Acute care phase

During the initial hospital phase following a stroke, the role for the occupational therapist is primarily one of inquiry and fact finding. One of the most common questions initially asked by a person in this phase is “Can I drive again?” or “When will I be able to drive again?” The therapist must be able to answer the question when asked and to speak with confidence about how this activity will be addressed along the continuum of care. The therapist can inquire whether the stroke survivor had been a licensed driver before and what was the frequency and circumstances of driving. For example, did the person drive to work or drive his or her children to school? Does the person live in a rural or suburban area? Was the person the primary driver in the family? Did the person drive intrastate, interstate, or just locally? Is the person at a stage at which he or she already had begun to limit driving to daylight only or within short distances of home? Is independent driving a goal for the person now? If the client has memory, cognitive, or speech deficits, the family may need to be consulted to obtain or verify the information given by the client. If the stroke survivor passes through the hospital phase quickly, then these questions may need to be explored more completely by the therapist in the next phase. The point is that driving should be addressed early and as commonly as dressing, grooming, and other mobility issues. Whether the appropriate time is in the acute care phase or the rehabilitation phase, the therapist should be equipped to address driving in an appropriate way.

Rehabilitation phase

As the stroke survivor moves into the rehabilitation phase, the foregoing information would be passed on to the rehabilitation unit therapist. The primary rehabilitation occupational therapist would pick up the issue by addressing driving as an IADL in the initial evaluation for an intervention plan with the stroke survivor as for other ADL such as dressing, bathing, and cooking. To address driving as an IADL and assess factors that may affect safe driving, the occupational therapist requires an understanding of all factors and skills involved in driving and activity demands of driving. With an understanding of the level of skill performance demanded in the driving task, the occupational therapist can include intervention, with driving in mind, much as the therapist would for other ADL tasks.

Driving an automobile is a complex task involving a hierarchy of skills. Adequate motor response and physical control of the vehicle are essential skills but are secondary to accurate perception and understanding of ever-changing traffic environments and unpredictable situations. A driver processes information and makes conscious or unconscious decisions using (1) environmental information such as traffic lights, road markings, road signs, and other road users; (2) attention and perceptual mechanisms using visual search, spatial relations, and time and space management; (3) reasoning, problem-solving, and planning to analyze each situation and understand cause and effect; and (4) response by physical control, adjustment, and compromise. Table 23-1 gives an overview of occupational performance in driving.

Table 23-1 Occupational Performance in Driving for a Stroke Survivor

Preexisting or progressive age-related conditions

In addition to conditions or problems associated with the primary diagnosis of a stroke, the therapist should explore other preexisting medical or aging conditions that require attention. Stressel³⁹ writes the following:

Several examples to illustrate this point are the stroke survivor who has had insulin-dependent type 2 diabetes for 25 years. He was diagnosed with diabetic retinopathy and had two laser surgeries for treatment. Another stroke survivor has been on kidney dialysis for two years after having an allergic reaction to a medication that damaged the kidneys. Each of these preexisting conditions, separate from any deficits related to the stroke, could increase risk factors associated with safe driving and should be addressed separately in terms of the affect on the driving task. Box 23-1 lists other examples of nonstroke factors to consider. Communication with the family, rehabilitation physician, neurologist, and perhaps the primary care physician is important to synthesize the patient’s entire medical history and consider all potential client factors that may affect the stroke survivor returning to independent driving.

After driving and community mobility are addressed in the initial gathering of the occupational profile, the second stage of involvement for the occupational therapist during the rehabilitation period is the crucial area of education of the stroke survivor and the family regarding individual responsibility in the whole process. In this phase, the client must be informed how, when, and by what process driving and community mobility will be addressed. The therapist should be able to speak with authority and confidence of the process of addressing driving, the timing, the referral procedure if referral to an OT driver rehabilitation specialist is necessary, and the available resources. The therapist must speak with first-hand knowledge of the value of the on-road evaluation, if necessary, so that the client and family will equally value the comprehensive driver evaluation services of the OT Specialist in Driving. The stroke survivor and family should know at that point that the client cannot drive until a conclusion has been reached by the collaboration of the OT practitioner and the rehabilitation team. By the OT practitioner giving the client the information at an early stage, the client will be prepared and more cooperative in moving through the process and knowing what to expect along the way. Speaking specifically about the activity of driving will help the client understand that the intervention plan includes treatment along the continuum of care that will improve and enhance his or her performance skills related to driving an automobile.

Driving is one area that scares many family members of stroke survivors. They need to be informed as well, so they can provide the necessary assistance and support for the client throughout the process in regards to the issue of driving. The family can begin dealing with the reality and can plan for alternative transportation choices for the stroke survivor until it has been finally determined that they have the driver competency to begin driving again. This should lessen the family’s fears and anxiety and bring them into an active role in the process while allowing them to remain in the background regarding the ultimate decisions about driving. In other words, the family cannot be blamed for the stroke survivor’s temporary or permanent loss of driving privileges. By addressing the driving issue in the medical setting, the family is relieved of having to address the issue themselves with the stroke survivor, which many times can cause frustration and emotional stress from the stroke survivor’s anger, lack of insight, or poor judgment.

Medical reporting with driver licensing authorities

Each state has licensing requirements and reporting laws. Many states do not require a driver to report a new medical episode resulting in disability between license renewals. Some states allow only a doctor to report a medical condition that may preclude safe driving. Other states may allow professionals such as a law enforcement officer or allied health professional or even nonprofessionals such as a neighbor or family member to report a driver’s medical condition or to raise a concern. Occupational therapists should investigate the requirements for the state in which they work to develop a consistent procedure to use with every client that includes a set policy approved by the administration and legal departments of the facility and understood by each team member. Many states have medical advisory boards to their departments of driver licensing that are good resources for licensing requirements and the medical reporting process.

