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'""a' cur injuries

Björn Peters

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Reprint from Proceedings of the 8th International Conference

on Transport and Mobility for Elderly and Disabled People,

Perth, Western Australia, September 1998, pp. 227 236

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# Swedish National Road and

' ansport Research Institute

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VTI särtryck 306 - 1998

Spinal cord injuries

and driving

Björn Peters

Reprint from Proceedings of the 8th International Conference

on Transport and Mobility for Elderly and Disabled People,

Perth, Western Australia, September 1998, pp. 227 236

Swedten

Read and

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m

First Published 1998

by Indomed Pty Ltd

for the

8th International conference

on Transnurt and Mobilitv for

El BI W and Disabled PBODIB

Perth, Western Australia

These volumes are conference publications ofthe papers to be presented at the 8th International

Conference on Transport andMobilityfor Elderly andDisabledPeople in Perth, Western Australia. The Scienti c and International Sub-committe is grateful to the authors who have made these volumes possible. The papers are published in the text provided, although some editing has been made to the format. The opinions expressed in these volumes are those of the authors.

This publication is copyright. Apart from fair dealing for the purpose of private study, research, criticism or review as permitted by the copyright act, no part may be produced without written permission from the author(s).

Volume 1

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SPINAL CORD INJURIES AND DRIVING

Björn Peters, M.Sc. & Ph.D. Student

Swedish Road and Transport Research Institute - VTI, Linköping

Division of Industrial Ergonomics, Linköping Institute of Technology, Linköping

Summary

A recently concluded report on traumatic spinal cord injuries (SCI) and driving will be presented. The purpose of the report was to reveal What has been done, What is currently done and What should to be done in the future to support SCI drivers mobility through improved car adaptations. SCI has a incidence of about 13 injuries per million inhabitants and a prevalence of 570 SCI per million. In Sweden more than 100 persons will annually be involved in an accident causing sever paresis and reduced mobility. Two groups of SCI can be distinguished: paraplegics (lower limb paresis) and quadriplegics (upper and lower limb paresis). If a lesion is located below 4th cervical vertebra (C4), chances are good for a SCI patient to drive given the right adaptation. Drivers with disabilities do not seem to have a different traffic accident involvement compared to other drivers but our knowledge is very limited. There is a need to develop improved assessment procedures that consider crashworthiness but also usability, comfort and trust from the driver s point of view. The procedure to obtain a driver s licence and access to an adapted car is currently too complex. In-car ITS applications can, rightly applied, improve mobility of SCI drivers but can also turn out to be another obstacle to overcome.

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Introduction

This paper is based on work performed in a national project called Evaluation of the importance of the vehicle in rehabilitation of spinal cord injuries (Peters, 1998). The focus will be devoted to drivers with Spinal Cord Injuries (SCI) but much of what is said applies to a much wider range of physical disabilities and driving. Mobility disabilities are the most frequent type of disability (over 80% of all disabled). A lost or reduced mobility has a strong affect on disabled people s possibilities to participate in daily life activities. Modern society is built for mobile and independent individuals.

Transportation for people with disabilities can basically be provided in three ways: private cars, public transportation and special transportation services, of which transportation in private cars (passenger and driver) is most frequently used. Even if a disability is sever and the available resources are very limited it is however possible, with the right adaptation, for many SCI individuals to drive their own car. Driving on your own provides an outstanding way to regain mobility and independence.

War veterans with leg and arm impairments in the U.S. and Germany were among the first to drive cars with converted controls for accelerator and brake. Still disabled drivers needs have had very little in uence on the design of standard production cars. If drivers with disabilities were considered as resources to detect design aws we would have cars better fitted for all.

Drivers with disabilities usually need a longer time for training as learner drivers and the car has to be adapted, all this make it more expensive for them to achieve a driving licence. This is the basis for the subsidise system in Sweden administrated by the social insurance offices. The procedure for obtaining a driver s licence and an adapted car is often both long and winding. The current procedure leaves a lot to improve also when considering the changes that will follow due to the implementation if ITS (Intelligent Transport Systems) applications.

