Beth Rolland, OTR, CDRS, CBIS, is a senior occupational therapists at Upstate University Medical Center. She is the President-elect of the Association for Driver Rehabilitation Specialists (ADED). She is has taught at Seton Hall, Columbia University and Kean University. Additionally, she is a lecturer at La Moyne College, Utica College, Cayuga College. She frequently speaks on the topic of Driving Rehabilitation.
Beth, first of all, I want to thank you for taking the time to have this interview with “Brain Injury Professional”. I am Dr. Nathan Zasler, one of the co-editors of the publication as well as Vice Chair of the International Brain Injury Association. Welcome.
My first question for you Beth is can you give our readers a brief summary of your experience in the realm of driver evaluation and acquired brain injury and where you started and where it has taken you?
Yes, absolutely. I graduated with my degree in Occupational Therapy from Columbia University in 1997 and began working at Kessler Institute for Rehabilitation in northern New Jersey. I learned quite a bit about how to evaluate and treat vision deficits, cognitive deficits and physical deficits that often accompany brain injury. In 2000, I started a satellite driving program in Saddle Brook, New Jersey. I ran that program for 16 years before I moved to Syracuse, New York where I live now. Currently my facility does not have a vehicle, but I am performing clinical pre-driving evaluations. I have been involved with driving rehabilitation on a national level for quite a few years. I have sat on the Board of Directors twice, first as a Member at Large and now as President Elect. I have also served on and chaired several committees, including the research committee, which I formed as an ad hoc in 2010. I realized there was a need for the national organization to start looking more at evidence-based practice, and to integrate research into our process. The committee was recently upgraded to a standing board committee three years ago. Many of our members would love to be involved with research but are not supported by their place of employment. It is a goal to connect these practitioners with academic researchers to collaborate on projects. It will be benefit all of us if we work together. I am currently spearheading an ad hoc committee that is working on gathering education, resources and research in the field of driving rehabilitation to look at what we have and what we are missing.
Congratulations on that! For those readers who are not familiar with ADED, can you tell us a bit about the organization, what the acronym stands for and what the goals of the organization are, please?
The acronym ADED is a bit misleading. The organization’s initial name was the Association of Driver Educators for the Disabled. At some point the name was changed to the Association for Driving Rehabilitation Specialists, which more accurately reflects our clientele, but the acronym remains. ADED was established in 1977 to support professionals working in the field of driver education, driver training and transportation equipment modifications for persons with disabilities and persons experiencing the aging process.
It supports therapists who are working in driver rehabilitation, manufacturers of adaptive equipment, and mobility equipment dealers who install adaptive equipment in vehicles through education, information dissemination and a certification program for professionals. ADED has been building its base of educational offerings. Every year there is a conference providing up to 30 hours of continuing education on a wide variety of topics as well as an exhibit hall full of the latest adaptive vehicles, equipment, and tools of the trade. It’s a great opportunity to see how things work and learn about the latest techniques and research, as well as network with other professionals in the field. ADED also offers two-day courses that are given around the country apart from the conference, as well as online education.
Let me shift to a different question regarding ADED. From a mission standpoint I know one of thegoals is to establish some basic parameters for how these evaluations are done. Can you tell us a little bit about what ADED has done in that direction?
DED has both a Code of Ethics and a Best Practices document, which outline the standards expected for providing driver rehabilitation services. The Best Practices document outlines the entire process of working with a client, including what should be included in an evaluation in both the clinic and in the vehicle. These documents help to guide practice and are updated regularly to reflect the best, evidence-based information.
Good and is there a revision planned or is that an ongoing evolution process?
There is a revision every few years on a regular cycle. Best Practices is almost due for another revision.
Great and how does that compare with the activities of AOTA relative to driving assessment?
