Predictors of Driving Ability Following Stroke: A Systematic Review

Serial Trichotomization to Determine Fitness to Drive: Results From a Cohort of Clients Referred to a Neurology Program

IMPORTANCE

Determining cognitive fitness to drive is challenging. A previous study used serial trichotomization with five cognitive tests to determine whether drivers should continue driving, undergo further evaluation, or stop driving.

OBJECTIVE

To examine agreement between serial trichotomization and fitness-to-drive determinations made by occupational therapists.

DESIGN

Drivers referred for cognitive screens completed all tests used in the previous study. Occupational therapists provided fitness-to-drive recommendations (safe, indeterminate, or unsafe) using all clinical information available. We examined the agreement between the tests' results (using cut points from the previous study) and occupational therapists' recommendations.

SETTING

Outpatient neurology program at a chronic care and rehabilitation hospital.

PARTICIPANTS

279 clients (M age  = 66.35 yr; SD = 13.25).

OUTCOMES AND MEASURES

Tests included the Trail Making Tests A and B, the Clock Drawing Test (CDT), the Montreal Cognitive Assessment, and the Motor-Free Visual Perception Test, using a road test as the gold standard. The previous study used dual cut points with 100% sensitivity and specificity to reduce false positives and false negatives.

RESULTS

Weighted κs ranged from .03 (95% confidence interval [CI] [-.01, .08]) for the CDT to .54 (95% CI [.46, .62]) for the Trail Making Test, Part B. Although the agreement between serial trichotomization and the final recommendations was moderate (κ = .59; 95% CI [.50, .67]), serial trichotomization appeared useful for identifying unsafe drivers.

CONCLUSIONS AND RELEVANCE

These results remind us of the variability inherent in stand-alone cognitive tests, even within a serial trichotomization framework, and the importance of clinical judgement and road tests in decision making about driving. Plain-Language Summary: It can be challenging for occupational therapists to accurately determine a client's cognitive fitness to drive. Many occupational therapists lack the time, have limited training, or do not have access to comprehensive driving evaluation tools. A serial testing approach can support occupational therapists in assessing a client's cognitive fitness to drive. This study used an approach based on a series of five cognitive tests to determine whether a client should continue driving, undergo further evaluation, or stop driving. The series of tests were used to classify drivers as safe, indeterminate, or unsafe. In principle, a driver would take the second test only if the driver was classified as indeterminate on the basis of first test, and so on. By applying the tests in sequence, few drivers should remain classified as indeterminate at the end of the series of tests. This serial approach has the potential to streamline the decision-making process for occupational therapists by classifying the more extreme unsafe cases while still providing an accurate assessment of cognitive fitness to drive.

A Three-Tiered Comprehensive Driving Evaluation Integrating a Driving Simulator Test for Drivers with Borderline Cognitive Fitness-to-Drive: Proof of Concept

Comprehensive driving evaluations for older adults with cognitive impairment are time-consuming, expensive, and involve risk. To minimize these challenges, we evaluated a three-tiered driving evaluation process incorporating cognitive tests (Step 1), a driving simulator test (Step 2), and a road test (Step 3). Participants in this study were referred to a driving assessment center for concerns about cognitive fitness-to-drive. Each participant completed all three evaluation steps. Their fitness-to-drive was determined independently by an occupational therapist and an experienced driving evaluator with a driver instructor background. Our main objective was to examine the agreement between the occupational therapist's determination of fitness-to-drive after each step and the driving evaluator's determination of fitness-to-drive after the road test. As a secondary objective, the occupational therapist's confidence in their determinations was also examined. Results showed agreement for 38.8% of participants after Step 1, 46.5% after Step 2, and 92.3% after Step 3. The mean occupational therapist's confidence rating in their determination (scale of 0 to 100; higher is better) was 36.15 after Step 1, 49.54 after Step 2, and 90.54 after Step 3. All drivers deemed to have passed the evaluation had been identified as such after the driving simulator test. These results suggest that the best agreement between the occupational therapist and the driving evaluator was reached after the final step. However, the results also indicate that for some participants, a road test may not be required following a driving simulator test. Eliminating the road test in some instances may create efficiencies and reduce cost and risk while maintaining accurate determinations of fitness-to-drive.

Exploring Factors Influencing Driving Simulator Performance in Patients With Acquired Brain Injury Using Hierarchical Clustering Analysis of Principal Components

Background Driving simulator training is widely recognized as an effective tool for driving rehabilitation. However, the key factors influencing simulator performance and the extent of training-related improvements remain insufficiently explored. This study aimed to identify the demographic, motor, and cognitive factors associated with driving simulator performance and post-training improvements in patients with acquired brain injury (ABI) using clustering analysis. Methods A total of 64 patients with ABI (59% cerebral hemorrhage, 34% cerebral infarction, 7% traumatic brain injury; mean age 64±13 years; 81% male) underwent comprehensive neuropsychological assessments and driving simulator evaluations before and after training. Multiple factor analysis was applied to integrate pre- and post-training variables and reduce dimensionality. Hierarchical Clustering on Principal Components was then performed to classify patients based on training effect patterns. The Kruskal-Wallis test and post hoc multiple comparisons were used to assess differences in background factors among the clusters. Results Three distinct clusters were identified: Cluster 1 (n=32) exhibited consistently high performance in reaction and city-driving tasks, Cluster 2 (n=19) demonstrated prolonged reaction times but showed significant improvements in city-driving tasks after training, and Cluster 3 (n=13) demonstrated severe city-driving errors and limited post-training improvement. Neuropsychological assessments revealed significant differences among the clusters (p < 0.05), with Cluster 1 consistently outperforming Clusters 2 and 3 across multiple cognitive domains, including attention, cognitive flexibility, visuospatial abilities, memory, and executive function. Conclusion Neuropsychological assessments may serve as predictors of both baseline driving performance and post-training improvements. Tailoring interventions to individual cognitive profiles, particularly focusing on attention, visuospatial abilities, and executive function, may enhance the efficacy of simulator-based rehabilitation and support the safe resumption of driving. Future longitudinal studies should examine how targeted cognitive training might improve driving performance in patients with different cognitive profiles.

Real-life study of the accuracy of tools for assessing fitness to drive after non-progressive acquired brain injury: a multi-centric study protocol (PREVAC study)

Non-progressive acquired brain injury can cause cognitive and behavioral damage. These disorders may hinder the driving abilities of affected individuals, increasing crash risk. Consequently, driving license regulations have required people who suffer from brain injury to be examined by an approved doctor for their driving license to remain valid. The decree of March 28, 2022 requires that approved doctors consider elements of patients' multiprofessional evaluation, but mentions neither the on-road driving assessment nor the neuropsychological assessment. However, these assessments are an integral part of the good practice recommendations certified by the French National Authority for Health. Practitioners in rehabilitation centers are used to applying the main recommendations despite the lack of consensus about the methods and tools used. Given these new regulations and the wide variety of real-life practices, this multicenter study aims to investigate the accuracy of tools for driving skill evaluation to guide professional practices. The cross-sectional study will investigate the sensitivity and specificity of both neuropsychological tests and an on-road assessment grid (Test Ride for Investigating Practical fitness to drive), through concordance analysis between the opinions expressed by professionals and between tools. Then, a cohort study will propose longitudinal follow-up of the drivers at 6 and 12 months in order to determine the predictive performance of the various assessments in terms of road risk, and to explore the relevance of educational support on driving habits and behavior. In this context, the quality of the decision-making process for maintaining a driving license is a major issue in limiting the road risk. As part of the measures issued by the Interministerial Road Safety Committee in 2023 aimed at "better detecting, assessing and monitoring unfitness to drive", this study presents a challenge in terms of supporting public policies. It aims to harmonize the multiprofessional evaluation recently made mandatory, in order to better inform the approved doctor's opinion.

