DUBAI DRIVER'S MEDICAL STANDARD

Transcription

1 DUBAI DRIVER'S MEDICAL STANDARD This document is provided by the Dubai Roads and Transport Authority and the Dubai Health Authority for the guidance of Medical Professionals in the medical assessment of drivers. Document issued by: Licensing Agency Roads and Transport Authority Dubai, United Arab Emirates Document Status: Current Version Number: 2.2 Document Release Date: 14 November 2012

2 CONTENTS INTRODUCTION 3 Chapter 1 NEUROLOGICAL DISORDERS 7 Appendix Epilepsy Regulations 24 Withdrawal of Anti-Epilepsy Medication & Provoked Seizures 26 Chapter 2 CARDIOVASCULAR DISORDER 37 Appendix Medication Exercise Testing Stress Myocardial Perfusion Scan/Stress Echocardiography Coronary Angiography Chapter 3 DIABETES MELLITUS 38 Appendix Police, Ambulance and Health Service Vehicle Driver Licensing 40 Qualifying Conditions for drivers on Insulin and Group 2 Entitlement: Information for drivers with Diabetes treated by non-insulin medication, 41 diet or both. A Guide to Insulin Treated Diabetes and Driving. 42 Chapter 4 PSYCHIATRIC DISORDERS/DISORDER including:- 43 Dementia, Learning Disability, Development & Behaviour Disorders Appendix Psychiatric Notes including:- Medication, Confidentiality & Patients 47 Chapter 5 DRUG AND ALCOHOL MISUSE AND DEPENDENCE 49 Chapter 6 VISUAL DISORDERS 53 Appendix Visual Requirements 56 Peripheral Field Defect Chapter 7 RENAL DISORDERS 57 RESPIRATORY & SLEEP DISORDERS Chapter 8 MISCELLANEOUS CONDITIONS 59 OLDER DRIVERS 60 IMPAIRMENT OF COGNITIVE FUNCTION Appendix1 ADVICE FOR DISABLED DRIVERS 61 INDEX 62 2

3 Dubai Driver's Medical Standard - INTRODUCTION This publication is provided for use by medical professionals who are involved in the medical assessment of vehicle drivers. This medical standard is owned by the Roads and Transport Authority (RTA) of Dubai, United Arab Emirates (UAE). The Dubai Driver's Medical Standard is based on the UK Government driver medical standard that is owned by the Driver and Vehicle Licensing Agency (DVLA). Consequently the use of the Dubai Medical Standard allows Dubai to align with the standard of driver medical assessments used by European Union countries. Medical professionals who are engaged by the RTA to provide driver medical assessments may use the Dubai Medical Standard to determine driver fitness. Other medical professionals not engaged by RTA may also use the medical standard as a guide when determining a person's medical fitness for a range of activities that may not necessarily be driving related. A key requirement for medical professionals who provide driver fitness assessments is to inform RTA of the result of the medical assessment electronically through the RTA's Online service. This is achieved by indicating that a client has no medical condition and is medically fit to drive. However by entering a Medical Condition Code from the medical standard, the medical professional informs the RTA of a client's medical condition. For the information of the medical professional, the standard also contains the probable action that RTA will take as a result of receiving information about a medical condition. There is no UAE legislation requiring a private driver to inform the RTA of a medical condition which may affect their ability to drive safely. However the driver can inform RTA of such a condition or a medical professional can inform RTA. However where legislation requires a medical assessment to be conducted on a driver, the medical professional must advise RTA of the result. Medical professionals should note that the RTA considers a range of factors when determining if a client will be licensed to drive a vehicle. The client's medical fitness is one factor that is considered. The RTA is the Dubai authority that determines who is licensed to drive. The Dubai Driver's Medical Standard will only be available electronically from the RTA Internet site. If medical professionals are using a hardcopy of the standard, a regular check should be made of the front page of the Online medical standard to ensure a newer version of the standard has not been released. The front page will contain a "Version Number" and a "Document Release Date" for easy checking. It is anticipated that the medical standard will be formally reviewed every two (2) years, however minor updates may be issued before the formal review occurs if necessary. The "assessing" medical professional determines the client's fitness to drive. If the assessing medical professional is unable to determine if the client is fit to drive they may seek an opinion from another medical professional or may request the client to have additional tests to allow the client's fitness to be determined. The full costs associated with a driver medical assessment will be met by the client. In determining a medical condition the medical professional should consider the nature of the condition, including if it is long term or permanent and if it is likely to cause a road safety risk to the driver or other road users. In considering a medical condition, medical professionals should also consider the affect of medication that the client may be taking for the medical condition. Importantly there may be a heightened risk where the client is taking a range of medications for a range of medical conditions. In the interests of road safety, those who suffer from a medical condition that is likely to cause a sudden disabling event while driving or who are unable to safely control their vehicle, should not drive. This should be the key determiner when a medical professional is assessing a client's medical condition. This includes where the client's medical condition is not listed in this medical standard. Commercial Driver Medical Assessments In 2009 the UAE federal government, Ministry of Interior, drafted Law Number 776. In February 2011 the Ministry requested UAE Licensing Authorities to implement this federal law. The law requires a range of commercial drivers to obtain a Commercial Driver Permit from the appropriate License Issuing Authority. Contained in the above law is the requirement for commercial drivers to have a medical assessment as a requirement before the Permit is issued. 3