While the majority of Certified Driving Rehabilitation Specialists (CDRS) through ADED are Occupational Therapists, ADED has a diverse membership that includes other healthcare professionals and driver educators as well. AOTA’s certification in Driving and Community Mobility is open only to Occupational Therapists and has a broader focus encompassing clinical interventions not specifically related to driving. AOTA’s certification is portfolio based rather than exam based. They have made a concerted effort to empower generalist OT’s who are not specializing in driving to address a client’s mobility needs and determine who would best benefit from a referral to a driving specialist in order to make use of limited resources. There are not enough of us out there to meet the need.
Let me shift gears a bit and ask you as a therapist who does this sort of work, what do you see as the major challenges with assessing people with acquired brain injury?
One of the greatest challenges is that we don’t have a clinical tool to assess cognition that will definitively tell you who will be safe to drive and who will not. As of now, there is no test or group of tests that has a high enough degree of confidence based on research to make a decision without putting someone behind the wheel. It is fairly easy for a driver rehabilitation specialist to determine who will need adaptive equipment to compensate for physical deficits, but with cognition it can be very difficult to assess that adequately outside the vehicle. This is one of the problems with not having enough evaluators with behind the wheel programs. One of ADED’s goals has been to move practitioners away from some of the older tests that research has shown NOT to have correlation to behind the wheel predictability and towards the ones that do. There are members who are striving to find that research and to do that research. Eventually, we may see a standardized assessment, but there are some researchers who believe that we may need to use a different cognitive battery with different populations in order to achieve the best validity.
My concern as a brain injury medicine subspecialist is the absence of a more standardized evaluation process whether off road or on road for people with brain injury related impairments. Any thoughts on this issue?
Yes. It is also difficult to standardize a behind the wheel evaluation. Driving in Manhattan, for instance, is very different from driving in the farmlands of Oklahoma, or in the Rocky Mountains in the snow. Even if you have the same route for everyone, traffic is different every single time you drive it. Pedestrians and bicycles are different every time. Traffic lights are different. Road conditions are different based on the weather. Drivers around you are making different good and bad choices. A driver needs to be able to handle the challenges unique to the roads on which they drive, so a standardized route is not necessarily the best scenario. There are recommendations for setting up a route in your particular area which include having a certain number of left turns, and including stretches of highway and also unstructured driving, which can be particularly challenging for some patients who have had brain injuries.
Researchers have been moving towards using simulators to provide the same route every time and provide some standardization. I think simulators are a terrific tool for research and training. They are not yet at the level they need to be to replace the behind the wheel evaluation, but they offer the opportunity to make a drive uniform for everybody. You can also manipulate variables such as weather, or number of left turns, or number of hazards and when they appear.
You don’t however get the forces you feel when you go around turns, or when you brake. This is part of what you use as a driver to adjust your performance.
My last question for you is what do you see as the future for virtual reality applications in the context of driver assessment?
I think there is some really great potential in that area, and I have seen the technology come a long way. Current VR is far more realistic, and there are richer and more detailed environments in which to be immersed. I think that one of the challenges that still remains is the motion sickness. Simulator sickness is a similar barrier. I think the technology has tremendous potential if we can figure out a way to get around that.
Great, and let me thank you again for doing this interview. We really appreciate your time and the information you provided to our readers.
You are so welcome.
About the Interviewer
Nathan Zasler, MD, is CEO & Medical Director for Concussion Care Centre of Virginia, Ltd., as well as CEO & Medical Director for Tree of Life Services, Inc. Dr. Zasler is board certified in PM&R, fellowship trained in brain injury and subspecialty certified in Brain Injury Medicine. He is an affiliate professor in the VCU Department of Physical Medicine and Rehabilitation, Richmond, VA, and an adjunct associate professor in the Department of Physical Medicine and Rehabilitation at the University of Virginia, Charlottesville. He is Chairperson Emeritus of IBIA and currently serves as Vice-Chairperson. He is co-chief editor of Brain Injury, NeuroRehabilitation and Brain Injury Professional. Dr. Zasler is an advocate, educator, clinical researcher, inventor, entrepreneur and busy practicing clinician who is involved with community-based neurorehabilitation, chronic pain management, and health care consultation, both clinical and medicolegal.