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Title: Evaluatie en Revalidatie van Rijvaardigheid bij Personen met Neurologische Aandoeningen
Other Titles: Evaluation and Rehabilitation of Driving Ability in People with Neurological Conditions
Authors: Devos, Hannes
Issue Date: 26-May-2011
Abstract: Driving an automobile is embedded in the social and economic lifestyle of the western industrialized world. Driving is considered to promote mobility, independence, and freedom. Seemingly easy as driving may appear, it is a highly complicated activity in a constantly changing environment. Several visual, motor, and cognitive processes are involved to ensure safe driving. Persons with acquired neurological conditions often suffer from visual, motor, and cognitive processes that may hinder safe driving. Fitness to drive evaluations are necessary to identify drivers that may cause serious harm to themselves and to other road users.The scope of this doctoral project was to facilitate the screening and assessment of fitness to drive, and to determine the most efficient rehabilitation concept to improve automobile driving in people with neurological conditions. Part 1 addressed the evaluation of fitness to drive in people with stroke and Parkinson disease. Part 2 involved the rehabilitation of driving skills following acquired brain injury.Part 1 focused on the efficiency of the fitness to drive evaluation. The evaluation of fitness to drive involves a 2-step process: a first-tier screening of fitness to drive and a final fitness to drive assessment. First-tier screening of fitness to drive is a difficult burden for primary care physicians, partly because they lack accurate in-clinic assessment batteries. The goal of the first two studies was to identify the most accurate screening tools for fitness to drive in people with stroke or Parkinson disease. In the systematic review and meta-analysis presented in chapter 1, we scrutinized 30 articles that jointly evaluated the fitness to drive of 1,728 stroke survivors. More than half (54%) of stroke survivors who wished to resume driving passed an on-road evaluation. Fifty-four potentially relevant determinants were reduced to three clinically relevant off-the-shelf tests: (1) Road Sign Recognition, (2) Compass, and (3) Trail Making Test, part B. Critical cut-off scores to fail the on-road assessment were calculated (8.5 for Road Sign Recognition, 25 for Compass, and 90 seconds for Trail Making Test B). Those three tests each identified potentially unsafe drivers with an accuracy of more than 80%. It was concluded that carefully selected in-clinic screening tools are useful in identifying unsafe drivers with stroke to be referred for an official driving assessment. Yet, the predictive validity of on-road assessments to decrease crash risk after stroke could not be established because of the limited number of studies. In chapter 2, we developed a short in-clinic screening battery to predict fitness to drive in 40 patients with Parkinson disease. We first selected a battery of potentially relevant off-road tests consisting of three questionnaires, five paper-and-pencil tests, and a driving simulator evaluation. The discriminative abilities of those tests were determined by comparing the scores of the 40 patients with Parkinson disease with the performance of 40 healthy age- and sex-matched individuals. The most accurate univariate tests were entered in a multivariate regression model. This model yielded a combination of general disease status (disease duration), visual function (contrast sensitivity), motor performance (motor part of the Unified Parkinson¬ís Disease Rating Scale) and cognitive status (Clinical Dementia Rating) as the best model to predict fitness to drive. This model correctly predicted 36 (90%) out of 40 drivers with Parkinson disease. When the driving simulator evaluation was added to the model, only one patient (2.5%) was misclassified. We concluded that a short in-clinic assessment battery that evaluates general disease symptoms, visual, motor, and cognitive functions predicts fitness to drive in Parkinson disease with a high degree of accuracy. The evaluation in a driving simulator is a useful surplus to evaluate driving skills because of its similarity to real-world driving.Chapter 3 focused on the confirmation of a short assessment battery to predict fitness to drive after stroke. The official driving assessment at the Center for Evaluation of Fitness to drive and Car Adaptations (CARA) of the Belgian Road Safety Institute involves the administration of medical, visual, neuropsychological, and on-road functions. The visual and neuropsychological assessments are highly intercorrelated. Moreover, the assessment in CARA is quite challenging for candidate drivers as it takes more than 3 hours to be completed. Therefore, the aim of this study was to condense this extensive test battery, without losing predictive accuracy. A previous study identified a combination of figure of Rey, visual neglect, and an on-road test as the best subset of predictors of fitness to drive after stroke. In a new cohort of 43 stroke survivors, the predictive accuracy of this short assessment battery was confirmed. The combination of those three tests accurately predicted fitness to drive of 37 (86%) out of 43 stroke participants. The predictive accuracy was similar to that of the previous study (87%). We proposed a clinical algorithm for deciding fitness to drive after stroke in Belgium that took into account the legislative requirements and the findings of this study. Part 2 focused on the rehabilitation of driving skills following brain injury. Chapter 4 reviewed 14 studies that investigated the usefulness of driving retraining programs to improve automobile driving in subjects with brain injury. Most studies included patients who had suffered an acute neurological disorder, such as stroke. The results of the studies were discussed in view of the rehabilitation concept that was used. Two different rehabilitation concepts were used to retrain driving skills. The non-contextual cognitive rehabilitation concept is a remedial approach, in which the cognitive skills necessary for driving are trained through off-the-shelf games, assuming a carryover effect to improved on-road functioning. The contextual rehabilitation concept adheres to the Motor Learning principles, in which driving-related tasks are trained intensively and repetitively, in a task-related context such as an actual car or a driving simulator. Although no meta-analysis was conducted, the studies suggested that targeted training in a contextual setting appeared to be superior to cognitive rehabilitation training to improve automobile driving in patients with neurological conditions. This notion was supported by a single-blind randomized controlled trial (RCT) with 6 months follow-up conducted by our group. The main finding of the RCT was that 19 (73%) out of 26 stroke drivers who received driving simulator therapy versus 11 (42%) out of 26 stroke drivers who received cognitive rehabilitation therapy passed the driving assessment and were legally allowed to resume driving. It was however unclear how skills trained via a driving simulator translated to improved on-road functioning.In chapter 5, the differential effects of two retraining programs to improve driving skills after stroke were compared until 6 months after stroke. Eighty-three first-ever stroke survivors were randomly allocated to a 15 hour driving therapy program that consisted either of simulator-based driving training or cognitive rehabilitation training. A standardized on-road test with established reliability and validity was used to evaluate on-road driving skills after stroke. The improvements in on-road skills were compared between the two interventions. The findings showed that participants in the driving simulator group improved more on the on-road test than those in the cognitive rehabilitation group, with apparent effects observed at the 6 months mark. However, the results revealed that not all on-road skills could be trained equally well. Most carryover was obtained in anticipation and perception of road signs and traffic signals, visual behavior and communication, quality of traffic participation, and turning left maneuvers.In chapter 6, all stroke subjects who originally participated in the RCT were invited to take part in a 5-year follow-up. The fitness to drive of 61 patients were determined through medical tests and, if applicable, visual, neuropsychological, and on-road tests. This article showed that the beneficial effect of driving simulator therapy evident at 6 months poststroke, could not be retained at 5-year follow-up. In contrast to common belief, no significant changes in depression severity could be found between drivers and nondrivers when controlling for age and health-related factors.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Research Group for Neuromotor Rehabilitation

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