by Carolyn Unsworth
Background: Driving a car provides individuals with both independence and freedom. It is also the most frequently used mode of transportation for Americans, accounting for 90% of trips made outside the home.1 However, driving is a complex daily living activity that demands that the driver use multiple cognitive, sensory, and motor skills. Natural health declines associated with normal aging, as well as a variety of medical conditions and illnesses, can impair these skills, affecting a client's ability to obtain or retain a driver's license. As health care professionals who emphasize participation in daily activities, we want to ensure that individuals are given every opportunity to enjoy the independence and freedom associated with driving for as long as possible. However, we are also responsible for ensuring the safety of all road users by making sure drivers have the skills necessary for safely driving and adhering to the road laws.
Generalist occupational therapists, as well as certified driver rehabilitation specialists (CDRSs) are required to make important recommendations concerning the fitness-to-drive of their clients on a daily basis. To assist in formulating these recommendations, occupational therapists usually undertake both off-road (clinic-based) and on-road (in-vehicle) assessments. When conducted together these are referred to as a comprehensive driver evaluation (CDE). Occupational therapists need standardized off-road assessments that are quick and easy to use and that provide clinically useful information about a client's sensory, physical, cognitive–perceptual, and behavioral skills, and have a predictive relationship with the driver's performance in a car. Furthermore, these assessments need to be affordable and presented together so clinicians don't waste time locating and accessing test materials. As the director of OT-DRIVE at La Trobe University in Australia, I worked with a team of researchers to develop the OT-DORA Battery over a 5-year period to meet this need.
Description: The OT-DORA Battery comes as a book, and it brings together previously published assessments as well as assessments developed specifically to include in the Battery. The OT-DORA includes all these assessments except the Mini Mental Status Examination, which needs to be obtained separately. The Battery takes about 90 minutes to administer, and the therapist can quickly put together the items needed for the test which include two chairs, a Snellen vision chart or equivalent, a vision wand or pens with colored caps, a stopwatch, an eye patch and blindfold, shoes or slippers, a ruler, a step or sturdy wood box, an eraser, and a goniometer to use with the upper and lower extremities.
At the back of the book is a thumb drive that contains two downloadable booklets that the occupational therapist needs:
- Administration Booklet (where the therapist records all the data)
- Client Response Booklet (that the therapist gives the client to complete, as guided by the OT-DORA instructions).
The OT-DORA book contains background information and then a detailed description of exactly how to administer and score the assessments included in the OT-DORA Battery. The Battery has seven sections (labeled A through G). Occupational therapists should undertake the first 6 screening sections (A through F) with all clients and complete the seventh summary section (G). Occupational therapists should do the detailed assessments that comprise the eighth section (H ) only when clinically indicated.
It is recommended that the OT–DORA be administered in the following order and with the listed assessments.
- Section A. Initial interview (driver history and projected needs)
- Section B. Medical history
- Section C. Medication screen
- Section D. Sensory assessment, including
- Visual acuity (Snellen Chart or equivalent)
- Visual Confrontation Test
- Motor Sequences Screen–Selected
- Test of Proprioception–Lower Limb
- Section E. Physical Assessment, including:
- Berg Balance Scale
- The Motricity Index
- Simulated Accelerator–Brake Test
- Right Heel Pivot Test
- Section F. Cognitive Assessment, including
- Occupational Therapy Drive Home Maze Test
- Road Law and Road Craft Test
- Mini Mental Status Examination (Not included, needs to be obtained separately)
- Section G. Summary of issues identified during the assessment
- Section H. Further assessments that are only administered if clinically indicated: including
- Bells Test
- Range of Movement–Goniometry
- Muscle Strength Scale
- The Whispered Voice Test
- Tardieu Scale of Muscle Tone
- Short Form McGill Pain Questionnaire and Visual Analogue Scale and Pain Diagram
Spaces are also included in the OT–DORA Battery to record other assessment results. For example, if there is an assessment of a skill (such as reaction time) that an occupational therapist regularly undertakes and wishes to continue to include as part of the clinical assessment, the results can be recorded on the OT–DORA Battery forms.
