03-21-05
Screening Driving and Community Mobility Status: A Critical Link to Participation and Productive Living
Joseph M. Pellerito, Jr. and Elin Schold Davis
Summary
Driving is a meaningful symbol of what it means to participate fully in mainstream American life. Irrespective of whether occupational therapists are driving generalists or driving specialists, they are uniquely positioned to address clients' driving and community mobility needs.
One of the most important rites of passage for people of all ages, but especially teenagers, is earning a driver's license. As a society, we are highly dependent on the automobile to meet our travel and community mobility needs.1,2 Driving is an important symbol of adult autonomy and independence. It provides a sense of personal competence and self-identity, enables access to essential services and meaningful social interactions, and can support the ability of older people to age in place in familiar surroundings.2 The independent community mobility afforded by driving also influences the roles people assume,3 the formation and maintenance of primary and secondary group ties, the daily operation of households and businesses, the pursuit of meaningful activities in a variety of social settings,4 and positive self-concept and high self-esteem.4,5 Overall, driving and the associated "car culture" influence the ways in which we interact with others, perceive the world and ourselves, and imagine how others perceive us.6
Furthermore, in contemporary industrialized societies, driving is not considered an inalienable right but a privilege that is granted by the government and defined in legal terms.7 However driving is much more than a privilege, luxury, or instrumental activity of daily living (IADL) as some would suggest; it can, in fact, be an activity of daily living (ADL)1 that is necessary for a full and productive life.
These and other factors underscore why occupational therapy driving generalists should address goals and premorbid activities related to driving and community mobility while conducting ADL and IADL evaluations. Doing so can help ensure that these critical life skills, considered by many to be as important as walking or communicating, are not overlooked by the rest of the health care team. Occupational therapy driving generalists can affect their clients' quality of life by properly screening driving and community mobility interests and needs. However, an essential point must be made: Clinical screens are never performed to confirm or rule out driving as a viable goal. Instead, interpreting the relationship of performance deficits to the IADL of driving, or administering more targeted clinical screens, is meant to identify clients' specific goals and areas to address in therapy and to help facilitate timely referrals to occupational therapy driving specialists.
Clients often express the desire to return to, or begin, driving or accessing alternative modes of transportation that will enable them to stay connected with family and friends, religious and social organizations, and their communities at large. Drivers with functional impairments, whether due to accidental injury, illness, aging-related changes, or some other cause have the same need to drive and access alternative transportation, with reasonable levels of safety and efficiency, as the general population. Yet persons experiencing difficulties with driving and community mobility may not be aware that there are occupational therapy driving specialists who are well-equipped and poised to address their concerns, or they may be uncertain about the steps necessary to engage them.
All occupational therapists should explore the ways in which an impairment or disability may be affecting their clients' driving and community mobility during the initial evaluation, and subsequent goal setting should reflect clients' driving and community mobility needs as necessary, irrespective of the setting. Occupational therapists should not wait for their clients (or their clients' caregivers) to broach this topic but should address it during the initial evaluation.
