Appendix A

Disability	Effects on Driving	Suggested Driving Aids
Lack of Range of Motion - Neck	Limited ability to see the full field of traffic	Convex or rear- and sideview mirrors
General Muscle Weakness	Difficulty turning steering wheel and applying pressure to brake and clutch Difficulty applying and releasing brake	Power steering, power brakes and automatic transmission Adaptation of parking brake (for the strongest limb)
Poor Endurance, Fatigue	Inability to drive for long periods of time without rest	Power steering, power brakes, cruise control
Small Body Size	Insufficient height to see out of windows Inability to reach brake, accelerator, dimmer switch and parking brake	Specially constructed seat to raise driver (some vehicles have seat height adjustments) Extensions on brake, accelerator, dimmer switch, and parking brake or hand-operated controls
Short Legs	Inability to reach brake and accelerator Inability to operate dimmer switch and parking brake	Extension of the brake and accelerator pedals Back cushion Seat cushion Hand-operated dimmer switch and parking brake
Short Arms	Inability to reach dashboard controls and ignition Possible inability to reach gear shift and turn signal Difficulty using conventional steering wheel Difficulty performing many hand-over-hand steering maneuvers	Back cushion Extensions for dashboard controls and ignition key Extensions on gear-shift lever and turn-signal lever Steering-column extension on adjustable steering wheel Small steering wheel (requiring fewer revolutions to turn the wheel)

