AutO&Mobility: driving with a visual impairment in the Netherlands

dr. Bart Melis-Dankers PhD

Royal Dutch VisioCentre of expertise for blind and partially sighted people

SMS-conferenceDecember 5, 2012København

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16.7 million inhabitants 316,000 visually impaired people [1.9%]

primary care: 700 optometrists and 2,500 opticians. secondary care: 707 ophthalmologists [1:23,600]. tertiary care: visual rehabilitation centres:

-- Royal Dutch Visio: 3,200 employees

-- Bartiméus: 2,200 employees

The Netherlands

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Optimization of independent mobility is important for

social participation. Driving is the main form of transport in NL.

7.7 million passenger cars. Driving itself is not the goal.

Independent mobility is! Safety first.

Rehabilitation programme AutO-Mobility:

Individual advice and training programme to optimize

independent mobility, if possible in motorised vehicles.

AutO-Mobility

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fitness to drive: NL in 1998

medical visual acuity: 0.5 in best eye [6/12, 20/40] visual field: ≥ 140°

practical the ability to drive safely and smoothly despite

one’s visual impairment. on road driving test by the Netherlands Bureau of

Driving Skills Certificates [CBR].

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VA = 0.2

visual acuity 0.5 : reading licence plate at 35m

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Step 1: Coeckelbergh & Kooijman

1998 – 2002

N = 67 participants. Visual acuity loss and/or visual field defect. All had insufficient medical fitness to drive. Practical fitness to drive test [CBR].

[Human Factors, 2004, 46(4): 748-760]

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central peripheral central and peripheral

VA Snellen

horizontal fielddiameter (degrees)

(n=24)

0.23

142

(n=36)

0.74

84

(n=7)

0.19

91

Visual Field Defect

passed

failed

practical fitness to drive:

6(25%)

15(42%)

2(14%)

21(58%)

5(86%)

18(75%)

N = 67 participants

Step 1: Coeckelbergh & Kooijman

1998 – 2002: data

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Step 1: Coeckelbergh & Kooijman

1998 – 2002: conclusion

N = 67 All had insufficient medical fitness to drive. 34% passed practical fitness to drive test [CBR]

The medical fitness to drive (visual acuity and visual

field) provides not sufficient information to decide about

the practical fitness to drive.

[Human Factors, 2004, 46(4): 748-760]

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Netherlands Bureau of Driving Skills Certificates [CBR] Ministery of Transport 2 driving schools University Medical Center Opthalmology Univeristy Medical Center Traffic Medicine Royal Dutch Visio: clinical physicist

optometrist

occupational therapist

neuro-psychologist

Step 2: build a consortium

2000 - 2004

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Impaired visual acuity:

Bioptic Telescope System [BTS]

Visual field defect: homonymous hemianopia

Scanning Compensatory Therapy [SCT]

Step 3: development of training

2004 - 2007

Road design Traffic signs / traffic lights Route signs

Other road users

VA = 0.16 = 20/125

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Bioptic telescope system [BTS]

monocular 2x - 3x magnification field of view: 15° weight: 12 gr.

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Correct BTS use

driving road signs crossings / traffic lights pedestrians / cyclists overtaking

safety first right moments short goal directed in time (not too early)

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Step 3a: pilot project BTS

2004 - 2007

inclusion: 0.16 <= BBCVA < 0.5 BTS-programme:

assessment day fitting BTS [optometrist] O&M-training 4 x 3 hours [O&M-trainer] driving lessons [driving

instructor] practical fitness to drive test [CBR]

9 subjects passed fitness to drive test with BTS

[Visual Impairment Research, 2008, 10: 1-6][Visual Impairment Research, 2008, 10: 7-22]

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The Effects of Compensatory The Effects of Compensatory Scanning Training on Driving for Scanning Training on Driving for Hemianopia PatientsHemianopia Patients

Gera de Haan MSc.University of Groningen, The NetherlandsClinical and Developmental Neuropsychology

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Current studyCurrent study

Aim:Examining the effect of compensatory scanning training on mobility for homonymous hemianopia.

Compensatory Scanning Training:1. Increase of awareness2. Systematic scanning strategy3. Transfer to mobility in daily life

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Systematic scanning Systematic scanning strategystrategyBased on training Pizzamiglio (1992) and Tant (2002) Scanning strategy:

◦ Fixate straight ahead◦ Large saccade towards blind hemifield◦ Saccade back to seeing hemifield◦ Fixate straight ahead◦ . . .

