Background: Little is known about the critical on-road driving skills that get affected after a stroke. The purpose of this study was to investigate the key on-road driving impairments and their associated cognitive deficits after a stroke. A second aim was to investigate if lateralization of stroke impacts results of the cognitive and on-road driving tests. Methods: In this cross-sectional study, 99 participants with a first-ever stroke who were actively driving prior to stroke underwent a cognitive battery and a standardized road test that evaluated 13 specific on-road driving skills. These on-road driving skills were mapped onto an existing, theoretical framework that categorized the on-road items into hierarchic clusters of operational, tactical, visuo-integrative, and mixed driving skills. The total score on the road test and the on-road decision, made by a certified fitness-to-drive expert, decided the main outcome. The critical on-road driving skills predicting the on-road decision were identified using logistic regression analysis. Linear regression analysis was employed to determine the cognitive impairments leading to poor total on-road scores. Analyses were repeated for right- and left-sided strokes. Results: In all, 37 persons scored poorly on the road test. These participants performed worse in all hierarchic clusters of on-road driving. Performances on the operational cluster and the visuo-integrative cluster best predicted on-road decisions (R2 = 0.60). ‘Lane changing' and ‘understanding, insight, and quality of traffic participation' were the critical skill deficits leading to poor performance on the road test (R2 = 0.65). Divided attention was the main determinant of on-road scores in the total group (R2 = 0.06). Participants with right-sided stroke performed worse on visual field, visual neglect, visual scanning, visuo-constructive skills, and divided attention compared with those with left-sided stroke. Divided attention was the main determinant of total on-road scores in the right-sided stroke group (R2 = 0.10). A combination of visual scanning, speed of processing, and executive dysfunction yielded the best model to predict on-road scores in left-sided strokes (R2 = 0.46). Conclusions: Poor performance in the road test after stroke is determined by critical operational and visuo-integrative driving impairments. Specific and different driving evaluation and training programs are needed for right- and left-sided strokes.

Keywords:
Stroke, Neuropsychology, Neurorehabilitation, Occupational therapy, Physical therapy, Activities of daily living, Stroke rehabilitation
1.
Logan PA, Dyas J, Gladman JR: Using an interview study of transport use by people who have had a stroke to inform rehabilitation. Clin Rehabil 2004;18:703-708.
2.
Devos H, Akinwuntan AE, Gelinas I, George S, Nieuwboer A, Verheyden G: Shifting up a gear: considerations on assessment and rehabilitation of driving in people with neurological conditions. An extended editorial. Physiother Res Int 2012;17:125-131.
3.
Bacon D, Fisher S, Morris JC, Rizzo M, Spanaki MV: American Academy of Neurology position statement on physician reporting of medical conditions that may affect driving competence. Neurology 2007;68:1174-1177.
4.
Molnar FJ, Patel A, Marshall SC, Man-Son-Hing M, Wilson KG: Clinical utility of office-based cognitive predictors of fitness to drive in persons with dementia: a systematic review. J Am Geriatr Soc 2006;54:1809-1824.
5.
Devos H, Akinwuntan AE, Nieuwboer A, Truijen S, Tant M, De Weerdt W: Screening for fitness to drive after stroke: a systematic review and meta-analysis. Neurology 2011;76:747-756.
6.
George S, Crotty M, Gelinas I, Devos H: Rehabilitation for improving automobile driving after stroke. Cochrane Database Syst Rev 2014;2:CD008357.
7.
Mazer BL, Sofer S, Korner-Bitensky N, Gelinas I, Hanley J, Wood-Dauphinee S: Effectiveness of a visual attention retraining program on the driving performance of clients with stroke. Arch Phys Med Rehabil 2003;84:541-550.
8.
Crotty M, George S: Retraining visual processing skills to improve driving ability after stroke. Arch Phys Med Rehabil 2009;90:2096-2102.
9.
Akinwuntan AE, De Weerdt W, Feys H, Pauwels J, Baten G, Arno P, Kiekens C: Effect of simulator training on driving after stroke: a randomized controlled trial. Neurology 2005;65:843-850.
10.
