Determinants of driving after stroke

Does aphasia impact on return to driving after stroke? A scoping review

PURPOSE

Stroke can affect driving, an important activity of daily living. Little is known about whether aphasia (language impairment) impacts driving post-stroke. This scoping review explores impacts and perceived impacts of aphasia on driving performance, and the process of returning to driving post-stroke.

MATERIALS AND METHODS

Scoping review using Arksey and O'Malley's framework, reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Bibliographic databases were searched and international clinical practice guidelines were sourced online. Full-text articles were independently assessed by two reviewers. Results were tabulated and summarised using narrative synthesis.

RESULTS

Forty-three literature sources and 17 clinical practice guidelines were identified. Six studies investigated return to driving with aphasia post-stroke; 37 sources from the broader literature contributed to objectives. It remains unclear whether aphasia impacts fitness-to-drive; however, people with aphasia face barriers in returning to driving due to: (1) uncertainty regarding the role of language in driving; (2) poor awareness and knowledge of aphasia, and (3) communication demands in the patient-journey and assessment.

CONCLUSIONS

The current evidence base is limited, inconsistent, and lacking in quality and recency and there is a lack of guidelines to support clinical practice. People with aphasia face barriers in returning to driving; however, it is unclear if aphasia affects fitness-to-drive post-stroke. Implications for rehabilitationPeople with aphasia, their caregivers and clinicians have identified return to driving as a top 10 research priority.We do not know if aphasia affects fitness-to-drive post-stroke, but communication difficulties can make the process of returning to driving more difficult.Speech pathologists have an important role in ensuring that driving is discussed with people with aphasia post-stroke.Speech pathologists should support the multidisciplinary team to understand and meet the communication needs of people with aphasia throughout the driving evaluation process.

Methods to evaluate driving competence for people with acquired brain injury (ABI): A systematic review

Driving is essential for independence, community involvement and quality of life. Driving is the primary transportation method in Saudi Arabia. Despite the high rates of brain injuries and disability in Saudi Arabia, currently there are no guidelines regarding driver assessment and rehabilitation to facilitate people with brain injuries to resume driving. Therefore, this systematic review aimed to understand the assessment methods used internationally to evaluate driving competence for people with acquired brain injuries (ABI). A systematic search of six electronic databases was conducted by two authors and twenty-six studies were identified for review. Four main approaches to driver assessment: clinical assessments such as neuropsychological tests, off-road screening tools, simulator testing, and comprehensive driving assessment were identified. However, our findings revealed a lack of consistency in their use to assess driving competence after ABI. On-road driving performance tests were predominantly used to determine driving competence either independently or in combination with another method in over two-thirds of the reviewed studies. While clinical assessments of cognitive impairments showed some capacity to predict driving performance of people with ABI, they should be used with caution since they cannot replace on-road driving performance tests. Driver assessment should be part of rehabilitation following high prevalence conditions such as ABI. This systematic review offers guidance for Saudi clinicians, as well as policymakers, about providing rehabilitation services for people with ABI, and recommendations for further research and collaborations to improve this much-needed area of practice.

Social Environmental Factors Related to Resuming Driving after Brain Injury: A Multicenter Retrospective Cohort Study

Many patients resume driving after brain injury regardless of their ability to drive safely. Predictors for resuming driving in terms of actual resumption status and environmental factors are unclear. We evaluated the reasons for resuming driving after brain injury and examined whether social environmental factors are useful predictors of resuming driving. This retrospective cohort study was based on a multicenter questionnaire survey at least 18 months after discharge of brain injury patients with rehabilitation. A total of 206 brain injury patients (cerebrovascular disease and traumatic brain injury) were included in the study, which was conducted according to the International Classification of Functioning (ICF) items using log-binominal regression analysis, evaluating social environmental factors as associated factors of resuming driving after brain injury. Social environmental factors, inadequate public transport (risk ratio (RR), 1.38), and no alternative driver (RR, 1.53) were included as significant independent associated factors. We found that models using ICF categories were effective for investigating factors associated with resuming driving in patients after brain injury and significant association between resuming driving and social environmental factors. Therefore, social environmental factors should be considered when predicting driving resumption in patients after brain injury, which may lead to better counseling and environmental adjustment.

Dialysis and driving: an anonymous survey of patients receiving dialysis for end-stage kidney disease

BACKGROUND

Driving is a complex task requiring multiple cognitive domains and the musculoskeletal system. Cognitive dysfunction is associated with driving impairment. Dialysis patients are known to have a high prevalence of cognitive impairment and other comorbidities, and may be at risk of driving impairment. No Australian guidelines address driving safety in dialysis patients.

AIMS

To estimate the proportion of dialysis patients who were driving and those at risk of driving impairment, and to investigate the agreement between objective and subjective markers of risk.

METHODS

This single-centre study involved dialysis patients voluntarily completing two questionnaires relating to risk of driving impairment; the first questionnaire focussed on objective markers, and the second questionnaire focussed on subjective markers. Risk of driving impairment was established using pre-determined criteria, and the agreement between objective and subjective markers was estimated using Cohen kappa.

