Clinical evaluation of the driving ability in stroke patients

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.

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

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

Prediction of Driving after Stroke: A Prospective Study

The process of determining whether patients with stroke should drive again often involves off-road evaluations and road tests that usually take about 2 to 3 h to complete. Objectives. This prospective study sought to identify the combination of tests that best predicts fitness to drive after stroke. The main aim was to develop a short and predictive predriving assessment battery. Methods. Sixty-eight consecutive stroke patients were studied who performed a mandatory predriving assessment at the Belgian Road Safety Institute, Brussels, within 18 months. Performance in a predriving assessment included medical examination (when needed), visual and neuropsychological evaluations, and an on-road test. Based on these assessments, a physician, psychologist, and the driving safety expert who administered the tests decided if a subject was either “fit to drive,”“temporarily unfit to drive,” or “unfit to drive.” Results. Logistic regression analysis revealed a combination of visual neglect, figure of Rey, and on-road tests as the model that best predicted ( R2 = 0.73) fitness to drive after stroke. Using a discriminant function that included the 3 tests of the logistic model, the fitness to drive judgments of 59 (86.8%) subjects were correctly predicted. The sensitivity and specificity of the predictions were 79.4% and 94.1%, respectively. Conclusion. Fitness to drive after stroke can be predicted from performance on a few road-related tests with a high degree of accuracy. However, some individuals require extended assessments and further tests.

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

OBJECTIVE

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

DESIGN

Cross-sectional comparison without randomization.

SUBJECTS/PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Behavioural ratings of self-regulatory mechanisms and driving behaviour after an acquired brain injury

OBJECTIVE

To explore whether measurements of self-regulatory mechanisms and cognition predict driving behaviour after an acquired brain injury (ABI).

DESIGN

Consecutive follow-up study.

PARTICIPANTS

At baseline participants included 77 persons with stroke and 32 persons with a traumatic brain injury (TBI), all of whom completed a multidisciplinary driving assessment (MDA). A follow-up cohort of 34 persons that succeeded the MDA was included. Baseline measurements: Neuropsychological tests and measurements of self-regulatory mechanisms (BRIEF-A and UPPS Impulsive Behaviour Scale), driving behaviour (DBQ) and pre-injury driving characteristics (mileage, compensatory driving strategies and accident rates). Follow-up measurements: Post-injury driving characteristics were collected by mailed questionnaires from the participants who succeeded the MDA.

METHODS

A MDA, which included a medical examination, neuropsychological testing and an on-road driving test, was considered in the decision for or against granting a driver's license. Self-regulatory mechanisms and driving behaviour were examined for research purposes only.

RESULTS

At baseline, self-regulatory mechanisms were significantly associated to aberrant driving behaviour, but not with neuropsychological data or with the outcome of the on-road driving test. Aspects of self-regulation were associated to driving behaviour at follow-up.

CONCLUSION

It is recommended that self-regulatory measurements should regularly be considered in the driving assessments after ABI.

Comparison of foot pedal reaction time among patients with right or left hemiplegia and able-bodied controls

BACKGROUND

Although inpatient stroke rehabilitation provides clinicians with the opportunity to prepare patients for continuation of prestroke activities, little is known about the patients' ability to safely resume driving at the point of discharge to the community.

OBJECTIVE

To compare foot pedal response times of 20 stroke patients with right hemiplegia (RH) or left hemiplegia (LH) and 10 controls.

METHODS

A cross-sectional design was used. Response times were measured using 3 foot pedal operation techniques: (1) right-sided accelerator with right leg operating accelerator and brake, (2) right-sided accelerator with left leg operating accelerator and brake, and (3) left-sided accelerator with left leg operating accelerator and brake. Outcomes included reaction time (RT), movement time (MT), and total response time (TRT).

RESULTS

Controls demonstrated faster RT than patients with RH (263 vs 348 ms; P < .001) or LH (316 ms; P < .05) for all conditions, as well as faster MT than patients with RH (P < .05 for all) but not LH when using the right leg (258 vs 251 ms; P = .82). Controls demonstrated faster TRT than patients with RH (P < .001 for all) but not LH when using the right leg (515 vs 553 ms; P = .44).