Clustering and Characteristics of Acute Acquired Brain Injury Patients With Driving Resumption Difficulty: The Role of Neuropsychological Tests, Frailty, and Gait Independence

OBJECTIVES

Decisions to resume driving after acute brain injury are often difficult. Predictors of decisions depend on the results of neuropsychological tests. As a result, few studies have investigated other characteristics. This study clustered participants who received support for resuming driving after acute brain injury based on neuropsychological tests and analyzed their characteristics.

MATERIALS AND METHODS

Participants were 74 patients with acute brain injury. Cluster analysis was used to classify participants based on attention and visuospatial cognitive functions. Each cluster group were compared using multiple comparison tests (Bonferroni method) in terms of clinical assessments, neuropsychological tests, and driving resumption ability.

RESULTS

The characteristics of the cluster group with poor results in the two neuropsychological tests were that they were often judged as unable to resume driving (p < 0.001), were in a state of frailty (p = 0.02), and had a low level of walking independence (p = 0.02).

CONCLUSIONS

When helping patients with acute brain injury to return to driving, not only the results of neuropsychological tests but also assessments of frailty before onset and level of walking independence are important.

The Multiple Errands Test-Home Version and Its Association With Driving Potential: A Pilot Study

IMPORTANCE

Driving is a complex occupation requiring the interplay of high-level cognitive, physical, sensory, and behavioral skills for safe performance. Occupational therapists need to routinely address driving with adults as an occupational performance area. Further research is needed to determine whether performance-based assessment tools can support occupational therapists in screening client driving potential.

OBJECTIVE

To conduct a pilot study to determine whether the Multiple Errands Test-Home Version (MET-Home), as a performance-based assessment, either alone or in combination with other assessments, should be further investigated for use by occupational therapists to screen clients' driving potential.

DESIGN

Cross-sectional pilot study.

SETTING

Private in-clinic and community setting, including participants' homes.

PARTICIPANTS

Convenience sampling recruited 28 participants through private occupational therapy driver assessors.

OUTCOMES AND MEASURES

Participants underwent a comprehensive in-clinic and behind-the-wheel assessment, as per standard practice, and three additional cognitive tests. Data were summarized with descriptive statistics, and univariate analyses were used to examine the relationships between cognitive assessment scores and driving outcomes.

RESULTS

The MET-Home, as a stand-alone tool and in combination with other cognitive assessment scores, was not associated with driving outcomes (pass-fail). However, participant self-assessment of their MET-Home performance was associated with driving outcomes (pass-fail; p = .014).

CONCLUSIONS AND RELEVANCE

Although our findings suggest that the MET-Home is unlikely to screen for driving potential, further research of performance-based assessment tool use by occupational therapists is needed to support identification of the optimal type and timing of client referral for comprehensive assessment. Plain-Language Summary: The Multiple Errands Test-Home Version (MET-Home) is commonly completed by occupational therapists. Although this pilot study revealed that MET-Home scores were not associated with driving outcomes, performance-based assessments such as the MET-Home have the potential to guide occupational therapists when screening clients to determine when further, comprehensive assessment is indicated.

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.

Discriminant Validity of the Standardized On-Road Assessment for Drivers (SOAD) Among Stroke Patients in Japan

INTRODUCTION

On-road tests are considered the gold standard for evaluating real-world driving skills. However, their reliability and validity remain inadequately established, particularly under varying legal and road conditions across countries.

AIM

This study investigates the discriminant validity of the closed-course version of the Standardized On-Road Assessment for Drivers (SOAD) in Japan.

METHODS

This study was conducted in five Japanese rehabilitation hospitals and affiliated driving schools. The participants consisted of 108 brain-injured individuals (mean age: 50.0 years) undergoing driving assessments. The inclusion criteria focused on physician-referred patients diagnosed with brain injuries. The SOAD closed-course test, consisting of 40 items, was compared with off-road cognitive assessments, including the Mini-Mental State Examination Japanese Version (MMSE-J), Trail Making Test Japanese Version (TMT-J), Rey-Osterrieth Complex Figure Test, Stroke Drivers Screening Assessment Japanese version (J-SDSA), and Kohs Block Design Test. Spearman's correlation was used to evaluate discriminant validity, distinguishing driving-specific skills from cognitive functions.

RESULTS

Weak to moderate correlations were found between SOAD and off-road tests, supporting the discriminant validity of SOAD. Among off-road tests, the J-SDSA dot time correlated most frequently with SOAD items, followed by MMSE-J and TMT-J. The highest correlation coefficient (-0.38) was observed between the J-SDSA dot error and a specific SOAD item.

CONCLUSION

These results show that SOAD demonstrates strong discriminant validity as a closed-course on-road assessment tool for brain-injured individuals and measures unique aspects of driving skills not captured by cognitive tests.

Difficulty resuming driving in acute acquired brain injury: Retrospective observational study using discriminant analysis

OBJECTIVES

We hypothesized that neuropsychological testing and history of falls would be associated with difficulty resume driving after acute acquired brain injury (ABI). This study aimed to analyze ABI facing difficulties in resuming driving in the acute phase.

METHODS

We retrospectively analyzed 63 patients receiving assistance in driving-resumption after ABI. Patients were categorized into two groups: driving-resumption-possible and driving-resumption-difficult. Discriminant analysis delineated characteristics of patients experiencing driving-resumption difficulty. Additionally, significant predictors were analyzed using ROC curves.

RESULTS

42 patients were able to resume driving, and 21 experienced difficulties in driving resumption. Factors predicting difficulty returning to driving were age, history of falls, TMT Part B, and ROCF. Furthermore, cut-off values for each were 72 years, 148 seconds for TMT Part B, and 29.5 points for ROCF.

CONCLUSIONS

Patients with advanced age, history of falls, delayed TMT Part B, and poor ROCF outcomes may face challenges in resuming driving after ABI. These factors may serve as a valuable metric to assess driving resumption difficulties after ABI.

The Effect of Cardiac Resynchronization Therapy on Right Ventricular Function: A Systematic Review and Meta-Analysis

Background: Right ventricular (RV) failure is an important predicting factor regarding overall and event-free survival regardless of baseline left ventricular (LV) function in patients with severe heart failure (HF). Previous studies have indicated that cardiac resynchronization therapy (CRT) improves LV and RV reverse remodeling in patients with systolic dyssynchrony within the left ventricle. However, there is conflicting evidence regarding the role of CRT in RV function. The aim of this systematic review and meta-analysis was to examine the implications of CRT on RV function indices. Methods: A systematic literature search was conducted using the MedLine and EMBASE databases and the Cochrane Library from their inception until 18 March 2024. Eligible were studies providing information on RV function indices, both at baseline and after CRT. Evidence was summarized using random-effects meta-analytic models. Results: In total, 30 studies were deemed eligible. CRT resulted in a significant improvement in right ventricular fractional area change (mean difference (MD) 5.11%, 95% confidence interval (CI) 2.83 to 7.39), tricuspid annular plane systolic excursion (TAPSE, MD 1.63 mm, 95% CI 1.10 to 2.16), and myocardial systolic excursion velocity (MD 1.85 cm/s, 95% CI 1.24 to 2.47) as well as a significant decrease in pulmonary artery systolic pressure (MD -6.24 mmHg, 95% CI -8.32 to -4.16). A non-significant effect was observed on TAPSE to PASP ratio and right ventricular global longitudinal strain. Conclusions: Our meta-analysis demonstrates that CRT is associated with a significant improvement in echocardiographic parameters of RV function. Further investigation is necessary to elucidate how these changes, both independently and in conjunction with LV improvement, impact patients' long-term prognosis, and to identify the specific patient populations expected to derive the greatest benefit.

