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Driving Evaluation
The Driving Evaluation The Driving Evaluation
Driving is an occupation g p
Therefore the evaluation should capture the
entire occupation
The driver
The context
The task of driving
C t f th l ti Components of the evaluation
History
Clinical Assessment
On Road Assessment
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History History
Personal information Personal information
Name
Age
Emergency contact
Diagnosis Diagnosis
Disability
Pertinent medical history
Physicians name and phone number
History History
Driving history
Drivers license status
Drivers license number and state of issuance
Number of years licensed to drive
Last time the person drove
General driving history
Need for community mobility
Year of vehicle Year of vehicle
Make of vehicle
Model of vehicle
Number of doors in vehicle
Manual or automatic transmission
Driving Habit Questionnaire (Owsley ref)
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History History
Occupational Profile p
Other pertinent information
Involvement with vocational rehabilitation services
Workmans compensation insurance
Willingness to participate in program
Support for transportation to driving program
Willingness to pay for services
Occupational Profile Occupational Profile
Who is the client?
Why is the client seeking services?
What occupations and activities are successful
or causing problems?
Driving / Community Mobility
Secondary to driving
What contexts support and inhibit driving
performance?
What is the clients history related to driving?
What are the clients priorities related to driving
and community mobility?
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Gathering the History Gathering the History
R f l S Referral Source
Client
Family
Telephone interview Telephone interview
In person interview
Body language of family
Clinical Assessment Clinical Assessment
T f li kill / d fi i Tests of client skills / deficits
Conducted in the clinic
Battery of assessment tools
Choose tools based on
Client specific diagnosis and needs
Evidence of value of tool
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Understanding the Statistics Understanding the Statistics
Common values associated with tools Common values associated with tools
Validity
Reliability
Sensitivity Sensitivity
Specificity
Validity Validity
The tool is measuring what says it measures The tool is measuring what says it measures
Considers how a tool acts
Does it relate to other items in the way you think
it should
Considers how a tool looks?
Does it look like it can do the job?
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Types of Validity Types of Validity
Content Validityy
Does the tool contain all the pieces of the phenomenon?
Expressed in words / explanation
Criterion Validity
Degree of correlation between two measures
Expressed as a correlation 0.0 1.0
Matched to a gold standard measure
Predictive Validity the tool will predict something will
happen in the future
Validity Validity

X
X
High Validity Low Validity
Bulls eye is what we want to measure
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Reliability Reliability
The extent to which a tool measures the
same thing each time
Tools designed with reduced/eliminated
errors will yield better reliability
You can expect the same measurement is
being conducted regardless of
Tester
Time tool is administered
Client
Types of Reliability Types of Reliability
External Error External Error
Inter-rater: same result between >1 rater
Intra-rater: one rater measures consistently
Internal Error
Test retest: multiple administrations yield same
lt results
Internal consistency: to what extent items are
associated with each other and the whole test
Expressed as a correlation 0.0 1.0
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Reliability Reliability
Bulls eye is what is being measured
X
X
X
X
X
High
Reliabilit
X
X
X
X
Low
Reliability
X
X
X
X
Reliability Reliability
High Reliability, but Low Validity
Sensitivity Sensitivity
The extent to which a tool detects when a deficit is
actually present
Look for greater than .8
High sensitivity will identify all/most of the people with
a certain problem p
Low sensitivity will miss the people who actually have
the problem
VERY important with screens used by the public
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Implications of Sensitivity Implications of Sensitivity
The OPTEC visual acuity slides have The OPTEC visual acuity slides have
high sensitivity
Identifies all/most of the people with poor
visual acuity
A computer-based cognitive screen with A computer-based cognitive screen with
low sensitivity
Will not identify cognitive deficits and
pass people with impairments
Specificity Specificity
The extent to which a tool detects a deficit when is The extent to which a tool detects a deficit when is
actually absent
Look for greater than .8
High specificity will not identify deficits that arent there
Low specificity will generate false positives
VERY important with screens used by the public
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Implications of Specificity Implications of Specificity
Manual muscle testing has high specificity
It is unlikely you will identify a person as having 2/5
strength when they are actually 4/5
A computer-based assessment with low specificity p p y
Falsely fails older drivers causing unnecessary license
revocation
What the Tools Measure What the Tools Measure
What constructs are being measured What constructs are being measured
Vision
Cognition
Motor performance
What does the literature say about a What does the literature say about a
relationship to driving?