The occupational therapist generates a profile of scores from the Battery and can compare these against cut scores provided in the book that guide clinical decision making. These decisions relate to the need to refer the client for other specialist assessment or treatment (e.g., to determine if the client's vision can be further enhanced), and whether to take the client for an on-road assessment.
Research: Data from three large and three smaller studies were collected to develop and investigate the psychometric properties of the OT–DORA Battery.2–6 A total of 632 drivers with and without impairments participated in the studies, which investigated the validity and reliability of the Battery as a whole,2 as well as validity, reliability, and item/person-level psychometrics for the new assessments developed for the Battery.3–6 The research demonstrated that the OT-DORA Battery is reliable and valid. However, since the reliability and validity of an assessment are never proven, ongoing studies to further develop the Battery, as well as demonstrate its psychometric properties, are required. Further research is currently underway and publications are in preparation.
Implications: The OT-DORA Battery can be used by both CDRSs and all occupational therapists who do not have specialist driver certification to:
- Screen drivers who may need referral for comprehensive driver evaluation
- Screen young adults with disabilities to determine if learning to drive may be a realistic goal
- Evaluate a driver's skills to determine if the driver can proceed to on-road testing
Occupational therapists who have the CDRS credential can use the OT-DORA battery as part of a comprehensive evaluation to determine fitness-to-drive for a range of experienced and novice drivers
How to obtain the OT-DORA Battery: The Battery is published by AOTA Press and may be ordered online at the AOTA Online Store here.7
References
1. Collia, D. V. Sharp, J., & Geisbrecht, L. (2003). The 2001 National Household Travel Survey: A look into the travel patterns of older Americans. Journal of Safety Research, 34(4), 461–470. http://dx.doi.org/10.1016/j.jsr.2003.10.001
2. Unsworth, C. A., Baker, A., Taitz, C., Chan, S. P., Pallant, J. F., Russell, K., Odell, M., & Coulson, M. (2012). Development of a standardised Occupational Therapy Driver Off Road Assessment (OT-DORA) battery to assess older and/or functionally impaired drivers. Australian Occupational Therapy Journal, 59(1), 23–36. http://dx.doi.org/10.1111/j.1440-1630.2011.00979.x
3. Krishnasamy, C., & Unsworth, C. A. (2012). Validity of the Occupational Therapy Drive Home Maze Test for right and left handed test takers. Accident Analysis and Prevention, 49, 274–277.
4. Krishnasamy, C., & Unsworth, C. A. (2011). Normative data, preliminary interrater reliability, and predictive validity of the Drive Home Maze Test. Clinical Rehabilitation, 25(1), 88–95. http://dx.doi.org/10.1177/0269215510382846
5. Unsworth, C. A., Pallant, J. F, Russell, K., Odell, M., & Coulson, M. (2011). Interrater reliability of the Road Law and Road Craft test as part of the OT-DORA Battery for off-road driver assessment. British Journal of Occupational Therapy, 74, 394–398. http://dx.doi.org/10.4276/030802211X13125646370960
6. Unsworth, C. A., Pallant, J., Russell, K., Germano, C., & Odell, M. (2010). Validation of a test of road law and road craft knowledge with older and/or functionally impaired drivers. American Journal of Occupational Therapy, 64, 306–315. http://dx.doi.org/10.5014/ajot.2011.000588
7. Unsworth, C. A., Pallant, J. P., Russell, K. J., & Odell, M. (2011). OT–DORA Battery: Occupational Therapy Driver Off-Road Assessment Battery. Bethesda, MD: AOTA Press.
Carolyn Unsworth, PhD, OTR, is the director of OT-DRIVE in the Department of Occupational Therapy at La Trobe University in Australia. The OT-DRIVE unit auspices the research, clinical, and postgraduate teaching programs in the areas of driver assessment and rehabilitation. She has also taught occupational therapy undergraduate and post graduate students in the U.S. (at Tufts University), Singapore, and Sweden, where she currently holds a position as an Adjunct Professor at Jönköping University. Carolyn completed her PhD in 1993 and her research and teaching interests include driver assessment and rehabilitation, clinical reasoning and decision making, outcomes measurement research (including the development of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT)), and evidence-based practice. She has authored more than 70 journal articles, 30 book chapters, and 2 books on driver assessment and clinical reasoning with clients who have cognitive and perceptual problems.