Download Recommendation 3: CMV Drivers with Hypertension

Appendix. Medical Review Board’s (MRB) 84 recommendations and/or motions to date as
summarized.* All votes unanimous unless otherwise noted.
Date
Recommendations
Topic
Parkinson’s
Disease (PD)
January
2010
Recommendation 1: Parkinson’s Disease and CMV Driver
Certification. The MRB recommends that FMCSA adopt the following
MEP Opinions on the certification of drivers with PD.
 A diagnosis of PD precludes an individual from obtaining
unconditional certification to drive a CMV for interstate commerce.
 A diagnosis of PD should not exclude all individuals; CMV
certification may be possible in some instances.
 A person with PD may be considered for CMV certification if he/she
meets a set of criteria based upon an evaluation by appropriate,
qualified specialists. This qualified specialist (e.g., neurologist,
movement disorders specialist, neuropsychologist, as appropriate)
should assess for symptoms that may adversely affect driving ability.
 Shows mild symptoms only, as indicated by a Hoehn Yahr (HY)
scale stage 1 or less, and a high score (90 percent or higher*) on the
Schwab and England Activities of Daily Living Scale**.
o *HY1 – Signs and symptoms on one side only, symptoms
mild, symptoms inconvenient but not disabling, usually
present with tremor of one limb.
o **90 percent – Completely independent. Able to do all
chores with some degree of slowness, difficulty, and
impairment. Might take twice as long. Beginning to be aware
of difficulty.
o Tolerates medications well, without cognitive, motor, or
other side effects that might affect driving.
o Shows no significant fluctuations in motor response or “onoff” effects (i.e., sudden fluctuations in disability involving
rapid and abrupt alterations between periods of good
mobility and periods of hypokinesia, tremor, and dyskinesia).
o Demonstrates satisfactory functioning on a battery of tests
assessing key cognitive functions important for safely driving
a motor vehicle (e.g., processing speed, attention, perception,
memory, executive functions, and emotion).
o Satisfactory functioning should be defined as performing
within or above the normal range using test norms that adjust
for relevant factors, such as age and education.
o Shows no evidence of a mood disorder or satisfactory control
of an existing mood disorder (see psychiatric disorders MEP
report).
o Provides written documentation of the specialist’s report at
the time of the CMV medical evaluation.
 The medical examiner form should be updated by
adding a place to indicate that the applicant has been
referred to a specialist who has documented the
individual’s condition relevant to safely operating a
CMV.
An individual with PD who meets the criteria for certification should
be re-evaluated on a semi-annual basis by a neurologist or other
qualified specialist, and obtain an annual neuropsychological
evaluation.
 The choice of a qualified specialist should be based on the judgment
of the medical examiner in the context of the complexity of the
examinee’s case.
 This choice depends on factors of illness severity, symptoms,
duration, stability over time, and such interventions as medications
required for management.
 It also depends on the available resources, with general preference
given to more highly trained and experienced consultants.
Recommendation 1: MS and CMV Driver Certification
The MRB recommends that FMCSA adopt the following MEP Opinions
on the certification of drivers with MS.
 A diagnosis of MS precludes an individual from obtaining
unconditional certification to drive a CMV for interstate commerce.
 A diagnosis of MS, however, should not exclude all individuals with
the disorder from driving a CMV; certification may be possible in
some instances.
 An individual with a diagnosis of MS may be considered for
certification to drive a CMV if that individual meets a set of criteria
(to follow).
o Based upon an evaluation by a qualified specialist (e.g.,
neurologist, MS specialist, neuropsychologist,
ophthalmologist, occupational therapist, as appropriate,
depending upon the signs and symptoms of the individual
being evaluated).
 Shows no signs of recent relapse or chronic progression.
 Tolerates medications well, without cognitive, motor, or other side
effects that might affect driving.
 Has satisfactory vision, including acuity, fields, and ocular alignment
(see vision MEP report).
 Demonstrates satisfactory cognitive functioning based upon a
standardized neuropsychological test battery assessing key domains
important for safely driving a motor vehicle (e.g., processing speed,
executive functioning, attention, perception, memory, and emotion).
Satisfactory functioning should be defined as performing within or
above the normal range using test norms that adjust for relevant
factors, such as age and education.
 Shows no evidence of a mood disorder or satisfactory control of an
existing mood disorder (see psychiatric disorders MEP report).
 Shows satisfactory motor function and mobility (see musculoskeletal
MEP report).
 Has no history of excessive fatigability or periodic fluctuations of
motor performance, as in relation to heat, physical and emotional
stress, and infections.
 Provides written documentation of the specialist’s report at the time

Multiple
Sclerosis
January
2010
Functional
Evaluation
January
2010
of his or her medical examination.
o The medical examiner form should be updated by adding a
place to indicate that the applicant has been referred to a
specialist who has assessed the individual’s condition
relevant to safely operating a motor vehicle.
 An individual with MS who meets the criteria for certification above
should be re-evaluated on a semi-annual basis by a neurologist or
other qualified specialist and obtain an annual neuropsychological
evaluation.
 The choice of a qualified specialist should be based on the judgment
of the medical examiner in the context of the complexity of the
examinee’s case. This choice depends on factors of illness severity,
symptoms, duration, stability over time, and interventions, such as
medications required for management. It also depends on the
available resources, with general preference given to more highly
trained and experienced consultants.
Note: The MRB accepts the aforementioned opinions of the MEP on
MS with the addition that not only are they semi-annually evaluated
by a neurologist or other qualified specialist, but also recertified.
Recommendation 1: Functional Evaluation/Fitness to Drive
Framework
The MRB recommends that FMCSA adopt the following MEP Opinions
on the functional evaluation of CMV drivers.
 FMCSA should adopt a general framework for determining fitness to
drive a CMV that relies upon a “functional” evaluation of multiple
domains (cognitive, motor, perceptual, and psychiatric), which are
important for safe driving.
o Such a framework could be applied across many
diseases/conditions, including ones that have rarely been
studied with respect to CMV driving.