Predictability of crashes
Indicative of driving performance
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Vision/ Perception Vision/ Perception
Assessment Instruments Assessment Instruments
Keystone Vision Tester Keystone Vision Tester
PortoClinic
OPTEC
Perimetry (Humphrey or Goldman)
Motor Free Visual Perceptual Test Motor Free Visual Perceptual Test
Test of Visual Perceptual Skills
Test of Visual Motor Skills
Bender Gestalt
Keystone Vision Tester Keystone Vision Tester
Vi l A it Visual Acuity
Color perception
Phoria
Stereopsis p
Contrast sensitivity
Glare recovery
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Porto Porto- -Clinic / Glare Clinic / Glare
Tests:
Visual Activity
Field Of Vision
Depth Perception
Color Perception
Simple Reaction
Complex Reaction
Response
Glare Recovery
Night Vision
OPTEC OPTEC
Interchangeable slides
Static Acuity
Peripheral Fields
Depth Perception
Color Discrimination
Phorias
Road Signs
Contrast Sensitivity
Newer versions- glare
recovery
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OPTEC OPTEC Far Visual Acuity Far Visual Acuity
OPTEC OPTEC Stereopsis Stereopsis
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OPTEC OPTEC Color Perception Color Perception
OPTEC OPTEC Lateral Phoria Lateral Phoria
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OPTEC OPTEC Vertical Phoria Vertical Phoria
OPTEC OPTEC Road Sign Road Sign
Recognition and Depth Recognition and Depth
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OPTEC OPTEC Contrast Sensitivity Contrast Sensitivity
Goldman Perimetry Test Goldman Perimetry Test
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Humphrey Field Analyzer Humphrey Field Analyzer
Perimetry Testing Perimetry Testing
Useful in identifying Useful in identifying
blind spots/field cuts
Gross deficits
obvious
Unknown effect of
mild deficit on
driving
Need referral to eye
care practitioner
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Motor Free Motor Free
Visual Perception Test 3 Visual Perception Test 3
Designed for complete Designed for complete
administration
Subtests
Spatial Relationships
Visual Closure
Visual Discrimination Visual Discrimination
Visual Memory
Figure Ground
Normed to age 90
Test of Visual Perceptual Skills Test of Visual Perceptual Skills
Can be divided by subtests Can be divided by subtests
Visual Discrimination
Visual Memory
Visual Spatial Relations
Visual Form Constancy
Visual Sequential Memory
Visual Figure Ground
Visual Closure
Normed to age 18
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Test of Visual Motor Skills Test of Visual Motor Skills
16 Geometric figures
Increasing in complexity
Normed to age 40
Bender Visual Motor Gestalt Test Bender Visual Motor Gestalt Test
P t ti f 9 Presentation of 9
figures for copying
Drawing done on
paper
Useful for ages up
to 85+
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Cognitive Assessment Instruments Cognitive Assessment Instruments
MMSE
Block Design
MMSE
Short Blessed
Trailmaking
Symbol Digit
Letter cancellation
U f l Fi ld f Vi
Block Design
Stroop Neuropsych
Clock Drawing Test
ACLS
Rey Osterreith Complex
Figure Test
Useful Field of View
Clinical Dementia Rating
COGNISTAT
Map skills test
Figure Test
Hooper Visual
Organization Test
Rules of the Road
Road Sign Test
Mini Mental State Exam Mini Mental State Exam
Questions about Questions about
Orientation
Memory
Identification of objects
Abstract thinking
Calculations
Abilit t f ll di ti Ability to follow directions
Visual-Perceptual-Motor Skills
May not recall name of facility
Be conscious of upper extremity involvement
Consider presence of visual deficits
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Short Blessed Test Short Blessed Test
Q ti M E S X Question Max Error Score X
What year is it now? 1 X 4
What month is it now? 1 X 3
Repeat this phrase: J ohn Brown, 42 Market Street, Chicago
About what time is it? (within one hour) 1 X 3
C t b k d 20 t 1 2 X 2 Count backwards 20 to 1 2 X 2
Say the months in reverse order 2 X 2
6.Repeat the phrase just given 5 X 2
Total Error Score
Trailmaking Trailmaking
Paper pencil test Paper pencil test
