Driving After Stroke: Clinical Use of Pre-driving Screen Data Stephanie Schurr, O.T. Reg. (Ont.)
Background Please see Dr. M. Bédard sjanuary 17 2017 presentation, available at www.nwostroke.ca Use two sets of cut-off data (i.e. More Screening Required and Absolute Fail ) from 5 common screening tests familiar to OTs - Trail Making Test (Parts A & B) - Clock Drawing Test - Motor-Free Visual Perception Test (3 rd /4 th Ed.) - Montreal Cognitive Assessment
Clinical Reasoning Shortage of published research evidence for off-road driving screen protocols Need to balance clients need/desire to drive with public safety On-road testing remains gold standard; however, high cost and potentially unsafe when working with very impaired individuals. Previous driving screening protocols required clients to pass 4 separate tests using reasoning from separate studies. Didn t credit clients for high scores on one test /borderline scores on others
Before Screening: Determine whether client meets basicphysical and visionrequirements for safe/legal driving Basic Medical Standards (from Ontario Highway Traffic Act) An applicant for or a holder of a driver's licencemust not, Suffer from any mental, emotional, nervous or physical disability likely to significantly interfere with his or her ability to drive a motor vehicle of the applicable class safely; or Be addicted to the use of alcohol or a drug to an extent likely to significantly interfere with his or her ability to drive a motor vehicle safely - Physical disability includes anything that would make driving unsafe, including reduced use of any limb (i.e. can client make a full hand-over-hand turn without an assistive device? Can client push and release pedals, move foot laterally to change pedals?) - When in doubt about physical status, recommend referral to Driver Rehabilitation Clinic
Vision Requirements Vision Standards -Class G and M This section requires that an applicant for or a holder of a Class G, G1, G2, M, M1 or M2 licencemust have, A visual acuity as measured by SnellenRating that is not poorer than 20/50, with both eyes open and examined together with or without the aid of corrective lenses; and A horizontal visual field of at least 120 continuous degrees along the horizontal meridian and at least 15 continuous degrees above and below fixation, with both eyes open and examined together Annual vision testing is covered by OHIP for anyone under 20, over 65, or presenting with certain medical conditions, including diabetes and visual field deficits. Strongly recommend optometrist testing whenever visual or perceptual deficits are suspected
Implementation Complete all tests in sequence Protocol recommends stopping when pass or fail determination made For clinical and research purposes, complete all tests Use adjusted cut-off values based on client education Consider client presentation, time to complete, additional formal/informal observations of client function and behaviour
Driving Screen for Clients with High School or Less Client s Name: SJ Number: Date: 1. Tests 2. Client s score 3. Criteria 4. Outcome 5. Circle recommendation 94 seconds Fit to Drive = DRIVE Trail Making Test B. seconds 95 to 191 seconds Grey Zone = (Next test) 192 seconds Unfit to Drive = (Next test) Clock Drawing Test points 7 points Grey Zone = (Next test) 5 to 6 points Grey Zone = (Next test) 4 points Unfit to Drive = STOP MVPT-4 38 Fit to Drive = DRIVE 19-37 Grey Zone = (Next test) 18 Unfit to Drive = STOP Trail Making Test A. seconds 28 seconds Fit to Drive = DRIVE 29 to 74 seconds Grey Zone = (Next test) 75 seconds Unfit to Drive = STOP Montreal Cognitive Assessment points 28 points Fit to Drive = DRIVE 17 to 27 points Grey Zone = MORE EVALUATION 16 points Unfit to Drive = STOP
Driving Screen for Clients with Post Secondary Education Client s Name: SJ Number: Date: 1. Tests 2. Client s score 3. Criteria 4. Outcome 5. Circle Recommendation Trail Making Test B. seconds 80 seconds Fit to Drive = DRIVE 81 to 177 seconds Grey Zone = (Next test) 178 seconds Unfit to Drive = (Next test) 7 points Grey Zone = (Next test) Clock Drawing Test points 5 to 6 points Grey Zone = (Next test) 4 points Unfit to Drive = STOP 38 Fit to Drive = DRIVE MVPT-4 19-37 Grey Zone = (Next test) 18 Unfit to Drive = STOP 25 seconds Fit to Drive = DRIVE Trail Making Test A. seconds 26 to 71 seconds Grey Zone = (Next test) 72 seconds Unfit to Drive = STOP Montreal Cognitive Assessment points 28 points Fit to Drive = DRIVE 17 to 27 points Grey Zone = MORE EVALUATION 16 points Unfit to Drive = STOP
MVPT-3 vs. MVPT-4 To determine cut-off values for MVPT-4: Determine which age group had a standard score of 100 for MVPT-3 high cut-off value of 58 (30-0 34-11) becomes our gold standard norm group For this age group on MVPT-3, low cut-off value of 41 translates to a standard score of 56. -On MVPT-4, Standard score of 100 for age 30-39 corresponds with raw score 38; standard score of 56 corresponds with raw score 18.
Post-Screening Discuss results with client Explain possibilities for off-road practice of component skills (e.g. figure-ground discrimination, processing speed) Limited evidence exists to directly relate off-road activities to improved driving performance Discuss next steps: Driver Assessment Clinic Re-screening (at least one month later) Driving cessation I am also sending my results to Dr. Bédardfor use in further research to validate the protocol.
Communication with MD/NP DATE Stroke Prevention Clinic Thunder Bay Regional Health Sciences Centre 201-984 Oliver Road Thunder Bay, ON P7B 7C7 Fax: 807-684-5883 Dr. Bon, RE: OHIP Number: Date of Birth: As you are aware, the Neurology Day Program has been participating in Mr./Mrs. s post-stroke rehabilitation. Here is a summary of the pre-driving screen completed during his/her admission to the Neurology Day Program. 1. Tests 2. Client s score 3. Criteria 4. Outcome 5. Circle recommendation Trail Making Test B. seconds 94 seconds Fit to Drive = DRIVE 95 to 191 seconds Grey Zone = (Next test) 192 seconds Unfit to Drive = (Next test) Clock Drawing Test points 7 points Fit to Drive = DRIVE 5 to 6 points Grey Zone = (Next test) 4 points Unfit to Drive = STOP MVPT-4 38 Fit to Drive = DRIVE 20 to 37 Grey Zone = (Next test) 19 Unfit to Drive = STOP Trail Making Test A. seconds 28 seconds Fit to Drive = DRIVE 29 to 74 seconds Grey Zone = (Next test) 75 seconds Unfit to Drive = STOP Montreal points 28 points Fit to Drive = DRIVE Page 1 of 1
Challenges Different physicians have different referral/reporting patterns Difficult to obtain consent for screening when client fears consequences of assessment Unable to test clients with language barriers (cultural and medical), very limited education Team disagreement
Thank you! If you would like to discuss OT driving screening further, please contact me at: Stephanie Schurr, O.T. Reg. (Ont.) Occupational Therapist St. Joseph s Care Group 807-346-2334 schurrs@tbh.net