4 The Law relates to the Ministry of Interior Law 21 of The changes impact sections 111, 112, 114 of the legislation. The law enhancement applies to: Non-UAE nationals who are: taxi drivers, drivers of heavy vehicles, drivers of buses and private / public chauffeur drivers. The law requires these drivers to meet an eligibility criteria to apply for a Commercial Driver Permit that is issued yearly. To be eligible for the Permit one requirement is that a driver must pass a medical assessment. In accordance with the federal law, the RTA will issue drivers with Commercial Driver Permits only after the RTA has been advised by an "assessing" medical professional that the client has passed a driver medical assessment. This medical standard is provided as guide for medical professionals in the assessment task. License Groups This medical standard refers to Group 1 and Group 2 license holders. Group 1 includes motor cars and motor cycles. Group 2 includes trucks and buses. The medical standards for Group 2 drivers are very much higher than those for Group 1 because of the size and weight of the vehicle. This also reflects the higher risk caused by the length of time the driver may spend driving in the course of his/her occupation. Multiple Medical Conditions It may be that a client suffers from multiple medical conditions that by themselves do not seriously impact the client's ability to drive safely. However in combination may pose an unacceptable risk of a medical event that causes a road crash. In this case the medical professional should advise RTA through the Online service using a medical code listed in the standard but enter the number 5 instead of 1 or 2 at the end of the medical code, such as Impairment due to Medication Some prescription drugs and medicines can affect the skills needed to drive safely, such as causing drowsiness, impaired judgement and other adverse effects. Health professionals prescribing medication should consider the risks associated with a medication or combinations of medications and the driving task. Health professionals should advise clients about these risks, and where appropriate, advise the client not to drive. Driving after Surgery Any decision about driving after surgery should take into account several issues. These include recovery from the surgical procedure, recovery from anaesthesia, the distracting effect of pain, impairment due to analgesia (sedation and cognitive impairment) as well as physical restrictions. The health professional should advise the client when it is safe to continue driving. It is the driver's responsibility to ensure they are fit to drive at all times. Role of the Medical Professional As above, the role of the medical professional is to assess the medical fitness of a client to drive. The medical standard is available to assist in this task. The medical professional is to advise the client at the end of the assessment if the client has a medical condition that may affect their ability to drive safely. The medical professional is to advise RTA of the result of the assessment through the RTA's Online service. The medical professional should not make statements to the client about their driver's license or the issue of a Commercial Driver Permit. This task will be done by the RTA. Where the client is suffering from a serious medical condition the standard indicates the action the RTA may take, for the information of the medical professional. Medical professionals should note in the standard that not all medical conditions will cause RTA to take an action, such as cancelling the client's driver's license. In many cases a medical condition that has not become serious or is being well managed may allow the client to continue driving. Through the RTA's Online service medical professionals will see a History of the client's previous "driving related" medical assessments. This is to allow informed decision-making by medical professionals by being aware of an existing medical condition that is provided to them by another medical professional through the History page. Where a driving license cancellation is required, RTA provides this advice to the client after the medical assessment result is received by RTA. Where a medical assessment is required for the issue of a Commercial Driver Permit, the 4

5 RTA will also inform the client's employer that the Permit cannot be issued on medical grounds, if the client has not passed the medical assessment. RTA's Online Service & Medical Condition Codes RTA approved medical assessors can access the RTA's Online service using a UserID and Password. Once a medical assessment has been completed the medical result can be provided through the Online service. Where a client has a medical condition, the Medical Condition Code that is listed against each medical condition in the medical standard, is to be entered into that data field. Based on the medical code RTA may change the client's driving approvals. Where a client has multiple medical conditions that makes the client a risk to the driving community the medical profession should choose one of the Medical Condition Codes that the client suffers from and use the number 5 as the last number of the code such as The five decodes as multiple medical conditions. The RTA's Online service provides a "Doctor's Remarks to Doctor" field. This section is for the doctor to provide information about the client's medical status to another doctor. Where the client suffers from multiple medical conditions this information should be added to the remarks field. The Online service also provides a "Doctor's Remarks to Client" field. The information entered into this field will appear on the client's copy of the medical assessment result. It will also be available for another doctor as information, such the instruction that was provided by the previous doctor to the client. Where a client is suspected of having a medical condition and further assessment is required, the medical professional should enter the appropriate Medical Condition Code. In this case RTA will take no action.. However the entry allows other medical professionals to be aware that the client may have a medical condition and that further assessment has been requested. Again if necessary enter information in the Doctor to Doctor Remarks field. Medical Codes The Medical Codes used in the Medical Standard are based on - a) Chapter in the standard, b) the medical condition number in that chapter of the standard and c) the vehicle classes driven. For instance a medical code of is decoded as Chapter 2 (Cardiovascular Disorder), Medical Condition 3 (Acute Coronary Syndromes) and 2. the driver type (a Heavy Vehicle driver). Where a doctor is further considering a client's medical condition or possibly requesting further testing the code ending in 3 or 4 should be entered, depending on the type of vehicle the client may drive. RTA will take no action in relation to the client's driving approvals but the code will update the driver's medical history page. This means if the client attends a different medical professional they will note that the client has already been seen by a medical professional who suspects the client may have a medical condition and what that medical condition may be. The second medical professional may then assess the client. There is no need for the client to return to the first medical professional if they do not wish. Similarly a client who does not agree with the result of a medical assessment may seek another opinion at any time. The Code does not appear in the medical standard, it is an RTA only code. It is used only by RTA when a driver, who has heavy vehicle license classes and is medically unfit to drive the vehicle classes wants to be assessed for a light vehicle (car / motorcycle). The RTA may approve this request, which means the driver should be assessed to drive light vehicles only. If his medical condition is acceptable to drive a light vehicle, the heavy vehicle class/es will be removed from the license. Driver Declaration The RTA's Online service provides the ability to print a Driver Declaration form. The Declaration form is closely based on the Driver Declaration form that is used by the DVLA (UK Government) for driver medical assessments. The doctor and the client should complete the form. The form is to assist and guide the doctor in the driver medical assessment process by highlighting potential medical conditions the client may have. The Declaration form also contains an approval from the client for the doctor to inform RTA about the result of the medical assessment. Importantly the form also provides an approval for a doctor to notify RTA of a serious medical condition that the client may have at any time during the currency of the client's Commercial Driver Permit. The currency of the Commercial Driver Permit will be displayed on the client's license history page (on RTA's Online service). Once the Declaration Form is completed it must be retained by the doctor company and available to RTA upon request. 5

