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

Peripheral visual field loss and activities of daily living

PURPOSE OF REVIEW

Peripheral visual field (VF) loss affects 13% of the population over 65. Its effect on activities of daily living and higher order visual processing is as important as it is inadequately understood. The purpose of this review is to summarize available literature on the impact of peripheral vision loss on driving, reading, face recognition, scene recognition and scene navigation.

RECENT FINDINGS

In this review, glaucoma and retrochiasmal cortical damage are utilized as examples of peripheral field loss which typically spare central vision and have patterns respecting the horizontal and vertical meridians, respectively. In both glaucoma and retrochiasmal damage, peripheral field loss causes driving difficulty - especially with lane maintenance - leading to driving cessation, loss of independence, and depression. Likewise, peripheral field loss can lead to slower reading speeds and decreased enjoyment from reading, and anxiety. In glaucoma and retrochiasmal field loss, face processing is impaired which impacts social functioning. Finally, scene recognition and navigation are also adversely affected, impacting wayfinding and hazard detection leading to decreased independence as well as more frequent injury.

SUMMARY

Peripheral VF loss is an under-recognized cause of patient distress and disability. All peripheral field loss is not the same, differential patterns of loss affect parameters of activities of daily living (ADL) and visual processing in particular ways. Future research should aim to further characterize patterns of deranged ADL and visual processing, their correlation with types of field loss, and associated mechanisms.

Eye movement in reading and linguistic processing among bilingualism in oculomotor apraxia in patients with aphasia

The present study compared linguistic processes and eye movement among individuals diagnosed with oculomotor apraxia (OMA) and the influence of bilingualism on OMA. Four patients consisting of one male and three females were diagnosed with OMA, and a group of four healthy individuals, comprising two males and two females who were all right-hand dominant. Also, a group of four stroke patients without ocular apraxia. Findings show that pointing skills in both the first (L1) and second language (L2) have increased, demonstrating statistical significance ( P-value < .001 and P-value = .02, respectively). Also, simple commands over time have increased in L1 and L2, showing statistical significance ( P-value < .01 and P-value < .01, respectively). Naming skills in L1 have increased over time, demonstrating statistical insignificance ( P-value < .01). However, in L2, no statistically significant change was observed ( P-value = .08). This skill in L1 in patients with OMA was significantly reduced compared to the healthy control group ( P-value = .03). Still, patients with OMA showed no statistically significant difference from their healthy counterparts ( P-value = .15). The orthographic ability of patients in L1 during the study period did not statistically change significantly ( P-value = .11). This skill level in L1 between patients with OMA and the healthy control group did not show a statistically significant difference ( P-value = .06). Still, there was a statistically significant change in the healthy control group in L2 ( P-value < .01). These findings suggest that the bilingual does not reflect a general executive in attentional guidance but could reflect more efficient guidance only under specific tasks.

Development of a Web-Based Mini-Driving Scene Screening Test (MDSST) for Clinical Practice in Driving Rehabilitation

(1) Background: For the elderly and disabled, self-driving is very important for social participation. An understanding of changing driving conditions is essential in order to drive safely. This study aimed to develop a web-based Korean Mini-Driving Scene Screening Test (MDSST) and to verify its reliability and validity for clinical application. (2) Methods: We developed a web-based MDSST, and its content validity was verified by an expert group. The tests were conducted with 102 elderly drivers to verify the internal consistency and reliability of items, and the validity of convergence with the existing Korean-Safe Driving Behavior Measure (K-SDBM) and the Korean-Adelaide Driving Self-Efficacy Scale (K-ADSES) driving tests was also verified. The test–retest reliability was verified using 54 individuals who participated in the initial test. (3) Results: The average content validity index of MDSST was 0.90, and the average internal consistency of all items was 0.822, indicating high content validity and internal consistency. The exploratory factor analysis for construct validity, the KOM value of the data, was 0.658, and Bartlett’s sphericity test also showed a strongly significant result. The four factors were road traffic and signal perception, situation understanding, risk factor recognition, and situation prediction. The explanatory power was reliable at 61.27%. For the convergence validation, MDSST and K-SDBM showed r = 0.435 and K-ADSES showed r = 0.346, showing a moderate correlation. In the evaluation–reevaluation reliability verification, the reliability increased to r = 0.952. (4) Conclusions: The web-based MDSST test developed in this study is a useful tool for detecting and understanding real-world driving situations faced by elderly drivers. It is hoped that the MDSST test can be applied more widely as a driving ability test that can be used in the clinical field of driving rehabilitation.