CONCLUSIONS

When using the nonparetic leg, patients with LH had braking response times comparable to controls, but patients with RH demonstrated significant impairment of both the paretic and nonparetic legs.

Predictors of Poststroke Driving or Riding in Indian Stroke Patients (POINT Study)

Background

There is no information regarding the proportion of stroke patients who drive or ride after a stroke from developing countries.

Aim

We aimed to study the predictors of poststroke driving or riding and its impact on social life in Indian patients. Methods This study was done in the stroke and neurology clinics of Christian Medical College, Ludhiana, from May 1, 2008 to May 31, 2010. Patients were recruited if they had completed ≥1-year follow-up. Subjects were interviewed using a structured questionnaire. Stroke outcome was assessed by using the modified Rankin scale. Outcome was classified as good (modified Rankin scale ≤2) and poor (modified Rankin scale >2).

Results

Two hundred and one patients were interviewed. Mean age was 58·0 ± 13·4 years (median 59 years, range 17–85 years), 139 (69·2%) were men. The mean duration of follow-up was 37·4 ± 29·2 months (range 19–210 months). Out of 201 patients, 132 (65·7%) drove or rode before stroke and among them only 54 (40·9%) returned to driving or riding after stroke [men 53 (98·1%)]. Among the 78 who did not return to driving or riding, 51 (65·4%) had an impact on social life. In the multivariate logistic regression analysis, the predictors of inability to drive were lower education (odds ratio 0·32, confidence interval 0·12–0·89, P = 0·03), unemployment (odds ratio 4·59, confidence interval 1·67–12·6, P = 0·003), and poor outcome (odds ratio 3·97, confidence interval 1·06–14·8, P = 0·04).

Conclusions

Only 40·9% of the patients returned to driving or riding. Lower education, unemployment, and poor recovery were the predictors of inability to drive or ride. Inability to drive had a major impact in their social life.

Retrospective cohort study of accident outcomes for individuals who have successfully undergone driver assessment following stroke

BACKGROUND

The occupational role of 'driver' is highly valued. Stroke can have a significant impact on an individual's ability to drive safely. Multi-disciplinary driver assessments are conducted to assess the safety of post-stroke individuals returning to driving, however, little follow-up of drivers following successful assessment has been performed.

AIM

The objective of this study was to investigate whether passing a multi-disciplinary driving assessment following stroke predicted medium- to long-term safe and confident driving.

METHODS

A retrospective cohort study with primary data collection through structured telephone interviews was undertaken. Respondents were individuals post-stroke aged 18-74years who had successfully passed a multi-disciplinary driver assessment.

RESULTS

 Forty-five respondents were interviewed an average of 20months following the assessment. Forty individuals were still driving. Twenty-five driving respondents reported driving in conditions that indicated confident driving. Confident driving was measured by driving frequency and distance, night driving, freeway driving and driving alone. The frequency of accidents and incidents suggests that 95% (n=38) of drivers are 'safe'. Eight respondents reported accidents, one of which was major. In two accidents the respondent was 'at fault'. A crash rate of 222 per 100,000 drivers is within the confidence interval for similar accidents in New South Wales.

CONCLUSIONS

The results of this small cohort study suggest that a multi-disciplinary driver assessment may be effective in identifying people following stroke with the ability to drive safely and confidently.

Driving ability in stroke patients with residual visual inattention: a case study

Driving ability of three patients having a right hemisphere infarct and residual visual inattention was examined. The neuropsychological examination included the Peripheral Perception Test and the Signal Detection Test from the Vienna Test System, and the Behavioural Inattention Test (BIT). Driving ability was assessed with an on-road evaluation. The patients had no neglect based on the BIT and had normal visual fields, but they showed slightly poorer visual search on the left side. All patients passed the official on-road driving test and were considered capable of driving. This study raises the question if acute neglect can recover to a degree in which driving may be possible.

Factors affecting return to driving post-stroke

BACKGROUND

Stroke can affect a person's ability to drive, an important means of transportation in the developed world.

AIMS

To determine percentage of patients and factors associated with return to driving post-stroke in a service with emphasis on driver assessment.

METHODS

Retrospective study of patients discharged from the Stroke Service of our 470-bed teaching hospital from 1998 to 2002.

