Driving following traumatic brain injury: prevalence, exposure, advice and evaluations

Return to Driving Following Moderate-to-Severe Traumatic Brain Injury: A TBI Model System Longitudinal Investigation

OBJECTIVE

To examine longitudinal patterns of return to driving (RTD), driving habits, and crash rates associated with moderate-to-severe traumatic brain injury (TBI).

SETTING

Eight TBI Model System sites.

PARTICIPANTS

Adults (N = 334) with TBI that required inpatient acute rehabilitation with follow-up of 197 and 218 at 1 and 2 years post-injury, respectively. Data collection at 2 years occurred almost exclusively during the pandemic, which may have affected results.

DESIGN

Longitudinal and observational.

MAIN MEASURES

Driving survey completed during rehabilitation and at phone follow-up 1 and 2 years after injury.

RESULTS

The rate of RTD was 65% at 1-year follow-up and 70% at 2-year follow-up. RTD at both follow-up time points was positively associated with family income. The frequency of driving and distance driven were diminished compared to before injury. Limitation of challenging driving situations (heavy traffic, bad weather, and at night) was reported at higher rates post-injury than before injury. Crash rates were 14.9% in the year prior to injury (excluding crashes that resulted in TBI), 9.9% in the first year post-injury, and 6% during the second year.

CONCLUSION

RTD is common after TBI, although driving may be limited in terms of frequency, distance driven, and avoiding challenging situations compared to before injury. Incidence of crashes is higher than population-based statistics; however, those who sustain TBI may be at higher risk even prior to injury. Future work is needed to better identify characteristics that influence the likelihood of crashes post-TBI.

On-road driving remediation following acquired brain injury: a randomized controlled trial

OBJECTIVE

To investigate the relationship between on-road driving remediation and achieving fitness to drive following acquired brain injury.

DESIGN

Randomized controlled trial.

SETTING

Tertiary hospital outpatient driver assessment and rehabilitation service, Australia.

PARTICIPANTS

Thirty-five participants (54.3% male), aged 18-65 years, 41 days-20 years post-acquired brain injury (including stroke, aneurysm, traumatic brain injury) recommended for on-road driving remediation following occupational therapy driver assessment were randomly assigned to intervention (n = 18) and waitlist control (n = 17) groups.

INTERVENTION

Intervention group received on-road driving remediation delivered by a qualified driving instructor in a dual-control vehicle. The waitlist control group completed a 6 week period of no driving-related remediation.

MAIN MEASURE

Fitness to drive rated following the conduct of an on-road occupational therapy driver assessment with a qualified driving instructor where outcome assessors were blinded to group allocation.

RESULTS

The intervention group were significantly more likely to achieve a fit to drive recommendation than no driving specific intervention (p = 0.003).

CONCLUSION

Following comprehensive assessment, individualized on-road driving remediation programs devised by an occupational therapist with advanced training in driver assessment and rehabilitation and delivered by a qualified driving instructor are significantly associated with achieving fitness to drive after acquired brain injury.

A Protocol for Remote Cognitive Training Developed for Use in Clinical Populations During the COVID-19 Pandemic

Many traumatic brain injury (TBI) survivors face scheduling and transportation challenges when seeking therapeutic interventions. The COVID-19 pandemic created a shift in the use of at-home spaces for work, play, and research, inspiring the development of online therapeutic options. In the current study, we determined the feasibility of an at-home cognitive training tool (NeuroTrackerX) that uses anaglyph three-dimensional (3D) glasses and three-dimensional multiple object tracking (3D-MOT) software. We recruited 20 adults (10 female; mean age = 68.3 years, standard deviation [SD] = 6.75) as the at-home training group. We assessed cognitive health status for participants using a self-report questionnaire and the Mini-Mental State Examination (MMSE), and all participants were deemed cognitively healthy (MMSE >26). At-home participants loaned the necessary equipment (e.g., 3D glasses, computer equipment) from the research facilities and engaged in 10 training sessions over 5 weeks (two times per week). Participant recruitment, retention, adherence, and experience were used as markers of feasibility. For program validation, 20 participants (10 female; mean age = 63.39 years, SD = 12.22), who had previously completed at least eight sessions of the in-lab 3D-MOT program, were randomly selected as the control group. We assessed individual session scores, overall improvement, and learning rates between groups. Program feasibility is supported by high recruitment and retention, 90% participant adherence, and participants' ease of use of the program. Validation of the program is supported. Groups showed no differences in session scores (p > 0.05) and percentage improvement (p > 0.05) despite the differences in screen size and 3D technology. Participants in both groups showed significant improvements in task performance across the training sessions (p < 0.001). NeuroTrackerX provides a promising at-home option for cognitive training in cognitively healthy adults and may be a promising avenue as an at-home therapeutic for TBI survivors. This abstract was previously published on clinicaltrials.gov and can be found at: https://www.clinicaltrials.gov/ct2/show/NCT05278273.

Different brain activation patterns in the prefrontal area between self-paced and high-speed driving tasks

The purpose of this study was to investigate the effects on prefrontal cortex brain activity when participants attempted to stop a car accurately at a stop line when driving at different speeds using functional near-infrared spectroscopy (fNIRS). Twenty healthy subjects with driving experience drove their own cars for a distance of 60 m five times each at their own pace or as fast as possible. The variation in the distance between the stop line and the car was not significantly different between the self-paced and high-speed tasks. However, oxygenated hemoglobin concentration in the prefrontal cortex was significantly higher in the high-speed task than in the self-paced task. These findings suggest that driving at high speed requires more divided attention than driving at self-paced speed, even though the participants were able to stop the car at the same distance from the target. This study shows the advantages and usefulness of fNIRS .

