Determinants of On-Road Driving in Multiple Sclerosis

Investigating the relationship between multiple sclerosis disability and driving performance: A comparative study of the multiple sclerosis functional composite and expanded disability status scale

INTRODUCTION

Multiple Sclerosis (MS) can affect the ability to perform complex tasks such as driving. The Expanded Disability Status Scale (EDSS) overlooks cognitive deficits crucial for driving. We investigated the relationship between the Multiple Sclerosis Functional Composite (MSFC), which includes cognitive assessment, and EDSS in relation to driving performance.

METHODS

 This exploratory study involved 30 MS patients (mean EDSS 2.4 ± 2.0) and 15 healthy controls. We correlated the results of the EDSS, MSFC, and driving performance tests, namely the Two-Hand Coordination Test (2HAND) and the Speed Anticipation Reaction Test (SART).

RESULTS

Patients did not differ from the healthy controls regarding age, sex, and driving experience. However, they exhibited lower mean Z-scores in MSFC, particularly in motor domains, but not in cognitive function. The mean Z-score for the 25-foot Walk test was -0.42 in patients compared to -0.04 in controls. For the 9-hole Peg Test, it was 0.17 in patients versus 1.47 in controls. Patients had a mean total error time of 19.7 seconds for both hands in the 2HAND test, compared to 7.7 seconds in controls. In MS patients, the MSFC and EDSS significantly correlated with SART and 2HAND components. While upper limb function (9-HPT) did not correlate with 2HAND, cognitive function (PASAT) did correlate with the number of 2HAND errors, indicating that cognitive dysfunction impacts driving performance more than physical dysfunction.

CONCLUSION

The MSFC may provide valuable insights into the driving abilities of MS patients, potentially offering advantages over the EDSS in predicting driving performance. Further research with larger, more diverse populations across various driving environments is necessary to validate these findings.

Impairment of daily occupations in multiple sclerosis: analysis of neuroimaging, general and social cognition, and reserve

BACKGROUND

Multiple Sclerosis (MS) can impact performance of daily occupations in both relapsing-remitting (RRMS) and secondary-progressive (SPMS) clinical courses. Work force participation decreases with advancing physical disability but the influence of non-motor factors, neuroimaging, and reserve have been scarcely investigated. We aimed to evaluate MRI, clinical, and cognitive (social and general) factors associated with impairment in different daily occupations and address whether cognitive and brain reserve have a positive impact on the ability to maintain these activities.

METHODS

We prospectively enrolled persons with MS (PwMS) who underwent clinical examination (Expanded Disability Status Scale - EDSS; Timed 25-Foot Walk Test - T25FW; and the Nine Hole Peg Test - 9HPT), general neuropsychological assessment (Brief Repeatable Battery of Neuropsychological Tests - BRBN, including the Symbol Digit Modalities Test - SDMT), social cognition evaluation (Reading the Mind in the Eyes Test), cognitive reserve questionnaire, and MRI (FreeSurfer). We also enrolled healthy subjects for comparison as a control group. Daily occupations (employment, money management, and driving abilities) were assessed in all individuals with questionnaires.

RESULTS

We included 62 PwMS (32 RRMS and 30 SPMS; mean age 42.8 years; median educational time 12.75 years) and 67 controls (mean age 39.7; median educational time 12.0 years) which were similar regarding demographics, education, and socioeconomic status (p > 0.1). Most PwMS (67.7%) had work-restrictions. They also reported fewer money management and driving abilities than controls (p < 0.001). Work-restriction was associated with physical disability (p = 0.006), SDMT and BRBN performance (p = 0.035 and p = 0.031, respectively), and T2-lesion volume (p = 0.022), with large effect sizes (d > 0.75). After hierarchical linear regression, money management was associated with hand dexterity, general and social cognition, and cognitive reserve (p < 0.03). Variables associated with driving abilities included fatigue, verbal fluency, striatum volume, and brain reserve (p < 0.05).