RESULTS

A total of 44.8% (99/221) of patients participated; 76.8% (76/99) of participants were driving, and 76.3% (58/76) of drivers were at risk of driving impairment. Factors associated with at-risk driving included post dialysis dizziness, leg weakness or numbness, falling asleep while driving and hypoglycaemia. Sixteen patients reported collisions since commencing dialysis. The questionnaires displayed slight agreement (Cohen kappa = 0.20) between objective and subjective markers.

CONCLUSIONS

Dialysis patients are at risk of driving impairment based on self-reported questionnaire responses. Discrepancies between patients' perceptions and objective markers were apparent. Further research into appropriate risk assessments, as well as development of guidelines to aid in determining driving safety in dialysis patients, is needed.

A Driver Training Program Intervention for Student Drivers with Autism Spectrum Disorder: A Multi-site Randomised Controlled Trial

The purpose of this multi-site randomised controlled trial was to evaluate the effectiveness of a Driving Training Program, an intervention designed for student drivers with autism spectrum disorder (ASD). Participants were 72 student drivers with ASD (ages 16-31) who were randomly assigned to an intervention or control group. Student drivers received ten driving lessons with a professional driving instructor via a standardised driving route. The Driving Performance Checklist was used as the outcome measure to evaluate the driving performance of student drivers during on-road pre- and post-observational drives. Both groups showed an improvement in driving performance, however, the extent of improvement between groups was not significant. Findings showed promising intervention efficacy for training student drivers with ASD to drive.

The determinants of motorized mobility scooter driving ability after a stroke

Purpose: To investigate the determinants related to the ability to drive a motorized mobility scooter after a stroke.Method: The study was a cross-sectional study. The ability to drive a motorized mobility scooter was measured with the Power Mobility Clinical Driving Assessment. The independent variables included cognitive functions measured by the Color Trails Test and reaction time test, visual functions measured by a visual acuity test and visual field test, and motor functions measured with a dynamometer, the Box and Block Test, and the Functional Independence Measure.Results: The correlation analyses revealed that the Power Mobility Clinical Driving Assessment scores had significant correlations with reaction time (ρ = -.65, p < 0.01), binocular visual field (r = .64, p < 0.01), binocular visual acuity (r = .40, p = 0.03), and the grip strength of the unaffected hand (r = .47, p = 0.01). The multiple regression analysis indicated that reaction time, binocular visual field, and the grip strength of the unaffected hand were the most significant determinants of the ability to drive a motorized mobility scooter (R² = .76).Conclusions: The reaction time, binocular visual field, and grip strength of the unaffected hand were the most significant determinants related to the ability to drive a motorized mobility scooter after a stroke. IMPLICATIONS FOR REHABILITATIONMotorized mobility scooter driving ability for stroke patients is correlated with demographics (age, mobility scooter driving experience, time since last drive) and cognitive, visual and motor functions (reaction time, binocular visual field, visual acuity, and the grip strength of unaffected hand).Primary determinants of motorized mobility scooter driving ability for stroke patients include reaction time, binocular visual field, and grip strength of the unaffected hand.Comprehensive assessments incorporating cognitive, visual and motor functions are needed to evaluate the ability to drive a motorized mobility scooter after a stroke.

Assessment for resumed driving in stroke patients via Functional Independence Measure1

BACKGROUND

Some stroke survivors hope to resume driving after hospital discharge. For those who had driven frequently before their stroke, a normal daily life depends on being able to drive.

OBJECTIVE

Our objective was to determine whether Functional Independence Measure (FIM) scores predict patient driving ability, which would make them a suitable index for determining if a stroke patient can resume driving.

METHODS

This was a retrospective study of 71 patients who suffered from stroke. We divided them into three groups based on their driving status after discharge: (1) resumed driving (Driver), (2) wish to resume driving (Wisher), and (3) no wish to resume driving (Non-wisher). We compared total FIM scores and subcategories of FIM scores across groups.

RESULTS

Scores on the Motor-FIM and Cognitive-FIM were highest in the Driver group, followed by the Wisher and Non-wisher groups. Moreover, scores on the 'problem solving' and 'memory' subcategories of the Cognitive-FIM were significantly higher in the Driver group than in the Wisher group.

CONCLUSIONS

The FIM could be a useful assessment tool for determining whether or not stroke patients can resume driving. Moreover, among the Cognitive-FIM sub-categories, problem solving and memory ability might be the scores most relevant for this decision.

Behind the wheel safety in palliative care: a literature review

BACKGROUND

Driving is a complex activity that requires physical abilities and adequate executive and cognitive functioning. There is concern among specialist palliative care services about patients continuing to drive despite having progressive incurable illnesses, comorbidities and medications to manage their symptoms.

OBJECTIVES

To determine the quality of literature available about driving that would apply to palliative care patients, specifically in relation to road test or simulated driving scores and neurocognitive testing.

METHOD

A literature search based on systematic principles was conducted on the Ovid Medline, PsycINFO, Embase and CINAHL database up to 14 October 2018. Patient populations with life-limiting illness such as cancer, cardiorespiratory and neurological diagnoses were included.

