Good afternoon, my name is Dr. Michael Whiting, and it's good to be with you this afternoon. I'm a physical medicine rehabilitation and an occupational medicine specialist practicing in Harrogate, Tennessee, and also a member of AOCOPM, so I'm glad you're all here and I appreciate your interest in this certification. We're going to be talking about the clinical area of neurology as it refers to the CME evaluation. This is an area where documents and disease tables are constantly being revised, and it's actually, we'll talk about it a little bit later, an area where there is some controversy right now. There are some waiting periods involved in some of these diseases, so if more than one applies to a particular driver because of multiple issues, then you want to examine the driver for certification after completion of the longest applicable waiting period. In terms of seizure disorders, the best predictor of a seizure risk for future seizures is how long they've been seizure-free and their time off of anti-seizure medications, for sure. The first condition we'll look at is epilepsy. It's by definition a disease characterized by recurrent, unprovoked seizures. Unprovoked is a key term. As far as the FMCSA is concerned, anybody who has had two unprovoked seizures has epilepsy. Provoked seizures are not epilepsy. Please remember that. There are some special rules following or pertaining to single, unprovoked seizures that you need to keep in mind. The advisory criteria, according to the regulations, are that epilepsy is a chronic functional disease characterized by seizures or things that happen without warning that result in loss of control, voluntary control that may lead to unconsciousness. Drivers cannot be qualified if they have a medical history of epilepsy, if they have a current clinical diagnosis, or if they're currently taking anti-seizure medications. That's anti-seizure medications for seizures. There are some medications that have been developed for seizures that are used mostly off-label for things that are not seizures, so that would be something you would want to inquire about. After an unprovoked first seizure, the driver should be seizure-free and off of medication for at least five years to distinguish between a medical history of a single instance of seizure and epilepsy. A second unprovoked seizure, regardless of time elapsed, the regulations say would constitute a history of epilepsy and would no longer allow the driver to meet the physical requirements for certification. The epilepsy medical guidelines are currently under review, and this is an area of controversy right now. There's a controversy specifically over single provoked seizures, provoked seizures. These are sometimes situations where there's not much of a chance of them recurring at all. If someone has, for example, a very low blood sugar that's caused by some sort of medication that they might take, and it's not likely to recur at all, sometimes, for example, this can happen as a reaction to anesthesia that's very simple. One seizure, but again, that's provoked. To quote one of my colleagues, the chances of a driver hopefully are not very good that they're driving while under anesthesia. There are going to be some guidelines and literature that you need to follow because this is an area that's not static, and we expect probably that the guidelines here will change over time. If people do have epilepsy for certification, recertification, again, there's a 10 year waiting period for being off of anti-seizure medication and seizure free, but again, remember that's anti-seizure medication for a seizure disorder. If they've completed that time period and they are seizure free, and you believe that the nature and severity of their condition doesn't endanger their health or the health of the public, you're good to certify them. You must not certify them if they have an established medical history of epilepsy, a clinical diagnosis of epilepsy, or anything else that's likely to interfere with consciousness or their ability to control a motor vehicle. The note there on the slide says that if you choose to certify somebody with an established medical history of epilepsy, to be sure to include in your documentation all the things that you used to make that decision. My advice would be that's going to be extremely carefully looked at, and I wouldn't go there. It's recommended that you not certify a driver if they're taking anti-convulsant medication because of a history of one or more seizures. It's okay if a medication that was developed for seizures is being taken for something that's not seizure. An example would be the very commonly prescribed medication, such as gabapentin, which is prescribed off-label for things like post-herpetic neuralgia, restless leg syndrome, diabetic neuropathy, and so forth. You can get additional tests if you need to, and additional consultation. If you're not sure, then feel free to get a specialist in neurologic disease to give you some advice. Then for follow-up, that's a one-year certification. There was an update in 2013 that