Community Mobility
Depending on a person's performance skills and patterns; context; activity demands; and client factors, such as age and health status, community mobility is most often accomplished by one or more of the following:
- Walking with or without an ambulation aid
- Using a wheeled mobility device that is manually propelled, such as a manual wheelchair, bicycle, skateboard, in-line roller skates, or manual scooter
- Using a powered or power-assisted wheeled mobility device such as a power wheelchair, Segway, manual wheelchair with power assist, or adult scooter
- Using public and private transportation such as a bus, train, taxi, subway, street car (i.e., trolley), and getting rides from others
- Driving a motor vehicle such as a car, van, sport utility vehicle, or truck with or without structural modifications, adapted driving equipment, or both
Figure 1. Responsibilities of Occupational Therapy Driving Specialists and Occupational Therapy Driving Generalists
The following indicate appropriate interventions and whether they should be performed by a driving generalist or a driving specialist:
- Address driving as a goal (generalist, refer client to a specialist at appropriate time)
- Use specific screens or assessments to determine client readiness for referral (generalist)
- Provide intervention to optimize the client factors necessary for driving (generalist or specialist)
- Perform a comprehensive driver evaluation-includes two portions, (a) the clinical evaluation and (b) the on-road evaluation (specialist)
- Provide intervention (postcomprehensive driving evaluation) to address or strengthen areas of identified or significant impairment (specialist, or the client may be referred to a generalist to address these areas)
- Prescribe vehicle adaptations (specialist)
- Train clients and determine their competence in using compensations and adaptations (specialist)
- Schedule reassessments for clients with progressive conditions (e.g., dementias, multiple sclerosis, Parkinson's disease, etc.) (specialist)
- Determine the need for driving cessation (exceptions may occur if impairments are absent or extreme) (specialist)
Figure 2. Primary and Ancillary Driver Rehabilitation and Community Mobility Team Members
Primary Team Members
- Client
- Client's chief caregivers
- Primary driver rehabilitation specialist assigned to the client's case, such as an occupational therapy driving specialist
- Vehicle modifier (also known as the mobility equipment dealer)
- Physician(s), such as the client's physiatrist or general practitioner
- Case manager
Ancillary Team Members
- Client's friends and extended family members
- Occupational therapy driving generalists
- Occupational therapy assistants
- Neuropsychologists and psychologists
- Other allied health professionals, such as speech-language pathologists, audiologists, physical therapists, therapeutic recreation specialists, social workers, nurses, physicians, orthotists, and prosthetists
- Other allied health professionals working as specialists in driving, such as occupational or physical therapy wheeled mobility and seating specialists, occupational therapy low-vision specialists, surgeons, ophthalmologists, and geriatricians
- Occupational therapists or other allied health professionals specializing in driver rehabilitation who are not assigned to a particular client's case but are consulted for input by the primary driving rehabilitation specialist
- State motor vehicle department staff responsible for licensing and relicensing driver applicants
Who Provides Driver Rehabilitation Services?
The terms occupational therapy driving generalist and occupational therapy driving specialist help consumers and professionals better discern a practitioner's level of education, training, and experience in the expanding field of driver rehabilitation and community mobility. Occupational therapy driving generalists have the ability to identify clients' concerns and limitations relative to driving and community mobility and may specialize in other areas of practice, such as hand therapy, mental health, and low-vision therapy. An occupational therapy driving specialist, also known as a driver rehabilitation specialist (DRS), has advanced training and is able to perform predriving clinical evaluations, on-road evaluations of driving performance, and driver training (see Figure 1 above).
The services that are offered by a driver rehabilitation program are usually a good indicator of the professionals who compose its team structure. Every driver rehabilitation program employs primary team members to provide key driver rehabilitation services irrespective of the program's service delivery model, team structure, or service offerings. Among the driver rehabilitation team members is the DRS, who plays the central role in providing efficacious driver evaluation and rehabilitation and, more recently, community mobility services to clients and their caregivers. DRSs conduct comprehensive driver rehabilitation evaluations with the aim of determining their clients' driver readiness. They work with other health care professionals, including ancillary team members, to help ensure that clients achieve their driver rehabilitation goals, community mobility goals, or both. See Figure 1 above for key driver rehabilitation and community mobility services, as well as the professionals responsible for the services rendered.
Not all DRSs possess an occupational therapy professional background. It is true that most DRSs begin their careers by functioning as occupational therapy driver generalists; however, some specialists began their careers in other health care fields, such as pharmacy practice and neuropsychology, as well as carrying out job responsibilities as driver educators. Occupational therapy driving generalists can develop expertise in the field of driver rehabilitation and community mobility and earn the distinction of being identified as an occupational therapy driving specialist.