CONCLUSIONS

PwMS have more frequent work-restrictions and impairment in money management and driving abilities compared to controls. Cognitive function, physical disability, and MS-lesion burden are strongly associated with work-restriction. Social cognition can also influence financial capacity. Cognitive and brain reserve can help retain some of these daily occupations.

Driving ability and predictors for driving performance in Multiple Sclerosis: A systematic review

OBJECTIVE

To provide an overview of the evidence on driving ability in persons with multiple sclerosis (PwMS), specifically to (i) study the impact of MS impairment on driving ability and (ii) evaluate predictors for driving performance in MS.

METHODS

To identify relevant studies, different electronic databases were screened in accordance with PRISMA guidelines; this includes reference lists of review articles, primary studies, and trial registers for protocols. Furthermore, experts in the field were contacted. Two reviewers independently screened titles, abstracts, and full-texts to identify relevant articles targeting driving in people with MS that investigated driving-related issues with a formal driving assessment (defined as either an on-road driving assessment; or naturalistic driving in a car equipped with video cameras to record the driving; or a driving simulator with a steering wheel, a brake pedal, and an accelerator).

RESULTS

Twenty-four publications, with 15 unique samples (n = 806 PwMS), were identified. To assess driving ability, on-road tests (14 papers) and driving simulators (10 papers) were used. All studies showed moderate to high study quality in the CASP assessment. About 6 to 38% of PwMS failed the on-road tests, showing difficulties in different areas of driving. Similarly, PwMS showed several problems in driving simulations. Cognitive and visual impairment appeared to most impact driving ability, but the evidence was insufficient and inconsistent.

CONCLUSION

There is an urgent need for more research and standardized guidelines for clinicians as one in five PwMS might not be able to drive safely. On-road tests may be the gold standard in assessing driving ability, but on-road protocols are heterogeneous and not infallible. Driving simulators assess driving ability in a standardized way, but without standardized routes and driving outcomes, comparability between studies is difficult. Different aspects, such as cognitive impairment or vision problems, impact driving ability negatively and should be taken into consideration when making decisions about recommending driving cessation.

SYSTEMATIC REVIEW REGISTRATION

Identifier [10.17605/OSF.IO/WTG9J].

Association between on-road driving performance test and usual walking speed or sustainable attention in the elderly; Preliminary survey

OBJECTIVE

An increase in older drivers has been widely recognized in Japan; accordingly, screening to prevent traffic accidents is a crucial issue for safe driving. As a preliminary study, we examined the association between on-road driving performance and cognition or physical performance in older individuals.

METHODS

The survey was conducted in 2020, and the participants were recruited in Katagami City, Akita, Japan. The Road Test was used to assess on-road driving performance. The physical assessment comprised the usual walking speed (UWS) and grip strength (GS), and the cognitive evaluation consisted of the National Center for Geriatrics and Gerontology Functional Assessment Tool (NCGG-FAT) and the Japanese version of Stroke Drivers' Screening Assessment (J-SDSA). A multiple regression model was also applied to examine the association between on-road driving performance and the physical items or cognitive domains of the NCGG-FAT and the J-SDSA in older individuals.

RESULTS

Twenty-one participants (mean age ± standard deviation [SD], 77.0 ± 5.5 years) were included in this study. A correlation analysis showed that the on-road test score was correlated with performances on the UWS (r = 0.53, p = .002), the word list memory (WM) test (r = 0.44, p = .046), the trail-making test-A (TMT-A) (r = -0.44, p = .048), the SDSA dot cancelation (DC) test (r = -0.63, p = .002), and the SDSA squares matrix compass test (SM) (r = 0.54, p = .048). According to a stepwise linear regression, the on-road test score was associated with the UWS (β = -0.01, p = .003) and the SDSA DC (β = 4.89, p = .01), with an adjusted R² = 0.54.

CONCLUSIONS

The results of the study suggested that the UWS and sustainable attention might be potential factors influencing on-road driving performance. Our preliminary findings warrant further investigation.

