Marilyn Di Stefano

Individualized Assessment of Driving Fitness for Older Individuals with Health, Disability, and Age-Related Concerns

Objective. Driver licensing agencies are faced with an increasing population of drivers who are seeking to maintain driving privileges whilst coping with functional changes associated with health, disability, or aging-related issues. Some of these changes impact upon the motor, sensory, and cognitive capacities essential for safe motor vehicle operation. The driver assessment process, as provided by occupational therapists and other professionals trained in the techniques of driver rehabilitation, can provide objective data to identify driver strengths and limitations and options available to increase mobility independence via consideration of adaptive mobility equipment, vehicle choice, driver training, or alternative transportation if necessary. This article provides an overview of the driver rehabilitation specialists assessment and training process, with an analysis of the key issues related to this form of assessment and the need for further research. Results/Discussion. The basic driver rehabilitation process is outlined including examples of common deficits, assessment considerations, and intervention approaches. The clinical and on-road assessment procedures are described, with illustrations of the reasoning process that leads to a determination of the persons overall driving competence and rehabilitation recommendations. A review of the literature is provided that examines the currently available documentation that supports this assessment and rehabilitation process. Conclusion. The article concludes with a review of current literature that examines the claim that detailed clinical and on-road assessment, as provided by driver rehabilitation specialists, is currently the best method for assisting drivers with complex health, disability, or aging-related issues to resume or retain driving privileges.

On the road again after traumatic brain injury: driver safety and behaviour following on-road assessment and rehabilitation.

Abstract Purpose: To examine pre- and post-injury self-reported driver behaviour and safety in individuals with traumatic brain injury (TBI) who returned to driving after occupational therapy driver assessment and on-road rehabilitation. Method: A self-report questionnaire, administered at an average of 4.5 years after completing an on-road driver assessment, documenting pre- and post-injury crash rates, near-crashes, frequency of driving, distances driven, driving conditions avoided and navigation skills, was completed by 106 participants, who had either passed the initial driver assessment (pass group n = 74), or required driver rehabilitation, prior to subsequent assessments (rehabilitation group n = 32). Results: No significant difference was found between pre- and post-injury crash rates. Compared to pre-injury, 36.8% of drivers reported limiting driving time, 40.6% drove more slowly, 41.5% reported greater difficulty with navigating and 20.0% reported more near-crashes. The rehabilitation group (with greater injury severity) was significantly more likely to drive less frequently, shorter distances, avoid: driving with passengers, busy traffic, night and freeway driving than the pass group. Conclusions: Many drivers with moderate/severe TBI who completed a driver assessment and rehabilitation program at least 3 months post-injury, reported modifying their driving behaviour, and did not report more crashes compared to pre-injury. On-road driver training and training in navigation may be important interventions in driver rehabilitation programs. Implications for Rehabilitation Driver assessment and on-road retraining are important aspects of rehabilitation following traumatic brain injury. Many drivers with moderate/severe TBI, reported modifying their driving behaviour to compensate for ongoing impairment and continued to drive safely in the longer term. Navigational difficulties were commonly experienced following TBI, suggesting that training in navigation may be an important aspect of driver rehabilitation.

