Return-to-driving following acquired brain injury: A neuropsychological perspective

Abstract

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.

CONCLUSION

The 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.

1 Background

Acquired brain injury (ABI) is a significant worldwide cause of disability (Andelic, 2013) and driving is an important activity of daily living that is central to post-injury community integration and is increasingly relied upon as the population ages (Mckerral et al., 2019). Return to driving after ABI has also been positively associated with return to employment, maintenance of social relationships, and engagement in recreational and other community activities (Anschutz et al., 2010; Klonoff, et al., 2006). Most recent multi-site research also reiterated that driving is associated with greater community participation, better functional outcomes, fewer symptoms of depression, and greater life satisfaction (Novack et al., 2021). Novack and colleagues also found that over the past 30 years, over 76%of individuals with moderate to severe TBI were able to return to driving although not everyone maintained this activity. Employment, race, family income, and seizures were strongly associated with successful post-injury driving resumption.

Driving safety still remains a major public health issue, as there is considerable empirical research suggesting that the risk of a motor vehicle accident after the return to driving is significantly higher and perhaps double that of people who have not had a brain injury (Bivona, 2012, Schanke et al., 2008). Even after passing a post injury driving test, people were found to have significantly more risky driving behaviors (Mckerral et al., 2019). There effective assessment and treatment methodologies relevant to driving have been found to improve post-injury driving outcome and thus, need to be advocated for individual and public health and safety. There are many good resources to help guide clinicians in assessing driving and predriving skills such as an entire issue of the Brain Injury Professional in 2018.

1.1 Post-injury functional status & return to driving

While one recognizes that return-to-driving following an acquired brain injury has serious implications, the process for returning to driving following ABI is multifaceted and involves many challenges. Before someone can safely return to driving after a brain injury, there are several clinical issues that need to be addressed. First and foremost, driving is a complex task that requires coordination of multiple cognitive abilities in a dynamic environment. Although no association has been recognized between specific cognitive skills and specific driving behaviors, domains such as attention, perceptual-motor skills, memory, and aspects of executive functions have been found to be most relevant to driving (Lundqvist, 2009). Slowed reaction time (Beaulieu-Bonneau et al., 2017), poor attention (Brouwer et al., 2017; Cyr et al., 2009), visuospatial deficits (Fueger & Huddleston, 2018), neurobehavioral and self-awareness changes (Arnould et al., 2015; Gooden et al., 2017), and dysexecutive symptoms including poor behavioral and emotional control (Hargrave et al, 2012; Rike et al., 2014) have been associated with reduced fitness to drive (D’Apolito, 2013).

1.2 Need for assessing driving capability

Despite the relationship between cognition and driving and the strong association between ABI and cognitive impairment, the great majority of individuals are not formally evaluated for driving competency. Some researchers indicated that about half the people who resume driving after ABI ever have their driving formally evaluated (Rapport et al., 2006) while others showed that between 42%and 85%of individuals with moderate and severe TBI do not have a professional evaluation of their driving ability (Fisk et al., 1998; Rapport et al., 2008). Of greater concern is that many individuals are not fully aware of their cognitive impairments and how they may affect driving (Patomella et al., 2008). These individuals are unlikely to seek any assessment or treatment or any assistance for their post-injury return to driving. More recently, Jayagopal and colleagues (2018) pointed out that in addition to not having their driving abilities assessed after brain injury, some individuals drive against recommendations.

Researchers have also noted that those who drive after ABI are at a greater risk of undergoing a motor vehicle crash than the average driver (Rabadi, 2010). The individual and public safety implications provide a strong reason to thoroughly assess the ability to return to driving following a brain injury.

Above all, the legal standards for public safety as well as the individual needs for community reintegration with increased autonomy following ABI warrant that the driving ability is reliably assessed in some manner (Bliokas et al., 2011). Local governing transportation authorities nevertheless provide no clear guidance for the process and the standards and mandates often lack clarity and also vary widely from State to State.