Association of Late Potentials With Fatal Arrhythmic Events in Patients With Brugada Syndrome-A Meta-analysis

Risk stratification of patients with Brugada syndrome (BrS) remains challenging. Signal-averaged electrocardiogram (SAECG) is a noninvasive tool that can be used to identify the electrophysiologic substrate potentially underlying fatal ventricular arrhythmias. The aim of this meta-analysis is to summarize the existing evidence about the role of late potentials (LP) as a predictor for arrhythmic events in patients with BrS. A systematic search in the MedLine database through to June 2022 without any limitations was performed. Ten studies were included in the quantitative synthesis (1431 patients with BrS, mean age 47.4 years, males 86%). Of these, 1220 patients underwent SAECG evaluation (53.2% had positive LP, and 20.6% had a fatal arrhythmic event). There was a nonsignificant association between positive LPs and fatal arrhythmic events [RR: 2.06 (0.98-4.36), P = 0.06, I 2 = 82%]. By including only studies with patients without a history of fatal arrhythmia, the association between LP with arrhythmic events remained nonsignificant [RR: 1.29 (0.67-2.48), P = 0.44, I 2 = 54%]. In conclusion, there is a possible association between LP and fatal arrhythmic events in patients with BrS, but the literature remains inconclusive. Large cohort studies using a multiparametric approach for risk stratification purposes are needed to improve the risk stratification of BrS and to optimize the selection of BrS patients that should be referred for implantable cardioverter-defibrillator.

Evaluating the Effectiveness of the Driving Resumption Assessment in Brain Disorders: Insights From a Retrospective Observational Study

Objectives For patients with brain disorders, regaining the ability to drive is crucial to their reintegration into society. Despite the existence of numerous assessment methods for determining the ability to resume driving, the most effective approach remains unclear. This study evaluated patients with brain disorders who had received support for driving resumption. We examined the factors influencing the acquisition of driving ability in this specific population. Methods This retrospective observational study was conducted from July 2019 to March 2022. Initially, a desk-based assessment was conducted using neuropsychological tests. Successful candidates subsequently underwent an on-road assessment at an affiliated driving school. Patients who passed both assessments were granted permission to resume driving. The participants were categorized into pass and fail groups based on their assessments, and a comparative analysis was conducted. Age, sex, type of brain disorder, functional independence measures (FIMs), assessments of higher cognitive skills, and physical function test results were evaluated. Results Forty-five patients (average age: 62±13 years) underwent evaluation. Logistic regression analysis for the desk-based assessment identified the Rey-Osterrieth complex figure test (ROCFT) (three-minute delayed recall) as the most influential factor (cutoff value: 21.5 points; sensitivity: 65%; specificity, 72.7%). In the on-road assessment, the 10-m walking test was significantly faster in the passing group than in the failing group (p<0.005). Conclusions We demonstrated that the ROCFT (three-minute delayed recall) was the most effective neuropsychological assessment tool for evaluating driving resumption. The assessment of walking speed may also be able to predict the resumption of driving in patients with brain disorders.

A systematic review of major evaluation metrics for simulator-based automatic assessment of driving after stroke

Background: Simulator-based driving assessments (SA) have recently been used and studied for various purposes, particularly for post-stroke patients. Automating such assessment has potential benefits especially on reducing financial cost and time. Nevertheless, there currently exists no clear guideline on assessment techniques and metrics available for SA for post-stroke patients. Therefore, this systematic review is conducted to explore such techniques and establish guidelines for evaluation metrics. Objective: This review aims to find: (a) major evaluation metrics for automatic SA in post-stroke patients and (b) assessment inputs and techniques for such evaluation metrics. Methods: The study follows the PRISMA guideline. Systematic searches were performed on PubMed, Web of Science, ScienceDirect, ACM Digital Library, and IEEE Xplore Digital Library for articles published from January 1, 2010, to December 31, 2023. This review targeted journal articles written in English about automatic performance assessment of simulator-based driving by post-stroke patients. A narrative synthesis was provided for the included studies. Results: The review included six articles with a total of 239 participants. Across all of the included studies, we discovered 49 distinct assessment inputs. Threshold-based, machine-learning-based, and driving simulator calculation approaches are three primary types of assessment techniques and evaluation metrics identified in the review. Discussion: Most studies incorporated more than one type of input, indicating the importance of a comprehensive evaluation of driving abilities. Threshold-based techniques and metrics were the most commonly used in all studies, likely due to their simplicity. An existing relevant review also highlighted the limited number of studies in this area, underscoring the need for further research to establish the validity and effectiveness of simulator-based automatic assessment of driving (SAAD). Conclusions: More studies should be conducted on various aspects of SAAD to explore and validate this type of assessment.

Validation of a computerized driving simulator test of cognitive abilities for fitness-to-drive assessments

Background

Driving requires a series of cognitive abilities, many of which are affected by age and medical conditions. The psychosocial importance of continued driving ushers the need for valid measurements in fitness-to-drive assessments. A driving simulator test could prove useful in these assessments, having greater face validity than other off-road tests and being more cost-effective and safer than ordinary on-road testing. The aim of this study was to validate a driving simulator test for assessment of cognitive ability in fitness-to-drive assessments.

Methods

The study included 67 healthy participants. Internal consistency of the simulator subtests was estimated. A correlation analysis between results on the simulator and the cognitive tests Trail Making Test (TMT) A and B and the Useful field of View test (UFOV) and multiple regression analysis were conducted. Finally, a comparison of results between age groups (>65 years) and (<65 years) was done.

Results

Results showed good internal consistency. Significant and moderate correlations were found for all reaction time in the simulator's subtests and UFOV 3, and all but two with TMT A. Lane positioning in the simulator showed significant and low to moderate correlations with UFOV 3 in all subtests. Reaction time and Double reaction time on subtest 3 were significantly correlated with UFOV 2 and UFOV 3 and TMT A, respectively. Test on Centerline (position) in subtest 3 as dependent variable was significantly correlated with UFOV 3. Significant means differences and large effect sizes between the age groups were found for all reaction time and lane positioning tests.

Conclusion

The findings of concurrent validity, especially with TMT A and UFOV 3 and its sensitivity for age-related differences, indicate potential for the simulator to be used as a complement in fitness-to-drive assessments. However, a clinical study is necessary to further examine its usefulness for patients with cognitive deficits.

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.

Interventions for Driving Disruption in Community Rehabilitation: A Chart Audit

PURPOSE

After injury or illness, a person's ability to drive may be impacted and they may experience a period of "driving disruption," a period during which they cannot drive although they have not permanently ceased driving. They may require additional information and supports from treating rehabilitation services; however, this process is less understood than others related to driving.

MATERIALS AND METHODS

This study aimed to document the prevalence of driving-related issues and the current practices of a community rehabilitation service, regarding driving interventions. An audit of 80 medical records was conducted in a multidisciplinary community rehabilitation service in Brisbane, Australia.