Virtual-Reality Performance-Based Assessment of Cognitive Functions in Adult Patients With Acquired Brain Injury: A Scoping Review

Individuals with acquired brain injury (ABI) commonly present with impairments in cognitive abilities. As these competencies seem to be predictive of patients' abilities to reintegrate into the everyday settings, it is crucial to assess them properly. However, previous research has indicated that patients may perform relatively well on standard tests of cognitive functioning, but may nonetheless encounter significant difficulties in organizing and executing everyday tasks. In order to overcome this issue, virtual reality (VR) methods have been introduced in clinical practice with the aim of creating assessments that simulate real-world activities and thus, provide a clearer picture of patients' functioning in everyday settings. This review offers an overview of VR assessment tools described in the scientific literature between 2010 and 2019. Overall, 38 relevant records describing 31 different tools were found. Among these tools, 16 assessed executive functions and prospective memory, while the other 15 assessed visuo-spatial abilities. Although promising results have been reported, our analysis indicated that about half of the tools deliver tasks that differ from everyday activities, thus limiting the generalizability of patients' performance to the real-world. Moreover, a variety of methodological shortfalls related to study Internal and External Validity have been highlighted, which hamper the possibility of drawing definite recommendations on tool choice. These limitations suggest the importance of putting considerable efforts into the improvement or development of VR tools for patients with ABI for both research and clinical purposes, considering the great potential of this form of assessment.

Return-to-driving following acquired brain injury: A neuropsychological perspective

BACKGROUND

Return to driving after an acquired brain injury (ABI) has been positively associated with return to employment, maintenance of social relationships, and engagement in recreational and other community activities. Safe driving involves multiple cognitive abilities in a dynamic environment, and cognitive dysfunction resulting from ABI can negatively impact driving performance.

OBJECTIVE

This manuscript examines the post-injury return-to-driving process, including performances on the in-office and on-road assessments, and the role of a rehabilitation neuropsychologist in helping patients resume driving.

METHOD

In this study, 39 of 200 individuals (approximately 20%) treated at an outpatient neurorehabilitation facility, who performed satisfactorily on a pre-driving cognitive screening, completed a behind-the-wheel driving test.

RESULTS

Of the 200 individuals, 34 (87%) passed the road test. Among the remaining five individuals who did not pass the road test, primary reasons for their failure included inability to follow or retain examiner directions primarily about lane position, speed, and vehicle control. The errors were attributable to cognitive difficulties with information processing, memory, attention regulation, and dual tasking.CONCLUSIONThe rehabilitation neuropsychologist contributed to the process by assessing cognition, facilitating self-awareness and error minimization, providing education about driving regulations and safety standards, and preparing for the road test and its outcomes.

Driving patterns, confidence, and perception of abilities following moderate to severe traumatic brain injury: a TBI model system study

OBJECTIVE

Describe driving patterns following moderate-to-severe traumatic brain injury (TBI). Participants: Adults (N = 438) with TBI that required inpatient acute rehabilitation who had resumed driving.

DESIGN

Cross-sectional, observational design.

SETTING

Eight TBI Model System sites.

MAIN MEASURES

A driving survey was completed at phone follow-up.

RESULTS

Most respondents reported driving daily, although 41% reported driving less than before their injury. Driving patterns were primarily associated with employment, family income, sex, residence, and time since injury, but not injury severity. Confidence in driving was high for most participants and was associated with a perception that the TBI had not diminished driving ability. Lower confidence and perceived loss of ability were associated with altered driving patterns.

CONCLUSION

Most people with moderate-to-severe TBI resume driving but perhaps not at pre-injury or normal levels compared to healthy drivers. Some driving situations are restricted. The relationship between low confidence/perceived loss of ability and driving patterns/restrictions suggests people with TBI are exhibiting some degree of caution consistent with those perceptions. Careful assessment of driving skills and monitoring during early stages of RTD is warranted, particularly for younger, male, and/or single drivers who express higher levels of confidence.

Return to Driving After Moderate-to-Severe Traumatic Brain Injury: A Traumatic Brain Injury Model System Study

OBJECTIVE

Describe who is able to return to driving (RTD) after moderate-to-severe traumatic brain injury (TBI), when this occurs, who maintains that activity, and the association with outcome.

DESIGN

Cross-sectional descriptive study.

SETTING

Eight follow-up sites of the TBI Model Systems (TBIMS) program.

PARTICIPANTS

618 participants enrolled in the TBIMS and 88 caregivers (N=706).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A survey was completed from 1-30 years postinjury focusing on RTD. Descriptors included demographic information, injury severity, and current employment status. Outcome was assessed at the time of the interview, including depression, quality of life, functional status, and community participation.

RESULTS

Of 706 respondents, 78% (N = 552) RTD, but 14% (N = 77) of these did not maintain that activity. Of those who RTD, 43% (N = 192) did so within 6 months of the injury and 92% did so within 24 months postinjury. The percentage of people driving after TBI did not differ significantly based on age at time of injury or follow-up. There were significant differences between drivers and nondrivers with respect to severity of injury, seizures, race, education, employment, rural vs urban setting, marital status, and family income. We performed a multivariate logistic regression to examine the association between driving status and demographic variables, adjusting for other variables in the model. The strongest associations were with current employment, family income, race, seizures, and severity of injury. Driving was associated with greater community participation, better functional outcomes, fewer symptoms of depression, and greater life satisfaction.

