Low Tech Presentation2 - cdn.ymaws.com · ï l í î l î ì í ô ñ 7$6. $1$

3/12/2018

1

From Diagnosis to Driving: Low Tech Modifications for Independence

J I L L S C L E A S E , C T R S , C D R SL E A B E R T O N I , O T R / L , C D R S

A B S T R A C T

T H I S C O U R S E I S D E S I G N E D T O I N T R O D U C E T H E C L I N I C I A N T O V A R I O U S L O W - T E C H C L A S S R O O M A N D O N R O A D

I N T E R V E N T I O N S T O I N C R E A S E T H E P O T E N T I A L F O R I N D E P E N D E N C E W I T H D R I V I N G . T H I S C O U R S E W I L L F O C U S O N A V A R I E T Y O F P O P U L A T I O N S / D I A G N O S I S I N C L U D I N G A D D / A D H D , A U T I S M , A N X I E T Y , C E R E B R A L P A L S Y , S P I N A

B I F I D A A N D L O W V I S I O N T O N A M E A F E W . W E W I L L A D D R E S S D I F F E R E N T H O M E P R O G R A M S P R E S C R I B E D T O

C L I E N T S T O P R O M O T E I N D E P E N D E N C E , S A F E T Y A N D S U C C E S S . S U C H I N D E P E N D E N C E C A N A N D W I L L A L L O W C L I E N T S T H E O P P O R T U N I T Y T O W O R K , H A V E I N C R E A S E D

S O C I A L L I V E S A N D T O P A R T I C I P A T E I N L E I S U R E A C T I V I T I E S O F I N T E R E S T . T H I S C O U R S E W I L L A L S O D E M O N S T R A T E T H E C O L L A B O R A T I O N B E T W E E N P A Y O R S O U R C E , T H E C L I E N T ,

T H E C E R T I F I E D D R I V E R R E H A B I L I T A T I O N S P E C I A L I S T ( C D R S ) A N D T H E M O B I L I T Y V E N D O R .

O B J E C T I V E S

1 . I D E N T I F Y D R I V I N G R E L A T E D H O M E P R O G R A M A C T I V I T I E S

2 . U N D E R S T A N D T H E R O L E O F D R S / C D R S W I T H A V A R I E T Y O F A G E G R O U P S & I M P A I R M E N T S

3 . B E C O M E F A M I L I A R W I T H T H E P O T E N T I A L T O D R I V E A S S E S S M E N T

4 . G A I N A K N O W L E D G E & U N D E R S T A N D I N G O F L O W V I S I O N D I A G N O S I S & M O D I F I C A T I O N S

T O P I C S O F D I S C U S S I O N

1 . R O L E O F C D R S

2 . D O C U M E N T A T I O N

3 . T R A I N I N G M E TH O D S

4 . E Q U I P M E N T

5 . M V D M E D I C A L R E V I E W P R O G R A M

6 . C A S E S T U D I E S

ROLE OF THE GENERALIST

o “When can I start driving?”

o Hospital-acute and rehabilitationo School Systemo Mental Healtho Veterans Administrationo Parentso Physicianso Others


o Driving is the ultimate level of independence (IADL)

Independence in community involvemento Choice of where to live, where to go to the

grocery store, care for children, etc.

Independence in employmento Choice of employment location, job mobility, job

responsibilities

3/12/2018

2


o Clinical IADL Evaluation

o Evaluate and interpret risks associated with changes due to acute or chronic conditions, i.e. vision, cognition, sensory motor

o Facilitate remediation of deficits

o Develop a transportation plan with client and family considering client diagnosis and risks


o Transportation Plan optionso Vehicle adaptationso Facilitate community mobilityo Discuss driving cessation?

o Document driver risk and recommendations

o Follow professional ethics on referral to licensing authority

o Determine when a referral to a CDRS is warranted and educate client/family on this option

CDRS VS. GENERALISTFAQS FROM CLIENTS

o W H Y I S A D R I V I N G A S S E S S M E N T N E C E S S A R Y ?

o H O W L O N G D O E S A D R I V I N G A S S E S S M E N T T A K E ?

o C A N ’ T I J U S T O R D E R M Y E Q U I P M E N T O N L I N E ?

o W H A T F U N D I N G S O U R C E S A R E A V A I L A B L E ?

M O T O R V E H I C L E D E P A R T M E N T : M E D I C A L R E V I E W P R O G R A M

o S T A T E L A W S F O R R E P O R T I N G

o I M M U NI T Y

o P H Y S I C I A N I N V O L V EM E N T

o M E D I C A L E X A M I N A T I O N R E P O R T

o V I S I O N E X A M I N A T I O N R E P O R T

M O T O R V E H I C L E D E P A R T M E N T : M E D I C A L E X A M R E P O R T

3/12/2018

3

M O T O R V E H I C L E D E P A R T M E N T : M E D I C A L R E V I E W P R O G R A M

o A R I Z O N A V I S I O N R E Q U I R EM E N T So 20/40 in 1 or both eyes = no restrictions

o 20/50 or 20/60 in both eyes = daytime only

o 20/70 or worse binocular; 20/50 or worse monocular= does not meet state requirements

o Peripheral vision 35 degrees nasal and 70 degrees temporal (in at least 1 eye)

M O T O R V E H I C L E D E P A R T M E N T : V I S I O N E X A M R E P O R T

M O T O R V E H I C L E D E P A R T M E N T : V I S I O N E X A M R E P O R T D R I V I N G … R I G H T O R P R I V I L E G E ?

o I S SUE OF P UBL IC SAFETY

o MUST FOL LOW STATE LAWS

o OT &HEAL TH PR OFESS IONAL S NEED TO P ROVIDE INFORMAT ION REGARDING TH IS IADL

FUNDING SOURCES

1 . V O C A T I O N A L R E H A B

2 . V A

3 . W O R K M A N ’ S C O M P

4 . P R I V A T E P A Y

5 . 3 R D P A R T Y A S S I S T A N C E

M S S O C I E T Y , J O E J A C K S O N F O U N D A T I O N ,

L O C A L O R G A N I Z A T I O N S

CDRS: TYPES OF EVALUATIONS

1 . N E W D R I V E R S / P O T E N T I A L T O D R I V E

2 . L O W V I S I O N / B I O P T I C D R I V E R

3 . S T A N D A R D F O R M E D I C A L C H A N G E

4 . S E N I O R S A F E T Y A S S E S S M E N T

5 . E Q U I P M E N T E V A L U A T I O N S• L O W T E C H V S . H I G H T E C H

6 . P A S S E N G E R A S S E S S M E N T

3/12/2018

4

DRIVING ASSESSMENT

1. Clinical Assessmento Initial intake o Cognitiono Visual Acuity/Peripheral visiono Visual Perceptiono Physical Examo Driver Performance Analysis Systemo Optec 2000