RESULTS

In total, 61% of clients were "driving-disrupted" on admission and 35% remained driving-disrupted on discharge. Majority of driving-disrupted clients had an acquired brain injury (ABI). Driving-related interventions were not routinely provided, with 29% receiving no information or supports. Clients with ABI more frequently received information; provision of psychosocial support and community access training was infrequent.

CONCLUSIONS

This study highlights that return to driving is a common issue and goal for people undergoing community rehabilitation, with the period of driving disruption extending beyond rehabilitation discharge. It also highlights gaps in community rehabilitation practice, and opportunities to better support these clients.IMPLICATIONS FOR REHABILITATIONMany clients of community rehabilitation services experience driving disruption, often beyond discharge.Driving disruption should be recognised and documented by community rehabilitation services.Current practices may not adequately address the practical and psychological needs of clients experiencing driving disruption.

Is it safe to control the car pedal with the lower limb of the unaffected side in patients with stroke?

OBJECTIVES

Few studies have examined motor function in determining the suitability of patients with stroke to resume driving a car. Patients with hemiplegia usually control car pedals with the unaffected lower limb. However, motor control on the unaffected side is also impaired in patients with stroke. This study aimed to clarify the neurophysiological characteristics of pedal switching control during emergency braking in patients with hemiplegia.

METHODS

The study participants consisted of 10 drivers with left hemiplegia and 10 age-matched healthy drivers. An experimental pedal was used to measure muscle activity and kinematic data during braking, triggered by the light from a light-emitting diode placed in front of the drivers.

RESULTS

The patient group took the same reaction time as the healthy group. However, from the visual stimulus to the release of the accelerator pedal, the patient group had higher muscle activity in the tibialis anterior and rectus femoris and had faster angular velocities of hip and knee flexion than the healthy group. In addition, the patient group had higher co-contraction activities between flexors and extensors. From the accelerator pedal release to brake contact, the patient group had slower angular velocities of hip adduction, internal rotation, ankle dorsiflexion, internal return, and internal rotation than the healthy group.

CONCLUSIONS

Patients with hemiplegia exhibited poor control of pedal switching using their unaffected side throughout the pedal-switching task. These results indicate that the safety related to car-pedal control should be carefully evaluated while deciding whether a patient can resume driving a car after a stroke.

Impact of baseline right ventricular function on the response to cardiac resynchronization therapy - A meta-analysis

Baseline right ventricular (RV) function potentially determines the response to Cardiac Resynchronization Therapy (CRT) but is not included in the current selection criteria. In this meta-analysis, we examined the value of echocardiographic indices of RV function as potential predictors of CRT outcomes in patients with standard indications for CRT. Baseline tricuspid annular plane systolic excursion was consistently higher in CRT responders, and this association appears independent of age, sex, ischemic etiology of heart failure, and baseline left ventricular ejection fraction. This proof-of-concept meta-analysis of observational data may justify a more detailed assessment of RV function as an additional component in the selection process of CRT candidates.

The Role of Electrophysiological Study in the Risk Stratification of Brugada Syndrome

Brugada syndrome (BrS) is a complex arrhythmogenic disease associated with an increased risk of sudden cardiac death (SCD). The role of electrophysiological study (EPS) for risk stratification purposes of asymptomatic BrS patients remains still controversial. This study aims to summarize the existing data about the role of electrophysiological study for arrhythmic risk stratification of BrS patients without a prior history of aborted SCD or fatal arrhythmic event. Two independent investigators (G.B. and G.T.) performed a systematic search in the MedLine database and Cochrane library from their inception until April 2022 without any limitations. The reference lists of the relevant research studies as well as the relevant review studies and meta-analyses were manually searched. Nineteen studies were included in the final analysis. The included studies enrolled 6218 BrS patients (mean age: 46.9 years old, males: 76%) while 4265 (68.6%) patients underwent an EPS. The quantitative synthesis showed that a positive EPS study was significantly associated with arrhythmic events in BrS patients (RR, 1.74 [1.23-2.45]; P = 0.002; I2 = 63%]. By including the studies that provided data on the association of EPS with arrhythmic events during follow-up in patients without a prior history of aborted SCD or fatal arrhythmic event, the association between positive EPS study and future arrhythmic events remained significant (RR, 1.60 [1.08-2.36]; P = 0.02; I2 = 19%). In conclusion, EPS is a useful invasive tool for the risk stratification of BrS patients and can be used to identify the population of BrS patients who may be candidates for primary prevention of SCD with implantable cardioverter-defibrillator (ICD) implantation.

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.

Use of P wave indices to evaluate efficacy of catheter ablation and atrial fibrillation recurrence: a systematic review and meta-analysis

BACKGROUND

To investigate the changes of P wave indices in atrial fibrillation (AF) patients after catheter ablation and the association between P wave indices and AF recurrence.

METHODS

PubMed, Embase, and Cochrane Database were searched through September 15th 2021 for studies on the association between P wave indices and AF with catheter ablation. Heterogeneity was estimated using the I² statistic, the random effects model was used to calculate the pooled results, and summary receiver operating characteristic curve (SROC) was used to evaluate the predictive value.

RESULTS

Among included fourteen studies with 1674 AF patients, we found significantly decreased P wave dispersion (P_dis) (mean difference [MD]: - 6.5 ms, 95% confidence interval [95% CI]: - 11.81 to - 1.18, P = 0.02) after cryoballoon ablation (CBA) or radiofrequency ablation (RFA), and maximum P wave (P_max) (MD: - 8.57 ms, 95% CI: - 17.03 to - 0.10, P = 0.05) after RFA only, but increased minimum P wave (P_min) (MD: 3.43 ms, 95% CI: 1.07 to 5.79, P < 0.01) after CBA only. P_dis measured before ablation was remarkably higher (MD: 5.79 ms, 95% CI: 2.23 to 9.36, P < 0.01) in patients with recurrence than without; meanwhile, P_max was higher measured both before and after ablation (MD: 6.49 ms, 95% CI: 2.30 to 10.69, P < 0.01 and MD: 11.2 ms, 95% CI: 2.88 to 19.52, P < 0.01). Furthermore, SROC analysis showed acceptable predictive efficiencies of P_dis (AUC = 0.776) and P_max (AUC = 0.759) for AF recurrence.

CONCLUSION

P_dis was significantly decreased after AF catheter ablation. Higher P_dis and P_max may have predictive values for AF recurrence.

Predictors of fatal arrhythmic events in patients with non-compaction cardiomyopathy: a systematic review

Left ventricular non-compaction cardiomyopathy (LVNC) is a congenital heart disease with autosomal dominant inheritance. This review aims to summarize the existing data about the predictors of fatal arrhythmias in patients with LVNC. Medline and Cochrane library databases were searched from inception to November 2021 for articles on LVNC. The reference lists of the relevant research studies as well as the relevant review studies and meta-analyses were also searched. Clinical symptoms and electrocardiogram findings such as left bundle branch block are significantly associated with ventricular arrhythmias. Other non-invasive tools such as Holter monitoring, echocardiography, and cardiac magnetic resonance (CMR) can provide additional value for risk stratification. CMR-derived left and right ventricular ejection fraction, left ventricular end-diastolic diameter, late gadolinium enhancement, and non-compacted to compacted myocardium ratio are predictive of ventricular arrhythmias. An electrophysiological study can provide additional prognostic data in patients with LVNC who are at moderate risk of ventricular arrhythmias. Risk stratification of LVNC patients with no prior history of a fatal arrhythmic event remains challenging. Symptoms assessment, electrocardiogram, Holter monitoring, and cardiac imaging should be performed on every patient, while an electrophysiological study should be performed for moderate-risk patients. Large cohort studies are needed for the construction of score models for arrhythmic risk stratification purposes.