 Of note, this framework is compatible with MRB
considerations regarding approach to drivers with
multiple conditions.
o The framework would serve as a functional “screen”
comprising elements of cognitive, psychomotor, and
psychiatric function. It would screen for primary effects of
illness (e.g., cognitive dysfunction), effects of medications
(e.g., sedation), and illness-medication interactions.
Examples include:
 Cognitive: processing speed, attention, perception,
memory, executive functions, and emotion.
 Psychomotor: heel-to-toe walking, rapid alternating
movement, and measures of perseveration for
psychomotor function.
 Psychiatric: Patient Health Questionnaire (PHQ) or
PHQ-2 for depression, among others.
o The screen would be administered by the medical examiner,
based on the obtained medical and psychological history, and
used as an additional guide for referral.
o
Narcolepsy
January
2010
Traumatic
Brain Injury
(TBI)
January
2010
Two key elements of this approach are validity of each
element of screening and practicality.
 The screen would need to comprise validated testing
measures and not be easily defeatable by examinees.
 The evaluation would need to be easily teachable to
medical examiners (e.g., through the National
Registry Program process) and relatively quickly and
effectively administered during the certification
examination.
o We suggest revisiting evidence reports on other conditions
(e.g., stroke, diabetes, TBI, etc.) and pooling these data to
examine the predictive value of various factors (e.g.,
cognitive, motor, medication, etc.) in determining ability to
drive safely and crash risk.
Recommendation 1: Narcolepsy. Retain the current regulation on
narcolepsy, which indicates that people with narcolepsy are ineligible for
a commercial driver’s license, even if treated.
The MRB recommends that FMCSA adopt the following MEP Opinions
on the certification of CMV drivers with TBI:
Recommendation 1: TBI and CMV Driver Certification. Individuals
who have sustained a penetrating injury to the brain or severe TBI (i.e.,
loss of consciousness ≥ 24 hours) should be permanently precluded from
obtaining certification to drive a CMV for interstate commerce.
Recommendation 2: Moderate TBI and CMV Driver Certification.
Individuals with moderate TBI should be precluded from obtaining
certification to drive a CMV for interstate commerce for 3 years. After a
3-year wait, the individual must be cleared by the treating provider
(minimum qualifications of M.D. or D.O.). The treating provider should
assess for the following symptoms of concern: headaches, irritability,
dizziness, imbalance, fatigue, sleep disorders, inattention, decreased
concentration and memory, noise and light sensitivity, thinking slowed,
difficulty recalling new material, personality change, difficulty starting or
initiating things, difficulty sequencing information, impaired attention to
details, impaired ability to benefit from experience, and deficits in
planning and carrying out activities. If seizure occurred during the
waiting period, follow current FMCSA guidance for individuals with a
seizure disorder. If cleared by the treating provider, then the driver should
be evaluated by a neurologist who is aware of the functional and
cognitive requirements of operating a CMV. Additional evaluation by a
neurologist should:
 Include complete neurological assessment.
 Access motor speed and dexterity, cognitive
function, and symptoms of depression through
objective testing.
 Refer individual to a neuropsychologist,
psychologist, or other specialist, as appropriate,
based on specific symptoms.
Recommend that the following cognitive domains
should be assessed (suggested assessment tools
listed):
 Verbal memory and verbal learning
(Hopkins Verbal Learning Test).
 Visual scanning, visual motor speed (Trail
Making Test A).
 Cognitive flexibility, executive function
(Trail Making Test B).
 Word fluency (COWAT – Controlled Oral
Word Association Test).
 Attention (Digit Span forward).
 Working memory (Digit Span backward).
 Visual scanning, visual motor speed, visual
memory (Symbol Digit Modalities).
 Motor speed and dexterity (Grooved
Pegboard Test).
 Delayed recall (Hopkins Verbal Learning
Test).
o Neurologist and medical examiner should assess the effects
of treatment, including medications, on functional and
cognitive abilities.
o Drivers with no or minimal abnormalities who are cleared
should be recertified every six months while under active
treatment.
o Examiner should be M.D./D.O.
o Once an individual is no longer under active treatment,
annual recertification is required for 3 years and then as
determined by the medical examiner.
Recommendation 3: Mild TBI and CMV Driver Certification:
 Individuals with mild TBI can be deemed medically qualified if
they are determined by their treating provider (minimum
qualifications of M.D./D.O.) to be clinically symptom free.
 No LOC – 30-day waiting period.
 LOC – 90-day waiting period to ensure individual remains
symptom free.

Individuals with mild TBI should be free of the
following symptoms of concern before they are
qualified: headaches, irritability, dizziness,
imbalance, fatigue, sleep disorders, inattention,
decreased concentration and memory, noise and light
sensitivity, thinking slowed, difficulty recalling new
material, personality change, difficulty starting or
initiating things, difficulty sequencing information,
impaired attention to details, impaired ability to
benefit from experience, and deficits in planning and
carrying out activities, seizures and no evidence of
intracranial blood if imaging was done
 Individuals who have experienced mild TBI and lost

Psychiatric
Disorders
January
2010
consciousness as a result and/or are found to be symptomatic at
exam time should be referred to a neurologist for additional
evaluation.

Evaluation should be the same as for those who
have experienced moderate TBI.
 Waiting period following mild TBI as symptoms of concern may
not be immediately apparent.

The more severe the injury, the greater the risk
of symptoms development.

If loss of consciousness, the driver should have
evaluation by specialist prior to returning to work.
Recommendation 4: Anti-Seizure Medication and CMV Driver
Certification. Individuals placed on anti-seizure medication either
following a single provoked seizure or prophylactically should not be
medically qualified to drive a CMV until they meet the current FMCSA
criteria for individuals taking anti-seizure medication.
Recommendation 5: Extremity Impairment and CMV Driver
Certification. Individuals who meet earlier criteria for certification after
TBI and whose only residual deficit is impairment of an extremity may
be eligible for a Skill Performance Evaluation (SPE) certificate and
should be referred to apply for one if otherwise medically qualified.
Recommendation 6: TBI and Medical Examiner Qualifications. Due to
the risk of seizures and neurological and cognitive dysfunction after TBI,
physicians (M.D. or D.O.) should perform the commercial driver medical
examination on those who have sustained TBI.