Predictors of On-Road Driver Performance Following Traumatic Brain Injury

OBJECTIVE To examine assessment outcomes and factors associated with passing an occupational therapy (OT) on-road driver assessment after traumatic brain injury (TBI). DESIGN Retrospective analysis of outcomes of on-road driver assessment completed by persons with TBI over an 8-year period. SETTING Inpatient and outpatient rehabilitation hospital. PARTICIPANTS A consecutive sample of individuals (N=207) with mild to severe TBI who completed an on-road driver assessment and were assessed at least 3 months postinjury. INTERVENTION Not applicable. MAIN OUTCOME MEASURE Outcome of on-road driver assessment. RESULTS Of the drivers with TBI, 66% (n=137) passed the initial on-road driver assessment (pass group), whereas 34% (n=70) required on-road driver rehabilitation and/or ≥1 on-road assessment (rehabilitation group). After driver rehabilitation, only 3 participants of the group did not resume driving. Participants who were men, had shorter posttraumatic amnesia (PTA) duration, had no physical and/or visual impairment, and had faster reaction times were significantly more likely to be in the pass group. In combination, these variables correctly classified 87.6% of the pass group and 71.2% of the rehabilitation group. CONCLUSIONS PTA duration proved to be a better predictor of driver assessment outcome than Glasgow Coma Scale score. In combination with the presence of physical/visual impairment and slowed reaction times, PTA could assist clinicians to determine referral criteria for OT driver assessment. On-road driver rehabilitation followed by on-road reassessment were associated with a high probability of return to driving after TBI.

Measurement properties of the Personal Care Participation Assessment and Resource Tool: a systematic review

Purpose: To systematically review research investigating measurement properties of the Personal Care Participation Assessment and Resource Tool (PC-PART), formerly the Handicap Assessment and Resource Tool (HART). Data sources: Seven databases were searched using (i) HART or PC-PART terms and (ii) known authors. Reference list searches, citation searches and author contact were secondary search methods. Study selection: Searches retrieved 492 articles. Those investigating at least one HART or PC-PART measurement property were selected. Three articles met review criteria. Secondary searching produced four additional studies. Data extraction: Two reviewers independently critiqued each article, using published quality criteria for (i) study methods and (ii) each measurement property. Results: There was positive evidence supporting content validity of the PC-PART in adult in-patient and community based, sub/acute health settings. Clinical utility was largely supported. There was inconclusive evidence for inter-rater reliability, construct validity and responsiveness. Conclusions: The PC-PART shows promise as a clinically relevant and useful assessment to aid decision making about admission or discharge from health care settings. Further research is needed to establish the PC-PART’s place in clinical practice across a range of patient groups and settings using sound methods to investigate structural validity, reliability, criterion validity, construct validity, clinical utility and responsiveness. Implications for Rehabilitation The PC-PART was designed to assess patients’ participation restrictions in necessary Personal and Instrumental Activities of Daily Living (PADL and IADL) for community living. The assessment may aid rehabilitation team decision making about priorities for intervention and readiness for discharge. Although there is strong evidence to support content validity, further testing of the PC-PART’s measurement properties is warranted to strengthen evidence to support its use.

Supporting individuals to make informed personal mobility choices : development and trial of an evidence-based community mobility education program.

Individuals want to make informed choices about mobility transitions to retain dignity and independence as they age. The Transport Accident Commission initiated the development, trial, and evaluation of a health promotion education program to meet this need. A participative model was applied and program instruction goals focused on community and driver safety, how health and aging influence transportation independence, mobility options, and resources. Data collected from 94 individuals yielded positive outcomes: the target group was reached (90% were 60 years or older), community mobility information was retained, and participants were satisfied with program content and resources.

Driving Task: How Older Drivers' On-Road Driving Performance Relates to Abilities, Perceptions, and Restrictions.