Association of electrocardiographic markers with myocardial fibrosis as assessed by cardiac magnetic resonance in different clinical settings

BACKGROUND

Cardiac magnetic resonance (CMR) is a unique tool for non-invasive tissue characterization, especially for identifying fibrosis.

AIM

To present the existing data regarding the association of electrocardiographic (ECG) markers with myocardial fibrosis identified by CMR - late gadolinium enhancement (LGE).

METHODS

A systematic search was performed for identifying the relevant studies in Medline and Cochrane databases through February 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com).

RESULTS

A total of 32 studies were included. In hypertrophic cardiomyopathy (HCM), fragmented QRS (fQRS) is related to the presence and extent of myocardial fibrosis. fQRS and abnormal Q waves are associated with LGE in ischemic cardiomyopathy patients, while fQRS has also been related to fibrosis in myocarditis. Selvester score, abnormal Q waves, and notched QRS have also been associated with LGE. Repolarization abnormalities as reflected by increased Tp-Te, negative T-waves, and higher QT dispersion are related to myocardial fibrosis in HCM patients. In patients with Duchenne muscular dystrophy, a significant correlation between fQRS and the amount of myocardial fibrosis as assessed by LGE-CMR was observed. In atrial fibrillation patients, advanced inter-atrial block is defined as P-wave duration ≥ 120 ms, and biphasic morphology in inferior leads is related to left atrial fibrosis.

CONCLUSION

Myocardial fibrosis, a reliable marker of prognosis in a broad spectrum of cardiovascular diseases, can be easily understood with an easily applicable ECG. However, more data is needed on a specific disease basis to study the association of ECG markers and myocardial fibrosis as depicted by CMR.

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.

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 .

Global longitudinal strain predicts responders after cardiac resynchronization therapy-a systematic review and meta-analysis

To evaluate the association between baseline global longitudinal strain (GLS) and ΔGLS (difference of baseline GLS and follow-up) and cardiac resynchronization therapy (CRT) response defined either with clinical or with echocardiographic characteristics. This meta-analysis was performed in accordance to both the Meta-Analysis of Observational Studies in Epidemiology and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Two independent investigators performed a comprehensive systematic search in MedLine, EMBASE and Cochrane databases through September 2019 without limitations. Data analysis was performed by using the Review Manager software (RevMan), version 5.3, and Stata 13 software. A p value of less than 0.05 (two-tailed) was considered statistically significant. Twelve studies (1004 patients, mean age 63.8 years old, males 69.4%) provided data on the association of baseline GLS with the response to CRT therapy. We found that CRT responders had significantly better resting GLS values compared with non-responders [GLS mean difference -2.13 (-3.03, -1.23), p < 0.001, I2 78%]. Furthermore, CRT responders had significantly greater improvement of GLS at follow-up compared with non-responders [ΔGLS mean difference -3.20 (-4.95, -1.45), p < 0.001, I2 66%]. These associations remained significant in a subgroup analysis including only studies with similar CRT response definition. In this meta-analysis, we found that CRT responders had a baseline and ΔGLS significantly higher than the non-responders strengthening the central role of GLS as a tool for selecting candidates for CRT. Furthermore, improved GLS values after CRT may be used to better define CRT responders.

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

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

Usability of Norm Values on Results from a Simulator Device and Cognitive Tests in Traffic Medicine

Introduction

Driving is an essential everyday task for most adults, and fitness to continue car-driving after a brain injury/disease is a common issue in rehabilitation settings. There is no consensus on how this assessment should be performed and thus further research and development are of great value. The aim was to study the usability of cut-off values, based on recently developed norm values for a driving simulator device (CyberSiM), as well as cognitive tests, for patients already considered fit-to-drive after a standardized traffic medical investigation.

Methods

The study had a retrospective case-control design. Norm results (n = 129) were compared with patient results (n = 126) divided into two age groups (≤59 years and ≥60 years). Results from Useful Field of View, Trail Making Test, Nordic Stroke Driver Screening Assessment as well as a simulator device (CyberSiM) were compared.

Results

The group of patients considered fit-to-drive after a traffic medicine assessment had worse results on all cognitive tests compared with norms. Results on CyberSiM subtests II and III did not differ from norms. The proportion of patients within suggested cut-off limits (mean±2SD norm) and considered fit to drive (mean±2SD norm) were highest (75–95%) for all three subtests of CyberSiM and for Useful Field of View in both age groups.

Conclusion

Availability of norm values in decision on continued driving is of value when interpreting the results of cognitive assessments sensitive to age, but it must be handled with care because many factors are important for individuals’ ability to drive.

Impact of renal sympathetic denervation on cardiac magnetic resonance-derived cardiac indices in hypertensive patients - A meta-analysis

BACKGROUND

Renal sympathetic denervation (RDN) is a safe device-based option for the treatment of hypertension although current guidelines do not recommend its use in routine clinical practice. In this meta-analysis, we investigated the effects of RDN in cardiac magnetic resonance (CMR)-derived cardiac indices.

METHODS

This meta-analysis was performed in accordance with the PRISMA statement. A comprehensive systematic search of MEDLINE database and Cochrane library through to January 2021 was performed. The inclusion criteria were studies that enrolled patients undergoing RDN in whom CMR data were provided for left ventricular end-diastolic volume indexed to body surface area (BSA) (LVEDVI), left ventricular end-systolic volume indexed (LVESVI), left ventricular mass indexed (LVMI), and left ventricular ejection fraction (LVEF) pre and post RDN. A random effects model was used for the analyses.

RESULTS

Our search strategy revealed 9 studies that were finally included in the meta-analysis (n=300 patients, mean age: 60 years old, males: 59%). Compared to control group, RDN patients showed significantly lower values in the attained volumes (LVEDVI: -6.70 ml/m2, p=0.01; LVESVI: -3.63 ml/m2, p=0.006). Moreover, RDN group achieved a statistically significant higher attained LVEF (3.49%, p=0.01). A non-significant difference was found in the attained LVMI between RDN and control groups (-2.59 g/m2, p=0.39). Compared to pre-RDN values, RDN reduces significantly the LVMI, the LVEDVI, and the LVESVI while a non-significant change of LVEF was found.

CONCLUSIONS

In conclusion, the current study demonstrates the potential beneficial role of RDN in CMR-derived cardiac indices that reflect adverse remodeling. However, large, randomized studies are needed to elucidate the role of RDN in cardiac remodeling in hypertension, heart failure, and other clinical settings.

Fitness to drive after acquired brain injury: Results from patient cognitive screening and on-road assessment compared to age-adjusted norm values

Fitness to drive after acquired brain injury or disease is a common question in rehabilitation settings. The aim of the study was to compare age-matched norms with patient cognitive test results used to predict fitness to drive. A second aim was to analyze the contribution from an on-road assessment to a final decision on resumption of driving after an acquired brain injury. Retrospective cognitive test results from four traffic medicine units (n = 333) were compared with results from a healthy norm population (n = 410) in Sweden. Patients were dichotomized according to the final decision as fit or unfit to drive made by the traffic medicine team. The norm group had significantly better results in all age groups for all cognitive tests compared with the patients considered unfit to drive and fit to drive. A binary regression analysis for the patient group showed an explained value for fit to drive/unfit to drive of 88%, including results for the Nordic Stroke Driver Screening Assessment total score, Useful Field of View total score and the final outcome from an on-road assessment. Results from the present study illustrate the importance of using several tests, methods and contexts for the final decision regarding fitness to drive.