Spinal cord injuries (SCI)

Spinal cord injuries seem to be a typical young male problem, more than 80% of SCI individuals are men. Traffic accidents with young male drivers or motorcyclists (median age 25 years) are the most frequent, approx. 50%, causes to SCI impairments (Kreuter, 1996). Today, though, a change in trend can be observed, age at the time of accident has increased (mean age 35 - 40 years), number of falling accidents and percentage of females injured have all increased to 30 - 35% (Kreuter, 1997).

The spinal cord is of vital importance for our ability to move. Both sensory and motor nerves enter the CNS (Central Nervous System) in the spine. A traumatic injury to the spine can cause a disconnection in sensor-motor nerves and affect the motor function. Skeleton, muscles, etc. can be intact but the control function is impaired.

The incidence of SCI in Sweden is approx. 13 injuries per million people. This means that just over 100 new SCI cases annually (Kreuter, 1996). The SCI prevalence in Sweden is approx. 5000 or 570 SCI per million inhabitants. Corresponding number for USA is much higher. The National Spinal Cord Injury Association (NSCIA) provides statistics for the USA population. The NSCLA estimate the incidence to approx. 40 new injuries per million inhabitants or approx. 10.000 new SCI cases annually. The prevalence is estimated

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to approx. 200.000 or 800 SCI individual per million inhabitants (Internet, l998a,

Internet, 1998b).

A SCI will cause paresis of varying degree in both limbs and trunk. The location of the injury along the spinal cord will determine the severity and range of paresis. Basically two types of SCI impairments can be distinguished: paraplegia (lower limb impairment) and quadriplegia (upper and lower limb paresis). An injury in the cervical area will result in a quadriplegic impairment (see Figure 1). Today even a very severe SCI is no invincible obstacle for driving a car but an injury located at the 4 cervical vertebra or above will cause a too sever disability. A SCI will also have secondary effects that can be of importance for a SCI driver e.g. reduced ability to control body temperature. But other vital abilities for driving like vision and cognition are usually not affected.

Most SCI drivers use a wheelchair for shorter transports. Some quadriplegic drivers have to drive while sitting in their wheelchair but most paraplegic drivers will use a manual wheelchair which they will load themselves. The most common main problems encountered for SCI drivers are:

. ingress and egress - transfer to and from a wheelchair ' loading and unloading wheelchair or other gods o attaching safety belt

0 using standard primary controls (accelerator, brakes, and steering wheel)

0 managing secondary controls (e.g. direction indicator, wipers, horn, headlight control) . maintaining seating posture (unstable trunk)

0 service and maintenance of the car

Drivers with SCI

There is very little known about traffic accidents where SCI drivers or other drivers with disabilities have been involved. There is though some evidence that accident involvement for drivers with disabilities is not very different from other drivers (Haslegrave, 1988). An almost 20 year old Swedish report on the traffic safety of drivers with disabilities

concluded that:

othere are very few methodologically well done investigations 0 usually exposure is not considered

. there is no knowledge with respect to different disabilities

0 the latest Swedish report on the subject was written in the 50ies

Since then, nothing have been done, at least in Sweden. A recent Finnish study (Lääperi,

Seppäläinen, Luoma Aho & Alaranta, 1995) showed however that a group (105) of drivers

with physical disabilities (of which 60% were SCI drivers) driving adapted cars had a

slightly higher accident rate (7.6%) compared to other drivers (7.0%). However, when the

exposure was considered they had a somewhat lower rate, 3.8 accidents per lO6 personkilometers compared to 4.1 accidents per 106 personkilometers for the average driving population. This report support the assumption that there is at least no difference in

risk but still we know too little. There is a need for further investigations in this area,

particularly with respect to the causes and consequences of accidents and also to

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investigate different groups of drivers with disabilities. One possible explanation why this kind of investigations have never been done is that it is very difficult to distinguish groups of drivers with different impairments. This will change as the new EC/ISO driving licences are introduced. These licences will hold a code describing the disability and what type of adaptation is required in the car. More than 80 different codes can be used to describe a disability.