2. BEHIND THE WHEEL ASSESSMENTo Location and goal of assessment changes

3. Recommendations and report to MD and MVD

Self-assessment questions

for client & family

D O C U M E N T A T I O N

• E V A L U A T I O N F O R M• Narrative Evaluation

• D A I L Y N O T E S

• M O N TH L Y S U M M A R I E S

• V E H I C L E M O D I F I C A T I O N P R E S C R I P T I O N

• D I S C H A R G E S U M M A R Y

• C E R T I F I C A T E O F C O M P L E T I O N

T A S K A N A L Y S I S O F D R I V I N G

o E N T E R I N G AN D E X I T I N G T H E V E H I C L Eo Functional transfers to the vehicle

o Passenger vs. driver

o WH E E L C H A I R / S C O O T E R L O A D I N Go How is the vehicle used?

o M A N AG E K E Y & S E A T B E L T

o S H I F T I N G G E A R So Gear shift on column or console

o B A C K I N G


o R I G H T & L E F T T U R N S

o A C C E L E R A T I O N

o B R A K I N G

o C O O R D I N A T I O N O F A L L V E H I C L E F U N C T I O N S

o Secondary Functionso In Motion: Horn, turn signals, wipers, cruise control, headlightso Stationary: Radio, climate control, windows

3/12/2018

5


o D E C I S I O N M A K I N G

o J U D G M E N T O F T I M E A N D S P A C E

o R E A C T I O N T I M E

o M E M O R Y

o G E O G R A P H I C O R I E N TA T I O N

o B E H A V I O R B E H I N D TH E W H E E L

Clinical: •Intake - Medical/Driving History

•Cognitive Testing •Adolescent checklist

•Ocutech Vision Screen•DPAS

If client has permit If client does not have permit

Provide Permit Test & do Active passenger

assessment

In Vehicle AssessmentActive PassengerBehind the WheelStarting in parking lot and increase as appropriate.

Demonstrates the potential to drive

•# of training hours including permit study if needed

Does not demonstrate the potential to drive

PT/OT/SLP or vison therapy •Re-evaluation in (length of time)

•Not going to be independent driver

Recommendation Options

Potential To Drive Evaluation

P OTENT IAL TO DR IVE

Common diagnoses:• Autism/Aspergers, learning disabilities, ADHD/ADD

Active Passenger Assessment:• Decision making, judgement, speed of processing• Visual search & divided attention during• Rules of the road & defensive driving knowledge• Road sign comprehension• Anticipation for lane change in preparation for upcoming turns• Attention to turn lane use

Other Considerations:• Adolescent checklist• Maturity level • Client’s goals vs. parent’s goals

IN OFF ICE TR EATMENT ACT IV I T IES

D R I V E F O C U S

T R E A T M E N T A C T I V I T I E S

• O R I E N T A T I O N• H A Z A R D P E R C E P T I O N• S P E E D A D J U S T M E N T• T I M E & S P A C E• C O M M U N I C A T I O N• V E H I C L E P O S I T I O N

3/12/2018

6

TREATMENT ACT IV I T I ES P OTENT IAL TO DR IVE

Home Activities:• Active passenger• MVD Practice tests• AAA computer-based workshops/permit prep• Riding bicycle

Apps & Technology Related:• Autocoach• DriveFocus• Driver’s Ed• Youtube• Wii

H O M E A C T I V I T I E S

NEW DR IVER TRAIN ING TASK L IS T

RESOURCES

CASE STUDY: “P OTEN T IAL TO DR IVE” CL IENT

J A M I E

Diagnosis:Mild Mental Impairment, Watson Syndrome, Sensory Overload issues

Age: 19

History:Per Mom - client attempted the permit test 6 times at the Motor Vehicle Department - it was provided on the computer, in written format and it was also read aloud to him. He almost passed it when provided verbally. Mom also reported that the client was fairly independent with ADL's and IADL's at home however has difficulty with tasks like money management, time management and activities that require socialization.

J A M I E ( C O N T I N U E D )

3/12/2018

7

J A M I E C O N T I N U E D

Cognitive assessment summary:Client scored a 36/50 on the Brief Cognitive Assessment Tool (BCAT), indicating mild cognitive impairment. Primary deficit areas included language, executive function, visuospatial, and delayed recall. The contextual memory factor portion of the exam assess current verbal memory skills. The client scored a 12/15 on this portion suggesting mild memory concerns. Additionally, the exam assesses the Executive controls functions factor which addresses skills such as judgment, problem solving and reasoning. The client scored a 3/7 on this portion, indicating presence of executive function impairments that may limit successful and independent living.

Plan:• 60 hours of training with 10 hours dedicated for 1:1 permit training• Reassess after behind the wheel assessment is able to be performed to

determine if client still demonstrates the potential to be a driver

TREATMENT PLAN:

J A M I E

• Assessment done 1/2016

• VR authorization received; Started 5/2016 with permit training • 3 sessions in office for permit study. Client was then provided with permit test

and passed. COC was issued for permit

• BTW training (start 6/2016-completed 2/2017) • Goals:

• Vehicle control: turn execution, speed maintenance, parking, freeway, lane changes

• Cognitive: Right of way application, defensive driving skills, reaction to environmental cues

• Home activities: Active passenger initially then once we felt he was ready (~30 hours in), we had the client start some BTW with his mom to supplement training


C H R I S T O P H E R

Diagnosis:Seizure Disorder, Mild Cognitive Issues

Age: 24

History:Client lives at home with his parents, who currently are his legal guardians. His last seizure was 13 months prior to evaluation. The client was very ill and had a fever of 106.2° F, he had not had a seizure for a year prior to this one. Per client's dad, he is independent with most ADL's and IADL’s however does require assistance with complex cooking tasks and complex home tasks. He is not currently working but is looking for a job.