RESULTS

37,546 articles were screened. 14 articles satisfied the search criteria. Six studies focused on patients with multiple sclerosis (MS). Four studies investigated driving ability in patients with Huntington's disease. The remaining four articles studied heart failure, chronic obstructive pulmonary disease (COPD), interstitial lung disease and patients with cancer. In the road test studies, 19%-47% of patients with MS and Huntington's failed the behind-the-wheel assessment. The simulated driving scores in seven studies demonstrated statistically significant differences in errors made between study participants and controls. Divided attention was found in seven studies to be associated with poorer road-test or simulated driving ability.

CONCLUSIONS

This review highlights the scarcity of studies available for patients who would be known to palliative care services. For most patient groups, a battery of neurocognitive tests combined with a road-test or simulated driving assessment is still considered the best practice in determining driving safety.

Driving and visual deficits in stroke patients

OBJECTIVE

The aim of the present study was to conduct an exploratory assessment of visual impairment following stroke, and to discuss the possibilities of reintroducing patients to the activity of driving.

METHODS

The Useful Field of View test was used to assess visual processing and visual attention.

RESULTS

A total of 18 patients were included in the study, and were assigned to either the drive group (n = 9) or the intention group (n = 9). In the drive group, one patient was categorized as moderate-to-high risk; whereas, in the intention group, one patient was categorized as low-to-moderate risk. Additionally, two patients in the intention group were categorized as high risk. The patients did not perceive their visual deficits as a limitation.

CONCLUSION

Visual attention is an interference factor in terms of the safe performance of driving after a stroke. All patients showed a high level of interest for the independence provided through being able to drive.

Childhood Stroke and Vision: A Review of the Literature

OBJECTIVE

Here we review the current literature regarding visual outcome after perinatal and childhood stroke.

BACKGROUND

Visual deficits following stroke in adults are common and have been previously reviewed. Less is known about visual deficits following stroke in neonates and older children. Most of the literature regarding this subject has focused on preterm infants, or on other types of brain injury. This review summarizes the types of visual deficits seen in term infants following perinatal stroke and children following childhood stroke and predictors of outcome. This review suggests areas for future research.

METHODS

We performed Ovid MEDLINE searches regarding visual testing in children, vision after childhood stroke, neuroplasticity of vision, treatment of visual impairment after stroke, and driving safety concerns after stroke.

RESULTS

Visual field defects were the most commonly reported visual deficits after perinatal and childhood stroke. There is a significant lack of literature on this subject, and most is in the form of case reports and case series. Children can experience significant visual morbidity after stroke, and have the potential to show some recovery, but guidelines on assessment and treatment of this population are lacking.

CONCLUSIONS

There were limitations to this study, given the small amount of literature available. Although stroke in children can result in severe visual deficits, most children regain at least a portion of their vision. However, more research is needed regarding visual assessment of this population, long-term visual outcomes, specific predictors of recovery, and treatment options.

A Case-Control Study Investigating Simulated Driving Errors in Ischemic Stroke and Subarachnoid Hemorrhage

Background

Stroke can affect a variety of cognitive, perceptual, and motor abilities that are important for safe driving. Results of studies assessing post-stroke driving ability are quite variable in the areas and degree of driving impairment among patients. This highlights the need to consider clinical characteristics, including stroke subtype, when assessing driving performance.

Methods

We compared the simulated driving performance of 30 chronic stroke patients (>3 months), including 15 patients with ischemic stroke (IS) and 15 patients with subarachnoid hemorrhage (SAH), and 20 age-matched controls. A preliminary analysis was performed, subdividing IS patients into right (n = 8) and left (n = 6) hemispheric lesions and SAH patients into middle cerebral artery (MCA, n = 5) and anterior communicating artery (n = 6) territory. A secondary analysis was conducted to investigate the cognitive correlates of driving.

Results

Nine patients (30%) exhibited impaired simulated driving performance, including four patients with IS (26.7%) and five patients with SAH (33.3%). Both patients with IS (2.3 vs. 0.3, U = 76, p < 0.05) and SAH (1.5 vs. 0.3, U = 45, p < 0.001) exhibited difficulty with lane maintenance (% distance out of lane) compared to controls. In addition, patients with IS exhibited difficulty with speed maintenance (% distance over speed limit; 8.9 vs. 4.1, U = 81, p < 0.05), whereas SAH patients exhibited difficulty with turning performance (total turning errors; 5.4 vs. 1.6, U = 39.5, p < 0.001). The Trail Making Test (TMT) and Useful Field of View test were significantly associated with lane maintenance among patients with IS (r_s > 0.6, p < 0.05). No cognitive tests showed utility among patients with SAH.

Conclusion

Both IS and SAH exhibited difficulty with lane maintenance. Patients with IS additionally exhibited difficulty with speed maintenance, whereas SAH patients exhibited difficulty with turning performance. Current results support the importance of differentiating between stroke subtypes and considering other important clinical characteristics (e.g., side of lesion, vascular territory) when assessing driving performance and reinforce the importance of physicians discussing driving safety with patients after stroke.

