefore unsafe) for their caregiver. Both growth and development and aging impact the equipment that will meet needs at a given age. Jacqueline, the client described in the case, may need to consider specialized passenger seats designed for the elderly. These motorized seats move outside the car and rotate, easing the activity demand of car transfers through compensatory mechanical movement and power (Figure 11-18).

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FIGURE 11-18 Bruno’s Lift-Up power mobility seat for Toyota Sienna minivans aids vehicle entry by modifying activity demands for caregiver and client. (Courtesy Bruno Independent Living Aids.)

Driving

Driving is cited again and again as the basis for personal independence, employment, and aging in place.7,59,102 A driver’s license has deep social and cultural contexts; it serves as a rite of passage for the teenager, provides the adult with an ability to pursue employment and recreational opportunities, and gives the aging population competence and wellness. Driving competence is regarded as instrumental for obtaining and maintaining an independent lifestyle and for aging in place for the older adult (Figure 11-19).

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FIGURE 11-19 This client was experiencing difficulties driving and at work, as progression of her multiple sclerosis exceeded the activity demands of pushing a manual wheelchair. Driving from a power wheelchair and using an electronic gas-brake hand control decreased the activity demands on her upper extremities, enabling her to drive safely and work full-time as a teacher.

Occupational Therapists and Driving

An understanding of the implications of medical conditions and disease processes, the ability to analyze ADLs and IADLs, knowledge of adaptive devices, and occupation-based interventions make OT practitioners uniquely qualified to provide driver rehabilitation. The social impact of an aging population (20% of the U.S. population will be 65 or older in 2030)70 has brought the issues of maintaining independence and quality of life, especially as they pertain to driving, to the forefront of attention. OTs already make up the overwhelming majority of professionals providing driver rehabilitation services for the physically disabled population.92 The profession has responded proactively to an increased number of senior drivers through the AOTA Older Driver Initiative.90 However, given the increasing numbers of senior citizens who grew up relying on cars to engage in occupations, the need to train additional therapists in this specialty practice area is tremendous.5

image Ethical Considerations

Driver rehabilitation specialists have a responsibility to their clients and to the larger community as well. Public safety is an important concern.

Generalist and Specialist Roles

All OTs should explore how impairments impact driving and should set goals related to their clients’ driving and community mobility needs.117 Generalists should sufficiently understand the skills needed to play a role in initial decisions about driving, but should appreciate that the clinical screenings they administer can neither confirm driving capability nor rule it out as a goal.90 An OT driving specialist (DRS) should be contacted if any questions about driving safety arise (Box 11-2). Driving presents a greater possibility of personal and public harm than does any other ADL or IADL; therefore OTs offering driver evaluation services receive advance training to effectively intervene in this complex occupation.15 OT driving specialists administer assessments specific to the requirements of driving, including those for vision, cognition, motor performance, reaction time, knowledge of traffic rules, and behind-the-wheel assessments of skill.15 They recommend whether to continue, modify, or cease driving; suggest vehicle modifications and adaptive devices; provide driver retraining or specialized driver education; and document all findings. OT practitioners who specialize in driving must be certified driver instructors to perform on-road assessments and provide driver training in some states.15,122

Box 11-2   Additional Resources

American Medical Association

Physician’s guide to assessment, older driver information

http://www.ama-assn.org (search for “older driver”)

American Association of Retired Persons

Information and publications on older driver issues

http://www.aarp.org (search for “older drivers”)

American Occupational Therapy Association

Physical Disability Special Interest Section—Driving Network Listserv

Listserv driving network for members, professional development tool, older driver driving and older driver on-line courses, as offered

http://www.aota.org (click on AOTA Listserv, then on Driving/Driver Rehabilitation)

Numerous topics on older drivers and community mobility

http://www.aota.org/olderdriver/

Association for Driver Rehabilitation Specialists (ADED)

Best Practices, standards of practice, models of practice, disability fact sheets, bulletin board for members

http://www.aded.net

National Mobility Equipment Dealers Association

Trade association for manufacturers of equipment and vehicle modifiers, quality assurance program (QAP)

http://www.nmeda.org

National Highway Traffic Safety Administration

Consumer and disabled driver safety information

http://www.nhtsa.dot.gov

Older driver information

image Ethical Considerations

No therapist should proceed with on-road driver evaluation without first meeting the industry standard or equivalent for driver instructors within his or her own state. Proceeding without this basic driver instructor training is not recommended; it has the potential to be unsafe and to result in the therapist teaching techniques incorrectly that must later be unlearned.

Specialty Training and Certification

Professional specialty designation expedites services, ensures appropriate matches between practitioner skills and client need, and validates the depth and breadth of OT practice.1a,10 The AOTA has recognized that Board and Specialty Certifications communicate expertise to consumers and professionals outside of the profession, and that they are recognized as quality markers by accrediting and regulatory agencies and sources of reimbursement.78 The AOTA offers a Specialty Certification in driving and community mobility for OT practitioners (OTs and certified occupational therapist assistants [COTAs]). This specialty designation is based on a peer-reviewed reflective portfolio. The process is prospective and includes three major sections: background, reflective portfolio, and ongoing professional development.9

The ADED offers certification in driver rehabilitation (Box 11-3). The CDRS credential allows individuals from allied health and driver training backgrounds who meet the criteria for educational background and experience to sit for an examination covering driver education, disabilities, and vehicle modifications.26 In some states, agencies such as the Department of Rehabilitation require the CDRS credential to provide services.

Box 11-3   Certification Programs

Association for Driver Rehabilitation Specialists (ADED)

Certification requirements, testing dates, sample tests

http://www.aded.net (click on certification link)

American Occupational Therapy Association

Community Mobility and Driving Certification

Professional development certification updates, requirements, and application process once available

http://www.aota.org

OTs with a specialty in driving may benefit from professional development by attending traffic safety and driver education courses. Driver instructor courses provide training in identifying behaviors and habits, teaching proper driving techniques, minimizing collision risk during an evaluation, recognizing specific driving pattern characteristics of novice and older drivers, and implementing training exercises and programs to improve outcomes. Resources for training include the local department of motor vehicles office, state trooper organization, high school driver education program, traffic safety council office, AARP, or driver refresher course, and ADED conference presentations.121

image Ethical Considerations

Principle C-46 of the Association for Driver Rehabilitation Specialists’ (ADED) Code of Ethics: “Driver rehabilitation specialists use only assessment techniques that they are qualified and competent to use. They do not misuse assessment results or interpretations.”

Occupational Therapy Assistants

The OT assistant (OTA) is a valuable asset to driver rehabilitation. Completion of standardized testing, vehicle entry/exit and lift safety training, transfer training, and functioning in the role of driver instructor are just some of the ways the OTA can contribute to a driving program. The OTA must work under the supervision of, and in partnership with, the OT.12

Appropriate utilization of OTA skills can be an asset to driving programs by assisting with cost containment. Expanded roles are possible when intervention protocols are developed, documented, and followed, again under the supervision of the OT. For example, OTAs can be utilized to determine the need for progression in driver training, if the driving skills being observed have been defined and training in recognizing them has been provided to the OTA. Clear treatment protocols facilitate supervision by enhancing communication between colleagues.