Additionally, there is no consensus about a standardized driving evaluation and training protocol, which is further confounded by conflicting data from the clinical and transportation research (Schultheis and Whipple, 2014). A multidisciplinary assessment, involving various professionals, including occupational therapist, physical therapist, physician, and neuropsychologist likely provides the best solution under these circumstances. A baseline neuropsychological evaluation followed by on-road driving assessment is customary in clinical practice and this protocol was also utilized in the current study.

1.3 Neuropsychological evaluation and return to driving

While driving assessment is multifaceted, a neuropsychological evaluation is often viewed as a reliable tool to estimate post-injury driving competency as it allows a clinician to evaluate cognitive performance on standardized testing (Alexandersen et al., 2009; Tamietto et al., 2006). Because people generally don’t forget how to drive, driving safety appears highly contingent on certain cognitive skills.

A recent meta-analysis of eleven studies of individuals with moderate to severe TBI (Egeto and colleagues (2019) provided preliminary evidence of association between neuropsychological test performance and driving ability after moderate to severe TBI, with executive functions having the largest effect size, followed by verbal memory, processing speed/attention, and visual memory. Of the individual tests, the Useful Field of Vision (UFOV) and Trail Making Test B were most effective with divided and selective attention having the largest effects followed by Trail Making Test A measuring simple attention. In another study using neuropsychological measures as well as a driving simulator, results noted that tapping and speed of information processing is slowed years after moderate-severe TBI and may impact driving (Beaulieu-Bonneau et al., 2017).

As driving involves complex visual processing, vision remains the primary and the only sensory modality assessed legally. The current legal standards nevertheless focus primarily on visual acuity, with no additional assessment requirements following a BI although post-BI visual dysfunction can take several forms including visual field defects, impaired contrast sensitivity, color/depth perception among others. Deficits in visual processing speed and attention have long been related to increased crash risk (e.g., Ball and Owsley, 1993; Ball et al., 1993; Duchek et al., 1998; Parasuraman and Nestor, 1991). Visual attention has also been associated with safe driving after a stroke (Braga et al., 2018).

In comparing right versus left hemisphere injuries, Devos and colleagues (2014) found that participants with right-hemisphere stroke performed worse with regard to 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 overall on-road performance in the right-sided stroke group. A combination of visual scanning, speed of processing, and executive dysfunction yielded the best model to predict on-road performance in left-sided strokes.

In a more recent study by Leon-Dominguez and colleagues (2017), integrity of executive functioning evidenced by strong performances on measures of attention, processing speed, planning, cognitive flexibility, and inhibitory control was associated with better driving ability. In fact, differences in reaction time on both simple and complex attention tasks were thought to potentially serve as neuropsychological markers for safe driving in healthy individuals.

Additionally, post-ABI executive dysfunction in the form of anosognosia is evidenced to influence driving outcomes both directly and also indirectly as a moderator of the relationship between neuropsychological functioning and driving performance, making neuropsychological status especially important in predicting driving outcomes for adults who fail to fully appreciate their impairments (Griffen et al., 2011).

1.4 Neuropsychological assessment protocol: Some considerations

With a close examination of the existing literature, it is apparent that there is a general agreement that certain cognitive domains such as attention, executive functions, perceptual-motor skills, processing speed, and to a somewhat lesser extent, memory, play a critical role in driving and that assessment of these areas can yield useful information relevant to driving rehabilitation following an acquired brain injury. Unfortunately, there is no consensus about what measures one should use to evaluate cognitive functions in preparation for a post-injury return-to-driving.