Prediction of Driving after Stroke: A Prospective Study

The process of determining whether patients with stroke should drive again often involves off-road evaluations and road tests that usually take about 2 to 3 h to complete. Objectives. This prospective study sought to identify the combination of tests that best predicts fitness to drive after stroke. The main aim was to develop a short and predictive predriving assessment battery. Methods. Sixty-eight consecutive stroke patients were studied who performed a mandatory predriving assessment at the Belgian Road Safety Institute, Brussels, within 18 months. Performance in a predriving assessment included medical examination (when needed), visual and neuropsychological evaluations, and an on-road test. Based on these assessments, a physician, psychologist, and the driving safety expert who administered the tests decided if a subject was either “fit to drive,”“temporarily unfit to drive,” or “unfit to drive.” Results. Logistic regression analysis revealed a combination of visual neglect, figure of Rey, and on-road tests as the model that best predicted ( R2 = 0.73) fitness to drive after stroke. Using a discriminant function that included the 3 tests of the logistic model, the fitness to drive judgments of 59 (86.8%) subjects were correctly predicted. The sensitivity and specificity of the predictions were 79.4% and 94.1%, respectively. Conclusion. Fitness to drive after stroke can be predicted from performance on a few road-related tests with a high degree of accuracy. However, some individuals require extended assessments and further tests.

Validity and reliability of the safe driving behavior measure in community-dwelling self-drivers with stroke

[Purpose] Driving is a vital component of recovery for stroke survivors facilitating restoration of their family roles and reintegration back into their communities and associations. The purpose of this study was to evaluate the validity and reliability of the Safe Driving Behavior Measure (SDBM) in community-dwelling self-drivers post-stroke. [Subjects and Methods] Participants were sixty-seven community-dwelling self-drivers who had received a diagnosis of first stroke in the past twelve months. To investigate the validity and reliability of the SDBM, this study evaluated two sessions, held three days apart in a quiet and well-organized assessment room. Cronbach’s alpha and the Intraclass Correlation Coefficient [ICC (2.1)] were used to evaluate statistically concurrent validity and reliability of the overall and three domain scores. Pearson’s correlations were used to quantify the bivariate associations among the three domains. [Results] The Cronbach’s alpha coefficients for the three domains of person-vehicle (0.989), person-environment (0.997), and person-vehicle-environment (0.968) of the SDBM indicated high internal consistency in community-dwelling self-drivers with stroke, in addition to excellent rest-retest reliability. [Conclusion] The results of this study suggest that the SDBM could be a reliable measure to evaluate automobile driving in community-dwelling self-drivers with stroke.

Functional Changes and Driving Performance in Older Drivers: Assessment and Interventions

With the increasing aging of the population, the number of older drivers is rising. Driving is a significant factor for quality of life and independence concerning social and working life. On the other hand, driving is a complex task involving visual, motor, and cognitive skills that experience age-related changes even in healthy aging. In this review we summarize different age-related functional changes with relevance for driving concerning sensory, motor, and cognitive functions. Since these functions have great interindividual variability, it is necessary to apply methods that help to identify older drivers with impaired driving abilities in order to take appropriate measures. We discuss three different methods to assess driving ability, namely the assessment of (i) functions relevant for driving; (ii) driving behavior in real traffic; and (iii) behavior in a driving simulator. We present different measures to improve mobility in older drivers, including information campaigns, design of traffic and car environment, instructions, functional training, and driving training in real traffic and in a driving simulator. Finally, we give some recommendations for assessing and improving the driving abilities of older drivers with multi-modal approaches being most promising for enhancing individual and public safety.

Assessment tools predicting fitness to drive in older adults: a systematic review

This systematic review synthesizes the research on screening and assessment tools used to determine older adults' fitness to drive. After a comprehensive search of the literature targeting tools commonly used by occupational therapists, 64 studies were reviewed and synthesized. The evidence demonstrated that a single tool measuring cognition, vision, perception, or physical ability individually is not sufficient to determine fitness to drive. Although some tools have stronger evidence than others, this review supports using different and focused assessment tools together for specific medical conditions. Results indicate that behind-the-wheel assessment remains the gold standard for driving evaluation; however, emerging evidence for observation of complex instrumental tasks of daily living and driving simulation supports further investigation with these tools.

P-Drive: Implementing an Assessment of On-Road Driving in Clinical Settings and Investigating Its Internal and Predictive Validity

We investigated (1) the psychometric properties of data gathered with the Performance Analysis of Driving Ability (P-Drive), an on-road assessment; (2) P-Drive's predictive validity in relation to a summed decision of passing or failing a medical driving evaluation; and (3) the success of implementing P-Drive. Drivers (N=99) with neurological impairment referred for a driving evaluation were observed on road and scored using P-Drive. Results showed evidence of person response validity and internal validity. P-Drive separated the drivers into four different strata (reliability coefficient=.92). A cutoff raw score of 81 was optimal, with sensitivity of 93% and specificity of 92%. Although only 9 occupational therapists (of 19 initially trained) contributed data for analysis, 17 reported using the assessment. Data gathered with P-Drive yielded evidence of excellent psychometric properties. Moreover, P-Drive was implemented successfully in clinical settings, although initial training to full implementation took longer than 1 yr.

Screening and assessment tools for determining fitness to drive: a review of the literature for the pathways project

With a brief introduction, 10 tables summarize the findings from the literature describing screening and assessment tools used with older adults to identify risk or determine fitness to drive. With a focus on occupational therapy's duty to address driving as a valued activity, this paper offers information about tools used by occupational therapy practitioners across practice settings and specialists in driver rehabilitation. The tables are organized into groups of key research studies of assessment tools, screening batteries, tools used in combination (i.e., as a battery), driving simulation as an assessment tool, and screening/assessment for individuals with stroke, vision impairment, Parkinson's disease, dementia, and aging. Each table has a summary of important concepts to consider as occupational therapists choose the methods and tools to evaluate fitness to drive.

