Rules of the Road

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April 2003

By Cathy Brighton, OT

A power mobility device (PMD) may be the most valuable piece of equipment that a rehabilitation therapist can procure for a client with mobility issues. Improvement in quality of life may be drastic and is often apparent the first time the person moves along the sidewalk. However, a PMD can also be a danger to the client and the general public when not handled safely. Use of a PMD in crowded areas, along roadways, or in traffic has inherent risks. Recent reports document injuries and deaths resulting from crashes between motor vehicles and PMD drivers. Use of PMDs is largely unregulated by any government body. There is now a heightened awareness among therapists to provide power mobility assessments that manage the risks for clients, the public, and therapists.

Rehab therapists are routinely identified as the experts who can identify the most appropriate mobility aid. If a PMD is under consideration, the therapist should assess a client’s ability to use the PMD in order to determine if it is the appropriate recommendation and then prescribe the appropriate model and features.

Currently, there are no proven predictors of skill levels required to operate a PMD. After 20 years of automobile driving research, the same is true of cars. Therefore, one of the best approaches is to perform an assessment that reflects the skills involved in driving a PMD, address the issues, and, if clinical reasoning indicates it is feasible, proceed with “on-road” assessment.

THE PMAX PROJECT

In 1999, the North Shore Health Region in British Columbia supported the author in undertaking a project to develop a Power Mobility Assessment intended for use by community therapists. A multi-faceted review of the literature failed to find an assessment that reflects the less obvious but nonetheless important components of driving that affect competency. Research that looks at determinants of competency in drivers of PMDs appeared to be nonexistent.

The result of this project is the North Shore Health Power Mobility Assessment (PMAX). The PMAX provides the therapist with a consistent assessment process. Unlike a recipe-type assessment, with the PMAX, the therapist follows the assessment like a guideline, using clinical reasoning to select the components that will adequately assess the individual’s needs.

The PMAX screens aspects of vision, perception, cognition, and behavior that are highly relevant to driving a PMD. The selection of screening tools was supported by evidence in driver research. Screening provides both qualitative and quantitative information to support a recommendation. It helps identify specific areas of performance that require further training. It includes client education material, which addresses the “rules of the road.” It results in a recommendation based on clinical reasoning as well as objective information (see Table 1).

Table 1. PMAX predriving assessment screens.

ON OR OFF THE ROAD

It is incumbent upon therapists to meet their professional practice standard. Assessment should always be relevant to the skills involved in the activity. Knowing that there are physical, perceptual, and cognitive components to driving, it is important to provide an assessment that includes these areas. Due to the complexity of skills, it is not feasible to assess every skill relevant to driving but it may be viewed as negligence not to screen the skills within the scope of the professional practice. Assessment should follow a clear, consistent process for every client that will withstand a legal challenge. The PMAX is a tool that provides a consistent assessment process.

Assessment generally begins with an interview and functional assessment of physical and cognitive abilities. This identifies the client’s goals, issues, and functional status. The therapist uses clinical reasoning to formulate ideas about the type of PMD that may suit the client’s needs. However, prior to going forward with an “on-road” assessment, it is critical to do a predriving assessment that includes hearing, vision, perception, decision making, memory, judgment, and level of self-awareness. It is essential to screen in this order, as hearing impacts all screening, visual impairment can impact perceptual testing, and perceptual impairment can impact the results of cognitive screening. Self-awareness is key in overcoming impairments and should also be considered throughout the process.

The therapist should be vigilant in keeping the client informed throughout the assessment process in order to maintain informed consent. This is of greater value than a written consent that may be determined later to be misunderstood by the client and therefore meaningless. The client must be made aware of the therapist’s role and responsibilities in the process—in that decisions are based on clinical reasoning and the final report must include favorable and unfavorable information; and that the information collected during the assessment will be shared with funding sources, health care team members, and other appropriate persons—and of any appeal process, should the client disagree with the results and recommendations.

Some rationales for including a predriving assessment are that it provides information to mitigate risks and critical information regarding the client’s mental capacity. Also, the referring source may not detail all pertinent information. The therapist may not know the client and there may be little opportunity to observe functionally prior to assessment. It assists the therapist in deciding if there are issues that should be further assessed, it assists the therapist in planning the “on-road” to meet the client’s abilities, and it provides insight to the client and/or family members regarding the client’s skills.

If the decision is made to proceed with an on-road assessment, the therapist must provide the client with suitable educational information about safe practices and before the test occurs. This can take the form of a brochure, video, or instruction. The client should be asked to become familiar with the material before the on-road assessment. Doing so reduces any new learning that may be involved, ensuring that the client has every opportunity to perform safely. Further, it reduces most of the real risks that are associated with the on-road assessment. If new learning is involved, the therapist cannot expect a client to perform safely if adequate training information is not provided. Ideally, the PMD should be equipped with a “kill switch” in order to intervene when approximately 300 pounds (PMD and driver) are moving toward a dangerous situation. The therapist should plan the session to meet the client’s abilities based on a predriving assessment.

