Association of Age and Neurological Severity at Intensive Care Unit Admission With Driving Resumption Within 30 Days of Stroke: A Single-Center Historical Cohort Study

Objectives Guidelines in several countries recommend against driving soon after a stroke; however, some patients resume driving within one month after onset. This study aimed to examine the relationship between neurological and social background factors at intensive care unit (ICU) admission and resumption of motor vehicle driving within 30 days of the first acute stroke/cerebral hemorrhage. Materials and methods Data were extracted from medical records of a single center linked to the National Cerebral and Cardiovascular Center Administration Office for Stroke Data Bank in Japan. The data included age, sex, Japan Coma Scale (JCS), National Institutes of Health Stroke Scale (NIHSS), employment status, family situation, and outcomes of driving resumption in patients with a valid driving license transported to the ICU within 24 hours of stroke onset. Time-to-event analysis was used to explore the associations between these factors and driving resumption, with data censored 30 days from onset. Results In total, 239 patients had complete medical records, of whom 66 resumed driving. A multivariate Cox proportional hazards analysis showed that fewer patients aged ≥65 years resumed driving than those aged <65 years (hazard ratio 0.46; 95% confidence interval: 0.25-0.84; p=0.009). Patients with NIHSS scores ≥5 and JCS scores ≥1 were also less likely to resume driving compared with those with scores <5 (0.22; 0.08-0.56; p=0.008) and 0 (0.13; 0.04-0.37; p<0.001), respectively. Conclusions Age, NIHSS score, and JCS score at ICU admission are independently associated with the likelihood of resuming driving within 30 days of stroke onset. These findings may aid with the provision of support and education to facilitate the efficient resumption of driving after an acute event.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Driving scenarios and environmental settings in simulator-based driving assessment systems for stroke: a systematic review

BACKGROUND

Driving simulators are effective tools to evaluate the driving abilities of patients with stroke. They can introduce various driving scenarios which will greatly benefit both the assessors and drivers. However, there is still no guidelines by which driving scenarios should be introduced in the driving assessment.

OBJECTIVES

We conducted a systematic review to examine the utilization of driving scenarios and environments in the simulator-based driving assessment for patients with stroke.

METHODS

A systematic review was conducted following PRISMA. We searched PubMed, Web of Science, ScienceDirect, ACM Digital Library, and IEEE Xplore Digital Library databases in January and June 2022 to identify eligible articles published since 2010.

RESULTS

Our searches identified 1,614 articles. We included 12 studies that applied driving simulators to assess the driving performance of patients with stroke. The driving scenarios were categorized into three categories - vehicle controls scenarios, hazard perception scenarios, and trajectory planning scenarios - based on a certain set of driving abilities. The most common driving scenarios are simple navigation (n = 8) and emergency stop (n = 8). The most frequently used driving area is urban (n = 9), and a variety of roads and traffic conditions were found in the included studies. Only 2 studies applied weather conditions, such as the clear and sunny condition or the windy condition.

CONCLUSION

It is recommended for future research to consider covering scenarios from the aforementioned three categories and further investigate the benefits of introducing complex weather conditions and localized traffic conditions in the driving assessment.

Driving Rehabilitation for Stroke Patients: A Systematic Review with Meta-Analysis

Driving enables stroke survivors to freely participate in social integration. The purpose of this review was to summarize the evidence for the therapeutic effects of driving rehabilitation for patients when they return to driving after stroke and evaluate the predictors of returning to driving to identify the factors impacting their driving rehabilitation. This study employed a systematic review and meta-analysis. PubMed and four other databases were searched until 31 December 2022. Our review included randomized controlled trials (RCT) and non-RCTs that investigated driving rehabilitation for stroke and observational studies. A total of 16 studies (two non-RCT and 14 non-RCT) were reviewed; two RCTs investigated the effect of driving rehabilitation with a simulator system, and eight and six non-RCTS evaluated the predictive factors of driving return post-stroke and compared the effects of driving rehabilitation for stroke, respectively. The National Institute of Health Stroke Scale (NIHSS) and Mini Mental State Examination (MMSE) scores and having paid employment were significant predictors of resuming driving after stroke. The results suggest that NIHSS, MMSE, and paid employment are predictors of returning to driving post-stroke. Future research should investigate the effect of driving rehabilitation on the resumption of driving in patients with stroke.

Stroke Recurrence among Stroke Patients Referred for Driving Assessment and Rehabilitation: A Cohort Study

Returning to driving is one of the priorities for stroke survivors. However, the fear of the risk of recurrent stroke has led to concern about allowing driving post-stroke. This study was performed to study the impact of various vascular risk factors on stroke recurrence among drivers referred to our national referral center for Driving Assessment and Rehabilitation Program (DARP). Medical records of subjects who were diagnosed to have a stroke and were referred to DARP were retrospectively reviewed. Data on demographics (age and gender) and vascular risk factors (hypertension-HT, diabetes mellitus-DM, hyperlipidemia-HL, cigarette smoking-SM, previous stroke-PS, and heart disease-HD) were collected. Subjects were contacted and records scrutinized for a report of recurrent stroke. A total of 133 subjects were recruited, median 54 years (range 20-77 years), 95.5% male, 59.4% had HT, 32.3% DM, 65.4% HL, 43.6% SM, 3.8% PS, and 8.3% HD. Over a median follow-up of 30 months (range 1-78 months), the recurrence rate of stroke was 11.3%, 3.69/100 patient-years. On uni-variable analysis, the risk of stroke recurrence rose with age (HR 1.08, 95%CI 1.02-1.15, p = 0.01) and heart disease (HR 5.77, 95%CI 1.46-22.83, p = 0.01). On multivariable analysis, only age remained significant (HR 1.07, 95%CI 1.00-1.13, p = 0.045). Among those aged > 60 years, the HR was 3.88 (95%CI 1.35-11.20, p = 0.012). The risk of stroke recurrence is higher among older drivers and is not influenced by other vascular factors.

