Okay, musculoskeletal, you can't be missing a foot, arm, leg, unless you've had an SPE. Now, you can't be missing a hand or finger which interferes with prehension or power grasping. These two fingers. So if they're missing the index or the thumb, then they have to have a SPE. If they're missing their little finger, we don't care, okay? They can't have defects that affect their ability to operate a motor vehicle. They might have their leg, but the ankle doesn't move, like, at all. That would be another thing they might, they would need an SPE for. They could, they could drive if they get their SPE, okay? So they can't have had any of these things that will interfere, any, it can't have any disease that will interfere with your ability to operate a motor vehicle, including musculoskeletal things. Because you've got to be able to do your driving things. So tasks you have to do, you have to manipulate the wheel, pedals, loads, secure, you have to, changing tires is actually beyond the scope of a driver. But you do have to be able to do your pre-vehicle check. You have to be able to walk all around the vehicle, fireability, all those things we talked about yesterday. So do they have anything that makes me worry about their ability to do this? They're merely walking into the office and watching them walk into the exam room will give you a lot of this information, okay? Just the person, you know, they have a limp, they're using a cane, all those kind of things are things that you're going to watch for and to help you assess the patient. Can they sit in the chair in the exam room? The patient that can't sit in the chair in the exam room really worries me about their ability to sit to drive the vehicle. I'm not aware of a commercial motor vehicle you can drive while you're standing. So if they can't sit in my exam room for 10 minutes, how in the world are they going to drive across three states in a truck? Now, we, and now at my clinic, they do have the most uncomfortable chairs. So if they get up after half an hour, we'll talk. But if they can't sit for three minutes, there's a problem. So when we're looking at this, you want to look at basic range of motion, especially the neck. Like, can they turn their head far enough to see the mirrors? Okay? Or do they have, you know, they have some spot, they have a spot, see cervical fusion where they can move their head like five degrees either direction or zero or have some condition that caused that. Resistive strength testing, I want to assess their condition, how bad is it, and how likely is it to interfere with their ability to drive safely? If they have yes, if they have question or yes answers to any of these questions, which are the musculoskeletal ones, I want to ask about them and document what I found, what I find. Do they, and we already covered all that. Okay. So I'm going to evaluate them. I'm going to come up with an opinion. I'm going to do the physical exam and document, you know, how long have they had it, what's really wrong, all those things that you want to know about skills performance evaluation, we already talked about. It has to do with a fixed deficit that is stable. So no, you can't go get your SPE the week after you get your new prosthetic leg, the first time you've ever had it. You need to be able to walk on it and get all that. You need to be done your rehabbing, it's all stable and you're now back to trying to do normal things. They have to be medically fit otherwise and you give them medical certificates that requires an SPE, they can't do an SPE without that medical certificate from you that says that everything else is normal. They don't want to waste their time doing SPE on somebody that's, you know, not going to pass for cardiac reasons. And they don't check anything except their physical skills. Like they don't recheck their blood pressure when they get to the SPE place. So I still get to decide if they have a fixed deficit. Now, specifically, if I determine they have a fixed deficit of less than the whole hand that's medically disqualified, then they need an SPE. But only for, like I said, it's prehension and power grip. And then, I mean, if they can grasp their steering wheel, they can demonstrate the ability to control the steering wheel and the gear shift and everything with their remaining three fingers, that's fine. But they have to go do the test. And then I'm going to point out they have to carry both their medical certificate and the SPE certificate when they get it. I ask them to bring in the SPE certificate if they're going to come to see me the next time. I just, I mean, I don't tell them that, they don't have to bring it in to keep driving. Just when you come next time, can you bring it with you? Every once in a while, those, I've only seen one that had one, that had one thing that like, that noted something that you may want to monitor. There's actually like, you know, they pass the test, but just barely, as you know, you know, watch the grip strength in the left hand, that kind of a thing. With that neck rotation for being fixed, do you make them get an SPE or what do you do? If they had fixed neck, if they can't, if I don't think they can rotate enough to see in both mirrors, I'm sitting for an SPE, because I wanted to show. Now, there are ways they can do it where they kind of tilt themselves, but I want them to demonstrate in a controlled setting that's safe. Because the SPE, they're in a lab, basically, that they can do it and be effective. So that there's no, there's no waiting period for a fixed deficit. You decide that they're stable. Okay. Then they're going to go for the SPE. This is, okay. So they're going to go leave my office and go see an orthopod or an PM&R doc who's going to say the thing is stable. Okay. That's the key part. And I recommend finding somebody in your