Driving with Chronic Conditions¹⁰³

Diagnosis	Effects on Driving	Remediation	Resources
Alzheimer's Disease/Dementia	Compromises in: Attention Processing speed Visual/spatial functioning Decision making Judgment Planning Memory Behavior Awareness of problem areas Warning signs: Driving too slowly Failure to observe signs or signals Difficulty interpreting traffic situations and predicting changes Failure to yield Easily frustrated or confused Frequently gets lost Needs instructions from passengers Poor road position or driving the wrong way down streets	Have a driver-rehabilitation specialist conduct a comprehensive evaluation (clinical plus driving) to determine extent of impairments, and level of hazard posed by driver Provide counseling (during early stages) about compensatory strategies (where and when to drive, taking a passenger), and planning for retirement from driving Because of the progressive nature of the disease, periodically re-evaluate driving safety in response to changes in the individual's level of functioning	Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, behind-the-wheel (BTW) training)
Parkinson's Disease (A disorder of the central nervous system that is slowly progressive)	Difficulty and slowness in initiating movement Resting tremors in forearms and elbow, with pill-rolling movements of the fingers Rigidity in muscles of the neck, trunk and forearm Difficulty with fine and gross motor skills While there is no loss in sensory function, there may be dementia and memory loss. People with Parkinson's may not know where they are in relation to the space around them.	Provide training focuses on compensatory techniques for decreased physical functioning (adaptive equipment is usually not needed) Evaluate the person's active range of motion to ensure that the person has the necessary range to reach controls Evaluate the person's reaction time and fine and gross motor coordination Do a cognitive assessment of the thought processes involved in driving Re-evaluate in response to significant changes in the person's level of functioning	Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (physical therapy, occupational therapy, psychologist, speech-language therapist)
Stroke (Syndrome that involves damage to brain tissue caused by a disruption of the blood supply to the brain. Which areas are affected will in part determine whether the effects of stroke are severe, moderate, or minimal, and whether they are temporary or permanent)	May affect vision perception, physical functionality, and reaction time, including: All or partial loss of muscle strength on one side of the body, and involuntary muscle movements, possibly interfering with the ability to use limbs necessary for operating primary and secondary controls; problem with sitting balance Possible partial loss of vision and/or perceptual changes, including visual field defects, inability to recognize and understand signs, signals, and markings Impaired cognitive skills, such as decision making and judgment (link to Cognitive Vitality Module) Impaired reaction time for responding to events on the roadway that require an immediate response (such as evasive maneuvers or sudden stops) Warning signs: Inappropriate driving speeds Needs help from passengers Failure to observe signs or signals Slow or poor decisions (poor judge of distances, too close to other cars) Easily frustrated or confused Pattern of getting lost, even in familiar areas Accidents or near misses Drifting across lane markings and into other lanes	Have a driver-rehabilitation specialist do a comprehensive evaluation (clinical plus driving) to determine extent of impairments Provide adaptive equipment for physical problems: Spinner knob Left-foot accelerator Right-side mounted turn-signal lever Parking-brake extension Chest harness for balance Hand-operated dimmer switch Provide physical therapy and occupational therapy (strength-building exercises) Teach compensatory scanning techniques if there is a visual field deficit Provide training, if necessary, in navigation skills Provide speech therapy for language skills (for both verbal and written information) Monitor side effects of medications and effects on driving	Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Note: Harvard and Shipp (1998) state that a person with left-sided neglect should not drive. 104
Spinal Cord Injury	Loss of strength and/or range of motion. Depending on location of injury, may affect breathing, use of arms, shoulders, hands, and legs Possible compromised visual perception and reaction time	Have a driver-rehabilitation specialist do a comprehensive evaluation (clinical plus driving) to determine extent of impairments Assess need for vehicle modifications and adaptive driving equipment, determined by the level and extent of spinal-cord involvement. Adaptive equipment may include: Reduced-effort steering systems Brake and accelerator control Joystick driving systems Mirror system for person who can't turn head Adaptive equipment/vehicle modifications for wheelchair access Monitor side effects of medications and effects on driving (Antispasmodic medication may be prescribed for a person with a high-level spinal-cord injury. Drowsiness, weakness, and fatigue are possible side effects of Valium, Dantrium, and Lioresal)	Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist)
Traumatic Brain Injury	Impairments in muscle function and joint mobility - from extensive loss of strength, range of motion, coordination, reaction abilities, and/or balance to little or no physical limitations Loss of sensation in various parts of the body Impaired problem-solving ability, judgment, memory, and attention span Impairments in ability to recognize road signs, signals and markings Impaired perceptual motor skills (spatial relationships and reaction time) Visual field deficits, resulting in inability to see whole roadway	Note: The ability to exercise sound judgment and carry out needed decision-making and problem-solving skills may be impaired to the point that reaching the goal of becoming a safe driver is unattainable. Assess what type of vehicle is needed and how the vehicle should be modified and equipped (determined by the extent of physical limitations). The adaptive equipment needs of people with traumatic brain injuries are impossible to generalize because of the uniqueness of the symptoms in each case Monitor side effects of medications and effects on driving (weakness and fatigue are possible side effects of anti-convulsant medications, such as Dilantin, Clonopin, Tegretol or Phenobarbital)	Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist)
