Progressive Neurological Conditions

Question 1

what is meant by progressive neurological condition?

Answer 1

Symptoms worsen over time

Question 2

A central nervous system tumor is one that can become progressive; severity symptoms increases over time. How does a CNS tumor affect whether or not a patient can get certification?

Answer 2

-Tumor can impair cognitive and judgment abilities
-tumor can affect sensory and motor functioning
-certification may be possible after surgery if the tumor is benign
-must consider the time that the driver is free seizures
-driver must be off anticonvulsants used to treat seizures in order to be considered for certification

Question 3

For which CNS conditions is there a one year waiting period which starts after surgical removal of the lesion/tumor?

Answer 3

Minimum — 1 year post-surgical removal of:
* Infratentorial meningiomas.
* Acoustic neuromas.
* Pituitary adenomas.
* Spinal benign tumors.
* Benign extra-axial tumors.

Question 4

For which CNS conditions is there a two year waiting period which starts after surgical removal of the lesion/tumor?

Answer 4

Benign supratentorial tumors
Spinal tumors.

If more than one waiting period applies (because of multiple conditions or other comorbid diseases), examine the driver for certification after the completion of the longest waiting period.

Question 5

Under which circumstances does a driver with a central nervous system tumor become ineligible for certification?

Answer 5

-incomplete appropriate waiting period
-primary or metastatic malignant tumors of the nervous system
-benign nervous system tumors

Question 6

If a driver with the central nervous system tumor does become certified, what kind of follow-up must they have?

Answer 6

-Yearly recertification
-annual medical exam
-consult with specialist as needed
-there must be no evidence of recurring meningioma

Question 7

What are the two most common types of dementia?

Answer 7

-Alzheimer’s
-picks disease

Always disqualify a driver who has developed dementia.

Question 8

Motor neuron diseases destroy motor neurons, which impairs important voluntary muscle activities such as speaking, walking, swallowing, and other movement. Name some examples of motor neuron diseases.

Answer 8

-Amyotrophic lateral sclerosis (ALS, also called Lou Gehrig’s disease)
-hereditary spinal muscular atrophy (both adult and juvenile forms)
-always disqualify any driver who has a motor neuron disease, because the diseases are debilitating

Question 9

What is multiple sclerosis? How does it affect certification?

Answer 9

-The myelin sheath of the neurologic system is attacked and scar tissue forms
-leads to gait problems, dizziness, vertigo, vision disturbances
- a driver with multiple sclerosis must be disqualified

Question 10

When can a driver who has been diagnosed with multiple sclerosis and disqualified from driving appeal?

Answer 10

-Course of their MS is benign with multiple dysfunction at least five years after diagnosis
-drivers diagnosis is possible/probable, as opposed to definite, MS
-no signs of relapse or progression
-neurological signs are functionally insignificant or nonexistent
-driver has a normal MRI and triple-evoked potential studies, OR has no new lesions on two studies done at least one year part

Question 11

Name some examples of peripheral neuropathies.

What is the damage that can result from peripheral neuropathies?

Answer 11

Examples of peripheral neuropathies: Guillain-Barré syndrome, diabetic neuropathy

Peripheral neuropathies cause damage to specific structures and peripheral nerves, such as the axons and myelin sheaths
-this damage can occur to both sensory and motor nerves
-progression is non-predictable

Drivers with peripheral neuropathies are disqualified, but appeal is possible.

Question 12

When doing the physical exam, how do you look for signs of peripheral neuropathy?

Answer 12

-Sensory modalities of pain
-light touch
-position
-vibratory sensation

Question 13

What happens if you find that a driver has peripheral neuropathy?

Answer 13

-Do not certify
-driver can appeal; they will have to be evaluated by neurologist or physiatrist
-specialist may recommend a simulated skills driving test
-if the appeal is successful driver must have certification annually (so they can be certified for maximum of one year)

Question 14

Normally, a driver with a peripheral neuropathy is disqualified from driving. If they appeal and are able to be certified, what is the maximum duration of time they can be certified?

Answer 14

Maximum certification period is one year

Question 15

Describe autonomic neuropathy.

Answer 15

This phrase means there is disease of the nerves of the autonomic nervous system that regulate vital functions.