Transport, driving and ageing

Transport is the invisible glue that holds our lives together, an under-recognized contributor to economic, social and personal well-being. In public health terms, the medical profession had previously allowed itself to focus almost exclusively on the downsides of transport. However, the research basis for transport, driving and ageing is steadily evolving and has important academic and practical considerations for gerontologists and geriatricians. For gerontologists, teasing out the critical role of transport in the health and well-being of older people is an imperative, as well as the key challenges inherent in transitioning from driving to not driving. The safe crash record of a group with significant multi-morbidity allows us to focus on the remarkable strategic and adaptive skills of older people. From a policy perspective, strictures on older drivers are an exemplar of institutionalized ageism. For geriatricians, a key challenge is to develop strategies for including transportation in our clinical assessments, formulating effective strategies for assessment of medical fitness to drive, incorporating enabling techniques, giving due consideration to ethical and legal aspects, and developing and promoting multi-modality and alternative transportation options.

Factors Influencing the Clinical Stratification of Suitability to Drive after Stroke: A Qualitative Study

While a clinical pre-selection screening process for a stroke patient's suitability for driving has been acknowledged, little is known about the factors or processes influencing this screening typically conducted by clinicians practicing at a generalist level. This study explored this clinical stratification process through the use of semi-structured interviews with senior occupational therapists (n = 17) and stroke physicians (n = 7) using qualitative description methodology. The findings revealed a trichotomy stratification of stroke patients for driving in the clinical setting; those who are fit to drive, unfit to drive, and a "maybe" group who need more detailed assessment and observation. Factors that had a major influence on this clinical-based stratification of driving suitability were client's levels of awareness, insight, and impulsivity. A period of prolonged contact with the client was preferential to guide the stratification decision in order for clinicians to build a comprehensive picture of the person. A mix of assessment approaches including standardized assessment but with increased emphasis on naturalistic observation of functional performance underpinned the clinical stratification process. This study uncovers some of the factors and processes influencing the early clinical-based stratification of driving suitability after stroke, and highlights the contribution of the generalist practitioner in the assessment of fitness to drive continuum.

Predictors of Driving Ability Following Stroke: A Systematic Review

BACKGROUND AND PURPOSE

The objective of this review is to identify the most consistent predictors of driving ability post stroke.

METHOD

A computerized search of numerous databases from 1966 forward was completed. Measured outcomes included voluntary driving cessation or results of on-road driving evaluation. Studies were evaluated using the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

17 eligible studies were identified. The most useful screening tests were tests assessing cognitive abilities. These included the Trail Making A and B tests, the Rey-Osterreith Complex Figure Design, and the Useful Field of View Test.

CONCLUSION

Cognitive tests that assess multiple cognitive domains relevant to driving appear to have the best reproducibility in predicting fitness to drive in stroke patients.

Rehabilitation for improving automobile driving after stroke

BACKGROUND

Interventions to improve driving ability after stroke, including driving simulation and retraining visual skills, have limited evaluation of their effectiveness to guide policy and practice.

OBJECTIVES

To determine whether any intervention, with the specific aim of maximising driving skills, improves the driving performance of people after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials register (August 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 3), MEDLINE (1950 to October 2013), EMBASE (1980 to October 2013), and six additional databases. To identify further published, unpublished and ongoing trials, we handsearched relevant journals and conference proceedings, searched trials and research registers, checked reference lists and contacted key researchers in the area.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-randomised trials and cluster studies of rehabilitation interventions, with the specific aim of maximising driving skills or with an outcome of assessing driving skills in adults after stroke. The primary outcome of interest was the performance in an on-road assessment after training. SECONDARY OUTCOMES included assessments of vision, cognition and driving behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted the data and assessed risk of bias. A third review author moderated disagreements as required. The review authors contacted all investigators to obtain missing information.

MAIN RESULTS

We included four trials involving 245 participants in the review. Study sample sizes were generally small, and interventions, controls and outcome measures varied, and thus it was inappropriate to pool studies. Included studies were at a low risk of bias for the majority of domains, with a high/unclear risk of bias identified in the areas of: performance (participants not blinded to allocation), and attrition (incomplete outcome data due to withdrawal) bias. Intervention approaches included the contextual approach of driving simulation and underlying skill development approach, including the retraining of speed of visual processing and visual motor skills. The studies were conducted with people who were relatively young and the timing after stroke was varied.

PRIMARY OUTCOME

there was no clear evidence of improved on-road scores immediately after training in any of the four studies, or at six months (mean difference 15 points on the Test Ride for Investigating Practical Fitness to Drive - Belgian version, 95% confidence intervals (CI) 4.56 to 34.56, P value = 0.15, one study, 83 participants).