On-Road Driving Assessment in a Driving School Course and the Results of a Cognitive Function Test After Stroke in a Depopulated Rural Area in Japan: Case Series of Eight Patients

Introduction

Returning to driving after a stroke is a step toward independence and improving quality of life. Cognitive function after stroke is one of the essential factors that affect driving ability, and on-road driving assessment in driving school courses is beginning to spread in Japan. We started on-road driving assessment in 2018, and we herein report eight patients who underwent on-road driving assessment in the last three years, presenting both off-road cognitive function tests and on-road driving assessment results.

Methods

Of the 320 consecutive stroke patients from 2018 to 2020, we retrospectively investigated the eight patients’ characteristics who underwent on-road driving assessment. We performed cognitive function tests, including behavioral inattention test (BIT), trail-making test, Wechsler Adult Intelligence Scale-III, and behavioral assessment of the dysexecutive syndrome. Patients who meet BIT > 35, at least three other subitem criteria, and no unevaluable subitems can undergo on-road driving assessment by a driving instructor. With the recommendation of the driving instructors, we comprehensively decided the permission to drive.

Results

All eight patients could return to driving after on-road driving assessment. Two patients could return to driving after nearly a year.

Conclusion

The patients did not meet all the cut-offs of the cognitive function test, but they were judged to return to driving by driving instructors. We finally permitted all eight patients to drive. On-road driving assessment in the driving school course might be helpful for determining the permission to return to driving.

Clinical predictors of driving simulator performance in drivers with multiple sclerosis

Background:

Drivers with multiple sclerosis (MS) may experience visual–cognitive impairment that affects their fitness to drive. Due to limitations associated with the on-road assessment, an alternative assessment that measures driving performance is warranted. Whether clinical indicators of on-road outcomes can also predict driving performance outcomes on a driving simulator are not fully understood.

Objective:

This study examined if deficits in immediate verbal/auditory recall (California Verbal Learning Test–Second Edition; CVLT2-IR) and/or slower divided attention (Useful Field of View™; UFOV2) predicted deficits in operational, tactical, or strategic maneuvers assessed on a driving simulator, in drivers with and without MS.

Methods:

Participants completed the CVLT2-IR, UFOV2, and a driving simulator assessment of operational, tactical, and strategic maneuvers.

Results:

Deficits in immediate verbal/auditory recall and slower divided attention predicted adjustment to stimuli errors, pertaining to tactical maneuvers only, in 36 drivers with MS (vs 20 drivers without MS; F(3, 51) = 6.1, p = 0.001, R2 = 0.3, [Formula: see text]).

Conclusion:

The CVLT2-IR and UFOV2 capture the visual and verbal/auditory recall, processing speed, and divided attention required to appropriately adjust to stimuli in a simulated driving environment. Clinicians may use the CVLT2-IR and UFOV2 as precursors to driving performance deficits in drivers with MS.

Vision, attention, and driving

Safe driving demands the coordination of multiple sensory and cognitive functions, such as vision and attention. Patients with neurologic or ophthalmic disease are exposed to selective pathophysiologic insults to driving-critical systems, placing them at a higher risk for unsafe driving and restricted driving privileges. Here, we evaluate how vision and attention contribute to unsafe driving across different patient populations. In ophthalmic disease, we focus on macular degeneration, glaucoma, diabetic retinopathy, and cataract; in neurologic disease, we focus on Alzheimer's disease, Parkinson's disease, and multiple sclerosis. Unsafe driving is generally associated with impaired vision and attention in ophthalmic and neurologic patients, respectively. Furthermore, patients with ophthalmic disease experience some degree of impairment in attention. Similarly, patients with neurologic disease experience some degree of impairment in vision. While numerous studies have demonstrated a relationship between impaired vision and unsafe driving in neurologic disease, there remains a dearth of knowledge regarding the relationship between impaired attention and unsafe driving in ophthalmic disease. In summary, this chapter confirms-and offers opportunities for future research into-the contribution of vision and attention to safe driving.