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.

Return to driving post stroke; patients' perspectives and challenges in Saudi Arabia

BackgroundReturning to driving remains one of the most important goals for stroke survivors. In Saudi Arabia, there are no structured processes to address the issue of return to driving in individuals with disabilities. There are increasing rates of strokes in the country and road traffic accidents are the highest in the region. Returning to driving among male stroke survivors in Saudi Arabia is of particular importance due to socio-economic and cultural reasons.AimsThe study aims to explore the factors involved in return to driving among stroke survivors in Saudi population.MethodsThis cross-sectional study was carried out on 100 male stroke survivors who had completed an inpatient rehabilitation program and had at least one follow-up assessment three months post-discharge. Information was collected regarding demographics, stroke characteristics, and factors related to pre and post-stroke driving. Data were analyzed using SPSS.ResultsMajority (60%) of patients were 51 years of age and above. Most commonly reported stroke impairments were weakness and spasticity with majority of participants having right-sided body involvement. Out of 94 stroke survivors who were driving prior to stroke, only 7 resumed driving. None of the stroke survivors who returned to driving reported receiving any formal driving assessment. Only one patient who reported being aware of the need of driving assessment did not resume driving after stroke.ConclusionsThere is a dire need to increase awareness and to develop a structured integrated system in Saudi Arabia to facilitate stroke survivors to return to driving.

Eye Tracking Measures for Studying Language Comprehension Deficits in Aphasia: A Systematic Search and Scoping Review

Aim The aim of this scoping review is to identify the eye tracking paradigms and eye movement measures used to investigate auditory and reading comprehension deficits in persons with aphasia (PWA). Method MEDLINE via PubMed, Cochrane, CINAHL, Embase, PsycINFO, OTseeker, Scopus, Google Scholar, Grey Literature Database, and ProQuest Search (Dissertations & Theses) were searched for relevant studies. The Covidence software was used to manage the initial and full-text screening process for the search. Results and Discussion From a total of 1,803 studies, 68 studies were included for full-text screening. In addition, 418 records from gray literature were also screened. After full-text screening, 16 studies were included for this review-12 studies for auditory comprehension in PWA and four studies for reading comprehension in PWA. The review highlights the use of common eye tracking paradigms used to study language comprehension in PWA. We also discusse eye movement measures and how they help in assessing auditory and reading comprehension. Methodological challenges of using eye tracking are discussed. Conclusion The studies summarized in this scoping review provide evidence that the eye tracking methods are beneficial for studying auditory and reading comprehension in PWA.

Voxel-Mirrored Homotopic Connectivity Associated With Change of Cognitive Function in Chronic Pontine Stroke

Recent neuroimaging studies have shown the possibility of cognitive impairment after pontine stroke. In this study, we aimed to use voxel-mirrored homotopic connectivity (VMHC) to investigate changes in the cognitive function in chronic pontine stroke. Functional MRI (fMRI) and behavioral assessments of cognitive function were obtained from 56 patients with chronic pontine ischemic stroke [28 patients with left-sided pontine stroke (LP) and 28 patients with right-sided pontine stroke (RP)] and 35 matched healthy controls (HC). The one-way ANOVA test was performed for the three groups after the VMHC analysis. Results showed that there were significant decreases in the bilateral lingual gyrus (Lingual_L and Lingual_R) and the left precuneus (Precuneus_L) in patients with chronic pontine ischemic stroke compared to HCs. However, in a post-hoc multiple comparison test, this difference remained only between the HC and RP groups. Moreover, we explored the relationship between the decreased z-values in VMHC and the behavior-task scores using a Pearson's correlation test and found that both scores of short-term memory and long-term memory in the Rey Auditory Verbal Learning Test were positively correlated with z-values of the left lingual gyrus (Lingual_L), the right lingual gyrus (Lingual_R), and the left precuneus (Precuneus_L) in VMHC. Besides that, the z-values of Precuneus_L in VMHC were also negatively correlated with the reaction time for correct responses in the Flanker task and the spatial memory task. In conclusion, first, the lingual gyrus played an important role in verbal memory. Second, the precuneus influenced the working memory, both auditory-verbal memory and visual memory. Third, the right-sided stroke played a greater role in the results of this study. This study provides a basis for further elucidation of the characteristics and mechanisms of cognitive impairment after pontine stroke.