Driving Program Structure

Therapists can be based in an agency, private practice, or hospital, and can offer different levels of services, ranging from referrals, consultations, and clinical screenings to comprehensive driver competency assessments. Most programs have just one driving program staff member in the vehicle during an on-road evaluation—usually the therapist fulfilling the evaluator and driving instructor roles. Additional specialization and expertise are required of the therapist when higher levels of driving technology are introduced.

Some programs choose to use staff or contracted driver instructors for the on-road portion while the therapist makes observations from the back seat. A variation is for the instructor to conduct the on-road evaluation alone without the therapist and report to the therapist on performance level. This is not recommended, especially when the client has significant mobility or performance skill involvement, because the therapist’s unique training may identify an issue otherwise overlooked. Programs with just one professional in the vehicle should consider outlining special criteria that would mandate the need for two staff members during the on-road assessment. Two professionals in the vehicle can offer better security and protection, for example, when witnesses are desired for all direct client contact.

Models of Practice

Practice models provide guidance for established and new driving programs and identify conceptual areas and detail practices that should be considered. In 2002, NMEDA and ADED released Model Practices for Driver Rehabilitation for Individuals with Disabilities, focusing on agency-sponsored evaluations and vehicle modifications, such as the Department of Rehabilitation (DR).108 In 2004, the ADED published Best Practices, delineating frameworks for driver rehabilitation services.24,25 In some states, the DR has existing guidelines and role delineations, which provide further models and references.137,138

Driving Program Goals: Driving competence can be disrupted by a single disability, multiple medical conditions, or factors of aging.32 Driving programs seek to provide safe and independent transportation for individuals. One may participate in transportation as a passenger or as a driver. Driver program services provide assessment in a natural environment under real-time conditions—an important aspect because outcomes in general can be overestimated in clinical settings.23 The performance skills and activity demands of the client, as well as other client factors, are assessed in efforts to determine what restorative, compensatory, or preventive interventions may be needed for safe transportation or driving.

Goals must include the specific driving occupations in which an individual wishes to engage. Although independent driving is the general goal, subset occupations exist within the task of driving. Some drivers want only to drive to the store, doctor, and church; others want to return to a job in which driving is an essential function of employment. A divorced or single mother with severe chronic pain may wish to regain the ability to transport her child for parental visitations. Driving needs and associated activity demands are personal and specific; identification of each client’s occupational needs is paramount to a meaningful assessment and a successful outcome. When needs and demands are identified early, the occupation of driving and required subskills can be interwoven into the fabric of intervention.

Best Practices Identified

Driver evaluation is a process that is dynamic and fluid (Figure 11-20). An individual’s readiness, performance skills, and rate of learning can affect the ease and speed of completing the driver evaluation process.144 Recommended and Best Practices provide frameworks that accommodate any level of a client’s performance skills.

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FIGURE 11-20 The flow chart illustrates the complexities and dynamics of the driving evaluation process.

Best Practices from the ADED include a clinical evaluation followed by (1) an on-the-road evaluation in an actual driving environment, (2) subsequent vehicle modification recommendations and wheelchair measurements, (3) recommended driver training and education, (4) a final fitting, and (5) licensing assistance.25,81 An on-road evaluation is indicated when program criteria are met. Programs set varied criteria based on specialized training received by staff, the scope of the program, comfort level, and safety issues. Recommendations for adaptive equipment are not advisable until a driver demonstrates in a behind-the-wheel assessment competency to access or use the equipment or a similar device.

Program Criteria

Driving programs must establish the necessary elements of an evaluation process and objective performance criteria to enable consistent and accurate decision making against which progress (or lack of it) can be measured. Use of Best Practices also provides a measure of liability protection. The Physician’s Guide to Assessing and Counseling Older Drivers (prepared by the AMA) outlines different levels of assessment, from the interview to a formal driver assessment.7 Factors listed as prompting physician concern about a client’s driving skills include acute events, chronic medical conditions, questioning of safety by an individual or family members, conditions that are unpredictable or episodic, and use of specific medications. These factors may also serve as a basis for development of criteria for driving assessments and behavior evaluations.

image Ethical Considerations

Therapists in this practice area must be able to withstand significant pressure in their decision making. A novice driver with significant cognitive and perceptual impairments, for example, may press to curtail the assessment process prematurely because of time and financial considerations. Pressure to sway the therapist’s opinion before completion of an assessment may come from biased third party payers; even family members may strongly attempt to influence the outcomes of the assessment in a direction that is not supported by performance observations.

Referral Process

Physicians, allied health care professionals, family members, and individuals are appropriate referral sources for community mobility and driving assessments. The referral process may be simple or complex and cannot always be completed in a seamless fashion. Verification of an individual’s insurance coverage can be time-consuming. Most private insurance sources do not pay for evaluations, and government insurance, such as Medicaid and Medicare, generally follows the private insurance industry. Although some therapists are able to obtain Medicare coverage, the reimbursement rate rarely covers the full costs of the assessment process.5

Each program must set criteria for accepting a referral for driver evaluation. A physician’s referral, recent medical records, a confirmed payment source, and a valid driver license or permit (for on-road segment) are frequently required. Most programs also create an intake form on which to record relevant background information about the client. During the referral process, it is important to communicate the program’s intent, so that anxiety can be minimized. Jacqueline was worried until the therapist from the driving program called and spoke with her. She was relieved to hear that an array of options was available to meet her needs. She had considered canceling the evaluation because of the devastating impact that loss of her license would have, but chose not to after reviewing goals with her therapist. As a result, she arrived for her evaluation optimistic and ready for productive changes in her driving system.

Driving Evaluations and Disabilities

Many different types of disabilities influence driving ability. Therapists can apply their knowledge of various conditions to understand the client factors that might be affected, and to anticipate how disease progression could influence the need for driving equipment over the course of time. The ADED Website provides fact sheets that discuss driving issues and assessments for several different types of disabilities.27 A discussion of driving issues related to some commonly seen disabilities is presented in the following sections.

Spinal Cord Injuries

Spinal cord injury (SCI) is the second leading cause of paralysis in the United States.49 The National Spinal Cord Injury Statistical Center at the University of Alabama at Birmingham reports that 262,000 people in this country have sustained an SCI.109 A significant percentage of SCIs are incomplete, and individuals may have motor and/or sensory function below the level of the lesion.110 Individuals with such injuries can be challenging in driver rehabilitation. Intervention requires the OT to engage in critical thinking, collaborate with physical therapy, and determine whether the client can demonstrate the necessary performance skills to meet the activity demands of driving without undue fatigue. Adaptations for driving may be temporarily needed while prolonged recovery occurs. Clients who have sustained complete SCI injuries have more straightforward intervention protocols based on the level of injury. All individuals who have sustained spinal cord injuries, however, have a high frequency of multiple diagnoses, including mild or undiagnosed traumatic brain injury (TBI).97 Therapists need to remain alert to possible signs of TBI so that intervention services can be modified accordingly.46,111

A driving evaluation for the client with an SCI focuses on the occupational performance subskills basic to all evaluations. Performance areas include mobility of a wheelchair or other wheeled device to and from the selected vehicle, transfers between the wheelchair and the vehicle, and overall vehicle entry and exit. The ability to manage equipment, including loading and unloading wheelchairs and locking and unlocking long leg braces, is also important. A thorough evaluation should assess driving competence in a natural setting and should ascertain the ability of the client to meet activity demands. The need for compensatory adaptive equipment must be established. Upper torso supports or chest straps are frequently recommended to maintain an upright position during a sharp or fast turn37; a diagonal seat belt alone may not be adequate to inhibit lateral movements.