RÉSUMÉ: Cette étude a examiné une cohorte de 227 conducteurs âgés et a étudié la relation entre leur performance sur la grille d’observation e-DOS pour manoeuvres de conduite et (1) les caractéristiques des conducteurs; (2) les capacités fonctionnelles; (3) les perceptions des capacités et le confort pendant la conduite, ainsi que (4) les restrictions auto-déclarées de la conduite. Les participants (hommes: 70%; âge: M = 81.53 ans, É-T = 3,37 ans) a achevé une série de mesures de la capacité fonctionnelle et d’écailles sur le confort, les capacités et les restrictions aperçut du Candrive / Ozcandrive protocole d’évaluation Année 2, avec une tâche de conduite e-DOS. Les observations des comportements de conduite des participants au cours de la tâche de conduite ont été enregistrées pour: la négociation au carrefour, le changement de voie, la fusion, les manoeuvres à basse vitesse, et la conduite sans manoeuvres. Les scores de conduite e-DOS étaient élevés (M = 94,74; É-T = 5,70) et étaient liés d’une façon significative aux capacité de conduite perçu des participants, la fréquence rapporté de la conduite dans des situations difficiles, et le nombre de restrictions de la conduite. Les analyses futures exploreront les changements potentiels dans les scores de tâches de conduite au fil du temps. ABSTRACT: This study examined a cohort of 227 older drivers and investigated the relationship between performance on the electronic Driver Observation Schedule (eDOS) driving task and: (1) driver characteristics; (2) functional abilities; (3) perceptions of driving comfort and abilities; and (4) self-reported driving restrictions. Participants (male: 70%; age: M = 81.53 years, SD = 3.37 years) completed a series of functional ability measures and scales on perceived driving comfort, abilities, and driving restrictions from the Year 2 Candrive/Ozcandrive assessment protocol, along with an eDOS driving task. Observations of participants’ driving behaviours during the driving task were recorded for intersection negotiation, lane-changing, merging, low-speed maneuvers, and maneuver-free driving. eDOS driving task scores were high (M = 94.74; SD = 5.70) and significantly related to participants’ perceived driving abilities, reported frequency of driving in challenging situations, and number of driving restrictions. Future analyses will explore potential changes in driving task scores over time.

Evaluation of the internal construct validity of the Personal Care Participation Assessment and Resource Tool (PC-PART) using Rasch analysis

BackgroundThe Personal Care Participation Assessment and Resource Tool (PC-PART) is a 43-item, clinician-administered assessment, designed to identify patients’ unmet needs (participation restrictions) in activities of daily living (ADL) required for community life. This information is important for identifying problems that need addressing to enable, for example, discharge from inpatient settings to community living. The objective of this study was to evaluate internal construct validity of the PC-PART using Rasch methods.MethodsFit to the Rasch model was evaluated for 41 PC-PART items, assessing threshold ordering, overall model fit, individual item fit, person fit, internal consistency, Differential Item Functioning (DIF), targeting of items and dimensionality. Data used in this research were taken from admission data from a randomised controlled trial conducted at two publically funded inpatient rehabilitation units in Melbourne, Australia, with 996 participants (63% women; mean age 74 years) and with various impairment types.ResultsPC-PART items assessed as one scale, and original PC-PART domains evaluated as separate scales, demonstrated poor fit to the Rasch model. Adequate fit to the Rasch model was achieved in two newly formed PC-PART scales: Self-Care (16 items) and Domestic Life (14 items). Both scales were unidimensional, had acceptable internal consistency (PSI =0.85, 0.76, respectively) and well-targeted items.ConclusionsRasch analysis did not support conventional summation of all PC-PART item scores to create a total score. However, internal construct validity of the newly formed PC-PART scales, Self-Care and Domestic Life, was supported. Their Rasch-derived scores provided interval-level measurement enabling summation of scores to form a total score on each scale. These scales may assist clinicians, managers and researchers in rehabilitation settings to assess and measure changes in ADL participation restrictions relevant to community living.Trial registrationData used in this research were gathered during a registered randomised controlled trial: Australian and New Zealand Clinical Trials Registry ACTRN12609000973213. Ethics committee approval was gained for secondary analysis of data for this study.

Measurement of activity limitations and participation restrictions: examination of ICF-linked content and scale properties of the FIM and PC-PART instruments.

