Predicting ability to drive after stroke

Predictors of driving outcome after traumatic brain injury

OBJECTIVE

To examine predictors of driving status and fitness to drive after traumatic brain injury (TBI).

DESIGN

Retrospective and prospective follow-up of a cohort ranging from 4 months to 10 years post-TBI.

SETTING

A Midwestern, urban university-affiliated rehabilitation hospital.

PARTICIPANTS

Seventy-one pairs of adults who had sustained a TBI and their significant others.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Driving status (whether the patient resumed driving), driving frequency (estimated miles driven per week), and postinjury driving records compiled by the Department of Motor Vehicles.

RESULTS

Logistic and hierarchical regression analyses indicated that the significant other's perceptions of the patient's fitness to drive were the strongest predictor of patients' driving status and driving frequency. However, years postinjury, disability at discharge, and current neuropsychologic functioning best predicted postinjury driving safety as measured by actual incidents. The relation between perception of patients' fitness and actual driving incidents, however, was modest.

CONCLUSIONS

Neuropsychologic and medical information available by traditional methods showed unique value in predictive driving safety. However, caregiver perception of patients' fitness was the overwhelming determinant of whether and how much patients drive. The bases on which caregivers form their opinions affect the safety of patients and the public. The rehabilitation setting is a unique resource for family education regarding abilities essential to safe driving.

Vision, attention, and self-reported driving behaviors in community-dwelling stroke survivors

OBJECTIVE

To elucidate the relationships among vision, attention, driving status, and self-reported driving behaviors in community-dwelling stroke survivors.

DESIGN

A cross-sectional design to compare stroke survivors to older adults without stroke on visual measures, attentional measures, and self-reported driving behaviors.

SETTING

Rehabilitation center at a university hospital.

PARTICIPANTS

Fifty stroke survivors and 105 older adults without neurologic or visual impairment.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Visual acuity, contrast sensitivity, peripheral vision, useful field of view (UFOV), Behavioral Inattention Test, and a driving habits questionnaire.

RESULTS

Stroke survivors had impaired contrast sensitivity, peripheral vision, and UFOV compared with older adults in good visual and neurologic health. Driving stroke survivors typically had less attentional impairment than nondrivers. Stroke survivors who returned to driving reported difficulty in challenging driving conditions, drove less, and relied more on other people for transportation than older adults without stroke.

CONCLUSIONS

These results suggest that vision and attention, both of which are important for driving, are often impaired in stroke survivors. The severity of these deficits could be an influence on driving status and driving behavior. Stroke survivors who return to driving strategically limit their driving exposure and rely on others for transportation, which suggests that they may deliberately self-regulate their driving behavior.

Determinants of driving after stroke

OBJECTIVE

To identify variables that best predict a team's decision of driving ability in stroke patients from a predriving assessment.

DESIGN

Retrospective study of a 2-year predriving evaluation.

SETTING

Belgian Institute for Road Safety.

PARTICIPANTS

One hundred four patients with sequelae of first stroke.

INTERVENTIONS

Predriving assessments and road test.

MAIN OUTCOME MEASURES

The suitability to resume driving based on a team decision and performance in the road test.

RESULTS

Forty-one patients (39.4%) were judged suitable, 45 (43.3%) not immediately suitable, and 18 (17.3%) not suitable to drive. Correlation coefficients and comparisons between groups revealed that most variables had significant individual relationships with the team decision and performance on the road test. After logistic regression analysis, side of lesion, kinetic vision, visual scanning, and a road test led to the best model in predicting the team decision (R(2) =.53). The road test was the most important determinant (R(2) =.42). Multiple regression analysis showed that the combination of acuity of left and right eyes and the figure of Rey was the best subset to predict the road test (R(2) =.28).

CONCLUSION

The predictive accuracy of the team's decision is limited, and the road test is even lower. Inclusion of more real-road-related tests in the predriving assessment is necessary.

Useful field of view after traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) survivors often have sensory and cognitive impairments that may interfere with driving ability. The Useful Field of View (UFOV) is a measure of visual information processing that is a good predictor of vehicle crash risk in older adults.

OBJECTIVE

The objective of this study was to explore the possibility that UFOV is compromised after TBI.

DESIGN

UFOV performance of 23 TBI survivors and 18 young adults without neurological impairment were compared.

CONCLUSION

TBI survivors had higher UFOV scores than young adults, which indicated a greater functional loss of peripheral vision. The results suggest that the UFOV may be a valuable instrument for assessing driving readiness in TBI survivors.

Driving skills in elderly persons with stroke: comparison of two new assessment options

OBJECTIVE

To compare the effectiveness of two methods of assessing off-road driving skills that claim to predict on-road driving fitness of persons with stroke.

METHOD

Fifty-six persons with stroke (age 44 to 82 yrs; mean, 60.2 yrs) completed the 2 off-road driving assessments along with standard clinical and on-road driving tests.

MAIN OUTCOME MEASURES

Linear stepwise regression on 4 variables of the Dynavision Performance Assessment Battery (DPAB), the Cognitive Behavioral Driver's Inventory (CBDI) variable (composite score), and the variables of age, gender, and lesion side.

RESULTS

A 4-minute endurance subtest from the DPAB was superior to the CBDI in predicting success/failure in the on-road driving test (75%). However, success on both the 4-minute endurance subtest from the DPAB and the CBDI tests significantly improved the prediction of on-road success. If participants passed the CBDI and the endurance test from the DPAB, they also passed the on-road assessment.

CONCLUSION

Driving fitness of elderly persons with stroke can be assessed with reasonable accuracy using off-road tests, minimizing the expense and risk associated with on-road assessments in this population.

Visual testing for readiness to drive after stroke: a multicenter study

OBJECTIVE

The purpose of this study was to determine the ability of a visual-perception assessment tool, the Motor-Free Visual Perception Test, to predict on-road driving outcome in subjects with stroke.

DESIGN

This was a retrospective study of 269 individuals with stroke who completed visual-perception testing and an on-road driving evaluation. Driving evaluators from six evaluation sites in Canada and the United States participated. Visual-perception was assessed using the Motor-Free Visual Perception Test. Scores range from 0 to 36, with a higher score indicating better visual perception. A structured on-road driving evaluation was performed to determine fitness to drive. Based on driving behaviors, a pass or fail outcome was determined by the examiner.

RESULTS

The results indicated that, using a score on the Motor-Free Visual Perception Test of < or =30 to indicate poor visual-perception and >30 to indicate good visual perception, the positive predictive value of the Motor-Free Visual Perception Test in identifying those who would fail the on-road test was 60.9% (n = 67/110). The corresponding negative predictive value was 64.2% (n = 102/159). Univariate logistic regression analyses revealed that older age, low Motor-Free Visual Perception Test scores and a right hemisphere lesion contributed significantly to identifying those who failed the on-road test.

CONCLUSIONS

The predictive validity of the Motor-Free Visual Perception Test is not sufficiently high to warrant its use as the sole screening tool in identifying those who are unfit to undergo an on-road evaluation.