The American Association of Motor Vehicle Administrators (AAMVA) at www.aamva.org is a nonprofit organization that develops model programs in motor vehicle administration, police traffic services, and highway safety. The AAMVA works with the National Highway Traffic Safety Administration to review Medical Advisory Boards and driver licensing renewal procedures throughout the United States. This information can be accessed from their website. The AAMVA also serves as an information and awareness resource regarding older driver issues.

That testing procedures in driver examination offices do not evaluate fully all skills related to driving is common knowledge, particularly when the driver may have a medical condition or deficit that is not physically obvious. Examiners may not have knowledge of an applicant’s diagnosis unless the person informs them or a physician provides written notification. These examiners do not have an understanding of possible implications of disability on driving skills. For example, a person with a complete right homonymous hemianopsia, which is a common vision deficit after a stroke, usually does not pass the visual requirements of most states for a minimum of 125 to 140 degrees of continuous field of vision. The typical methods of vision testing by driver licensing offices measure only visual acuity and not visual fields. A person can have 20/40 visual acuity, which is acceptable in most states; however, the driver examiner may never know the person has homonymous hemianopsia.

Predriving clinic screening

A comprehensive driving evaluation for a person who has had a stroke may include the steps illustrated in Fig. 23-4. The process for addressing driving and community mobility as an IADL starts during the initial OT in the acute care setting and continues through inpatient rehabilitation therapy, outpatient rehabilitation therapy, and beyond. Along this continuum of care, the occupational therapist should continue including the IADL of driving and/or community mobility until the conclusion is drawn and the outcome decided. A successful completion of this process depends on many factors that can influence the outcome, as noted in Fig. 23-5. A predriving screening by the occupational therapist should be completed prior to the client being discharged from inpatient rehabilitation and outpatient therapy. The purpose of the predriving screen near discharge is multifaceted. The OT Generalist in Driving should:

Figure 23-4 The driving evaluation process for a stroke survivor.

Figure 23-5 Factors that influence the driving evaluation process.

The inpatient and outpatient occupational therapist should have knowledge of the appropriate state licensing laws and understand the necessary level required in each performance skill area needed for safe driving so that the appropriate information can be passed on to the OT Specialist in Driving. For example, if the patient has left neglect or serious visual-perceptual deficits, these conditions are contraindicative for safe driving unless they resolve early. Another example is the field of vision requirement already discussed. If a stroke survivor has a complete homonymous hemianopsia, then the therapist should tell the client and family that a return to driving is not possible because of the requirements of the state unless the condition resolves itself enough to meet the field of vision requirements. Table 23-2 has examples of problem areas to note.

Table 23-2 Examples of Stroke-Related Deficits to Identify during Initial Assessment That May Impact Driving Performance

When structuring the predrive clinical screening, the therapist should be guided by common sense and evidence-based practice where applicable to use appropriate clinical tools and tests as they relate to driving. Although typical clinical tools and equipment in an OT department can be used for this screening, the therapist may need additional specialized equipment for more relevance to driving. Clients may be more cooperative with the clinical evaluation for the IADL of driving if they appreciate its relevancy to the driving task. For example, the client may feel frustrated and angry working on a puzzle or paper maze during the therapist’s predrive clinical screening but may understand the importance of a test that provides specific data related to driving such as reaction time, driving risk behavior assessed using a clinical tool to measure divided and selective attention, and a measuring of cognitive abilities for safe driving with a clinical tool that assesses memory, judgment, decision-making, attention, and motor speed abilities. The therapist should describe the relevance of any test given, so the client will be motivated to perform well on the test. The assessment of motor/praxis skills and sensory-perceptual skills is generally easy for the therapist to set up because the assessment and techniques used in these areas are similar to those used in other settings and with other disabilities. The difference is that the therapist must keep a mind set on the activity demands of driving as they do similarly with cooking, dressing, and other ADL they consider.

The therapist should attempt to use clinical tools and tests during this phase that have the most significance to the driving task. Box 23-2 lists some of the more common clinical tests. Additional tools and devices are available on the market that can be used in the clinic with driver-related tasks and have a degree of face validity and statistical correlation (Box 23-3).

Engum and colleagues⁹ noted the following: “Knowing the patient’s diagnosis or pathology typically does not yield predictions about the patient’s ability to drive. . . . Even loss of brain mass is not deemed to be an exact predictor of driving skills . . . neuropsychological tests, which can detect gross organic impairment or provide useful catalogs of patients’ impairments and abilities, do not seem to assess driver potential.” The OT Generalist in Driving must collaborate with the OT Specialist in Driving to coordinate the tests and tools used, so duplication is not done.

Their four-year research project with more than 230 brain-damaged patients led to the development of the Cognitive Behavioral Drivers Inventory (CBDI). This inventory is designed to assess aspects of cognitive functioning such as attention, concentration, rapid decision-making, visual-motor speed and coordination, visual scanning and acuity, and shifting attention from one task to another. Their results demonstrated that more than 95% of the patients receiving passing scores on the CBDI were judged independently by an on-road driving test as safe to operate a motor vehicle. Conversely, all patients who failed the CBDI were judged as unsafe drivers in the independently administered road test.⁹ A subsequent study by some of the same authors in 1988 completed a double-blind test of the validity of the CBDI. Again, the authors found a high correlation between the results of the CBDI and the independent road test.⁸ Although the CBDI is psychometrically strong, it has no face validity. The CBDI is useful, but the Elemental Driver Simulator has face validity and may be better understood by patients as being relative to driving because it involves operating simulated primary car controls (Fig. 23-6).

