In a previous blog I wrote about successful collaboration with an OT who is a CDRS (Certified Driving Rehabilitation Specialist) on helping individuals who have difficulty learning to drive, or who have acquired problems that make it diffcult to continue to drive.
There is a great interview that just came out in Elsevier’s Practice Update on the subject. It is conducted by our optometric colleague, Dr. Kathy Freeman, and the OT/CDRS with whom I collaborate, Beth Rolland. If you are registered for the site, you can access it here. If you are not, you can register for the site (it is free). In the interim, I am reproducing the interview here.
Dr. Kathy Freeman of PracticeUpdate talks with Beth Rolland, a registered occupational therapist and certified driving rehabilitation specialist, or CDRS, about working with people with various disabilities who want to drive, focusing particularly on those with visual disabilities.
Dr. Freeman: Ms. Rolland,could you tell us a little bit about what you do in the rehab setting for patients who wish to drive, in a general sense? Then we can home in on the vision aspect.
Ms. Rolland: Absolutely. First, there is a difference in the roles of a general occupational therapist (OT) and a driving specialist OT. As a CDRS, I work with a wide range of clients, and what I do depends entirely on what the client’s needs are. I work with new drivers who have various disabilities, not just vision. They have cerebral palsy, spina bifida, and other disabilities that are physically related. I also work with drivers who have ADHD or who are on the autism spectrum. These clients often need extra help learning to drive because they learn differently. They frequently have spatial skill deficits and trouble dissociating head and eye movements. We evaluate what they need and get them the help they require, both in and out of the car. I also work with many clients who have had an illness or injury that affects their ability to drive, and that might be a physical injury, like an amputation, or maybe a stroke. But it could also be a vision deficit from an illness or injury. For example, people with head injuries or strokes have various vision deficits depending on where the stroke occurred in the brain. I also screen older drivers. CDRSs help make the decision when it is time to stop driving, and, again, that could be for physical, visual, or cognitive reasons.
With vision in particular, we start by evaluating the individual’s skills, strengths, and weaknesses in terms of vision. We do a good vision screening in the office and evaluate the client’s ocular motor skills, binocular vision, depth perception, and visual fields. We consider the extent of the peripheral vision, and not just whether the client has peripheral vision, but if he or she can pay attention to it. Often, in clients with neurological disorders, we are looking for spatial neglect, as well as how they use their eyes functionally.
Assessing the client
Dr. Freeman: So, when clients come to you for help with driving, you determine their visual abilities for the driving task.
Ms. Rolland: I think it’s important to note that when we first we evaluate clients in the office and we do a screening, if there is an issue, particularly with vision, we are going to try to get them intervention before we start working in the car. If possible, we want the problem to be fixed. Maybe that’s as simple as getting them a new pair of glasses. If it’s something that’s not fixable, such as a field cut, or if it’s something they’ve been dealing with for a long time, then we might see how they’re doing functionally in the car without sending them to someone for intervention. We want to know how functional they are with that deficit. However, there are a lot of clients I work with who could make improvements in their functional vision. I may send them to an eye doctor, just to make sure that they have the glasses that they need. For instance, many older drivers will come to me, and they might not have been to an eye doctor in a long time, and their vision is horrendous, or they may have cataracts. I might be the first one to figure that out, so I send them to an eye specialist to have that taken care of, and then they might come back to me to work in the car.
Dr. Freeman: What information do you want from the eye care practitioner?
Ms. Rolland: First and foremost, it is very important for us to know the visual acuity, because that is going to be a part of the state law requirements. The requirements vary from state to state. In Pennsylvania, for instance, there is a field-of-view requirement. In New Jersey, there’s no such requirement. In New Jersey, you’re allowed to drive with homonymous hemianopsia, which makes a lot of people shudder. In Pennsylvania, that would not be allowed. I would also like to know if there has been a visual field test. If so, I would like to see that because it is more accurate than the screen in my office. It is important to know the state law, but a visual field test helps tremendously to know if a person can legally drive in that state, and also what he or she can actually see.
Overall, we want the acuity, and the visual field test. I am thrilled if I can get some kind of binocular information, such as depth and vergence. I don’t get that very often, but once in a while I see it.
Dr. Freeman: Do you use the Useful Field of View?