Requirements for driving

The national drivers licence regulations issued by the SNRA (Swedish National Road Administration) determine the medical requirements for driving. Visual requirements are fairly detailed and also restrictions due to some illnesses but requirements for mobility impairments are rather vague. If a mobility disability can be fully compensated by

prosthesis or by adapting the car to he driver there are no restrictions for driving. Approval decisions are taken on a case by case basis. Basically the intentions is that the same

demands to drive safely apply to both able-bodied and disabled drivers. However, there is no guidance on how to determine if a disability has been compensated for. Considering the disabilities of a SCI driver in particular these requirements can be broken down into the following items, the driver should:

0 be able to reach all controls needed to operate the car

. have sufficient force to operate all controls even in an emergency situation 0 be able to react fast enough (reaction performance) in an emergency situation

- be able to apply and maintain a sufficient force to operate controls in an emergency situation (endurance)

0 co-ordinate control operations

' not have a high risk of getting spastic cramp attack while driving

Missing or insufficient abilities will have to be replaced or supported to obtain satisfactory performance. Koppa (1990) proposed three basic requirements for vehicle adaptations to be considered for physically disabled:

l. Ingress and egress the driver should be able to enter and leave the car without assistance

2. Primary and secondary controls - the driver should be able to operate the car without assistance at the same performance level as an able bodied driver under all traffic conditions

3. Occupant safety - the driver should provide the same level of passive safety as drivers of standard production cars.

These are fundamental requirements but there are probably very few adaptations if any which completely fulfil them. Apart from Koppa s list of requirements there are other aspects that should also be considered vital like the need to sometime install AC (Air Condition) to provide a suitable climate and defroster device for people living in a cold climate. In an emergency situation the driver might need to be able to call for help. Service and maintenance are also aspects that need to be considered.

In Sweden there are no regulations controlling who is allowed to adapt cars even if it has been requested in an official report (SOU, 1994). Nor does there exist any guidelines for adapting cars to disabled drivers. If the adaptation is extensive the vehicle inspection

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has to approve of the changes made to the car. Other countries like England and Norway

have issued guidelines for adapting cars (DOT, 1992), (SINTEF, 1993). Examples of

guidelines for adapting primary controls applied in England and Norway are:

. force needed to operate the accelerator should be limited 10% of max. strength . force needed to operate the brake and clutch should be limited to 30% of max.

strength for normal driving conditions, emergency braking can require more but well within the individuals max. capacity

' required steering force should be between 10 - 30% of max. strength depending on driving condition

These recommendations are largely based on research made by Kember (1991).

Disabled drivers are some times, but not always, tested before they enter a driving course. Usually a test rig, with a steering wheel and pedals, is used to collect data on reach,

strength, reaction time etc. These data can be used to decide what kind adaptation is needed in the car. Usually the adapted car and the driver is never assessed together. It is known that even if the car is adapted many drivers with disabilities experience driving as very

cumbersome and they limit their travelling (Nicolle, Peters & Vossen, 1994), (Peters &

Nilsson, 1993). This indicate that more can be done to provide independent mobility to SCI

drivers. Verwey (1994) listed a number of issues that should be considered when assessing

adapted cars for SCI drivers:

0 the risk of overloading the upper limbs because too many tasks have be performed 0 the risk of interference between control tasks

. super light controls can require continuos corrections which could be very tiring 0 control-by wire controls might suppress relevant feedback to the driver

' mental load can be affected by the in output relation of the control function

0 there is a risk that the design of controls might prevent the driver from distributing available resources to prevent overload

In summary it can be seen that there is a need to develop assessment tools and

procedures where the adaptation is evaluated together with the driver. It is proposed that a checklist should be compiled in which the driver s opinion together with objective tests like brake and steering performance are recorded. Subjective aspects that should be

included are functionality, comfort and the driver s trust in the adaptation. Such an

assessment tool should also consider workload aspects. Also crashworthiness has to be tested. Currently there are rather few international regulations that apply to adapted cars

(Veenbaas & Brekelmans, 1996). Two ISO standards for wheelchairs and restraint systems

are on the way to be established: ISO WD 7176-19 and ISO CD 10542.