Quick and easy to administer
Trails A connect numbers sequentially
Trails B connect numbers/letters
alternatively and sequentially
Assesses:
Attention Problem solving
Scanning Divided attention
Planning Attention shift
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Symbol Digit Modalities Test Symbol Digit Modalities Test
Attention
Attention Shift
Working Memory
Visual Motor
Integration
Uttl Letter Cancellation Uttl Letter Cancellation
Visual scanning tasks
Field cuts will become apparent
Consider literacy or language issues
Scored by
Ti Time
Omissions
Comissions
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Useful Field of View Useful Field of View
Visual Processing Speed
Divided Attention
Selective Attention
Evidence of predictability
for crashes
Clinical Dementia Rating Clinical Dementia Rating
Trained healthcare professional a semi-structured
i t i interview
Six cognitive-functional categories:
1- Memory
2- Orientation
3- J udgment
4- Community Affairs
5- Home & Hobbies
6 Personal Care 6- Personal Care
Five-point scale for each category:
0 = Normal (no significant problem)
0.5 = Questionable Impairment (more than just normal aging)
1 = Mild Impairment (mildly impaired relative to peers)
2 = Moderate Impairment
3 = Severe Impairment
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COGNISTAT COGNISTAT
Language
Constructional ability
Memory
Calculation skills Calculation skills
Reasoning/judgment
Block Design Block Design
Id tifi i ith Identifies issues with:
Planning
Organization
Problem solving
Frustration
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Stroop Stroop
Neuropsychological
BLUE GREEN
Neuropsychological
Screen
Paper test
Quick to administer
BLUE GREEN
GREEN BLUE
RED RED
TAN BLUE
GREEN TAN
Assesses
Selective attention
Mental flexibility
GREEN TAN
BLUE RED
Clock Drawing Test Clock Drawing Test
Tests Tests
Orientation
Conceptualization of time
Visual spatial organization
Memory
Executive function Executive function
Auditory comprehension
Visual memory
Motor programming
Numerical knowledge
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Clock Drawing Test Clock Drawing Test
All hours are place in correct numeric order starting All hours are place in correct numeric order, starting
with 12 at the top
Only the numbers 1-12 are included, no duplicates,
omissions or foreign marks
Numbers are drawn inside the clock circle
Numbers are spaced equally or nearly equally from
each other
Numbers are spaced equally or nearly equally from
the edge of the circle
One clock hand correctly points to the two oclock
Other hand correctly points to the eleven oclock
There are only two clock hands
Allen Cognitive Level Screen Allen Cognitive Level Screen
Leather lacing
Quick / easy to administer
Level 5.6 to drive safely
Poor face validity
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Rey Rey- -Osterrieth Osterrieth
Complex Figure Test Complex Figure Test
Visual memory Visual memory
Visual motor integration
Visual spatial organization
Coordination
Bilateral coordination
Attention
Frustration
(Osterrieth, 1996)
Hooper Visual Organization Test Hooper Visual Organization Test
R i i l bl f i f Requires visual assembly of pieces of a
picture to create a whole
Measures
Arousal
Visual analysis & synthesis
Concept formation
Short and long term memory
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Rules of the Road Rules of the Road
Typically a paper pencil test Typically a paper pencil test
Can be developed by the program
Should draw from state test
Research shows varied relationship to
driving driving
Problem: rules on paper learned at age
16 for first licensure
Road Sign Test Road Sign Test
Typically administered with paper/pencil Typically administered with paper/pencil
Computer based versions
Categories by shape and color
Research shows varied relationship to
driving
Problem:
Some signs are regional
Signs learned for first licensure test
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Motor Performance Assessments Motor Performance Assessments
Range of Motion Range of Motion
Dynamometer
Strength
Coordination
Proprioception
Ambulation (Rapid Pace Walk)
