Predictors of the On-Road Driving Assessment After Traumatic Brain Injury: Comparing Cognitive Tests, Injury Factors, and Demographics

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.

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

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

Return to Cycling Following Brain Injury: A Proposed Multidisciplinary Approach

Cycling is an important form of exercise, recreation, and transportation. Following traumatic brain injury, the benefits of cycling for health, fitness, and community mobility must be considered alongside potential risk for recurrent injury. In addition to medical concerns and exercise tolerance, key domains include motor function, attention, and visuospatial and executive function, which have previously been explored with regard to driving. Cycling skill is a combination of cognitive and motor function, and can be trained with appropriate education and intervention. We discuss the relationship of brain injury rehabilitation to specific features of cycling, including case studies.

Predictors of Driving Status in Service Members and Veterans at 1 Year Posttraumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

To identify predictors of driving status in service members and veterans 1 year following a traumatic brain injury (TBI).

SETTING

The 5 Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs).

PARTICIPANTS

A total of 471 service members and veterans (128 with mild/complicated mild TBI and 343 with moderate/severe TBI) who received TBI-focused inpatient rehabilitation at one of the VA PRCs and who participated in a 1-year postinjury follow-up assessment.

DESIGN

Secondary analysis from the Department of Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems (VA PRC TBIMS) national database.

MAIN MEASURES

Primary outcome was a single item that assessed driving status at 1 year postinjury. Predictor variables included demographics; sensory impairment, substance use, and employment status at time of injury; PTSD symptoms reported at study enrollment; and functional impairment rated at rehabilitation discharge.

RESULTS

In unadjusted bivariate analyses, among those with a mild/complicated mild TBI, older age and greater functional impairment were associated with lower likelihood of driving. Among those with a moderate/severe TBI, discharge to a nonprivate residence, greater functional impairment, and higher PTSD symptoms were linked to lower likelihood of driving. Adjusted multivariate analyses indicated that functional impairment was uniquely associated with driving status in both TBI severity groups. After controlling for other predictors, self-reported PTSD symptoms, particularly dysphoria symptoms, were associated with lower likelihood of driving in both severity groups.

CONCLUSION

Given the significance of clinician-rated functional impairment and self-reported PTSD symptoms to the prediction of driving status 1 year post-TBI among service members and veterans, rehabilitation efforts to improve functioning and reduce negative affect may have a positive impact on driving and community integration.

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.

On-road driving test performance in veterans: Effects of age, clinical diagnosis and cognitive measures

INTRODUCTION

Veterans are at heightened risk of being in a motor-vehicle crash and many fail on-road driving evaluations, particularly as they age. This may be due in part to the high prevalence of age-associated conditions impacting cognition in this population, including neurodegenerative diseases (e.g., Alzheimer's Disease) and acquired neurological conditions (e.g., cerebrovascular accident). However, understanding of the impact of referral diagnosis, age and cognition on Veterans' on-road driving performance is limited.

METHODS

109 Veterans were referred for a driving evaluation (mean age = 72.0, SD = 11.5) at a driving assessment clinic at the Minneapolis Veterans Affairs Healthcare System. Of the 109 Veterans enrolled, 44 were referred due to a neurodegenerative disease, 37 due to an acquired neurological condition, and 28 due to a non-neurological condition (e.g., vision loss). Veterans completed collection of health history information and administration of cognitive tests assessing visual attention, processing speed, and executive functioning, as well as a standardized, on-road driving evaluation.

RESULTS

A total of 17.9% of Veterans failed the on-road evaluation. Clinical diagnostic group was not associated with failure rate. Age was not associated with failure rates in the full sample or within diagnostic groups. After controlling for age, poorer processing speed and selective/divided attention were associated with higher failure rates in the full sample. No cognitive tests were associated with failure rates within diagnostic groups.

CONCLUSION

Referral diagnosis and age alone are not reliable predictors of Veterans' driving performance. Cognitive performance, specifically speed of processing and attention, may be helpful in screening Veterans' driving safety. Practical Applications: Clinicians tasked with assessing Veterans' driving safety should take into account cognitive performance, particularly processing speed and attention, when making decisions regarding driving safety. Age and referral diagnosis, while helpful information, are insufficient to predict outcomes on driving evaluations.