Cognitive and motor deficits contribute to longer braking time in stroke

Background

Braking is a critical determinant of safe driving that depends on the integrity of cognitive and motor processes. Following stroke, both cognitive and motor capabilities are impaired to varying degrees. The current study examines the combined impact of cognitive and motor impairments on braking time in chronic stroke.

Methods

Twenty stroke survivors and 20 aged-matched healthy controls performed cognitive, motor, and simulator driving assessments. Cognitive abilities were assessed with processing speed, divided attention, and selective attention. Motor abilities were assessed with maximum voluntary contraction (MVC) and motor accuracy of the paretic ankle. Driving performance was examined with the braking time in a driving simulator and self-reported driving behavior.

Results

Braking time was 16% longer in the stroke group compared with the control group. The self-reported driving behavior in stroke group was correlated with braking time (r = − 0.53, p = 0.02). The stroke group required significantly longer time for divided and selective attention tasks and showed significant decrease in motor accuracy. Together, selective attention time and motor accuracy contributed to braking time (R² = 0.40, p = 0.01) in stroke survivors.

Conclusions

This study provides novel evidence that decline in selective attention and motor accuracy together contribute to slowed braking in stroke survivors. Driving rehabilitation after stroke may benefit from the assessment and training of attentional and motor skills to improve braking during driving.

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.

"Invisible" visual impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments

BACKGROUND

Visual impairments (VIs) have a negative impact on life and affect up to 60% of stroke survivors. Despite this, VIs are often overlooked. This paper explores how persons with VIs experience vision care within stroke health services and how VIs impact everyday life the first 3 months post stroke.

METHODS

Individual semi-structured interviews were conducted with 10 stroke survivors 3 months post stroke, and analyzed using qualitative content analysis.

RESULTS

The main theme, "Invisible" visual impairments, represents how participants experience VIs as an unknown and difficult symptom of stroke and that the lack of attention and appropriate visual care leads to uncertainty about the future. VIs were highlighted as a main factor hindering the participants living life as before. The lack of acknowledgement, information, and systematic vision rehabilitation leads to feelings of being unsupported in the process of coping with VIs.

CONCLUSION

VIs are unknown symptoms pre stroke and sequelas after stroke that significantly affect everyday life. VIs and vision rehabilitation needs more attention through all phases of stroke health services. We request a greater awareness of VIs as a presenting symptom of stroke, and that visual symptoms should be included in stroke awareness campaigns. Further, we suggest increased competence and standardized evidence-based clinical pathways for VIs to advance all stroke health services including rehabilitation in order to improve outcomes and adaptation to future life for stroke survivors with VIs.

The right hemisphere is important for driving-related cognitive function after stroke

Considering quality of life (QOL) after stroke, car driving is one of the most important abilities for returning to the community. In this study, directed attention and sustained attention, which are thought to be crucial for driving, were examined. Identification of specific brain structure abnormalities associated with post-stroke cognitive dysfunction related to driving ability would help in determining fitness for car driving after stroke. Magnetic resonance imaging was performed in 57 post-stroke patients (51 men; mean age, 63 ± 11 years) who were assessed for attention deficit using a standardized test (the Clinical Assessment for Attention, CAT), which includes a Continuous Performance Test (CPT)-simple version (CPT-SRT), the Behavioral Inattention Test (BIT), and a driving simulator (handle task for dividing attention, and simple and selective reaction times for sustained attention). A statistical non-parametric map (SnPM) that displayed the association between lesion location and cognitive function for car driving was created. From the SnPM analysis, the overlay plots were localized to the right hemisphere during handling the hit task for bilateral sides (left hemisphere damage related to right-side neglect and right hemisphere damage related to left-side neglect) and during simple and selective reaction times (false recognition was related to damage of both hemispheres). A stepwise multiple linear regression analysis confirmed the importance of both hemispheres, especially the right hemisphere, for cognitive function and car driving ability. The present study demonstrated that the right hemisphere has a crucial role for maintaining directed attention and sustained attention, which maintain car driving ability, improving QOL for stroke survivors.