Cerebral Palsy	Depending upon location of brain damage: Sensory and perceptual problems Intellectual impairment Seizure disorders and emotional problems Involuntary muscle movements, imbalance in muscle tone and strength The presence of spasticity may make it difficult to execute the fine motor movements needed to operate the primary and secondary driving controls. Involuntary movements may lead to inadvertent activation of the driving controls.	Determine driving potential by assessing the extent of visual/perceptual impairment, cognitive impairment and quality of muscle tone and movements Assess ability to independently get into, get properly seated in and get out of a standard-size sedan (a van equipped with the necessary adaptive driving equipment and modified to accept a wheelchair in the driver's station may be the vehicle of choice)	Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Van modification and training (if necessary)
Friedreich's Ataxia (Spinal cord and cerebellar degeneration)	Diminished muscle control Diminished ability to coordinate arms and hands because of severe tremors Visual and perceptual limitations Mental deterioration Slowed reaction time Difficulty getting into and out of a standard-size sedan	Note: The ability to coordinate the various arm and leg movements required to operate primary and secondary controls may be so impaired that attaining the goal of safe driving is impossible even with adaptive driving equipment. Because of the progressive nature of the disease, conduct periodic re-evaluation of driving ability and equipment in response to changes in the individual's level of function	Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Van modification and training (if necessary)
Multiple Sclerosis (MS) (Chronic disabling disease of the central nervous system)	Symptoms may include weakness; inability to coordinate voluntary muscular movements; losses in sensation; blurred or double vision; loss of balance; and impairments in conceptual thinking, memory, attention span and judgment	Note: The disease is unpredictable and not all people with MS experience the same symptoms, which makes it difficult to generalize adaptive equipment or training needs. Symptoms range from few to cognitive, perceptual, or sensory problems so severe that it is impossible for the person to drive safely. Periodically re-evaluate driving ability and equipment needs to track changes in level of function Conduct a complete vision exam periodically (driving could be ruled out solely on the basis of vision deficits)	Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Van modification and training (if necessary)
Muscular Dystrophy (A group of chronic, progressive diseases that result in degeneration of skeletal or voluntary musculature)	Note: The age of onset and rate of progression vary according to the type of dystrophy involved. Effects include: Weakening of the respiratory muscle, leading to endurance problems Muscle weakness in the arms, legs and trunk, leading to the need for a wheelchair for mobility Weakening of heart muscle, leading to fatigue and impairments in the ability to independently carry out activities of daily living Limited ability to reach, grasp, and operate driving controls; turn a standard steering wheel through its full circular motion; and accurately view and interpret the roadway and surroundings, because of losses in strength and flexibility Impairments in the ability to get into and out of a standard-size sedan	Determine what type of vehicle is needed: May range from a standard-size sedan with minimal adaptive driving equipment to an extensively modified van with adaptive driving equipment and modified to accept a wheelchair in the driver's station Because of the progressive nature of the disease, periodically re-evaluate driving ability and equipment needs	Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Van modification and training (if necessary)
Rheumatic Disease (Includes 100 different conditions that cause aching and pain in the joints and connective tissues throughout the body, accompanied by heat, swelling, redness, and stiffness. Three prevalent forms are rheumatoid arthritis, ankylosing spondylitis, and degenerative joint disease)	Loss of joint mobility resulting in diminished ability to reach, grasp, manipulate, and release standard and primary and secondary driving controls Diminished strength and endurance, making long-distance driving difficult	Provide adaptive equipment, depending on the parts of the body affected Provide driving equipment and adaptive aids, including extended gear lever, extended parking brake, tilt steering, power seats, power windows, power steering and power brakes Provide additional mirrors for drivers with limited ability to turn their heads Provide more extensive adaptive equipment and vehicle modifications if ability to use legs and/or arms is severely affected Monitor side effects of medications and effects on driving (people with rheumatic disease may be taking anti-inflammatory or pain-relieving medications such as Decadron, aspirin, Anaprox, Butazolidin, Clinoril, or Motrin. Potential side effects vary depending on the prescribed medication)	Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Van modification and training (if necessary)
Spina Bifida (A birth defect resulting from the failure of the vertebral canal to close normally around the posterior end of the spinal cord)	Note: Mental retardation and other cognitive disorders usually occur if hydrocephalus is not arrested early (resulting in poor attending behavior, short attention span and memory deficits) Inability to reach and operate brake and accelerator pedals, floor-mounted parking brake or floor-mounted dimmer switch because of weakness or paralysis of the leg and feet muscles Abnormal (or absent) sensation in the lower back and legs, making it difficult to independently get into or out of a car Impairment in visual/perceptual functioning, resulting in less ability to accurately perceive the roadway and its surroundings Auditory impairments (localization, discrimination and identification) Impairment in proprioceptive abilities (body scheme, right/left discrimination, spatial relationships) and kinesthetic abilities (position in space)	Conduct a visual examination to detect possible deficits in eye movement Conduct a visual/perceptual assessment Provide vehicle modifications or adaptive equipment, depending on the parts of the body affected and the loss in strength/joint mobility(Examples of adaptive equipment that may be helpful include hand controls for brake and accelerator, spinner knob, hand-operated dimmer switch and transfer board) If the person uses a wheelchair, provide an appropriately modified van	Ophthalmologist, optometrist Physiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) Van modification and training (if necessary)