allowed for an eight-year seizure-free and off-medication period. This was a requirement for an exemption, so you could ... Again, you can only certify when they've been off meds and seizure-free for up to 10 years, and sometimes that requires an exemption letter. Seizures after an insult to the brain, remember that seizures sometimes occur with a cerebrovascular insult to the brain, and sometimes they can cause a fixed neurologic deficit. Usually unprovoked seizures occur within the next five years in a fairly significant percentage of folks. Whether or not they had early seizures doesn't seem to make a difference. What does seem to make a difference is people who've had cortical or subcortical issues, those are at higher risk. The same risk of seizure recommendations are applicable for intracerebral and subarachnoid hemorrhages as well. People can have a seizure at the time of a brain insult or later. Seizures typically are a reflection of where the injury happened, but they could also indicate severity. Neurologic conditions where you have early seizures are also risky for later provoked seizures, particularly things like depressed skull fractures and those kind of things. Early seizures does cause a significant risk for later epilepsy associated with what caused the seizure in the first place. The risk for an unprovoked seizure is greatest in the first couple years after that initial insult, whatever it might be. For people who survive a severe head injury, the risk for unprovoked seizures does not seem to significantly decrease over time. Again, that's severe head injuries, and we'll talk more about that later. People should not be considered for certification based on the risk for unprovoked seizures. It's important to realize that if someone has had penetration of the dura, whether it be for surgery or by a bullet or something like that, they have a risk for epilepsy similar to other severe head trauma. That is equivalent to severe head trauma. If they've had surgery like this, then you should not certify them. The waiting period for a central nervous system insult related to seizures is a minimum of a year seizure free and off of anticonvulsant medications, provided it was a mild insult with no early seizures, none, not the first one, or a stroke without any kind of risk for seizures. That typically would be one that's non-hemorrhagic and a intracerebral or subarachnoid hemorrhage without risk for seizures. There would be a minimum two-year seizure free waiting period and a two-year period of being off medications for either a mild insult with early seizures or a moderate insult without them. Then a minimum of five years for a moderate insult with early seizures, a stroke with a seizure risk, or an intracerebral or subarachnoid hemorrhage with risk. Keep in mind that the difference between one and two years were referable to mild and moderate insults have to do with whether or not there were early seizures. Mild or moderate seizures, again, maximum certification would be for a year. They have to complete the minimum waiting period of being seizure free and off of anticonvulsants. The other thing is, this is a key, they have to have a normal physical exam, normal physical exam, and they have to have a normal neuro exam. That includes a neuro-ophthalmologic evaluation, so they have to have a neuro-ophthalmologic evaluation, and they have to have undergone neuropsych testing. You have to have documentation of that. They have to have clearance from a neurologist who understands what's involved in driving a commercial motor vehicle. Keep in mind, that's maximum for a year and normal physical exam. That includes neuro exam, and that includes neuro-ophthalmology evaluation and neuropsych testing and neurologic clearance from a neurologist. It's recommended that we do not certify these folks if they have a severe brain insult with or without any kind of seizure. If they have a mild or moderate insult, again, not to certify them if they haven't completed the waiting period in terms of being seizure free and off of anticonvulsant medication, or if they have an abnormal regular physical exam or neuro exam, or if they don't have either neuro-ophthalmology evaluation or neuropsych testing, and if they don't have clearance from a neurologist. You can get any other test that you feel like you need to. For example, if they have everything except maybe the neuropsych test, you can say to them, I can't certify you, but you need to get the neuropsych eval, and then they should be followed up again on an annual basis. In terms of metabolic seizures, these are seizures due to some sort of metabolic illness. It's a normal reaction sometimes to the properly functioning nervous system. We've all heard of febrile seizures that children and adults sometimes get, or those other things that I mentioned earlier, but if there's a systemic metabolic illness, typically the seizures are related to that alteration of homeostasis, and those are not known to be associated with any tendency to have further seizures. The risk for those recurring would be related