CONCLUSIONS

Over a span of 30 years, three-quarters of people experiencing moderate-to-severe TBI return to driving a personal vehicle, although not everyone maintains this activity. Employment, race, family income, and seizures are strongly associated with RTD.

Driving Behaviors 2-3 Years After Traumatic Brain Injury Rehabilitation: A Multicenter Case-Control Study

Introduction: Driving an automobile is an important activity for the social participation of individuals with traumatic brain injury (TBI). Return to safe driving is usually addressed during rehabilitation, but we know little about driving behaviors in the years following TBI rehabilitation.

Objective: To explore self-reported and objective (official driving records) post-rehabilitation driving behaviors and offenses in individuals with TBI: (a) having passed a driving evaluation, (b) who did not undergo a driving evaluation, and (c) non-injured controls.

Methods: Cross-sectional design with 162 adults: (a) 48 participants with mild, moderate, or severe TBI whose drivers' license was suspended and reinstated following a driving evaluation during rehabilitation (TBI-DE; M = 42.2 years of age, SD = 11.5); (b) 24 participants with TBI who maintained their driving privileges without undergoing a driving evaluation (TBI-NE; M = 36.5 years of age, SD = 9.9); (c) 90 non-injured controls (M = 43.8 years of age, SD = 11.4). Participants with TBI were recruited from seven rehabilitation centers, 2–3 years after the end of rehabilitation in the province of Quebec, Canada. During a telephone interview, data were obtained regarding self-reported driving: (a) habits; (b) self-efficacy; (c) anger expression; (d) sensation-seeking; (e) violations/errors; (f) accidents, driving offenses, and demerit points for the two-year interval predating the study. Objective data for driving offenses, accidents, and demerit points were obtained from the automobile regulatory body for the same period and for the two-year interval before the injury for the TBI groups.

Results: Compared to non-injured controls, the TBI-DE group reported significantly lower scores for self-reported verbal aggressive expression of anger and driving violations/errors. Conversely, their official driving records showed significantly more demerit points for the last 2 years, and a significantly higher frequency of serious post-rehabilitation accidents (10), compared to the TBI-NE group (one) and the control group (none). Compared to pre-injury levels, individuals with TBI had significantly more demerit points post-rehabilitation.

Conclusions: Individuals with TBI may underestimate risky driving behaviors even if they have been deemed fit to drive. Reduced self-awareness, memory, and dysexecutive problems following TBI could influence self-report of driving behaviors and explain discrepancies between self-reported and objective driving-related behaviors. Recommendations for research and practice are provided.

Driving after brain injury: Does dual-task modality matter?

BACKGROUND

Virtual reality technology allows neuropsychologists to examine complex, real-world behaviors with high ecological validity and can provide an understanding of the impact of demanding dual-tasks on driving performance.

OBJECTIVE

We hypothesized that a task imposing high cognitive and physical demands (coin-sorting) would result in the greatest reduction in driving maintenance performance.

METHODS

Twenty participants with acquired brain injury and 28 healthy controls were included in the current study. All participants were licensed and drove regularly. Participants completed two standardized VRDS drives: (1) a baseline drive with no distractions, and (2) the same route with three, counterbalanced dual-tasks representing differing demands.

RESULTS

A series of 3 (Task)×2 (Group) ANOVAs revealed that the ABI group tended to go slower than the HC group in the presence of a dual-task, F (1, 111) = 6.24, p = 0.01. Importantly, the ABI group also showed greater variability in speed, F (1, 110) = 10.97, p < 0.01, and lane position, F (1, 108) = 7.81, p < 0.01, an effect driven by dual-tasks with both a cognitive and motor demand.

CONCLUSIONS

These results indicate that long-term driving difficulties following ABI are subtle and likely due to reduced cognitive resources.

Risk of Motor Vehicle Collision or Driving Impairment After Traumatic Brain Injury: A Collaborative International Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize knowledge of the risk of motor vehicle collision (MVC) following a traumatic brain injury (TBI) and the associated risk of driving impairment, as measured by on-road tests, computerized simulators, and self-reported or state-recorded driving records.

METHODS

Our international team searched 7 databases for studies published between 1990 and 2015 of people with TBI, controls, and data concerning either MVC or driving impairment. The included articles examined the risk of MVC among people with TBI; we excluded studies that examined the risk of having a TBI associated with being involved in an MVC.

RESULTS

From 13 578 search results, we included 8 studies involving 1663 participants with TBI and 4796 controls. We found no significant difference in the risk of MVC (odds ratio = 1.24, 95% confidence interval = 0.80-1.91, P = .34). When we restricted the analysis to self-report, the risk of MVC was higher for those without a TBI (odds ratio = 1.63, 95% confidence interval = 1.21-2.22, P = .002). In contrast, participants with TBI consistently performed worse during on-road assessments and had more problems with vehicular control.

CONCLUSION

Limitations of reviewed studies included small sample sizes, failure to specify TBI severity or time postinjury, and absence of objective measures of risk. Findings concerning the relationship between TBIs from non-MVC causes and crash risk are, therefore, inconclusive and do not provide evidence for major changes to existing clinical guidelines for driving with TBI.