C H R I S T O P H E R C O N T I N U E D

C H R I S T O P H E R ( C O N T I N U E D )

Cognitive assessment summary:Client scored 18/30 on the Montreal Cognitive Assessment (MOCA), indicating mild cognitive impairment. Primary deficit areas included language and following written directions. The client does demonstrate the potential to be a successful driver. However, he also demonstrated some difficulty with written instructions and questions.

Plan:• 60 hours of training with 10 dedicated for permit training• Reassess after behind the wheel assessment is able to be performed to

determine if client still demonstrates the potential to be a driver• Due to the client's guardianship, permission must be obtained from the

judge for the client to pursue driving privileges & participate in training

TREATMENT PLAN

C H R I S T O P H E R


• Started 7/2015 with permit training • Lapse in starting due to pending court approval for driving privileges• In office for permit study. Client was then provided with permit test and

passed. COC was issued for permit

• BTW training • Goals:

• Vehicle control: turn execution, speed maintenance, parking, freeway, lane changes

• Cognitive: Right of way application, defensive driving skills, reaction to environmental cues

• Issues that impacted progress: Seizure occurred in 2/2016 prior to completing training

• Client returned after 3 months & was seen for several sessions before clearance

3/12/2018

8


S A M A N T H A

Diagnosis:High-Functioning Autism

Age: 18

History:Client is a Senior in High School, she is independent with most ADL's but at time requires reminders. Per the client's mom Samantha requires limited supervision with things like community mobility, financial planning and living arrangements.

S A M A N T H A C O N T I N U E D

S A M A N T H A C O N T I N U E D

Cognitive assessment summary: Client scored a 40/50 on the Brief Cognitive Assessment Tool (BCAT), indicating mild cognitive impairment. Primary deficit areas included language, executive function, visuospatial, and delayed recall. The contextual memory factor portion of the exam assess current verbal memory skills. The client scored an 11/15 on this portion suggesting mild memory concerns. Additionally, the exam assesses the Executive controls functions factor which addresses skills such as judgment, problem solving and reasoning. The client scored a 5/7 on this portion, indicating presence of executive function impairments that may limit successful and independent living.

Plan: • 80 hours of training (to include permit training)• Reassess after 20 hours of training to determine if she has the

potential for being a safe, independent driver.

TREATMENT PLAN

S A M A N T H A


• VR authorization received; Started 9/2016 with permit training • 3 sessions in office for permit study

• BTW training (start 5/2017-ceased 9/2017) • Goals:

• Vehicle control: turn execution, speed control and adjustments• Cognitive: Right of way application, defensive driving skills, attention to environment

and pre-planning• Home activities: Active passenger, anxiety management• Inconsistencies in training: easily overwhelmed, inconsistent scanning/mirror use, adjusting

speed for changes in road/other vehicles, decision making when timing maneuvers with traffic, divided attention, sensory processing

• Issues impacting progress: Lapse from permit to being seen for BTW assessment (8 months); vehicle control improved but plateau reached in cognitive areas of driving

D A N I E L


Diagnosis:Autism, ADD, Bipolar disorder, OCD

Age: 26

History:Client has never driven in any respects and has not yet attempted studying for the permit test or taken the permit test. He reports that he was evaluated by VR around the age of 18-19 however was determined "unemployable" and was told by a psychologist that he was not a driving candidate due to processing speed impairments at that time. He reports that he has since developed more and feels ready to try to work again and pursue driving.

D A N I E L C O N T I N U E D

3/12/2018

9

D A N I E L ( C O N T I N U E D )

Cognitive assessment summary: Client scored a 48/50 on the Brief Cognitive Assessment Tool (BCAT), indicating normal cognitive function.

Active Passenger and Overall Findings: The client demonstrated good decision making when timing lane changes in traffic however did have some difficulty with timing right/left turns with the flow of traffic when at traffic lights. Additionally, some difficulty in verbally expressing concepts and rules of the road to evaluator was observed. On 1 occasion, client did become distractible, requiring redirection. These areas and their impact on performance will need to be further assessed from the driver position once client obtains an Instruction permit.

Plan: • 60 hours of training with 10 dedicated to permit training• Reassess after 20 hours of training to determine if he has the potential

for being a safe, independent driver

TREATMENT PLAN

D A N I E L

• Assessment done 11/7/2016

• VR authorization received; Started 2/6/2017 with permit training • 4 sessions in office for permit study. Client was then provided with permit test and

passed. COC was issued for permit

• BTW training (start 5/2017-still ongoing) • Goals:

• Vehicle control: turn execution, smooth/timely acceleration and deceleration, speed maintenance

• Cognitive: Right of way application, attention to critical objects• In Office activities: Drive Focus, SPORT, DPAS• Home activities: Self-study materials for permit & active passenger encouraged at

initial assessment, multi-tasking with Wii• Issues that have impacted progress: lapse while awaiting MD prescription (after permit)

and lapse while awaiting VR authorization renewals (2-4 months each time expired)


N O R M A

Diagnosis:Spina Bifida with Hydrocephalus (with Shunt)

Age: 21

History:Client states she is independent with all activities of daily living. She resides with her mom and siblings. She works full time at a call center. She ambulates with bilateral forearm crutches. She is approximately 4 feet tall. She already holds an Instruction permit.

N O R M A ( C O N T I N U E D )

N O R M A ( C O N T I N U E D )

Cognitive assessment summary: Client scored a 22/30 on the Montreal Cognitive Assessment (MOCA), indicating mild cognitive impairment. She ambulates with bilateral forearm crutches. She states she is unable to feel her left leg from the knee down. She states she has full sensation in her right lower extremity. She demonstrated full range of motion in bilateral upper and lower extremities.

Plan: • 60 hours of training

• The client was positioned on two cushions under her and one cushion behind her back secondary to her short stature and the seat was moved forward to where she could appropriately reach the brake/accelerator pedals with her right foot.