to, is the thing that was the inciting event in the first place likely to recur? That's what you need to consider there. In terms of systemic metabolic illness, there's no waiting time, but you do not certify the driver until you know what the cause of the seizure is, and you know that treatment is not only adequate, but safe and stable. Maximum certification time is two years, and so if the underlying dysfunction has been corrected and there are no other disqualifying things, you can then certify them. You would not certify them if you think that there is any danger to the driver or to the public, if you think there is additional monitoring or testing that need to be done, and that might be done on a case-by-case basis in order to determine their fitness or duty. Traumatic brain injury, this is an area kind of where I live, not that I have one, I treat a lot of them, but traumatic brain injury is where you have an insult to the brain caused by something external. It may or may not produce a loss of consciousness or an altered state of consciousness. It can be anything from a very short-term getting your bell rung on the football field to coma with long-term issues. There may be behavioral or emotional issues along with this. Some people who experience traumatic brain injury have issues with memory and reasoning, attention, concentration, speech or language issues, or emotional or behavioral issues that would keep them from being certified. Traumatic brain injury is classified by the duration of how long, in other words, how long they had loss of consciousness and their depth of dural penetration, if there is any, and they're characterized mild, moderate, and severe. A severe head injury is where the dura is penetrated. If it's penetrated at all, period, it's a severe injury, and if they've had a loss of consciousness more than 24 hours. Either one would classify as a severe head injury. In this case, there is a very high risk for unprovoked seizures, and that doesn't get better over time. A moderate head injury, there is no dural penetration, but the loss of consciousness is more than 30 minutes, but not more than 24 hours. Again, remember, for severe head injury, if there's dural penetration, that's severe, period. If there's loss of consciousness more than 24 hours, that's severe. If both happen, that's severe. For moderate, there's no dural penetration, and loss of consciousness is at least 30 minutes, but no more than 24 hours. Mild head injury, again, no dural penetration. There could be either no loss of consciousness or loss of consciousness for less than 30 minutes. It's going to be really important that you differentiate mild traumatic brain injury with or without early seizures. If there is surgery involving dural penetration, as we said before, then they have a significant risk for subsequent epilepsy, similar to head trauma. You would not certify those folks. The certification period, waiting period for these guys would be two years minimum, seizure-free and off of anticonvulsant medications. If they had a mild TBI, that would be with early seizures. That would be two years off, or a moderate without early seizures. A five-year period of waiting, in terms of being seizure-free and off of anticonvulsant medications would be for a moderate TBI with early seizures. Again, the difference between two years and five years with a moderate TBI would be whether or not they had early seizures. Maximum certification is two years for a mild TBI with no early seizures, and one year for everything else. If a driver has a mild or moderate TBI, then you can certify them. If the appropriate waiting time and time off of anti-seizure medications has been completed, if they have a normal physical exam and a normal neurologic exam, which must include a neuro-ophthalmologic and a neuropsych exam, they have to have clearance from a neurologist who understands what they're going to be doing as well. You would not certify these folks if they have a severe TBI, whether or not they had early seizures. If it meets the criteria for severe, they do not get certified. If they meet the criteria for mild or moderate TBI, then you would not certify them if they haven't had the appropriate waiting time or time off of anti-seizure medication, or if they don't have a normal physical exam and neuro exam, which would include neuro-ophthalmologic and neuropsych exam, or if they don't have clearance from a neurologist or any combination of those things. You want to monitor and test these people on an as-needed basis, on a case-by-case basis. If you need to get a consultant before you make a decision, absolutely feel free to do that. These guys should all have an annual medical exam. When I say these guys, that's not gender-specific, any of these drivers. Let's move on into stroke. A lot of people have survived stroke in our society, and it is a huge cause of long-term disability. The most common ones are embolic and thrombotic, and there is a risk for complicating seizures depending upon where the lesions are located. Lesions that are in the brainstem or