Buckle up!

Die Verkehrsmedizin als Teil der Rechtsmedizin erfüllt in der Schweiz eine wichtige präventive Aufgabe in der Sicherung aller Verkehrsteilnehmer: Sie begutachtet die medizinisch basierte Fahrfähigkeit und Fahreignung. Als empirisch konsolidiertes Querschnittsfach hat sie Informationen aus einer Vielzahl von medizinischen Fachgebieten. Wie reagiert die Verkehrsmedizin aber auf den vermehrten Anspruch evidenzbasierter Gutachten und auf anstehende Herausforderungen?

Über einen historischen Abriss motivierten wir die Vorteile und das Potential einer teilweise durch Fahrsimulation ergänzten Untersuchung und einer dediziert auf Fahrsimulation basierenden, klinisch-prospektiven Forschung.

Neben vorhandener Literatur stützen sich historische Aspekte u.a. auf vorhandene Expertise. Die Bewertung der Fahrsimulation für die Verkehrs- bzw. Rechtsmedizin der Schweiz stützt sich auf die Diskussion selektierter Literatur.

Auftrag und Anspruch der Verkehrsmedizin haben sich mehrfach verändert. Eine übersichtsartige Betrachtung existenter Literatur legt nahe, dass massgeschneiderte Fahrsimulatoren Teil einer modernisierten Verkehrsmedizin sein können, um anstehende Herausforderungen adäquat adressieren zu können. Bisher existiert kein derartiges dediziertes Forschungsinstrument in der Schweiz.

Eine auf verkehrsmedizinische Fragestellungen massgeschneiderte, realitätsnahe und niedrigschwellige Fahrsimulation als Werkzeug für klinische Studien und Individualuntersuchungen verspricht neben einer wissenschaftlichen Produktivität einen umsetzbaren und vermittelbaren Mehrwert für das übergeordnete Ziel der Sicherheit aller Verkehrsteilnehmer.

Effect of cognitive rehabilitation on neuropsychological and semiecological testing and on daily cognitive functioning in multiple sclerosis: The REACTIV randomized controlled study

BACKGROUND

Specific cognitive rehabilitation (SCR) has been suggested for multiple sclerosis (MS). A randomized controlled trial (RCT) evaluating the therapeutic effects of SCR is necessary.

OBJECTIVE

To demonstrate the superiority of a SCR program (REACTIV) over nonspecific intervention (NSI) for neuropsychological (NP) assessment, virtual reality (VR) cognitive testing and daily cognitive functioning.

METHODS

A single-blind RCT compared SCR and NSI in patients with MS with cognitive complaint. Both programs included 50 individual sessions, 3 times a week for 17 weeks in a real-world setting. The primary end-point was NP assessment. Secondary end-points included semiecological VR tasks (Urban Daily Cog®) and daily cognitive functioning assessment. Maintenance of the effects at 8 months was studied.

RESULTS

Of the 35 patients, 18 completed the SCR, and 17 completed the NSI. Several NP and semiecological scores improved significantly more after SCR than after NSI. More NP scores improved significantly after SCR than after NSI. SCR improved daily cognitive functioning. Most improvements were maintained at 8 months.

CONCLUSION

SCR performed in a real-world setting is superior to NSI for improving performance in specific cognitive domains and information processing speed, and for improving cognitive functioning, as evaluated by ecological tools close to daily life and a daily cognitive functioning questionnaire.