6 This Standard & RTA's Online Service The Medical Standard is to assist Medical Professionals to assess drivers in a consistent and transparent manner. Medical professionals do not need to use the Medical Standard to determine if a client does not have a medical condition and is fit to drive. However to advise RTA of the result of a medical assessment the RTA Online service must be used. If the client has a medical condition the medical condition code from the medical standard must be entered into the Online service. Please note: The RTA does not have access to Doctor to Doctor Remarks or Doctor to Client Remarks. No review of the medical assessment is provided by RTA. The use of medical codes within the medical standard informs RTA of the result of the medical assessment and highlights the need for subsequent actions. Most of RTA's actions are automated system generated from the medical code that has been entered. Notifying RTA In the interests of road safety and community well being, if a medical professional who may not be engaged by RTA to provide driver medical assessments, considers a client with a medical condition as posing an unacceptable risk to community safety they are encouraged to inform RTA by writing to the: Director (Driver Licensing) Licensing Agency Roads and Transport Authority PO Box Dubai UAE For enquiries please contact the RTA Call Centre on This document may be cited in part or in whole for the specific guidance of medical professionals and patients. However the document must not be reproduced in part or in whole for commercial purposes. This medical standard is published by the RTA Dubai, UAE. The Dubai Medical Standard is closely based on the Driver Medical Standard "At a glance guide to the current medical standards of fitness to drive", that is issued by the Government of the United Kingdom (UK). The RTA has approval from the UK Government to reference its medical standard and considers the UK medical standard as the main source of driver medical information that is contained in the Dubai Medical Standard. 6

7 CHAPTER 1 NEUROLOGICAL DISORDERS NEUROLOGICAL DISORDERS 1.EPILEPSY Epileptic attacks are the most frequent medical cause of collapse at the wheel. NB: If within a 24 hour period more than one epileptic attack occurs, these are treated as a single event. Epilepsy includes all events: major, minor and auras. 2. FIRST UNPROVOKED EPILEPTIC SEIZURE/SOLITARY FIT GROUP 1 ENTITLEMENT ODL CAR, M/CYCLE Medical Code Provided a license holder/applicant is able to satisfy the epilepsy requirements, license will be issued. if seizure-free for 1 year since the last attack with medication if necessary in the absence of any other disqualifying condition. (See Appendix to this Chapter) Medical Code Medical Code months off driving from the date of the seizure unless there are clinical factors or investigation results which suggest an unacceptably high risk of a further seizure, ie. 20% or greater per annum. Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code Requires a driver to remain seizure-free for 10 years since the last attack without anticonvulsant medication. Medical Code Medical Code years off driving from the date of the seizure if the license holder has undergone recent assessment by a neurologist and there are no clinical factors or investigation results (eg. EEG, brain scan) which indicate that the risk of a further seizure is greater than 2% per annum. They should have taken no anti-epilepsy medication throughout the 5-year period immediately prior to the granting of the license. Medical Code For Group 2 licensing. the following features are consistent with a person having a good prognosis: No relevant structural abnormality of the brain on imaging; No definite epileptiform activity on EEG; Support of the neurologist; Seizure risk considered to be 2% or less per annum. 3. EPILEPSY/EPILEPTIC SEIZURES General guidance for ALL neurosurgical conditions if associated with epilepsy or epileptic seizures Medical Code In all cases where epilepsy has been diagnosed, the epilepsy requirements apply. These cases will include all cases of single seizure where a primary cerebral cause is present and the liability to recurrence cannot be excluded. An exception may be made when seizures occur at the time of an acute head injury or intracranial surgery. Medical Code Medical Code In all cases where a liability to epileptic seizures either primary or secondary has been diagnosed, the specific epilepsy requirements for this group applies. The only exception is a seizure occurring immediately at the time of an acute head injury or intracranial surgery, and not thereafter and/or where no liability to seizure has been demonstrated. Following head injury or intracranial surgery, the risk of seizure must have fallen to no greater than 2% per annum before returning to vocational driving. Medical Code