TREATMENT PLAN

N O R M A

• Assessment done 1/26/17

• BTW training (start 5/2017-still ongoing) • Goals:

• Vehicle control: turn execution, smooth/timely acceleration and deceleration, speed maintenance, parking, lane position/changes

• Cognitive: Right of way application (novice driver)

• Considerations in training: Vehicle choice for training vehicle, seating position (cushion use), heel shelf/prop to allow heel to be grounded to floorboard

• Issues that have impacted progress: lapse while awaiting VR authorization (4 months), coordination with client’s work schedule, multiple cancellations

3/12/2018

10

MODIFICATI ONS:

N O R M A C O N T I N U E D )

B U I L T U P H E E L R E S T


E S T E V A N

Diagnosis: Arthrogryposis

Age: 16

History: Client is 16 years old and has Arthrogryposis, he has had multiple bilateral elbow and wrist surgeries. He has never driven in any capacity. He reports that he was born with his bilateral elbows in full extension and had multiple surgeries on bilateral elbows and wrists to fix them in a position for function. This resulted in his bilateral elbows being fixed in 90 degrees flexion and his bilateral wrists being fixed in a neutral position. He has the ability to actively flex bilateral elbows slightly further than the 90 degrees but does not have extension past this. His active shoulder ROM for flexion, abduction, adduction is WFL. He has minimal function in bilateral hands. He has good lower extremity function overall and walks without an assistive device.

E S T E V A N C O N T I N U E D E S T E V A N ( C O N T I N U E D )

Clinical assessment summary: The client has adequate cognitive and visual skills needed for driving. Primary deficits are upper extremity impairments. Equipment needs will need to be TBD once the client is able to be seen behind the wheel in the driver position

Plan: • Initial: Use the 10 pre-approved hours for classroom training to work towards

the Instructor’s permit and perform behind the wheel assessment once permit is obtained

• After BTW:• Steering devices trialed (single post, amputee hooks)• Steering wheel extension consideration due to range of motion

impairments • Multiple other issues that need to be corrected for the client to operate

the in motion controls such as signals and wipers but those will be addressed in training

• 50 hours of behind the wheel instruction (once nears the end of training, a prescription will be generated to have his personal vehicle modified)

TREATMENT PLAN

E S T E V A N

• Started immediately with permit training (10 hours pre-approved)

• Received permit and completed BTW assessment 12/2015

• VR auth received and started BTW training 3/2016• Goals:

• Vehicle control: turn execution, parking, curving, controlling vehicle for defensive driving maneuvers, freeway

• Cognitive: Right of way application (new driver)

• Completed BTW training in 7/2016 and vehicle modification prescription was generated

VEHI CLE MODIFICATI ON PRESCRIPTIONE S T E V A N

1. Three steering devices mounted at the 12, 4 and 8 o’clock positions • MPD Amputee rings were used with a 1-inch extension

2. EMC Digi-tone for operation of in motion secondary controls. • Right/left turn signals, horn, wipers, dimmer and cruise.

***2004 Nissan Murano with 181k mileage. Unfortunately due to the vehicle age and mileage, the modifications were never approved through VR. The client will require purchasing a new vehicle that will meet VR standards for the work to be completed

3/12/2018

11


P E D R O

Diagnosis: Battered Syndrome

Age: 17

History: Client has a club foot, scoliosis, missing ribs and asthma. He is 4'5" tall and ambulates without an assistive device. He has scoliosis and is missing a couple ribs on one side causing his torso to be twisted. He is independent with all ADL's and IADL's. He is a senior in High School.

P E D R O ( C O N T I N U E D )

P E D R O C O N T I N U E D

Clinical assessment summary:

• Strength was tested and observed to be WFL for driving. Client's demonstrated good coordination with his right lower extremity.

BTW summary:

• Due to the client's short stature he was positioned on several seat cushions to obtain the appropriate line of sight. Once the appropriate line of sight was obtained he was positioned appropriately behind the steering wheel to determine if he would need pedal extensions. In the Elantra training vehicle we were able to obtain the a safe and appropriate seating position with only cushions.

TREATMENT PLAN

P E D R O

• 60 hours• 10 hours for permit study• 50 hours of behind the wheel training with initial 10 hours of trial training recommended


• Vehicle control: acceleration/deceleration control, turn execution, lane position

• 45 hours BTW training completed • Assisted client with identifying a vehicle and prescription written for custom cushion• Prescription written 8/2015

• Client's vehicle modified and check out drive followed by licensure 1/2016

VEHI CLE MODIFICATI ON PRESCRIPTION

P E D R O

C U S T O M C U S H I O N F O R L I N E O F S I G H T

3/12/2018

12

C U S T O M C U S H I O N T O D E C R E A S E D U M P I N

D R I V E R ' S S E A T

L O O P W I T H P V C P I P E I N S E R T E D T O

S E C U R E C U S H I O N O N D R I V E R ' S S E A T

C U S T O M C U S H I O N F O R L I N E O F S I G H T CASE STUDY: “P OTEN T IAL TO DR IVE” CL IENT

M I C A Y L A

Diagnosis:History of brain tumor which resulted in right side coordination deficits; learning disability

Age: 19

History:Micayla currently resides with her parents in Phoenix and is attending community college full-time with goal to become a child life specialist. She reports independence with ADLs and IADLs, including cooking, laundry, and washing dishes. She currently relies on her parents or Uber for transportation and reports motivation to drive for independence and because she “likes to be early” and does not like to have to rely on others. She reports attempting driving a golf cart in 3/2017 but had issues coordinating right foot between accelerator/brake

M I C A Y L A ( C O N T I N U E D ) M I C A Y L A ( C O N T I N U E D )

Clinical assessment summary: • Strength was tested and observed to be WFL for driving. Despite this, impaired

coordination was observed in right upper/lower extremity with dysmetria evident and increased time required for motor planning. This may impede ability to safely and reliably transition between accelerator/brake. This will be further assessed behind the wheel and adaptive driving equipment needs will be determined.

BTW summary: • Due to known coordination impairments with right lower extremity, left foot

accelerator and using both arms to steer, however coordination and proprioception impairments were still seen with her left foot when utilizing accelerator/brake and she had tendency to mix accelerator/brake pedals at times.