Reaction to a Visual Stimulus: Anticipation with Steady and Dynamic Contractions

Reacting fast to visual stimuli is important for many activities of daily living and sports. It remains unknown whether the strategy used during the anticipatory period influences the speed of the reaction. The purpose of this study was to determine if reaction time (RT) differs following a steady and a dynamic anticipatory strategy. Twenty‐two young adults (21.0 ± 2.2 yrs, 13 women) participated in this study. Participants performed 15 trials of a reaction time task with ankle dorsiflexion using a steady (steady force at 15% MVC) and a dynamic (oscillating force from 10‐20% MVC) anticipatory strategy. We recorded primary agonist muscle (tibialis anterior; TA) electromyographic (EMG) activity. We quantified RT as the time interval from the onset of the stimulus to the onset of force. We found that a dynamic anticipatory strategy, compared to the steady anticipatory strategy, resulted in a longer RT (p = 0.04). We classified trials of the dynamic condition based on the level and direction of anticipatory force at the moment of the response. We found that RT was longer during the middle descending relative to the middle ascending and the steady conditions (p < 0.01). All together, these results suggest that RT is longer when preceded by a dynamic anticipatory strategy. Specifically, the longer RT is a consequence of the variable direction of force at which the response can occur, which challenges the motor planning process.

Hazard perception of stroke drivers in a video-based Japanese hazard perception task

Objective: Hazard perception (HP) is the ability to identify a hazardous situation while driving. Though HP has been well studied among neurologically intact populations, little is known about the HP of neurologically impaired populations (in this study, stroke patients). The purpose of this study is, first, to investigate the HP of stroke patients and, second, to verify the effect of lesion side (right or left hemisphere) on HP, from the viewpoint of hazard types. Methods: Sixty-seven neurologically intact age-matched older drivers and 63 stroke patients with valid driver's licenses conducted a video-based Japanese HP task. Participants were asked to indicate the hazardous events in the driving scenario. These events were classified into 3 types: (1) behavioral prediction hazards (BP), which are those where the cause is visible before it becomes a hazard; (2) environmental prediction hazards (EP), which are those where the ultimate hazard may be hidden from view; and (3) dividing and focusing attention hazards (DF), which are those where there is more than one potential hazard to monitor on approach．Participants also took part in the Trail Making Test (TMT) to evaluate visual information processing speed. Results: The results showed that the number of responses was significantly fewer for stroke patients than for age-matched drivers for all hazard types (P < .001), and this difference was not affected by lesion side (P > .05). It was also found that stroke patients showed a slower response time than age-matched drivers only for BP (P < .001). The lesion side did not affect response latency (P > .05). Results of the TMT revealed that age-matched drivers completed the task significantly faster than stroke patients (P < .001) and that neither TMT-A nor TMT-B differentiated between patients with left hemisphere damage and patients with right hemisphere damage (P > .05). Conclusions: Firstly, HP in stroke patients is low compared to age-matched drivers. Secondly, even if stroke patients notice hazards, their response may be delayed in a BP situation, due to a slower visual information processing speed. Thirdly, the lesion side does not appear to affect HP.

The Effectiveness of Driving Game on Trunk Control and Gait Ability in Stroke

Patients who require neurological rehabilitation often do not comply with conventional programs because they find the therapy uninteresting. As a result, specialized interactive video games have been designed to be more enjoyable than conventional therapy (CT) tasks. This study aimed to assess the trunk control and gait ability of patients with chronic stroke after participation in driving-based interactive video games (DBIVG). Participants included 24 chronic stroke patients allocated to an experimental group (n = 13, CT + DBIVG) or a control group (n = 11, CT + treadmill walking training). Both groups received CT five days/week; the experimental and control groups participated in DBIVG and treadmill walking training, respectively, three days/week for four weeks. The primary outcome of trunk control was measured by the trunk impairment scale (TISall) and TIS subscales, including static sitting balance (TISssb), dynamic sitting balance (TISdsb), and trunk co-ordination (TISco). Gait ability was measured by the dynamic gait index (DGI), timed walking test (TWT), and time up and go test (TUGT). Both groups demonstrated significant improvements in TISall, TISdsb, and TUGT results. The experimental group showed significantly greater improvement in TISssb, TISco, and DGI than the control group. Our findings indicate that DBIVG can improve trunk control and gait ability in patients with chronic stroke.

Driving and Low Vision: Validity of Assessments for Predicting Performance of Drivers

The authors conducted a systematic review to examine whether vision-related assessments can predict the driving performance of individuals who have low vision. The results indicate that measures of visual field, contrast sensitivity, cognitive and attention-based tests, and driver screening tools have variable utility for predicting real-world driving performance.