In the currently reported SNRA project 20 SCI drivers were interviewed and then they made a brake test in their own car with hand-controlled accelerator and brake. They drove with constant speed of 40 km/h in a street with no other traffic when they were told to brake as fast as possible until they had stopped the car. The average reaction time (from

stimuli to onset of brake) was 0.66 seconds (SD = .08) and average maximum deceleration

during he brake manoeuvre was 7.88 m/s2 (SD = 1.17). The average force applied to the brake control was 164.7 N (SD = 89.9). This type of test can reveal some gross mismatches in the adaptation but a more elaborated test should also consider brake performance when braking has to be executed simultaneous with steering control actions.

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Financial support, driving licence and approval of adapted cars

In Sweden drivers with a permanent disability can apply for a vehicle grant administered by the social insurance offices since October 1988. The financial support consists of three separate forms of subsidises: 1. A basic grant for car purchase up to 7 600 US dollars, 2. An additional grant (income related) for car purchase up to 5 000 US dollars, 3. Adaptation grants to cover the full cost of the adaptation. In order to be able to apply for these grants you have to be under 65 years of age, need the car to get to work or school or be granted an early retirement pension. If you are between 18 - 49 years old or have children under 18 you can also apply. Parents with disabled children can get financial support to adapt the car. Financial support to cover driver educational costs can also be granted but this is very rare, as it has to be clear that access to a driving licence will be required in order for the applicant to get a job. Less than 1% of the total funds have been used for these purposes.

Between October 1988 and September 1996 21,698 grants have been issued at a cost of 215 million US dollars. The average grant was just over 9,900 US dollars. The rejection rate has been almost constant during the period at a level of 40%. A renewed application for vehicle grants can be submitted every 7 years. It is the local social insurance offices that decide what type of adaptation the driver will get subsidised for. An official report proposed that the government should increased the resources for the vehicle grants and to extend the target group and apply a more liberal view when granting disabled financial support (SOU, 1994). Lately, though the government has announced a decrease in resources allocated to vehicle grants.

The National Social Insurance Board is currently evaluating the criteria applied for vehicle grants at the different local social insurance offices. Decisions concerning vehicle grants used to be handled on a regional level but are now taken at a local level this might lead to diverting criteria applied for individual cases. There is a risk that the decision maker will not be able to gain as much knowledge as needed for various disabilities and specific needs in order to provide the most suitable car adaptation.

The procedure for disabled persons wanting to drive is both complex and includes a number of contacts with authorities and filling out papers (see Figure 2). This procedure could be improved and the communication between instances involved could be enhanced. Today the SNRA have overall responsibility that all modes of transportation (private

driving, railroads, ships etc.) are accessible for elderly and disabled travellers. It has been

proposed that the Department of Transport should be responsible and the SNRA administrate the vehicle grants. This would decrease the number of instances involved, conform to the SNRA responsibility of elderly and disabled travellers, and better utilise available knowledge of traffic and driving requirements (Peters, 1998).

Approval procedures for adapted cars also have to be improved. A vehicle inspection draft protocol was developed some years ago by SINTEF in Norway. This document should be analysed and adapted to Swedish conditions.

ITS in-car applications

In a Swedish official report on ITS applications and introduction the authors specifically point to the prospects of ITS with regard to disabled (SOU, 1996). Examples of ITS applications that could be of great relevance to SCI drivers are listed in Table 1.

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Table 1 ITS applications of relevance to SCI drivers

Traffic information Vehicle control Security Parking

Of course ITS introduction will not solve all problems and might even introduce new obstacles for independent mobility of disabled. The technology has its pros and cons. If the needs and resource limits of elderly and disabled are not considered then there is a risk of repeating the mistakes that was done when self service banking machines were introduced and many disabled had to face new barriers and a decreased level of service (Hoyn a,

Jönsson, Lorentzon & Fasen, 1995).