• She was then trialed with mechanical hand controls (left side push/pull) using right arm to steer with spinner knob at 4 O’clock position. She drove in an empty parking lot with this equipment and acceleration/deceleration was smooth overall and turns were consistent with those of a novice driver. She reported feeling a lot more comfortable with this equipment and reported it didn’t take as much “thought” as the other 2 styles of driving did.

3/12/2018

13

TREATMENT PLAN

M I C A Y L A

• 15 hours of trial training recommended


• Vehicle control: acceleration/deceleration control, turn execution, lane position

• 12 hours BTW training completed however no significant progress made

• Continued barriers remained in no-low traffic areas including impaired motor planning, inattention to critical objects, lack of maturity

• Decision was made to cease training at this time and have client work on alternative therapies to improve foundational skills more

TREATMENT PLAN

M I C A Y L A

Clinical: •Review from vision specialist

•Large print clinical assessments•In office and outside functional vision assessment

In Vehicle AssessmentPassenger assessment using vision device

Evaluation Route

Does not demonstrate the ability to be a safe independent driver

Vision therapy Vision device neededDriving retirement


Low Vision Evaluation

BTW training recommended to learn effective use of vision

device and compensatory strategies

Cleared to return to driving

Vision specialist recommends how often

reassessment/monitoring is needed

BI OPTIC DRI VING• State vision requirements

• Does my state allow bioptic driving?

• Vision examination report (from eye doctor) with referral

• Behind the wheel training:• How to focus bioptic lenses• Use of bioptics and timing in dips ( I dip vs. U dip)• Glare recovery & Need for filters

B I OPTIC DRI VING

• Active passenger

• Spotting activities• Stationary objects• Moving objects (while stationary)• Stationary targets while moving (i.e. road signs, traffic lights)• Moving objects while moving (i.e. other vehicles)

• Road sign training• ID shape/color, use of “flag” at 4-way stop

H O M E A C T I V I T I E S

B TLS R OAD S IGNS FOR HOME PRACT ICE

3/12/2018

14

BI OPTIC DRI VING

• Lane choice

• Glare management • hat, filters, visor, window tint

• Monitor time of day

• Parking • End spot vs. between 2 vehicles

• Take the route of less risk• Protected turns vs. unprotected

• Speedometer use

• Apps• Waze GPS, Speedometer app

C O M P E N S A T O R Y S T R A T E G I E S CASE STUDY: LOW VI SION CLIENT

S U Z A N N E

Diagnosis:Achromatopsia

Age: 34

History: The client is a student at Arizona State University, she currently uses various contact lenses while at school and when a passenger in the vehicle. She has received her bioptic telescope lens system approximately 2 months prior to her evaluation. She is independent with all ADL’s and IADL’s.

S U Z A N N E ( C O N T I N U E D )

Vision Correction:

The client’s vision with the 4X Ocutech BTLS was documented as per the Vision Examination Report (VER) dated to be September 4, 2014:

• Carrier lens correction: 20/125 OD and 20/200 OS; both 20/125 • Bioptic telescope 20/30 OD acuity.• Impaired night vision is not a concern as documented per the VER

TREATMENT PLAN

S U Z A N N E

• Evaluated 10/2014• 20 hours of behind the wheel training• Requested an additional 20 hours secondary to issues with certain colors

• Breaks in training secondary to waiting on VR auth and for client to get shades from NOIR

• NOIR provided a variety of shades to try

• Discharged/licensed 12/2015

• Resources• Suzanne's blog - http://suzannegermano.blogspot.com/• achromatopsia.info• Dr. Windsor - Indiana


Contacts: Kontour Brand

1) 55 min brown with a hint of red (I am not sure what that hint is exactly my eye doctor might be able to find out from Kontur)

2) NARS black with red I believe this color can only be gotten through Dr Windsor in Indiana He is an expert in Achromatopsia and has helped many drive who were always told they would never drive. He is 100% worth the trip to Indiana

3) Night driving 10 min grey just to cut a bit of the edge off from the headlights


3/12/2018

15

S U Z A N N E ( C O N T I N U E D )S U Z A N N E ( C O N T I N U E D )

The first two still allow seeing green lights.

For my "sunglasses" NOIR fitovers cut for ocutech to slide through. You can now get them through ocutech.

#90 red my favorites I use most of the time#93 red darker I use sometimesI just got but haven't had a chance to try#95 a light red for dark stormy daysdark stormy days I have been using the dark amber slip in from ocutech WITHOUT

the notch

I just use a hairband to block the bit of light that comes in around the cutout

My scope filter cap is brown.

I see green lights through scopeI see yellow/red through carrier

I personally feel red is the most important to see. I do know Achromats that drive only seeing green and no red.


H A I R T I E T O B L O C K O U T L I G H T

CASE STUDY: LOW VI SION CLIENT

A L E X

Diagnosis:Achromatopsia

Age: 17

History: The client was issued BTLS ~1.5 years ago and has had an Instruction permit since. Since this time, he has been driving with his dad, although mostly at nighttime. They report client does well driving at nighttime however primary issues are driving during daytime due to glare and difficulty in seeing traffic light colors (primarily green lights/arrows). Alex is interested in being able to drive at all times of day if possible.

A L E X ( C O N T I N U E D )

Vision Correction:

The client’s vision with the 4X Ocutech BTLS was documented as per the Vision Examination Report (VER):

• Uncorrected: 20/120 OD and 20/160 OS• BTLS correction 20/30 OD and carrier lens correction to 20/100 OS• Impaired night vision is not a concern as documented per the VER• Per VER, needs annual vision report

A L E X

3/12/2018

16


At Assessment:• Came with red filtered wraparound glasses

• Issue: blocked all green lights

• Slip-in style trialed but not working due to peripheral glare

• 20 hours BTW training recommended

• Encouraged BTLS use as passenger & while walking


Treatment Plan:• Trialed NOIR shades while parked & looking at traffic light• Had client follow-up with low vision doctor

• Contact lenses, different color fit-over shades, filter cap for BTLS with fit-over in a different shade

• Decided on different tint of red with gray peripheral

• Glare reduction alternatives • Hat, visor, window tint

• Strategies to read speedometer• Digital speedometer, marking common speeds, increase dash brightness/contrast


L I S A

Diagnosis:Massive Hemorrhagic stroke right side with left side weakness

Age: 51

History: Client suffered her stroke in December of 2012. She ambulates with a wide base quad cane. She has left sided weakness and is currently participating in outpatient therapy. She is a 2nd grade teacher and wants to return to driving to run daily errands, travel to/from work and medical appointments and participate in community activities of interest.