SECONDARY OUTCOMES

road sign recognition was better in people who underwent training compared with control (mean difference 1.69 points on the Road Sign Recognition Task of the Stroke Driver Screening Assessment, 95% CI 0.51 to 2.87, P value = 0.007, one study, 73 participants). Significant findings were in favour of a simulator-based driving rehabilitation programme (based on one study with 73 participants) but these results should be interpreted with caution as they were based on a single study. Adverse effects were not reported. There was insufficient evidence to draw conclusions on the effects on vision, other measures of cognition, motor and functional activities, and driving behaviour with the intervention.

AUTHORS' CONCLUSIONS

There was insufficient evidence to reach conclusions about the use of rehabilitation to improve on-road driving skills after stroke. We found limited evidence that the use of a driving simulator may be beneficial in improving visuocognitive abilities, such as road sign recognition that are related to driving. Moreover, we were unable to find any RCTs that evaluated on-road driving lessons as an intervention. At present, it is unclear which impairments that influence driving ability after stroke are amenable to rehabilitation, and whether the contextual or remedial approaches, or a combination of both, are more efficacious.

Comparison of foot pedal reaction time among patients with right or left hemiplegia and able-bodied controls

BACKGROUND

Although inpatient stroke rehabilitation provides clinicians with the opportunity to prepare patients for continuation of prestroke activities, little is known about the patients' ability to safely resume driving at the point of discharge to the community.

OBJECTIVE

To compare foot pedal response times of 20 stroke patients with right hemiplegia (RH) or left hemiplegia (LH) and 10 controls.

METHODS

A cross-sectional design was used. Response times were measured using 3 foot pedal operation techniques: (1) right-sided accelerator with right leg operating accelerator and brake, (2) right-sided accelerator with left leg operating accelerator and brake, and (3) left-sided accelerator with left leg operating accelerator and brake. Outcomes included reaction time (RT), movement time (MT), and total response time (TRT).

RESULTS

Controls demonstrated faster RT than patients with RH (263 vs 348 ms; P < .001) or LH (316 ms; P < .05) for all conditions, as well as faster MT than patients with RH (P < .05 for all) but not LH when using the right leg (258 vs 251 ms; P = .82). Controls demonstrated faster TRT than patients with RH (P < .001 for all) but not LH when using the right leg (515 vs 553 ms; P = .44).

CONCLUSIONS

When using the nonparetic leg, patients with LH had braking response times comparable to controls, but patients with RH demonstrated significant impairment of both the paretic and nonparetic legs.

Car driving in schizophrenia: can visual memory and organization make a difference?

PURPOSE

Driving is a meaningful occupation which is ascribed to functional independence in schizophrenia. Although it is estimated that individuals with schizophrenia have two times more traffic accidents, little research has been done in this field. Present research explores differences in mental status, visual working memory and visual organization between drivers and non-drivers with schizophrenia in comparison to healthy drivers.

METHODS

There were three groups in the study: 20 drivers with schizophrenia, 20 non-driving individuals with schizophrenia and 20 drivers without schizophrenia (DWS). Visual perception was measured with Rey-Osterrieth Complex Figure test and a general cognitive status with Mini-Mental State Examination.

RESULTS

The general cognitive status predicted actual driving situation in people with schizophrenia. No statistically significant differences were found between driving and non-driving persons with schizophrenia on any of the visual parameters tested, although these abilities were significantly lower than those of DWS.

CONCLUSION

The research demonstrates that impairment of visual abilities does not prevent people with schizophrenia from driving and emphasizes the importance of general cognitive status for complex and multidimensional everyday tasks. The findings support the need for further investigation in the field of car driving for this population - a move that will considerably contribute to the participation and well-being. Implication for Rehabilitation Unique approach for driving evaluation in schizophrenia should be designed since direct applications of knowledge and practice acquired from other populations are not reliable. This research demonstrates that visual perception deficits in schizophrenia do not prevent clients from driving, and general cognitive status appeared to be a valid determinant for actual driving. We recommended usage of a general test of cognition such as Mini-Mental State Examination, or conjunction number of cognitive factors such as executive functions (e.g., Trail Making Test) and attention (e.g., Continuous Performance Test) in addition to spatial-visual ability tests (e.g., Rey-Osterrieth Complex Figure test) for considering driving status in schizophrenia.

Predictors of Poststroke Driving or Riding in Indian Stroke Patients (POINT Study)

Background

There is no information regarding the proportion of stroke patients who drive or ride after a stroke from developing countries.

Aim

We aimed to study the predictors of poststroke driving or riding and its impact on social life in Indian patients. Methods This study was done in the stroke and neurology clinics of Christian Medical College, Ludhiana, from May 1, 2008 to May 31, 2010. Patients were recruited if they had completed ≥1-year follow-up. Subjects were interviewed using a structured questionnaire. Stroke outcome was assessed by using the modified Rankin scale. Outcome was classified as good (modified Rankin scale ≤2) and poor (modified Rankin scale >2).

Results

Two hundred and one patients were interviewed. Mean age was 58·0 ± 13·4 years (median 59 years, range 17–85 years), 139 (69·2%) were men. The mean duration of follow-up was 37·4 ± 29·2 months (range 19–210 months). Out of 201 patients, 132 (65·7%) drove or rode before stroke and among them only 54 (40·9%) returned to driving or riding after stroke [men 53 (98·1%)]. Among the 78 who did not return to driving or riding, 51 (65·4%) had an impact on social life. In the multivariate logistic regression analysis, the predictors of inability to drive were lower education (odds ratio 0·32, confidence interval 0·12–0·89, P = 0·03), unemployment (odds ratio 4·59, confidence interval 1·67–12·6, P = 0·003), and poor outcome (odds ratio 3·97, confidence interval 1·06–14·8, P = 0·04).