neighborhood that will do, that is an orthopod or a PM&R doc, know who will actually do them. Because I've had, I had one guy that bounced all around a university medical center and saw like three orthopods and they all refused. I don't do forums. So it can't be, it can't be, it's only extremities. It can't be a progressive disease. And they, and they have to still have all the adequate range of motion, everything that they demonstrate they can do. So it doesn't apply to a torso, doesn't apply if there's, if there's requirements in their SPE, like that they have to have their prosthesis in place, they have to have their prosthesis in place. They can't drive without that. And, and they just have to start with a PM&R or orthopedic surgeon who will determine that it is stable. That's all they have to say is it's stable. And everything else, they'll get you your card requiring SPE. Either their SPE is a different length of time. It doesn't matter. So neuromuscular diseases come in this box too. They can, they can be a, this is more of a challenge. So you may want to have a neurologist or PM&R person see somebody with a neuromuscular disease. Now, if they've got like a super mild case of something, I might sort and they're basically normal, I might certify them myself. I might do the exam myself, convince myself they're normal and move on. But if they don't have the super mild case of something, they've got ALS or something, I really want somebody else to help me with this and decide if this person's safe to drive. They might pass the test now, but were they going to be in three months or six months? And the one thing that you'll get oftentimes from that specialist is advice on how often, you know, they should be reassessed every so often. I would, if I, if I had that ALS person or somebody was real mild, but they've been diagnosed, I might ask the neurologist specifically, how long do you think this person is stable or how often should we reassess their, their progress? Do you think about all the parts of driving, not just sitting in this, in the driver's seat? Prognosis is, and a proper diagnosis, and then the prognosis are key things. And that's where you ask somebody to help you figure it out. You can ask the driver to do a driving test. There's no formal mechanism for that. You'd have to kind of informally negotiate something with the drive, with the employer. But that's something that you could think about. And you're always the final decider. Autonomic neuropathy is something I've seen actually two now. You know, these are people that, that are worried me. So people that are admittedly, I, I, I really, if they're that far along, there are not neuropathy. I really worry if they can drive safely. My big concern from patients I've dealt with that are on these medicines is, can they do it all day long? Like, can they, you know, they may be good for a couple of hours on their medicine, but can, you know, you don't want to get halfway there and then they, they can't do the job. And so they, they start, well, I won't tart my load. We'll just see what happens. And, you know, end up dumping coal all over the school bus or something. So if they have abnormal muscle activity, that's a question. I want the neurologist or the, I want an opinion. It depends on what they have. It really depends on what they have. I mean, myotonia or Isaac's or Stiffman syndrome probably will not be adequate. But if I, they've got one of those diseases, I really want input from the neurologist. Maybe it's stable, maybe it's congenital and maybe they're okay, but I really want them to vote. Congenital myopathies. This is a list of some of them. Again, we're considering the strength and endurance. If they're pretty close to normal, I might certify this person. If they're flaccid, I'm not going to certify them. Inflammatory myopathies, same thing, complex disorders, get input from a, from a specialist. And I probably would not certify most of them unless they're, and I probably would not certify most of them unless they're pretty much normal. Motor and neuron diseases. ALS, I probably wouldn't certify unless I've got lots of muscular dystrophy. This all depends. This says do not certify. This is all, muscular dystrophy is all over the place. Some people have a little bit and they're fine. Some people have a lot, same deal. Assess the driver and make your decision. Neuromuscular junction disorders, same thing. Depends on how severe it is and get input. Any questions? All the, all the neuromuscular diseases, it's all the same thing. Talk to, get your specialist input and make your decision. Any questions? Good job. So the question was asked, there's a couple of questions in the, in the chat, which we'll, which we'll address. So can you remind me how to do 70 degrees apart of the vision test? Sure. So what you're doing is I want to make sure they've got vision 70 degrees on either side of the patient. So you can do this. The way I do this is by, by confrontation. So I'm looking direct at the patient. They're looking directly at me and I look at their eyes. I bring my fingers in from behind their head and I let them know that I haven't told them they can see the thing move. 70 degrees out on the side, which is almost horizontal, but not quite is what I'm looking for. So I want them to be able to see when they're about this far out. That's my 70 degrees on either side. That's the thing on the side. The other question, somebody mentioned about charging. So I don't know. The charging is what, what your local market will bear. This does vary quite a bit as you move around the country and is often negotiated between an employer and the provider. Any other questions online or live before we call this a day? Okay.

musculoskeletal

neuromuscular

Skills Performance Evaluation

driving capability

vision testing