8 4.WITHDRAWAL OF ANTI- EPILEPSY MEDICATION AND DRIVING 5.PROVOKED SEIZURES (apart from alcohol or illicit drug misuse) See Appendix to this Chapter for full details. Medical Code Medical Code See Appendix to this Chapter for full details. Medical Code See Appendix to this Chapter for full details. Medical Code Medical Code See Appendix to this Chapter for full details. Medical Code Medical Code Medical Code See Appendix at end of this Chapter for Epilepsy Requirements 8

9 LOSS OF CONSCIOUSNESS/LOSS OF OR ALTERED AWARENESS ** Excluding Cough Syncope ** (See Chapter 7) A full history is imperative to include pre-morbid history, prodromal symptoms, period of time unconscious, degree of amnesia and confusion on recovery. A neurological cause, for example, epilepsy, subarachnoid haemorrhage, can often be identified by the history, examination and the appropriate referral made. 80% of all cases have a cardiovascular cause and again, these can be determined by history, examination and ECG. Investigate and treat accordingly and use the relevant guidelines. The remaining cases can be classified under five categories in the FOLLOWING TABLE: NEUROLOGICAL DISORDERS 6. Reflex Vasovagal Syncope Definite provocational factors with associated prodromal symptoms and which are unlikely to occur whilst sitting or lying. Benign in nature. If recurrent, will need to check the 3 Ps apply on each occasion (provocation/prodrome/postural). (If not see Number 8 below). 7. Loss of consciousness/ loss of or altered awareness likely to be unexplained syncope but with a high probability of reflex vasovagal syncope. These have no clinical evidence of structural heart disease and a normal ECG. GROUP 1 ENTITLEMENT ODL CAR, M/CYCLE Medical Code No driving restrictions. Medical Code Medical Code No driving restrictions. Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code No driving restrictions Medical Code NB Cough Syncope see Chapter 7 Medical Code Can drive 3 months after the event. Medical Code NB Cough Syncope see Chapter 7 9

10 8. Loss of consciousness/ loss of or altered awareness likely to be cardiovascular in origin (excluding 1 or 2). Factors indicating high risk: (a) abnormal ECG (b) clinical evidence of structural heart disease (c) syncope causing injury, occurring at the wheel or whilst sitting or lying (d) more than one episode in previous six months. Further investigations such as ambulatory ECG (48hrs), echocardiography and exercise testing may be indicated after specialist opinion has been sought. **for Pacemakers see Chapter 2 Medical Code License refused/revoked for 6 months if no cause identified. Can drive 4 weeks after the event if the cause has been identified and treated. Medical Code Medical Code License refused/revoked for 12 months if no cause identified. Can drive 3 months after the event if the cause has been identified and treated. Medical Code NEUROLOGICAL DISORDERS 9. Presumed loss of consciousness/loss of or altered awareness with seizure markers This category is for those where there is a strong clinical suspicion of a seizure but no definite evidence. Factors to be considered: - Unconsciousness for more than 5 minutes. - amnesia longer than 5 minutes - injury - tongue biting - incontinence - remain conscious but with confused behaviour - headache post attack 10. Loss of consciousness/loss of or altered awareness with no clinical pointers. This category will have had appropriate neurological and cardiac opinion and investigations but with no abnormality detected. GROUP 1 ENTITLEMENT ODL CAR, M/CYCLE Medical Code months off driving from the date of an episode of loss of consciousness/loss of or altered awareness. However, if a person has a previous history of epilepsy or a solitary seizure, 12 months freedom from any further episode of loss of consciousness with seizure markers must be attained. If a person suffers recurrent episodes of loss of consciousness with seizure markers, 12 months freedom from such episodes must be attained. Medical Code Medical Code License refused /revoked for 6 months Medical Code NB Cough Syncope see Chapter 7 GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code years off driving from the date of an episode if the license holder has undergone assessment by an appropriate specialist and no relevant abnormality has been identified on investigation, for example EEG and brain scan, where indicated. Medical Code Medical Code License refused /revoked for 1 year Medical Code

11 NEUROLOGICAL DISORDERS 11.. PRIMARY/CENTRAL HYPERSOMNIAS: including Narcoleptic syndromes 12. CHRONIC NEUROLOGICAL DISORDERS e.g. Multiple sclerosis, motor neurone disease, etc which may affect vehicle control because of impairment of coordination and muscle power. See also Appendix 1 for information on Driving assessment for disabled drivers. 13. PARKINSON S DISEASE GROUP 1 ENTITLEMENT ODL CAR, M/CYCLE Cease driving on diagnosis. Medical Code License may be issued when there has been a period of between 3 and 6 months satisfactory control of symptoms with appropriate treatment. If not on appropriate treatment, licensing may be allowed subject to a satisfactory objective assessment of maintained wakefulness, such as the Osler test. Medical Code Medical Code Providing medical assessment confirms that driving performance is not impaired, can be licensed. The driver may require certain vehicle controls. Medical Code Medical Code License refused or revoked if condition is disabling and/ or there is clinically significant variability in motor function. Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV Cease driving on diagnosis. Medical Code License may be issued subject to specialist assessment and a satisfactory objective assessment of maintained wakefulness, such as the Osler test. Medical Code License refused or revoked if condition is progressive or disabling. Medical Code If driving would not be impaired and condition stable, can be considered for licensing subject to satisfactory reports and annual review (individual basis). Medical Code Medical Code License refused or revoked if condition is disabling and/or there is clinically significant variability in motor function. Medical Code LIABILITY TO SUDDEN ATTACKS OF UNPROVOKED OR UNPRECIPITATED DISABLING GIDDINESS Cease driving on diagnosis. Medical Code Driving will be permitted when satisfactory control of symptoms achieved. If remains asymptomatic. Medical Code License refused or revoked if condition sudden and disabling. Medical Code Consider underlying diagnosis and if likely to cause recurrent attacks, must be symptom-free and completely controlled for 1 year from last attack before re-application. Medical Code