Ms. Rolland: I do not have it in my clinic. I think if you talked to 100 different driving specialists, you would see a tremendous amount of variation in what we have available to us, including Useful Field of View. There is some driving research that shows a correlation with that test. So, it’s definitely a good tool, and I’d love to have one. I know that most of us are going to use a piece of equipment like an Optec Rehab Vision Tester (Stereo Optical) in the office. Many eye specialists don’t really like the Optec, because they say it is not very accurate. That might be true, but most state departments of motor vehicles (DMV) use a machine like an Optec, and the clients are all going to be asked to put their head in it when they are at the DMV. For that reason, it makes sense for us to use it. It’s also very quick and easy for us to pick up a problem. I would rather send too many clients to an eye specialist to figure out what is going on with their vision than miss something. There is a particular series of slides that the Optec makes that are devoted to driving. For instance, it has some road signs in it, and it has depth slides and color recognition slides. Most of us have that package, and that’s what we’re using in the clinic.
Dr. Freeman: What other assessments do you do?
Ms. Rolland: In the clinic, we assess physical skills and cognitive skills, such as memory, multitasking, attention, and speed of processing. We also work with clients in the car. We have them out on the road, and we try to help them best use their vision. If they have a vision deficit, we try to help them use strategies to learn how to compensate for that. There are some clients who can compensate very well, and some who cannot. So, it comes down to making a decision about safety, given the vision that patient has. Can we make the client safer, or are we not able to get the client to the point where he or she is actually safe? In that case, we’re making the decision not to recommend driving.
Part of that decision happens on the road, based on what we’re observing. Are they missing things like signs or pedestrians? Are they making good decisions about space and speed when they make turns? Are they placing the car where it needs to be? You know, a lot of our new drivers with learning disabilities have very poor spatial skills; so, they have difficulty making a turn and placing and maintaining the car in the lane, especially maintaining their lane in curves, for instance.
What happens if a client can’t be rehabilitated?
Dr. Freeman: You work with people on these skills, but if they aren’t able to be rehabilitated to the point where you are comfortable with their safety, do you have a formal verification or certification process, or is it just a discussion, a recommendation?
Ms. Rolland: All of us require that a physician refer a client to us, and so when our recommendation is, “No, I don’t think this person is safe to drive,” that goes back to the doctor. Whether we can actually make a recommendation to the state board of motor vehicles varies by state. In New Jersey, I can report right to the Motor Vehicle Commission and tell them that I think a driver is not safe on the road.
Dr. Freeman: Are you required to report that?
Ms. Rolland: I believe that there is an ethical obligation to report that. If I’m in the car and someone is very unsafe, I feel there’s a very strong ethical compulsion to report that there’s a problem with that driver being on the road, to protect public safety.
Dr. Freeman: In Pennsylvania, as an example, the examining optometrist or ophthalmologist is required by law to report patients who do not meet the visual requirements for driving to the DMV.
Ms. Rolland: Absolutely. But, you know, that would depend on state law. In New Jersey, the only law regarding vision is about acuity. The bottom line is that you have to have 20/50 vision in both eyes, or if you only have it in one, you need to see your eye doctor and a vision release form must be signed. If a client can’t make that minimum standard, the eye doctor should be making that decision right off the bat: “You are not legal to drive in the state of New Jersey.” We have some eye doctors who are very reluctant to do that. They are afraid that they will lose patients. It is difficult for many doctors to take that step and make that decision. I wish that they would be more proactive with the folks who do not meet the visual requirements.
But we are here to help with that process. So, that’s actually a very good thing about seeing a driving specialist. We usually see the client once if we’re just doing an evaluation of, for example, an older driver. We see them once; we make a decision. We say, “Sorry, we don’t recommend that you drive,” and then we don’t see them again. For us, it’s a little easier to have that conversation. We know they are not going to need to come back to have an eye exam next year; there’s not that relationship that someone has with an eye doctor. I do understand where that comes from.
Working with the eye care practitioner
Dr. Freeman: Beyond getting the information about visual functioning, how do you work with the eye care practitioner?
Ms. Rolland: This depends on the eye care specialist. If it’s just a matter of thinking that the visual acuity in one eye is not good enough for driving in New Jersey or thinking that a client’s vision could be better with a new pair of glasses, I can send the person to any eye doctor, or refer him back to his own eye doctor. But many people would benefit from a vision therapy program, and driving specialists tend to know where they are. Some eye care practitioners will do therapy in their office, and many rehab centers have vision therapy programs. In fact, there is one here at my rehab hospital in New Jersey. I might see somebody who has good vision but is not using it well; her visual scanning may be very unorganized and not very functional. It may be too slow, which could be a processing speed problem, but it could also be that the ocular motor skills are not smooth and accurate, and she is just not finding things quickly with her eyes, which is hugely important for driving.