Steering devices may be needed to accommodate hand and upper extremity impairments, and pedal blockers may be necessary to prevent accidental activation of the brake and gas pedals by lower extremity spasms.

In clinical practice, most individuals with paraplegia and tetraplegia at the C7-8 level can drive a car that has the following modifications (Figure 11-21):

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FIGURE 11-21 A basic setup for paraplegics includes spinner knob for steering and mechanical hand controls to operate accelerator and brake. This equipment can be used in many cars, vans, trucks, and sport utility vehicles.

1. Standard power steering and power brakes with automatic transmission.

2. Mechanical hand controls to operate accelerator and brake.

3. A steering device, usually a spinner knob or V-grip.

4. An upper torso support strap (this is a positioning device only and should never be considered as a safety device to replace a seat belt).

5. Accessible or remote switch for horn, dimmer, wipers, and turn signals.

6. A parking brake extension.

The Consortium for Spinal Cord Medicine Clinical Practice Guidelines suggest that independent driving from a wheelchair is possible for persons with C6 tetraplegia; however, achieving this functional outcome depends on the unique characteristics of the case.57 An extensively modified van may be required when an individual is unable to transfer independently, or when transfers are physically taxing.37 Structural modifications to the van (e.g., a raised door, a raised roof, a lowered floor) may be necessary to accommodate the wheelchair and the driver. With current technologies, and after extensive evaluation and training, some clients with a C4-5 SCI can safely drive systems with high-technology modifications (Figure 11-22).

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FIGURE 11-22 High-tech equipment compensates for limited motor skills. The evaluation van equipped with electronic mobility controls (EMC) has a left-side electronic gas-brake, a remote left elbow secondary control button, a 7-inch remote steering wheel (on right) with trip-in steering device, and a membrane switch console for functions including gear shift, windows, and headlights.

Driving From a Wheelchair

When a person needs to drive from a wheelchair, client education and informed choice are necessary to address increased safety risk. It is generally accepted that the hierarchy of safe seating for a driver begins with the driver seat of the original equipment manufacturer (OEM), which is designed to withstand crash forces. The OEM seat is followed by an aftermarket powered seat base (which moves up/down and forward/back and rotates to facilitate transfers). Driving from a wheelchair is next, with a power wheelchair considered safer than a manual wheelchair, even when both are WC19 compliant. Both types of wheelchairs have been crash tested at low speeds, but the heavier weight of the power wheelchair allows it to withstand forces at the higher speeds typical in many driving situations. For safety reasons, it is not possible to drive from a scooter.

Driving from a manual wheelchair can present several complicating factors. Some persons lack the strength to push the manual wheelchair up the ramp of a lowered floor minivan, which has a 1 : 6 slope. This slope is twice as steep as the minimum slope for an ADA ramp and consequently requires more strength to navigate. Compounding the problem is the fact that the weight of the device required to secure the wheelchair to the van floor adds 10 to 15 pounds to the wheelchair. Still another problem is that the securement device, which is permanent, precludes a folding wheelchair from folding.

When the client is driving from a wheelchair, a wheelchair assessment is needed to ensure that the person is stable and appropriately positioned, and that the wheelchair is compatible with driving.37 A wheelchair that is too wide can make it difficult to position an individual squarely in front of the steering wheel for optimal control. Some wheelchairs in which the seat rests on a single post are not suitable as a driving platform, because the post is prone to shear on impact. Other wheelchair models have independent suspension and can negatively impact driver stability by causing inadvertent movements. Driver stability is critical to safely operate certain high-tech control systems, because inadvertent movements can result in loss of vehicle control. Last, OTs must be aware of whether the type of wheelchair being considered for their client has automatic lock-down systems. Powered lock-down devices are not available for all models of power wheelchairs.

Traumatic Brain Injury

Approximately 1.7 million people in the United States sustain a traumatic brain injury (TBI) each year.46 TBI can impact driving by disrupting the motor control and attention needed to maintain constant lane position, thereby diminishing the accuracy of visual perception and memory and decreasing visual problem solving, eye-hand coordination, and reaction time.41 It is no surprise that the severity of TBI is related to the individual’s ability to drive safely; however, research shows that between 40% and 60% of people with moderate to severe brain injury return to driving after injury.146 A large number of these people do not undergo evaluations for driving competency.52

Self-report and the perceptions of close relatives about an individual’s fitness to drive have been shown to be strong predictors of whether a person with TBI would return to driving,126 suggesting that OTs should begin the evaluation process by gathering information from the client and family.52 OTs should be careful about the timing of consultations, pre-driving assessments, and referrals to on-road driving programs with clients in this group. Clients whose functional return has stabilized require less adaptive equipment than those who are newly injured. A referral made too early can use up limited therapy visits from an insurance provider or can tax the financial resources of the individual or family. Exploration of driving potential becomes appropriate when evidence indicates that the client has insight about his or her physical and cognitive limitations, and when improvement in factors such as the ability to demonstrate new learning, divide attention, and incorporate good judgment into decision making has been demonstrated.

Consultation with the driving specialist can help the therapist identify performance skill needs that can be integrated into inpatient, outpatient, day treatment, or community intervention programs before the actual referral is made. Evidence suggests that the Useful Field of View (UFOV),31 a test that measures aspects of visual attention, is predictive of the attention and visual processing skills needed for on-the-road performance in individuals with moderate and severe TBI.52 Consequently, areas of focus during pre-driving training might include enhanced rapid understanding of visual information146 or an improved attentional window, so that more visual information is taken into account when driving decisions are made (Figure 11-23).32,114

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FIGURE 11-23 The attentional window or white area appears normal in the first slide and continues to shrink as visual processing speed and divided attention are increasingly impaired.

Active Passenger and Narrative Driving: This therapy program is performed in a moving vehicle. The client can participate only as a passenger for safety reasons. Tasks of visual scanning and coordination are performed with the client ideally in the front passenger seat of the vehicle. However, these tasks have also been successfully assigned to people secured in their wheelchair in the back of a paratransit vehicle. The activity is designed to establish new behaviors and habits for novice drivers, and to improve, speed up, or reinforce patterns and behaviors in experienced drivers. The goal of the “active passenger” is to visually scan and then verbally narrate salient contextual changes in the environment, such as road signs, road markings, traffic signals, hazards, or developing situations that require attention. This should be done only for a brief period—10 to 15 minutes—until endurance is built up. For example, a client with a head injury may travel with a parent, and as they travel down the road may call out, “Pedestrian on the right, red light, 35 mph sign, car turning left,” etc. Several variations of the activity may be tried:

• The driver and the “active passenger” can play together to see who sees the situation or directional signs first.

• The “active passenger” can perform all motions of driving—head turning, steering, gas/brake, turn signal indicators—in addition to narrating the route.

• The “active passenger” can act as a navigator with written directions to a destination. The driver should know the route ahead of time.

Therapists who use this program need to carefully match home program demands with the performance skill of the client and other client factors. All variations of the program should start in low-speed residential areas and should increase to faster speed zones as visual scanning improves.

Progressive Mobility: Progressive mobility programs are an excellent way to provide clients with a graded experience with opportunities for improvement. Used as a precursor to driving, or as a home program, progressive mobility programs are valuable in identifying progress and appropriateness for a driving referral. The person must be competent in simple, low-speed contexts before mastering more complex ones.

