Driving After Stroke Jennifer Milsovic, OTR/L

Adventist Rehabilitation Hospital of Maryland

Objectives

Discuss appropriate candidates for return to driving

after stroke

List all of the steps in the process of returning to driving

after stroke

Name at least 3 types of adaptive driving equipment

that may be used for persons following stroke

Who of the Following is a

Candidate to Drive?

A person with mild memory and mild attention deficits

A person with flaccid hemiplegia in the right upper and

lower extremities

A person with severe receptive and severe expressive

aphasia

A person with homonymous hemianopsia

Skills Required for

Safe Driving Visual (acuity, contrast sensitivity, visual fields, binocular

vision, fixation, scanning, visual perception)

Cognitive (orientation, alertness, processing speed,

immediate memory, short-term memory, sustained attention,

divided attention, selective attention, problem solving,

judgment/reasoning, planning)

Physical (right lower extremity and bilateral upper extremity

ROM, strength, coordination, reaction time,

sensation/proprioception; trunk control, cervical ROM)

Emotional/Behavioral

Can My Patient Drive

Following a Stroke?

Maybe, but he/she needs clearance first

Why does my patient need to be cleared?

Liability Issues

Maryland Motor Vehicle Administration (MVA) requires

that a person who has had a stroke must self-report

his/her condition

What Steps Should My Patient

Take Before Resuming Driving?

Obtain clearance from his/her physician

AND/OR

Report his/her condition to the MVA

Online

By phone

By mail

AND/OR

Obtain a driving evaluation

The Driving Evaluation

Part One: Clinical Evaluation Done in the clinic

Purpose is to identify any potential barriers to safe driving and identify any potential adaptive equipment needs

Components include:

An extensive interview to determine medical and social history, driving history, ADL/IADL status

An assessment of vision and visual perception

An assessment of cognition

An assessment of physical functioning

Part One: Clinical Evaluation

(Continued) After the evaluation, a recommendation is made

If all areas of functioning are grossly intact, recommend proceeding to behind-the-wheel evaluation

If deficit areas are present that would preclude safe driving, recommend service(s) to further evaluate and remediate deficits (i.e. neuro-optometry, OT, PT, speech therapy, neuro-psychology, etc.)

If deficits are severe or co-morbidities (such as dementia) are present, recommend retirement from driving and counsel client on alternative transportation

If deficits are mostly physical in nature (i.e. hemiparesis) with little to no visual or cognitive impairment, recommend proceeding to training with adaptive equipment

Note: aphasia alone does not preclude safe driving

The Driving Evaluation Part Two: Behind-the-Wheel Evaluation

Evaluation is done in a car with an instructor brake

Client is usually taken on a standard route that includes all traffic environments and cognitively taxing situations

In some cases, for clients with mild memory or attention impairments, evaluation may be done in familiar areas

Evaluator assesses the occurrence of critical errors (i.e. not stopping at a stop sign, hitting a curb, drifting into another lane)

Evaluator assesses the repeated occurrence of smaller errors (i.e. repeatedly not signaling for turns, repeatedly drifting within the lane, repeatedly not noticing signs until the last minute)

Part Two: Behind-the-Wheel Evaluation

(Continued)

After the evaluation, a recommendation is made

Continue driving in the same capacity that client was prior

to stroke

Continue driving, but with restrictions (i.e. radius

restriction, daytime-only restriction, etc.)

If deficit areas emerge during behind-the-wheel

evaluation, recommend service(s) to further evaluate and

remediate deficits (i.e. neuro-optometry, OT, PT, speech

therapy, neuro-psychology, etc.)