L I S A ( C O N T I N U E D )

TREATMENT PLAN

L I S A

Lisa independently entered/exited the vehicle and stowed/recovered her WBQC. When Lisa initially got into the vehicle she positioned herself to the right side of the steering wheel; minimal to moderate cues were provided to have Lisa center herself behind the steering wheel. She was introduced to a spinner knob at 2:00 with a cross over turn signal secondary to her left upper extremity weakness. Upon driving in a minimum traffic residential area Lisa hugged the right hand side of the road. At this time it was discussed whether or not she had left neglect; Lisa confirmed that she had been diagnosed with left neglect but had been working consistently with her PT, OT, and SLP therapist and had made good progress. It was noted that she was able to successfully scan to the left when driving and during the clinical portion of the evaluation however her body position in the vehicle as well as the vehicle position on the road were of concern. Since Lisa was able to demonstrate the ability to correct her positioning and maintain appropriate position it was recommended Lisa participate in 10 hours of behind the wheel training/continued assessment with the above mentioned equipment.

TREATMENT PLANL I S A

• Initial Evaluation: 7/2013

• BTW training began• Client emotionally Labile• Breaks for client to work with SLP Therapy

• Licensed with restrictions; spinner knob, turn signal crossover, no nighttime driving, 8 miles from home 9/2014

• Licensed with restrictions; spinner knob, turn signal crossover and no nighttime 2/2015

• Evaluated to remove Night time restriction 11/2015• Licensed with restrictions; spinner knob, turn signal crossover

Lisa returned in 11/2016 to be assessed for equipment to transport her Pride GoGO Elite Traveler Scooter

3/12/2018

17


A N N A

Diagnosis: Brain tumor

Age: 17

History: Brain tumor removed in 2004, 2004; right side weakness, recurrent in 2010 no surgery but underwent radiation. Anna is a Junior in High School and would like to be able to drive to school her Senior year. She is very active in the Christian youth Theatre.

A N N A ( C O N T I N U E D )

• Anna has a right visual field cut; she has no peripheral vision on her right. She appears to compensate well when ambulating and when reading or writing.

• Requested client obtain a Motor Vehicle Department Vision Examination Report from her Optometrist or Ophthalmologist prior to any behind the wheel training.

• Recommended 50 hours of behind the wheel training with a left foot accelerator and spinner knob at 10:00

TREATMENT PLAN


• Vision Examination Report received – Anna diagnosed with Right Homonymous Hemianopsia

• Does not meet Arizona Visual Requirements

• Sent Anna to vision specialist to see if she was a candidate for prism glasses

• Anna was a candidate for prism glasses • Received her prism glasses and worked with a vision specialist for a couple months

before returning for training with adaptive equipment

A N N A ( C O N T I N U E D ) P R I S M G L A S S E S


Anna was seen for a check out drive on May 23, 2013

Licensed with the following restrictions:Corrective Lenses/Prism GlassesLeft Foot AcceleratorSpinner KnobAutomatic Transmission


A L E X A N D E R

2012Diagnosis:

Macular Degeneration

Age: 79

History: Client presents to Tempe office for a comprehensive driving evaluation with Bioptics (BTLS) Client diagnosed with Macular Degeneration approximately 4 years ago. Client lives in Sedona, AZ with his wife. He is a musician and teaches piano lessons in a 35 mile radius from his home. He would like to continue driving to common destinations as well as his students home. Does not drive in Big cities.

3/12/2018

18

TREATMENT PLAN

A L E X A N D E R

• Client initially seen in Tempe September 2012• Recommended client be seen in Sedona and have client drive to local destinations

and 2-3 student homes• Provided at home activities to increase timing of “I” dip and spotting• Encouraged client to walk and be an active passenger using bioptics

• Client seen in Sedona September 2012• Licensed with bioptics and re-evaluate in 1 year secondary to some cognitive issues

found during testing

• Client seen in Sedona September 2013• Licensed with bioptics and re-evaluate 1 year

• Client seen in Sedona September 2014• Licensed with bioptics and re-evaluate 2 years

• Client seen in Sedona September 2016• Licenses with bioptics and re-evaluate in 2 years

• Client must have vision evaluated annually

A L E X A N D E R ( C O N T I N U E D )

Alexander’s vision with the 4X Ocutech BTLS was documented as per the Vision Examination Report dated September

• Carrier lens correction: 20/320 OD and 20/30 OS. • Bioptic telescope OS with 20/30 acuity.• Visual fields are reported as 70 degrees temporal and 50 degrees

nasally OU. • Impaired night vision is not a concern as documented per the

Vision Examination Report.

Clinical: Intake Medical/Driving History

Cognitive testingMVPT

Physical assessment Wheelchair Measurements (if needed)

Ocutech Vision ScreenDPAS

In Vehicle Assessment Evaluation route

Does not demonstrate the ability to be a safe

independent driver yet Therapy to work on

strength, range of motion, transfers, etc.


Standard Evaluation for Medical Change

Driving retirement

Cleared to return to driving • ? re-evaluate in # of

months

Training or 1-2 follow-up sessions for

consistency/restriction

HOME ACTIV I T I ES

Cognitive:• Lumosity; Elevate• BCAT• AARP Brain Games• Brain Injury Cognitive Stimulation Home Program (www.uab.edu)• CogniFit• Drive Focus• DriversEd.com• Divided Attention – Have client follow simple recipe while distracting with

known questions

Bilateral Hand Tasks:• Pat table & stir dry rice/beans with other hand• Use thera-band. Secure one piece on a door knob (close door) and stand on

another piece (or hook to wheel chair) pull up with one under foot/chair and pull sideways with the hooked to the door knob

• Hand cycle

HOME ACTIV I T I ES

Visual Perceptual/scanning:• Eyecanlearn.com

• “Visual Learning for Life” worksheets

• Puzzles• Jigsaw, Mazes

• Games• Scrabble, construction/3D model building, Bingo, “Memory” card game

• Worksheets• Connect the Dots, word searches, crosswords, letter cancellation (timed), find the

differences

• Books• “I spy”, “Where’s Waldo”

C AS E S T U D Y : M E D I C AL C HANG E , N O E Q U I P ME N T

G A R R E T T

Diagnosis:Anoxic brain injury (3 years ago)

Age: 22

History: Client reports that as a result of brain injury, his right arm and memory were primarily affected, however states he has had a “speedy recovery”, completed therapies, and feels he has regained most function. He currently resides with his family and reports he has returned to being independent with ADLs and IADLs, such as cooking, working, and managing his own finances. He reports motivation to return to driving for further independence with daily activities.