The concept is to increase the speed at which an individual is moving to give the body opportunities to integrate appropriate responses with the contextual features of the environment. Collaboration or co-treatment with physical therapy is necessary to verify an individual’s ability to perform the separate motor task before additional therapeutic demands are introduced. The hierarchy of a progressive mobility plan may appear as follows:

• Low-speed ambulation or wheeled mobility graded from light to crowded indoor environments (hospital, shopping mall) with successful outcome indicated by appropriate directional changes, recognition and use of communication, and safe motor skills in a smooth, integrated pattern

• Moderate- to fast-speed ambulation or wheeled mobility indoors and in natural community contexts with the same parameters as above and with greater emphasis on dynamic and flexible responses to real-time changes in a situation

• Graded bicycling or wheeled mobility in light to congested outdoor areas (quiet park or residential street, surface streets) with emphasis on integration of visual/perceptual systems with performance skills and patterns

Cerebral Vascular Accident

A cerebral vascular accident (CVA) can have varying results on function depending on the anatomic brain structures that are damaged. Deficits that can interfere with driving include hemiparesis or hemiplegia, visual limitations, problems with memory and concentration, slowed reactions, spasms, speech and reading difficulties, and other consequences.142 One study of driving after stroke estimated that in a sample of 239 stroke survivors, 30% of those who had driven before the stroke returned to driving after the stroke.74 Almost half of this sample did not receive any professional advice about driving, suggesting a potential area of intervention for OTs.

Hemianopia is a common occurrence following a CVA.123 Visual field loss is of concern to the OT because it can significantly impact driving safety.7 However, evidence suggests that people with hemianopia or quadrantanopia with no lateral spatial neglect can demonstrate safe driving.69 Whether or not hemianopia interferes with safe driving may vary from individual to individual and may depend on other factors, including the absence of visual neglect and other visual spatial disorders.163 To best advise clients, OTs will need to familiarize themselves with the department of motor vehicles (DMV) visual field requirements in their states, because they vary substantially.118

Equipment used for driving after a CVA depends on the individual’s functional impairments. If the person cannot steer with both hands, a steering aid may be needed to assist with turning. When paralysis of the right leg occurs, modification of the vehicle with a left foot accelerator might be appropriate, if the person is able to operate it reliably. Extra mirrors may be necessary to compensate for visual deficits.

Older Drivers: A Growing Population

Driving a car is the preferred transportation for seniors130; however, aging and age-related diseases can lead to unsafe driving, vehicle crashes, or driving cessation.83 Because of increased susceptibility to injury, fatal crash rates for older adults start to rise at age 75 and increase significantly after age 80.84 This statistic and figures showing a growing population of older drivers (20% of the population by the year 2020),150 as well as an increase in crash rates per mile driven by age 70,85 have made senior driving an urgent public concern. Age by itself, however, is not sufficient for assessment of driving ability. The impact of functional impairments appears to play a role in safe driving and can become evident in stressful situations such as merging or changing lanes.85

Traditionally, OTs have recommended adaptive equipment for senior drivers. However, several new directions for practice have emerged from systematic literature reviews of older adult driving research.55 For instance, therapists are encouraged to help clients understand the role of medical and pharmaceutical treatments for visual, cognitive, and motor problems and to educate them as to their impact on driving.83 Other evidence implies that interventions should employ experiential training with sensory and cognitive elements to remediate impaired skills in vision, cognition, and motor function. To help clients develop compensatory strategies to restrict driving (e.g., driving only during the day, omitting travel during peak hours), research suggests that intervention should be designed to foster self-awareness about driving limitations. Finally, to increase client commitment, practitioners are called on to clearly relate interventions to driving skills. Additional research suggests that OTs must gain awareness of how driving errors relate to traffic violations,53 must play a role in formulating public policy related to older driver relicensure,140 and must advocate for roadway construction38 and vehicle design22 that support senior driving.

image Threaded Case Study

Jacqueline, Part 2

Jacqueline has impaired neck and hand range of motion (ROM) as a result of arthritic changes. Jacqueline was issued an adaptive key holder to open the car door and a recommendation to purchase a steering wheel wrap to build up the grip on the steering wheel; the knobby wrap provided a larger-diameter wheel to grip. When neck rotation for blind spot checks was discussed, she reported that she has had “near misses” while changing lanes, nearly colliding with cars she didn’t see. It is important to note that many older drivers never received formal driver training and are unaware that a blind spot check is required. In Jacqueline’s case, it is a skill that requires mobility that she doesn’t have, such as turning the head enough to look behind her shoulder.

Introduction of a wide-angle interior rearview mirror and blind spot mirrors on her exterior mirrors greatly improved Jacqueline’s safety and confidence in seeing what she needed to see. She was also assisted in properly adjusting her driver seat to the appropriate position behind the wheel; in her current car, the old seats caused her to sit too low. Sitting lower than was optimal resulted in poor field-of-view out the windshield, in addition to a poor mechanical advantage in turning the steering wheel. An additional cushion was required to raise her so that her eye level was 2 to 3 inches above the top of the steering wheel.

Her performance on the road was greatly improved by these changes. Jacqueline’s driving was now at a safer and more competent level. However, when an older adult has limited driving competence even with adaptations or interventions, the therapist should consider graded licensing, which permits driving under certain limitations (e.g., dawn to dusk, no freeway). A recommendation for a graded license extends the older adult’s ability to function independently.4,27

Resources to Help Seniors

Self-report measures are based on self-assessment and can help the therapist to identify driving behaviors, increase driving safety awareness and knowledge, and promote safer driving outcomes among older adults.54 These measures can be helpful for initiating discussions about driving safety and for encouraging at-risk drivers to seek further assessment.112

• The Driving Decisions Workbook,151 developed by the University of Michigan Transportation Research Institute, is a paper-and-pencil self-assessment tool for older drivers who are experiencing declines in their driving abilities. It provides information about health-related changes in abilities and feedback as to how these changes influence driving, and it suggests strategies for increasing safety. The Self-Awareness and FEedback for Responsible Driving (SAFER Driving) survey is a Web-based survey that asks questions about how health concerns caused by medical conditions and medications impact safe driving. The survey calculates how these health concerns cause driving declines, provides individualized feedback for continuing safe driving, and advises professional assessment if needed.152

• The Seniordrivers.org Website portal offers several different self-assessments of driving skills.131 The Roadwise Review is a free online screening tool that measures eight functional abilities (leg strength and general mobility, head/neck flexibility, high- and low-contrast visual acuities, working memory, visualization of missing information, visual search, visual information, and processing speed) that are best correlated with safe driving. The Drive Sharp Calculator is a 5-minute screening that rates crash risk based on the useful field of view. The Drivers 55 Plus is a 15-question self-rating form that includes questions, facts, and suggestions for safe driving.

The American Society on Aging (ASA), in cooperation with NHTSA, has developed two educational programs to help professionals better address the challenges of keeping older adults mobile. The DriveWell ToolKit and Training Program19 seeks to promote community conversations and improved driver safety and transportation choices, to influence older drivers to change when and how they drive, to encourage the use of alternate forms of transportation, and to stimulate communities to offer transportation choices to meet the needs of older adults. The Driving Transitions Education Program20 provides professionals with step-by-step procedures for responding to inquiries about driver safety, preparing seniors to make decisions related to mobility, and increasing professional competency and comfort when addressing transportation alternatives.