Post-Concussion Driving Behaviors and Opinions: A Survey of Collegiate Student-Athletes

Post-concussion driving restrictions are eminent, but we lack understanding of current behaviors and opinions about driving following concussion among populations at risk of concussion. We aimed to describe post-concussion driving behaviors and opinions among collegiate student-athletes. Student-athletes completed a survey (response rate = 45.3%, 223/492) regarding their post-concussion driving behaviors and opinions. Response frequencies and percentages are presented. Student-athletes self-reported a total of 169 lifetime concussions (0.76 ± 1.02 each). Of the 169 concussions, 52.1% (88/169) were diagnosed and 52.7% (89/169) occurred while the student-athlete possessed a valid driver's license. Student-athletes refrained from driving following 43.8% (39/89) of the concussive events. Student-athletes who refrained most commonly did so for only 24-48 h (20.5%, 8/39) and because a health care provider advised them to (33.3%, 13/39). Student-athletes most commonly reported that they would feel "very unsafe" driving a car immediately following injury (38.4%, 84/219). When asked whether driving restrictions would influence their decision to report the injury to a health care provider, 7.9% reported that it "definitely would" (17/214), 26.6% "probably would" (57/214), 17.8%"neutral" (38/214), 24.8% "probably would not" (53/214), and 22.9% "definitely would not" (49/214). Despite generally believing that driving immediately following a concussion is unsafe, a majority of student-athletes did not refrain from driving at any point following their previous concussions. Post-concussion driving restrictions may have some influence on student-athletes' decisions to report the injury to a health care provider. Health care providers play a critical role in post-concussion driving restriction, but lack standardized recommendations to guide their care.

Driving after an injury or disease affecting the brain: an analysis of clinical data

Introduction

Traffic safety may be affected if a licence holder has experienced illness or injury that may have an impact on cognition. Occupational therapists are involved in assessing cognitive functions that might affect a patient’s ability to drive a car using different evaluation tools in different countries and settings. The aim of this study was to look at the predictive value of some of the assessment tools available to occupational therapists for making judgements about resuming driving after cognitive impairment due to brain trauma or disease.

Method

A retrospective study based on clinical data from 204 patients referred to a specialist department for recommendations on ability to drive after brain injury or disease. All patients underwent three assessments: stroke drivers screening assessment, useful field of view and simulated driving skill. In addition, an on-road assessment was added in 76% of the sample.

Results

Useful field of view had the highest sensitivity (78%) and, combined with the results from the simulator, the sensitivity was 87%. The specificity for the two methods was 55%.

Conclusion

The results from useful field of view and a simulator test combined best predicted the final recommendation from the multi-professional team discussion on which clients should be recommended not to resume driving.

Neurocognitive Models of Medical Decision-Making Capacity in Traumatic Brain Injury Across Injury Severity

OBJECTIVE

To identify neurocognitive predictors of medical decision-making capacity (MDC) in participants with mild and moderate/severe traumatic brain injury (TBI).

SETTING

Academic medical center.

PARTICIPANTS

Sixty adult controls and 104 adults with TBI (49 mild, 55 moderate/severe) evaluated within 6 weeks of injury.

DESIGN

Prospective cross-sectional study.

MAIN MEASURES

Participants completed the Capacity to Consent to Treatment Instrument to assess MDC and a neuropsychological test battery. We used factor analysis to reduce the battery test measures into 4 cognitive composite scores (verbal memory, verbal fluency, academic skills, and processing speed/executive function). We identified cognitive predictors of the 3 most clinically relevant Capacity to Consent to Treatment Instrument consent standards (appreciation, reasoning, and understanding).

RESULTS

In controls, academic skills (word reading, arithmetic) and verbal memory predicted understanding; verbal fluency predicted reasoning; and no predictors emerged for appreciation. In the mild TBI group, verbal memory predicted understanding and reasoning, whereas academic skills predicted appreciation. In the moderate/severe TBI group, verbal memory and academic skills predicted understanding; academic skills predicted reasoning; and academic skills and verbal fluency predicted appreciation.

CONCLUSIONS

Verbal memory was a predictor of MDC in controls and persons with mild and moderate/severe TBI. In clinical practice, impaired verbal memory could serve as a "red flag" for diminished consent capacity in persons with recent TBI.

Examining Driving and Participation 5 Years After Traumatic Brain Injury

Participation is often considered a primary goal of traumatic brain injury (TBI) rehabilitation, but little is known about the influence of driving on participation after TBI. The objective of this study was to examine the independent contribution of driving status to participation at 5 years post TBI, after controlling for demographic, psychosocial, and functional factors. Participants ( N = 2,456) were community-dwelling individuals with moderate to severe TBI, age 18 to 65 at time of injury, and enrolled in the TBI Model Systems (TBIMS) National Database (NDB). Hierarchical linear regressions for the dependent variable of participation at 5 years post TBI were performed. Findings showed that driving was a highly significant independent predictor of participation and was a stronger relative predictor of participation than FIM® Cognitive, FIM® Motor, and depression. The independent contribution of driving to participation suggests the need to develop evidenced-based occupational therapy assessments and interventions that facilitate safe engagement in the occupation of driving to address the long-term goal of improved participation.

Driving assessment and rehabilitation using a driving simulator in individuals with traumatic brain injury: A scoping review

BACKGROUND

Due to the heterogeneity of the lesion following a traumatic brain injury (TBI) and the complexity of the driving task, driving assessment and rehabilitation in TBI individuals is challenging. Conventional driving assessment (on-road and in-clinic evaluations) has failed demonstrating effectiveness to assess fitness to drive in TBI individuals.

