Veterans Affairs Rehabilitation Driving Programs: What Don t We Know?

Transcription

1 Veterans Affairs Rehabilitation Driving Programs: What Don t We Know? Kristy I. Gronseth, OTR/L, Certified Driver Rehab Specialist Adrienne Toubbeh, OTR/L, SCI Therapy Supervisor Spinal Cord Injury/Disorders Care Line New Mexico VA Health Care System Albuquerque, New Mexico

2 Disclosures Presenters have no interests to disclose. PESG and PVA staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with PVA. PESG, PVA, and all accrediting organizations do not support or endorse any product or service mentioned in this activity Commercial Support was not received for this activity.

3 LEARNING OBJECTIVES At the conclusion of this activity, the participant will be able to: Identify 5 signs and symptoms that would precipitate a referral to a VA Driver Rehabilitation Program. Identify 5 key component skills which could be remediated prior to a referral to a VA Driver Rehabilitation Program. Describe simple and complex adaptive devices and, low and high technology durable medical equipment. Explain how to make a referral to VA Driver Rehabilitation Program.

4 DRIVING THE LAST BASTION OF INDEPENDENCE

5 Maintaining independence in home and community mobility is the key to successful quality of life: Improves socialization Encourages participation in community activities Leads to a more active lifestyle

6 Maintaining independence in community mobility is the key to successful quality of life (Con t): Potential for reduction of: Hospitalization/Re-hospitalization Social isolation Pressure ulcers Depression Cognitive decline

7 CUES that could precipitate a referral to a regional VA Driver Rehabilitation Program Physical Visual Cognitive Behavioral

8 Physical Components Strength Upper Extremity Lower Extremity Trunk Static Dynamic Neck

9 Physical Components (Con t.) Range of Motion Upper Extremity Active Gravity Eliminated Strength Lower Extremity Active Gravity Eliminated Strength Neck To Left To Right

10 Effects of Deficit Decreased range of motion can make operating your vehicle dangerous as you may not be able to: Maneuver the steering wheel Use the turn signal Adjust the mirrors Properly apply the gas and brake

11 Effects of Deficits Decreased physical strength Can make it difficult to steer into turns To shift gears To reach for your seat belt

12 Effects of Deficits Decreased range of motion may also make it difficult to: Transfer into/out of your vehicle To close the door To apply your seat belt

13 Physical Components (Con t.) Sensation Deep Pain/Temperature Light Touch Proprioception

14 Effects of Deficits Decreased sensation can make it difficult to Feel the pedals at your feet causing difficulty to properly accelerate/decelerate = Fender benders

15 Physical Components (Con t.) Hearing Balance: Sitting: Static and Dynamic Standing: Static and Dynamic

16 Effects of Deficits Decreased hearing may make it difficult to hear and quickly react to emergency vehicles, horns, etc.

17 Cognitive Components Memory Long Term Memory Short Term Memory Working Memory Immediate Recall Delayed Recall

18 Long Term Memory Can last as little as a few days or as long as decades LTM is typically divided up into two major headings: Declarative Memory Implicit Memory (Procedural Memory) Landauer,Thomas K. (1986). "How much do people remember? Some estimates of the quantity of learned information in long-term memory". Cognitive Science: A Multidisciplinary Journal 10 (4): doi: /s cog1004_4

19 Declarative/Explicit Memory Refers to all memories that are consciously available Name of your teacher The smell of baking bread bringing back memories of grandma s house Remembering what to do at a 4-way stop

20 Implicit Memory (Procedural Memory) Refers to the use of objects or movements of the body Such as how exactly to use a pencil or ride a bicycle Rote

21 Short Term Memory Refers to capacity for holding a small amount of information in mind in an active, readily available state for a short period of time Most definitions of STM limit the duration of storage to less than 1 minute E.g., remembering a phone number or directions, making a left hand turn Baddeley, A. D., Thomson, N., & Buchanan, M. (1975). Word length and the structure of short term memory. Journal of Verbal Learning and Verbal Behavior, 14, pp

22 Working Memory Working memory is a theoretical framework that refers to structures and processes used for temporarily storing and manipulating information. As such, working memory might also be referred to as working attention. Construction zone, major freeway interchanges

23 Delayed Recall The ability to recall a piece of information at a given period of time after it was learned A new math formula and being able to apply it Being given directions and accurately following them Reference: Encyclopedia on Early Childhood Development, Glossary-Brain, December 5, 2008 Centre of Excellence for Early Childhood Development

24 Cognitive Components Con t Executive Functions: Problem solving Processing speed Insight Attention: Sustained Alternating Divided

25 Executive Functions A theorized cognitive system in psychology that controls and manages other cognitive processes. This concept is used by psychologists and neuroscientists to describe a loosely defined collection of brain processes which are responsible for planning, cognitive flexibility, abstract thinking, rule acquisition, initiating appropriate actions and inhibiting inappropriate actions and selecting relevant sensory information.