CarFit, a joint effort by AOTA, ASA, AARP, and AAA, is a national campaign designed to help seniors ensure that their vehicles are properly adjusted to them.44,143 The program seeks to minimize risk of injury and fatalities associated with age-related fragility. Occupational therapists and trained technicians work with each participant to ensure that he or she “fits” the vehicle properly for maximum comfort and safety.

Arthritis

Arthritis is the most prevalent disease of people over 65 years of age. The pain, fatigue, ROM deficits, diminished strength, and reaction time caused by arthritic conditions can negatively impact driving performance.154 Depending on the location of joint involvement, arthritis can limit specific driving skills. For example, involvement of the cervical spine can impair head turning and the ability to check traffic to the side and rear of a vehicle. Clients report difficulties in turning a key, operating switches for the secondary controls, entering and exiting a vehicle, managing seat belts, and operating gas and brake pedals. Loading and unloading mobility devices can also prove to be problematic. Strategies to facilitate safe driving in this group can include instruction in proper body mechanics and energy conservation techniques and use of adaptations, including key turners, mirror extensions, and back supports.

Theoretical Constructs

Activity analysis using the Occupational Therapy Practice Framework-2 provides a strong foundation for a thorough driver evaluation. Client factors and performance skills are first assessed in the clinic. The physical context of actual driving conditions encountered during the on-road test provides an opportunity for the therapist to evaluate the integration of performance skills and client factors.

Occupational role theory, which enables a therapist to match activity demands with desired roles, is also helpful in driver assessment. Occupational roles may have specific demands related to transportation equipment and parking environments. A construction site inspector who enters and exits a vehicle several times a day may need to consider driving from a transfer seat or from a wheelchair in a van. A certified public accountant who audits businesses that have parking structures or covered parking may need a minivan that does not exceed certain height restrictions. The older driver may be satisfied with the freedom to drive to church, medical appointments, and the grocery store. In each example, selection of the vehicle and its modifications are impacted significantly by the occupational roles chosen by the client.

Driving Assessment

Clinical Assessment

Clinical assessment is also referred to as a screening or pre-driving evaluation. The clinical assessment can be performed solely by the OT or by many members of the rehabilitation team together.42,88,122 Its purpose is to build rapport and identify strengths and weaknesses in potential performance skills and client factors related to driving. The clinical assessment begins with a review of medical history, medication and side effects, and episodes of seizure or loss of consciousness (which might include past and present experience with adaptive controls), and a discussion about the purpose of the evaluation. An interview process with open-ended questions often yields greater results and more readily unveils unexpected, pertinent, and critical information that should be pursued further. Open-ended questioning with Jacqueline revealed the lack of a backup transportation plan; this information enabled the therapist to provide appropriate intervention through referral to paratransit services.

Before proceeding with an evaluation, the OT should determine whether a client’s condition is stable, improving, or progressively deteriorating. In progressive conditions, a mobility history should be taken to determine and document the rate of progression. Without this information, it is very difficult to project what the client’s future needs for adaptive controls will be. The clinical assessment will then independently assess the individual’s performance skills and client factors required for safe driving.

Visual Functioning

A comprehensive vision screening is important because vision is the primary sense used to gather information for driving-related decision making.135 Vision testing is completed before other testing to eliminate impaired acuity as a factor. A comprehensive vision screening includes near and far acuity, phoria or alignment, saccades, oculomotor pursuits, ROM, convergence, and field of vision.25,39 Glare recovery is relevant for assessment in the older adult; this is a recommended best practice.25

Motor Skills

Muscle strength, active ROM, grip, and reaction time are frequently cited as basic abilities that must be measured.25,39,88,94 Research linking crash risk to age-related functional decline has highlighted the importance of neck flexibility for checking the sides and rear of a vehicle, and of sufficient leg strength for controlling the brake and accelerator pedals.60 Ability to stabilize and align posture and position by oneself (dynamic and static posture) is also important. The quality of performance skill elements, such as coordination, manipulation, and flow of movement, should also be ascertained.37 Force readings with a torque wrench or a Chatillon scale provide data that facilitate appropriate matching of the client’s strength and effort with the activity demands of steering or braking, particularly in more complex modifications for driving.

Cognitive and Visual-Perceptual Skills

Safe drivers must have mental functions to accommodate to a rapidly changing environment by adequately blending cognitive and visual-perceptual abilities. The Physician’s Guide to Assessing and Counseling Older Drivers7 identifies memory, visual-perceptual skills (e.g., visual processing, visual search, visual spatial skills), selective and divided attention, and the executive skills of sequencing, planning, judgment, decision making, language skills, and vigilance as useful for safe driving. Driving places particular demands on attention.7 Selective attention, for example, is needed for a person to attend to urgent stimuli without being distracted by unimportant ones. Divided attention is required to focus on multiple relevant stimuli frequently encountered in a complex driving environment. Evaluation of attentional functioning is important in the older driver, as this skill can deteriorate with age. The UFOV31 is used to measure aspects of visual attention, including divided and selective attention. Reductions in the useful field of view have been associated with an increase in vehicle crash frequency. The ability to multitask is a related critical driving skill that requires dividing attention.114 Multitasking is the simultaneous performance and monitoring of two or more equally important activities, such as maintaining lane positioning while turning one’s head for a visual traffic check.

Many other cognitive and visual-perceptual tests are appropriate for identifying potential impairments to driving. For instance, the Assessment of Driving Related Skills (ADReS), utilized by physicians to screen older drivers,7,113 employs the UFOV, the Trail Making Test, Part B, and the Clock Drawing Test to identify increased cognitive and visual-perceptual risk factors. However, practitioners should be aware that recommendations for driver license status should not be made on the basis of clinical test scores alone. No clear evidence suggests that any one test or group of tests identifies at-risk drivers or accurately predicts driving competence.25,30,39,60 Properly used and selected, however, cognitive and visual-perceptual testing helps the driver evaluator identify impairments, improve behind-the-wheel risk management, and plan appropriate treatment for driver rehabilitation interventions.

Vehicle Options

Car Considerations: A basic level of service provided by most driving programs is the car evaluation. A car is generally appropriate if a person is able to enter and exit a vehicle and can load mobility devices into it independently. The standard car recommendation is a midsize vehicle with power steering, power brakes, and an automatic transmission. A two-door car can be advantageous for wheelchair loading by the driver, although some find the larger and heavier vehicle door difficult to manage. Fewer two-door models are being manufactured, resulting in more frequent use of four-door vehicles.

When loading a manual wheelchair into a car is not feasible, a mechanical device such as a car-top or rear bumper loader may provide the driver with some independence. However, this type of equipment has become relatively rare because of the reduced roof surface areas and diminished load capacities of many modern cars. Clients with limited ambulation who use a scooter or wheelchair for long distances may be able to continue to use their standard sedan, sport utility vehicle, truck, or minivan with the assistance of a power hoist to lift the mobility device (Figure 11-24).

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FIGURE 11-24 The Curbsider, by Bruno, hoists a scooter or a fully assembled power wheelchair, up to 250 lb, from the sidewalk and lifts it into the back of a standard minivan.