Beyond cognitive dysfunction: Relevance of ecological validity of neuropsychological tests in multiple sclerosis

In neurological diseases such as multiple sclerosis (MS), a neuropsychological assessment is often requested to assist clinicians in evaluating the role of cognition in a patient's level of everyday functioning. To be effective in this charge, it is assumed that performance on neuropsychological tests is related to how a person may function in everyday life, and the question is often asked: "Are neuropsychological tests ecologically valid?" In this review, we synthesize the literature that examines the use of neuropsychological tests to assess functioning across a variety of everyday functioning domains in MS (i.e. driving, employment, instrumental activities of daily living (IADLs)). However, we critically examine the usefulness of asking this broad question regarding ecological validity, given the psychometric and conceptual pitfalls it may yield. While many neuropsychological tests may be generally considered "ecologically valid" in MS, it is much more helpful to specify for whom, under what circumstances, and to what degree.

Reliability and validity of on-road driving tests in vulnerable adults: a systematic review

The on-road driving test is considered a ‘gold standard’ evaluation; however, its validity and reliability have not been sufficiently reviewed. This systematic review aimed to map out and synthesize literature regarding on-road driving tests using the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. Cochrane Library, PubMed, CINAHL, and Web of Science databases were searched from initiation through February 2018. All articles addressing reliability or validity of on-road driving tests involving adult rehabilitation patients were included. The search output identified 513 studies and 36 articles, which were included in the review. The Washington University Road Test/Rhode Island Road Test, performance analysis of driving ability, test ride for investigating practical fitness-to-drive, and K-score demonstrated high reliability and validity in regard to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. The Washington University Road Test/Rhode Island Road Test and test ride for investigating practical fitness-to-drive were analyzed based on Classical Test Theory techniques, and performance analysis of driving ability and K-score were analyzed based on Item Response Theory techniques. The frequency of studies were Washington University Road Test/Rhode Island Road Test (n=9), Test Ride for Investigating Practical fitness-to-drive (n=8), performance analysis of driving ability (n=4), and K-score (n=1). From the viewpoint of accuracy and generalization, the Washington University Road Test/Rhode Island Road Test, test ride for investigating practical fitness-to-drive, and performance analysis of driving ability were identified as highly qualified concerning on-road driving tests. However, the ability to assess real-world driving depends on various environmental conditions.

Cognitive performance and cognitive workload in multiple sclerosis: Two different constructs of cognitive functioning?

BACKGROUND

Cognitive impairment in individuals with Multiple Sclerosis (iwMS) is traditionally diagnosed using performance measures on cognitive tests. Yet, performance on cognitive tests does not convey the amount of mental effort or cognitive workload it takes to complete the task. The main aim was to evaluate whether cognitive performance and cognitive workload are two different constructs of cognitive functioning in iwMS.

METHODS

IwMS were categorized into cognitive impairments (iwMS+, n = 10) and no cognitive impairments (iwMS-, n = 12) using their performance on Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Their scores on BICAMS, Stroop, and trail making tests were compared to age- and education-matched controls (n = 22). Cognitive workload was assessed using the self-reported NASA Task Load Index and the Index of Cognitive Activity, derived from pupillary response.

RESULTS

IwMS+ performed worse on most cognitive tests compared to iwMS- and controls. However, iwMS+ did not report or exhibit greater cognitive workload compared to the other groups. Potential confounding variables, such as sex, use of antidepressants, and symptoms of depression, fatigue, and dysautonomia did not influence the lack of correlation between cognitive performance and cognitive workload in all three groups.

CONCLUSION

Cognitive performance and cognitive workload seem to measure different cognitive constructs of cognitive functioning in MS. Our results suggest that iwMS+ do not show effective allocation of cognitive resources to compensate for deteriorated performance in cognitive tests.

Independent outdoor mobility of persons with multiple sclerosis - A systematic review

BACKGROUND

Multiple sclerosis (MS) can manifest itself in many ways, all of which can affect the independent outdoor mobility of persons with MS (pwMS). In most studies, mobility of pwMS is defined by the ability to walk. However, mobility comprises more than walking alone. This systematic review provides an overview of the literature on several types of independent outdoor mobility of pwMS. We aimed to identify which specific factors may influence outdoor mobility and how the lives of pwMS may be affected by a reduced mobility.