Transfers
Range of Motion Range of Motion
Older adults and cognitive involved Older adults and cognitive involved
clients only need a screen
Medically involved rehabilitation clients
need a thorough ROM assessment
CVA
TBI TBI
MS
Parkinsons
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Trunk/ Neck Range of Motion Trunk/ Neck Range of Motion
Rotation of trunk/neck associated with Rotation of trunk/neck associated with
and predictive of driving performance
Client seated in a chair and asked to
turn to look at a target
Observation of
Trunk rotation
Neck rotation
Eye gaze
ROM ROM
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Gross Strength Gross Strength
Use standard manual muscle testing Use standard manual muscle testing
Shoulder flexion
Shoulder abduction
Elbow flexion and extension
Hip flexion
Knee flexion and extension
Ankle dorsi and plantar flexion
Grip Strength Grip Strength
Dynamometer Dynamometer
Use standard ASHT administration
Sit in a straight-backed chair
Feet flat on the floor
Shoulders adducted in neutral
Arms unsupported Arms unsupported
Elbows flexed at 90 degrees
Forearm rotation neutral
Wrist in 0-30 degrees of dorsiflexion
Wrist in 0-15 degrees of ulnar deviation
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Coordination Coordination
Finger to nose
Foot tap
Observation during other tasks
Proprioception Proprioception
Important for right leg and foot Important for right leg and foot
Manually assess
Shoulder flexion
Shoulder internal / external rotation
Elbowflexion / extension Elbow flexion / extension
Ankle dorsi / plantar flexion
Knee flexion / extension
Hip internal / external rotation
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Rapid Pace Walk Rapid Pace Walk
Gait
Balance
Motor planning
C di ti Coordination
Ability to follow directions
Ability to initiate movement
What Does it All Mean? What Does it All Mean?
Performance on assessment tools paints a
picture
Outlines what you MIGHT see during the road
test
Clinic based tests do not definitively predict
crashes or performance yet
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What You Might See What You Might See
Deficit Area Driving Performance
Getting lost
Memory
Forgetting directions
Incorrect operation of controls
Attention
Distracted
Near misses
Tunnel vision attention
Difficulty changing lanes
Decreased speed
Problem solving
Inability to find way
Overwhelmed with change
Difficulty pulling into traffic
What You Might See What You Might See
Deficit Area Driving Performance
Poor gap acceptance
J udgment
Poor gap acceptance
Unsafe merging
Knowledge Disobedience of road signage
Decision
making
Cant choose parking space
Difficulty pulling into traffic g yp g
Visual acuity
Inability to read signs
Decreased speed
Visual spatial
Hitting curb around corners
Stopping too close/far from other cars
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What You Might See What You Might See
Deficit Area Driving Performance
Near misses
Visual field
Near misses
Poor lane keeping
Visual scanning
Poor/no reaction to obstacle
Near misses
Visual Motor
Poor lane keeping
P ti f t
Visual Motor
Poor execution of turns
Strength
Difficulty transferring
Difficulty managing key/ignition
Inability to reach top of steering wheel
What You Might See What You Might See
Deficit Area Driving Performance
Range of
Motion
Inability to reach top of steering wheel
Limited access to foot pedals
Inability to turn around for lane change
J erky steering / acceleration
Coordination Over/undershooting for controls
Delayed initiation of movement
Proprioception Mistaking accelerator for brake
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The Moral of the Story The Moral of the Story
Ch t l b d h t d t Choose your tools based on what you need to
assess
Consider the diagnosis and driving environment
Know the value of the tool
What it is measuring What it is measuring
Psychometric properties
Anticipate possible driving behaviors based on
assessment performance
Driver Driver Vehicle Fit Vehicle Fit
Ergonomic Perspective
Small drivers in large vehicles
Prevent injury through:
Proper positioning
