Staggering Statistics

Return to driving can be a difficult feat after sustaining an injury or in the presence of a debilitating condition… take these stats for a test drive:

81% of the 39.5 million adults in the U.S. aged 65+ hold a driver’s license

25.5 million Americans have disabilities that make traveling outside the home difficult

Examples of diagnoses that can affect an individual’s ability to return to driving: MS, Parkinson’s, Alzheimers, epilepsy, cerebrovascular disease

30-66% of CVA survivors return to driving

Common Diagnoses

Endocrine and Metabolic Disorders 

• Diabetes
• Hepatic Encephalopathy

Neurological and Physical Disorders

• Arthritis
• Dementia
• Multiple Sclerosis
• Obstructive Sleep Apnea
• Parkinson’s Disease
• Stroke
• Traumatic Brain Injury

Visual and Other Sensory Disorders

• Age-Related Macular Degeneration
• Cataracts
• Glaucoma
• Hemianopia & Quadrantanopia
• Vestibular Disorders
  

Deficits That Might Impact Driving

Visual Impairments: This is often the first thing that comes to mind when considering someone’s ability to return to driving. Some common changes in vision can include: visual scanning, attention, acuity, contrast sensitivity, or depth perception. If visual changes go unnoticed, we as clinicians may not adequately assess our client’s ability to safely return to the roads. Utilizing visual assessments, like those found here, during screenings can help gain a better picture of what deficits we should target in our treatment sessions. 

Cognitive Impairments: In order to remain safe while on the road, there are several cognitive skills necessary including but not limited to: insight, executive function, visual perception, sequencing, attention, and problem solving. If any of these skills are noted as deficit areas for your client, it is important to inquire about the patient’s intent to return to driving and assess their ability to utilize these skills in simulated scenarios. 

Motor Impairments: We also need to be on the lookout for physical limitations to the act of driving in order to fully assess whether a patient is safe to drive. Deficits in: reaction time, motor coordination, bilateral integration, strength, range of motion, and endurance will all need to be adequately assessed prior to return to driving. 

Sensation Impairments: Sensory changes are another consideration clinicians need to be aware of because these impairments can limit an individual’s ability to operate a vehicle and can alter their hearing, body awareness while in a vehicle, and perception of stimuli both inside and outside the vehicle. Educating patients on compensatory strategies, devices, and modifications will serve as an effective use of time during treatment sessions to address sensory impairments and support successful return to driving. 

Check out this source that discusses these impairments while also providing direct links to different outcome measures that can be used to assess these deficit areas!

Activity Analysis: Driving 

If you, the reader, are an occupational therapist then you are an experienced activity analyst and have likely performed (at least) a few in your day. If you are unfamiliar with what an activity analysis is, that’s OK! We are going to provide you an example of what our OT counterparts look for when completing one. An activity analysis is used to break down a task into very specific pieces which allows OTPs to identify what the specific deficit areas are and how to best help the client reach their goals. Below is a VERY general activity analysis of driving that depicts the performance skills & body functions necessary for driving. Keep reading to learn about the compensatory strategies and/or devices as we discuss this in a later section. You can learn more about the language and terminology used in this activity analysis by perusing the Occupational Therapy Practice Framework.

Performance Skills

Performance skills are goal-directed actions that are observable and that reflect a client’s ability to perform a task or occupation. These skills consist of motor, process, and social skills…

Motor Skills: There are so many small movements necessary to safely and successfully operate a vehicle including the client’s ability to:

• Reach: Clients must be able to extend their upper extremities to turn/guide the steering wheel from side to side as well as stabilize the wheel while accelerating forward. Clients will also reach to operate things like music, A/C (or heat), adjust mirrors when necessary, opening/closing the door, and donning/doffing the seatbelt. 

• Grip: Client must be able to grip the steering wheel both firmly and loosely while directing as well as turning the vehicle. Clients will also need to grip the seat belt, the door handle, and the gear shift. 

• Bend: The client will need to be able to flex or rotate the trunk to get in and out of the car, check their blind spots, use their mirrors, and position the seat of the car. 

• Coordinate: The client will have to coordinate movements of two or more body parts at the same time including: their upper and lower extremities, head and neck movements, and trunk rotation or flexion.

• Calibrate: Using appropriate speed/force when pressing the gas or brake pedals and when manipulating the steering wheel will be necessary to ensure safety of the client and those around them while on the road. 

• Flow: Using fluid arm/wrist movements when turning the wheel is another consideration for safe driving because if the movement is jerky it can cause the client to move the vehicle in an unintended direction. 

• Endure: The client will have to be able to perform all of the motor skills necessary for driving for the duration of the drive without fatiguing.

Process Skills: These skills typically involve preventing problems and/or carrying out specific steps to a task. Just as there are many motor performance skills necessary when driving, there are several processing skills necessary to navigate the road safely, such as the client’s ability to:

• Attend: The client will need to focus on the act of operating the vehicle and sharing the road with others while being conscious of potential hazards.