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.

The use of minimal fluoroscopy for cardiac electrophysiology procedures: A meta-analysis and review of the literature

BACKGROUND

Conventional catheter ablation involves prolonged exposure to ionizing radiation, potentially leading to detrimental health effects. Minimal fluoroscopy (MF) represents a safer alternative, which should be explored. Data on the safety and efficacy of this technique are limited.

HYPOTHESIS

Our hypothesis is that MF is of equal efficacy and safety to conventional catheter ablation with the use of fluoroscopy by performing a meta-analysis of both randomized controlled trials (RCTs) and real-world registry studies.

METHODS

Pubmed and Embase were searched from their inception to July 2020 for RCTs, cohort and observational studies that assessed the outcomes of catheter ablation using a MF technique versus the conventional approach.

RESULTS

Fifteen studies involving 3795 patients were included in this meta-analysis. There was a significant reduction in fluoroscopy and procedural time with no difference in acute success (odds ratio [OR]:0.74, 95% CI: 0.50-1.10, p = .14), long-term success (OR:0.92, 95% CI: 0.65-1.31, p = .38), arrhythmia recurrence (OR:1.24, 95% CI: 0.75-2.06, p = .97) or rate of complications. (OR:0.83, 95% CI: 0.46-1.48, p = .65). Additionally sub-group analysis for those undergoing catheter ablation for atrial fibrillation (AF) did not demonstrate a difference in success or complication rates (OR:0.86, 95% CI: 0.30-2.42, p = .77). Multivariate meta-regression did not identify the presence of moderator variables.

CONCLUSION

This updated meta-analysis demonstrated an overall reduction in procedural and fluoroscopy time for those undergoing a minimal fluoroscopic approach. There was no significant difference in either acute or chronic success rates or complications between a MF approach and conventional approach for the management of all arrhythmias including those undergoing catheter ablation for AF.

On-Road Driving Assessment in a Driving School Course and the Results of a Cognitive Function Test After Stroke in a Depopulated Rural Area in Japan: Case Series of Eight Patients

Introduction

Returning to driving after a stroke is a step toward independence and improving quality of life. Cognitive function after stroke is one of the essential factors that affect driving ability, and on-road driving assessment in driving school courses is beginning to spread in Japan. We started on-road driving assessment in 2018, and we herein report eight patients who underwent on-road driving assessment in the last three years, presenting both off-road cognitive function tests and on-road driving assessment results.

Methods

Of the 320 consecutive stroke patients from 2018 to 2020, we retrospectively investigated the eight patients’ characteristics who underwent on-road driving assessment. We performed cognitive function tests, including behavioral inattention test (BIT), trail-making test, Wechsler Adult Intelligence Scale-III, and behavioral assessment of the dysexecutive syndrome. Patients who meet BIT > 35, at least three other subitem criteria, and no unevaluable subitems can undergo on-road driving assessment by a driving instructor. With the recommendation of the driving instructors, we comprehensively decided the permission to drive.

Results

All eight patients could return to driving after on-road driving assessment. Two patients could return to driving after nearly a year.

Conclusion

The patients did not meet all the cut-offs of the cognitive function test, but they were judged to return to driving by driving instructors. We finally permitted all eight patients to drive. On-road driving assessment in the driving school course might be helpful for determining the permission to return to driving.

Investigating feasibility and preliminary efficacy of a simulator-based driving intervention for people with acquired brain injury: A randomised controlled pilot study

OBJECTIVE

To investigate the feasibility and preliminary efficacy of a driving simulator intervention on driving outcomes following acquired brain injury.

DESIGN

Pilot randomised controlled trial.

SETTING

Occupational therapy driver assessment and rehabilitation service.

SUBJECTS

Individuals post-acquired brain injury aiming to return to driving.

INTERVENTION

Eight sessions of simulated driver training over four weeks, in addition to usual care. Control: Usual care only.

MAIN MEASURES

Feasibility outcomes: Participant recruitment and retention; data completeness; therapy attendance and fidelity; adverse events. Performance outcomes: on-road driving performance; Simulator Sickness Questionnaire; Brain Injury Driving Self-Awareness Measure and Driving Comfort Scale - Daytime, assessed at baseline and five weeks post-randomisation.

RESULTS

Out of 523 individuals screened, 22 (4%) were recruited and randomised, with 20 completing their allocated group (n = 12 Simulator, n = 8 Usual Care). For those who completed training, session attendance was 100% with simulator sickness rated, on average, as mild. Six individuals (50%) in the Simulator group failed the on-road assessment, versus two (25%) in the Usual Care group (P = 0.373). On average, the Simulator group reported a positive change in confidence ratings (M = 5.77, SD = 13.96) compared to the Usual Care group, who reported a negative change (M = -6.97, SD = 8.47), P = 0.034. The Simulator group (M = 0.67, SD = 3.34) demonstrated no significant change in self-awareness relative to the Usual Care group (M = -0.83, SD = 1.83, P = 0.325).

CONCLUSIONS

With adjustments to inclusion criteria and recruitment strategies, it may be feasible to deliver the intervention and conduct a larger trial. There is potential benefit of simulator training for improving driver confidence after acquired brain injury.

Cognitive and motor deficits contribute to longer braking time in stroke

Background

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

Methods

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

Results

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

Conclusions

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

Effects of various antipsychotics on driving-related cognitive performance in adults with schizophrenia

The aim of this study was to determine whether the driving-related cognitive performance differs among adults with schizophrenia taking different types of antipsychotics. Neurocognitive performance was assessed using the Cognitive Perceptual Assessment for Driving (CPAD), a computerized battery of tests of visual perception, attention, working memory, reaction time, and inhibitory control for driving ability. One hundred and two adults with schizophrenia who were on antipsychotic monotherapy participated in the study. Of these, 15 were on haloperidol, 28 on risperidone, 14 on olanzapine, 28 on aripiprazole, and 17 on paliperidone. Sixty-four (63%) of the 102 subjects were regarded as competent to drive. Of the subjects taking haloperidol, 33% passed the CPAD, while the passing rates of subjects taking risperidone, olanzapine, aripiprazole, and paliperidone were 57%, 57%, 75%, and 82%, respectively, with a significant difference between the haloperidol and aripiprazole groups (p = 0.005) and between the haloperidol and paliperidone groups (p = 0.001). Additionally, scores on CPAD depth perception (number of correct responses), divided attention, digit span test, and trail-making test B subtests were significantly better for the aripiprazole and paliperidone groups than for the haloperidol and risperidone groups. In this cross-sectional design study, adults with schizophrenia treated with aripiprazole or paliperidone antipsychotic monotherapy demonstrated superior driving-related cognitive performance than those treated with haloperidol or risperidone antipsychotic monotherapy.

Decisions on driving after brain injury/disease: Feasibility and construct validity of a new simulator assessment tool

Introduction

Driving is a complex activity involving a high level of cognitive abilities and thus might be affected after a brain injury/disease. The aim of this research was to evaluate the feasibility and construct validity of a driving simulator tool as a complement to existing driving assessments of patients with cognitive dysfunctions after a brain injury/disease.

