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Evidence Report Stroke and Commercial Motor Vehicle Driver Safety

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Evidence Report Stroke and Commercial Motor Vehicle Driver Safety Evidence Report Stroke and Commercial Motor Vehicle Driver Safety Presented to The Federal Motor Carrier Safety Administration September 15, 2008 Prepared for Prepared by MANILA Consulting Group, Inc. ECRI Institute 1420 Beverly Road, Suite 220 5200 Butler Pike McLean, VA 22101 Plymouth Meeting, PA 19462 Evidence reports are sent to the Federal Motor Carrier Safety Administration’s (FMCSA) Medical Review Board (MRB) and Medical Expert Panels (MEP). The MRB and MEP make recommendations on medical topics of concern to the FMCSA. The FMCSA will consider all MRB and MEP recommendations, however, all proposed changes to current standards and guidance (guidelines) will be subject to public notice and comment and relevant rulemaking processes. Policy Statement This report was prepared by ECRI Institute under subcontract to MANILA Consulting Group, Inc., which holds prime GS-10F-0177N/DTMC75-06-F-00039 with the Department of Transportation’s Federal Motor Carrier Safety Administration. ECRI Institute is an independent, nonprofit health services research agency and a Collaborating Center for Health Technology Assessment of the World Health Organization. ECRI Institute has been designated an Evidence- based Practice Center (EPC) by the U.S. Agency for Healthcare Research and Quality. ECRI Institute’s mission is to provide information and technical assistance to the healthcare community worldwide to support safe and cost-effective patient care. The results of ECRI Institute’s research and experience are available through its publications, information systems, databases, technical assistance programs, laboratory services, seminars, and fellowships. The purpose of this evidence report is to provide information on the current state of knowledge on this topic. It is not intended as instruction for medical practice, nor for making decisions on individual patients. Authors James Reston, PhD, MPH (The ECRI Institute) Meredith Noble, MS (The ECRI Institute) Jessica Williams, PhD, MPH, RN (Manila Consulting Group) Stephen Tregear, DPhil (Manila Consulting Group) i Table of Contents EXECUTIVE SUMMARY ....................................................................................................................................... 1 PURPOSE OF EVIDENCE REPORT ........................................................................................................................................ 1 IDENTIFICATION OF EVIDENCE BASES .................................................................................................................................. 1 GRADING THE STRENGTH OF EVIDENCE ............................................................................................................................... 2 ANALYTIC METHODS ....................................................................................................................................................... 2 PRESENTATION OF FINDINGS ............................................................................................................................................ 2 EVIDENCE‐BASED CONCLUSIONS ....................................................................................................................................... 3 Key Question 1: Are individuals who have experienced a stroke at an increased risk for a motor vehicle crash (crash risk or driving performance)? ........................................................................................................... 3 Key Question 2: If so, can neuropsychological testing of individuals who have experienced a stroke predict crash risk? ................................................................................................................................................. 3 Key Question 3: Among individuals who have experienced a TIA, what is the risk of experiencing a future stroke?........................................................................................................................................................ 4 PREFACE ............................................................................................................................................................ 7 ORGANIZATION OF REPORT .............................................................................................................................................. 7 SCOPE .......................................................................................................................................................................... 7 BACKGROUND ................................................................................................................................................... 9 I. DEFINITIONS, ETIOLOGY, AND SIGNS AND SYMPTOMS OF TRANSIENT ISCHEMIC ATTACK AND STROKE .................................. 10 A. Transient Ischemic Attack .......................................................................................................................... 11 B. Strokes ........................................................................................................................................................ 12 II. EPIDEMIOLOGY OF TIA AND STROKE ............................................................................................................................. 15 A. Transient Ischemic Attack .......................................................................................................................... 15 B. Strokes ........................................................................................................................................................ 17 III. RISK FACTORS FOR CEREBROVASCULAR DISEASE ............................................................................................................ 30 A. Unmodifiable Risk Factors: ......................................................................................................................... 31 B. Modifiable Risk Factors: .................................................................................................................................. 32 IV. HEALTH CONSEQUENCES OF TIA AND STROKE ............................................................................................................... 38 A. General Overview of Health Consequences of TIA and Stroke ........................................................................ 38 V. DIAGNOSIS AND SCREENING FOR TIA AND STROKE .......................................................................................................... 43 NIH Stroke Scale to Assess Neurological Deficit .................................................................................................. 44 VI. TREATMENT OPTIONS FOR TIA AND STROKE AND POTENTIAL SIDE EFFECTS ........................................................................ 45 A. Immediate Treatment ................................................................................................................................ 45 B. Hospital Discharge and Ambulatory Care Visits ......................................................................................... 46 C. Outpatient Rehabilitation .......................................................................................................................... 47 D. Medications ................................................................................................................................................ 47 E. Treating Heart Disease ............................................................................................................................... 49 F. Surgery and Procedures ............................................................................................................................. 49 G. What is in the future for stroke treatment? ............................................................................................... 52 ii V. WHAT IS THE IMPACT OF CEREBROVASCULAR DISEASE ON A PERSON’S DRIVING ABILITY? .................................................. 53 VII. CAN SIDE EFFECTS OF TREATMENT FOR CEREBROVASCULAR DISEASE HAVE AN IMPACT ON DRIVING ABILITY? ................... 58 STROKE AND DRIVING REGULATIONS ................................................................................................................................ 59 Current U.S. Federal Regulatory and Medical Advisory Criteria for CMV Operators .......................................... 59 Current FMCSA Guidance to Medical Examiners ................................................................................................ 60 Medical Fitness Standards and Guidelines for Individuals Performing Transportation Safety in the United States ...................................................................................................................................................... 63 Regulatory Medical Fitness Standards in Various Countries ............................................................................... 69 METHODS ......................................................................................................................................................... 71 KEY QUESTIONS ........................................................................................................................................................... 71 IDENTIFICATION OF EVIDENCE BASES ................................................................................................................................ 71 Searches .............................................................................................................................................................
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