Figure 23-6 The Elemental Driving Simulator.

(Courtesy Life Science Associates, Bayport, NY.)

Gianutsos,¹¹ the originator of the Elemental Driving Simulator, stated, “road tests lack the basic psychometric requisites of tests—standardization, reliability and empirical validity.” She described the Elemental Driving Simulator as a “computer-based quasi-simulator that is based on objective, norm-referenced measures of the cognitive abilities regarded as critical for driving.” These cognitive abilities include mental processing efficiency, simultaneous information processing, perceptual-motor skills, and impulse control. The Elemental Driving Simulator also attempts to measure insight and judgment by comparing self-appraisal with performance. Research by Gianutsos¹¹ and Engum and colleagues⁹ indicated a significant correlation in the Elemental Driving Simulator and CBDI. These researchers believe that their results confirm the reliability and validity of their clinical driving assessment programs. By using the Elemental Driving Simulator or CBDI, the therapist obtains not only objective data but also recorded information relevant to the driving task. More importantly, data from these tests have demonstrated reliability and validity with published norms and standardized rules. The drawbacks to these tools are that they are expensive, time consuming to give, and require the use of a proper computer, which can be intimidating for an older person.

The predriving clinical evaluation can be organized similar to or along with a typical discharge evaluation of performance skill areas and an ADL and IADL evaluation. The screening would be an obvious emphasis on driving skill requirements in an attempt to determine if the person is ready for referral for the on-road assessment or if the referral should be delayed to a better time. One should remember that if the person is referred too early, the results may produce negative consequences for the person’s driving privileges.

The 2008 OT Practice Framework¹ describes performance skills as observable, concrete, goal directed actions that a client uses to engage in daily life occupations. Multiple factors, such as the context in which the occupation is performed, the specific demands of the activity being attempted, and the client’s body functions and structures, affect the client’s ability to demonstrate performance skills. With this in mind, the OT Generalist in Driving should evaluate the stroke survivor’s performance skills for driving with consideration of all of the client factors, contextual/environmental factors, and the activity demands of the occupation of driving for this particular individual.

Discussion of the components of a predriving clinical evaluation at this stage follows.

Motor and praxis skill assessment

The motor and praxis skill assessment should involve a brief functional look at the patient’s active range of motion, muscle strength, sensory modalities, bilateral and unilateral gross and fine motor coordination, and any abnormalities such as muscle tone, spasticity, stereotypical patterns, and associated reactions. A slowing of physical functioning can affect reaction time in responding to stimuli in the environment. Slower reaction time among older drivers may be caused by motor change or delayed visual processing. The loss of strength and range of motion can prevent the person from safely operating the primary or secondary controls of the vehicle. If the person has the necessary isolated control in the affected arm with appropriate sensation and smooth coordination, he or she may be able to continue using this arm for two-handed steering. For liability reasons, the OT Generalist in Driving will not evaluate or recommend adaptive equipment for driving but should be familiar with options available for the stroke survivor, so that the intervention plan may include education of the client and family on the importance of seeing the OT Specialist in Driving. The OT Generalist in Driving should also consider the person’s functional mobility in regards to ambulating to and from a vehicle and loading any assistive devices. Preintervention in this area can save time for the OT Specialist in Driving.

In driving, an affected limb cannot be used at all if the necessary functional skills are not available since it could be unsafe and cause the driver to lose control of the vehicle. An example would be an upper extremity that has a stereotypical flexor pattern with little isolated control. If the patient cannot use the affected arm safely, then various kinds of adaptive equipment and driving aids are available that can be used to aid one-handed steering or for reach of secondary control functions that the impaired extremity should operate. For example, the left hand generally operates the turn signals and the right hand generally operates the gear selector. Fig. 23-7 gives examples of adaptive equipment for driving that is recommended by the OT Specialist in Driving to assist with various vehicle controls. Some states require a spinner knob even if the person can palm the wheel and control it well with the remaining good arm. Compensatory techniques with special equipment can assist only with physically controlling a vehicle and do not resolve the person’s other potential problem area with cognitive and sensory-perceptual skills.

Figure 23-7 Typical driving aids for a person recovering from stroke.

(Courtesy Mobility Products and Design, Winamac, Ind.)

Regarding lower extremity function, if the patient does not have isolated control in the right lower extremity, then the person will require a left foot gas pedal (see Fig. 23-7). If the person has recovery in muscle strength, sensation, and coordination in the right leg, then the patient may be able to continue using this leg normally on the pedals. If the person wears a lightweight short leg brace and has some minimal movement in the ankle, and all other factors—such as strength, sensation, and coordination—are good, then this person still may be able to use the right leg for gas and brake operation or just gas operation. If movement to the brake pedal is slow with or without a brace, or the hip or knee fatigues quickly, then teaching a two-footed driving method may be possible if this is allowed in the state of residence and the person has plantarflexion and dorsiflexion in the affected ankle. Proprioception is necessary and should be evaluated carefully. The OT Specialist in Driving will determine if the stroke survivor has good foot placement, good pedal regulation, and acceptable reaction time using the affected leg. The in-vehicle and on-road evaluation will determine which method and what equipment, if any, is viable and necessary. After the moving assessment, the therapist may determine that the person requires equipment when initially it was thought he or she could use the affected upper or lower limb.

For secondary controls that are operated in a stationary position, the stroke survivor may be able to use compensatory methods for these controls; for example, using the left hand for inserting and turning the ignition key or operating the gearshift lever. If this is difficult, adaptive aids such as a gear selector crossover and key extension may be appropriate. Special panoramic mirrors can be beneficial when neck range of motion is limited or to increase visual awareness to the rear, sides, and blind spots (Figs. 23-8 and 23-9). These mirrors do not compensate for loss of peripheral vision, so they are not useful for correction of homonymous hemianopsia.