the cerebellum are typically not associated with an increased seizure risk. Lesions that are in the cortical or subcortical areas and where those deficits have occurred, they are associated with increased seizure risk. Cortical and subcortical deficits, increased seizure risk. Cerebellum and brainstem, no increased seizure risk. These guys have to have evaluation by a neurologist, period. If they have embolic or thrombotic infarctions, they're going to usually have residual impairments, either cognitive, physical, or both. They will often have fatigue. They will often have a flare of their neurologic deficits if they work really long hours or if they're working under really stressful conditions. Most people who have a stroke, regardless of its cause or origin or where it affects the brain, will typically get pretty much all the recovery they're going to get within a year. Certainly, they're going to get to 90% of what they're going to be long-term within a year. When you evaluate these folks, you must evaluate them with a very detailed neurologic evaluation. You need to look at their cognition. That would be immediate and short-term memory, their ability to calculate, their orientation, their attention, their concentration, their ability to solve simple problems, judgment. You want to evaluate their vision. You want to evaluate their physical strength and their reaction time, their coordination, and their balance and their agility, for sure. For these drivers, you want to have them have a minimum of one-year waiting period if there isn't a risk of seizures. That would be strokes that are located in the cerebellum or brain stem that are vascular. A minimum of five years if there is a risk. That would be the cortical and subcortical deficits. Maximum certification will be a year. Again, if you certify these folks, even if it's a year, they have to have completed the appropriate waiting period. They have to have a normal physical exam and a normal neuro exam that includes those things I mentioned earlier, as well as the neuro-ophthalmology and neuropsych exam. They cannot have any sort of neurologic deficits that would interfere with the ability to operate a motor vehicle, and they have to have neurologic clearance. You would not certify these drivers if they haven't had the appropriate waiting period. You would not certify them if they're on oral anticoagulant therapy, and a lot of patients will be. They may not know if what they're on, their medication that's on, is actually an anticoagulant. It's amazing how many people are on blood thinners and don't know that they are. So again, that's oral anticoagulant therapy, all right? And because of the increased risk of bleeding. You would not certify them if they have any other, if they're on any other medication or combination of medications that have a risk of significant complications on the neurologic system. You would not certify someone with cognitive or physical impairments that would interfere with commercial driving, particularly in some of the conditions that drivers have to do. And you would not clear them if they don't have evaluation from a neurologist who has evaluated these things in addition to your evaluation. So again, in these cases, you may very well need to have them evaluated by a consultant. Feel free to utilize consultants. And again, these guys also should have an annual evaluation, medical evaluation. So drivers with a history of headache. There are several, and this is not just the headaches that we all get from time to time. These are chronic headaches or chronic recurring headaches that could potentially interact with other neurologic things. So these would be things that have associated complications like migraines or as a result of some other type of syndrome that might interfere with balance or vision, those kinds of things. So there are several kinds of headaches that might interfere with the ability to operate a commercial motor vehicle, and they are listed here. Migraines are very, very common. And the thing that happens with those frequently that can be problematic is interfering with vision, visual disturbances, particularly sometimes either not only with the aura that happens before them, but also during the migraine episode. Tension headaches can do this. Cluster headaches can do this. If they have headaches related to a previous traumatic brain injury, headaches that are associated with substance use or withdrawal from substances, any kind of atypical cranial neuralgia or nerve related pain or any kind of atypical face pain. You want to consider how often do they have these headaches and what their severity is. You want to ask specifically about that. You want to ask, are there any things that happen along with them, such as the disturbance of vision? And you want to ask them, what treatment do they use? What side effects do they have? What restrictions do they have when they use it? How often do they have to use it? How often do the, how long do the headaches last? That sort of thing. So these guys don't have a specific specified waiting period, but