Task-Related Differences in Eye Movements in Individuals With Aphasia

Background: Neurotypical young adults show task-based modulation and stability of their eye movements across tasks. This study aimed to determine whether persons with aphasia (PWA) modulate their eye movements and show stability across tasks similarly to control participants.

Methods: Forty-eight PWA and age-matched control participants completed four eye-tracking tasks: scene search, scene memorization, text-reading, and pseudo-reading.

Results: Main effects of task emerged for mean fixation duration, saccade amplitude, and standard deviations of each, demonstrating task-based modulation of eye movements. Group by task interactions indicated that PWA produced shorter fixations relative to controls. This effect was most pronounced for scene memorization and for individuals who recently suffered a stroke. PWA produced longer fixations, shorter saccades, and less variable eye movements in reading tasks compared to controls. Three-way interactions of group, aphasia subtype, and task also emerged. Text-reading and scene memorization were particularly effective at distinguishing aphasia subtype. Persons with anomic aphasia showed a reduction in reading saccade amplitudes relative to their respective control group and other PWA. Persons with conduction/Wernicke’s aphasia produced shorter scene memorization fixations relative to controls or PWA of other subtypes, suggesting a memorization specific effect. Positive correlations across most tasks emerged for fixation duration and did not significantly differ between controls and PWA.

Conclusion: PWA generally produced shorter fixations and smaller saccades relative to controls particularly in scene memorization and text-reading, respectively. The effect was most pronounced recently after a stroke. Selectively in reading tasks, PWA produced longer fixations and shorter saccades relative to controls, consistent with reading difficulty. PWA showed task-based modulation of eye movements, though the pattern of results was somewhat abnormal relative to controls. All subtypes of PWA also demonstrated task-based modulation of eye movements. However, persons with anomic aphasia showed reduced modulation of saccade amplitude and smaller reading saccades, possibly to improve reading comprehension. Controls and PWA generally produced stabile fixation durations across tasks and did not differ in their relationship across tasks. Overall, these results suggest there is potential to differentiate among PWA with varying subtypes and from controls using eye movement measures of task-based modulation, especially reading and scene memorization tasks.

Driving restrictions post-stroke: Physicians' compliance with regulations

OBJECTIVE

Suffering a stroke might lead to permanent cognitive and/or physical impairment. It has been shown that these impairments could have an impact on an individual's fitness to drive. In Sweden, as in many other countries, there are regulations on driving cessation post-stroke. Information on driving cessation should be given to all patients and noted in the journal. The present study sought to determine physician's compliance to driving regulations post-stroke as well as follow-up and gender aspects.

METHOD

A retrospective study of medical records on stroke patients was carried out. The study covered all of the medical records on stroke incidents (n = 342) during a year at a typical medium to large-sized hospital in Sweden.

RESULTS

A journal entry on driving cessation post-stroke was missing in 81% of the medical records. Only 2% of the patients were scheduled for a follow-up meeting specifically concerning fitness to drive. Significantly more men than women had an entry on driving in the journal.

CONCLUSIONS

We conclude that the Swedish regulations on driving cessation post-stroke were not followed at the participating hospital. It is crucial that all stroke patients receive information on driving cessation because their condition might affect fitness to drive. Analysis of follow-up records showed that there was no consistent method for assessment of a patient's fitness to drive. There was also a gender difference in the material, which warrants further investigation.

More Than the Verbal Stimulus Matters: Visual Attention in Language Assessment for People With Aphasia Using Multiple-Choice Image Displays

PURPOSE

Language comprehension in people with aphasia (PWA) is frequently evaluated using multiple-choice displays: PWA are asked to choose the image that best corresponds to the verbal stimulus in a display. When a nontarget image is selected, comprehension failure is assumed. However, stimulus-driven factors unrelated to linguistic comprehension may influence performance. In this study we explore the influence of physical image characteristics of multiple-choice image displays on visual attention allocation by PWA.

METHOD

Eye fixations of 41 PWA were recorded while they viewed 40 multiple-choice image sets presented with and without verbal stimuli. Within each display, 3 images (majority images) were the same and 1 (singleton image) differed in terms of 1 image characteristic. The mean proportion of fixation duration (PFD) allocated across majority images was compared against the PFD allocated to singleton images.

