CAOT Position Statement
Occupational Therapy and Driver Rehabilitation (2009)

The Canadian Association of Occupational Therapists (CAOT) recognizes that driving promotes community mobility for individuals, families and groups. Community mobility plays an important role in health, well-being and participation. An understanding of the relationship among the person, occupation, and environment uniquely positions occupational therapists to provide valued and evidence-based services that promote driving as an occupation.

Recommendations:

1. Occupational therapists collaborate with stakeholders at national and regional levels to promote and engage in research to further our understanding of driver safety and the influence of driving and community mobility on health.
2. Occupational therapists explore opportunities for support and partnership for the expansion of a continuum of driver safety services including fitness to drive screening, driver rehabilitation and vehicle modification, and planning for driving retirement.
3. Occupational therapists continue to use and develop consensus regarding standards and protocols for driver rehabilitation in Canada.
4. Occupational therapists engage in continuing professional development to enhance their skills and knowledge in the field of driver rehabilitation.

CAOT Initiatives
CAOT will:

1. Engage and collaborate with a wide range of stakeholders such as consumer coalitions, federal, provincial and territorial governments, traffic planning agencies, non-governmental organizations and health and human service research organizations to inform and influence policy and research activities related to driver safety and driver rehabilitation services. Such activities include work to implement the National Blueprint for Injury Prevention in Older Adults.
2. Seek opportunities to work with relevant stakeholders on initiatives to promote the role of occupational therapy in driver rehabilitation and driver safety.
3. Partner with provincial and territorial occupational therapy organizations to develop strategies to promote awareness of driving as a meaningful occupation that benefits health and well-being.
4. Promote access to research-based evidence to support driver rehabilitation services.
5. Promote of the development and use of consensus protocols related to driver rehabilitation such as the Driver Safety Concern Form (CAOT, 2007) and the recommended behaviours and manoeuvers to be assessed as part of a comprehensive driving evaluation (Korner-Bitensky, Toal-Sullivan, & von Zweck, 2007a).
6. Promote learning opportunities to maintain and strengthen capacity of occupational therapists in a three-tier expertise framework:  generalist health professional training, advanced occupational therapy training, and advanced-specialized occupational therapy training.
7. Promote the development and dissemination of evidence-based resources, such as fact sheets and brochures to communicate the role of occupational therapy for driver rehabilitation, driver safety and driving retirement among all stakeholders. Dissemination methods may include publications in CAOT and other peer-reviewed journals, conferences and the CAOT website. 

Background

Occupational therapists have expertise in enabling others to attain their desired level of function and engagement in life's occupations in the areas of productivity, self-care and leisure. Because driving is itself a meaningful occupation and contributes to participation in other meaningful life occupations, occupational therapists have a long history of providing driver rehabilitation services. Research indicates that occupational therapists are the health professionals most likely to assess driving and community mobility (Korner-Bitensky, Sofer, Gélinas, & Mazer, 1998). Occupational therapists recognize that an individual's ability to drive is determined by a range of interacting factors. The Canadian Model of Occupational Performance and Engagement (Townsend & Polatajko, 2007) describes the interrelationship among the environment, occupation and individual factors and provides a framework for enabling occupation.

Driving, meaningful occupation and health
The World Health Organization (WHO) categorizes driving as a human function of daily activities and community participation (WHO, 2002). There is growing evidence regarding the link between the ability to engage in driving and individual well-being. For example, the literature indicates a correlation between driving retirement and depression and other physical deterioration (Marottoli et al., 1997; Siren, Hakamies-Blomqvist, & Lindeman, 2004). There is general acceptance that driving promotes community mobility and is a method of maintaining social networks and independence, both positive indicators of health (Hawley, 2001).

Driving safety and health status
There is growing awareness of the need to understand and evaluate the impact of health changes on an individual's ability to drive at any age. Seven provinces require physicians to report medically unfit drivers to their ministries of transportation (Canada Safety Council, 2005). Occupational therapists have an important, proactive role in enabling and extending a client's community ability by delivering intervention services, which can focus on novice driver training, cognitive and motor skill remediation, compensatory driving strategies and planning for driving retirement.  Services can be delivered to individuals or in group driver refresher programs.