you want to make absolutely sure that you do not certify them until you know what's causing their headaches and you know that they're stable with their treatment and that there's no threat to the driver or to the public. And I always, in my particular practice, I always need to get a, I want to get documentation or at least have a discussion with the person who is treating their headaches and prescribing for them. And their maximum certification would be two years. So you could certify them if you think that there's no issue with safety for the driver or the public, but if you have any doubts about safety of their medical condition, then you would not certify them. Again, feel free to use a consultant if you need to, or get additional tests if you want, or talk to whoever you need to talk to. And these folks should have biennial medical examinations as a routine part of follow-up. Syncope, this is, syncope is not a medical condition. It's merely a symptom of something else, and it could potentially present a threat to public safety or to the driver if they lose control of the vehicle. So it's a consequence frequently of an arrhythmia while they're driving, and that could be very, very dangerous. There are some medications that can cause syncopal effects, particularly if they're managing arrhythmias. If people have a known arrhythmia and they're taking a medication for that, that is still not 100% fail-safe. And so if an arrhythmia occurs, that's a potential problem. And syncope that happens more than once, and it hasn't been explained, we don't know why people have it, or if it's syncope that comes from a known cardiac cause, that constitutes a significant risk. So you need to, as a medical examiner, you need to make sure that you know what the diagnosis is and that it distinguishes between honest-to-gosh syncope, which is a loss of consciousness, or what we call presyncope, which is feeling lightheaded or dizzy. You need to make sure that the medications that people are using don't make them more liable to have problems with it, for example, a drop in their blood pressure, fatigue, any kind of electrolyte shifts, like taking their sodium down low or they're interfering with potassium, those kind of things, or having an imbalance. You need to make sure that you differentiate cardiac from non-cardiac origin for syncope. You also need to make sure that if it's cardiac-based, whether or not the basis of it is from a conduction system problem in the cardiovascular system before you consider certifying them. And you need to know if there is a neurologically-based syncope, and that could be from seizures, that could be from migraine attacks, and other things. And you need to make sure that those have been adequately evaluated, and that the person is stable, and they do not constitute any kind of, any risk to the driver or the public. There is a set of specific recommendations for each diagnosis in the cardiovascular advisory panel guidelines for medically examining commercial motor vehicle drivers that has specific recommendations for hypersensitive carotid sinus with associated syncope and neurocardiogenic syncope. And so you can get those, you can get those from the FMCSA. So certification for syncope, there's no recommended waiting time, but until you know what causes the problem, and you know that the treatment is effective, and you know that they're safe and stable, and you know what other conditions they have that may or may not have specific ramifications for this, and if so, they're being treated by appropriate guidelines. So if you know all of those things, then they can be certified or recertified for no more than a year. So you would certify them if they have been treated for symptomatic disease, but they are asymptomatic, they're on meds, they're tolerating those just fine, they're at really low risk for syncope or near syncope, and they have been cleared by the appropriate specialist based upon what the cause of their syncopal issue was, whether it be a cardiologist, neurologist, or whatever, who, again, understands what the ramifications are for driving a commercial motor vehicle. You would not certify these people if they have syncope, regardless of what's causing it, or if they are at a higher risk, regardless of what's causing it. And you must distinguish between those treatments that reduce the risk of syncope and those where they're still at risk for syncope. It's not just a reduced risk or if they're still at risk. It's not just a reduced risk or if they're still at risk. You have to absolutely be as sure as you can be whether or not there's a risk or syncope or some sort of incapacitated state, whether it be sudden or gradual, particularly if there's an underlying heart disease, and that's especially the case if there's an issue with the conduction system. So these folks should be monitored carefully. You will need to, the driver will have to comply with the medication and treatment guidelines, and they will have to have an annual evaluation by a cardiovascular specialist, again, who understands what the ramifications