3/12/2018

19

G A R R E T T C O N T I N U E DG A R R E T T C O N T I N U E D

Clinical Summary:• Cognitive and vision assessment findings were positive• Range of motion was tested and is WNL, with exception of right upper

extremity supination (client able to supinate to neutral position only). Despite this, upper extremity function remains WFL for driving tasks.

• Lower extremity strength and range of motion WNL

Behind the Wheel Summary:• Independent transfer and with vehicle orientation tasks• Good reaction time and divided attention• Good right of way application and judgement timing turns• Good defensive driving and scanning of environment• Licensed with no restrictions


M O L L Y

Diagnosis:Normal pressure hydrocephalus/MCI (onset 9 months prior to assessment)

Age: 72

History: Client reports primary deficits since diagnosis has been cognition & balance. She completed PT & OT therapies ~1 month prior to this assessment. She stopped driving on her own ~2 years ago due to noticing drifting in lane; she was diagnosed with hydrocephalus shortly after this & shunt was placed.

M O L L Y C O N T I N U E D

M O L L Y C O N T I N U E D

Initial summary:• Initially seen & did well with exception of lane position however reports “good

days & bad days”; consistency drive recommended• At consistency drive: Worsened lane position (veering/hugging, curves, &

parking), Delayed braking & delay to notice/respond to critical items• Provided home activities & discussed outpatient therapies

Follow-up Summary:• Returned 6 months later after completing OT & vision therapies• Significant improvement in all behind the wheel skills observed• Cleared to return to driving

K E N I

Diagnosis: Parkinson's (Neuro Movement Disorder)

Age: 67

History:• 2012 Client presents to the clinic for a comprehensive driving

evaluation secondary to his diagnosis of Parkinson's. Client was pulled over by a police officer because the officer thought he was nodding off due to his decreased neck strength.

• Client stated he was able to hold his head up for 7-10 minutes without an issue. During assessment client was unable to keep his head up in an upright position for more than 2-3 minutes

C AS E S T U D Y : M E D I C AL C HANG E

3/12/2018

20

TREATMENT PLAN

K E N I

• Identify if the Arizona MVD would allow a neck brace as a restriction on a driver's license

• Yes they will as long as client is able to safely drive, complete appropriate blind spot checks, etc.

• Identify a neck brace that would allow the client to maintain his head in an upright position and complete blind spot checks

L I C E N S E D W I T H R E S T R I C T I O N

T O B E R E - E V A L U A T E D I N

1 Y E A R

K E N I C O N T I N U E D

• 2014: Client returned for re-evaluation (6 months late) Client continues to ambulate without an assistive device but has since retired. States he where's the neck brace the majority of the time. Notable decrease in client's roadway knowledge, delay in trail making and visual memory. Also noted a decrease in Traffic Perceptual skills.

• Outcome:• Difficulty maintaining his head in an upright position to maintain appropriate

line of sight throughout the behind the wheel session, Mr. Prasad was seen with various neck braces in an attempt to solve this issue and while some appeared better than others Mr. Prasad was NOT able to maintain and appropriate upright position with an adequate line of sight.

• Difficulty maintaining lane position• Delayed braking & impaired depth perception• Decreased ability to identify and predict a safe response to unpredictable

driver behavior encountered on the road• Driving Retirement recommended


B U D

Diagnosis:Alzheimer’s disease/vascular dementia

Age: 76

History: • 2017: The client resides at home with his wife. He reports his current

driving habits include primarily local driving as he avoids nighttime and freeway driving. He has a son nearby who assists with transportation if they need to go somewhere outside of their comfort area. Although his wife does drive, Bud is the primary driver in the household

• 2018: Client continues to live at home with his wife. He has been restricted for the past year (mileage, daylight only, no freeway) however during intake, reported he has driven some outside of restriction and at night. Unable to recall date, phone #, address during intake.

B U D C O N T I N U E D

2 0 1 7

2 0 1 8

3/12/2018

21

B U D C O N T I N U E D

2017 Summary:• Independent vehicle orientation• Good attention to environment

• Ex. School zone, road signs, brake lights/turn signals

• Good judgement timing turns & right of way application• Poor recall of instructions & poor pathfinding: Seen for mileage restriction at his

home and did well within familiar area• Restrictions added: 5-mile restriction, daylight only, no freeway

2018 Summary:• Max cues vehicle orientation (differentiate pedals, where to insert key, choosing

correct gear)• Issues with hitting both pedals simultaneously • Wide multi-lane left turn with vehicle alongside (steer assist required)• Inattention and delay to notice critical objects (multiple brake assists)

• Ex. School zone, traffic light changes, vehicle brake lights/turn signals

• Retirement recommended. Discussed with client & his wife and provided transportation option resource

DR IVER CESSAT ION

Abbreviated Clinical: •Intake

Medical/Driving History – form mailed to client

•Cognitive testing: Roadway knowledge•Ocutech Vision Screen

•DPAS

In Vehicle Assessment Evaluation Route

Some concerns present Full evaluation

recommended


Senior Safety Evaluation

Does not demonstrate the ability to be a safe independent driver Driving Retirement

Recommended

Demonstrates the ability to be a safe, independent driver

*Education re: continued driver safety

SEN IOR SAFETY RESOURCES

• Community based events (CarFit)

• AAA Resources (computer based & in-person workshops)

• RoadwiseRx.com

• Transportation options• Start the conversation for planning ahead

Clinical: Intake Medical/Driving History

Cognitive testingMVPT

Physical assessmentWheelchair Measurements

Ocutech Vision ScreenDPAS

In Vehicle Assessment Introduce client to adapted equipment in parking lot and

increase driving area as appropriate

Does not demonstrate the ability to be a safe

independent driver yet Therapy to work on

strength, range of motion, transfers, etc.