• Heed: Obeying traffic laws.

• Inquire: Locate road signs for navigation and safety. 

• Initiates: Performing necessary components of driving without hesitation that can jeopardize safety.

• Sequence: Knowing what actions come next.

• Organize: Setting up the car environment (mirrors, seat, sun visor etc.) to promote success.

**Not included are social skills; driving by nature is not a social activity however we have to remember that driving can promote our client’s ability to engage in meaningful social occupations. **

Body Functions/Body Structures: 

Mental: We have talked about a few of the different cognitive areas that must be intact before a client can safely return to driving but here is a further breakdown of the different mental functions utilized while driving – some of which are often forgotten. 

Higher level cognitive functioning	Judgment; executive functions; insight
Attention	Sustained; divided
Memory	Long term; Short term; Working
Emotional	Regulation; Emotional appropriateness (think road rage)
Orientation	Person, time, place, self, and others
Mental functions of sequencing complex movements	Regulating speed, response time, & force generation of motor production
Consciousness	Awareness & Alertness; Wakeful state
Sleep/Energy	Alert; Not fatigued

Musculoskeletal: Specific movements of the body are used during the act of driving; the body’s ability to transition smoothly from position to position accommodates the dynamic nature of driving. 

Head & Neck 

• Mobility and strength of eyes 
• Cervical rotation 

UEs

• Shoulder flexion, abduction, adduction
• Elbow flexion/extension
• Supination/pronation 
• Wrist flexion/extension 
• Digit flexion/extension

Trunk

• Flexion
• Rotation 

LEs

• Hip flexion (transitioning from brake to gas)
• Knee flexion/extension 
• Dorsiflexion & Plantarflexion 

Breaking down the act of driving into small components can allow clinicians to target specific deficit areas that can isolate barriers to the return to driving and maximize potential to return to driving. But what if the client is not safe to return to driving?

Approaching This Difficult Conversation

Driving represents independence and autonomy for most Americans, so the topic of driving cessation can be a daunting one. When discussing the topic with clients and their families, it’s important to actively listen and acknowledge their feelings and concerns. Answer any questions honestly and defer to others with the knowledge if you can’t answer. Provide them with practical information such as a list of local driving rehabilitation specialists and information about the driving evaluation process. 

When communicating with clients and families, be honest without taking away hope for recovery. Focus on the “right now” by informing them that driving is not recommended at this stage of recovery and explain why driving is unsafe at this time. You may need to further educate them on the disease process and its impact on the performance skills required for driving. If insight into deficits is impaired, it’s especially important to educate caregivers and work on improving the client’s insight into potential difficulties with driving.

Formal Driver Evaluation & Process

When clients want to return to driving, it’s important to familiarize yourself with the process and with local resources so that you can provide them with accurate information. The process begins with a doctor’s order for a formal driving evaluation, most often performed by a Certified Driving Rehabilitation Specialist. Inform your patients that they must be medically cleared to return to driving and that the evaluation is to ensure their safety and the safety of others while on the road. 

The occupational therapy driving evaluation begins with an extensive battery of visual, cognitive, and motor assessments to determine whether there are any impairments that will affect driving. Once the client passes the “pencil and paper” portion of the evaluation, an on-road driving test will be performed. The client will get behind the wheel with a driving rehabilitation specialist in a car that allows for safety controls, such as passenger side brakes. The therapist will then assess functional driving skills in the natural context. Once completed, recommendations for further treatment of underlying driving skills, vehicle modifications, and adaptive equipment training can be provided to promote independence in driving. 

If a client is deemed unsafe to return to driving, it’s important that the therapist communicates all recommendations with the client and relevant others clearly. They should understand why the recommendations are being made and how their impairments make driving unsafe.

Additional Considerations:

• Some states require healthcare workers to report individuals who have impairments that contraindicate driving to the state Department of Motor Vehicles and all states have anonymous voluntary reporting procedures. You must have discussed driving cessation with the client prior to making a report.
• Be empathetic when making recommendations as driving cessation is an emotional topic for both clients and their loved ones.
• Be clear with your clients that insurance typically doesn’t cover the cost of the driving evaluation and that it will be out of pocket. Help them locate local driving rehabilitation specialists if your facility does not offer them in-house. If there are none in the area, you can help refer them to their local DMV for further visual testing and a written licensing exam and/or help with creating a treatment plan that supports return to driving.

Have You Heard of CarFIT?

CarFIT is a free evaluation and training program to assess older adults’ safety within their vehicle with a focus on how each individual vehicle is adjusted specifically to the person operating it. Specifically, volunteers who provide these evaluations look at:

• Steering wheel tilt: towards chest & not the face

• Distance between the chest and the airbag: 10in

• Line of sight above steering wheel: 3in over the steering wheel

•  Mirrors and ability to check blind spot

• Operation of the vehicle controls

Anyone can become trained to perform a CarFIT evaluation, check out their site to look into training opportunities near you or virtually as well as other resources used to ensure safety on the road!