Recommendation 1: Psychiatric Disorders. The MRB recommends to
FMCSA that the following matrix be adopted for evaluating CMV drivers
with chronic psychiatric conditions. Patients with acute psychiatric
conditions are not able to be potentially qualified until the condition is
evaluated, diagnosed, and successfully treated.
Disorder
Severity*
Examiner
Psychotic Disorders†
Mild
Psychiatrist or advanced-degree mental
health professional
Moderate
Psychiatrist or advanced-degree mental
health professional
Severe
Psychiatrist
Mood Disorders‡
Mild
Treating healthcare and/or mental health
professional
Moderate
Psychiatrist or advanced-degree mental
health professional
Severe
Psychiatrist
Personality Disorders§ Mild
Treating healthcare and/or mental health
professional
Moderate
Psychiatrist or advanced-degree mental
health professional
Severe
Psychiatrist
*Severity is inferred largely based on prior history. Mild is considered
minimally incapacitating, readily controlled with one medication or no
medication. Moderate is sometimes incapacitating, recurring, and/or
persistent, requiring one or two medications to control, but control is
generally complete or nearly complete. Severe is substantially
incapacitating, frequent and/or prolonged, requiring multiple medications
to control; control is incomplete. Those with severe disorders may be able
to qualify at a later date. They generally should not have had severe
conditions in the prior 5 years.
**Supportive letter from the treating healthcare professional is required.
***Supportive letter from a psychiatrist is required.
†Active psychosis are not qualified. At least 1 year without symptoms
must be present prior to consideration of commercial driving. Those with
a brief, reactive psychosis may be re-evaluated earlier, at 6 months, if the
clinical condition has resolved.
‡This includes anxiety, depressive, and bipolar disorders. Drivers with
mania, severe major depression, or suicidal behavior or ideation are not
qualified. At least 1 year without symptoms must be present prior to
consideration of commercial driving. Non-psychotic major depressive
disorder without suicidal behavior and symptom free may be re-evaluated
at 6 months.
§This includes obsessive compulsive and antisocial personality disorders.
Individual clinical assessment is recommended with determination of
suitability for commercial driving based upon whether the disorder and
behavior pose a driving risk to the public. These traits include aggression,
hostility, impulsivity, disregard for the law, and other psychological
symptoms.
Recommends the duration of certification be a maximum of 1 year for
mild conditions and 6 months for moderate conditions.
§§These individuals are believed to nearly always be unable to be
qualified. There may be limited, highly select exceptions. Careful
evaluation of those cases is recommended prior to consideration of
potential ability to operate commercial vehicles.
The MRB affirms a prior recommendation to FMCSA that these
psychiatric conditions be included in the Fitness for Duty matrix on
multiple conditions. Special consideration (scrutiny) should be given to
the certification of drivers handling hazardous materials/waste or driving
buses.
Recommendation 2: Anti-convulsants Taken for Non-epileptic
Conditions. The MRB recommends to FMCSA that CMV drivers taking
anti-convulsant medications be evaluated individually by the healthcare
providers prescribing the medication, and that a supportive opinion
regarding driving safety be obtained prior to consideration of CMV
Fitness for
Duty Matrix
January
2010
Psychiatric
Disorders
July 2009
Stroke
January
2009
operation. The supportive opinion should state the purpose of the
medication and that the medication is not used for control of a seizure
disorder. Those with mild, stable conditions and lack of adverse effects
may be qualified for up to 1 year. Other individuals may be qualified for
a maximum of 6 months, and some with adverse effects may not be
qualified.
Note: The MRB voted and unanimously approved these
recommendations to include the revisions discussed by the MRB.
Revisions are indicated in italics.
Recommendation 1: Fitness for Duty. See Table 3 above.
Recommendation 1 (approved 3-1-1). The MRB recommends to
FMCSA that all individuals with the following psychiatric disorders
undergo psychological evaluation by a licensed mental health
professional that is prepared at or above the master’s degree level in order
to further assess the functional ability of the driver:
 Psychotic disorder.
 Bipolar disorder.
 Major depressive disorder with a history of psychosis,
suicidal ideation, homicidal ideation, or a suicide attempt.
 Obsessive compulsive disorder.
 Antisocial personality disorder.
Recommendation 1: Stroke
The MRB recommends to FMCSA that the following changes be made to
the current guidance about stroke (first outlined in the report of the
Conference on Neurologic Diseases and Commercial Driving, 1988):
 To be qualified to drive at the appropriate time after a stroke (1
or 5 years depending on the type of stroke) requires an
examination by a neurologist who is an MD or DO, in addition to
a commercial driver medical examiner (CDME) examination by
an MD or DO.
o If the neurologist identifies cognitive or neuromuscular
deficits, then a neuropsychological evaluation or
functional evaluation, respectively, shall be performed.
o Functional evaluation could include aspects previously
recommended by the MRB. (Musculoskeletal Disorders
and CMV Driver Safety, April 7, 2008)
o Neuropsychological evaluation could include aspects
recommended by the Medical Expert Panel (MEP).
(Stroke and CMV Driver Safety, January 12, 2009)
o Subsequent re-evaluations should be done on at least an
annual basis by a neurologist who is an MD or DO, in
addition to a CDME examination by an MD or DO.
Recommendation 2: Transient Ischemic Attacks (TIAs)
 The MRB recommends that commercial drivers who have had a
General/CDM
E
January
2009
Psychiatric
Disorders
October
2008
TIA should not drive for 1 year.
o To be qualified to drive after a TIA requires an
examination by a neurologist who is an MD or DO, in
addition to a CDME examination by an MD or DO.
o Re-evaluations should be done on at least an annual basis
by a neurologist who is an MD or DO, in addition to a
CDME examination by a MD or DO.
Recommendation 1: Educational Standards for CDMEs
The MRB recommends that FMCSA implement minimum
educational standards for qualifying CDMEs. The MRB recommends
the following minimum professional qualifications: physicians (MD
or DO), advanced practice nurses (APNs), or physician assistants
(PAs).
Recommendation 1: Psychiatric Standards
The MRB stated that input is needed from the psychiatric field before
they consider any motions on this topic.