Van Considerations: Drivers who depend primarily on a wheelchair most often choose between full-size vans and minivans. Therapists should have an idea of where a client plans to drive, so that the advantages and disadvantages of the two vehicle alternatives in those environments can be discussed. Providing information on the differences between minivans and full-size vans, including accessibility, ground clearance, load capacity, durability, and cost, enables clients to make educated choices that suit their needs, budget, and lifestyle. In any van, the interplay between a person who drives from a wheelchair and the vehicle is complex. A more skilled evaluation is needed when a person drives from a wheelchair because of the numerous variables that affect equipment selection and driving performance.

An automatic mechanical lift is required to independently enter a full-size van with a wheelchair or scooter.119 Mechanical lifts can be mounted on the rear or side of a full-size van. Platform-style lifts are the only types that comply with Federal Motor Vehicle Safety Standards (Figure 11-25). Minivans should be equipped with fully automatic mechanical side ramps for independent exit and entry (Figure 11-26). Although they have limited interior space, minivans are appealing to many people because they drive more like a car and get better gas mileage than a full-size van. Also, minivans fit more easily than full-size vans into home and public garages.

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FIGURE 11-25 A platform-style lift can be located at the side or rear of a van. Additional entry headroom, obtained through a lowered floor, provides client with appropriate visibility when driving from a power wheelchair.

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FIGURE 11-26 Minivan conversion with side ramp access and a lowered 10-inch floor. The ramp angle can be decreased for easier entry and exit.

Other Vehicles: Sport utility vehicles (SUVs) and trucks, both midsize and full-size, present additional options for individuals who require limited adaptive equipment to drive successfully. Four-wheel drive is a feature that can be included in a modified vehicle at significant additional cost. However, when clients decide on vehicle options besides vans or cars, it becomes more difficult to ensure that the modifications they require to drive safely and independently will be compatible with the chosen vehicle type.

Stationary Assessment

The stationary component involves an examination of the person’s habits and routines before starting the engine. Adaptive equipment is set up with the vehicle parked. As needed, the engine is turned on to assess performance skills in steering, acceleration, and braking. Stationary performance alone is inadequate to predict on-road performance or final equipment needs. The purpose of the stationary assessment process is to enable proposed equipment to be verified, modified, or discarded. This process continues until client and equipment needs are thoroughly clarified. If subsequent on-road performance indicates that the activity demands of driving exceed performance skills, the stationary process is repeated using the next level of equipment. This trial-and-error approach is an expected and necessary step in assistive technology evaluation.32

Pre-driving Habits and Routines

Pre-driving skills that require assessment include the client’s mobility in approaching the vehicle, the ability to open and close the door, and the ease of getting into and out of the driver’s seat. The ability to load and unload a mobility device such as a cane, walker, scooter, or wheelchair must also be taken into account. Additional areas for consideration include fastening the seat belt (and chest strap when needed), adjusting the position of the driver seat and mirrors, ascertaining that the dashboard instrumentation can be seen, and inserting and turning a key (or managing keyless entry operation). Adaptive devices used to facilitate independence include adaptive key holders, loops to ease lower extremity management, adaptations to extend reach for wheelchair loading, and modifications for independent retrieval and operation of the seat belt.

Primary Controls

Steering Control Assessment: The first step in the primary control assessment phase is to position the client to maximize motor skill performance before the primary controls—those devices that control steering, acceleration, and braking of a vehicle—can be properly addressed. Care must be taken to ensure that the driver is seated squarely in front of the steering wheel to provide optimal mechanical advantage for steering. Positioning is also critical in assisting drivers to withstand the inertial forces caused by braking and turning without falling over and losing control. Trunk stabilization enhances control of the extremities and consequently the primary controls. Poor trunk stability may necessitate that special positioning devices such as an upper torso support or chest strap be employed. Therapists must also consider positioning as it relates to maintaining a functional field-of-view for the driver.29 In a van, the distance from the floor to the eyes should be between 40 and 46 inches to allow an appropriate driver field-of-view. Once postural issues have been resolved, equipment set-up proceeds to the primary controls.

All steering systems include an element of resistance. Automotive manufacturers do not have universal standards for grading resistance. As a result, one car manufacturer’s power steering can be as difficult or as easy to turn as another vehicle’s manual steering. Knowledge about the trends and patterns in steering system resistance among popular vehicle models is helpful in making appropriate recommendations and achieving desired outcomes. However, it is very difficult to remain current about this type of technology because it changes quickly. Rehabilitation engineers and vehicle modifiers can be a valuable information resource for OTs in this area.

The first step in evaluating steering control is to determine whether a client’s motor skills are adequate to turn the steering wheel of his or her proposed vehicle. The upper or lower extremities can be appropriately used for steering. When feet are employed, a specialized wheel is mounted on the floor of the vehicle. Steering competence is demonstrated by having the client slowly turn the steering wheel to the lock position in both directions without exhibiting undue effort or pain. Rapid turning can cover substitution patterns or decreased strength and does not address performance skills adequately or allow motor performance to be analyzed.

If a driver cannot use both hands to steer, a steering device is frequently recommended as an initial step to improve mechanical advantage. One-handed steering by palming the wheel can result in inadequate control, especially during sharp, fast turns and evasive maneuvers. Adaptive steering devices such as a spinner knob, V-grip, tri-pin, palmar cuff, or amputee ring, improve control and speed when turning the wheel (Figure 11-27).58 Once the client’s performance skills have been well matched to the activity demands of the steering set-up, verification of competence through a dynamic on-road evaluation can begin.

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FIGURE 11-27 These steering devices accommodate a variety of hand and upper extremity impairments. (Courtesy Mobility Products and Design.)

Steering Systems: Steering systems are divided into those that use an OEM steering column, and higher-technology systems in which the OEM steering column is modified or absent. Modifications such as extended steering columns, steering wheels with smaller diameters, and steering adjustments to decrease the strength needed to turn a wheel by 50% or 75%153 are compatible with OEM columns. High-technology options offering flexibility for positioning in the vehicle include a horizontal mechanical steering wheel and a 7-inch remote steering wheel. Additional systems allow a driver to steer, brake, and accelerate using a single vertical column control (Scott System, Scott System Inc., Denver, Colo)62 or a joystick (Aevit J Series, Augusta, Me).68 Such systems can enable driving with a single limb. High-level systems can change the number of wheel turns from lock to lock to enhance the ability of certain clients to steer. However, it is important to remember that longer, more complex van evaluations and lengthier driver training are needed when high-tech systems such as these are recommended.

Airbag Issues: A critical final step in steering assessment occurred as a result of airbags.104 The driver airbag is located in the steering wheel hub. Newer vehicles have advanced airbag technologies that tailor airbag deployment to the severity of the crash and thus reduce injury; however, close or direct contact with an airbag module during deployment can still cause serious or fatal injury. The NHTSA continues to recommend that drivers sit with at least 10 inches between the center of their breastbone and the center of the steering wheel.107 In some instances, wheelchair seated drivers are positioned very close to the steering wheel, so they can reach adaptive equipment. NHTSA will grant permission for installation of an on/off switch to disconnect a driver airbag under certain circumstances.101 These include a medical condition that places the driver at specific risk and inability to adjust the driver’s position to stay at least 10 inches from the steering wheel.106 Therapists should document the client’s distance from the steering wheel.

Accelerator and Brake Controls: In general, only after the stationary steering process is complete does the evaluation proceed to consideration of the accelerator and brake controls. Modified accelerator and brake controls can be installed in most vehicles. Simple modifications such as pedal extensions can compensate for limited reach in short persons. OEM pedals can be extended up to 12 inches. Maintaining an appropriate seated distance from an airbag can often prevent fully reaching the accelerator and brake pedals and has resulted in an increased need for this type of modification.