RESULTS

PWA allocated significantly greater PFD to the singleton than to the majority images in both nonverbal and verbal conditions. Those with greater severity of comprehension deficits allocated greater PFD to nontarget singleton images in the verbal condition.

CONCLUSION

When using tasks that rely on multiple-choice displays and verbal stimuli, one cannot assume that verbal stimuli will override the effect of visual-stimulus characteristics.

Assessing Cognitive Ability and Simulator-Based Driving Performance in Poststroke Adults

Driving is an important activity of daily living, which is increasingly relied upon as the population ages. It has been well-established that cognitive processes decline following a stroke and these processes may influence driving performance. There is much debate on the use of off-road neurological assessments and driving simulators as tools to predict driving performance; however, the majority of research uses unlicensed poststroke drivers, making the comparability of poststroke adults to that of a control group difficult. It stands to reason that in order to determine whether simulators and cognitive assessments can accurately assess driving performance, the baseline should be set by licenced drivers. Therefore, the aim of this study was to assess differences in cognitive ability and driving simulator performance in licensed community-dwelling poststroke drivers and controls. Two groups of licensed drivers (37 poststroke and 43 controls) were assessed using several cognitive tasks and using a driving simulator. The poststroke adults exhibited poorer cognitive ability; however, there were no differences in simulator performance between groups except that the poststroke drivers demonstrated less variability in driver headway. The application of these results as a prescreening toolbox for poststroke drivers is discussed.

Development of the Adelaide Driving Self-Efficacy Scale

Objective: To describe the development of the Adelaide Driving Self-Efficacy Scale (ADSES) and to report on its reliability and validity.

Methods: A set of 12 driving behaviours, developed through literature review, clinical experience and expert review, were rated for self-efficacy using a Likert scale. Internal consistency was investigated using a Cronbach's alpha coefficient and construct validity by comparing ADSES scores of stroke and non-stroke drivers. Criterion-related validity was examined by comparing ADSES scores with the result on a standardized on-road assessment.

Setting: A rehabilitation hospital in Adelaide, South Australia.

Participants: Staff from the hospital and stroke patients from the rehabilitation unit. Data from a non-stroke sample (n -/ 79) and stroke patients (n -/ 81) were used to test internal consistency and construct validity. A separate group of 45 people recommended for a driving assessment, of whom 34 were stroke patients, were used to test criterion validity.

Results: Cronbach's alpha coefficient was 0.98, indicating high internal consistency. The non-stroke and stroke groups showed significant differences in ADSES scores (t(158)-/ 5.5, P B < 0.05), demonstrating construct validity. Differences in ADSES scores for those participants who passed or failed the on-road assessment were significant for both the entire driving assessment group (t(43)-/ 3.2, P B < 0.05) and the stroke subgroup (t(43)-/ 3.2, P B < 0.05), indicating criterion validity.

Conclusion: The ADSES has demonstrated internal consistency and construct validity with the stroke and non-stroke population. The scale demonstrated criterion validity in its relationship with outcome of an on-road driving assessment. It appears to be a reliable and valid measure of driving self-efficacy.

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.

The influence of a concurrent cognitive task on lower limb reaction time among stroke survivors with right- or left-hemiplegia

OBJECTIVE

To determine the impact of cognitive interference on foot pedal reaction time among stroke survivors with right- (RH) or left-hemiplegia (LH).

DESIGN

Cross-sectional comparison without randomization.

SUBJECTS/PATIENTS

10 patients post-stroke with RH, 10 with LH; 10 age-matched controls.

METHODS

Foot pedal response times were measured using three different reaction time (RT) paradigms: simple RT, dual-task RT (counting backward by serial 3 seconds), and choice RT (correct response contingent on stimuli to eliminate pre-programing). RH and LH used the non-paretic leg for all trials. Three 3 (RT task) × 3 (group) mixed-model factorial ANOVAs were used to compare RT, movement time (MT), total response time (TRT).

RESULTS

Overall controls demonstrated faster RT than RH (332 ± 73 versus 474 ± 144 ms, P < 0.001) or LH (402 ± 127 ms, P < 0.05); LH group demonstrated faster RT than those with RH (P < 0.05). Control subjects demonstrated significantly faster RT than RH for all RT conditions (P < 0.05 for all). In contrast, controls achieved significantly faster RT than LH for the choice RT condition only (P < 0.05), but not for the simple (P = 0.12) or dual-task RT conditions (P = 0.25).