Hearing/Vesti October
2008
bular
Function
Recommendation 1: Hearing Standards. The MRB recommends that
FMCSA retain the current standards on hearing. Note: The motion was
approved with a 3 to 1 vote.
General
Recommenda
tions
(including
Fitness for
Duty)
Recommendation 1: Fitness for Duty Standard
The MRB recommends that FMCSA change the fitness for duty standard
to the following:
 CMV drivers shall have the physical and mental fitness required
to safely operate a CMV. Drivers who are not fit may present a
safety hazard to themselves and to the public.
 Physical and mental disorders may reduce driver performance
and increase the risk of CMV crashes. Drivers with multiple
medical disorders and/or taking licit or illicit drugs may pose
additional increased risk for crash.
Recommendation 2: Evaluation of Fitness for Duty See Table 3 above.
Note the matrix was drafted for further study at this meeting.
Recommendation 3: Fitness for Duty – Remediation
The MRB recommends to FMCSA that remediation of some physical or
mental conditions is possible, and drivers may be eligible for certification
to drive a CMV following resolution of these conditions.
Recommendation 4: Mental Fitness for Duty
The MRB recommends to FMCSA that drivers who physically or
verbally threaten medical staff have demonstrated a lack of mental fitness
to drive. They should not be qualified pending an evaluation, counseling,
or other appropriate measure.
Recommendation 5: Review of Guidelines
July 2008
Chronic
Kidney
Disease
July 2008
Musculoskele
tal Disorders
April
2008
The MRB recommends that FMCSA seek and receive adequate funding
for regular review of the guidelines. This includes all of the guidelines
that have been discussed to date and those to be generated in the future.
Reviews of each guideline should be conducted at least every 3 years to
determine whether existing guidelines should be reaffirmed or revised.
Recommendation 1: Identification of Individuals with Chronic Kidney
Disease (CKD)
The MRB recommends that FMCSA accept most of the Renal Disorders
MEP advice and to require a blood test to measure serum creatinine and
glomerular filtration rate (GFR) estimated through creatinine clearance
for those drivers who have any of the following conditions: personal
history of potential CKD, age over 65 years, diabetes mellitus,
hypertension (as specified on the CDME examination form), and
proteinuria.
Recommendation 2: Screening of Individuals in Stages 1, 2, or 3
Chronic Kidney Disease
The MRB recommends that FMCSA accept the Renal Disorders MEP
recommendation that drivers screened for renal disease be staged.
 Drivers with a more severe, higher stage renal disease should be
screened more frequently.
 Drivers in Stages 1, 2, or 3 should have screening with repeat
creatinine measurement and GFR performed with each CDME
examination.
 Drivers in Stages 1 or 2 should be re-evaluated at least every 2
years.
 Drivers in Stage 3 should be re-evaluated at least annually.
Recommendation 3: Certification of Individuals in Stage 4 Chronic
Kidney Disease
The MRB recommends that FMCSA require those drivers with renal
disease in Stage 4 (GFR 15-29 mL/min), be recertified at least every 6
months, including a GFR measurement and a supportive letter from their
treating nephrologist. They should also receive a cardiovascular
evaluation at least annually.
Recommendation 4: Certification of Individuals in Stage 5 Chronic
Kidney Disease and/or on Dialysis
Drivers in Stage 5 and/or on hemodialysis or peritoneal dialysis are
recommended to be precluded from driving a CMV. Patients with
successful kidney transplantation may seek certification.
Recommendation 1. The focus of the evaluation of musculoskeletal
conditions should be on function rather than diagnosis.
Recommendation 2. FMCSA should obtain information about the
physical requirements needed to safely drive a CMV, to include pre-trip
and en route safety inspections.
Recommendation 3. FMCSA should convene an expert panel tasked with
developing a physical screening instrument for the medical examiner.
Recommendation 4. FMCSA should standardize the driving-specific
work capacity evaluation (road test) to include pre-trip and en route
safety inspections.
Vision
April
2008
Chronic
Kidney
Disease
April
2008
Other
Motions
April
2008
Recommendation 1: Monocular Vision. The current standard which
precludes individuals with monocular vision from driving a CMV for the
purposes of interstate commerce should not be changed at this time.
Recommendation 2: Red-Green Color Deficiency. The current standard
regarding red-green color deficiencies should not be changed at this time,
and a revision in testing guidelines should be considered with regard to
specific tests.
Recommendation 3: Visual Field (VF) Loss. The current standard of 70º
may be adequate and whether this needs a modification and what that
modification should be has yet to be determined. The methods of VF
testing should be clarified.
Recommendation 4: Cataracts. There is insufficient evidence to modify
the current standard to include the possible impact of cataracts on CMV
driving ability.
Recommendation 5: Diplopia. There should be no change to the standard
on diplopia.
Recommendation 1: Individuals with Renal Transplants
 Individuals who have undergone renal transplant with successful
kidney transplantation may drive a CMV 90 days postoperatively
provided that they have been cleared as fit for duty by their transplant
physician.
 With the exception of differences in recertification periods,
individuals who have undergone successful renal transplantation
should be assessed as per recommendations 1 through 4. (See July
2008 recommendations.)
 All individuals who have undergone successful renal transplantation
should be recertified at 3, 6, and 12 months postoperatively.
Thereafter, individuals should be recertified on an annual basis.
Recommendation 1. The MRB recommends to the FMCSA that they
seek and receive appropriate resources to develop, implement, and
maintain a nationwide database on all CMV operators involved in fatal
vehicle crashes for the purposes of developing quality data from which
evidence-based guidance may be used to reduce the unacceptably high
number of fatalities among CMV operators. Such data should include:
 CDME examination forms (most recent and prior).
 Driver records, including citations and prior crashes, injuries
whether occupational or not.
 Post-mortem data (including cause of death and evidence of other
condition(s).
 Toxicological test results from the post-mortem studies.
 Personal medical records including evidence of diagnoses and/or
treatment for any prior disorders.
Recommendation 2. The MRB recommends to the FMCSA that they
Sleep Apnea
January
2008
seek and receive appropriate resources to develop, implement, and
maintain a prospective nationwide database of CMV operators.