Method

A descriptive and prospective research design was achieved. For construct validation, decisions were based on results from the Useful Field of View, Nordic Stroke Driver Screening Assessment, Trail Making Test and, when necessary for the decision, an on-road observation. Results from the simulator tool were not included in the clinical decision process.

Results

A total of 129 patients from four different rehabilitation services were included. The results showed a significant difference in test results between those who were considered medically fit versus unfit to drive. A factor analysis revealed four components, all including attention in combination with processing speed, visuospatial function, simultaneous capacity and executive function; these are all represented in the simulator tool. A correlation analysis showed that simulator subtest 3 (response/divergent response to stimuli) had the strongest correlation with most of the other tests included.

Conclusions

The simulator was found to be feasible and valid and found to include components other than those measured in the other tests.

Association of QRS narrowing with response to cardiac resynchronization therapy-a systematic review and meta-analysis of observational studies

Prolonged QRS duration, which reflects a higher degree of mechanical dysynchrony, is a predictor of response to CRT. However, the association of QRS narrowing after biventricular pacing with CRT response rates is not clear. Our aim was to conduct a systematic review and meta-analysis on the association between QRS narrowing after cardiac resynchronization therapy (CRT) and clinical and echocardiographic response to CRT in patients with heart failure. Two independent investigators searched MedLine and EMBASE databases through July 2018 without any limitations. Studies providing estimates (continuous data) on the association of QRS shortening with either clinical (defined as New York Heart Association (NYHA) reduction ≥ 1) or echocardiographic (defined as left ventricular end-systolic volume (LVESV) reduction ≥ 15%) response to CRT were finally included in the quantitative synthesis. We included 32 studies (14 studies (1274 patients mean age 64 years old, males 79.3%) using clinical CRT response and 18 studies (1270 patients, mean age 64 years old, males 69.1%) using echocardiographic CRT response). A significant association between QRS narrowing and shorter attained QRS duration with clinical and echocardiographic CRT response was observed. The observed association was independent of the timing of QRS width measurement after CRT implantation. Acute and late improvement of electrical dysynchrony as depicted by QRS narrowing following biventricular pacing is associated with clinical and echocardiographic response to CRT. However, large prospective studies are needed to further examine our findings.

Driving after pediatric traumatic brain injury: Impact of distraction and executive functioning

OBJECTIVE

The objective of the current study was to examine the driving performance of young drivers with a history of moderate to severe traumatic brain injury (TBI) compared with an uninjured control group. The impact of cell phone related distraction (conversation and texting) and executive functioning (EF) were also explored.

METHOD

Individuals aged 16-25 years with (n = 19) and without (n = 19) a history of TBI engaged in a simulated drive under 3 distraction conditions (no distraction, cell phone conversation, and texting). Mean speed, maximum speed, standard deviation of speed, standard deviation of lane position, and crash rates were used as outcomes. The Global Executive Composite (GEC) from the Behavior Rating Inventory of Executive Functioning (BRIEF) was used to measure EF.

RESULTS

Significant Injury × Distraction × GEC interaction effects were noted on max speed and speed variability, with a trending Distraction × GEC interaction noted for lane position variability. The effect of distraction was most notable among individuals with greater GEC scores, across both injury groups.

CONCLUSIONS

A history of pediatric TBI did not specifically impact driving performance independent of EF, with EF playing a central role in functioning across domains of driving performance. Consistent effect of EF suggests that deficits in driving performance may be associated with EF specifically, with individuals with EF difficulties following TBI at greater risk for poor driving performance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Feasibility and Validity of a Low-Cost Racing Simulator in Driving Assessment after Stroke

There is a myriad of methodologies to assess driving performance after a stroke. These include psychometric tests, driving simulation, questionnaires, and/or road tests. Research-based driving simulators have emerged as a safe, convenient way to assess driving performance after a stroke. Such traditional research simulators are useful in recreating street traffic scenarios, but are often expensive, with limited physics models and graphics rendering. In contrast, racing simulators developed for motorsport professionals and enthusiasts offer high levels of realism, run on consumer-grade hardware, and can provide rich telemetric data. However, most offer limited simulation of traffic scenarios. This pilot study compares the feasibility of research simulation and racing simulation in a sample with minor stroke. We determine that the racing simulator is tolerated well in subjects with a minor stroke. There were correlations between research and racing simulator outcomes with psychometric tests associated with driving performance, such as the Trails Making Test Part A, Snellgrove Maze Task, and the Motricity Index. We found correlations between measures of driving speed on a complex research simulator scenario and racing simulator lap time and maximum tires off track. Finally, we present two models, using outcomes from either the research or racing simulator, predicting road test failure as linked to a previously published fitness-to-drive calculator that uses psychometric screening.

A Systematic Review Examining Associations between Cardiovascular Conditions and Driving Outcomes among Older Drivers

There is a vast literature on stroke as a cardiovascular disease and driving outcomes, however little is known about other cardiovascular conditions and driving. The purpose of this review is to examine the literature for studies assessing the effect of non-stroke, vascular conditions on daily driving, reported crash risk and driving decline in older adult drivers as captured by naturalistic methodologies. A systematic review of Embase, Ovid and Scopus Plus examined articles on driving and vascular conditions among older adults. A search yielded 443 articles and, following two screenings, no articles remained that focused on non-stroke, vascular conditions and naturalistic driving. As a result, this review examined non-stroke, vascular conditions in nine driving studies of older adults that used road testing, driving simulators and self-report measures. These studies fell into three categories—heart failure, vascular dementia and white matter hyperintensities/leukoaraiosis. The combined findings of the studies suggest that heart failure, vascular dementia and white matter hyperintensities (WMH) negatively impact driving performance and contribute to driving cessation among older adults. Future research should examine cardiovascular risk factors like hypertension, hypercholesterolemia, myocardial infraction or atherosclerosis using naturalistic driving measurement, as well as traditional measures, in order to more fully characterize how these conditions impact older adult driving.

The determinants of motorized mobility scooter driving ability after a stroke

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

Comparison of Rotational with Orbital Atherectomy During Percutaneous Coronary Intervention for Coronary Artery Calcification: A Systematic Review and Meta-Analysis

BACKGROUND

Percutaneous coronary intervention (PCI) outcomes for patients with significant calcification have been consistently inferior compared to patients without significant calcification. Procedural success and long-term outcomes after PCI have been worse in patients with severe coronary calcium.

OBJECTIVE

A Bayesian meta-analysis of outcomes comparing rotational atherectomy (RA) with orbital atherectomy (OA) was performed.

METHODS

PubMed, Embase, and Cochrane Library databases were searched through 30th November 2018 and identified 4 observational studies.

RESULTS

The primary end-point, Major Adverse Cardiac Event (MACE) composing of death, MI and stroke at 1 year was more likely with RA (OR = 1.61; 95% CI: 1.11-2.33; p = 0.01) as compared to OA. The driver of the difference in MACE between the two groups was a statistically significant difference in mortality favoring OA (OR = 4.65; 95% CI: 1.36-15.87; p = 0.01). Peri-procedural MI, the other component of the primary end-point was 1.3 times more likely in the RA arm (OR = 1.35; 95% CI 0.95-1.92; p-0.09) and was not statistically different between the groups. The odds of a vascular complication were not different in the two groups (OR = 1.26; 95% CI: 0.73-2.17; p = 0.41). In an adjusted Bayesian analysis, mortality (OR = 3.69; 95% CI: 0.30-38.51), MACE (OR = 1.68; 95% CI: 0.55-5.49), MI (OR = 1.42; 95% CI: 0.50-4.29) and dissections/perforations (OR = 0.38; 95% CI: 0.10-1.38) were not different in RA and OA groups.