Akinwuntan AE, Feys H, De Weerdt W, Baten G, Arno P, Kiekens C: Prediction of driving after stroke: a prospective study. Neurorehabil Neural Repair 2006;20:417-423.
11.
Akinwuntan AE, Devos H, Feys H, Verheyden G, Baten G, Kiekens C, De Weerdt W: Confirmation of the accuracy of a short battery to predict fitness-to-drive of stroke survivors without severe deficits. J Rehabil Med 2007;39:698-702.
12.
Rey A: L'examen psychologique dans les cas d'encephalopathie traumatique. Arch Psychol 1941;28:215-285.
13.
Zimmermann P, Fimm B: A test battery for attentional performance. New York, Psychology Press, 2002.
14.
Ball KK, Roenker DL, Bruni JR: Developmental changes in attention and visual search through adulthood. Amsterdam, North Holland, Elsevier, 1990.
15.
De Raedt R, Ponjaert-Kristoffersen I: Predicting at-fault car accidents of older drivers. Accid Anal Prev 2001;33:809-819.
16.
Akinwuntan AE, De Weerdt W, Feys H, Baten G, Arno P, Kiekens C: Reliability of a road test after stroke. Arch Phys Med Rehabil 2003;84:1792-1796.
17.
Akinwuntan AE, De Weerdt W, Feys H, Baten G, Arno P, Kiekens C: The validity of a road test after stroke. Arch Phys Med Rehabil 2005;86:421-426.
18.
Michon JA: Explanatory pitfalls and rule-based driver models. Accid Anal Prev 1989;21:341-353.
19.
Devos H, Akinwuntan AE, Nieuwboer A, Tant M, Truijen S, De Wit L, Kiekens C, De Weerdt W: Comparison of the effect of two driving retraining programs on on-road performance after stroke. Neurorehabil Neural Repair 2009;23:699-705.
20.
Akinwuntan AE, Feys H, DeWeerdt W, Pauwels J, Baten G, Strypstein E: Determinants of driving after stroke. Arch Phys Med Rehabil 2002;83:334-341.
21.
Cohen J: A power primer. Psychol Bull 1992;112:155-159.
22.
Belsey DA, Kuh E, Welsch RE: Regression diagnostics: identifying influential data and sources of collinearity. New York, John Wiley and Sons, 1980.
23.
Cushman LA, Cogliandro FC: On-road driving post-stroke: cognitive and other factors. Arch Clin Neuropsychol 1999;14:799.
24.
Aslaksen PM, Orbo M, Elvestad R, Schafer C, Anke A: Prediction of on-road driving ability after traumatic brain injury and stroke. Eur J Neurol 2013;20:1227-1233.
25.
Marshall SC, Molnar F, Man-Son-Hing M, Blair R, Brosseau L, Finestone HM, Lamothe C, Korner-Bitensky N, Wilson KG: Predictors of driving ability following stroke: a systematic review. Top Stroke Rehabil 2007;14:98-114.
26.
McEvoy SP, Stevenson MR, Woodward M: The prevalence of, and factors associated with, serious crashes involving a distracting activity. Accid Anal Prev 2007;39:475-482.
27.
Akinwuntan AE, Devos H, Verheyden G, Baten G, Kiekens C, Feys H, De Weerdt W: Retraining moderately impaired stroke survivors in driving-related visual attention skills. Top Stroke Rehabil 2010;17:328-336.
28.
Uc EY, Rizzo M, Anderson SW, Shi Q, Dawson JD: Driver identification of landmarks and traffic signs after a stroke: 84th Annual Meeting of the Transportation Research Board. Washington, DC, 2005, pp 9-14.
29.
Paolucci A, McKenna K, Cooke DM: Factors affecting the number and type of impairments of visual perception and praxis following stroke. Aust Occup Ther J 2009;56:350-360.
30.
Gerritsen MJ, Berg IJ, Deelman BG, Visser-Keizer AC, Meyboom-de Jong B: Speed of information processing after unilateral stroke. J Clin Exp Neuropsychol 2003;25:1-13.
31.
Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar K, Fraas M, Felicetti T, Laatsch L, Harley JP, Bergquist T, Azulay J, Cantor J, Ashman T: Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil 2011;92:519-530.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.