OBJECTIVE

We aimed to determine if driving simulators represent an interesting opportunity in assessing and rehabilitating driving skills in TBI individuals.

METHODS

We searched PubMed, CINAHL and Cochrane library databases between 27-02-2014 and 08-04-2014 for articles published since 2000 with the contents of simulator driving assessment and rehabilitation.

RESULTS

Out of 488, eight articles with the subject of simulator driving assessment and two with the subject of simulator driving rehabilitation in individuals with TBI were reviewed.

CONCLUSIONS

Driving simulators represent a promising avenue for the assessment and rehabilitation of driving skills in TBI individuals as it allows control of stimuli in a safe, challenging and ecologically valid environment and offer the opportunity to measure and record driving performance. Additional studies, however, are needed to document strengths and limitations of this method.

Training driving ability in a traumatic brain-injured individual using a driving simulator: a case report

Background

Traumatic brain injury (TBI) causes functional deficits that may significantly interfere with numerous activities of daily living such as driving. We report the case of a 20-year-old woman having lost her driver’s license after sustaining a moderate TBI.

Objective

We aimed to evaluate the effectiveness of an in-simulator training program with automated feedback on driving performance in a TBI individual.

Methods

The participant underwent an initial and a final in-simulator driving assessment and 11 in-simulator training sessions with driving-specific automated feedbacks. Driving performance (simulation duration, speed regulation and lateral positioning) was measured in the driving simulator.

Results

Speeding duration decreased during training sessions from 1.50 ± 0.80 min (4.16 ± 2.22%) to 0.45 ± 0.15 min (0.44 ± 0.42%) but returned to initial duration after removal of feedbacks for the final assessment. Proper lateral positioning improved with training and was maintained at the final assessment. Time spent in an incorrect lateral position decreased from 18.85 min (53.61%) in the initial assessment to 1.51 min (4.64%) on the final assessment.

Conclusion

Driving simulators represent an interesting therapeutic avenue. Considerable research efforts are needed to confirm the effectiveness of this method for driving rehabilitation of individuals who have sustained a TBI.

Neuropsychological Assessment of Driving Capacity

Clinicians are increasingly requested to make determinations regarding patients' driving capacity in the context of neurological injury/conditions and a growing cohort of older drivers. The capability to drive safely involves a number of cognitive, physical, and sensorimotor abilities that may be impacted by injury, illness, or substances that influence alertness. Neuropsychological measures are an important component of a multidisciplinary approach for evaluation of driving capacity. Clinicians should become familiar with measures that have the best predictive validity so they may incorporate a patient's neurocognitive strengths and weaknesses in decisions about driving ability.

Traumatic brain injury, driver aggression and motor vehicle collisions in Canadian adults

OBJECTIVE

This study examines the associations between lifetime traumatic brain injury (TBI), driver aggression, and motor vehicle collisions among a population sample of adults who reside in the province of Ontario, Canada.

METHOD

A cross-sectional sample of 3993 Ontario adults, aged 18-97 were surveyed by telephone in 2011 and 2012 as part of Center for Addiction and Mental Health's ongoing representative survey of adult mental health and substance use in Canada. TBI was defined as trauma to the head that resulted in loss of consciousness for at least five minutes or overnight hospitalization.

RESULTS

An estimated 91% (95% CI: 90.0, 91.9) of individuals in this sample held a valid Ontario driver's license at the time of testing. Among those, 16.7% reported a history of lifetime TBI and 83.3% reported no TBI. The prevalence of TBI was higher among men than women. Relative to licensed adults without TBI, adults with a history of TBI had significantly higher odds of engaging in serious driver aggression in the past 12 months, such as making threats to hurt another driver, passenger or their vehicle (AOR=4.39). These individuals also reported significantly higher odds (AOR=1.74) of being involved in a motor vehicle collision that resulted in hurting themselves, their passenger(s) or their vehicle.

CONCLUSION

This is the first population-based study to demonstrate a relationship between a history of TBI and higher rates of serious driver aggression and collision involvement. Given the large proportion of adult drivers with a history of TBI, these individuals may account for a disproportion burden of all traffic safety problems. Whether the increased road safety risk of adults with a history of TBI is reflective of neurocognitive deficits or is merely evidence of a cluster of unsafe activities produced by a higher risk lifestyles requires further research attention.

Determining fitness to drive: A systematic review of the methods and assessments used after mild traumatic brain injury

Introduction

Limited evidence is available to support knowledge of the time-frame and capacity for fitness to drive after mild traumatic brain injury. The aim of this systematic review was to identify what methods and assessments are, or could be used to determine fitness to drive for this population.

Method

We undertook a systematic search of six electronic databases. Two authors rated all studies for methodological content and quality, and standardised data were extracted. Narrative analysis was conducted to understand the content of eligible studies.

Findings

A total of 2022 articles were retrieved; seven articles met the inclusion criteria. Self-reported questionnaires, non-standardised assessments, questionnaires completed by next-of-kin, and simulator tests were the primary methods used to determine fitness to drive. Only one assessment has been used to aid recommendations about fitness to drive in the acute hospital setting. Six additional standardised assessments were identified that have the potential to predict fitness to drive in this population group; however, these assessments require further psychometric testing prior to use.