Rehabilitation programs vary considerably in their selection of measures as well as the steps in the driving rehabilitation process. The lack of clarity around the constructs such as executive functions, or what aspects of attention and visual-motor performance are more relevant to driving do not help either. Nonetheless, neuropsychological tests such as Useful Field of View (UFOV), Trail Making Test (TMT) A and B, and Rey-Osterreith Complex Figure (ROCF) have been found to be good predictors of the on-the-road test outcome due to their ability to cross the three most-studied domains of attention, perception, and executive functioning (Marshall et al., 2007). Other tests, including Benton Judgment of Line Orientation, WAIS Block Design, and Rey Auditory Learning Test (AVLT), as well as brief screening instruments such as Montreal Cognitive Assessment (MoCA) have also garnered adequate support in the return to driving literature.

Rather than looking for a fixed neuropsychological battery, a neuropsychologist may select such measures with established clinical and empirical support in addressing post-ABI return to driving. It is also important to note that researchers such as Barrash et al. (2010) have found that the demographic corrections diminish predictive accuracy for driving performance, corroborating the findings of Silverberg and Millis (2009) that competency in complex real-world activities depends on ability levels, regardless of demographic considerations. It may also be necessary to evaluate visual acuity, visual fields, color and depth perception and other visual functions when visual dysfunction is suspected considering the significant role vision plays in driving. Likewise, assessment of motor functioning by a physical/occupational therapist should be taken into account, particularly when a patient is experiencing significant residual physical challenges. Despite an apparent need for relying on multiple types of assessment to aid the return-to-driving decision, there is no strong evidence of significant predictive variables (Palubiski et al., 2016).

1.5 Behind-the-wheel (BTW) driving test and return to driving

Because cognitive and psychological variables, which are not-so-readily-visible, can affect driving, some researchers suggest adding a behind-the-wheel (BTW) road test to the pre-driving assessment protocol to improve estimation of driving capability (Lundqvist, 2009). Behind the wheel driving assessment is found to be a valid measure of driving ability for stroke patients (Akinwutkin et al., 2005) and in fact, a road test is considered by some as a “gold standard” for evaluating driving fitness for individuals with significant disability. Many rehabilitation programs, therefore, require that in addition to the neuropsychological assessment, individuals interested in resuming driving following a brain injury also undergo a behind-the-wheel test prior to resuming driving.

The road testing is usually performed by the Department of Public Safety (DPS) or through a therapeutic driving assessment by a certified driving rehabilitation specialist (CDRS) and a passing grade is considered to be strongly correlated to safe driving. Baseline neuropsychological test performance can significantly inform the on-road assessment, although actors such as injury severity, time since injury at driving assessment are found to be better predictors for on-road driving performance (Mckay et al., 2016).

In a recent exploratory study by Stolwyk et al. (2019) individuals with TBI who failed the on-road testing demonstrated worse driving performance relative to controls across multiple driving operations and error types, including observation of road environment, maintenance of lane position, and speed and basic car control. Longer time since injury and reduced visual perception were significantly correlated with poorer driving skills. Researchers (Ross et al., 2018) advocate for individualized on-road driving training lessons to individuals who fail the initial on-road test followed by reassessment and license restrictions if needed.

The present study will review the performance on the in-office pre-driving cognitive screening, as well as therapeutic on-road behind-the-wheel driving assessment for a group of individuals with acquired brain injury treated in a rehabilitation setting.

1.6 Neurorehabilitation and return to driving

Although pre-driving screenings and on-road assessments help with gauging a person’s driving capability following a brain injury, identifying driving-related deficits becomes truly meaningful only if the post-ABI return-to driving process also involves an intervention component. For example, if any impairments or limitations are found that can potentially interfere with safe driving, a treatment plan will then need to be created to address the deficits in order to help facilitate a return to driving. Further, ongoing monitoring or re-assessment will also be necessary to examine potential functional progress before one can undergo a behind-the-wheel driving assessment. Often times, the individual will also need to gain awareness and insight into brain-related issues that may have to be worked on before a safe return to driving. Additionally, the individual may need education about the Department of Public Safety (DPS) regulations regarding return to driving. Such education and supportive feedback assume a crucial role in rehabilitation planning and continued progress toward the goal of returning to driving, as these measures also help improve the potential intrinsic motivation and a sense of hope.