Adaptive Driving Equipment Evaluation

Driving retirementBTW training to include vehicle modification,

check out, and Certificate of Completion

drive

THE CDRS’ ROLE I N EQUIPMENT

o T H E E Q U I P M E N T P U Z Z L Eo Vehicle + Mobility + Client Function = Recommendationo Ensure compatibility

o D R I V I N G E Q UI P M E N To Hand controls, steering devices, left foot accelerator, high tech

o T R AN S F E R D E V I C E So Driver vs. Passenger

o P O WE R M O B I L I T Y L I F T / R AM Po Interior vs. Exterioro Trucks vs. van

3/12/2018

22

I N VEHI CLE TRAI NI NG

o 3 P I E C E S T O S U C C E S S F U L D R I V I N G :o Vehicle controlo Rules of the roado Defensive Driving

I N VEHI CLE TRAI NI NG

o T R A I N I N G I S P R O G R E S S I V Eo Experienced driver vs. Novice Drivero Driving Environment

o Right Turnso Left Turnso Amount of Traffico Amount of Speed and Speed Control

o G O A L : C O N S I S T E N C Y I N P E R F O R M A N C E O V E R T I M E


o C D R S R O L E V S . I N S T A L L E R

o B A S I C C L I E N T D E S C R I P T I O N

o P E R S O N A L V E H I C L E

o P O W E R M O B I L I T Y ( I F A P P R O P R I A T E ) o Load/unloado Restraint inside vehicle

o E N T R Y / E X I T T O T H E V E H I C L Eo Transfer ability or device useo Door handle accesso Key vs. keyless entry


o S E AT I NG & P O S I T I O NI NGo Line of sight & use of mirrorso Legroom & console locationo Wheel type (stationary, tilt, telescope)o Seatbelt access

o S E C O N D AR Y C O NT R O L So Turn signalso Headlights, wipers, cruise control, horn

o D R I V I NG MO D I F I C AT I O NSo Steeringo Acceleration/Brakingo Consider: sensation & need for pedal guard


o MISC. RECOMMENDAT ION So Remote Ignitiono Back up camera/monitoro GPS/Bluetootho Emergency brakeo HVAC/defrostero Trunk accesso Window controls

o O T HE R C O N S I D ER AT I O NS :o Vehicle make/model/mileageo Payor source

P R E S C R I P T I O N : V E H I C L E E N T R Y / E X I T

W H E E L C H A I R C O N S I D E R A T I O N S

3/12/2018

23

V E H I C L E E N T R Y / E X I T

L I F T C O N S I D E R A T I O N S

W H E E L C H A I R C O N S I D E R A T I O N S

o Physical abilities needed to stow/retrieve device

o WC-19 rating (http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-

lists/wheelchairs)

W C - 1 9 N O N - C O M P L I A N T

W C - 1 9 C O M P L I A N T

W H E E L C H A I R S E C U R E M E N T

M A N U A L V S . A U T O M A T I C L O C K D O W N

C A S E S T U D Y : D R I V E R W I T H E Q U I P M E N T

o 33 years old with cerebral palsyo Slight startle reflexo When seated the client tends to lean forward

o Mobility device: power wheelchair, walkero Client needs new power wheelchair

o Need new vehicle to transport Dana if Dana is not a driver

D A N A

D A N A

• Evaluated 01/2016• Determined Dana would drive from her power wheelchair if she is deemed a driver• Provided home exercises• Recommended client having a seating evaluation now as client fatigues

when ambulating further then household distances

• Seen in Lake Havasu (client's home town)• Sept, Oct, and Nov 2016• Vehicle vendor brought various vans to client's home to be assessed while in Lake Havasu

to determine appropriate vehicle for passenger only that would work if client deemed a driver

• Vehicle Modification Prescription written for passenger only vehicle 12/2016

• Vehicle modification Checkout completed 03/2017

• Seen in Lake Havasu• March, June, November 2017

D A N A ( C O N T I N U E D )

3/12/2018

24

D A N A – H O M E E X E R C I S E S D A N A

Dana has been very committed to driving, she has participated in the home exercises originally recommended and in order to assist with bilateral hand tasks clients dad built a practice station

H A N DC O N T R O L

S P I N N E R P O S T

D A N A

• Barriers:• Client is going to college, class schedule limits availability• Delays in Authorization from VR• Distance - client lives 3 hours away from Tempe location

• Equipment:• Left side push/pull mechanical hand control• Spinner post at 2:00 (began with a spinner knob; client had increased difficulty with lane

position and turns)• Pedal guard• IMEC chest strap

Scheduled to be seen April, May of 2018; if client successful client's vehicle will be modified for her to drive June 2018

C A S E S T U D Y : P A S S E N G E R A S S E S S M E N T

o 1 5 Y O W I T H C E R E B R A L P A L S Y & D E V E L O P M E N T A L D E L A Y

o M O B I L I T Y D E V I C E S : M A N U A L W H E E L C H A I R & S T R O L L E R

o V E H I C L E : 2 0 1 4 F O R D E C O N O L I N E E - 1 5 0

o O T H E R C O N S I D E R A T I O N S :o Assistance client currently requireso Health/age of parents

S H E L B Y

C A S E S T U D Y : P A S S E N G E R A S S E S S M E N T

o P L A N :o Wheelchair & stroller measurements obtained (including height with client

seated in each device)o Verified both were WC-19 compliant

o Vehicle measurements obtained (inside height where client would be seated, door opening)

o Prescription completed: o Under vehicle platform lift o 4-point securementso Seatbelt receiver

S H E L B Y

F I N D Y O U R L O C A L C D R S & O T H E R D R I V E R R E H A B R E S O U R C E S A T

W W W . A D E D . N E T

3/12/2018

25

THANK YOU!

[email protected]@drivingtoindepence.com

W W W . D R I V I N G T O I N D E P E N D E N C E . C O M

Low Tech Presentation2 - cdn.ymaws.com · ï l í î l î ì í ô ñ 7$6. $1$

Documents

Transcript of Low Tech Presentation2 - cdn.ymaws.com · ï l í î l î ì í ô ñ 7$6. $1$