12 NEUROLOGICAL DISORDERS 15. TIA / STROKE TIA GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code STROKE Must not drive for 1 month. May resume driving after this period if the clinical recovery is satisfactory. Seizures occurring at the time of a stroke/tia or in the ensuing 24 hours may be treated as provoked for licensing purposes in the absence of any previous seizure history or previous cerebral pathology. Seizures occurring at the time of intracranial venous thrombosis require 6 months free from attacks before resuming driving. Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV License refused or revoked for 1 year following a stroke or TIA. Medical Code Can be considered for licensing after this period provided that there is no debarring residual impairment likely to affect safe driving and there are no other significant risk factors. Licensing will also be subject to satisfactory medical reports including exercise ECG testing. Where there is imaging evidence of essentially normal carotid arteries Group 2 licensing may be allowed without the need for functional cardiac assessment. Medical Code ACUTE ENCEPHALITIC ILLNESSES AND MENINGITIS Medical Code ) If no seizure(s), may resume driving when clinical recovery is complete. 2) If associated with seizures during acute febrile illness, license refused or revoked for 6 months from the date of seizure(s). 3) If associated with seizure(s) during or after convalescence, will be required to meet epilepsy requirements. Medical Code See Appendix to this Chapter for full regulations. Medical Code Must stop driving, and meet current epilepsy requirements before driving resumes. 1) As for Group 1 provided no residual disabling symptoms, and clinical recovery is complete. 2) Must stop driving. Meningitis 5 years free from seizures without anticonvulsant medication. Encephalitis - 10 years free from seizures without anticonvulsant medication. Medical Code See Appendix to this Chapter for full regulations. 12

13 NEUROLOGICAL DISORDERS 17.TRANSIENT GLOBAL AMNESIA 18.ARACHNOID CYSTS A. Asymptomatic and untreated GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code Provided epilepsy, any sequelae from head injury and other causes of altered awareness have been excluded, no restriction on driving. Medical Code Medical Code No restriction GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code A single confirmed episode is not a bar to driving; the license may be retained. If two or more episodes occur, driving should cease. Specialist assessment required to exclude all other causes of altered awareness. Medical Code Medical Code No restriction B. Craniotomy and/or endoscopic treatment 19. COLLOID CYSTS: A) Asymptomatic and untreated B) Craniotomy and/or endoscopic treatment 20. PITUITARY TUMOUR 6 months off driving. Medical Code Medical Code No restriction. 6 months off. Medical Code Medical Code Provided no visual field defect (if visual field loss, see Vision section): Can drive 2 years after treatment, provided that there is no debarring residual impairment likely to affect safe driving. Medical Code Medical Code No restriction unless prescribed prophylactic medication for seizures when there should be individual assessment. Can drive 2 years after treatment, provided that there is no debarring residual impairment likely to affect safe driving. Medical Code Medical Code Provided no visual field defect (if visual field loss, see Vision section) A. CRANIOTOMY 6 months off driving. 2 years off driving B.TRANSPHENOIDAL SURGERY/OTHER TREATMENT (e.g. drugs, radiotherapy) or Untreated Drive on recovery Medical Code Can drive when there is no debarring residual impairment likely to affect safe driving. Medical Code

14 NEUROLOGICAL DISORDERS 21.BENIGN SUPRATENTORIAL TUMOUR e.g. WHO GRADE 1 MENINGIOMAS GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code A TREATMENT BY CRANIOTOMY 6 months off driving when there is no debarring residual impairment likely to affect safe driving. Epilepsy requirements apply if relevant history of seizure(s). Refusal or revocation. In the absence of any seizures, relicensing can be considered 5 years after surgery, with evidence of complete removal. If tumour is associated with seizures, 10 years freedom from seizures without anti-epilepsy drugs following surgery is required. Specialist assessment may be required. B TREATMENT WITH STEREOTACTIC RADIOSURGERY 1month off driving; can drive when there is no debarring residual impairment likely to affect safe driving. Epilepsy regulations apply if relevant history of seizure(s). Can be considered 3 years after the completion of the primary treatment of the tumour, provided that there is evidence on imaging of stability. If tumour association with seizure(s), 10 years freedom from seizures without anti-epilepsy drugs following surgery is required. Specialist assessment may be required. C TREATMENT WITH FRACTIONATED RADIOTHERAPY Can drive on completion of treatment, provided that there is no debarring residual impairment likely to affect safe driving Epilepsy regulations apply if relevant history of seizure(s). D WHO GRADE II MENINGIOMAS TREATED BY CRANIOTOMY AND/OR RADIOSURGERY AND/OR RADIOTHERAPY: Requires 1 year off driving, dating from the completion of treatment. Epilepsy requirements apply if relevant history of seizure(s). Refusal or revocation. In the absence of any seizures, re-licensing can be considered 5 years after surgery, with evidence of complete removal. If tumour is associated with seizure(s), 10 years freedom from seizures without anti-epilepsy drugs following surgery is required. Specialist assessment may be required. E Asymptomatic, incidental meningiomas: untreated Retain Medical Code Refusal/revocation until 2 scans 12 months apart showing no growth. Medical Code See Appendix at end of this Chapter 14