Table 1. Driver Rehabilitation and Community Mobility: Key Services and the Professionals Responsible for Providing Them
| Services |
Professional(s) Responsible for Service Delivery |
| Informal predriving clinical screens |
Occupational therapy driving generalists during an ADL or IADL evaluation or a separate predriving screening tool |
| Formal clinical driver rehabilitation evaluations |
Occupational therapy driving specialists |
| In-vehicle predriving assessments to help determine the best vehicle type, adapted driving aids, and structural modifications before taking the client on the road |
Occupational therapy driving specialists or other health science professionals and driver educators specializing in driver rehabilitation services |
| On-road evaluations to examine the client's ability to access a vehicle, stow and secure an ambulation aid as necessary, and drive a vehicle with or without structural modifications, adaptive driving equipment, or both |
Occupational therapy driving specialists, other health science professionals specializing in driver rehabilitation services, or driver educators |
Off-street training (i.e., closed-circuit course)-can be conducted on a driving range or in an isolated parking lot, which enables clients to practice driving skills in a protected physical environment
Driving simulators can be used to assess driver readiness or for driver remediation and training in a protected virtual environment |
Occupational therapy driving specialists, other health science professionals specializing in driver rehabilitation services, or driver educators |
| On-road training using a specific vehicle with or without modifications, adapted driving controls, or both |
Occupational therapy driving specialists, other health science professionals specializing in driver rehabilitation services, or driver educators |
| Recommendations for adapted driving aids |
Occupational therapy driving specialists, other health science professionals specializing in driver rehabilitation services, or driver educators |
| Recommendations for vehicle modifications |
Occupational therapy driving specialists, other health science professionals specializing in driver rehabilitation services, or driver educators |
| ClientÐvehicle fittings |
Occupational therapy driving specialists, other health science professionals specializing in driver rehabilitation services, or driver educators |
| Developing and implementing driving cessation plans and providing counseling that includes exploring strategies to facilitate alternative community mobility |
Occupational therapy driving specialists and generalists, other health science professionals specializing in driver rehabilitation services, driver educators, physicians, neuropsychologists, psychologists, or social workers |
| Identifying and using alternatives to driving for community mobility |
Occupational therapy driving specialists and generalists, other health science professionals specializing in driver rehabilitation services, or driver educators |
| Exploring funding options for driver rehabilitation and community mobility services and equipment |
Occupational therapy driving generalists and specialists, other health science professionals specializing in driver rehabilitation services, driver educators, physicians, neuropsychologists, psychologists, or social workers |
Each of the groups presented in Table 1 above represent the professionals who provide driver rehabilitation and community mobility services to people with disabilities, aging-related concerns, and others, such as caregivers, state licensing personnel, and private and public businesses. Occasionally individuals will have earned a combination of credentials and have professional experience that affords them multiple perspectives, such as occupational therapy driving specialists who have become certified driver educators (or vice versa). In addition, any professional working as a DRS (including occupational therapy driving specialists) can become certified driver rehabilitation specialists (CDRSs).
What is the difference between the DRS and CDRS? Not all driving specialists have completed the requirements set forth by the Association for Driver Rehabilitation Specialists (ADED) to become a CDRS. Many DRSs practice without having become CDRSs because the credentialing process is voluntary. However, it is generally accepted within the professional community that certification helps to improve overall standards and quality of practice. Undoubtedly, the confusing language that is rooted in the evolving professional lexicon will continue to complicate the choices that professionals and consumers must make with regard to professional training and seeking services.
Informal Clinical Screens vs. the Clinical Evaluation
The following information is designed to help occupational therapy driving generalists make a clear distinction between informal clinical screens (which should be initiated during initial evaluations) and the formal clinical driver rehabilitation evaluations that occupational therapy driving specialists conduct.
The Screening Process
The rehabilitation team can perform an ongoing assessment of the client's skills related to driving. Some occupational therapy clinics use existing tools, whereas others coordinate efforts with their local driver rehabilitation service providers to develop a screening instrument specifically for their setting. In these cases the battery of tests should cover essential client factors including physical abilities, attention, visual perception, and cognition, but use different testing instruments to avoid a practice effect.
In some settings, such as an outpatient occupational therapy clinic, a client may be referred to an occupational therapy driving generalist for an assessment to determine his or her readiness to participate in a comprehensive driver rehabilitation evaluation. The following two options can be used in this predriving screening process.
AAA Roadwise Review
The American Automobile Association (AAA) provides a self-assessment tool for seniors available on CD-ROM.8 The assessments measure the user's vision in various circumstances, flexibility, and other skills related to crash indicators among older drivers. The program also offers information on how to compensate for functional changes. Users work with a partner and progress at their own pace, pausing the program as needed. AAA recommends that older drivers use the screening periodically so they can make adaptations that will allow them to continue driving safely for longer.