Figure 23-8 SmartView Mirror by Interactive Driving Systems. This mirror eliminates the confusion noted in the typical spot convex mirror and increases rear vision by dividing the mirror into two areas. The outside half of the SmartView mirror (white arrow) shows objects in the blind spot of the vehicle, or Danger Zone. If a car is detected in the Danger Zone, the driver must not move in front of it. In this photograph, the car shown is detected by the mirror to be in the driver’s Danger Zone. The upper inside quadrant of the mirror (black arrow) is boxed and shows the Safe Zone. If a car is seen in the box—and stays in the box—the driver may move in front of it.

(Courtesy Interactive Driving Systems, Cheshire, Conn.)

Figure 23-9 A, The Lanechanger mirror combines a standard rearview mirror with a convex mirror. B, This convex mirror provides a wider angle of vision and increased safety.

(Courtesy The Lanechanger, Quebec, Canada.)

Sensory-perceptual assessment

A visual assessment is crucial because driving depends so much on visual input. A visual assessment in regards to the task of driving is more than mere checking of a patient’s visual acuity and depth perception. Scheiman,³² a rehabilitation optometrist who works with patients with various diagnoses, stated that good vision is more than clear vision: “the individual must have the ability to use his eyes for extended periods of time without discomfort, be able to analyze and interpret the incoming information, and respond to what is being seen.” His experience indicates that nearly half of the patients admitted to a rehabilitation center with stroke or traumatic brain injury have visual system deficits, primarily in the area of binocular vision and accommodation. Other commonly reported vision problems include reduced visual acuity, decreased contrast sensitivity, visual field deficits, visual neglect, strabismus, oculomotor dysfunction, and accommodative and stereopsis dysfunction. See Chapter 16.

The stroke survivor should be evaluated visually according to the vision requirements for licensing of the state. This usually includes visual acuity of 20/40 in at least one eye and a total field of vision of at least 130 to 140 degrees. Eye test charts can be used to ascertain visual acuity. A commercially available stereoscopic vision tester that is self-contained and often used by driver licensing agencies may be applicable to a clinical setting. In addition to visual acuity, these machines also screen for depth perception or stereopsis, contrast sensitivity, road sign recognition, phoria, fusion, and horizontal perimeter vision. These machines have limitations that the therapist must take into consideration when using them and interpreting the results. For example, stereoscopic vision testers rely on binocular vision. If a patient does not possess binocular vision for whatever reason, this machine can be used only on a limited basis. Box 23-4 lists vision testing resources. If any suspicions of problem areas arise, the stroke survivor should be referred to an eye care specialist. If the patient does not meet basic state requirements, an eye care specialist should see the patient before an on-road assessment. For example, if the stroke survivor does not meet the state’s visual requirement for peripheral vision, then he or she and the family should be educated on this fact and never referred to the OT Specialist in Driving. This information should be reported to the state’s medical review board with the Department of Driver Licensing, so the state can make a decision to suspend the person’s driving privileges (see Box 23-4).

Some states allow a loss of vision in the upper quadrant as long as the lateral median in the superior quadrant is normal (Fig. 23-10). The exact degree of visual field available in each eye should be assessed quantitatively. Gianutsos and Suchoff¹³ have suggested that perimetric and functional visual fields also are important to assess. A patient with complete homonymous hemianopsia may have only 110 degrees of total visual field. Whenever an occupational therapist suspects that a patient has any degree of peripheral vision loss, an objective test using machines such as the Goldman or Humphrey perimeter test should be used. An OT clinic generally cannot afford expensive, large objective perimeter machines that can quantitatively measure exact degrees of visual fields in all quadrants. The therapist can perform a finger confrontation test or use a horizontal perimeter tool, and while this will confirm a complete hemianopsia, the test is not inclusive or objective. Before concluding that the patient cannot drive with this impairment, the therapist must make a referral to a local eye care specialist that uses one of the machines noted previously to get an accurate report of the exact field of vision.

Figure 23-10 Representation of normal visual field in the eyes and typical visual field defects.

Aside from visual deficits that may occur because of the stroke, the occupational therapist also must consider the normal change in visual skills occurring due to the person’s age. Testing eye range of motion, tracking, pursuits, and saccades can be done quickly with a few handheld sticks or a tracking ball. As does any organ in the body, the eye loses some of its capability with age. The pupil of the eye becomes less elastic and restricts the amount of light let into the retina. Many elderly patients complain of difficulty driving at night or during weather conditions when the illumination is poor, such as in rain, fog, or snow. Cataracts, glaucoma, and macular degeneration are common among elderly persons. Cataracts, a clouding of the lenses, also can affect night driving and can produce hazy vision during the day. Cataract surgery has a 90% success rate in a healthy older person who does not have comorbidities. Glaucoma, an increase in ocular pressure that damages the optic nerve and retinal nerve fibers, begins by affecting side vision first and eventually compromises central vision. It is a treatable condition, and a referral to the appropriate eye care specialist is important before performing the on-road assessment. The therapist should consider diabetic retinopathy for a person with a history of diabetes. When the degree of macular degeneration is so great that it affects the central vision to a point that the person cannot see anything in this visual area, then the patient needs to stop driving. Therapists can assess visual scanning, awareness, and attention in the clinic by using some of the subtests in the visual-perceptual and cognitive tests discussed later in this chapter.