The health conditions associated with aging can affect driving in several ways, including reduction of visual acuity, difficulty with depth perception, reduction of a useful field of vision, slowed reaction time and sensory processing, and increased likelihood of drug interactions. Seniors are the fastest growing segment of the driving population and driving is vital to their independence. Yet, older driver mortality and morbidity is on the rise. The leading cause of accidental deaths for persons 65 to 75 years old in Canada today is driving-related accidents. More specifically, individuals over 75 have a 3.5 times higher crash rate compared to 35 to 44 year olds (Canada Safety Council, 2005). With the senior population on the rise, it is projected that by 2040 there will be almost double the number of older drivers in Canada.

Driver rehabilitation services and occupational therapy in Canada
An understanding of the relationship among the person, occupation, and the environment uniquely positions occupational therapists to provide client-centred driver rehabilitation programs with a focus on engagement and community participation. By using evidence-based evaluation procedures, occupational therapists develop profiles of client skills, strengths and areas of concern, and combine this information with their understanding of the skills and knowledge required to drive safely. Occupational therapists also use best-evidence resources related to the environment, including innovations in vehicle modification.  Occupational therapists consider the needs of the individual driver, family and society. Occupational therapy supports safe driving through policies, programs and interventions directed toward, but not limited to, driver evaluation and retraining, novice driver training, cognitive, motor and perceptual remediation, vehicle modification and driving retirement. Occupational therapists frequently provide services as members of multi-disciplinary teams and in a variety of settings, including hospital in-patient occupational therapy departments and private practice.  Services may also be delivered in driver refresher programs for older drivers wishing to foster their own fitness to drive abilities.

Occupational therapy and driving research
Canadian occupational therapy researchers have contributed significantly to the development of research evidence for driver rehabilitation.

Driving is an issue that affects a wide cross-section of the Canadian population, which includes drivers of all ages.  A 10-year retrospective review of clients of a Canadian Driver Rehabilitation Centre found an even distribution of individuals with respect to age, with the 70 to 79 year old category having the highest representation (Klavora, Young, & Heslegrave, 2000).

Information regarding measurement tools and surveys of occupational therapy practice related to driving following a cerebral vascular accident and spinal cord injury have added valuable knowledge to the evidence base (Cimolino & Balkovec,1988; Korner-Bitensky, Sofer, Kaizer & Gélinas, 1994).  Initiatives to increase consistency of practice among Canadian occupational therapists include the dissemination of consensus statements regarding driver assessment protocols such as the Driver Safety Concern Form (CAOT, 2007). Other activities include the identification of recommended behaviours and manoeuvers to be assessed as part of a comprehensive driving evaluation (Korner-Bitensky, Toal-Sullivan, & von Zweck, 2007a), participation in driver consensus groups, reports to federal and provincial jurisdictions on the topic of driver safety, and leadership in a national older driver injury prevention project. The outcome of this project was the development of a National Blueprint for Injury Prevention in Older Adults. The Blueprint provides a strategy designed to support older adults in maintaining safe driving practice and reduce driving accident, therefore contributing to healthy living and well-being, injury prevention, reduced mortality and enhanced public safety. 

Advocacy
Research indicates that return to driving post-injury is strongly influenced by a client's significant others' opinions as to his or her fitness to drive (Coleman, Rapport, Ergh, Ricker, & Mills, 2002). This finding supports occupational therapy's role in advocating for the client and educating the family when driving is a reasonable client-identified goal.