Conclusions

Only 40·9% of the patients returned to driving or riding. Lower education, unemployment, and poor recovery were the predictors of inability to drive or ride. Inability to drive had a major impact in their social life.

Driving ability in stroke patients with residual visual inattention: a case study

Driving ability of three patients having a right hemisphere infarct and residual visual inattention was examined. The neuropsychological examination included the Peripheral Perception Test and the Signal Detection Test from the Vienna Test System, and the Behavioural Inattention Test (BIT). Driving ability was assessed with an on-road evaluation. The patients had no neglect based on the BIT and had normal visual fields, but they showed slightly poorer visual search on the left side. All patients passed the official on-road driving test and were considered capable of driving. This study raises the question if acute neglect can recover to a degree in which driving may be possible.

Assessing executive function in relation to fitness to drive: a review of tools and their ability to predict safe driving

BACKGROUND/AIM

The assessment of executive functions is an integral component in determining fitness to drive. A structured review was conducted to identify assessment tools used to measure executive function in relation to driving and to describe these tools according to: (i) specific executive function components assessed; (ii) the tool's validity in predicting safe driving; and (iii) clinical utility.

METHODS

Sixty-nine articles were reviewed, identifying 53 executive function tools/assessments used in driving research. Each tool was critically appraised and the findings were compiled in a Driving Executive Function Tool Guide.

RESULTS

Among the 53 tools, there were 27 general assessments of cognition, 19 driving-specific and seven activities of daily living/instrumental activities of daily living assessments. No single tool measured all executive function components: working memory was the most common (n = 20/53). Several tools demonstrated strong predictive validity and clinical utility. For example, tools, such as the Trail Making Test and the Maze Task, have the shortest administration time (i.e. often less than 10 minutes) and the most easily accessible method of administration (i.e. pen and paper or verbal). Driving-specific tools range from short questionnaires, such as the 10-minute Manchester Driving Behaviour Questionnaire, to more complex tools requiring about 45 minutes to administer. CONCLUSIONS AND SIGNIFICANCE OF THE STUDY: The appropriateness of a tool depends on the individual being assessed and on practical constraints of the clinical context. The Driving Executive Function Tool Guide provides useful information that should facilitate decision-making and selection of appropriate executive function tools in relation to driving.

Older drivers: On-road and off-road test results

Eighty-five volunteer drivers, 65-85 years old, without cognitive impairments impacting on their driving were examined, in order to investigate driving errors characteristic for older drivers. In addition, any relationships between cognitive off-road and on-road tests results, the latter being the gold standard, were identified. Performance measurements included Trail Making Test (TMT), Nordic Stroke Driver Screening Assessment (NorSDSA), Useful Field of View (UFOV), self-rating driving performance and the two on-road protocols P-Drive and ROA. Some of the older drivers displayed questionable driving behaviour. In total, 21% of the participants failed the on-road assessment. Some of the specific errors were more serious than others. The most common driving errors embraced speed; exceeding the speed limit or not controlling the speed. Correlations with the P-Drive protocol were established for NorSDSA total score (weak), UFOV subtest 2 (weak), and UFOV subtest 3 (moderate). Correlations with the ROA protocol were established for UFOV subtest 2 (weak) and UFOV subtest 3 (weak). P-Drive and self ratings correlated weakly, whereas no correlation between self ratings and the ROA protocol was found. The results suggest that specific problems or errors seen in an older person's driving can actually be "normal driving behaviours".

Retraining moderately impaired stroke survivors in driving-related visual attention skills

BACKGROUND

Visual inattention is a major cause of road accidents and is a problem commonly experienced after stroke.

PURPOSE

This study investigated the effects of 2 training programs on performance in the Useful Field of View (UFOV), a validated test of driving-related visual attention skills.

METHOD

Data from 69 first-ever, moderately impaired stroke survivors who participated in a randomized controlled trial (RCT) to determine the effects of simulator training on driving after stroke were analyzed. In addition to regular interventions at a rehabilitation center, participants received 15 hours of either simulator-based driving-related training or non-computer-based cognitive training over 5 weeks.

RESULTS

Total percentage reduction in UFOV and performance in divided and selective attention and speed of processing subtests were documented at 6 to 9 weeks (pretraining), 11 to 15 weeks (posttraining), and 6 months post stroke (follow-up). Generalized estimating equation (GEE) model revealed neither group effects nor significant interaction effects of group with time in the UFOV total score and the 3 subtests. However, there were significant within-group improvements from pre- through posttraining to follow-up for all the UFOV parameters. Post-hoc GEE analysis revealed that most improvement in both groups occurred from pre- to posttraining.

CONCLUSION

Both training programs significantly improved visual attention skills of moderately impaired stroke survivors after 15 hours of training and retention of benefit lasted up to 6 months after stroke. Neither of the training programs was better than the other.