METHODS

A systematic literature search was performed, using three databases (PubMed, PsychInfo and Web of Science). Studies had to describe a group of pwMS sclerosis and had to concern some type of mobility other than walking.

RESULTS

The 57 studies that fulfilled the criteria included in total 10,394 pwMS and in addition, 95,300 pwMS in separate prevalence study. These studies showed that pwMS as a group have a decreased fitness to drive, make use of a wheelchair or mobility scooter more often and have difficulties making use of public transport. Mobility problems especially occur in patients with cognitive problems, secondary progressive MS or high disability scores.

CONCLUSIONS

The reduced mobility may prevent pwMS participating in society. However, few studies investigating interventions or rehabilitation options to improve mobility were found in the existing literature, highlighting an until now under recognised unmet need.

Clinical Determinants of Fitness to Drive in Persons With Multiple Sclerosis: Systematic Review

OBJECTIVE

To critically appraise the evidence for the clinical determinants of fitness to drive in adults with multiple sclerosis (MS).

DATA SOURCES

The research librarian and lead author searched 7 databases for driving simulator and on-road studies for adults with MS published in the English language from 1991 to 2018.

STUDY SELECTION

Three reviewers independently screened titles, abstracts, and full-texts for studies with: cohort, case-control, or cross-sectional designs; participants, 18 years or older, with relapsing or progressive MS; visual, cognitive, or motor clinical assessments as predictors; and driving performance through simulator or fitness to drive through on-road assessment as outcomes.

DATA EXTRACTION

Using the 2017 American Academy of Neurology guidelines, reviewers independently classified each study from class I to class IV, or highest to lowest amount of rigor. For each clinical assessment, reviewers independently rated the level of confidence for predicting driving performance or fitness to drive from level A, highly probable; B, probable; C, possible; to level U, insufficient conclusions.

DATA SYNTHESIS

Through qualitative synthesis, 2 class III and 4 class IV driving simulator studies employed 24 clinical assessments with level C (n=4) or level U (n=20) confidence for predicting driving performance. Six class II and 3 class IV on-road studies employed 35 clinical assessments with level B (n=9), level C (n=22), or level U (n=4) confidence for predicting fitness to drive.

CONCLUSIONS

This systematic review identified mostly insufficient conclusions for predicting driving performance in driving simulator studies, and possible conclusions for predicting fitness to drive in on-road studies. The best available evidence suggests that the Stroke Driver Screening Assessment and Useful Field of View test probably predict fitness to drive in adults with MS (level B). Class I studies that compare predictors of fitness to drive with large prospective samples of adults with and without MS are necessary for highly probable conclusions.

Validation of a short cognitive battery to screen for fitness-to-drive of people with multiple sclerosis

BACKGROUND AND PURPOSE

Some symptoms of multiple sclerosis (MS) affect driving. In a recent study, performance on five cognitive tests predicted the on-road test performance of individuals with relapsing-remitting MS with 91% accuracy, 70% sensitivity and 97% specificity. However, the accuracy with which the battery will predict the driving performance of a different cohort that includes all types of MS is unknown.

METHODS

Participants (n = 118; 48 ± 9 years of age; 97 females) performed a comprehensive off-road evaluation that lasted about 3 h and a standardized on-road test that lasted approximately 45 min over a 2-day period within the same week. Performance on the five cognitive tests was used to predict participants' performance on the standardized on-road test.

RESULTS

Performance on the five tests together predicted outcome of the on-road test with 82% accuracy, 42% sensitivity and 90% specificity.

CONCLUSIONS

The accuracy of predicting the on-road performance of a new MS cohort using performance on the battery of five cognitive tests remained very high (82%). The battery, which was administrable in <45 min and cost ~$150, was better at identifying those who actually passed the on-road test (90% specificity). The sensitivity (42%) of the battery indicated that it should not be used as the sole determinant of poor driving-related cognitive skills. A fail performance on the battery should only imply that more comprehensive testing is warranted.