Right hemianopia:

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Participants in driving Participants in driving studystudy RCT of 60 hemianopic patients with mobility problems

Effect of Scanning Compensatory Training on mobility and Quality of Life

------------------------------------------------------------------------------- N = 27 adults reporting mobility problems because of a

homonymous hemianopia, the hemianopia existing for at least 6 months

N = 21 left-sided hemianopia, N = 6 right-sided hemianopia

N = 18 male, N = 9 female M(age) = [27-71] M(TimeSinceLesion) = 24 months [6.5-122]

No severe motor, neuropsychologic or hearing impairments

No ophthalmologic dysfunctioning and binocular visual acuity > 0.5

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Training group

T1 T2Control group T3Training

T1 T2Training

pre

post

-3mth

DesignDesign

Tests on T1, T2 and T3: Impaired Mobility Questionnaire (IMQ; Turano, 1999) Tracking Task Obstacle course (with dual task) Hazard perception (Vlakveld, 2011)

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Training group

T1 T2Control group T3Training

T1 T2Training

pre

post

-3mth

DesignDesign

Tests on T1, T2 and T3: Impaired Mobility Questionnaire (IMQ; Turano, 1999) Tracking Task Obstacle course (with dual task) Hazard perception (Vlakveld, 2011) Driving simulator Fitness to drive

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inclusion: homonymous hemianopia SCT-programme:

assessment day optimizing optics [optometrist] SCT-training 10 x 1.5 hours [O&M-trainer] driving lessons [driving

instructor] practical fitness to drive test [CBR]

Step 3b: scanning compensatory therapy

2007 - 2012

Result

Result

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Practical Fitness to drive: Practical Fitness to drive: TRIPTRIP

Test Ride for Investigating Practical fitness to drive

57 items: insufficient, doubtful, sufficientDriving test taken by ‘blind’ CBR-expertFactors:

◦ VIS: visual factor◦ OPER: operational factor◦ TACT: tactical factor

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Fitness to driveFitness to drive N = 27 Hemianopia patients (total N = 57) N = 21 left-sided, N = 6 right-sided hemianopia N = 18 male, N = 9 female M(Age) = 52 [27-71]

CBR (Dutch department of motor vehicles) 2 on-road driving assessments:

Before onset of training (N=27) 15 passed (56%)

12 failed (44%)

After training (N=10) 6 failed 4 passed

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Fitness to drive: TRIPFitness to drive: TRIPTRIP-factors improve after training

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ConclusionConclusion

Self-reported mobility in daily life improved (IMQ) Faster responses to stimuli in the blind periphery (Tracking

Task) Higher walking speed in obstacle course with cognitive dual

task Part of patients with hemianopiae is practical fit to drive,

even without training. Visual aspects of driving are most problematic. Negative judgement due to insufficient viewing strategy, but

also due to operational and tactical driving. Training improves visual and tactical aspects. No age-related effect found.

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Hemianopia does not necessarily impair fitness to drive

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report to the minister of Transport

decisions: May 2009 and February 2010

visual acuity impairment: VA >= 0.50 : unrestricted driving

license 0.40 <= VA < 0.50 : CBR-test without BTS 0.16 <= VA < 0.40 : CBR-test with BTS

visual field defect: HVF >= 120° : unrestricted driving

license 90° <= HVF < 120° : CBR-test

Step 4: lobby to change regulations

2007 - 2010

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South

NWNorth

SW

Step 5: extending consortium

2009 - 2010

°

°

4 regions: 12 locations education of:

9 information officers 31 optometrists 25 O&M trainers 6 clinical physicists 5 neuro-psychologists 23 driving instructors 8 CBR experts on practical fitness to drive 12 CBR driving examiners

September 2010: AutO-Mobility nationally available

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BTS: SCT: driving licenses issued: 70 19 not fit to drive: >250 >80

Remember:

AutO&Mobility is about mobility (and not driving per se).

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2012: BTS-program for nystagmus patients

Current situation

December 2012

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New programmes for: mobility scooter [16 km/h = 10 miles/h] microcars [45 km/h = 30 miles/h] patients with combined acuity and field impairment patients with visual and neurological impairment

Step 6: future developments

2012 - 2015

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ITMA 2012: May 19-22

International Traffic Medicine Association

Hamburg

www.trafficmedicine.org

-----------------------------------------------------------------

ESLRR 2012: September 13-15

European Society for Low Vision Research and Rehabilitation

Oxford

www.eslrr.eu

Interesting congresses

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Royal Dutch Visio

www.auto-mobiliteit.org

BartMelis@visio.org

Please contact

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Practical fitness to drive: Practical fitness to drive: TRIPTRIPMain reason for negative judgement

    VIS OPER TACT GLOB TOT    Mean (SD)Drive1

(N=27)  2.60

(0.51)2.70

(0.48)2.67

(0.41)2.52

(0.64)2.66

(0.43)Failed

(N=12)  2.20

(0.53)2.40

(0.58)2.36

(0.44)1.92

(0.52)2.32

(0.45)Passes

(N=15)  2.92

(0.10)2.95

(0.10)2.92

(0.10)3.00

(0.00)2.93

(0.06)p-value   .001 .007 .001 <.001 .001LHH (N=21)   2.50

(0.54)2.64

(0.52)2.61

(0.45)2.38

(0.67)2.58

(0.46)RHH (N=6)   2.94

(0.10)2.93

(0.13)2.88

(0.10)3.00

(0.00)2.93

(0.07)p-value   .002 .032 .019 <.001 .003Men (N=18)   2.61

(0.41)2.73

(0.41)2.71

(0.35)2.56

(0.57)2.69

(0.31)Women

(N=9)  2.58

(0.70)2.64

(0.61)2.58

(0.52)2.44

(0.80)2.60

(0.62)p-value   .896 .643 .451 .667 .609

ratings on the individual TRIP-items, split by factor (N=27)