Occupational therapy practice in predriving assessment post stroke in the Irish context: findings from a nominal group technique meeting

PURPOSE

Practice in the area of predriving assessment for people with stroke varies, and research findings are not always easily transferred into the clinical setting, particularly when such assessment is not conducted within a dedicated driver assessment programme. This article explores the clinical predriving assessment practices and recommendations of a group of Irish occupational therapists for people with stroke.

METHOD

A consensus meeting of occupational therapists was facilitated using a nominal group technique (NGT) to identify specific components of cognition, perception, and executive function that may influence fitness to return to driving and should be assessed prior to referral for on-road evaluation. Standardised assessments for use in predriving assessment were recommended.

RESULTS

Thirteen occupational therapists speed of processing; perceptual components of spatial awareness, depth perception, and visual inattention; and executive components of planning, problem solving, judgment, and self-awareness. Consensus emerged for the use of the following standardised tests: Behavioural Assessment of Dysexecutive Syndrome (BADS), Test of Everyday Attention (TEA), Brain Injury Visual Assessment Battery for Adults (biVABA), Rivermead Perceptual Assessment Battery (RPAB), and Motor Free Visual Perceptual Test (MVPT).

CONCLUSION

Tests were recommended that gave an indication of the patient's underlying component skills in the area of cognition, perception, and executive functions considered important for driving. Further research is needed in this area to develop clinical practice guidelines for occupational therapists for the assessment of fitness to return to driving after stroke.

Establishing criterion validity of the Useful Field of View assessment and Stroke Drivers' Screening Assessment: comparison to the result of on-road assessment

OBJECTIVES

We sought to determine the criterion validity of the Useful Field of View (UFOV) assessment and Stroke Drivers' Screening Assessment (SDSA) through comparison to the results of on-road assessment.

METHOD

This was a prospective study with people with stroke. Outcome measures used were UFOV, SDSA, and the results of on-road assessment.

RESULTS

Both the results on UFOV (Divided Attention subtest, p<.01; Selective Attention subtest, p<.05) and SDSA (p<.05) were significantly related to the recommendation from on-road assessment. The Divided Attention subtest of the UFOV had the highest sensitivity value (88.9%).

CONCLUSIONS

UFOV and SDSA are valid assessments of driving ability for stroke. The Divided Attention subtest of the UFOV can guide decision making of occupational therapists in stroke driver rehabilitation and in determining those who require further assessment on road because they pose a safety risk. Screening assists people with stroke to decide whether they are ready to have an on-road assessment.

Australian Occupational Therapy Driver Assessors’ Opinions on Improving On-Road Driver Assessment Procedures

OBJECTIVE. We collected practitioner opinions to improve the validity and reliability of the on-road driver assessment procedures used in Australia.

METHOD. We used focus groups to document the views of experienced occupational therapy driver assessors using a purposive sampling method.

RESULTS. Eight focus groups were conducted with 55 clinicians practicing in urban and rural regions. There was strong support for greater standardization of procedures for all tests. For drivers seeking unrestricted (open) licenses, use of standard routes with predetermined assessment points was important where practicable. Where use of a nonstandard route for this purpose was unavoidable, it was important to specify a minimum set of requirements related to route characteristics and assessment items.

CONCLUSION. Australian occupational therapy driver assessors support greater standardization of test routes and procedures to improve reliability and validity. However, the extent to which standardization can be achieved is limited by variable road traffic environments where assessments are conducted.

Occupational Therapists’ Capacity-Building Needs Related to Older Driver Screening, Assessment, and Intervention: A Canadawide Survey

BACKGROUND. Older driver safety is a growing concern. We identified capacity-building needs of occupational therapists related to older driver screening, assessment, and intervention.

METHOD. A Canadawide survey was undertaken involving 133 occupational therapists working with an older clientele. A standardized questionnaire elicited information regarding (1) actual practices related to older driver screening, assessment, and intervention; (2) perceived competence; and (3) need for continuing education.

RESULTS. Occupational therapists were twice as likely to use screening tools rather than in-depth assessments (n = 79 vs. n = 37). Only 25 occupational therapists offered on-road assessment, and even fewer offered retraining (n = 11). Occupational therapists more often felt very competent in domains related to screening as opposed to assessment, and most were interested in continuing education.

CONCLUSION. Driving services offered were primarily related to screening compared with assessment or intervention. Occupational therapists would benefit from driving-related professional training aimed at enhancing professional capacity in this arena.

Return to driving after traumatic brain injury: a British perspective

PRIMARY OBJECTIVE

To identify the current legal situation and professional practice in assisting persons with traumatic brain injury (TBI) to return to safe driving after injury.

METHODS AND PROCEDURES

A brief review of relevant literature, a description of the current statutory and quasi-statutory authorities regulating return to driving after TBI in the UK and a description of the nature and resolution of clinical and practical dilemmas facing professionals helping return to safe driving after TBI. Each of the 15 UK mobility centres was contacted and literature requested; in addition a representative of each centre responded to a structured telephone survey.

MAIN OUTCOME AND RESULTS

The current situation in the UK is described, with a brief analysis of the strengths and weaknesses both of the current statutory situation, and also the practical situation (driving centres), with suggestions for improvements in practice.

CONCLUSION

Although brain injury may cause serious limitations in driving ability, previous drivers are not routinely assessed or advised regarding return to driving after TBI.