The Clinical Usefulness of the Practice Resource for Driving after Stroke (PReDAS)

Occupational Therapists (OTs) have identified a critical need for organized, evidence-based resources to approach driving post-stroke. The Practice Resource for Driving After Stroke (PReDAS) is a resource to support the clinical reasoning and practice of health professionals for addressing driving in acute stroke care. The purpose of this pilot study is to evaluate the usefulness of the PReDAS to support clinician and patient decision-making about return to driving after stroke/Transient Ischemic Attack (TIA) in the acute care hospital setting. OTs, physicians, and patients diagnosed with stroke/TIA were surveyed regarding their experience with the PReDAS in acute care. Patient participants were also contacted for a follow-up questionnaire. OT, physician and patient stakeholders reported the PReDAS was useful to support decision-making for driving. The majority of patients recalled information provided in acute care and abstained from driving as advised. This study provides preliminary support for the clinical usefulness of the PReDAS.

Rethinking Driving Against Medical Advice: The Situated Nature of Driving After Stroke

Background: As stroke can result in functional impairments that impact driving ability, many jurisdictions mandate a 30-day period of driving restriction post-stroke. However, between 26% and 38% of clients drive against medical advice during this period. Purpose: Informed by critical reflexivity of the literature and the first author's practice, this critical analysis paper (1) explicates and critiques how adherence to guidelines regarding driving after stroke in the first 30 days is conceptualized in individualistic, biomedically centred research and (2) argues for expanded understandings of driving based on a transactional occupational perspective. Key Issues: Individualistic, biomedical perspectives view driving against medical advice as an individually located phenomenon, generating partial understandings and individually focused solutions. Re-conceptualizing driving after stroke as a transactional occupational choice provides a productive basis for understanding and addressing driving within practice and research. Implications: Concepts from occupational science can generate new insights for research and client-centred practice regarding driving following stroke.

Post-stroke fatigue: A factor associated with inability to return to work in patients <60 years-A 1-year follow-up

This study investigated the association between post-stroke fatigue and inability to return to work/drive in young patients aged <60 years with first stroke who were employed prior to infarct while controlling for stroke severity, age, extent of disability, cognitive function, and depression. The Fatigue Severity Scale (FSS) was used to evaluate post-stroke fatigue in this 1-year prospective cohort study. Follow-ups were completed at 3, 6, and 12 months post rehabilitation discharge. A total of 112 patients were recruited, 7 were excluded, due to loss to follow-up (n = 6) and being palliative (n = 1), resulting in 105 participants (71% male, average age 49 ±10.63 years). Stroke patients receiving both inpatient and outpatient rehabilitation were consecutively recruited. Persistent fatigue remained associated with inability to return to work when controlling for other factors at 3 months (adjusted OR = 18, 95% CI: 2.9, 110.3, p = 0.002), 6 months (adjusted OR = 29.81, 95% CI: 1.7, 532.8, p = 0.021), and 12 months (adjusted OR = 31.6, 95% CI: 1.8, 545.0, p = 0.018). No association was found between persistent fatigue and return to driving. Fatigue at admission was associated with inability to return to work at 3 months but not return to drive. Persistent fatigue was found to be associated with inability to resume work but not driving. It may be beneficial to routinely screen post-stroke fatigue in rehabilitation and educate stroke survivors and employers on the impacts of post-stroke fatigue on return to work.

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.

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

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

Increased Risk of Traffic Injury After a Cerebrovascular Event

Background and Purpose- We aimed to determine the long-term risks of a motor vehicle collision after a cerebrovascular event and whether the risks were similar after left- or right-hemispheric events. Methods- We used a population-based registry to identify patients diagnosed with a transient ischemic attack or stroke (hemorrhagic or ischemic) between 2003 and 2013 in Ontario, Canada. Hemispheric laterality was determined using radiological and clinical findings. We identified subsequent serious injuries involving the patient as a driver using linked administrative data. Secondary outcomes included serious injuries involving the patient as a pedestrian, as a passenger, or other traumatic events (fall, fracture, ankle sprain). We used proportional hazard models accounting for death as a competing risk to test the association of hemispheric laterality and outcomes with and without adjustment for age, sex, discharge modified Rankin Scale score, home location, and prior driving record. Patients were followed through to 2017. Results- Among 26 144 patients with hemispheric cerebrovascular events, 377 subsequent serious traffic injuries as a driver (2.2 per 1000 person-year) were identified over a median follow-up of 6.4 person-years. The rate did not differ by laterality (adjusted hazard ratio, 1.00; 95% CI, 0.82-1.23). The risk of a serious traffic injury as a pedestrian was significantly higher after a right-sided than left-sided event (adjusted hazard ratio, 1.27; 95% CI, 1.02-1.58). Subsequent risks for other traumatic injuries did not differ by laterality of cerebrovascular event. Conclusions- The risk of a serious traffic injury as a pedestrian is substantially higher after a right-hemispheric cerebrovascular event compared with a left-sided event. Walking should be promoted for exercise in survivors of a stroke or transient ischemic attack, but these vulnerable road users may benefit from additional poststroke rehabilitation to optimize safety.