Because speed and movement can influence visual and visual-perceptual skills, the therapist must make the final determination of the proficiency and effectiveness of these areas for driving in the vehicle and in the dynamic moving traffic environment. For example, the speed of a vehicle decreases visual acuity and side vision. If a person has 200 degrees of visual field, at 20 miles per hour, the field is reduced to 104 degrees; at 40 miles per hour, to 70 degrees; and at 60 miles per hour, to 40 degrees. Speed also decreases visual acuity; the faster the speed, the less time available to react to visual stimuli in the environment.³⁴ The Visual Attention Analyzer Model 2000 (Visual Resources, Chicago, Ill.) assesses the size of the useful field of view and comprises three subtests to evaluate processing speed, divided attention, and selective attention (see Chapter 19). This machine can be helpful to the OT Generalist in Driving as the machine evaluates and provides training modules that can be used in intervention to improve the person’s visual attention and processing speed.

Visual-perception and cognitive assessment

According to Toglia,⁴⁰ the limitation to the deficit-specific approach to perception is that “it equates difficulty in performance of a specific task with a deficit . . . [and] does not consider the underlying reasons for failure or the conditions that influence performance.” For example, a patient may score low on a typical OT clinical test of visual-perceptual skills; nevertheless, the results may be a consequence of reduced visual acuity or accommodation and not necessarily a specific visual-perceptual deficit.

A stroke survivor who has serious visual-perceptual deficits will have difficulty throughout rehabilitation.⁴³ The occupational therapist will complete documentation and observations of deficits in these areas during routine evaluation and intervention. The stroke survivor should not be referred to the OT Specialist in Driving until the deficit areas no longer interfere with basic ADL. If the therapist understands the definition of each visual-perceptual category and the way deficits in each area affect a person’s basic self-care skills, a further analysis of the activity demands of driving can show the way persistent problems in these areas can interfere with driving performance skills (see Chapter 18 and Chapter 19).

Driving requires a combination of perceptual skills in which cognitive performance plays a major role. Strong cognitive abilities are fundamental to attentiveness in the driving task, recognition of stimuli, and choice of the appropriate way to respond. A decline in cognitive abilities can significantly influence a person’s ability to plan, judge, and act adequately. A cognitively impaired person may have difficulty maneuvering a vehicle through rapidly changing traffic with many unexpected actions and reactions from other drivers, passengers, pedestrians, and bicyclists. Cognitive impairment has been linked to higher motor vehicle crash rates in elderly individuals.⁶ Problem areas may involve attention, orientation, concentration, learning (short-term memory), and problem-solving. Diffuse cognitive deficits occur more frequently in patients with large frontal strokes, visuospatial deficits in right hemisphere strokes, and apraxia in left hemisphere strokes.⁴⁶ Unilateral neglect has been reported in half of the patients with right brain damage and in 20% to 25% with left brain damage.³⁸ Diller and Weinberg⁷ reported that “patients with left hemiparesis often experience accidents that are related to difficulties in dealing with space, while accidents in patients with right hemiparesis are often related to slowness in processing information.”

Patients are generally more aware of motor problems than they are of cognitive problems.¹³ Gresham and colleagues¹⁴ noted that “unawareness of the stroke (or its manifestations) is often found in patients with lesions in the nondominant hemisphere. It can lead to impulsive, unsafe behavior in a patient who may otherwise appear relatively normal with respect to physical functioning.” Patients’ poor insight into their own problem areas can be dangerous because patients may not be aware of serious driver errors and the potentially fatal consequences of their actions.

The occupational therapist can use common verbal and written tasks to assess the areas of visual perceptual functioning such as spatial relations, visual discrimination, form constancy, depth perception and visual memory, sequential memory, and visual closure. Two commonly used tests are the Gardner Test of Visual Perceptual Skills and the Motor-Free Visual Perception Test—3, which is standardized for adults age 70-years-old or older. The Motor-Free Visual Perception Test—Vertical is for those who have difficulty with horizontally presented stimuli such as stroke survivors.

Therapists can use a variety of cognitive tests to assess memory, language, orientation, attention, concentration, reasoning, and problem-solving. The Helm-Estabrooks Cognitive Linguistic Quick Test can be administered in 20 to 30 minutes; is standardized for adults with acquired neurological dysfunction, ages 18- to 89-years-old; and can be used to identify a person’s cognitive strengths and weaknesses. This test gives a “snapshot” assessment of the status of these five cognitive domains: attention, memory, language, executive functions, and visuospatial skills (see Chapters 18 and 19).

During the administration of these clinical tests, one must remember that these tests are static and two-dimensional and do not begin to simulate the dynamics of the driving task. French and Hanson¹⁰ stated “controversy continues about which cognitive-perceptual assessments are the best predictors of behind-the-wheel performance.” The authors summarized studies performed by Galski, Bruno, and Elhe in 1992 that found a significant correlation between seven tests: “Part A of the Trailsmaking Test, the Rey-Osterreith Complex Figure Test, the Porteus Maze Test, the Visual Form Discrimination, the Double Letter Cancellation, the Wechsler Adult Intelligence Scale—Revised Block Design Test, and Raven’s Progressive Matrices and the behind-the-wheel evaluation . . . . the [continued] research suggests that a combination of neuropsychological testing, visual screening, physical functioning, and actual driving (simulators and on-the-road evaluations) is necessary to predict driving performance.”

Engum and colleagues⁹ defined basic operational and behavioral skills as “attention, concentration, rapid decision-making, stimulus discrimination/response differentiation, sequencing, visual-motor speed and coordination, visual scanning, and acuity and attention shifting.” Table 23-3 describes several performance areas and the way deficits in these areas can affect driving performance.