RESULTS

Of 72 drivers pre-stroke, 54% recalled a driving assessment and 68% returned to driving. Younger patients (58.6 ± 12.0 vs. 66.5 ± 10.5, p = 0.008) with lower Modified Rankin Score (median 1 vs. 2, p = 0.0001) and normal cognition (55 vs. 43%, p = 0.45) were more likely to resume driving. More patients who were assessed returned to driving than those who were not (74 vs. 61%, p = 0.31).

CONCLUSIONS

A relatively high level of return to driving can be achieved post-stroke with a pro-active approach to driver assessment and rehabilitation. A structured assessment and referral programme should be offered where appropriate.

Evaluation of the driving ability in disabled persons: A practitioners' view

PURPOSE AND METHODS

The purpose of this paper is to present, on the basis of four genuine cases from the Rehabilitation Research Unit of Oulu University, the theoretical frame in which evaluations of driving ability of disabled persons can be made.

RESULTS

First, it is not the operations with the control devices but the correct mental actions which the driver carries out with the help of the control devices which are crucial for safe driving. Second, driving ability is only partly a biomedical object of research and one ought to avoid an excessive medicalisation of an evaluation of driving ability. Third, the driver meets traffic situations not by his or her separate biological or psychological functions, such as vision, attention, memory, thinking, motives, but as an integrated whole, as a personality.

CONCLUSIONS

By its complexity an evaluation of driving ability can be compared to an evaluation of working capacity where often a multidisciplinary team is needed. When evaluating driving ability we have to take a step from low-level motor operations towards high-level mental actions, from the measurement of acuity of eyesight towards the testing of the flexibility of perception, from the diagnosis-based evaluation to the patient-based evaluation, from using the common pencil-paper tests towards the traffic-related task-specific tests and from the testing of separate single general non-driving-related factors towards an evaluation of the theoretically based driving performance as whole.

Predictors of a successful driver evaluation in stroke patients after discharge based on an acute rehabilitation hospital evaluation

OBJECTIVE

One of the most common concerns of a stroke patient is the ability to drive. We aimed to determine which neurologic impairments on an acute rehabilitation admission evaluation predict the likelihood of a successful driver evaluation after discharge.

DESIGN

Prospective study in an acute stroke rehabilitation unit.

RESULTS

A total of 45 stroke patients undertook a driver evaluation at our institution. The mean age +/- standard deviation was 71.0 +/- 9.8 yrs, Mini-Mental State Examination score was 22.7 +/- 8.1, upper limb and lower limb Motricity Index scores were 63.7 +/- 34.8 and 71.8 +/- 24.3, Limb Placement Task was 4.6 +/- 3.6 inches, and admission total FIM score was 68.5 +/- 18. The admission variables differed between those who failed (n = 10) vs. those who passed the in-clinic driver evaluation (n = 29, 75%): Mini-Mental State Examination (17.5 +/- 9.7 vs. 24.6 +/- 6.7, P = 0.004), and upper limb (82 +/- 23.7 vs. 57.4 +/- 36.1, P = 0.05) and lower limb (87.6 +/- 11.8 vs. 66.4 +/- 25.2, P = 0.01) Motricity Index scores.

CONCLUSIONS

Patients who undertook and passed the in-clinic driver evaluation had, at admission, higher Mini-Mental State Examination and Motricity Index scores with normal visual field defects.

The assessment of fitness to drive after a stroke: the Nordic Stroke Driver Screening Assessment

The British Stroke Driver Screening Assessment (SDSA) is a set of four simple cognitive tests to evaluate driving fitness in stroke patients. To evaluate its usefulness in a Scandinavian context, we adapted the tests and assessed a group of 97 stroke patients from Sweden and Norway, using a driving test as the criterion. When results were calculated according to the original method, based on a discriminant function, less than 70% of the participants were correctly classified. To improve the predictive potential, a new discriminant analysis was performed, using the scores of a subsample of 49 patients, and validated on the remaining 48 participants. In total, 78% of the patients were correctly classified, but specificity was superior to sensitivity. We conclude that the Nordic version of the SDSA is a useful instrument, provided that test scores are interpreted in a balanced manner, taking into account the possibility of compensatory traffic behavior.