15 NEUROLOGICAL DISORDERS 22 A BENIGN INFRATENTORIAL TUMOURS e.g. meningioma with surgery by craniotomy with or without radiotherapy. GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code Drive on recovery. GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code As for Group 1 provided that there is no debarring residual impairment likely to affect safe driving. B ACOUSTIC NEUROMA/SCHWANNOMA Sudden and disabling giddiness. Medical Code Disabling giddiness and/or the condition is bilateral. Medical Code

16 23 MALIGNANT TUMOURS (including metastatic deposits) and gliomas Medical Code Medical Code A Supratentorial a Grades 1 and II gliomas b WHO Grade III meningioma c Grades III and IV gliomas and metastatic deposit(s). d Solitary metastatic deposit 1 year off driving, from time of completion of the primary treatment. 2 years off driving from time of completion of primary treatment. At least 2 years off driving from time of completion of primary treatment. If totally excised, can be considered for licensing 1 year after completion of primary treatment if free from recurrence and no evidence of secondary spread elsewhere in the body. Permanent refusal or revocation. Permanent refusal or revocation. Permanent refusal or revocation. Permanent refusal or revocation. B Infratentorial Tumours a Grade 1 As for benign tumours: ie. drive on recovery. b Grades II, III & IV As for Supratentorial tumour Permanent refusal or revocation. c Medulloblastoma or Low Grade Ependymoma If totally excised, can be considered for licensing 1 year after primary treatment, if free from recurrence. If entirely infratentorial, can be considered for licensing when diseasefree for 5 years after treatment. d High Grade Ependymomas, Other Primary Malignant Brain Tumours A period of 2 years off driving is required following treatment. Permanent refusal or revocation. e Metastatic deposits Can be considered 1 year after completion of primary treatment if otherwise well. Medical Code Permanent refusal or revocation. Medical Code See Appendix at end of this Chapter 16

17 NEUROLOGICAL DISORDERS 24 SIGNIFICANT HEAD INJURY GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code Usually requires 6-12 months off driving depending on features such as seizures, PTA, dural tear, haematoma and contusions. There will need to have been a satisfactory clinical recovery and in particular no visual field defect, or cognitive impairment likely to affect safe driving. See also Appendix 1 and 2. Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code Refusal or revocation. May be able to return to driving when the risk of seizure has fallen to no greater than 2% per annum, and with no debarring residual impairment likely to affect safe driving. Medical Code

18 25 SPONTANEOUS ACUTE SUBDURAL HAEMATOMA (treated by craniotomy) 26 CHRONIC SUBDURAL (treated surgically) Medical Code months off driving Medical Code Medical Code Resume driving on recovery. Medical Code Medical Code Medical Code Medical Code months 1 year off driving, depending on features. Medical Code SUBARACHNOID HAEMORRHAGE A. NO CAUSE FOUND Medical Code Provided comprehensive cerebral angiography normal, may resume driving following recovery. Medical Code Provided comprehensive cerebral angiography normal, 6 months off driving and may regain license if no debarring residual impairment likely to affect safe driving. B. DUE TO INTRACRANIAL ANEURYSM a SURGERY CRANIOTOMY Anterior or posterior cerebral aneurysm b With NO deficit Driving permitted when clinically recovered from craniotomy 1 year off driving c With deficit 6 months off driving. Refusal or revocation. Specialist assessment to determine when driving may start: risk of seizure must have fallen to no greater than 2% per annum with no debarring residual impairment likely to affect safe driving. C Middle Cerebral Aneurysm a With NO deficit b With deficit 6 months off driving after craniotomy 1 year off driving after craniotomy. 18 months 2 years off driving after craniotomy. Refusal or revocation. Specialist assessment to determine when driving may start: risk of seizure must have fallen to no greater than 2% per annum with no debarring residual impairment likely to affect safe driving. See Appendix at end of this Chapter 18

19 NEUROSURGICAL DISORDERS D ENDOVASCULAR TREATMENT E NO TREATMENT i.e. Aneurysm responsible for SAH but no intervention. F TRULY INCIDENTAL FINDINGS OF INTRACRANIAL ANEURYSM (aneurysm has not been responsible for subarachnoid haemorrhage) GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Cease driving until clinically recovered. 6 months off driving after diagnosis Can be licensed if no complications. GROUP 2 ENTITLEMENT VOC LGV/PCV Refusal or revocation. The risk of seizure must have fallen to no greater than 2% per annum with no debarring residual impairment likely to affect safe driving. Refusal or revocation. G NO TREATMENT H SURGERY CRANIOTOMY I ENDOVASCULAR TREATMENT Retain. Resume driving on recovery. Cease driving until clinical recovery Medical Code See Appendix at end of this Chapter To be acceptable for licensing, anterior circulation aneurysms (excluding cavernous carotid) must be <13mm in diameter. Posterior circulation aneurysms must be <7mm diameter. 1 year off driving. Cease driving until clinical recovery unless there are complications from the procedure. Medical Code