CONCLUSION

Our study is the first published Bayesian meta-analysis comparing MACE and peri-procedural outcomes in RA compared to OA. These findings lay the foundation for a randomized comparison between the two competing technologies.

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.

Restitution metrics in Brugada syndrome: a systematic review and meta-analysis

BACKGROUND

Brugada syndrome (BrS) is an ion channelopathy that predisposes affected subjects to ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death. Restitution analysis has been examined in BrS patients but not all studies have reported significant differences between BrS patients and controls. Therefore, we conducted a systematic review and meta-analysis to investigate the different restitution indices used in BrS.

METHODS

PubMed and Embase were searched until April 7, 2019, identifying 20 and 27 studies.

RESULTS

A total of ten studies involving 178 BrS (mean age 38 years old, 63% male) and 102 controls (mean age 31 years old, 42% male) were included in this systematic review. Pacing was carried out at the right ventricular outflow tract (RVOT)/right ventricular apex (RPA) (n = 4), RPA (n = 4), or right atrium (RA) (n = 1). Basic cycle lengths of 400 (n = 4), 500 (n = 2), 600 (n = 6) and 750 ms (n = 1) were used. Recording methods include electrograms (n = 4), monophasic action potentials (n = 5), and electrocardiograms (n = 1). Signals were obtained from the RVOT (n = 8), RVA (n = 3), RA (n = 1), or the body surface (n = 1). The maximum restitution slope for endocardial repolarization at the RVOT was 0.87 for BrS patients (n = 5; 95% confidence interval [CI] 0.68-1.07) compared with 0.74 in control subjects (n = 4; 95% CI 0.42-1.06), with a significant mean difference of 0.40 (n = 4; 95% CI 0.11-0.69; P = 0.007).

CONCLUSIONS

Steeper endocardial repolarization restitution slopes are found in BrS patients compared with controls at baseline. Restitution analysis can provide important information for risk stratification in BrS.

Evaluating the Measurement Properties of the ScanCourse, a Dual-Task Assessment of Visual Scanning

IMPORTANCE

The ScanCourse is used by occupational therapists to evaluate visual scanning ability during locomotion. Its measurement properties have not been examined.

OBJECTIVE

To assess the interrater reliability, test-retest reliability, and construct validity of the ScanCourse.

DESIGN

This study involved data collection at two time points. To assess test-retest reliability, the ScanCourse was administered twice within a 2-week period. To assess interrater reliability, a second rater was present for one session. To assess level of agreement, a Bland-Altman plot was created. To assess absolute reliability, the standard error of measurement was calculated. To evaluate construct validity, the results of the ScanCourse were compared with results of the Bells Test and Trail Making Test A and B.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Forty-one patients with neurological impairments.

OUTCOMES AND MEASURES

The ScanCourse (participants identify numbered cards placed on both sides of a hallway at various heights during locomotion).

RESULTS

The ScanCourse was found to have excellent interrater reliability (intraclass correlation coefficient [ICC] [1,1] = .998; 95% confidence interval [CI] [.996-.999]), test-retest reliability (ICC [1,1] = .912; 95% CI [.811-.959]), a high level of agreement, and a low standard error of measurement (.503), and it was found to be significantly correlated with Trails A (r_s = -.436, p = .009) and B (r_s = -.364, p = .029).

CONCLUSIONS AND RELEVANCE

The assessment was found to have strong measurement properties, and it is therefore an appropriate tool for assessing dual-task visual scanning among those with neurological impairments.

WHAT THIS ARTICLE ADDS

This research demonstrates that the ScanCourse is reliable between raters and over time and that scores on the measure vary as anticipated with scores on a related measure, which provides evidence of its validity. These findings support its use in practice.

Association of QT dispersion with mortality and arrhythmic events-A meta-analysis of observational studies

BACKGROUND

The risk stratification of coronary heart disease (CHD) and/or heart failure (HF) patients with easily measured electrocardiographic markers is of clinical importance. The aim of this meta-analysis is to indicate whether increased QT dispersion (QTd) is associated with fatal and nonfatal outcomes in patients with CHD and/or HF.

METHODS

We systematically searched MEDLINE and Cochrane databases without restrictions until August 15, 2018 using the keyword "QT dispersion". Studies including data on the association between QTd and all-cause mortality, sudden cardiac death (SCD) or arrhythmic events in patients with HF and/or CHD were classified as eligible.

RESULTS

In the analysis including patients with CHD and/or HF, we found that QTd did not differ significantly in patients with SCD compared to no SCD patients while QTd was significantly greater in the group of all-cause mortality patients and in patients who experienced a sustained ventricular arrhythmia. Subgroup analysis showed that in myocardial infarction studies, QTd was significantly higher in patients with an arrhythmic event compared to arrhythmic event-free patients while a nonsignificant difference was found in QTd in patients who died from any cause compared to survivors. Similarly, in HF patients, the QTd was significantly greater in patients with an arrhythmic event while a nonsignificant difference was found regarding all-cause mortality and SCD outcomes.

CONCLUSIONS

QTd has a prognostic role for stratifying myocardial infarction or HF patients who are at higher risk of arrhythmic events. However, no prognostic role was found regarding all-cause mortality or SCD in this patient population.

Electrographic indices in migraine patients: A systematic review and meta-analysis

BACKGROUND AND AIM

Migraine patients can exhibit autonomic dysregulation, in turn leading to cardiac conduction and repolarization abnormalities. This systematic review and meta-analysis evaluated the electrocardiographic changes in migraineurs.

METHOD

PubMed and Embase databases were searched for human studies using the search terms 'migraine' and 'electrocardiogram' until 15th December 2018, identifying 108 and 131 studies.

RESULTS

Thirteen studies involving 667 migraineurs and 208 normal subjects included (mean age=30.7, total male percentage=19.8%) were included. A longer mean QTc interval (standard mean difference=7.89, 95% confidence interval=[3.29, 12.49], p=0.0008) and higher frequency of QTc prolongation (risk ratio [RR]=6.23, [2.86-13.58], p<0.00001), but no difference in PR-interval (SMD=4.33, [-3.90-12.56], p=0.30) were observed during migraine attacks compared to pain-free periods. P-wave dispersion was higher in migraine patients compared to controls (mean difference=3.62, [1.03-6.21], p=0.006). RR-interval were statistically indistinguishable between migraine patients and controls (SMD=0.08, [-0.65-0.81], p=0.83), or between migraineurs with and without aura (SMD=-0.03, [-0.44-0.38], p=0.89). Deep breathing ratio was significantly lower in migraineurs compared to controls (SMD=-0.27, 95% CI=[-0.46, -0.08], p=0.006) but similar between migraineurs with and without aura (SMD=-0.04, [-0.27-0.19], p=0.74). No significant difference in Valsalva ratio is found between migraineurs and controls (SMD=0.10, [-0.32-0.53], p=0.63) or between migraineurs with and without aura (SMD=-0.17, [-0.40-0.06], p=0.14). Root mean square of successive differences (RMSSD) (SMD=-0.07, [-1.10-0.95], p=0.89) and standard deviation of NN intervals (SDNN) (SMD=-0.10, [-0.61-0.41], p=0.71) did not significantly differ between migraine patients and controls.

CONCLUSION

Electrocardiographic alterations are observed in migraine patients compared to controls, especially during migraine attacks.