This national resource would collect medical and safety information on
CMV drivers to assess the relationship between the driver’s physical and
mental health and driver safety.
Recommendation 1: General Guidance
The FMCSA’s current guidelines for individuals who have OSA should
be replaced with the following general guideline statement:
 A diagnosis of OSA precludes an individual from obtaining
unconditional certification to drive a CMV for the purposes of
interstate commerce.
 A diagnosis of OSA, however, should not exclude all individuals
with the disorder from driving a CMV; certification may be
possible in some instances. An individual with a diagnosis of
OSA may be certified to drive a CMV if that individual meets the
following criteria:
o Has untreated OSA with an apnea-hypopnea index (AHI)
≤ 20 AND
o Has no daytime sleepiness OR
o Has OSA that is being effectively treated.
 An individual with OSA who meets the requirements for
certification described above should be recertified annually,
based on demonstrating satisfactory compliance with therapy.
Recommendation 2: Specific Guidance: Drivers Who
Should be Disqualified Immediately or Denied Certification
The MRB believed that the following populations of individuals should
not be certified or recertified as being medically qualified to drive a
CMV.
 Individuals who report that they have experienced excessive
sleepiness while driving.
 Individuals who have experienced a crash associated with falling
asleep.
 Individuals with an AHI greater than 20, until such an individual
has been adherent to Positive Airway Pressure (PAP). They can
be conditionally certified based on the criteria for Continuous
Positive Airway Pressure (CPAP) compliance as outlined in
Recommendation 3.
 Individuals who have undergone surgery and who are pending
the findings of a 3-month post-operative evaluation.
 Individuals who have been found to be non-compliant with their
treatment at any point.
Recommendation 3: Specific Guidance: Conditional Certification
The following groups of individuals with OSA should be conditionally
allowed to drive a CMV:
 Individuals with a body mass index (BMI) ≥ 33 kg/m2 may be
conditionally certified for 1 month pending the findings of a
sleep study. This period should be less than 1 week. However,
given the current infrastructure for sleep studies in the United
States, obtaining a sleep study within 1 week is unlikely to be
feasible in many cases. Consequently, the Board recommends a
transition period of 2 years during which timely efforts are made
to improve the infrastructure so that the period between
requesting a sleep study and obtaining that study can be reduced
to 1 week for certification purposes.
 Individuals recently diagnosed with OSA may be conditionally
certified for 1 month during which time they will be started on
CPAP therapy. At the end of this month, they can be
conditionally certified for 3 months if compliance to CPAP is
documented in the 2 previous weeks. Compliance should be
reassessed at 3 months. At the 3-month assessment, individuals
who demonstrate treatment compliance may be certified for 1
year. Commercial drivers need to be informed that if they stop
using their CPAP during the 1-year period, they should stop
driving a commercial vehicle. They should be warned that if they
stop using their CPAP and are involved in a crash, it is likely
they will be considered legally liable. At 1 year, future
recertification should depend on proof of continued compliance
with treatment. At the end of 1 year, the certifying physician
should review all compliance data for that year. Ideally, in time,
with newer CPAP machines, these data will include not only
compliance but information about efficacy of treatment. It is
conceivable that if at the end of 1 year the individual is no longer
compliant with therapy, certification may not be renewed or only
renewed for a brief period to allow compliance with therapy to be
re-established.
 Minimally acceptable compliance is defined here as more than 4
hours of use for at least 70% of the days, based on current
standards of practice. (Gay et al., 2006)
Recommendation 4: Specific Guidance:
Referral for Confirmation of Diagnosis or Stratification of Severity
The MRB recommended the following guidelines to confirm a diagnosis
of OSA and its stratification by severity:
 Individuals who meet the following criteria should be required to
undergo an evaluation to confirm the diagnosis of, and, if
necessary, stratify the severity of OSA:
o Those categorized as high risk for OSA according to the
Berlin Questionnaire OR
o Those with a BMI ≥ 30 kg/m2 OR
o Those judged to be at risk for OSA based on a clinical
evaluation.
Recommendation 5: Specific Guidance:
Identification of Individuals with Undiagnosed OSA
The MRB believed one of the roles of the medical examiner is to identify
individuals who may have undiagnosed OSA and consequently proposes
the following guideline:
 Medical examiners should actively screen for OSA in all
individuals who request fitness-for-duty certification for the
purposes of driving a CMV in interstate commerce.
o
Symptoms suggestive of OSA include: chronic loud
snoring, witnessed apneas or breathing pauses during
sleep, and daytime sleepiness.
o Risk factors for OSA are: advancing age, BMI ≥ 28
kg/m2, small jaw, large neck size (≥ 17 inches (male) ≥
15.5 (female)), small airway (a narrow or edematous
oropharynx), and family history of sleep apnea.
o Conditions known to be associated with a high risk of
OSA include the following: hypertension (treated or
untreated), Type 2 diabetes (treated or untreated), and
hypothyroidism (untreated).
Recommendation 6: Specific Guidance: Method of Diagnosis and
Severity
The MRB recommended that the FMCSA consider adopting the
following guidelines on the appropriate methods to confirm a diagnosis
of OSA and stratify its severity:
 The preferred method of diagnosis and assessment of disease
severity is overnight polysomnography (PSG).
o Acceptable alternative methods for assessment of risk in
CMV drivers include objective recording devices
validated against PSG that include at least 5 hours of
measurements of: oxygen saturation AND nasal pressure
AND sleep/wake time.
 Regardless of the type of study performed, individuals should be
tested while on their usual chronic medication regime.
Recommendation 7: Specific Guidance: Treatment of OSA – Positive
Airway Pressure (PAP)
The MRB recommended the following guidelines on the appropriate
treatment of individuals with moderate-to-severe OSA:
 All individuals with OSA who require treatment should be
referred to a qualified physician with relevant expertise in sleep
apnea.
 PAP is the preferred method of therapy.
 Adequate PAP pressure should be established through one of the
following means:
o An in-laboratory titration study.
o An auto-titration system without an in-laboratory
titration.
 Individuals with OSA who have been treated with PAP may be
certified if they have been successfully treated for a minimum of
1 week.
o Successful PAP treatment is defined as follows:
• Demonstration of good compliance with treatment (see
below).