Assessment of Driving-Related Skills
The Assessment of Driving-Related Skills (ADReS) is designed for use by physicians. It is composed of brief assessments that target essential functions required for safe driving including vision, cognition, and motor skills. Any impairment in these functions may increase the client's risk for a crash; however, the ADReS does not claim to predict crash risk. The ADReS uses the Snellen Chart to test visual acuity, confrontation testing to evaluate visual field of view, the Trail Making Test Part B, the Clock Drawing Test, rapid pace walk, manual range of motion testing, and manual muscle strength testing. The ADReS is fully described and a score sheet is provided in the Physicians Guide to Assessing and Counseling Older Drivers.7
Client Self-Assessments
There are many resources designed to facilitate self-screening and to help clients self-identify driving impairment indicators. For example, the ADED Web site provides warning signs listed by disability.9 Additionally, the National Highway Traffic Safety Administration's Safe Mobility for Life project has developed the free brochure, How is Your Driving Health? Self-Awareness Checklist and Tips To Help You Drive Safely, Longer.10 The Driving Decisions Workbook,11 AAA Roadwise Review,8 and the Adapted Driving Decision Guide12 also are excellent tools that can promote self-assessment and meaningful dialogue among clients, caregivers, and occupational therapy driving specialists and driving generalists. For example, the Adapted Driving Decision Guide12 was produced in cooperation with health care and industry professionals, consumers, and their caregivers. The Guide should not replace a comprehensive driver rehabilitation evaluation conducted by an occupational therapist DRS. Rather, it is intended to provide occupational therapist DRSs and occupational therapy driving generalists, clients, caregivers, and others with information about (a) practical ways to assess an individual's driver readiness; (b) the steps involved in selecting an appropriate vehicle that can meet a client's unique set of needs and wants; (c) structural vehicle modifications and adaptive driving aids that can enhance vehicle accessibility and a driver's performance; and (d) the potential impact that driving cessation and access to alternative community mobility can have on a client's quality of life.
Table 3. Clinical Assessments Used by Driving Specialists During a Clinical Evaluation
| Clinical Evaluation Components |
Client Factors |
Assessment Tools |
| Initial interview with client and caregiver |
Client's medical and social history |
Interview guide that is program-specific |
| Physical assessments |
Range of motion, Strength, Fine motor coordination, Muscle tone |
Goniometric ROM measurements15,16, Manual Muscle Test17, Functional muscle testing16, Hand-held dynamometry16,18, Hand-held pinch gauge16,18, Nine Hole Peg Test18,19 |
|
Proprioception |
Examination and observation |
|
Kinesthesia |
Examination and observation |
|
Endurance |
Observation |
|
Balance (static and dynamic), Sitting balance, Standing balance, Ambulation status/primary ambulation aid used, Wheeled mobility and seating |
Clinical Test of Sensory Interaction and Balance20, Berg Balance Scale21, Fregly and Graybiel Quantitative Ataxia Test22, Tinetti Assessment Tool (including balance test and gait test)23,24, Dynamic Gait Index, Interview and observation, Consultation with the primary occupational therapist and physical therapist generalists and seating specialists as needed |
|
Tactile sensation, Light and deep pressure stereognosis |
Sensation kit |
|
Brake reaction time |
Brake reaction test |
| Visual assessments |
Visual acuity, Peripheral vision, Depth perception, Color perception, Road sign recognition, Binocular glare testing, Contrast sensitivity, Stereopsis, Contrast sensitivity, Peripheral vision, Tracking, Convergence, Saccades, Pursuits |
Optic Vision Tester25, Snellen Chart |
| Cognitive and visual perceptual assessments |
Form constancy, Visual memory, Visual closure, Visual discrimination |
Motor-Free Visual Perceptual Test (MVPT-3), Trail Making Test26 |
|
Search, identify, predict, decide, and execute |
Driver performance test |
Conclusion
Each member of the driver rehabilitation team performs a vital role during the informal predriving clinical screen and comprehensive driver rehabilitation evaluation (i.e., formal clinical evaluation and on-road evaluation), the formulation of recommendations, the vehicle modification process, the clientÐvehicle fitting, and on-road driver training. In addition to informally screening clients (e.g., learning about their driving and community mobility interests and needs) and assisting them with completing driver readiness self-assessments, occupational therapy driving generalists can help them locate comprehensive driving programs that employ occupational therapy driving specialists and facilitate referrals for them to access comprehensive driver rehabilitation services. Occupational therapy driving specialists are highly competent to perform comprehensive driver rehabilitation evaluations (including addressing alternatives to driving that enable community mobility) and to provide interventions that foster positive client outcomes, such as enhanced occupational performance, satisfaction, role competence, health and wellness, and quality of life.13
The best service delivery models acknowledge that consumers and professionals are part of the same team.14 Initially, clients should be educated about their choices, financing options, training, and resources for long-term vehicle and equipment maintenance. They then should articulate their personal needs, goals, values, and preferences so that solutions can be created through an open exchange of information.