Conclusion

While a variety of methods and assessments are currently used, there is little research evidence to suggest when individuals are able to return to driving after mild traumatic brain injury. Research is urgently required to determine a consistent and standardised approach to assessing fitness to drive following mild traumatic brain injury.

Driving after traumatic brain injury: evaluation and rehabilitation interventions

The ability to return to driving is a common goal for individuals who have sustained a traumatic brain injury. However, specific and empirically validated guidelines for clinicians who make the return-to-drive decision are sparse. In this article, we attempt to integrate previous findings on driving after brain injury and detail the cognitive, motor, and sensory factors necessary for safe driving that may be affected by brain injury. Various forms of evaluation (both in clinic and behind-the-wheel) are discussed, as well as driver retraining and modifications that may be necessary.

Predictors of driving avoidance and exposure following traumatic brain injury

BACKGROUND

An estimated 40% to 60% of individuals who experience a moderate to severe traumatic brain injury (TBI) return to driving. However, little is known about driving behavior post-TBI and how this may be related to demographic, injury, and outcome factors.

METHODS

A total of 184 participants who experienced moderate to severe TBI were included in this study. Participants completed a telephone survey regarding return to driving and current driving behavior. Structural equation modeling was used to analyze predicted relationships between demographic and injury-related variables with driving exposure and avoidance within 5 years of injury.

RESULTS

The model indicated that participants who were older and female tended to avoid a greater number of challenging everyday driving scenarios. Participants who had more severe injuries and those with poorer performance on cognitive measures at the time of rehabilitation discharge were likely to drive less frequently and over less distances at follow-up, though they did not avoid challenging driving situations.

CONCLUSIONS

Young men and those with more severe injuries may require additional attention regarding their driving behavior following TBI.

Managing driving issues after an acquired brain injury: strategies used by health professionals

BACKGROUND/AIM

The ability to drive safely can be affected by an acquired brain injury. Following acquired brain injury, clients may experience driving disruptions, formal assessment, return to driving or permanent cessation. Health professionals may be involved in formal driving or component skills' assessment and rehabilitation, or interventions for continued community participation. Meeting the needs of clients related to driving remains a challenging area of clinical practice. The aim of this study was to investigate how driving issues are currently managed by acquired brain injury rehabilitation teams.

METHOD

This study utilised a qualitative phenomenological approach to gain insight into the approaches undertaken by four rehabilitation teams working with clients post-acquired brain injury. Semi-structured, audiotaped interviews were conducted with 25 participants who had identified driving as part of their role.

RESULTS

Health professional participants described three major areas of clinical focus, describing strategies and challenges associated with each. These were as follows: 'Integrating driving goals into rehabilitation' which involved optimising timing and acknowledging the clients' focus on driving while enhancing driving and rehabilitation outcomes; 'Managing emotional responses' which required protecting therapeutic relationships and providing information, as well as responding to more extreme responses; and finally 'Managing unlicensed driving and meeting long-term needs', which participants identified as the most challenging aspect. Strategies involved using set procedures, building on knowledge of the client, supporting the family and exploring alternatives.

CONCLUSION

The teams described a range of strategies used to address the challenges related to driving and driving cessation which can be applied to successfully manage this issue in acquired brain injury rehabilitation.

Neurocognitive predictors of financial capacity in traumatic brain injury

OBJECTIVE

To develop cognitive models of financial capacity (FC) in patients with traumatic brain injury (TBI).

DESIGN

Longitudinal design.

SETTING

Inpatient brain injury rehabilitation unit.

PARTICIPANTS

Twenty healthy controls, and 24 adults with moderate-to-severe TBI were assessed at baseline (30 days postinjury) and 6 months postinjury.

MAIN OUTCOME MEASURES

The FC instrument (FCI) and a neuropsychological test battery. Univariate correlation and multiple regression procedures were employed to develop cognitive models of FCI performance in the TBI group, at baseline and 6-month time follow-up.

RESULTS

Three cognitive predictor models of FC were developed. At baseline, measures of mental arithmetic/working memory and immediate verbal memory predicted baseline FCI performance (R = 0.72). At 6-month follow-up, measures of executive function and mental arithmetic/working memory predicted 6-month FCI performance (R = 0.79), and a third model found that these 2 measures at baseline predicted 6-month FCI performance (R = 0.71).

CONCLUSIONS

Multiple cognitive functions are associated with initial impairment and partial recovery of FC in moderate-to-severe TBI patients. In particular, arithmetic, working memory, and executive function skills appear critical to recovery of FC in TBI. The study results represent an initial step toward developing a neurocognitive model of FC in patients with TBI.

Evaluation and management of mild traumatic brain injury: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time.

METHODS

The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined.

RESULTS

A total of 112 articles were reviewed and used to construct a series of recommendations.

CONCLUSION

The previous recommendation that brain computed tomographic (CT) should be performed on patients that present acutely with suspected brain trauma remains unchanged. A number of additional recommendations were added. Standardized criteria that may be used to determine which patients receive a brain CT in resource-limited environments are described. Patients with an MTBI and negative brain CT result may be discharged from the emergency department if they have no other injuries or issues requiring admission. Patients taking warfarin who present with an MTBI should have their international normalized ratio (INR) level determined, and those with supratherapeutic INR values should be admitted for observation. Deficits in cognition and memory usually resolve within 1 month but may persist for longer periods in 20% to 40% of cases. Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.

Crash risk factors related to individuals sustaining and drivers following traumatic brain injuries

OBJECTIVE

Some crashes result in drivers experiencing (or sustaining) a traumatic brain injury (TBI) while other crashes involve drivers that have already experienced a TBI. The objective of this study is to examine the factors that influence these two TBI crash groups.