• Resolution of excessive sleepiness when driving.
 Individuals with OSA who are treated with PAP must
demonstrate compliance with treatment and this must be
documented objectively.
o Compliance is defined as using PAP for the duration of
total sleep time.
• Optimal treatment efficacy occurs with 7 hours or more
of use during sleep; however, 4 hours of documented
time at pressure per major sleep episode is minimally
acceptable.
 Based on current standards of practice, an acceptable CPAP use
is at least 4 hours of use per night on at least 70% of nights.
Recommendation 8: Specific Guidance: Treatment of OSA –
Alternatives to PAP
The MRB recommended the following guidelines on the appropriate
treatment of individuals with moderate-to-severe OSA who require a
treatment other than PAP:
 Dental appliances and surgery are considered to be potential
alternatives to PAP for the treatment of OSA.
o Currently there is no method of measuring compliance
among individuals treated with dental appliances.
Consequently, use of dental appliances cannot be considered
an acceptable alternative to PAP in individuals who require
certification to drive a CMV in interstate commerce.
Compliance among individuals who have undergone surgical
treatment for OSA is less of an issue. Consequently, surgical
treatment (bariatric, upper airway soft tissue, facial bone, and
tracheostomy) is deemed an acceptable alternative to PAP
(see later recommendations).
Recommendation 9: Specific Guidance: Treatment of OSA — Bariatric
Surgery
The MRB recommended the following guidelines pertaining to obese
individuals with moderate-to-severe OSA who undergo bariatric surgery:
 Individuals who have undergone bariatric surgery may be
certified if they are:
o Compliant with PAP (see guideline for PAP
requirements) OR
o Six months post-operative (to allow time for weight loss)
AND
o Cleared by treating qualified physician with relevant
expertise in sleep apnea AND
o Sleep exam indicates that AHI ≤ 10 AND
o No longer excessively sleepy.
 For individuals certified based on these criteria, there should be
re-evaluation by sleep study within 2 years if they are not on
PAP therapy.
 Individuals who are off PAP therapy should be given
information that they need to seek re-evaluation if they gain
significant weight (> 5%) or their symptoms of OSA recur.
Recommendation 10: Specific Guidance: Treatment of OSA —
Oropharyngeal Surgery
For individuals with moderate-to-severe OSA who undergo
oropharyngeal surgery:
 Individuals with OSA who have been treated with oropharyngeal
surgery may be certified if they:
o Are > 1 month post surgery AND
o Are cleared by treating qualified physician with relevant
expertise in sleep apnea AND
o Do not experience daytime sleepiness AND
o Have an AHI < 10.
 Annual recertification required
o Annual objective testing with AHI < 10 AND
o No daytime sleepiness.
Recommendation 11: Specific Guidance: Treatment of OSA – Facial
Bone Surgery
For individuals with moderate-to-severe OSA who undergo facial bone
surgery:
 Individuals with OSA who have been treated with facial bone
surgery may be certified if they:
o Are > 1 month post surgery AND
o Are cleared by treating qualified physician with relevant
expertise in sleep apnea AND
o Do not experience daytime sleepiness AND
o Have an AHI < 10.
 Annual Recertification required
o Annual objective testing with AHI < 10 AND
o No daytime sleepiness.
Recommendation 12: Specific Guidance: Treatment of OSA –
Tracheostomy
The MRB recommended the following guidelines for individuals with
moderate-to-severe OSA who undergo tracheostomy:
 Individuals with OSA who have been treated with oropharyngeal
surgery may be certified if they:
o Are > 1 month post surgery AND
o Are cleared by treating qualified physician with relevant
expertise in sleep apnea AND
o Do not experience daytime sleepiness AND
o Have an AHI < 10.
 Annual recertification required
o Annual objective testing with AHI < 10 AND
o No daytime sleepiness.
Recommendation 13: Patient Education. For the education of
individuals who meet the criteria for certification to drive a CMV,
individuals with OSA who meet the criteria for certification should be
provided with education on the following: the importance of adequate
sleep, lifestyle changes (weight loss, smoking cessation, exercise,
reduced alcohol intake), importance of treatment compliance (if relevant),
consequences of untreated OSA (loss of certification, crash,
hypertension, cognitive dysfunction, heart disease, reduced quality of life,
reflux, headaches, shorter survival, and sleep disruption), and effects of
respiratory or central nervous system depressants on OSA.
Recommendation 14: Additional Recommendations. The FMCSA
should consider creating incentives for large trucking companies to
develop fatigue management models (e.g. Schneider Model), as well as
couple a dissemination program with these models.
Seizure
Disorders
January
2008
Diabetes
July 2007
Recommendation 1: Fitness-to-Drive Certification of Individuals With
a History of Epilepsy
For individuals with a history of epilepsy, retain the existing guidance on
the management of seizures and commercial drivers, supporting a
minimum of 10 years off anti-seizure medications and seizure free.
Recommendation 2: Fitness-to-Drive Certification of Individuals With
a History of a Single Unprovoked Seizure
For individuals with a history of a single, unprovoked seizure, retain the
existing guidance on the management of seizures and commercial drivers,
supporting a minimum of 5 years off anti-seizure medication and seizure
free.
Recommendation 3: Fitness-to-Drive Certification of Individuals with a
History of a Provoked Seizure or Seizures
Individuals with cases of provoked seizures that are caused by structural
brain lesions (e.g., tumor, trauma, and infection) should be assessed more
stringently than those with other causes (e.g., a single, unprovoked
seizure caused by exposure to a medication such as lidocaine). The MRB
recommended individualization of time restrictions from driving for a
minimum of 5 years, but up to 10 years—based on consultation with a
neurologist. This applies only to individuals who are off medication and
seizure free.
Recommendation 4: Additional Recommendations
Individuals with a probable, single episode of drug toxicity may be
treated less restrictively than those with structural brain lesions
depending on the outcome of the neurological consultation.