References
1. Molnar, L. J., Eby, D. W., & Miller, L. L. (2003). Promising approaches to enhancing elderly mobility (Report No. UMTRI-2003-14). Ann Arbor, MI: University of Michigan Transportation Research Institute.
2. U.S. Department of Transportation. (2003). Safe mobility for a maturing society: Challenges and opportunities. Washington, DC: Author.
3. Enterlante, T. M., & Kern, J. M. (1995). Wives' reported role changes following a husband's stroke: A pilot study. Rehabilitation Nurse, 20(3), 155-160.
4. Carr, D. B. (1993). Assessing older drivers for physical and cognitive impairment. Geriatrics, 48(5), 46-51.
5. Galski, T., Bruno, R. L., & Ehle, H. T. (1992). Driving after cerebral damage: A model with implications for evaluation. American Journal of Occupational Therapy, 46, 324-331.
6. Vidich, A. J., & Lyman, S. M. (1994). Qualitative methods: Their history in sociology and anthropology. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research. Thousand Oaks, CA: Sage.
7. Wang, C. C., Kosinski, C. J., Schwartzberg, J. G., & Shanklin, A. V. (2003). Physicians guide to assessing and counseling older drivers. Washington, DC: National Highway Traffic Safety Administration.
8. American Automobile Association. (n.d.). The AAA roadwise review: A tool to help seniors drive safely longer. Retrieved January 25, 2005, from www.aaany.com/safety/driver_training/ story.asp?xml=roadwise_review.xml&SrcID=06
9. Association for Driver Rehabilitation Specialists. (2004). Fact sheets. Retrieved December 23, 2004, from http://www.driver-ed.org/i4a/pages/index.cfm?pageid=102
10. National Highway Traffic Safety Administration. (n.d.). How is your driving health? Self-awareness checklist and tips to help you drive safely, longer. Retrieved December 23, 2004, from http://www.nhtsa.dot.gov/people/injury/olddrive/ modeldriver/1_app_c.htm
11. Eby, D. W., Molnar, L. J., & Shope, J. T. (2000). Driving decisions workbook (Report No. UMTRI-2000-14). Ann Arbor, MI: University of Michigan Transportation Research Institute.
12. Pellerito, J. (Ed). (2005). Adapted driving decision guide. In Driver rehabilitation and community mobility: Principles and practice. St. Louis: Mosby.
13. American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.
14. Reimer-Reiss, M. L., & Wacker, R. R. (2000). Factors associated with assistive technology discontinuance among individuals with disabilities. Journal of Rehabilitation, 66(3). Retrieved January 4, 2005, from http://www.findarticles.com/p/articles/mi_m0825/is_3_66/ai_66032259
15. Norkin, C. (2003). Measurement of joint motion: A guide to goniometry. Philadelphia: F. A. Davis.
16. Pedretti, L. W. (2001). Occupational therapy: Practice skills for physical dysfunction (5th ed.). St. Louis: Mosby.
17. Hislop, H. J., & Montgomery, J. (Eds.). (2002). Daniels and Worthingham's muscle testing: Techniques of manual examination (7th ed.). Philadelphia: Saunders.
18. Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: Normative data for adults. Archives of Physical Medicine and Rehabilitation, 66, 69-74.