Often, for those kinds of clients, or people with a new field cut who have not adapted to it yet, we would like to see them go through a program in which they could maximize the skills that they have. With a field cut, although we may not be able to change their visual field, maybe we can make them faster and more accurate at finding things with their eyes. Some people come through our vision program with a homonymous hemianopsia or a quadranopsia, or something like that. We work on strategies to get better at using that vision. I also frequently send people to vision therapy programs at eye care specialists’ offices, new drivers especially.
The other point I would like to make is that, especially with the difficult diagnoses, such as homonymous hemianopsia, some eye doctors will say, “Absolutely not; no driving,” even if it is legal in New Jersey. I would challenge that and recommend that they send the person to a driving specialist, and see what the person can do on the road. By referring him, the eye care specialist is not saying that the client is safe to drive, but rather, “Let’s get the client checked out, and see if he can drive safely,” with someone who has the training and experience, and who can make that decision by being in the car and actually observing what’s going on. I don’t think you’d find that any driving specialist would work with a person with that kind of deficit fewer than five times in the car.
We are looking for consistency over time, and how the client manages to compensate. If we give him a chance, he may actually surprise us and be able to pull it off. It is such an important thing for people to drive; we don’t want to go without checking all the bases. By the same token, if someone is very impaired visually, we really do need to tell him no.
Dr. Freeman: So, you would prefer that it happen at the eye doctor level, rather than the eye doctor send the patient to you?
Ms. Rolland: If the deficit seems severe, yes. If it’s borderline, then, absolutely, send the client to me. Let’s make a decision. But someone who has advanced macular degeneration, for example, doesn’t need to come to me. That person should be told that she cannot legally drive, and, in that case, you have the state law to fall back on. You’re not making a value judgment. You’re saying, “I’m sorry. The state won’t allow it.” That’s an easier decision for eye doctors to make, I think.
How do driving safety courses come into play?
Dr. Freeman: What do you think is the role of courses like the AARP Driver Safety Course and other mature driver safety programs?
Ms. Rolland: I think those are fantastic refresher courses. They review laws that have changed, as well as new technology in the car, such as air bags and anti-lock brakes. Things do tend to change. There are great courses that I recommend for most people, especially because completion means that people can get a discount on their insurance. I take a course every 3 years for the discount, but I always learn something, and I’m a certified driving instructor in New Jersey! The courses are wonderful, but they do not have the component of going in the car; so, they cannot really test somebody’s skills. CDRSs put people in the car and see how they really do out on the road. The driving courses will augment a person’s knowledge, and that’s a very valuable thing; however, they’re not the same as getting someone in the car and evaluating his or her skills.
Dr. Freeman: Do you also work with bioptic telescopes for driving?
Ms. Rolland: I actually don’t, but there are driving programs with CDRSs who are trained to use bioptics. The use of bioptics also varies by state. Some states don’t allow bioptic driving; a lot of states have very strict requirements for bioptic driving. For example, in Indiana, there is a very strict requirement of how many hours the driver is required to be trained in the car, and this has to include hours after daylight. I think it has to include bad weather. In any case, there is a whole protocol of using that bioptic first outside the car, and then moving into the car.
Not all driving specialists are comfortable with bioptics, but there are CDRSs who are trained to work with these clients. If a program does not do bioptics, the people there likely know who does.
Finding a CDRS
Dr. Freeman: How does an eye care practitioner or a general practitioner, for that matter, find a driving specialist like yourself, or a driving program like the one you have described?
Ms. Rolland: That’s a very good question. These programs are rare. I just came off a 4-year stint on the board of directors for our national association, the Association for Driver Rehabilitation Specialists (ADED). One of our biggest goals is increasing the number of practitioners so that they’re easier to find. In some areas of the country, there are quite a few, but, in others, they are few and far between. I would suggest that if you are looking for someone to do a driving evaluation, you do look for a certified specialist, because a CDRS has a required amount of education, has to sit for a certification exam, and must abide by the continuing education requirements. CDRSs can be found using the locator feature on the ADED website: www.ADED.net.