Driving with Visual Impairments¹⁰⁵

Visual/Perceptual Impairment (Deficit)	Effects on Driving	Remediation	Resources
Depth Perception Impairment (Ability to judge distances)	Difficulty with timing of turns Difficulty with stopping distance Difficulty with timing of pulling out into traffic Difficulty with determining lane position Difficulty merging with traffic Difficulty judging distance Stopping too soon or going over line at intersections Difficulty in parking lots	Provide cuing hints: "When you slow down to stop, make sure you can see the back wheels of the car in front of you and some of the pavement." "If a car fills your rearview mirror, it is too close." Teach the person how to do vision aerobics	Ophthalmologist, optometrist Rehab facility with driving program (clinical evaluation, BTW training)
Acuity Impairment	Delay in responding to environment (because of difficulty in anticipating and detecting hazards) Inability to read street/highway signs and other information Increased difficulties in low-light conditions	Advise the person to get new lens prescription Provide specialized driver training	Ophthalmologist, optometrist Rehab facility with driving program (clinical evaluation, BTW training) MVA referral for low-vision driving program
Blurred or Double Vision (May be a result of the following eye diseases: Diabetic Retinopathy, Cataracts, Macular Degeneration)	Delay in ability to recognize threats Slow to recognize road signs Difficulty staying in lane Sensitivity to light and glare, making night driving difficult	Diabetic Retinopathy: Suggest ophthalmologic laser surgery or vitrectomy Macular Degeneration: Provide low-vision optical aids Cataracts: Suggest eye surgery	Ophthalmologist, optometrist Rehab facility with driving program (clinical evaluation, BTW training) MVA referral for low-vision driving program
Visual Attention/Fixation Impairment (The act of keeping one or both eyes pointed directly at an object of regard for as long as needed or requested)	Distractibility Difficulty maintaining lane position Staying at traffic signals too long	Provide Visual Attention Analyzer Provide evaluation	Family physician Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist)
Visual Field Defects (Client fails to see all relevant information or is missing a particular zone in his/her peripheral field)	Missing streets or stimuli on the impaired side Difficulty maintaining lane position Difficulty following the edge of the road May not see vehicles during quick glances for lane changes May deny the problem (See also "Peripheral Vision Impairment")	Note: Persons with visual field defects with intact visual attention capabilities will attempt to compensate for the loss by engaging visual attention. They will direct eye movements toward the side of vision loss in an attempt to gather visual information from that side. Persons with visual field cuts combined with visual inattention should not resume driving, since he or she will likely be a hazard. Encourage extra head turns and additional mirrors Provide evaluation	Family physician Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) MVA referral for low-vision driving program
Lack of Color Discrimination	Diminished ability to perceive the difference between a red and green traffic light	Encourage client to learn sequence for traffic signals and sign shapes	Ophthalmologist, optometrist State-licensed driving instructors and schools
Impairment in Ability to Accommodate and Focus (The ability to automatically, and without strain, bring near objects into clear focus. Relaxation of accommodation allows distant objects to become clear) Impairment in Convergence and Divergence (The ability to smoothly and automatically bring the eyes together to look at things closely, or move them apart to look at things at a distance)	Difficulty reading street signs Difficulty reading speed on speedometer Difficulty using information seen in mirrors Difficulty positioning vehicle in turns and curves Tendency to drive slowly in order to have the time to figure out what is happening	Teach the person how to do vision aerobics	Ophthalmologist, optometrist General rehab facility (PT, OT, psychologist, speech-language therapist)
Impairment in Ocular Motility, Range of Motion, and Pursuit Movements (The ability to coordinate and move the eyes smoothly through all planes)	Diminished ability to attend to all stimuli in the environment; will likely miss the most important information Difficulty maintaining lane position May be slow in pulling out into traffic May miss important stimuli in the environment (signs, pedestrians, bicyclists) Usually poor at dealing with intersections or cross-traffic May move eyes randomly and be distracted by any movement May appear clumsy or lack balance	Note: The level of impairment will affect client's ability to be trained/remediated. Provide evaluation and training	Ophthalmologist, optometrist Rehab facility with driving program (clinical evaluation, BTW, training) General rehab facility (PT, OT, psychologist, speech-language therapist)
Peripheral Vision Impairment	May miss important stimuli in the environment Difficulty with timing of turns Difficulty negotiating cross-traffic	Suggest wide-angle rearview mirrors Encourage more head movements Note: If the jurisdiction has a specific requirement for peripheral vision, a license may not be granted to individuals who do not meet the minimum requirement.	Ophthalmologist, optometrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) MVA referral for low-vision driving program
Impaired Figure-Ground Discrimination	Unable to distinguish foreground from background Difficulty finding stop sign among other stimuli in environment Difficulty as traffic and/or road scene increases in complexity Difficulty finding controls or dashboard information quickly	Recommend that client drive only in familiar areas, during non-rush hours Provide evaluation and training	Ophthalmologist, optometrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) State-licensed driving instructors and schools
Parts-to-Whole Deficits	Can see individual items in road scene but may not realize what's happening in the whole environment Unable to look ahead in anticipation of potential threats (e.g., may see stopped cars, police cars, and ambulances, but not recognize that there has been an accident)	Note: The level of impairment will affect prognosis for remediation. Provide evaluation and training	Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) State-licensed driving instructors and schools
Position in Space Deficits	Unsure of position as related to another object Problems particularly when close to other objects, such as in parking lots Difficulty stopping at limit line Trouble orienting vehicle when in curves or coming out of turns	Note: Problem does not usually improve significantly with cues or practice.	Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) State-licensed driving instructors and schools
Impaired Right/Left Discrimination	Confuses right and left Ends up on wrong side of road Puts wrong turn signal on	Note: Driving may be appropriate only in familiar and routine driving areas. Provide evaluation and training	Ophthalmologist, optometrist Neurologist, neuropsychologist, psychologist, psychiatrist Rehab facility with driving program (clinical evaluation, BTW training) General rehab facility (PT, OT, psychologist, speech-language therapist) State-licensed driving instructors and schools

¹⁰² NHTSA, Safe Mobility for Older People Notebook.

¹⁰³ Ibid.

¹⁰⁴Harvard, A.B., and Shipp, M.K. (1998) Disabilities and Their Implications for Driver Assessment and Training. Ruston, LA: Louisiana Tech University (reprinted/adapted with permission from Reed, K.L. (1991) Quick Reference to Occupational Therapy. New York, NY: Aspen Publishers, Inc.).

¹⁰⁵ NHTSA, Safe Mobility for Older People Notebook.