are for driving a commercial motor vehicle. And sometimes when I talk to these specialists, these cardiologists or whatever, I have to give them a little bit of a splurge, about what driving a commercial motor vehicle is, what they're gonna be doing, under what conditions they're gonna be doing, prolonged driving, those kinds of things, how many hours at a time, vibration, weather issues, those kinds of things. And sometimes that changes their perspective. And again, these guys have to be re-evaluated on an annual basis. For drivers who have a history of vertigo and dizziness, this is an issue where balance and orientation is important in terms of how well their central nervous system and peripheral nervous system are functioning, particularly in vestibular, visual, and proprioception. And if these systems aren't working well together, then that is not safe, and that constitutes a safety issue, not only for the driver, but also the public. The most common medications that are used to treat these things are the antihistamines, the benzodiazepines, and aphenothiazines. Okay, if someone's taking a benzo or aphenothiazine to treat vertigo, they cannot, cannot, cannot be qualified. Okay? You should give special consideration if they're taking antihistamines, because antihistamines can sometimes be an issue producing sedation, sleepiness, that kind of thing. So you wanna be really, really careful with that. Their maximum waiting period, or minimum waiting period is two months of being asymptomatic if they have benign positional vertigo, or if they have peripheral vestulopathy. You wanna be careful, and you wanna evaluate if they have any, if the vertigo or the medication to treat it affects their cognition, if it affects their judgment, if there's any issue with attention or concentration, if there's any sensory issues, paresthesias, numbness, tingling, any of that, if there's any kind of issue with balance or coordination, you wanna ask specifically about that. And you wanna also test for that in your physical exam. Maximum certification is for two years. You would certify them. If they have benign positional vertigo, they have to meet the specific criteria for that, and they've completed the symptom-free period. If they have acute or chronic peripheral vestibulopathy, they have to have completed that appropriate symptom-free waiting period. And they can't have any factors that would interfere with either their health and safety or that of the public if they were driving a commercial motor vehicle. You would not certify them if they've been symptomatic within the past two months, even if they do have benign positional vertigo. You would not certify them if they've been symptomatic in the last two months with acute and chronic peripheral vestibulopathy at all. You would not certify them with Meniere's disease, because that one is just too unpredictable. You would not certify them with non-functioning labyrinth or with labyrinthine fistulas. With vertigo, again, feel free to get a consultant. If you need to, on a case-by-case basis, and they should be followed up biannually with a medical examination. So let's look at some neurologic examples and case studies. We have a, that you might encounter on the exam. You have a lady who's 44. She's 64 inches tall, weighs 145 pounds. She does have a muscle disease. She's on Avonex, which means she's got MS. She got that diagnosis three months ago. She doesn't, she denies any effects from medication. Her vision and sensory issues are fine. She doesn't have any issues with balance or headaches. She occasionally has an itch or tingling in her left arm. Okay, that is a sensory symptom, despite the fact that she's denied it. She is right-handed. She sees her neurologist on a monthly basis. She has brought you records. MRI shows that there are plaques that are suspicious for demyelination, which is consistent with MS. Her lumbar puncture was normal at diagnosis. Her neurologist is treating her, and her neuro status is stable. Her vital signs are stable. Her vision and hearing acuity, that's why VA and HAR are fine. Her blood pressure and pulse are fine. Her urinalysis is fine. She has grade five strength in her upper limb, and on the right, and grade four out of five strength on the left. Grade five out of five, remember, is full range of motion, able to tolerate against gravity, and able to tolerate maximum resistance. The difference between that and grade four, grade five and grade four, is that grade four is also full range of motion against gravity, and able to tolerate most, but not the most severe resistance. Lower extremity strength is five over five bilaterally. Muscle stretch reflexes are two plus, that's normal. Her grip strength is normal. There's no balance issues on exam, and she got a 27 out of 30 for the both the mental exam. So the question is, what's the best outcome possibly for her? She meets the standards for evaluation, but she does, because NS is a progressive potential disease, she does have to have periodic monitoring. So the maximum that she could get would be a one year