METHODS

Data from the Iowa Department of Public Health's Brain Injury Registry and Department of Transportation's crash records were linked together and used in logistic regression models to predict the likelihood of a driver sustaining a TBI in a crash and those who drive after a TBI.

RESULTS

Between 2001 and 2006, there were 2382 crashes in which an individual sustained a TBI. As expected, a higher likelihood of sustaining a TBI was observed for motorcycle drivers who did not wear a helmet and in crashes that resulted in total or disabling vehicle damage. Focusing specifically on the post-TBI drivers (and not occupants), 1583 were involved in crashes. These post-TBI drivers were less likely to wear seatbelts or have passengers in the vehicle at the time of the crash, and were more likely to crash at night. Post-TBI drivers were also involved in significantly more multiple crashes (about 14%) when compared to drivers who have not experienced a TBI (about 10%) during the study period. When controlling for gender, date of injury, and severity of TBI (using Glasgow Coma Scale), individuals that sustained a TBI when they were younger were more likely to be involved in multiple crashes.

CONCLUSIONS

Different factors influence the crash likelihood for those that sustain a TBI in a crash and those that crash following a TBI. In general, post-TBI drivers have a higher occurrence of multiple crashes and this should be further explored to guide driver rehabilitation, evaluation, and training.

Intelligent speed adaptation as an assistive device for drivers with acquired brain injury: a single-case field experiment

Intelligent speed adaptation (ISA) was tested as an assistive device for drivers with an acquired brain injury (ABI). The study was part of the "Pay as You Speed" project (PAYS) and used the same equipment and technology as the main study (Lahrmann et al., in press-a, in press-b). Two drivers with ABI were recruited as subjects and had ISA equipment installed in their private vehicle. Their speed was logged with ISA equipment for a total of 30 weeks of which 12 weeks were with an active ISA user interface (6 weeks=Baseline 1; 12 weeks=ISA period; 12 weeks=Baseline 2). The subjects participated in two semi-structured interviews concerning their strategies for driving with ABI and for driving with ISA. Furthermore, they gave consent to have data from their clinical journals and be a part of the study. The two subjects did not report any instances of being distracted or confused by ISA, and in general they described driving with ISA as relaxed. ISA reduced the percentage of the total distance that was driven with a speed above the speed limit (PDA), but the subjects relapsed to their previous PDA level in Baseline 2. This suggests that ISA is more suited as a permanent assistive device (i.e. cognitive prosthesis) than as a temporary training device. As ABI is associated with a multitude of cognitive deficits, we developed a conceptual framework, which focused on the cognitive parameters that have been shown to relate to speeding behaviour, namely "intention to speed" and "inattention to speeding". The subjects' combined status on the two independent parameters made up their "speeding profile". A comparison of the speeding profiles and the speed logs indicated that ISA in the present study was more efficient in reducing inattention to speeding than affecting intention to speed. This finding suggests that ISA might be more suited for some neuropsychological profiles than for others, and that customisation of ISA for different neuropsychological profiles may be required. However, further studies with more subjects are needed in order to be conclusive on these issues.

Financial capacity following traumatic brain injury: a six-month longitudinal study

OBJECTIVE

To longitudinally investigate financial capacity (FC) following traumatic brain injury (TBI).

DESIGN

Longitudinal study comparing FC in cognitively healthy adults and persons with moderate to severe TBI at time of acute hospitalization (Time 1) and at 6 months postinjury (Time 2).

SETTING

Inpatient brain injury rehabilitation unit.

PARTICIPANTS

Twenty healthy adult controls and 24 adult persons with moderate to severe TBI.

MAIN OUTCOME MEASURES

Participants were administered the Financial Capacity Instrument (FCI-9), a standardized instrument that measures performance on 18 financial tasks, 9 domains, and 2 global scores. Between- and within-group differences were examined for each FCI-9 domain and global scores. Using control group referenced cut scores, participants with TBI were also assigned an impairment rating (intact, marginal, or impaired) on each domain and global score.

RESULTS

At Time 1, participants with TBI performed significantly below controls on the majority of financial variables tested. At Time 2, participants with TBI demonstrated within group improvement on both simple and complex financial domains, but continued to perform below adult controls on complex financial domains and both global scores. Group by time interactions were significant for four domains and both global scores. At Time 1, high percentages of participants with TBI were assigned either "marginal" or "impaired" ratings on the domains and global scores, with significant percentage increases of "intact" ratings at Time 2.

CONCLUSIONS

Immediately following acute injury, persons with moderate to severe TBI show global impairment of FC. Findings indicate improvement of both simple and complex financial skills over a 6-month period, but continued impairment on more complex financial skills. Future studies should examine loss and recovery of FC following TBI over longer time periods and a wider range of injury severity.

Higher-order reasoning training years after traumatic brain injury in adults

OBJECTIVE

To conduct a feasibility study to compare the effects of top-down Strategic Memory and Reasoning Training (SMART) versus information-based Brain Health Workshop (BHW, control) on gist-reasoning (ie, abstracting novel meaning from complex information), memory, executive functions, and daily function in adults with traumatic brain injury.