26 Executive Functions Psychologist Don Norman and Tim Shallice have outlined 5 types of situations where routine activation of behavior would not be sufficient for optimal performance: Those that involve planning or decision making. Those that involve error correction or troubleshooting. Situations where responses are not well-learned or contain normal sequences of actions. Dangerous or technically difficult situations. Situations which require the overcoming of a strong habitual response or resisting temptation. References: Shallice, T. (1988) From Neuropsychology to Mental Structure. ISBN Shallice, Tim, & Cooper, Rick. (2011). The Organisation of Mind. Oxford: Oxford University Press. ISBN

27 Executive Function Example Being offered a piece of chocolate cake you would automatically want to take it, BUT if you were on a diet, your executive system would assist you in resisting the cake. Sitting at an unprotected intersection, waiting to make a left turn, resisting the urge to just jump into traffic being impulsive.

28 Gestalt A German word for form or shape In English it is used to refer to a concept of wholeness The whole - the sum of its parts

29 Gestalt Theory Gestalt psychology or gestaltism (German: Gestalt - "essence or shape of an entity's complete form") of the Berlin School is a theory of mind and brain positing that the operational principle of the brain is holistic, parallel, and analog, with self-organizing tendencies. The Gestalt effect refers to the form-forming capability of our senses, particularly with respect to the visual recognition of figures and whole forms instead of just a collection of simple lines and curves. The phrase "The whole is greater than the sum of the parts" is often used when explaining Gestalt theory.

30 Effects of Deficits Decreased Mental Stamina Can make problem solving difficult e.g., construction zones, unfamiliar areas Can cause safety deficits as your mind does not have the ability to quickly react when it is fatigued.

31 Visual Components Far Acuity State Requirements Best Corrected: Most are 20/40 but check with you state Division of Motor Vehicles

32 Perceptual Components Depth perception Color perception Peripheral Fields Complex discrimination Simple discrimination Visual processing speed Visual Attention Visual memory Visual Closure

33 Effects of Deficits Vision Changes: Decreased contrast sensitivity may make driving in the shade or twilight difficult. Decreased depth perception may make parking difficult. Decreased peripheral vision may make reaction times slower as you may not see objects in time.

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36 Decreased vision/perception Decreased ability to see or perceive what you see often happens with stroke which affects how your brain interprets the driving scene. If you can not correctly interpret the driving environment, then you can not correctly react to it.

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38 Self Regulation Components Anxiety Anger Management Impulse Control Stress Reduction

39 Task Analysis of Driving Entry/Egress Transfer in and out, open/close door, seat adjustment Seat Belt application/ removal Ignition Mirror adjustment rearview and side mirrors Gear Selection Wheel mounted Console Transmission Manual/Automatic

40 Task Analysis of Driving Con t. Primary Controls Steering Gas Brake Secondary Controls Wiper/washer Turn signal Environmental controls Radio Horn Cruise Control Emergency Brakefoot/hand powered Clutch

41 Task Analysis of Driving Con t. Visual Scanning SIPDE - Search, Identify, Predict, Determine, Execute Balance Reactions- In curves and turns Vestibular Component Vestibuloocular Reflex - maintain objects on the fovea, which thereby allows a person to visualize objects clearly during brief head movements

42 Driving Functions Left Upper Extremity Right Upper Extremity Left Lower Extremity Right Lower Extremity

43 Driving Functions Left Upper Extremity Close/open car door Adjust side mirrors Locks/window operation Parking brake release Seat adjustment Tilt steering adjustment Hood release/gas tank door release Lights/high beams Cruise control Turn signals Horn Washer/wiper Steering Adjust visor Emergency Flashers

44 Driving Functions Right Upper Extremity Rearview mirror Seatbelt Ignition Gear selector Heat/air conditioning Radio Adjust visor Trunk release Parking brake Washer/wiper Emergency Flashers Steering Cell phone Cruise control Horn Coffee

45 Driving Functions Right Lower Extremity Gas operation Brake operation Left Lower Extremity Clutch Emergency brake High beam (older model vehicles)

46 IMPLICATIONS OF DISABILITY Decreased coordination Spasticity/Flaccidity Decreased muscle strength Visual changes Mobility aids Energy level, transfer ability Insight Decreased cognitive ability Slowed response times Decreased/absent sensation

47 ADAPTIVE EQUIPMENT Primary Controls Hand controls Electronic gas/brake Left foot accelerator Steering controls Reduced effort steering/braking

48 Primary Controls Steering

49 Primary Controls Steering

50 Primary Controls Acceleration/Brake

51 Primary Controls Acceleration/Brake

52 Primary Controls Acceleration/Brake

53 Primary Controls Acceleration/Brake

54 ADAPTIVE EQUIPMENT Secondary Controls Headlight dimmer operation Horn operation Signal light operation Dashboard controls Parking brake Windshield wiper operation Windshield washer operation Gear Shift Operation HVAC Radio/cd player Dimmer Cruise on/set Power window operation Ignition control