As stated earlier it is known that SCI drivers find it more tiresome to drive long distances compared to able-bodied drivers. Many of SCI drivers have a CC (Cruise Controller) installed in their cars. Ninety-five percent (19 out of 20 subjects) of lower limb disabled drivers who participated in a driving simulator study had a conventional CC

installed in their own car (Peters, 1996). For these drivers the CC is not just a comfort

system it is support that allows them to better dispose their resources and permit them to drive longer distances. One problem associated with the CC is that the driver has to disengage the CC when approaching a slower lead vehicle. This limits the benefits when driving in more busy traffic environments. The ACC (Adaptive CC) is an ITS application that can solve this problem. An ACC is a CC combined with a distance sensor that can determine the distance to vehicles in front and based on this information speed will be controlled to maintain a safe headway. The driver does not have to interact with the ACC when approaching a slower vehicle. This type of speed controller can also be developed to include a stop-and go function to be used at traffic lights. Such a ACC system was tested with 20 lower limb disabled driver in an advanced driving simulator and it was found that the ACC was very well accepted, trusted and it decreased the workload experienced by the drivers (Peters, 1996).

The ACC application is an example of how to utilise the emerging possibilities of ITS for SCI drivers but as we install more support systems in the car we will also add on to the already high workload of the SCI driver. Even support systems require some interaction and control actions from the driver. Let us take the ACC example above, the SCI driver have to activate the ACC in a situation where often both hands are occupied (steering and speed control). Many conventional CC has control buttons on the direction indicator stalk or buttons on the steering wheel. Both these will be very difficult to access for quadriplegic driver. But if the ACC was integrated in the accelerator or a spare resource like voice control was used then an ACC would be a real support system for the SCI driver.

The control-by-wire technology is also a very interesting concept for a more exible

interface between the driver and the car (Clough, Ives & Nwagboso, 1993). This

technology has become more available with growing interest from the car manufacturers to

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use this technology in conventional cars. The technological development seems to be promising but still we do know to little about the needs of drivers with disabilities.

Conclusions and recommendations

There is a need for better traffic accident statistics for drivers with disabilities The financial support has to be evaluated from a user s point of view

Reform the licensing procedure and introduce assessment centres

Develop test procedures for adapted cars that considers safety, usability, comfort and

trust

Formulate requirement for ITS applications that considers drivers with disabilities 0 Utilise the emerging control-by wire technology to facilitate car adaptations

Acknowledgements

The project reported here was initiated and funded by the Swedish National Road Administration and I wish to thank the project co ordinator Alice Dahlstrand and her colleague Per Dahl. This presentation was sponsored by the VTI.

References

(Internet, 1998a) Factsheet #2: Spinal Cord Injury Statistics, Available www: http://www.spinalcord.org/resource/factshts/fact02.html

(Internet, 1998b) Spinal Cord Injury Facts and Figures at a Glance January 1998. http://www.spinalcorduab.edu/frames/sitecontents.html.

Clough, B. A., Ives, D., & Nwagboso, C. 0. (1993, ). Concept 2001 - Automated Modular Vehicle for the Disabled. Paper presented at the Road Vehicle Automation, Research Centre,

School of Engineering, Bolton, UK.

DOT. (1992). Guidelines on the adaptation of car controls for disabled people . London UK: Dept

of Transport, TRRL, [MechL

Elkind, J. (1990). The Incidence of Disabilities in the United States. Human Factors 23(4), 397 405.

Haslegrave, C. M. (1988). Driving for Handicapped People. In A. Mital & W. Karwowski (Eds.), Ergonomics in Rehabilitation (pp. 13 - 34). Philadelphia: Taylor & Francis.

Höynä, U. K., Jönsson, L., Lorentzon, P., & Fasen, P. (1995). Automatic Service Machines

-Service for Everybody? . Stockholm: The National Swedish Board for Consumer Policies and The Swedish Handicap Institute.

Kember, P. (1991). Strenght abilities of disabled drivers and control characteristics of cars (TRRL Contractor Report 215). Crowthorne: Work organisation and Ergonomics Laboratory, College of Manufacturing, Cranfield Institute of Technology.