PARTICIPANTS

Twenty-eight participants (of the 35 recruited), 16 men & 12 women, aged 20 to 65 years (M = 43, SD = 11.34) at chronic stages posttraumatic brain injury (2 years or longer) completed the training. Fourteen participants that received SMART and 14 participants that completed BHW were assessed both pre- and posttraining. Thirteen of the SMART trained and 11 from BHW participated in a 6-month testing.

DESIGN

The study was a single blinded randomized control trial. Participants in both groups received a minimum of 15 hours of training over 8 weeks.

RESULTS

The SMART group significantly improved gist-reasoning as compared to the BHW group. Benefits of the SMART extended to untrained measures of working memory and participation in functional activities. Exploratory analyses suggested potential transfer effects of SMART on memory and executive functions. The benefits of the SMART program as compared to BHW were evident at immediately posttraining and 6 months posttraining.

CONCLUSION

This study provides preliminary evidence that short-term intensive training in top-down modulation of information benefits gist-reasoning and generalizes to measures of executive function and real life function at chronic stages of post-TBI.

A verbal cuing device for persons with brain injury: development and proof-of-concept case study

The ability to successfully return to driving following neurologic injury is one of the most critical factors in re-establishing independence and the most notable safety concern of health providers and family members. This assistive technology study describes the development of a verbal cuing device called the Electronic Driving Coach used as an adjunct to driver training following brain injury. We review literature on rates of return to driving following brain injury and factors associated with predicting return to driving and driving ability. We then address critical factors to return to driving addressed by this emerging technology and describe how the verbal cuing device called the Electronic Driving Coach was designed. We provide a proof-of-concept case study that evaluates use of the verbal cuing device with a person who has experienced a traumatic brain injury. Last, we discuss practical considerations for developing and using assistive driving devices in persons with cognitive impairments, including drivers who have experienced a stroke.

Role of premorbid factors in predicting safe return to driving after severe TBI

PRIMARY OBJECTIVE

The present study explored the possibility of predicting post-injury fitness to safe driving in patients with severe traumatic brain injury (TBI) (n = 66).

METHODS AND PROCEDURE

Sixteen different measures, derived from four domains (demo/biographic, medico-functional, neuropsychological, and psychosocial) were used as predictor variables, whereas driving outcomes were assessed in terms of driving status (post-TBI drivers versus non-drivers) and driving safety (number of post-TBI car accidents and violations).

MAIN OUTCOMES AND RESULTS

About 50% of the patients resumed driving after TBI. Compared to post-TBI non-drivers, post-injury drivers had shorter coma duration. With regard to driving safety, the final multiple regression model combined four predictors (years post-injury, accidents and violations before TBI, pre-TBI-risky-personality-index, and pre-TBI-risky-driving-style-index) and explained 72.5% of variance in the outcome measure.

CONCLUSIONS

Since the best three predictors of post-injury driving safety addressed patients' premorbid factors, the results suggest that in order to evaluate the actual possibility of safe driving after TBI, it would be advisable to consider carefully patients' pre-TBI histories.

Time-sharing strategies in driving after various cerebral lesions

PRIMARY OBJECTIVE

To analyse time-sharing strategies in patients with cerebral lesions when they performed everyday in-car tasks in real-life highway driving. A case-control study.

METHODS AND PROCEDURES

Thirteen male patients with brain damage and 11 healthy controls participated. The frequency and duration of glances at the in-car tasks, total time of eyes-off the road during tasks, speed and lateral displacement of the car were recorded.

MAIN OUTCOMES AND RESULTS

Long glances away from the road and consequent large lateral displacements were characteristic for patients with anterior damage, while the patients with more posterior lesions used frequent short glances at the in-car task.

CONCLUSION

Two different time-sharing strategies that appeared to be related to different aetiology were found in the patients, indicating different control of the driving task. It is proposed that standardized on-road dual tasks should be used for detecting problems in allocation of attention during driving.

Validation of the stroke drivers screening assessment for people with traumatic brain injury

Cognitive impairments resulting from brain injury affect driving performance. The question of fitness to drive often arises during rehabilitation. Healthcare professionals need reliable criteria against which decisions about driving fitness can be made. Nouri et al. developed the Stroke Drivers Screening Assessment (SDSA), which was found predictive of on-road driving performance in stroke patients. The purpose of this study was to determine whether the SDSA, either alone or combined with other tests, predicted fitness to drive in brain injured people. Fifty-two participants were assessed on the SDSA plus additional cognitive tests. Their fitness to drive was examined on the public road. The SDSA predictions based on equations developed for stroke patients were not an accurate predictor of road test performance. Discriminant analysis was used to identify tests predictive of fitness to drive. Results indicated that a combination of the SDSA, the Stroop and the AMIPB Information Processing tasks correctly classified 87% of cases and may be useful predictors of driving fitness following brain injury. However, cross-validation on an independent sample of people with brain injury is required.

UFOV performance and driving ability following traumatic brain injury

PRIMARY OBJECTIVE

To investigate the relationship between performance on the Useful Field of View Test (UFOV) and driving performance following traumatic brain injury (TBI).

PARTICIPANTS

Sixty people with TBI referred for driving evaluation.

MEASURES

Useful Field of View Test, Global Rating Scale and Driver Assessment Scale.

RESULTS

Subject performance diminished as the complexity of the UFOV sub-tests increased. There was a significant relationship between UFOV performance, particularly on the second sub-test, and on-road driving performance. Subject age and Trail Making Test, Part B were also predictive of driving performance.

CONCLUSIONS

The UFOV can be used as a screening measure to determine readiness to participate in an on-road driving assessment.