20 NEUROLOGICAL DISORDERS 28 ARTERIOVENOUS MALFORMATION A SUPRATENTORIAL AVMs Intracerebral haemorrhage due to supratentorial AVM: a Craniotomy b Other treatment (embolisation or stereotactic radiotherapy). c No treatment. GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code months off driving; can be relicensed when there is no debarring residual impairment likely to affect safe driving. 1 month off driving; can drive when there is no debarring residual impairment likely to affect safe driving. As above. GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code Refusal or revocation until lesion is completely removed or ablated and 10 years seizure-free from last definitive treatment. There must be no debarring residual impairment likely to affect safe driving. As above. Permanent refusal or revocation. B Incidental finding of a supratentorial AVM (no history of intracranial bleed) a No treatment Retain Permanent refusal or revocation. b Surgical or other treatment C INFRATENTORIAL AVMs Intracranial haemorrhage due to AVM: See above: as for AVM with intracranial haemorrhage. Refusal or revocation until lesion is completely removed or ablated. 10 years seizure-free from last definitive treatment. There must be no debarring residual impairment likely to affect safe driving. a Treated by craniotomy b Embolisation/stereotactic radiotherapy c No treatment. Can drive when there is no debarring residual impairment likely to affect safe driving. As above. As above. Refusal/revocation. Re-license on confirmation of complete obliteration with no debarring residual impairment likely to affect safe driving. As above. Permanent refusal/revocation. See Appendix at end of this Chapter 20

21 NEUROLOGICAL DISORDERS D Incidental finding of an infratentorial AVM a No treatment Retain GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE GROUP 2 ENTITLEMENT VOC LGV/PCV Individual assessment. b Surgical or other treatment 29 DURAL AV FISTULA 30 CAVERNOUS MALFORMATION A Supratentorial a Incidental Can drive when there is no debarring residual impairment likely to affect safe driving. Medical Code Medical Code License may be issued subject to individual assessment. Medical Code Medical Code No restriction Refusal/revocation. Re-license on confirmation of complete obliteration with no debarring residual impairment likely to affect safe driving. Medical Code Medical Code License may be issued subject to individual assessment. Medical Code Medical Code No restriction b Seizure, no surgical treatment Epilepsy requirements apply if history of seizure(s). Epilepsy requirements apply if history of seizure(s). c Haemorrhage and/or focal neurological deficit, no surgical treatment d Treated by surgical excision (craniotomy) e Treated by radiosurgery irrespective of whether Incidental or symptomatic Can drive when there is no debarring residual impairment likely to affect safe driving. Epilepsy requirements apply if history of seizure(s). 6 months off; can drive when there is no debarring residual impairment likely to affect safe driving Epilepsy requirements apply if history of seizure(s). No restrictions Epilepsy requirements apply if history of seizure(s). Permanently revoke/refuse Revoked/refuse until 10 years postobliteration of the lesion and Epilepsy requirements apply. No restrictions Epilepsy requirements apply if history of seizure(s). 21

22 B Infratentorial Medical Standard for the assessment of drivers. Issued by the RTA & DHA, Dubai, UAE. a Incidental No restriction No restriction b With focal neurological deficit or haemorrhage. c Treated by surgical excision (craniotomy). Can drive when there is no debarring residual impairment likely to affect safe driving. Epilepsy requirements apply if history of seizure(s). As above. Can drive when there is no debarring residual impairment likely to affect safe driving. Epilepsy requirements apply if history of seizure(s). As above. Medical Code NB. - Multiple cavernoma: no firm evidence of morbidity. - Size is not an issue. See Appendix at end of this Chapter Medical Code

23 NEUROLOGICAL DISORDERS 31 INTRACEREBRAL ABSCESS/ SUBDURAL EMPYEMA 32 HYDROCEPHALUS 33 INTRAVENTRICULAR SHUNT OR EXTRAVENTRICULAR DRAIN Insertion or revision of upper end of ventricular shunt or extra-ventricular drain. 34 NEUROENDOSCOPIC PROCEDURES, eg. III rd ventriculostomy GROUP 1 ENTITLEMENT ODL - CAR, M/CYCLE Medical Code One year off driving. Medical Code Medical Code If uncomplicated, retain license. Medical Code Medical Code months off. Can then be relicensed when there is no debarring residual impairment likely to affect safe driving. Medical Code Medical Code months off. Can then be relicensed when there is no debarring residual impairment likely to affect safe driving. Medical Code GROUP 2 ENTITLEMENT VOC LGV/PCV Medical Code Refusal or revocation. Very high prospective risk of seizure(s). May consider licensing if 10 years seizurefree from treatment. Medical Code Medical Code Can be issued with a license if uncomplicated and no associated neurological problems. Medical Code Medical Code Doctor's assessment may allow license issue. Medical Code Medical Code Doctor's assessment may allow license issue. Medical Code INTRACRANIAL PRESSURE - MONITORING DEVICE Inserted by Burr hole surgery. Medical Code The prospective risk from the underlying condition must be considered. Medical Code Medical Code The prospective risk from the underlying condition must be considered. Medical Code