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.

Slowed driving-reaction time following concussion-symptom resolution

BACKGROUND

Concussed patients have impaired reaction time (RT) and cognition following injury that may linger and impair driving performance. Limited research has used direct methods to assess driving-RT post-concussion. Our study compared driving RT during simulated scenarios between concussed and control individuals and examined driving-RT's relationship with traditional computerized neurocognitive testing (CNT) domains.

METHODS

We employed a cross-sectional study among 14 concussed (15.9 ± 9.8 days post-concussion, mean ± SD) individuals and 14 healthy controls matched for age, sex, and driving experience. Participants completed a driving simulator and CNT (CNS Vital Signs) assessment within 48 h of symptom resolution. A driving-RT composite (ms) was derived from 3 simulated driving scenarios: stoplight (green to yellow), evasion (avoiding approaching vehicle), and pedestrian (person running in front of vehicle). The CNT domains included verbal and visual memory; CNT-RT (simple-, complex-, Stroop-RT individually); simple and complex attention; motor, psychomotor, and processing speed; executive function; and cognitive flexibility. Independent t tests and Hedge d effect sizes assessed driving-RT differences between groups, Pearson correlations (r) examined driving RT and CNT domain relationships among cohorts separately, and p values were controlled for false discovery rate via Benjamini-Hochberg procedures (α = 0.05).

RESULTS

Concussed participants demonstrated slower driving-RT composite scores than controls (mean difference = 292.86 ms; 95% confidence interval (95%CI): 70.18-515.54; p = 0.023; d = 0.992). Evasion-RT (p = 0.054; d = 0.806), pedestrian-RT (p = 0.258; d = 0.312), and stoplight-RT (p = 0.292; d = 0.585) outcomes were not statistically significant after false-discovery rate corrections but demonstrated medium to large effect sizes for concussed deficits. Among concussed individuals, driving-RT outcomes did not significantly correlate with CNT domains (r-range: -0.51 to 0.55; p > 0.05). No correlations existed between driving-RT outcomes and CNT domains among control participants either (r-range: -0.52 to 0.72; p > 0.05).

CONCLUSION

Slowed driving-RT composite scores and large effect sizes among concussed individuals when asymptomatic signify lingering impairment and raise driving-safety concerns. Driving-RT and CNT-RT measures correlated moderately but not statistically, which indicates that CNT-RT is not an optimal surrogate for driving RT.

Role of vehicle assistive devices for safe return to driving after severe acquired brain injury

BACKGROUND

Driving is a complex activity that requires a wide range of cognitive, behavioral, sensory and motor competences that are often impaired in cases of severe acquired brain injury (sABI). A safe return to driving is an objective significantly correlated with recovery of personal independence and social-occupational role.

AIM

The study investigated elements predictive of the possibility of a safe return to driving after sABI, concentrating on motor disability and the need to prescribe vehicle assistive devices.

DESIGN

Retrospective study.

SETTING

Out-patients of a rehabilitation center for sABI.

POPULATION

A series of 217 patients with stable sABI, well reintegrated at family and social level, were enrolled between January 2006 and June 2019.

METHODS

The subjects were assessed for residual competences. Those who passed assessment of cognitive-behavioral and visual impairment were assessed for motor disability and the need for vehicle assistive devices to enable a safe return to driving.

RESULTS

About 79% of the population were judged suitable for a return to driving. More than 50% of the latter were only able to return to driving with the aid of vehicle assistive devices. Etiological and demographic variables were not predictive of assessment outcome, whereas the various Griffith motor disability categories were correlated with need for vehicle assistive devices, which are most needed in non-traumatic subjects.

CONCLUSIONS

Although the literature on return to driving after brain injury focuses mainly on cognitive-behavioral impairment, in a significant percentage of cases it is also necessary to carefully analyse and manage motor disabilities that may result from sABI.