CONCLUSIONS

Compared to controls, response time was significantly impaired among LH and RH when the response could not be pre-programmed. While current simple RT testing commonly employed by driver rehab specialists may be sufficient for detecting RT deficits in patients with RH, simple or dual-task RT tests alone may fail to detect RT deficiencies among LH, even when testing the non-paretic limb. Choice RT should be added to post-stroke driver fitness assessment, particularly for patients with LH.

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.

Greater Activity in the Frontal Cortex on Left Curves: A Vector-Based fNIRS Study of Left and Right Curve Driving

OBJECTIVES

In the brain, the mechanisms of attention to the left and the right are known to be different. It is possible that brain activity when driving also differs with different horizontal road alignments (left or right curves), but little is known about this. We found driver brain activity to be different when driving on left and right curves, in an experiment using a large-scale driving simulator and functional near-infrared spectroscopy (fNIRS).

RESEARCH DESIGN AND METHODS

The participants were fifteen healthy adults. We created a course simulating an expressway, comprising straight line driving and gentle left and right curves, and monitored the participants under driving conditions, in which they drove at a constant speed of 100 km/h, and under non-driving conditions, in which they simply watched the screen (visual task). Changes in hemoglobin concentrations were monitored at 48 channels including the prefrontal cortex, the premotor cortex, the primary motor cortex and the parietal cortex. From orthogonal vectors of changes in deoxyhemoglobin and changes in oxyhemoglobin, we calculated changes in cerebral oxygen exchange, reflecting neural activity, and statistically compared the resulting values from the right and left curve sections.

RESULTS

Under driving conditions, there were no sites where cerebral oxygen exchange increased significantly more during right curves than during left curves (p > 0.05), but cerebral oxygen exchange increased significantly more during left curves (p < 0.05) in the right premotor cortex, the right frontal eye field and the bilateral prefrontal cortex. Under non-driving conditions, increases were significantly greater during left curves (p < 0.05) only in the right frontal eye field.

CONCLUSIONS

Left curve driving was thus found to require more brain activity at multiple sites, suggesting that left curve driving may require more visual attention than right curve driving. The right frontal eye field was activated under both driving and non-driving conditions.

Returning to driving after stroke: A systematic review of adherence to guidelines and legislation

Introduction

This systematic review aimed to determine whether stroke survivors routinely received return-to-driving education in the acute hospital setting prior to discharge home; and if education was provided, were the restrictions in driving guidelines adhered to.

Method

A systematic search was conducted of PubMed, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Web of Science, Scopus, Pedro and OTseeker databases for original research reporting findings on the adherence to return-to-driving legislation and clinical guidelines after stroke, and return-to-driving behaviours in stroke survivors up to 1 month post stroke.

Results

Three studies met the inclusion criteria and reported on a combined total of 252 stroke survivors living in the United Kingdom. Forty-eight per cent of stroke survivors received education on the 1 month driving restriction. A total of 61.4% of participants waited 1 month prior to returning to driving.

Conclusion

This review found that there is limited literature available on the management of return to driving following acute stroke but there is evidence that education may not be routinely provided in the acute hospital setting and that many stroke survivors could be returning to driving within the 1 month restriction.

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.

Assessment of novel binocular colour, motion and contrast tests in glaucoma

The effects of glaucoma on binocular visual sensitivity for the detection of various stimulus attributes are investigated at the fovea and in four paracentral retinal regions. The study employed a number of visual stimuli designed to isolate the processing of various stimulus attributes. We measured absolute contrast detection thresholds and functional contrast sensitivity by using Landolt ring stimuli. This psychophysical Landolt C-based contrast test of detection and gap discrimination allowed us to test parafoveally at 6 ° from fixation and foveally by employing interleaved testing locations. First-order motion perception was examined by using moving stimuli embedded in static luminance contrast noise. Red/green (RG) and yellow/blue (YB) colour thresholds were measured with the Colour Assessment and Diagnosis (CAD) test, which utilises random dynamic luminance contrast noise (± 45 %) to ensure that only colour and not luminance signals are available for target detection. Subjects were normal controls (n = 65) and glaucoma patients with binocular visual field defects (n = 15) classified based on their Humphrey Field Analyzer mean deviation (MD) scores. The impairment of visual function varied depending on the stimulus attribute and location tested. Progression of loss was noted for all tests as the degree of glaucoma increased. For subjects with mild glaucoma (MD -0.01 dB to -6.00 dB) significantly more data points fell outside the normal age-representative range for RG colour thresholds than for any other visual test, followed by motion thresholds. This was particularly the case for the parafoveal data compared with the foveal data. Thus, a multifaceted measure of binocular visual performance, incorporating RG colour and motion test at multiple locations, might provide a better index for comparison with quality of life measures in glaucoma.