Recommendation 1: Specific Guidance
Individuals are physically qualified to drive a commercial motor vehicle
if they have an established medical history or clinical diagnosis of
diabetes mellitus only if they:
a) Are examined and certified annually by a commercial driver medical
examiner (CDME) who is a licensed physician (MD/DO) at least
annually.
b) If on insulin, they must:
1. Be free of insulin reactions (an individual is free of insulin reactions
if
that individual does not have severe hypoglycemia).
2. Not have hypoglycemia unawareness.
3. Be able to and demonstrate willingness to properly monitor and
Certified
Driver
Medical
Examiner
April
2007
Schedule II
Drugs
April
2007
manage
their diabetes, and sign a questionnaire documenting adherence and
awareness of hypoglycemic risk
4. Not be likely to suffer any diminution in driving ability due to their
diabetic
condition;
5. Agree to and comply with the following conditions:
i) A source of rapidly absorbable glucose shall be carried at all
times while
driving;
ii) Blood glucose levels shall be self-monitored 1 hour prior to
driving
and at least once every 4 hours while driving or on duty prior to
driving using a portable glucose monitoring device equipped with a
computerized memory;
iii) Submit blood glucose logs to the CDME at the annual
examination
or when otherwise directed by an authorized agent of the Federal
Motor Carrier Safety Administration; and
iv) Provide a copy of the physician’s report to the medical
examiner at the time of the annual medical examination.
Recommendation 1: CDME Description and Examiner Qualifications
Commercial drivers are older, heavier, and sicker than ever before.
Medicine and medical technology are more complex than at any time in
history and our highways and roads are busier and more dangerous with
each passing year. For these reasons, the Medical Review Board of the
Federal Motor Carrier Safety Administration (FMCSA) believes that
public safety is best served by having the best-trained medical
professionals possible engaged in the evaluation and certification of
commercial drivers. We urge that the FMCSA establish a prerequisite
that Commercial Driver Medical Examiners be licensed MDs or DOs.
Recommendation 1: Schedule II Drugs Exception
An individual is considered medically fit to drive if he/she:
1. (b)(12)(i) Does not use a controlled substance or drug identified in 21
CFR 1308.11 Schedule I, an amphetamine, a benzodiazepine, a
narcotic, a Schedule II medication, or any other habit-forming
substance or drug;
2. (b)(12)(ii) Exception. A driver may use such a licit substance or drug
if the substance or drug is prescribed for that individual for a
legitimate medical reason by a licensed physician (MD or DO) who:
 Is familiar with the driver’s medical history and assigned duties
and
 Has warned the driver that the prescribed substance or drug may
adversely affect the driver’s ability to safely operate a
commercial motor vehicle (CMV).
Cardiovascula April
2007
r Disease
and:
The driver is independently evaluated by a Commercial Driver Medical
Examiner (CDME) who also:
 Is a licensed physician (MD or DO);
 Is familiar with the driver’s medical history and assigned duties;
 Has warned the driver that the prescribed substance or drug may
adversely affect the driver’s ability to safely operate a CMV;
 Has informed the driver that if the driver does not take the
substance or drug as prescribed, the driver is using the substance
or drug improperly and is not covered by this exception; and
 Reviews a form for this purpose that is signed by the driver*.
Specifically excluded from the exception are drivers who:
 Use substances or drugs administered parenterally (e.g.
intravenously, transdermally, subcutaneously, intrathecally, or
intramuscularly);
 Have initiated or increased doses of one of these substances or
drugs within the past 2 weeks after such changes;
 Have a history of substance, drug or alcohol abuse, or addiction;
or
 Require the ingestion of substances or drugs while driving.
Factors to be considered by the CDME in determining whether to certify
the driver include:
 Driving history;
 Psychiatric and psychological history;
 Dose(s) of the prescribed substance or drug;
 Underlying and comorbid conditions; and
 Duration of action and pharmacokinetics of the prescribed
substance or drug.
*The driver questionnaire would address the medication, purpose, side
effects, proper usage, and whether it may have an impairing effect. If the
driver does feel impaired, the driver must sign that he/she will stop
driving. The questionnaire must have the driver assert that his/her
statements are true and spell out the consequences of an untruthful
declaration.
Recommendation 1: CMV Drivers Without Known Heart Disease:
1. Revise the current definition for abnormal exercise tolerance
testing definition for abnormal exercise tolerance testing (ETT)
to an inability to exceed 6 METS (metabolic equivalents) on
ETT.
Recommendation 2: CMV Drivers With Known Chronic Heart Disease
(CHD)
1. Clarify that for all guidelines in this section, the expectation is
that drivers with known CHD will have had all of their
medications titrated to the optimal dose.
2. CMV drivers with angina pectoris may be qualified if the pattern
of angina is stable.
3. Current Federal Motor Carrier Safety Administration (FMCSA)
guidelines state that an individual with angina pectoris who has
undergone a percutaneous coronary intervention (PCI) may be
qualified to drive if he or she meets four conditions. The MRB
recommends removing the requirement for a normal ETT 3 to 6
months following PCI.
4. Current FMCSA guidelines require individuals who have
undergone coronary artery bypass surgery to be recertified every
year for 5 years, then undergo an exercise tolerance test annually.
The MRB recommends an exercise tolerance test every 2 years.
Recommendation 3: CMV Drivers with Hypertension
1. Add statements explaining the general principles of certification
of individuals with hypertension. These are:
a) Certification and recertification of individuals with
hypertension should be based on a combination of factors:
blood pressure, the presence of target organ damage, and comorbidities.
b) To provide consistency in certification, blood pressure
recorded at the certification (or recertification) examination
should be used to determine blood pressure stage. The
certifying examiner may decide on the length of certification
for drivers with elevated blood pressure despite treatment.
c) All CMV drivers should be referred to their personal
physician for therapy, education, and long-term management.
d) Add an expectation throughout this section that blood
pressure has been measured appropriately.
2. Add an expectation throughout this section that blood pressure
medication has been titrated appropriately. Target blood pressure
for titration should be < 140/ < 90.
3. Add text that medical examiners should ensure that individuals
with hypertension are properly educated about making
appropriate lifestyle changes and complying with medication.
4. Eliminate ambiguity about thresholds that define hypertension
stage. Updated guidelines on hypertension stages should be
consistent with those recommended by the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure.