55 Secondary Controls

56 Secondary Controls

57 Now that we know what is needed to drive, how do we evaluate/treat toward the task? Care Provider/Functions: Physician Physician Assistant Occupational Therapist Physical Therapist Speech Therapist Assistive Technology Specialist Clinical Rehabilitation Engineer Vision Team Psychologist Recreation Therapist Nursing Pharmacist Prosthetists/Orthotists

58 Strategies

59 Pre-Driving Skills to address in the clinic Coordination Quick use of extremities Crossing streets Managing social interactions Managing time Handling an emergency situation independently Caring for oneself when alone Reading maps Managing money Managing emotions and feelings Regulating sensory input Impulse control Stress reduction Resource: AOTA Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56 (6),

60 Treatment Strategies Cooking activities Calling movie theatres and getting movies and times Gardening for balance and core strength Bowel and bladder care Wii games on sissel disks Power wheelchair runs in community setting Dynamic visual scanning axs. Physical endurance axs. Cognitive endurance axs. Cognitive processing speed exs. (ie. Time scanning puzzles, etc.) Learning how to maneuver through public transportation system Assembly/disassembly of w/c at edge of mat Core strength axs. Dynamic standing balance Balloon/ball toss at varying speeds Balloon/ball toss with divided attn. task

61 Role of a Certified Driver Rehabilitation Specialist Clinical Evaluation On-road Evaluation In-vehicle training In-clinic training Recommendation of vehicle for purchase Recommendation and prescription for passengers Recommendations for alternative modes of transportation

62 Clinical Assessment Physical/visual perceptual/ cognitive functioning Driving history Road knowledge Wheelchair assessment Family Situation Housing Situation Financial Situation Ability to transfer Endurance Mobility aids

63 When to refer to CDRS Need for adaptive equipment to drive Need for adaptive behaviors for driving Need for evaluation when a client is on the fence Need for passenger evaluation Need to assist families in making the decision of whether to pull the keys Need to convince drivers to not drive Need to educate in alternative transportation

64 Referring to a DVA Driver Rehabilitation Program Types of VA Consults Internal: PM&RS and SCI (as available) E-Consult Inpatient and Outpatient Use when you wish to consult the PM&RS or SCI Driver Rehabilitation Specialist ask a question Interfacility Consult Referral to closest VA Driver Rehabilitation Service Requires services at a higher level not available at your facility Fee-Service When there is no Driver Rehabilitation Program at your local VA system but there is a community resource

65 E-Consult: When you don t know, ask a clinical question The obvious: TBI, SCI, MS, Amputation Can a patient with a right lower amputation (or Bilateral LE or triple amputation) drive? Can a patient with homonymous hemianopsia Known visual/perceptual deficits Less obvious: Mild dementia ADD Sleep Apnea Receptive aphasia Falls Vertigo/Meniere s Mild Neuropathy

66 Integrated Care: Interfacility Consults

67 Different ways of conveying the same information:

68 Integrated Care Consult: Fee Service (to community resource) Integrated Care Consult Request Fee Service for Driver Rehabilitation In-clinic evaluation, and if appropriate, On- Road evaluation and training. Use the same process as with Interfacility consult

69 Pearls If your patient is having difficulty with simple tasks then continue to work on those tasks, monitor improvement towards independence. Consider their abilities as it relates to all you learned here, then refer them to the Driver Rehabilitation Specialist when they have maximized their potential. Don t just treat ADL or Mobility. Think of the person as a whole Think of the big picture what you would want for your own life should direct your treatment strategies and goals for the Veterans you serve. Consider how they may benefit society if they are functioning at their highest capacity. Think about the implications of what might happen if they can t drive. The Driver Rehabilitation Specialist is a consult away. The Driver Rehabilitation program is available to support you. We are a team. Not all deficits are major; however, they could possibly have major implications in driving. All allied health professionals have a role and responsibility in returning the Veteran to his/her highest level of independence. Want it as much as they do.

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71 REFERENCES AOTA.org AAApublicaffairs.com Cognitivefun.net Driver Rehabilitation and Community Mobility, Joseph Michael Pellerito, Jr. Landauer, Thomas K. (1986). "How much do people remember? Some estimates of the quantity of learned information in long-term memory". Cognitive Science: A Multidisciplinary Journal 10 (4): doi: /s cog1004_4

72 REFERENCES Shallice, T. (1988) From Neuropsychology to Mental Structure. ISBN Shallice, Tim, & Cooper, Rick. (2011). The Organisation of Mind. Oxford: Oxford University Press. ISBN Baddeley, A. D., Thomson, N., & Buchanan, M. (1975). Word length and the structure of short term memory. Journal of Verbal Learning and Verbal Behavior, 14, pp History of Psychology by David Hothersall (2004), chapter seven, for complete history

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