24 36 IMPLANTED ELECTRODES: A DEEP BRAIN STIMULATION FOR MOVEMENT DISORDER OR PAIN Medical Code If no complications from surgery and seizure free, can drive when there is no debarring residual impairment likely to affect safe driving. Medical Code If no complications from surgery, seizure free and underlying condition non-progressive, fitness to drive can when there is no debarring residual impairment likely to affect safe driving. B IMPLANTED MOTOR CORTEX STIMULATOR FOR PAIN RELIEF If aetiology of pain is non-cerebral e.g. trigeminal neuralgia, 6 months off. If the aetiology is cerebral e.g. stroke, 12 month off. Can then drive when there is no debarring residual impairment likely to affect safe driving. Refusal or Revocation. Medical Code Medical Code APPENDIX THE CURRENT EPILEPSY REQUIREMENTS FOR GROUP 1 AND GROUP 2 ENTITLEMENT GROUP 1 Epilepsy is considered a disability. This means that: 1) A person who has suffered an epileptic attack whilst awake must refrain from driving for at least one year from the date of the attack before a driving license may be issued. 2) A person who has suffered an attack whilst asleep must also refrain from driving for at least one year from the date of the attack. However, if they have had an attack whilst asleep more than three years previously and have had no attacks whilst awake since that original attack whilst asleep, then they may be licensed even though attacks whilst asleep may continue to occur. If an attack whilst awake subsequently occurs, then the formal epilepsy regulations apply and require at least one year off driving from the date of the attack. AND in both cases 3) i) so far as practicable, the person complies with advised treatment and check-ups for epilepsy, and ii) the driving of a vehicle by such a person should not be likely to cause danger to the public. GROUP 2 During the period of 10 years immediately preceding the date when the license is granted the applicant/license holder should: 1) be free from any epileptic attack AND 2) have not taken medication to treat epilepsy AND 3) not otherwise be a source of danger whilst driving. In addition The liability to seizures arising from a cause other than epilepsy is considered a disability. In addition, someone with a structural intracranial lesion who has an increased risk of seizures will not be able to drive vehicles of this group until the risk of a seizure has fallen to no greater than 2% per annum, which is a recommended level by a Panel of UK doctors. 24

25 GUIDANCE FOR CLINICIANS ADVISING PATIENTS ABOUT THEIR DRIVING LICENSE IN THE CASE OF BREAK-THROUGH SEIZURES IN THOSE WITH ESTABLISHED EPILEPSY: In the event of a seizure, the patient must be advised not to drive unless they are able to meet the conditions of the asleep concessions. The RTA Licensing Agency should also be advised as this person may be a risk to road safety. GUIDANCE FOR WITHDRAWAL OF ANTI-EPILEPSY MEDICATION BEING WITHDRAWN ON SPECIFIC MEDICAL ADVICE (N.B. This advice only relates to treatment for epilepsy) From a medico-legal point of view, the risk of further epileptic seizures occurring during this therapeutic procedure should be noted. If an epileptic seizure does occur, the patient will need to satisfy driving license requirements before resuming driving and will need to be counselled accordingly. The current epilepsy requirements require a period of at least one year free of any manifestation of epileptic seizure or attacks whilst awake from the date of the last attack; special consideration is given where attacks have occurred only whilst asleep. It is clearly recognised that withdrawal of anti-epilepsy medication is associated with a risk of seizure recurrence. A number of studies have shown this, including the randomised study of anti-epilepsy drug withdrawal in patients in remission, conducted by the Medical Research Council Anti-epileptic Drug Withdrawal Study Group (UK). This study shows a 40% increased associated risk of seizure in the first year of withdrawal of medication compared with those who continued on treatment. It is recommended that patients should be warned of the risk they run, both of losing their driving license and also of having a seizure which could result in a road traffic accident. Please advise that patients should be advised not to drive from commencement of the period of withdrawal and thereafter for a period of 6 months after cessation of treatment. It is considered that a person remains as much at risk of seizure associated with drug withdrawal during the period of withdrawal as in the 6 months after withdrawal. This advice may not be appropriate in every case. One specific example is withdrawal of anticonvulsant medication when there is a well-established history of seizures only while asleep. In such cases, any restriction in driving is best determined by the physicians concerned, after considering the history. It is up to the patient to comply with such advice. It is important to remember that the epilepsy requirements are still relevant even if epileptic seizures occur after medication is omitted, for example on admission to hospital for any condition. PROVOKED SEIZURES: For Group 1 and possibly Group 2 drivers or applicants, provoked or acute symptomatic seizures may be dealt with on an individual basis if there is no previous seizure history. Seizures associated with alcohol or drug misuse, sleep deprivation or a structural abnormality are not considered provoked for licensing purposes. Similarly, reports of seizures as a side-effect of prescribed medication do not automatically imply that such events will be considered as provoked. Doctors may wish to advise patients that the period of time likely to be recommended off driving will be influenced inter alia, by:- a) whether it is clear that the seizure had been provoked by a stimulus which does not convey any risk of recurrence and does not represent an unmasking of an underlying liability; and, b) whether the stimulus had been successfully/appropriately treated or is unlikely to occur at the wheel. In the absence of any previous seizure history or previous cerebral pathology, the following seizures may also be treated as provoked: eclamptic seizures reflex anoxic seizures an immediate seizure (within seconds) at the time of a head injury seizure in first week following a head injury (see head injury section). at the time of a stroke/tia or within the ensuing 24 hours during intracranial surgery or in the ensuing 24 hours. Seizures occurring during an acute exacerbation of multiple sclerosis or migraine should be assessed on an individual basis by the doctor. 25