Visual impairment in stroke patients--a review

Approximately 30% of all stroke patients suffer from post-stroke visual impairment. Hemianopia is the most common symptom, but also neglect, diplopia, reduced visual acuity, ptosis, anisocoria, and nystagmus are frequent. Partial or complete recovery of visual disorders can occur, but many patients suffer permanent disability. This disability is often less evident than impairment of motor and speech functions, but is negatively correlated with rehabilitation outcome and can lead to a significant reduction in day-to-day functioning. To be visually impaired after stroke reduces quality of life and causes social isolation because of difficulties in navigating/orientating in the surroundings. A thorough diagnosis including targeted examination and later follow-up with eye examination and perimetry is essential in order to establish the extent of the visual impairment and to select the best rehabilitation strategy. Patients seem to profit from visual rehabilitation focused on coping strategies.

Department of Transportation vs self-reported data on motor vehicle collisions and driving convictions for stroke survivors: do they agree?

OBJECTIVE

Research on stroke survivors' driving safety has typically used either self-reports or government records, but the extent to which the 2 may differ is not known. We compared government records and self-reports of motor vehicle collisions and driving convictions in a sample of stroke survivors.

METHODS

The 56 participants were originally recruited for a prospective study on driving and community re-integration post-stroke; the study population consisted of moderately impaired stroke survivors without severe communication disorders who had been referred for a driving assessment. The driving records of the 56 participants for the 5 years before study entry and the 1-year study period were acquired with written consent from the Ministry of Transportation of Ontario (MTO), Canada. Self-reports of collisions and convictions were acquired via a semistructured interview and then compared with the MTO records.

RESULTS

Forty-three participants completed the study. For 7 (13.5%) the MTO records did not match the self-reports regarding collision involvement, and for 9 (17.3%) the MTO records did not match self-reports regarding driving convictions. The kappa coefficient for the correlation between MTO records and self-reports was 0.52 for collisions and 0.47 for convictions (both in the moderate range of agreement). When both sources of data were consulted, up to 56 percent more accidents and up to 46 percent more convictions were identified in the study population in the 5 years before study entry compared to when either source was used alone.

CONCLUSION

In our population of stroke survivors, self-reports of motor vehicle collisions and driving convictions differed from government records. In future studies, the use of both government and self-reported data would ensure a more accurate picture of driving safety post-stroke.

What people say about travelling outdoors after their stroke: a qualitative study

BACKGROUND/AIM

Reduced walking ability and loss of confidence are common after stroke. Many people cannot drive or use public transport, which can restrict participation. This qualitative study aimed to explore the experiences and attitudes of people following stroke to travelling outdoors early after hospital discharge.

METHODS

Two semi-structured interviews were conducted with 19 people post-stroke, all of whom were receiving rehabilitation to increase outdoor travel. Mean age was 68.6 years (SD 11.7years). Eight significant others also participated. Interviews were conducted at home (median 21 days post-discharge), with a second interview three months later. Questions focussed on common destinations, modes of travel including driving when relevant and factors that influenced outdoor travel. Qualitative data were analysed using constant comparative (grounded theory) methods, resulting in themes and categories.

RESULTS

People with stroke were categorised as either a hesitant or confident explorer, in relation to walking, catching public transport and driving. Factors influencing outdoor travel included their emotional disposition, having meaningful destinations, expectations of recovery and the sphere of influence, including family and therapists. These factors could have an enabling or restricting effect. A pre-stroke walking habit also positively contributed to outdoor travel. Gate-keeping by therapists, general practitioners and family members seemed to adversely affect travel.

CONCLUSIONS

  This emerging theory offers insights into the experiences and attitudes to outdoor travel of people who were ambulant and participating in community rehabilitation following a stroke. Future research could explore the experiences of people with more severe mobility, cognitive and communication problems.

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.

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.