Table 23-3 Effects of Various Deficits in a Stroke Survivor on Driving Performance

An appropriate end to the predrive clinical evaluation may involve several tests to assess procedural memory for driving, knowledge of road rules, and road sign and/or situational problem-solving, reasoning, and judgment. Several formal tests can be used. The Driver Performance Test, distributed by the Advanced Driving Skills Institute (Orlando, Fla.), is a video of simulated real-world driving scenes and provides insight into the patient’s perceptual capabilities, psychomotor responses, and decision-making strategies. Using a driver education defensive driving technique of identifying, predicting, deciding, and executing, the Driver Performance Test requires the patient to search for hazardous situations or conditions, identify potential and immediate hazards, predict the effect of the hazard, decide the way to evade the hazard, and execute evasive driving actions.⁴⁴ The drawback to this test is that it takes about 45 minutes to administer. Additional time is then necessary to review the answer video with the patient, an essential step for any learning or understanding to take place for the patient or the therapist.

Because the Driver Performance Test has no statistical validity, the therapist should decide whether to use valuable time administering it during this phase or letting the driver rehabilitation therapist use it in the next phase of the process. An important consideration is that this rapidly timed test may produce stress in the stroke survivor because it requires quick problem-solving and decision-making, marking on an answer sheet while having attention divided, and retaining information. The test taker has only a few seconds to choose an answer and then must go on to the next traffic scene because the test has no built-in delay or pause. If the test taker gets behind, he or she may become disorganized or distracted and not be able to respond to the next scene. Although quick thinking and reaction are important for driving, the Driver Performance Test may be a better tool to use after the patient has passed all clinical tests and road tests, and may be a more effective tool to use when the therapist determines that the patient needs more practice, training, or review in the areas tested by the Driver Performance Test (Box 23-5).

Patient’s liability

The driver has an ethical responsibility to avoid harming self or others. Each state department of motor vehicles grants a person the privilege of a driver’s license based on criteria and regulations that vary from state to state. The driver must realize that the driving privilege can lead to potential disaster through injury to persons and destruction of property if residual functional deficits interfere with driving skills. Persons recovering from a stroke who cannot master the operational, tactical, and strategic skills necessary to operate a motor vehicle safely present a clear risk of injury to themselves, their passengers, pedestrians, and other operators of motor vehicles.²

The OT should address the liability issues for the family before discharge as an inpatient. The family should understand that following the rehabilitation team’s recommendations for driving cessation until a driving assessment can be made will lessen their liability risk. Families are entrusted with ensuring compliance with the recommendations after discharge from the inpatient rehabilitation stay. They should be encouraged, if necessary, to take the stroke survivor driver’s license and/or vehicle keys and even relocate any vehicle to which the person may have access before the person is discharged from the rehabilitation facility. The entire rehabilitation team must reinforce this information so the family is informed properly, prepared, and willing to take their role and responsibility seriously and to follow through with the recommendations.

The rehabilitation team or family member should never hesitate to report the stroke survivor to the department of driver licensing if the person does not comply with the team’s recommendations and is deemed unsafe to self or the public while driving. If the physician hesitates to address driving to a patient or thinks liability may be avoided by not addressing the issue, another team member should contact the department of driver licensing if allowable in that state. Each state differs in the requirements for reporting a person, so the occupational therapist should investigate the procedure for the patient’s resident state. Obtaining a copy of the state’s statute is important, as is talking to the department of driver licensing or medical review board. By performing a an internet search using the letters “DMV,” each state Division of Motor Vehicles website can be found.

The March 1993 AOTA physical disabilities special interest section newsletter discussed the legal considerations for driver rehabilitation programs in terms of the responsibility of the patient, physician, and occupational therapist.³⁰ To avoid any legal difficulties with the driver’s insurance, the stroke survivor should notify his or her car insurance company about the stroke, the results of the driving evaluation, and the validation of the person’s driving ability by the department of motor vehicles. Failure to notify the insurance company may result in a claim of fraud if the patient has an accident. As a result, the stroke survivor who is driving may be held completely or partially liable for costs rewarded in court judgments for property damage, bodily damage, pain, suffering, and loss of any parties involved in the accident because of contributory negligence.

Physician’s liability

In the past 20 years, court precedent has established that physicians have responsibility for protecting the public health even if it conflicts with the patient’s right to privacy and confidentiality. This duty to warn society for the greater good has been upheld by the courts. Consequently, the physician’s liability to inform third parties has increased. Few, if any, exceptions to this rule exist, so any person who has had a brain trauma or damage should be assessed objectively for safe driving skills. Failure to address these issues with the stroke survivor and concerned others may expose a health care provider to a charge of negligence.

Some states have mandatory reporting laws. A physician must report a new disability or diagnosis to the department of driver licensing. In states that lack this law, some physicians may overlook, ignore, or hesitate to report a patient for fear of losing a patient. The physician may feel a loyalty toward patients he or she has treated for many years. A patient may attempt to influence the physician’s decision by indicating that he or she is the only driver in the family and driving is crucial to continued independent living. Although this may be true, the physician’s first thought should be the safety and protection of the patient and the public. If the physician or others on the rehabilitation team are unsure the patient will comply with the recommendations as given regarding driving, the person should be reported to the department of driver licensing without hesitation.

The American Medical Association (AMA) now encourages physicians to make driver safety a routine part of geriatric medical services. The AMA in 2003 published the Physician’s Guide to Assessing and Counseling Older Drivers. Information about this book and other resources is available through their website at www.ama-assn.org/go/olderdriver. The physician’s decision to report a patient should be based on the amount of risk involved in allowing the person to continue driving. The physician should protect patients from further harm or injury to themselves or others. States that have a mandatory reporting law also protect individuals by a state statute who report medical conditions from being sued for slander or character defamation by divulging personal information to the department of driver licensing. For further protection, the name of the reporting person is not revealed to the licensee.