CLINICAL REHABILITATION IMPACT

Evaluation of the competences necessary for a return to driving after sABI requires a multiprofessional team that must also assess motor disability and know the possible vehicle assistive devices that can enable most candidates to overcome the limits imposed by their disability.

Exploring driving characteristics of fit- and unfit-to-drive neurological patients: a driving simulator study

Objective: To identify driving characteristics of fit-, unfit-, and conditionally fit-to-drive neurological patient populations using a driving simulator with three high-risk scenarios comprising rural, highway, and urban environments.Methods: The study included 91 neurological patients undergoing a multidisciplinary assessment for driver's license revalidation, consisting of a clinical, neuropsychological, functional, and on-road evaluation. The groups drove through three independent driving scenarios, during which a variety of measures describing reaction time, vehicular control, and traffic rule compliance were performed. One-way analysis of variance (ANOVA) with Bonferroni correction was used for group comparison, independently for each driving scenario, and Pearson correlations were calculated between simulator variables and neuropsychological test scores.Results: The fit- and unfit-to-drive population significantly differed (p < .05) in reaction times, regardless of the scenario. No significant differences in traffic rule compliance or vehicular control parameters were observed in the rural environment (p > .05). On the highway, the unfit group exhibited greater variability of steering wheel angle, higher steering reversal rate, and a higher rate of turn signal errors. In the urban environment, the unfit group oversped more, had more collisions, and exhibited greater lane position variability. The latter, along with reaction times in the rural and highway scenarios, was also shown to significantly differ between the conditional and unfit group (p < .05). No significant differences were observed between the fit and the conditional group (p > .05). Weak to moderate associations (range: -0.5 to 0.29) between neuropsychological tests and various simulator variables were also observed.Conclusions: Our results show that driving simulators are able to capture differences between (fit- and unfit-to-drive) neurological patient populations and therefore bear the potential for being used as a deficit-independent screening, assessment, or rehabilitation tool. The conditionally-fit-to-drive group exhibited less discriminative features, which points to greater importance of human judgment for this population. The observation that differences in most of the parameters were environment-dependent suggests that developers of future driver simulation tools should carefully design scenarios in order to fully exploit their assessment potential.

A Systematic Review and Meta-Analysis on the Association Between Driving Ability and Neuropsychological Test Performances after Moderate to Severe Traumatic Brain Injury

OBJECTIVES

Guidelines on return-to-driving after traumatic brain injury (TBI) are scarce. Since driving requires the coordination of multiple cognitive, perceptual, and psychomotor functions, neuropsychological testing may offer an estimate of driving ability. To examine this, a meta-analysis of the relationship between neuropsychological testing and driving ability after TBI was performed.

METHODS

Hedge's g and 95% confidence intervals were calculated using a random effects model. Analyses were performed on cognitive domains and individual tests. Meta-regressions examined the influence of study design, demographic, and clinical factors on effect sizes.

RESULTS

Eleven studies were included in the meta-analysis. Executive functions had the largest effect size (g = 0.60 [0.39-0.80]), followed by verbal memory (g = 0.49 [0.27-0.71]), processing speed/attention (g = 0.48 [0.29-0.67]), and visual memory (g = 0.43 [0.14-0.71]). Of the individual tests, Useful Field of Vision (UFOV) divided attention (g = 1.12 [0.52-1.72]), Trail Making Test B (g = 0.75 [0.42-1.08]), and UFOV selective attention (g = 0.67 [0.22-1.12]) had the largest effects. The effect sizes for Choice Reaction Time test and Trail Making Test A were g = 0.63 (0.09-1.16) and g = 0.58 (0.10-1.06), respectively. Years post injury (β = 0.11 [0.02-0.21] and age (β = 0.05 [0.009-0.09]) emerged as significant predictors of effect sizes (both p < .05).

CONCLUSIONS

These results provide preliminary evidence of associations between neuropsychological test performance and driving ability after moderate to severe TBI and highlight moderating effects of demographic and clinical factors.