The “on-road” assessment should be tailored to the client’s intended use for the PMD. General driving skills should be addressed along with the specific maneuvers required in the individual’s environment. The therapist should make observations of the person-environment interaction. It should progress from quiet to busy environments, according to the client’s abilities. Despite the pressure of time, the therapist should not proceed faster than the client’s abilities demonstrate. The technical expertise of a medical supplier can complement the therapist in finding solutions that best suit the client’s needs. It is essential, however, that the therapist take the lead in determining the plan of the on-road assessment, as ultimately the therapist will be responsible for the assessment and must support recommendations according to the results.

The environment should be observed for its feasibility for safe PMD use. The combination of driver skill and environmental challenges should be weighed together using clinical reasoning. Occasionally, hazardous environments may present unacceptable risks and preclude power mobility as an option for even the most competent drivers. The combination of a client with only fair divided attention skills living in an area with heavy pedestrian and car traffic would pose a high risk. The same client could manage well in a different environment.

Assessment should conclude with an interview to discuss the outcome. The final recommendation should be supported with objective screening results and on-road assessment performance. The therapist can report only on the performance observed and cannot ensure that the client will always choose to follow the rules of the road. A time frame for follow-up should be included.

ROADBLOCKS AND SAFE ROUTES

A therapist must be confident that the client is competent; however, determining mental capacity to drive a PMD is tricky. Generally, a client is considered mentally competent and responsible for their behaviors until there is evidence otherwise. A mentally competent individual may be seen as one who is able to comprehend the nature of a particular conduct in question and to understand its quality and its consequences. In contrast, a mentally incompetent person may be unable to understand or to act knowingly upon information provided. Knowing the client can accept responsibility for his or her actions ensures that precautions established for safe operation information can be provided and reviewed with the client.

If the therapist has concerns regarding the client’s capacity, power mobility would have to be declined or deferred until collaborative information ruled out incompetence. In this case, the therapist has a professional obligation to address their concerns within their scope of practice. The concern should be discussed with the client. This may result in: further assessment by the therapist, referral to an appropriate resource with expertise to address the issue, or collaboration with appropriate health team members.

Issues such as hearing or vision impairments, perceptual deficits, dementia, alcohol use, impulsivity, mental slowness, and environmental challenges can result in unsafe handling of a PMD, which puts the client and public at risk. These issues should be addressed consistently in the assessment process. Clinical reasoning should guide the therapist as to the depth of assessment needed. For example, taking cognitive screening tests would be time wasted for a client who operates several remote controls simultaneously in his living room while working on his computer. Conversely, a therapist’s practice may be questioned if assessment fails to identify an impairment such as significant hearing loss. In such a case, the therapist should teach compensatory strategies and ensure the client understands the importance of wearing hearing aids.

When a client is unable to operate the PMD independently but has insight and shows potential to benefit from training, the therapist may recommend a training period and a follow-up evaluation to reassess “on-road.” This would involve identifying someone to provide the training and setting up the parameters of the training. The client and trainer should understand and accept that there are risks involved.

If a client is unable to operate a PMD safely and independently, the decision to recommend a PMD should be weighed heavily against the risks of injury to the client or others. A support person may volunteer to supervise the client at all times. With the best intentions, this can still lead to danger in unpredictable conditions.

Alcohol use poses risks to safe driving but should not be the reason to deny a PMD. If the client is competent, he or she must take personal responsibility for their actions. However, the therapist should routinely provide information explaining safe use of a PMD, which includes instructions not to “drive while under the influence.”

Dementia may raise concerns but screening and functional performance should be used. Unfortunately, there are no proven parameters for driving cessation when dementia is present.

A recommended rule of thumb is “if in doubt, collaborate.” The most difficult decisions are better made with more information. It is helpful to advise clients that they can be held personally liable for damages they may incur and to seek the advice of their household insurer. Support persons and family doctors should be included in decision-making.

CONCLUSION

It is often an easy clinical decision for a therapist when a client is clearly competent or clearly not a suitable candidate for power mobility. However, when it is not clearly evident, the therapist will meet the needs of all concerned by providing an assessment that reflects the skills of driving. Until research provides clearer guidance, a consistent assessment process that reflects the skills of driving can be considered the best practice possible.

The PMAX has been available for use since June 2000 and has been distributed in Canada and the United States. It has been presented at several conferences and workshops, and it is an evolving tool, which requires research validation. Preliminary research is planned to determine efficacy.

Cathy Brighton, OT, is a consultant for Veterans Affairs Canada. For further information or to get a copy of the PMAX, contact her via email at c.brighton@shaw.ca or by mail: 245 East Windsor Rd, North Vancouver, BC, Canada, V7N 1K2.

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