When right hemiplegia or right lower extremity amputation is present, the right foot is unable to operate the standard pedals. Intuitively, some clients cross over with the left foot to operate the brake and accelerator pedals. This is an unsafe practice because it places the client off-center for proper steering, and the awkward posture involved can cause strain on body structures over time. A left-sided accelerator pedal can be placed to the left of the standard brake pedal to compensate for this condition; however, OTs will need to make sure that the device can be operated reliably.29 The driver must also be educated about the necessity of instructing anyone who will be operating the vehicle (e.g., mechanics, parking attendants) on how to use this modification.

In cases where the lower extremities are not functional for operating foot pedals, a device called a hand control can be used. A hand control consists of rods connected to the OEM accelerator and brake pedals. In a right angle push-pull type of hand control, the motion of pulling down at an angle presses the rod attached to the right foot pedal and causes acceleration. Pushing forward depresses the rod attached to the left foot pedal and activates the brake. Depending on style, hand controls utilize various upper extremity movements (rotary, push-pull, push-pull down, or push-rock motions) to activate the brake and accelerator pedals. Hand controls that use a motor to move the pedals are known as powered controls.153 High-technology accelerator and brake controls have servomotors activated by vacuum, hydraulic, or electronic means. A careful match must be made between the functionality provided by these devices and the client’s strength and motor control. These controls are very sensitive; when they are used, postural control is absolutely critical. Inadvertent movements may result in loss of vehicle control (Figure 11-28).

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FIGURE 11-28 Assessment of visual processing, divided attention, coordination, and judgment must be made in the natural driving environment. Performance in complex and faster traffic situations is essential, because activity demands increase with speed and visual clutter.

Secondary Controls

Secondary controls are those used to manage the vehicle and to interact with the elements and other roadway users.153 A driver must be able to activate four secondary controls at will when the vehicle is in motion: turn signal indicators, horn, dimmer, and windshield wipers.91 The switches to control these functions can be placed on the hand control itself, or in a spot where they can be controlled through elbow and sometimes lower extremity motions. Some people lack the motor function to access multiple switches. In such cases, secondary functions can be controlled by a single sequencing switch.

Activation of the switch initiates a tone assigned to a particular function. Releasing the switch activates the function. The transmission, parking brake, heater and air conditioner, and hazard light and headlights can be operated when the vehicle is parked.153

On-Road Assessment

Standard of Competence

Once the stationary assessment has accomplished the task of setting the driver up with primary controls, the ability to use these controls must be observed during the actual process of driving. This is commonly referred to as the behind-the-wheel or on-road portion of the evaluation. The current industry standard is to accept the on-road driving test as the definitive measure of driving competence.60,99 The on-road assessment should take a minimum of 45 minutes. A shorter period is inadequate to make the necessary observations, particularly those required to make a determination about whether the client is able to sustain mental and physical effort during the drive. The on-road assessment should not be longer than 2 hours of actual driving time.

The individual in the role of the driving instructor orients a driver in the use of adaptive driving equipment, maintains vehicle control by intervening for safety when necessary, and directs the route. A method of keeping track of driving performance, such as recording observations of driving errors, is recommended. Criteria for assessing driving performance should reflect physical management of the vehicle, ability to use adaptive equipment, interaction with other traffic, adherence to rules of the road, and safety judgment.56,86

Driving Route

Driving routes used for the assessment should incorporate a sampling of road conditions, traffic patterns, and unusual settings common to the local region. The driving route should allow the driver time to become familiar with the vehicle and adaptive equipment in a low-stimulation environment. This period of learning and accommodation will be longer for the novice or apprehensive driver. Initially the assessment will involve straight-line driving to determine ability to maintain lane position or make accommodations to position. The assessment route should progress through faster and more congested traffic and various dynamic traffic conditions, so that information can be gathered about the driver’s performance in a wide variety of conditions (Figure 11-29). Competence implies that a client can repeat a performance skill consistently and that his or her success was not based on the absence of environmental or traffic challenges. Repeated success in executing maneuvers in situations requiring the use of judgment must be demonstrated before competence can be ascertained. Because drivers’ skills greatly vary, bailout points are needed along the route to give the therapist the option of terminating the on-road assessment. Therapists should always work within a window of comfort and should take clients only in situations in which it is possible to provide override control.

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FIGURE 11-29 This client drives a steep mountain pass near his home. During the follow-up evaluation in his new Driving Systems, Inc. (DSI) unilever van, a test drive was performed in nearby foothills to ensure that adjustments were adequate for steep inclines. This essential step identified additional adjustments needed before delivery.

Driver Recommendations and Interventions

Possible Outcomes

The driver evaluation culminates in a decision about driver competency, identification of the necessary adaptive equipment and vehicle, and, when appropriate, a recommendation for the number of driver training hours required to raise performance skill to a safe and independent level. New driver evaluators need to be cautious not to misconstrue new driver or older driver patterns as uncorrectable errors incompatible with driving. Conversely, less-experienced driver evaluators need to weigh errors, especially with neurologically involved clients, in whom consistency of performance can be an issue. Possible outcomes for a driver evaluation are as follows:

1. The client demonstrates driving competence: no adaptive equipment or driver training is required.

2. The client requires changes to achieve driving competence: adaptive driving equipment and/or training is required.

3. The client’s performance skills are borderline: an extended evaluation and/or driver training is required.

4. It is not safe for the client to drive at this time: continued therapy or medical intervention and time for additional recovery of function may change outcome. Re-evaluation in 6 to 12 months is recommended.

5. It is unsafe for the client to drive, and there is no potential for improvement.

After the on-road assessment has been completed, the driving team reviews the results with the driver. Asking the client for feedback before reviewing results provides a valuable perspective on his or her insight. Results cannot be shared with family without permission from the client; a verbal agreement from the client to share results should be documented.

Jacqueline was very nervous in freeway situations and made some noncritical errors, but overall, she thought she did well, especially because better positioning in the car seat decreased her shoulder pain. The therapist agreed. A recommendation of 4 hours of driver training was made to focus on defensive driving skills, compensatory strategies for older drivers, use of expanded mirrors, and freeway maneuvers. In this case, the therapist used the ADED Best Practices resources to assist her in formulating the criteria that she utilized in making recommendations for Jacqueline’s additional training.

Written Report

The comprehensive driving report should contain a summary of the clinical assessment and driving performance observations and should provide a statement on the client’s potential to be a safe and independent driver. It should specify the type of vehicle necessary to accommodate the recommended modifications, dealer sources for providing the modifications, and other pertinent information. Recommendations about the types of follow-up services required (e.g., fitting sessions at the selected vehicle modifier) and who is best suited to provide them are warranted. The report should also estimate the amount (duration, frequency, and total length) of driver training needed, should indicate specific areas of emphasis for training, and should provide resources indicating where the training is available.25,137,138

Driver Training

Training in the use of assistive technology, including adaptive driving equipment, is a key component of the process of delivering comprehensive assistive technology services.58 Individuals with cognitive and perceptual impairments often need to relearn driving behaviors or to implement compensatory skills to attain consistent driving performance, even though they may not require adaptive equipment. Extensive training with a focus on vehicle control and recovery, especially in unexpected situations and at high speeds, is essential when high-technology equipment is used. Some clients will require training in their own vehicle, because the unique modifications that they need for driving may not be available in any of the evaluation program vehicles. Depending on each state’s requirements, driver training may occur before or after the vehicle is modified.