Appropriate use of vehicle safety features
Address positioning with regard to:
Seat
Seat belt
Mirrors
Air bag
Foot pedals
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Driver Driver Vehicle Fit Guidelines Vehicle Fit Guidelines
Sit 10 12 fromairbag Sit 10-12 from airbag
Angle steering wheel at chest
Eyes at least 3 above steering wheel
Access to foot pedals
Mirrors positioned to allow greatest visual access to
environment environment
Head rest positioned no lower than ear level
Seat belt- shoulder belt crossing middle of clavicle
Seat belt- lap belt low across hips on ASIS on pelvis
Road Test Road Test
Assesses driving in naturalistic environment Assesses driving in naturalistic environment
Provides real life perceptual challenges
Sensory feedback while driving
Consequences for actions
Real life problem solving
INVALUABLE in making clinical
determinations about safety
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What Is Needed for Road Tests? What Is Needed for Road Tests?
Vehicle
Adaptive equipment
Vehicle
2 door versus 4 door
Bench seats
Steering column shifter
No center console
Mirrors
p q p
Hand controls
Steering devices
Cross over turn signals
Mirrors
Courses
Eye check
Instructors mirror
Score sheet / Criteria
Specific skills
Pass / Fail
Courses
Off road
Neighborhood
High traffic
Highway
What the Therapist Needs What the Therapist Needs
Practice, practice, practice Practice, practice, practice
Patience
Ability to multi-task
Strong nerves
Good visual, cognitive & response skills
Good communication skills
Dedication to public safety
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The Road Test The Road Test
P i l diffi l Progressively more difficult
Vehicle skills
Off road
Residential area Residential area
Higher traffic
Highway
Vehicle Skills Vehicle Skills
Transfer into vehicle Transfer into vehicle
Adjust seat
Don seatbelt
Adjust mirrors
Put key in ignition Put key in ignition
Identify turn signals
Locate wiper control
Locate horn
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Driving Skills Driving Skills
Use of vehicle controls Use of vehicle controls
Stopping
Gap Acceptance / Following Distance
Lane Keeping
Turning (left and right)
Lane changing Lane changing
Merging
Speed control
Parking
Residential Area Driving Residential Area Driving
Limited difficulty
Low traffic
Allows for further accommodation to
vehicle
Observation of basic vehicle operation
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Moderate Traffic Driving Moderate Traffic Driving
I i ti l ti d d d Increasing stimulation and demand
Avoidance of other vehicles
Observance of markings and signage
Increased need for scanning Increased need for scanning
Requires more processing
Therapist able to present challenges
Highway Driving Highway Driving
R i i Requires merging
Increased speed requires increase
processing
Hi h t d i i Higher stress driving
Negotiation around other vehicles
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Additional Driving Skills Additional Driving Skills
Route planning Route planning
Toll management
Drive ups
Location of cross streets
Multistep driving
Distractions
Response to obstacles
Interpretation and Synthesis Interpretation and Synthesis
Clients fall into one of three categories Clients fall into one of three categories
Able to drive safely
May benefit from injury prevention education
Need intervention to drive safely
Remediation
Modifications Modifications
Changes to routines
Unable to drive safely
Recommend driving cessation
Report to the state
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Discussing the Results Discussing the Results
Quiet private area Quiet, private area
With support present
Present strengths and weaknesses in skills
Give recommendation
Discuss what the recommendation means
Tell client who else will be informed
Documentation Documentation
Valuable in supporting recommendations Valuable in supporting recommendations
Continued driving
Driving cessation
Must be thorough
Consider the audience and explain when Consider the audience and explain when
necessary
Describe errors completely
Send to appropriate identified individuals