Prior to continuing to drive, take a refresher course to

remediate premorbid bad driving habits

If Adaptive Equipment

is Needed… Steps in process to drive with adaptive equipment

1. Driver training with adaptive equipment

a. Done in a vehicle with an instructor brake

b. Initiated in an empty parking lot and progresses through increasingly complex traffic environments

2. Client is given prescription to have equipment installed in his/her vehicle

3. Client is encouraged to use a NMEDA-certified equipment dealer to have equipment installed

4. Client returns to driving program to have equipment inspected to ensure that it was installed according to prescription

5. Client takes driving test at MVA with adaptive equipment and, upon passing, receives license that denotes adaptive equipment

Types of Adaptive

Equipment Commonly Used

Following Stroke

Left Foot

Accelerator

• Used when right lower extremity is

too weak or uncoordinated to

operate gas/brake

• Must be used when AFO is worn on

right lower extremity

• Includes pedal guard to ensure that

right foot doesn’t accidentally kick

OEM pedal

• Removable

Spinner Knob

• Used when one arm is too weak or

uncoordinated to assist with

steering functions

• In Maryland, must be used for

“one-handed” driving

• Can be placed at any position on

steering wheel

• Removable

Crossover

Turn Signal

• Used when left hand is too weak or

uncoordinated to operate existing

turn signal

• Attaches directly to existing turn

signal

Additional Adaptive Equipment

Adapted mirrors (to expand visual field in client with visual deficits)

Remote turn signals and secondary controls (if client has difficulty

with existing turn signal and crossover turn signal)

Reduced-effort steering (if arm used for steering is weak or has

decreased ROM)

Parking brake extension (if parking brake is on left side of floor and

client has left hemiparesis)

Key extender (if patient has right hemiparesis and has difficulty

reaching/turning key on left)

Additional Adaptive Equipment

(Continued)

Transfer assists (to assist client with lower extremity

weakness to get in and out of vehicle)

Wheelchair lifts/hitches/car toppers (to stow wheelchair

while client is driving)

Chest straps (worn in addition to seatbelt for clients

with decreased trunk control)

Miscellaneous Information Driving evaluations are not covered by insurance,

except for Workman’s Compensation and Division of

Rehabilitation Services

A doctor’s prescription is required prior to participating

in a driving evaluation

Adaptive equipment is not covered by insurance,

except for above payers

After having adaptive equipment installed, client should

notify insurance company

To Review: Steps in Return

to Driving Process If no adaptive equipment is needed:

1. Discuss return to driving with physician

2. Participate in a comprehensive driving evaluation (clinical and behind-the-wheel evaluations)

3. Report condition to MVA

If adaptive equipment is needed:

1. Discuss return to driving with physician

2. Participate in a clinical evaluation

3. Participate in training with adaptive equipment

4. Have adaptive equipment installed in personal vehicle

5. Return to driving program to have equipment inspected to ensure that it was installed according to prescription

6. Report condition to MVA

7. Take driving test at MVA

How Can the Clinician Facilitate

the Client’s Return to Driving?

1. Educate the client regarding:

a. Self-reporting regulations

b. The driving evaluation process

c. The process for obtaining adaptive equipment if applicable

2. Advise client to speak with physician regarding return to driving

3. Assess visual, cognitive and physical skills needed for return to driving

4. Treat any visual, cognitive or physical skills needed for return to driving

Who of the Following is a

Candidate to Drive?

A person with mild memory and mild attention deficits

A person with flaccid hemiplegia in the right upper and

lower extremities

A person with severe receptive and severe expressive

aphasia

A person with homonymous hemianopsia

Questions?

References Customer Self-Report of a Medical Condition. (2012). Retrieved

April 11, 2012, from http://www.mva.maryland.gov/About-MVA/INFO/26200/26200-11T.htm

Pierce, S., Blackburn, S. (2007, June). Building Blocks for Becoming a Driver Rehabilitation Therapist. Course conducted from Adaptive Mobility Services, Orlando, FL.

Redpenning, S. (2006). Driver Rehabilitation Across Age and Disability: An Occupational Therapy Guide. Bethesda, MD: AOTA Press.

Stav, W., Hunt, L., & Arbesman, M. (2006). Occupational Therapy Practice Guidelines for Driving and Community Mobility for Older Adults. Bethesda, MD: AOTA Press.