Abstract Purpose: To explore the operationalization of activity and participation-related measurement constructs through comparison of item phrasing, item response categories and scoring (scale properties) for two separate instruments targeting activities of daily living. Method: Personal Care Participation Assessment and Resource Tool (PC-PART) item content was linked to ICF categories using established linking rules. Previously reported ICF-linked FIM content categories and ICF-linked PC-PART content categories were compared to identify common ICF categories between the instruments. Scale properties of both instruments were compared using a patient scenario to explore the instruments’ separate measurement constructs. Results: The PC-PART and FIM shared 15 of the 53 level two ICF-linked categories identified across both instruments. Examination of the instruments’ scale properties for items with overlapping ICF content, and exploration through a patient scenario, provided supportive evidence that the instruments measure different constructs. Conclusions: While the PC-PART and FIM share common ICF-linked content, they measure separate constructs. Measurement construct was influenced by the instruments’ scale properties. The FIM was observed to measure activity limitations and the PC-PART measured participation restrictions. Scrutiny of instruments’ scale properties in addition to item content is critical in the operationalization of activity and participation-related measurement constructs. Implications for Rehabilitation When selecting outcome measures for use in rehabilitation it is necessary to examine both the content of the instruments’ items and item phrasing, response categories and scoring, to clarify the construct being measured. Measurement of activity limitations as well as participation restrictions in activities of daily living required for community life provides a more comprehensive measurement of rehabilitation outcomes than measurement of either construct alone. To measure the effects of interventions used in rehabilitation, it is necessary to select measures with relevant content and scale properties that enable evaluation of change in the constructs that are expected to change, as a result of the rehabilitation intervention.

Interventions for resuming driving after traumatic brain injury

Abstract Purpose: To describe the goals, processes, resources and outcomes of on-road training lessons provided to drivers with traumatic brain injury (TBI) who failed an initial occupational therapy (OT) driver assessment. Method: Descriptive cohort study using file audit design of 340 drivers with mild to severe TBI. Measures included; number and goals of on-road training lessons and reassessments, time from injury to independent driving, license restrictions, years licensed, physical/visual impairments and injury severity. Results: Initial OT driver assessment was passed by 72% (n = 246) cases. Of the 28% (n = 94) who failed, 93% (n = 87) resumed driving following on-road training; 42 (45%) with an open licence, 45 (48%) with restricted licence and seven (7%) failed to meet licencing standards. Individuals required, on average, 7.0 driving lessons (14 driving instructor hours), and 2.5 on-road reassessments, (9.8 OT and 3.8 driving instructor hours). Lesson goals were recommended to develop compensatory strategies for cognitive impairments (64%), improve previously learned driving skills (57%), improve confidence (53%), and address physical (26%) or visual impairment (16%). Conclusions: Investment in on-road training lessons addressing individual goals, followed by reassessment and use of restricted licenses, can achieve successful return to driving following TBI. Implications for Rehabilitation Driver rehabilitation specialists should offer on-road driver training to individuals with moderate to severe TBI who fail an initial driver assessment. Goal directed driving lessons can train individuals with moderate to severe TBI to compensate for cognitive, physical, visual, and psychological barriers to driving, enabling them to pass a reassessment and return to driving. Restricted licences may enable some drivers with TBI to meet their driving needs and achieve safe return to driving.

Personal Care Participation Assessment and Resource Tool: Clinical utility for inpatient rehabilitation

Background. Evidence supports validity of the Personal Care Participation Assessment and Resource Tool (PC-PART), but clinical utility remains unverified. Purpose. This study aimed to investigate occupational therapists’ perceptions about the PC-PART’s clinical utility for inpatient rehabilitation. Method. Using mixed methods, occupational therapists who had used the PC-PART as part of a research study in an inpatient rehabilitation setting completed a questionnaire (n = 9) and participated in a focus group (n = 6) to explore their perspectives about its clinical utility. Quantitative data were summarized and qualitative data analyzed using inductive thematic analysis. Findings. Quantitative data highlighted both positive and negative aspects of the PC-PART’s clinical utility. Five themes emerged from the qualitative data: nature of information gathered; familiarity with the instrument; perceived time and effort; item phrasing, interpretation, and presentation; and external influences on clinical use. Implications. The PC-PART was perceived to support gathering of clinically useful information, helpful to intervention and discharge planning. Recommendations for improving some item phrasing, operational definitions, and instructions were identified. Although standardized assessments were valued, use in routine practice was challenging, requiring a knowledge translation strategy.