A review of past court opinions and judgments reveals rulings for and against physicians. Jacobs,¹⁷ in a 1978 article titled “Reporting the Handicapped Driver,” cited several lawsuits against physicians. In a 1920 invasion of privacy lawsuit, Simonsen v. Swenson, the physician was vindicated of any wrongdoing by proving that the public welfare was being protected. In Freese v. Lemmon, 210 NW2d 576 (Iowa, 1973), a physician was found guilty of malpractice because he failed to warn and counsel a patient about the possible effects a medical condition might have on driving ability. In this case, the patient had been diagnosed with epilepsy. The physician did not advise the person to stop driving. The person had a seizure while driving and struck a pedestrian. In a 1986 lawsuit Tarasoff v. Regents of the University of California (551 p. 2d 334, at 344 [1986]), a psychologist working in the student health department on campus was held liable because of his failure to alert and advise campus authorities properly when a student reported to him an intention to murder his girlfriend. The court ruled the psychologist had a duty to break confidentiality and warn the potential victim. The court’s opinion concluded that the “protective privilege ends where the public peril begins.” The court also stated the following:³ “The physician treating a mentally ill patient, just as a doctor treating a physical illness, bears a duty to use reasonable care to give threatened persons such warnings as are essential to avert foreseeable danger arising from his patient’s condition or treatment.”

Antrim and Engum,² in an article titled “The Driving Dilemma and the Law: Patients Striving for Independence Versus Public Safety,” described other legal cases illustrating practitioner liability. In Naidu v. Laird, 539 A2d 1064 (Del. 1988), the court heard that Laird was killed in a car accident by a known psychotic person who had been involved in several similar accidents in which he drove his car deliberately into someone else’s car. When taking his medication, the psychotic person was generally manageable, appropriate, and capable of living semi-independently. When not taking his medication, he had violent tendencies that presented a risk of harm to himself and others. Laird’s widow sued the psychotic person and the treating physician, Dr. Naidu, for wrongful death. The court ruled in favor of the plaintiff. The court stated “a psychiatrist owes an affirmative duty to persons other than the patient to exercise reasonable care in the treatment and discharge of their patients.” Antrim defined reasonable care as the degree of care, skill, and diligence that a reasonably prudent psychiatrist engaged in a similar practice and in similar conditions ordinarily would have exercised in like circumstances.

Antrim and Engum² further discussed the California case Myers v. Quesenberry, 144 Cal App 3d 888 (1983), which involved a car accident of a patient of Dr. Quesenberry who was being treated for diabetes and receiving prenatal care. The doctor knew that his patient had been seriously affected during two previous pregnancies that resulted in one stillbirth. During the third pregnancy, the patient’s diabetes could not be stabilized. During an office examination, the physician discovered the fetus had died. Dr. Quesenberry advised the patient to have a dilation and curettage procedure. He instructed her to drive immediately to a hospital. Emotionally distraught, the patient suffered a diabetic attack in route and lost control of her car, striking a pedestrian, Myers. The court noted that a fundamental principle of tort law held physicians liable for injuries caused by their failure to exercise reasonable care. A physician must warn a patient if the patient’s condition or medications renders certain conduct such as operating a motor vehicle dangerous to others.

A physician must appreciate the complexity and dangers of driving and understand that certain conditions or deficits may impair driving performance. A physician should recognize limitations in having the tools and abilities to evaluate a person’s driving skills fully in the office or hospital. A physician should be informed about the expertise and role of the occupational therapist and the driver rehabilitation therapist to refer patients for a medical-oriented and comprehensive driving evaluation.

Occupational therapist’s liability

The occupational therapist’s responsibility can be as great and serious as the physician’s is. The level of liability increases as the therapist’s role and responsibility increase. The therapist seeing the patient in the acute care setting who addresses only driving from a factual standpoint has little liability, if any. However, if the inpatient or outpatient occupational therapist chooses not to inform the patient or the family of their responsibility with this issue, then the therapist may be liable for an act of omission.

The OT Specialist in Driving or the driver rehabilitation therapist has the greatest degree of vulnerability to liability lawsuits compared with an occupational therapist in the clinic or hospital. The nature of the job, in which the therapist takes a person in traffic, has inherent risks. A definitive legal case that eases the liability position of the driver rehabilitation therapist was White v. Moss Rehab, et al. (Philadelphia, 1995) when the court declined “to recognize a common-law third party cause of action for educational malpractice against a driving school.” The driver rehabilitation program was found not to be liable for the driving mistake of a former patient that resulted in a motor vehicle accident that caused the death of a passenger in another vehicle.

For risk management the driver rehabilitation therapist should follow safe, accepted practices (Box 23-9). The evaluation car must be viewed as an evaluation tool that must be adjusted to each client’s use and maintained in proper working order just as any machine in the OT clinic. Proper training by qualified professionals in the field and practice with in-car skills prepares the therapist for the work in the car. An Adaptive Mobility Services workshop titled Take the Wheel: A Driver Education Workshop for the Therapist provides this type of knowledge, instruction, and practice in a real evaluation vehicle with mock patients.

An occupational therapist must be credentialed adequately to enhance the value of his or her professional opinion. The therapist must have a strong working knowledge of each step of a comprehensive driving evaluation and must use the accepted practices in the industry conscientiously. The therapist must follow any industry guidelines, standards of practice, and code of ethics that exist for the OT profession. Wendy Kaplan¹⁹ in a 1999 AOTA physical disabilities special interest section quarterly newsletter article titled “The Occupation of Driving: Legal and Ethical Issues” stated that “Therapists should be aware of medical reporting requirements for impaired driving laws that exist in their state of practice. The AOTA Code of Ethics creates an obligation for administrative occupational therapists to be aware of the laws related the health care practitioners and driving as well as to disseminate that knowledge. It is the role of the manager to create departmental policies consistent with those laws and provide the administrative support necessary for observance of those policies.” For legal protection, all therapists, and especially those in this specialty area, should have their own professional liability insurance in addition to coverage from the employer. If the therapist is ever drawn into a lawsuit, he or she must have representation by a personal attorney and not a third-party interest.