19. Oxford, G. K., Vogel, K. A., Le, V., Mitchell, A., Muniz, S., & Vollmer, M. A. (2003). Brief report: Adult norms for a commercially available Nine Hole Peg Test for finger dexterity. American Journal of Occupational Therapy, 57, 570-573.
20. Shumway-Cook, A., & Horak, F. B. (1986). Assessing the influence of sensory interaction of balance. Suggestion from the field. Physical Therapy, 66, 1548-1550.
21. Center for Gerontology and Health Care Research. (2004). Balance scale. Retrieved January 25, 2005, from http://www.chcr.brown.edu/Balance.htm
22. Graybiel, A., & Fregly, A. R. (1966). A new quantitative ataxia test battery. Acta Otolaryngol, 61(4), 292-312.
23. Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of American Geriatrics Society, 34, 119-126.
24. Raiche, M. (2000). Tinetti Balance Scale. Retrieved January 25, 2005, from http://www.injuryresearch.bc.ca/Publications/ Repository/Tinetti%20Balance%20Scale.pdf
25. Stereo Optical Company. (1993). Optic Vision Tester: Reference and instruction manual. Chicago: Author.
26. University of Iowa. (n.d.). Trail Making Test. Retrieved January 25, 2005, from http://www.medicine.uiowa.edu/igec/tools/assets/trail_making_test.pdf
Joseph M. Pellerito, Jr., MS, OTR, is the academic program director and associate professor in the Occupational Therapy Program in the Eugene Applebaum College of Pharmacy and Health Sciences at Wayne State University in Detroit, Michigan. His book, Driver Rehabilitation and Community Mobility: Principles and Practices is a comprehensive textbook on driver rehabilita- tion and community mobility and features contributions from more than 50 leading experts in the field. For more information, contact him at pellerito@wayne.edu or 313-577-5880.
Elin Schold Davis, OTR/L, CDRS, is project manager of AOTA's Older Driver Initiative. Since 1982 she has practiced at the Sister Kenny Rehabilitation Institute in Minneapolis, Minnesota, with a focus on adult rehabilitation. She helped create Sister Kenny's renowned Brain Injury Clinic specializing in the assessment and treatment of adults with mild to moderate cognitive impairment, and has devoted the past 10 years to advancing occupational therapy's role in driving rehabilitation, with a primary focus on cognition. She is chair of the AOTA Older Driver Initiative Expert Panel, and a member of the American Society on Aging's DriveWell Speakers Bureau.
For More Information
AAA Roadwise Review
Self-assessment tool for seniors. Available from AAA at www.aaany.com. ($9.95 for AAA members, $14.95 for nonmembers. To purchase, call 516-873-2364 or 315/797-6121, or e-mail webtrafficeng@aaany.com)
American Occupational Therapy Association (AOTA)
Driving Microsite contains resources and information for professionals and consumers. Go to www.aota.org and click on Older Driver Safety.
AOTA CE Workshop
Occupational Therapy and the Older Driver: Addressing the IADL of Community Mobility and Driving
Earn 1.3 AOTA CEUs (13 contact hours) April 2Ð3, Chicago, IL; June 25Ð26, Providence, RI ($250 for AOTA members, $355 for nonmembers. For details go to www.aota.org and click on Continuing Education.)
Association for Driver Rehabilitation Specialists (ADED)
Certifies driver rehabilitation specialists and provides information for professionals and consumers
711 S. Vienna Street
Ruston, LA 71270
318-257-5055
800-290-2344
www.driver-ed.org
AOTA Online Course
Driving and Community Mobility for Older Adults: Occupational Therapy Roles
Earn .5 AOTA CEUs (5 contact hours). ($112.50 for members, $160 for nonmembers. For details, go to www.aota.org and click on Continuing Ed. Order #0L25-MI)
Driving Rehabilitation: A Guide for Assessment and Intervention
By W. B. Stav, 2004. New York: Harcourt Brace Jovanovich. ($49.95 for members, $70.95 for nonmembers. To order, call toll free 877-404-AOTA. Order #1316)
Reference Information:
Pellerito, J. M., & Schold Davis, E. (2005). Screeing driving and community mobility status. OT Practice, 10(5), 9-14.
©Copyright 2005. The American Occupational Therapy Association. All rights reserved.