Modified motor vehicles: the experiences of drivers with disabilities

Purpose: Driving is often a rehabilitation goal of people with acquired disability, and vehicle modifications are typically required to facilitate this outcome. Though there have been several survey studies on vehicle modifications for people with disability, there has been no qualitative work on understanding people with disabilities' experiences of being a modified vehicle driver.Method: An interpretative phenomenological approach was used to understand the lived experiences of drivers with disability. Semi-structured interviews were conducted (n = 8) with drivers who used a variety of vehicle modifications from simple to highly complex. Using NVivo, Stage 1 of the coding involved case by case analysis and Stage 2 cross case analysis to identify themes that best captured drivers' experiences.Results: Four core themes were identified: knowing vs. challenging limitations, making complex driving considerations, considering undesired alternative transportation options, and responding emotionally to temporary vehicle loss. The Person-Environment-Occupation model was used as an orientating framework to discuss findings.Conclusions: This explorative small scale study highlights that less than full utilisation of modified vehicles is not a result of driver choice, but rather a complex interface between drivers' physical and psychological limitations, and physical environments that do not support the needs of drivers with disability.Implications for RehabilitationThe development of resources that identify environmental factors in public spaces (e.g., number and location of parking for people with disability, steps, slopes, ticket machines and their height and location) could support the driving choices of people with disabilities.It is important to assess psychological limitations of driving as well as physical limitations.Driving goals and driving capacity across different locations requires periodic review post-rehabilitation.More advocacy for improving community accessibility is required.

Safe return to driving following severe acquired brain injury: role of a short neuropsychological assessment

BACKGROUND

Driving is a complex ability requiring a broad range of motor, cognitive-behavioral and visual skills that may be impaired after severe acquired brain injury (sABI). Resumption of driving is perceived as a major need by patients, being closely linked to personal autonomy, work and social activities.

AIM

The objective of this study was to identify a short battery of neuropsychological tests with predictive value with regard to safe return to driving after sABI.

DESIGN

Observational study.

SETTING

Outpatient of a rehabilitation center for sABI.

POPULATION

A continuous series of 127 patients with stable sABI, well-reintegrated at a family and social level, dismissed since at least one year from the end of their intensive rehabilitation, enrolled between 2006 and 2014.

METHODS

Patients underwent an extensive battery of neuropsychological tests (pencil and paper and specific PC programs), aimed at assessing cognitive functions, in performance and verbal tasks. The results were analyzed in relation to their on-road performance during the driving test conducted by the office of the Italian Government Authority (success or failure of the test).

RESULTS

No correlations were found between demographic data, etiology, driving experience, verbal competence and the decision of the competent authority. Significant correlation was found between attention, executive functions, overall visual-spatial exploration and driving performance.

CONCLUSIONS

Both "pencil and paper" and computerized tests in the cognitive domains of attentive functions, and those involving performance with visual-spatial material, are significantly correlated with the driving test outcome, even if there is not enough evidence of the relative value of off-road compared to direct on-road tests.

CLINICAL REHABILITATION IMPACT

We propose a small neuropsychological battery of tests with normative data for Italian population, predictive with respect to the ability to drive safely. We recommend to use it as first screening before submitting patients to more demanding and risky on-road driving tests.

Evidence Based Review of Fitness-to-Drive and Return-to-Driving Following Traumatic Brain Injury

The purpose of this study was to conduct an evidence-based review to determine predictors of fitness to drive and return to driving in persons with traumatic brain injury (TBI). Relevant databases (MEDLINE/PubMed, CINAHL, Cochrane Library, and SCOPUS) were searched for primary articles published before June 2016 using MeSH search terms. Using the American Academy of Neurology’s classification criteria, 24 articles were included after reviewing 1998 articles. Studies were rated by class (I–IV), with I being the highest level of evidence. Articles were classified according to TBI severity, as well as types of assessments (on-road, simulator and surveys). There were no Class I studies. Based on Class II studies, only Post-traumatic amnesia (PTA) duration was found to be probably predictive of on-road driving performance. There is limited evidence concerning predictors of return to driving. The findings suggest further evidence is needed to identify predictors of on-road driving performance in persons with TBI. Class I studies reporting Level A recommendations for definitive predictors of driving performance in drivers with TBI are needed by policy makers and clinicians to develop evidence-based guidelines.