Recommendation 4: CMV Drivers With Supraventricular Tachycardias
1. Resolve the ambiguity associated with “lone atrial fibrillation” by
making it clear that the diagnosis refers to individuals with atrial
fibrillation with no identifiable underlying disease. This is
usually diagnosed in younger persons.
2. Provide details of how risk for stroke from embolization among
individuals with atrial fibrillation should be determined.
3. FMCSA requested clarification of the role of aspirin and vitamin
K inhibitors in reducing stroke risk in individuals with atrial
fibrillation. The MRB referred FMCSA to the current American
College of Cardiology/American Heart Association/European
Society of Cardiology (ESC) guidelines for appropriate
antithrombotic treatment of those with atrial fibrillation.
4. Individuals with atrial fibrillation at moderate to high risk for a
stroke should be recertified annually. In order to be recertified,
the individual must have his or her anticoagulation monitored at
least monthly and demonstrate adequate rate/rhythm control.
Recommendation 5: CMV Drivers with Pacemakers
1. Revise current guidelines. The MRB no longer accepts a
pacemaker as definitive treatment for neurocardiogenic syncope.
2. Add text documentation accompanying the CVD guideline
update that describes the appropriate evaluation of an individual
who presents with syncope to ensure that efforts are made to
distinguish individuals with cardiogenic syncope from those with
syncope from other causes.
Recommendation 6: CMV Drivers and Cardioverter Defibrillators
1. The MRB recommends that the current FMCSA CVD guidelines,
which preclude any individual with an implanted cardioverter
defibrillator (ICD) from being certified to drive a CMV, be
upheld.
Recommendation 7: CMV Drivers with Abdominal or Thoracic Aortic
Aneurysms
1. The upper limit for the abdominal aortic aneurysm (AAA)
diameter below which an asymptomatic individual may be
certified should be increased to 5.5 cm for men and 5.0 cm be set
for women.
2. Change the current guidelines to read: individuals with an AAA
4.0 to 5.4 cm in diameter can be certified if they are
asymptomatic AND are cleared by a MD/DO vascular surgeon.
Individuals with an AAA 4.0 to 5.4 cm in diameter cannot be
certified if they are either symptomatic OR recommended they
undergo surgery.
3. Add guidance to the current guideline for individuals who have
undergone endovascular AAA repair (EVAR), ensuring that
recertification after EVAR requires compliance with the followup protocol.
4. Increase the upper limit for the thoracic aortic aneurysm (TAA)
diameter below which an asymptomatic individual may be
certified from 3.0 cm to 5.0 cm.
5. The annual acceptable rate of expansion of thoracic aneurisms is
.5 cm or less and for abdominal aneurisms is 1 cm or less.
Recommendation 8: CMV Drivers With Peripheral Vascular Disease
1. Amend the current guidelines for certification of individuals with
intermittent claudication to disqualify CMV drivers only when
pain occurs at rest.
Recommendation 9: CMV Drivers With Venous Disease
1. Active deep vein thrombosis (DVT) should disqualify an
individual from driving a CMV.
2. Individuals who have experienced DVT that has resolved should
be maintained on anticoagulation with a vitamin K antagonist for
a minimum of 3 months (preferably 6 months) following
resolution.
3. If on a vitamin K antagonist such as warfarin (Coumadin),
drivers need to be regulated at least 1 month prior to certification
(or recertification) and have their INR monitored at least monthly
thereafter.
4. International normalized ratio (INR) should be maintained within
the target range: 2.0–3.0.
5. Individuals treated with subcutaneous heparin or low molecular
weight heparin may be certified (or recertified) to drive a CMV
as soon as the DVT has resolved.
Recommendation 10: CMV Drivers With Cardiomyopathy
1. Change the prohibition against individuals with hypertrophic
cardiomyopathy to reflect the fact that not all individuals with
hypertrophic cardiomyopathy are at risk for sudden
incapacitation or death. Permit those who meet all the following
criteria to be certified to drive:
 No history of cardiac arrest.
 No spontaneous sustained ventricular tachycardia (VT).
 Normal exercise blood pressure (e.g., no decrease at
maximal exercise).
 No non-sustained VT.
 No family history of premature sudden death.
 No syncope.
 Left ventricular (LV) septum thickness < 30mm.
Low-risk individuals must be followed closely for changes in risk
status.
2. Change the criteria for individuals with idiopathic dilated
cardiomyopathy who do not have symptomatic heart failure (HF) to:
 Sustained ventricular arrhythmia for 30 seconds or more OR
requiring intervention
Left ventricular ejection fraction (LVEF) ≤ 40%.
Schedule II
Drugs
January
2007
Diabetes
Novembe
r 2006
Recommendation 1. The FMCSA should obtain additional information
about how other entities (Federal agencies and non-U.S. transportation
organizations) deal with similar issues.
Recommendation 2. The FMCSA should review the current drug test
regimen with an eye to expanding it to include drugs not currently
covered.
Recommendation 3. The absence of acceptable evidence-based research
does not imply the absence of a potential effect that would adversely
affect a driver’s abilities.
Recommendation 1: General Guidance
1. Individuals with diabetes mellitus are at increased risk for a motor
vehicle crash when compared with individuals who do not have
diabetes mellitus.
2. Hypoglycemia is an important risk factor for a motor vehicle crash
among individuals with diabetes mellitus.
3. There is insufficient evidence to support the premises that treatmentrelated factors are associated with an increased incidence of severe
hypoglycemia among individuals with diabetes mellitus, or that
hypoglycemia awareness training is effective in preventing the
consequences of hypoglycemia.
*Numerous recommendations and motions approved for more research enumerated largely in response to
limited evidence in specific evidence reports are omitted for the sake of space limitations. There also are
two specific and detailed recommendations for increased research that have been retained in the above
table.
**This table also omits additional, earlier recommendations regarding the multiple conditions matrix
approved by the MRB January 2010 as largely redundant. It also omits specific calls for additional
evidence reports and medical expert panels on additional topics.
***Repeated recommendations regarding musculoskeletal disorders and implantable defibrillators,
addressed July 2009, were omitted.