The driver rehabilitation therapist should possess all necessary clinical and vehicle tools, tests, and skills used to pass judgment fairly and accurately on a person’s driving future. The therapist should evaluate a client’s driving ability fully, considering the safety of the client and the public at large. The therapist should avoid zealousness as an advocate for the client whose skills are in question. The occupational therapist’s perspective of looking at the whole person is key to making the best decision. The contextual and environmental factors are very important to consider. The person may only need to drive within a 5 mile radius of his or her home and has lived at the same address for many years. If the patient will require a manual wheelchair permanently, then this may affect the vehicle and equipment recommendations. If the person will be moving to a different location to be close to family and is unfamiliar with the area, then memory, learning skills, and directionality may be greater factors than when a person will be returning to a familiar environment in which he or she has resided for many years.

Antrim² is a practicing attorney and a member of the board of reviewers of the journal Cognitive Rehabilitation. He strongly suggests that current legal authority appears ready to impose liability on health care professionals for negligence in failing to address their patients’ abilities to drive. Antrim recommends that health care professionals use a standard of care in making these recommendations and that their evaluation process should include guidelines for making those decisions reasonably and responsibly. The AOTA Practice Guidelines for Driving and Community Mobility for Older Adults offers recommended practices for the occupational therapist.

In a 1986 article, Steich³⁷ explained that the law holds professionals to a higher standard than it does the public because professionals consider themselves more highly skilled in their particular fields of expertise. For example, the driver rehabilitation therapist owes a greater duty of care to a client and the public than does a parent teaching a child to drive. Steich goes on to explain that the occupational therapist must do something wrong or fail to do something that should have been done to be held liable. If the policies and procedures of a program define the steps that should be performed to complete a comprehensive driver evaluation but the therapist fails to use the tool or procedure defined, the therapist may be held liable for omitting that portion of the test. Legal counsel should review the wording of the driving program policies and procedures.

The therapist is responsible for ensuring that all evaluative or testing equipment works when needed. For example, therapists can use several commercially available devices to test visual acuity and night vision. If the machine that measures night vision is not working when the therapist evaluates a patient with a diagnosis in which night vision could be a suspected problem (such as glaucoma), the therapist may be found negligent for not having the machine fully functioning when the patient was evaluated. The therapist may make a statement in the summary indicating that rendering an opinion on the issue was impossible; however, in making a conclusion regarding the person’s driving ability, night vision should be tested appropriately.

Communication and documentation

Communication and documentation are important keys to lessening everyone’s liability throughout the entire process of addressing driving issues for the stroke survivor. The stroke survivor and the family need to be informed of the requirements of the state department of driver licensing. These requirements vary from state to state. In the rehabilitation phase, the stroke survivor and family should sign a document that becomes a permanent part of the medical record that describes the information, recommendations, and follow-up plans given by the rehabilitation team regarding driving and community mobility.

Documentation of addressing the IADL of driving and community mobility is crucial and necessary for several purposes. This documentation can be used to justify an adaptive equipment purchase for a third-party payer, inform the department of motor vehicles and a physician of the patient’s driving performance, and help defend the therapist in a court of law or during a deposition in which professional judgment or expertise is deposed. The therapist should keep in mind that if something is not documented on paper, in the eyes of the court it was not done. This documentation is more vulnerable than usual because it is scrutinized far more than is the documentation of in-house therapy for ADL training. Because driving is an ADL that can kill,²⁸ the parties involved must maintain the highest degree of competence, thoroughness, and seriousness at all times. The documentation of a driving program is at greater risk to be subpoenaed by an attorney searching for liability for a lawsuit.

The OT notes should document all aspects of how the IADL of driving was addressed just as they would for any other ADL or IADL. For example, reports throughout the continuum of OT at the various levels of rehabilitation and recovery should include such things as interactions with the stroke survivor, the way the patient performed in each step, and the clinical reasoning inherent in the decision-making and final outcome regarding the person’s ability to drive. Therapists should avoid statements such as “the patient has potential to be a safe driver.” The therapist must have enough confidence with the patient’s abilities and in his or her own professional judgment to document “the patient is a safe driver.”

Another method of documentation is to say “today the patient drove safely in the following situations.” The documentation should account for the time and days spent with a patient. The therapist should note positive and negative observations or scores. Incomplete, illegible, and poorly written documentation is hard to defend in court if an expert witness is used to judge the driver rehabilitation therapist’s work and decisions. As with the physician cases noted previously, an expert witness with similar practice to the therapist’s may be called to testify regarding standard procedure in similar conditions. This witness may not be able to testify that the driver rehabilitation therapist acted with a reasonable care of duty if the documentation cannot support conclusions with evidence. Evidence of professional continuing education is important to show that the therapist knowledge is updated with current standard of practice.

After a complete driving evaluation, the therapist should explain final recommendations thoroughly to the stroke survivor and family members. The referring physician should receive written notification of the outcome of the evaluation. The therapist should document the results, recommendations, and follow-up services to be done in the client’s chart. The client should sign the written recommendations to demonstrate legal proof of explanation of the findings. If the results of the evaluation are negative, a team member may inform the proper driver licensing authority in the client’s state of residency.