Question 16

What bodily functions can autonomic neuropathy affect?

Answer 16

-Blood pressure
-heart rate
-bowel and bladder functions
-digestion

Question 17

You cannot certify a driver with peripheral neuropathy, although those patients can appeal. Can you certify a driver who has an autonomic neuropathy?

Answer 17

There are two circumstances when you can certify a driver with autonomic neuropathy.
1. Etiology of the autonomic neuropathy is confirmed and treatment has been shown to be safe.

2. When the nature and severity of disease is not severe enough to pose a danger to public safety.

Question 18

When are you unable to certify a driver who has an autonomic neuropathy?

Answer 18

1. driver has our cardiovascular autonomic neuropathy that causes resting tachycardia or orthostatic blood pressure
2. Other organ autonomic responses that could interfere with ability to drive safely

Question 19

If a driver with an autonomic neuropathy gets certified, what’s the maximum certification period?

Answer 19

-Maximum certification is for two years
-driver might need additional testing on a case-by-case basis and/or specialist consultation
-driver must be examined at least every two years, but more often when indicated

Question 20

Name two examples of neuromuscular junction disorders.

Answer 20

1. Myasthenia gravis
2. myasthenic syndrome

Question 21

What is the pathophysiology of neuromuscular junction disorders?

Answer 21

-Receptors are blocked at the post synaptic neuromuscular junction
-leads to muscle weakness; vision can also be affected
-fatigue is a common manifestation

Question 22

Can patients with neuromuscular junction disorders be certified?

Answer 22

No. They cannot be certified. However, appeal as possible with evaluation by a neurologist or physiatrist.

Specialist may recommend simulated skills driving test.

If appeal is successful, driver will require annual recertification with specialist evaluation if the appeal is approved.

Question 23

What is muscular dystrophy?

Answer 23

-Hereditary, progressive, degenerative disease of the muscle that interferes with safe driving

Question 24

Can you be certified if you have muscular dystrophy?

Answer 24

No. However, appeal is possible.

Specialist may recommend simulated skills driving test.

If appeal is successful, driver will require annual recertification with specialist evaluation if the appeal is approved.

Question 25

What is the pathology of myopathies?

Answer 25

-There different forms of myopathies; they may involve breakdown of muscle fibers, inflammation of muscle fibers, or some other muscle problem
-muscle fibers are not functioning correctly
-patient will have muscle weakness, cramps, stiffness, and spasm

Question 26

______ myopathies can be progressive or nonprogressive. This term refers to a group of muscle disorders that appear at birth or in infancy.

Answer 26

Congenital

Question 27

Name two examples of congenital myopathies.

Answer 27

1. Central core disease - persistent, mild muscle weakness in the muscles near the core of the body, usually upper legs and hips.
   -Weakness does not worsen over time
   -infants with this appear floppy
2. Centronuclear myopathy
   -characterized by weak skeletal muscles
   -weak arms/legs, droopy eyelids, problems with eye movements
   -progressive-gets worse over time
   -is the only congenital myopathy that can be treated
3. Congenital muscular dystrophy
   -group of genetic, degenerative disorders that affect voluntary muscles; symptoms manifest at or near birth
4. Rod (nemaline) myopathy
   -most common congenital myopathy
   -tone and contraction of skeletal muscles is weak, but the weakness does not usually worsen

Question 28

Describe the pathophysiology of inflammatory myopathies.

Answer 28

-There is myositis, meaning inflammation of muscle tissues; the inflammation is chronic
-there is no known cause
-treatment is possible

Question 29

Name three types of inflammatory myopathies.

Answer 29

1. Dermatomyositis
   -patient has chronic muscle inflammation and weakness
   -skin rash appears around the time of the weakness
2. Inclusion body myositis
   -onset of weakness is gradual
   -affects muscles that are both close to and distal from trunk of the body
   -can affect just one side of the body; no known cure or standard treatment
3. Polymyositis
   -really seen in patients under age 18; most commonly occurs in patients aged 31 to 60 years
   -weakness begins with muscles close to the trunk of the body
   -eventually causes difficulty with climbing stairs, reaching, and getting up from a seated position

Question 30

Are patients who have congenital and inflammatory myopathy eligible for certification?

