The right to drive: Wheelchair prescription with transportation in mind.
Driving is the ultimate activity of daily living. It is more than just a means of getting from A to B – it is a symbol of freedom and a link to work, family and independence. The ‘right’ to drive enables individuals to be independent in many occupational performance areas, including self-care, work and leisure activities. Regaining the capacity to drive following illness or injury can mark a major milestone toward functional independence and well-being.
Advances in vehicle modifications and driving adaptations, specifically for vans, have increased the number of wheelchair users that utilize personal vehicles as either passengers or drivers.The number of vehicles with adaptive equipment is expected to continue to increase as the population ages and as access to employment,travel and recreation continues to improve for persons with disabilities.
It is essential that the seating specialist consider driving when prescribing wheelchairs for their clients.In some cases,a one-inch difference in the width of a wheelchair can determine if the client will need a full-size van or a minivan.
Assessing the client’s needs
Before prescribing a wheelchair, the seating specialist should ask the client if they will be a driver or passenger and ensure that the client has a driver/passenger evaluation. A prescription for an appropriate vehicle and/or adaptive driving equipment will be provided to ensure that the vehicle fits the physical and lifestyle needs of the client. An evaluation achieves three things:
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✓determines the client’s capabilities
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✓prescribes the type of adaptive equipment that best suits the client’s needs
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✓indicates whether or not driver education is appropriate
Determining driver candidacy encompasses a combination of occupational therapy expertise and certified driving instruction. The objective data from each phase of the evaluation gives the occupational therapist the framework for assess- ing driving potential and need for equipment. Evaluators also consult on compatibility and transportation safety issues for passengers with disabilities.They assess the type of seating need- ed and the person’s ability to enter and exit the vehicle.They provide advice on the purchase of modified vehicles and recommend appropriate wheelchair lifts or other equipment for a vehicle.
Generally,the evaluation has two components: a clinical assessment and a behind-the-wheel assessment.
The clinical assessment is conducted by an occupational therapist/driver rehab specialist to determine any problem areas while the client is driving and what vehicle and equipment is necessary to meet the client’s needs. The clinical evaluation determines if the client possesses the skills to be a driver. It includes a vision screen, visuo-perceptual screen, cognitive assessment (including judgement and decision-making abilities) and reaction time testing. A physical assessment evaluates muscle strength,flexibility, coordination and range of motion and deter- mines upper- and lower-extremity strength and tone to determine the ability to transfer, ability to load the wheelchair into a vehicle and the ability to operate adaptive driving controls.
Results of a wheelchair assessment will influence the final equipment prescription and vehicle recommendations. For example,a manual wheelchair user may not have sufficient skills to push the chair up a minivan ramp or the chair may be too wide to be accommodated on a power lift. He or she may sit too tall to have sufficient headroom for driver visibility. Considerations for loading the wheelchair into the vehicle, either manually or with a powered device,may depend on the type of wheelchair.
For a proper vehicle evaluation, the driver rehab specialist must be aware of all the vehicles on the market and their differences. He or she must be able to recommend specific vehicles or loading devices that are compatible with the client’s own vehicle and wheelchair. Wheelchair measurements are necessary to consider in recommending structural modifications to the van for a wheelchair lift, lowered floor and/or raised roof. Would changing something about the wheelchair make a difference in the vehicle to be used and, if so, can it be changed? The expensive modifications that allow good doorway clearance,interior headroom and driver visibility may be eliminated if there were changes in the wheelchair prescription. This could reduce the expense and need for structural modifications.
The behind-the-wheel assessment addresses not only gas, brakes and steering but includes how the person will open the door, enter the vehicle,position themselves in the driver’s station and put the key in the ignition.
The equipment evaluation requires the trial use of various hand controls,steering devices and other secondary controls before the proposed setup can be finalized and the person can actually be observed driving. Proper seated positioning behind the wheel is crucial for safe, comfortable driving. When a vehicle begins to move at high speeds, inertia can affect the stability of the driver’s trunk or extremities when operating a vehicle with any type of adaptive equipment.
The behind-the-wheel assessment analyzes the impact that the client’s deficits may have on driving performance.The driver rehab specialist may need to relocate, adjust or even change adaptive equipment after seeing the client drive. It would be a very costly mistake if a van which costs $80,000 was chosen based on a stationary assessment only and, upon delivery, it was discovered that the wheelchair was not compatible with the vehicle.
When prescribing a wheelchair, the following must be considered:
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✓a wheelchair that is wider than 26" will not fit on a minivan lift system
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✓a wheelchair that is wider than 29" will not fit on a minivan ramp system
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✓the length of the lift platform must be longer than the length of the wheelchair
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✓a client who is taller than 44" seated height will require structural modifications to enter a minivan
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✓the interior height of a minivan without modifications is 48"
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✓the interior height of a minivan with a lowered floor is 56–58"
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✓the door height of a full-size van is 48" (54" with a lowered floor)
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✓the interior height of a full-size van is 52" (58" with a lowered floor)
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✓when driving from a mid-wheel power chair, front stabilization is required to minimize rocking motion of chair due to the momentum of accelerating and braking
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✓low back wheelchairs do not provide adequate support for driving
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✓lateral support is required to address dynamic forces acting on the client in the vehicle
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✓ if prescribing a manual chair,ensure that the client has enough strength to propel up the ramp of a minivan wheelchair tie-down attachments can add up to 40 lb. to the wheelchair (this is a consideration for lightweight wheelchairs).
Understanding your options
There are a variety of products available for independent driving from a wheelchair. Attend new product demos to learn of new products such as lifting devices and wheelchair models and options. Due to the variety of devices available,it is important to consult with a mobility equipment dealer to determine the most appropriate equipment/vehicle combination for your client’s needs. Get to know the driving specialist and mobility vendors in your area. Invite the driver rehab specialist to attend seating clinics for an old client who is getting a new chair to ensure that vehicle compatibility issues are considered.
The mobility device, vehicle and driving equipment are the most expensive items purchased by the disabled consumer. If these items are prescribed in isolation, the likelihood of their compatibility is slim. Lack of service coordination may result in unnecessary expense or effort for a client working towards independent community mobility. Driver rehabilitation and seating professionals need to work together to ensure that this does not happen.
“Impossible is only what
you want it to be.”
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