certificate. In her case, her physical exam is pretty normal, other than the fact that she has some tingling and itching. Okay, that may or may not be significant. If she, you wanna just evaluate how severe that is, and how much of an area that is. And then in a year that could have changed. So that would be something to evaluate. Neat, she has prehensile grasp and pinch ability that is because she's grade four and grade five, which is fine to be able to handle tasks that she would use as a driver. And she doesn't have any symptoms of an advancing process. So she has left arm mild symptoms. That's a little bit weaker than on the right. So the question is at what level of arm strength would you be able to certify her under the provisions of the alternate standard, which would require her to have a skilled performance evaluation. So the key here is, don't fall into this trap, that standard, the standard, the alternate standard, it has to do with fixed deficits of the arms and legs. She doesn't have a fixed deficit of the arms and legs. And she does not need an SPE certificate because it's only for people who have fixed deficits. So don't worry about that, okay? So if she has signs of progression, you would not certify her. If there were significant signs and symptoms that had functional ramifications, either identified by yourself or the neurologist, you would not certify her. If there were new lesions compared to a previous evaluation, at least a year apart, you would not certify her because that is evidence of progressive disease. And you would not certify her if there were issues with excess fatigue or significant fluctuations in motor strength, particularly as it relates to physical and emotional stress or significant infections. So the second scenario, let's look at this one. This is a gentleman who's 57. He's 5'7", he weighs 130 pounds. He is on no medications. He presents for recertification. His last evaluation was almost two years ago. And in the last five years, he said, when you ask about that, he said he had a little bleed in his head that caused a small stroke about eight months ago on his left side, because he said the bleed was from an arteriovenous malformation. Now, if he isn't able to tell you why he had the stroke, you absolutely need to find out what that was. But in this case, he has a residual right hemiplegia. He has not been able to go back to work. He did not have any surgical repair at the ABM yet, and he's not sure if that's gonna happen or not. And he's still going to physical and occupational therapy. When you evaluate him, his visual acuity is 20 over 25. His hearing acuity is fine. His pulse and his blood pressure are fine. His urinalysis is fine, and otherwise, vision is fine. He does walk with a limb. He kind of drags that hemiplegic leg, and his right upper limb kind of hangs down, being a bit flaccid. He has a little bit of internal rotation at his shoulder. He does have motor and sensory deficits consistent with right hemiplegia, and he does have some short-term memory issues and attention issues, but otherwise, his exam is fine. So the question is, what's the best outcome for this guy? Well, he is not able to be qualified because he has a ruptured AVM. It has not been treated. He has hemiplegia, and he has cognitive issues. Any of those would be disqualified. So once he completes his PT and OT, will he be a candidate? No, he will not, no matter what the treating therapist says, because he still will have the cognitive issues. He will still have the AVM that hasn't been repaired. Now, documentation from the treating therapist might be helpful if those things were, other things were not the case, okay? But remember, his treating therapist doesn't decide if he can do what is necessary for operating a commercial motor vehicle. That is the certified medical examiner's decision. I have had situations where the treating therapist was also qualified in terms of work fitness and work hardening and those kind of things and functional evaluations, and I've had them say the person I've tested them for all the tasks that the company that they work for says that they need to be able to do, and they can do all of those things, and so they meet those requirements. And my response is they still have the cognitive issue, and they still have the AVM that hasn't been repaired, so they're still not able to be certified. So remember that the test on these neurologic issues will look at not only the issues pertaining to the diagnosis, but as well as can the driver do what they need to do in order to function as a commercial motor vehicle operator. So keep that in mind when you are negotiating this exam and study it for us. So if there are any questions, I'll be glad to answer those. Thank you very much for your attention. I hope this was helpful. Again, if you have any questions, holler at me, and I'll be glad to answer those. So thank you very much for your attention.

neurological considerations

seizure disorders

epilepsy

traumatic brain injuries

strokes

driver certification

neurologic exams

commercial driving