Certification
All registered occupational therapists in Canada should have the knowledge and skills to deliver some driver evaluation and rehabilitation services.  CAOT endorses a three-tier expertise framework; generalist health professional training, advanced occupational therapy training, and advanced-specialized occupational therapy training (Korner-Bitensky, Toal-Sullivan & von Zweck, 2007b). The occupational therapy generalist has a skill set that enables addressing the subskills of driving, such as range of motion and fine and gross motor function. An occupational therapist with advanced training in driver rehabilitation may assess more detailed aspects of driving, such as visual scanning and the use of adaptive equipment. An occupational therapist with additional specialized training may deliver in-depth pre-driving assessments and on-road evaluations with a registered driving instructor (Davis, 2003), and may be certified as a recognized driver rehabilitation specialist. However, there may be a growing expectation for those delivering driver rehabilitation services to become certified driver rehabilitation specialists in order to demonstrate a recognized level of competency. Limited certification options are available in Canada to allow occupational therapists to gain advanced skills in driver evaluation, vehicle modification, and motor and perceptual remediation.

References
Canada Safety Council (2005). Seniors behind the wheel. Retrieved February 24, 2009, from http://www.safety-council.org/news/sc/2000/senior_wheel.html.

Canadian Association of Occupational Therapists (2007).  Driver Safety Concern Form. Retrieved February 24, 2009, from http://www.caot.ca/pdfs/Recommendation2.pdf.

Cimolino, N., & Balkovec, D. (1988). The contribution of a driving simulator in the driving evaluation of CVA. Canadian Journal of Occupational Therapy 55(3), 119-125.

Coleman, R.D., Rapport, L.J., Ergh, T.C., Ricker, J.H., & Mills, S.R. (2002). Predictors of driving outcome after traumatic brain injury. Archives of Physical Medicine Rehabilitation, 83(10), 1451-22.

Davis, E.S. (2003).  Defining OT roles in driving. OT Practice, 13, 15-18.

Hawley, C. A. (2001.) Return to driving after head injury. Journal of Neurology, Neurosurgery and Psychiatry (70), 761-766.

Klavora, P., Young, M.,  & Heslegrave, R. (2000).  A review of a major driver rehabilitation centre: a ten-year client profile. Canadian Journal of Occupational Therapy, 67(2), 128-134.

Korner-Bitensky, N., Sofer, S., Kaizer, F., Gélinas, I., & Talbot, L. (1994). Assessing ability to drive following an acute neurological event: Are we on the right road? Canadian Journal of Occupational Therapy 61(3), 141-148.

Korner-Bitensky, N., Sofer, S., Gélinas, I., & Mazer, B.L. (1998). Evaluating driving potential in persons with stroke: A survey of occupational therapy practices. American Journal of Occupational Therapy, 52(10), 916-919.

Korner-Bitensky, N., Toal-Sullivan, D., & von Zweck, C. (2007a). Driving and older adults: A focus on assessment by occupational therapists. Occupational Therapy Now, 9(5), 10-12.

Korner-Bitensky, N., Toal-Sullivan, D., & von Zweck, C. (2007b).  Driving and older adults: Towards a national occupational therapy strategy for screening.  Occupational Therapy Now, 9(4), 3-5.

Marottoli, R.A., Mendes de Leon, C.F., Glass, T.A., Williams, C.S., Cooney, L.M. Jr., Berkman, L.F., & Tinetti, M.E. (1997). Driving cessation and increased depressive symptoms: prospective evidence from the New Haven Established Populations for Epidemiologic Studies of the Elderly. Journal of the American Geriatric Society, 45(2), 202-206.

Siren, A., Hakamies-Blomqvist, L., & Lindeman, M. (2004). Driving cessation and health in older women. Journal of Applied Gerontology, 23(1), 58-69.

Townsend, E. & Polatajko, H. (2007).  Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation.  Ottawa, ON: CAOT Publications ACE.

World Health Organization. (2002). Towards a common language for functioning, disability and health: ICF. Retrieved October 17, 2004, from http://www3.who.int/icf/beginners/bg.pdf.

Position statements are on political, ethical and social issues that impact on client welfare, the profession of occupational therapy or CAOT. If they are to be distributed past two years of the publication date, please contact the Director of Professional Practice, CAOT National Office, CTTC Building, 3400-1125 Colonel By Drive, Ottawa, ON. K1S 5R1. Tel. (613) 523-2268 or e-mail: practice@caot.ca.

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