Other Ways to Support Return to Driving

Alternative modes of transportation: If a client is unsafe to return to driving, it is likely this news will be upsetting, which emphasizes the need for clinicians to be prepared with other options for transportation to provide to the client and their family. This is heavily dependent on whether you live in an urban or rural area, however here are some ideas to research within your area!

Taxis/Uber/Lyft

Pros: More access in urban settings & locating phone numbers for taxi services can be done online with a google search and there are easy-to-use apps for the other services. 

Cons: Timing is not always reliable so if you are using a taxi to attend a scheduled event or appointment you must be wary about calling with plenty of time in advance. The cost of these services can add up too depending on how often clients are requesting them.

Loved ones: Leaning on your friends and family to help with driving can seem like a burden, but if this option is available, clinicians should encourage it.

Pros: Spending more time with loved ones can help those who are unable to return to driving avoid isolation and spend time with loved ones. This option may be the cheapest option yet which will be more sustainable.  

Cons: Clients may feel like a burden, scheduling conflicts due to work etc., and can lead to conflict amongst families if nobody is available to drive or perhaps don’t want to.

Private companies: The access of these services will again depend on the location in which clients live, however there are companies that you can schedule pick up times which serves to increase access to transportation to appointments, leisure pursuits, etc.

Pros: Some of these companies have equipment that can be used for transporting clients who are wheelchair bound and/or have other challenges with car transfers. These employees are trained on safety procedures. 

Cons: Price and availability within an area.

Treatment Targets

Strengthening

Let’s say you have a client who has the potential to return to driving but requires assistance with specific components of driving you observed in the activity analysis… One area you might need to improve for your client is their ability to perform/sustain movements and operate the vehicle through strengthening. 

Visual Perceptual

In addition to visual motor skills, visual perceptual skills such as visual closure, figure-ground, visual memory, visual discrimination, form constancy, spatial relations, and visual memory must also be intact. These skills allow drivers to judge distances between other cars, discriminate between road signs and obstacles and the surrounding environment, identify vehicles from different angles, and see features of the environment that are partially hidden. Incorporating visual perceptual tasks in your treatment plan can  support return to driving for appropriate clients.

Cognitive

All components of cognition are needed to safely drive. Memory, cognitive flexibility, attention, reaction time, situational awareness, problem-solving, organization, self-awareness, and motor planning are all needed to plan, execute, and continually monitor one’s driving performance. Interventions to target memory, attention, metacognitive strategy training, safety awareness, and problem-solving in simulated and natural driving scenarios can be performed in both the inpatient and outpatient settings to support driving rehabilitation.

Range of Motion

Drivers need adequate range of motion in their upper and lower extremities to be able to manipulate all parts of the car. Range of motion impairments can prevent a driver from turning the steering wheel fully to avoid obstacles, operate the gas and brake pedals, and maintain grasp on the steering wheel. The primary movements for hazard avoidance are shoulder flexion, shoulder rotation, forearm rotation and wrist deviation.  40-80 degrees of right knee flexion and 20-85 degrees of left knee flexion are also needed to operate the pedals, with differing degrees needed when changing gears. Work on improving clients’ range of motion to functional ranges or suggest modifications to compensate for range of motion deficits. Prescribing a customized home exercise plan can also support return to driving by addressing underlying range of motion and strength deficits. 

Topographical Orientation/Spatial Awareness

A driver must be able to navigate in space, identify left from right, follow maps or GPS directions, and understand the spatial relations between themselves, the environment, and the car. Impairments in this area can lead to driving dangerously close to other cars, misjudging turns, and getting lost more frequently among others. Spatial awareness can be addressed via community skills training, wayfinding in the hospital or community settings, recalling landmarks, and constructing puzzles or other projects. Help clients explore car modifications such as parking assists, front sensors, and front and rear cameras that can help compensate for spatial awareness deficits.

Caregiver Section

Research shows that the driving cessation of a loved one, most often a spouse, can negatively impact caregivers who typically take over as primary driver. These caregivers report loss of personal space and time, loss of employment, and lower life satisfaction. They also report a general lack of practical information regarding return to driving and need for more socioemotional support from healthcare workers. 

Caregivers are also our clients and their needs should be considered in a comprehensive treatment plan. This may help decrease caregiver burden and help them navigate the role change that comes with driving cessation, both permanent and temporary.

Caregiver Intervention Ideas

• Provide information about local caregiver support groups 
• Provide information about respite care for caregivers of patients with greater needs or neurocognitive impairments
• Provide information for local accessible cab services or other appropriate public transportation
• Help caregivers find financial support resources for car modifications or driving evaluation, which are often costly and out-of-pocket
• Help caregivers structure their schedules
• Help caregivers and clients identify others who can help in case the caregiver isn’t available to drive
• AAA and AOTA’s Driver Planning Agreement contract can help caregivers broach the topic with their loved ones and ensure their wishes are respected

Check out our article discussing caregiver burnout and strategies to help support caregivers!

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