Koppa, R. J. (1990). State of the Art in Automotive Adaptive Equipment. Human Factors 32(4), 439 - 456.

Kreuter, M. (1996). Fordonets betydelse för ryggmärsskade personer vad gäller livskvalité, arbets-, fritids- och socialt liv (Opublicerad rapport ). Göteborg: Spinalenheten, Sahlgrenska sjukhuset.

Kreuter, M. (1997). Ryggmärgsskador - orsaker, köns och åldersfördelning, Personal communication.

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Lääperi, T., Seppäläinen, R., Luoma-Aho, E., & Alaranta, H. (1995, September 8 - 10, 1995).

Traffic accident risk of disabled drivers having special driving control equipment: A driver survey and accident data. Paper presented at the Scandinavian Medical Society of Paraplegia (SMSOP), Oslo, Norway.

Nicolle, C., Peters, B., & Vossen, P. H. (1994, 30 November - 3 December 1994). Towards the

Development of ATT Guidelines for Drivers with Special Needs. Paper presented at the First World Congress on Applications of Transport Telematics and Intelligent Vehicle Highway Systems, Paris, France.

Peters, B. (1996, October 14 18, 1996). Evaluation of an Adaptive Cruise Control (ACC) Svstem

used by Drivers with Lower Limb Impairments. Paper presented at the Thrid World Congress on Intelligent Transport Systems, Orlando, USA.

Peters, B. (1998). Drivers with Spinal Cord Injuries - a state of the art / Bilförare med traumatiska ryggm'argsskador - en kunskapsöversikt (in Swedish) (VTI Report 426). Linköping: VTI.

Peters, B., & Nilsson, L. (1993, ). Driving Performance of DSN (Drivers with Special Needs)

using Hand Controls for Braking and Accelerating. Paper presented at the 26th

International Symposium on Automotive Technology nd Automation (ISATA), Aachen, Germany.

SINTEF. (1993). Retningslinjer for tilpassing av bil (NKH/ISO kode 12 12 OO). Oslo: SINTEF Unimed f.d. Rådet for tekniske tiltak for funksj onshemmede.

SOU. (1994). Rätten till ratten - Reformerat Bilstöd, Slutbetänkande av Bilstödsutredningen 1993 (SOU 1994:45). Stockholm.

SOU. (1996). Bättre trafik med väginformatik (SOU 1996: 17). Stockholm: Delegationen för Transporttelematik.

Veenbaas, R., & Brekelmans, J. A. W. J. (1996). Car adaptations and the EEC directives/ECE

regualtions (Open 96.0R.VD.O43.1/ROV). Delft, Holland: TNO Road Vehicles Research Institute.

Verwey, W. B. (1994). On Evaluating Vehicle Adaptations for Disabled Drivers (Report IZF 1992

C-36). Soesterberg, Holland: TNO Institute for Perception.

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Figures

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Figure ] Dermatomal map (Derma = skin, tom : cut) showing the distribution of senso-motor nerves(S = sacral, L = lumbar, T = thoracal, C = cervical)

Start Doctor s certificate Rehabilitation clinic

Special conditions for driving Comments & conditions County administration Traf c inspector, SNRA

| Decision by each authority |

Vehicle grant application Driver education grant application Social insurance o ice Social insurance of ce

Decision and check of nancial tender

Soajl insurance\office Further rehabilitation if needed Performance tests. . Rehabilitation centre. . .

Assessment centre/dr1v1ng school

Adaptation of the vehicle Education and Trainin Adaptation company Driving school

Failed

Approval of adaptation Driving licence test Vehicle inspection Tra ficjnspector

Driver licence conditions

County administration Drivers licence

and Adapted car

Goal

Figure 2 The procedure to driving licence and adapted car for a disabled learner driver. Boxes with dotted lines are to be considered as non mandatory or non regular steps.

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Figure

Table 1 ITS applications of relevance to SCI drivers
Figure 2 The procedure to driving licence and adapted car for a disabled learner driver.

References

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