Follow-up Services

Follow-up services are another important aspect of comprehensive assistive technology service delivery. When adaptive equipment is recommended, a follow-up evaluation ensures that the equipment is positioned and adjusted to meet the client’s functional needs.25,137 Follow-up services include midfit and final fit sessions for quality assurance and verification of safety. When an adapted vehicle is delivered, this is the first time that the client, adaptations, and selected vehicle have interfaced. Some adjustment is almost always needed to meet functional goals and to have the adaptations perform as envisioned.23 An on-road session is recommended to ensure that adjustments are adequate for function when dynamic forces involved in driving come into play.

Licensing Assistance

Dealing with licensing situations related to a disability or medical condition can be daunting and intimidating to a client. OTs must be knowledgeable about the licensing practices and protocols in their state. This knowledge enables the therapist to educate and inform the client about the steps for completing the licensing process. Some situations may call for the therapist to provide assistance at the local agency, so the client can obtain or extend a student or special permit. Contact with such agencies requires the written authorization of the client. Only minimal information pertinent to the issue at hand should be revealed. Best Practices include maintaining common agency forms or driver handbook materials in the clinic for distribution to the client as appropriate.25

Driving Retirement

One of the most difficult tasks facing a driver evaluator is notifying a client that he or she is unable to achieve, or no longer retains, the performance skills required for safe and independent driving. Such decisions need to be carefully thought through and then communicated to the driver with compassion and understanding. The AMA refers to the transition from driver to nondriver as driving retirement.7 Referring the client to the motor vehicle department to exchange the driver license for a photo identification card, which looks like a license, is essential for legal identification and psychosocial reasons. The therapist can work on alternate community mobility goals when appropriate to maximize independence and well-being.

Educating individuals on alternative means of transportation and immediately providing materials regarding local options can prove helpful at a difficult time. When driving retirement is considered and planned for in advance, as recommended by many agencies, the transition is eased. OTs play a significant role in promoting long-term planning through community mobility interventions with their clients.121

Jacqueline is not ready to retire from driving; she had competency verified and is receiving intervention for freeway situations. She feels confident and able to address any driving concerns raised by family members. She told her therapist that she shared the good news regarding her driving skills with her family, although not all were convinced. Her therapist encouraged her to rely on the outcome demonstrated by her performance skills and to perhaps begin discussing transportation needs that will arise when she transitions into driving retirement.

Legal Issues and Public Policy

Therapists and physicians need to be aware of their states’ laws concerning medical conditions and driving. Most states do not require that medical conditions, seizures, or loss of consciousness be reported to the motor vehicle department.81 Instead, most rely on voluntary reporting of medical conditions by the driver.7,56 Although some states advocate reporting by the family, physician, or law enforcement officials, not all states provide immunity for such reporting. Once identified to the motor vehicle department, the client undergoes a license review process that varies from state to state; therapists should know their states’ policies on graded licensing.

Summary

Community mobility, whether it occurs while accessing a school bus, driving one’s own vehicle, or riding in the local senior transport van, is a pivotal IADL. All forms of community mobility have the ability to enable engagement in necessary and meaningful occupations and are thus the concern of OT practitioners, regardless of whether they are generalists or specialists in the practice area. Individual evaluation, with consideration of valued occupational roles and the transportation systems available to a person, provides a foundation for determining the necessary level of intervention. Evidence-based research should be utilized to support practice, but without losing sight of the importance of driving and community mobility for facilitating social participation and involvement in other occupations throughout the lifespan. OTs are challenged to provide driving and community mobility services that will be widely recognized and valued by consumers, communities, and organizations.

image Threaded Case Study

Jacqueline, Part 3

Jacqueline received intervention in private and public transportation arenas. She was referred for a driver evaluation by her primary therapist and is now participating in a paratransit program for respite and a supplemental transportation plan. She was anticipated to require adaptations because of arthritis in her neck, shoulders, hands, and lower extremities: an adaptive key holder, door opener, blind spot mirror, and steering wheel cover improved function by modifying the physical context of her occupations. Jacqueline received training in adaptive techniques for vehicle entry/exit, car transfers, wheelchair loading, and driving performance. She still could use a wheelchair carrier but has chosen to wait because of the cost. Jacqueline’s quality of life has been greatly improved through therapeutic intervention in many aspects of her community mobility. She is quite pleased with the driving outcomes achieved with her therapist.

Review Questions

1. Define functional ambulation. List three activities of daily living or instrumental activities of daily living in which functional ambulation may occur.

2. Who provides gait training?

3. What is the role of the OT practitioner in functional ambulation?

4. How do OT and PT practitioners collaborate in functional ambulation?

5. List and describe safety issues for functional ambulation.

6. Name five basic ambulation aids in order of most supportive to least supportive.

7. Discuss why great care should be taken during functional ambulation within the bathroom.

8. List at least three diagnoses for which functional ambulation may be appropriate as part of OT services.

9. What purpose does a task analysis serve in preparation for functional ambulation?

10. What suggestions could be made regarding carrying items during functional ambulation when an ambulation aid is used?

11. What is the objective in measuring seat width?

12. What is the danger of having a wheelchair seat that is too deep?

13. What is the minimal distance for safety from the floor to the bottom of the wheelchair step plate?

14. List three types of wheelchair frames and the general uses of each.

15. Describe three types of wheelchair propulsion systems and tell when each would be used.

16. What are the advantages of detachable desk arms and swing-away footrests?

17. Discuss the factors for consideration before wheelchair selection.

18. Name and discuss the rationale for at least three general wheelchair safety principles.

19. Describe or demonstrate how to descend a curb in a wheelchair with the help of an assistant.

20. Describe or demonstrate how to descend a ramp in a wheelchair with the help of an assistant.

21. List four safety principles for correct moving and lifting technique during wheelchair transfers.

22. Describe or demonstrate the basic standing pivot transfer from a bed to a wheelchair.

23. Describe or demonstrate the wheelchair-to-bed transfer, using a sliding board.

24. Describe the correct placement of a sliding board before a transfer.

25. In what circumstances would you use a sliding board transfer technique?

26. List the requirements for client and therapist to perform the dependent transfer safely and correctly.

27. List two potential problems and solutions that can occur with the wheelchair-to-car transfer.

28. When is the mechanical lift transfer most appropriate?

29. How is community mobility defined?

30. What are the primary advantages and disadvantages of public and private transportation?

31. What unique qualifications do therapists have, enabling them to address community mobility issues?

32. What basic element of community mobility can be addressed by the therapist?

33. Why are specialized skills needed for driver evaluations?

34. Describe the driving evaluation process and dynamics.

35. What are the four basic components for protecting passengers seated in a wheelchair within motor vehicles?

36. Name four ways the OTA may be used in a driver evaluation program.

37. What are the five Best Practices components in the driver evaluation process?

38. What is the best method to determine driver competency?

39. How long should the on-road evaluation session be?

40. Why are older driver issues of particular interest?

41. What additional credentials can therapists obtain in the field of driver rehabilitation?

42. What is the function of driver training?

43. Why is a follow-up evaluation necessary with adaptive equipment?

44. What legal issues must be considered by a driver rehabilitation therapist?

45. Where can the interested therapist go for additional information on this area of practice?

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Suggested Readings

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