Answer 30

No. If there is diagnosis of congenital myopathy disorder, do not certify.

-Driver can appeal and get evaluated by a neurologist or physiatrist
-specialist may recommend simulated skills driving test
-if the driver wins the appeal, annual recertification with specialist evaluation is required

Question 31

What is metabolic muscle disease?

Answer 31

-Conditions that affect metabolism of a muscle
-May affect glycogen, glycolytic metabolism, lipid metabolism, mitochondrial metabolism, or potassium balance of a muscle
-could be episodic or could be insidiously progressive

Question 32

Can a patient who is diagnosed with metabolic muscle disease be certified?

Answer 32

No. If there is diagnosis of metabolic muscle disease, do not certify

Pt can appeal and get evaluated by a neurologist or physiatrist
-specialist may recommend simulated skills driving test
-if the driver wins the appeal, annual recertification with specialist evaluation is required

Question 33

What is Parkinson’s disease?

Answer 33

-Chronic progressive syndrome

Manifestations include:
-muscles are rigid
-bradykinesia (person moves very slowly)
-tremors with postural changes

Question 34

Can a patient who is diagnosed with Parkinson’s disease be certified?

Answer 34

No. Do not certify.

Pt can appeal and get evaluated by a neurologist or physiatrist
-specialist may recommend simulated skills driving test
-if the driver wins the appeal, annual recertification with specialist evaluation is required

Question 35

Describe the manifestations of extrapyramidal disorders with hyperkinesias.

Answer 35

-Mild to severe or excessive motor activity
examples:
-torsion dystonia’s, such as primary torsion dystonia, spasmodic torticollis
-choreas
-Myoclonus
-tics
-benign essential tremor

Certification decisions are based on individual signs and symptoms. Some, but not all patients, with these disorders can be certified. Others will indisputably need to be disqualified, if their disorder will interfere with safe driving.

Question 36

What is cerebellar degeneration?

Answer 36

-Group of diseases caused by various etiologies that are characterized by gait ataxia, lack of coordination, tremors, and/or dysarthria

Question 37

Can a patient who has a form of cerebellar degeneration or ataxia be certified?

Answer 37

No. They are disqualified.

Appeal is possible if cellular ataxia is reversible or if the drivers deficits are stable and minimal.
Appeal will require specialty consultation and evaluation.

Question 38

A group of disorders is characterized by abnormal muscle excitability. This excitability is caused by abnormalities either in the nerve or the muscle membrane. Give three examples of diseases that are found in this group of disorders.

Answer 38

1. myotonia - the muscle locks in place after contraction and is only able to release slowly
2. Issac’s syndrome - also called neuro- myotonia. Caused by hyperexcitability and continuous firing of peripheral nerve axons that activate muscle fibers.
3. Stiff person syndrome - patient has fluctuating muscle rigidity in the trunk and limbs, and heightened sensitivity to stimuli.

Question 39

Can patients who have conditions associated with abnormal muscle activity be certified?

Answer 39

There are two situations when a patient who has a condition associated with abnormal muscle activity can be certified.
1. When the etiologies confirmed in treatment has been shown to be safe for the patient’s condition.
2. When the nature and severity of the disease is not severe enough to pose a danger to public safety.

Question 40

Some conditions that are associated with abnormal muscle activity guidelines disqualify a driver from being certified. What are these three conditions?

Answer 40

1. Myotonia
2. Issac’s syndrome
3. stiff person syndrome

Question 41

If a driver with abnormal muscle activity is able to be certified, what is the maximum certification allowed?

Answer 41

-Maximum certification is two years
-additional testing on a case-by-case basis
-specialty consult may be needed
-medical exam is required at least once every two years, more often when indicated

Question 42

Which progressive neurological diagnoses can be appealed if the driver is not certified?

Answer 42

-Multiple sclerosis
-peripheral neuropathies
-neuromuscular junction disorders
-myopathies
-parkinsonism
-cerebellar degeneration/ataxias

Qualified driver can be certified for one year. However, the recommended waiting periods range from 1 to 10 years or more, and all require that the driver is not taking anticonvulsant medications and is free of seizures.