As pointed out by Ross and colleagues (2016) on-road driver assessment and on-road retraining are important aspects of post-injury rehabilitation. These researchers observed that many participants with moderate-to severe TBI in their study were able to use on-road assessment and training experience, to improve their navigational skills, modify their driving behaviors, and continue driving safely. Even 41/2 years after successfully completing driver assessment and rehabilitation, these individuals reported on a self-report questionnaire no difference between pre- and post-injury crashes.

The variety of clinical and driving relevant issues is usually best addressed through a multi-disciplinary treatment model, often with heavy occupational therapy involvement, but also with consistent collaboration with neuropsychology and other disciplines. The importance of return to driving requires that all disciplines must contribute to a successful and safe completion of the return to driving process. For example, despite the significant implications of visual dysfunction for driving, researchers have suggested that judgement on practical fitness to drive cannot be based solely on the visual field size even in individuals with residual hemianopsia. Often dynamic issues such as visual scanning and operational training into steering stability, speed adaptation, and anticipating environmental changes are meaningful and can be incorporated into treatment to improve driving fitness (de Haan et al., 2014). Such operational training often requires team effort, including assistance from disciplines such as occupational therapists and driving rehab specialists. A rehabilitation program is often expected to provide an effective and safe environment to address emergent issues with the help from an interdisciplinary team. The current study is representative of such a setting.

1.7 Role of neuropsychology in preparation for return to driving

The neuropsychologist’s role in assisting patients return to driving can range from nonexistent to highly involved and complex. In neurorehabilitation, return to driving is a common community reintegration goal although it is not always clear whether it is a realistic, achievable goal for any given individual with a given ABI.

As noted earlier, most brain injuries have cognitive sequelae which have variable implications for return-to-driving. A neuropsychologist is often a primary resource who is entrusted with the responsibility to assess post-injury cognitive functioning and to provide recommendations for returning to work, driving, and other activities. The assessment may involve relatively brief testing or perhaps a comprehensive neuropsychological evaluation, which serves the purpose of providing an in-depth view of post-injury functional strengths and relative weaknesses and their implications for everyday living, including driving.

Most community reintegration-driven rehabilitation programs also incorporate a briefer neuropsychological assessment following some degree of recovery to “screen” for driving readiness. The test measures used in this pre-driving screening may differ across clinicians, programs, and settings, but they all target cognitive areas, such as visuospatial skills, processing speed, attention, memory, and executive functioning that are particularly relevant to driving. The prescreening findings, when pooled together with other interdisciplinary assessment data, can be very useful in developing and navigating a potential path to return-to-driving.

In addition to assessment, neuropsychologists working in rehabilitation settings are often actively involved in intervention, which ranges from cognitive retraining to psychotherapy, psychoeducation, and family support, as well as advocacy. In cognitive training the neuropsychologists help individuals learn strategies to compensate for residual deficits and/or improve functioning. Brain injury survivors at times not only need to cope with loss of driving privileges for a short duration, but perhaps may also need to mentally prepare themselves for not driving for an extended period of time. The psychologist role also involves preparing the person both cognitively and emotionally for either a return to driving or an alternative plan for transportation. Research suggests that there are various psychological approaches to address driving cessation if that is the plan (Rapaport et al., 2017).

Having a neuropsychologist or rehabilitation psychologist involved in this process can be helpful from a psychological as well as awareness point of view. Lack of awareness or insight is highly prevalent in population with acquired brain injury. In fact, self-awareness deficits in brain injury have been reported as occurring in up to 97%of patients with Traumatic Brain Injury (Sherer et al., 1998). Poor self-awareness can lead some individuals to believe that because they still remember how to drive that they must still be safe to resume driving. People often require education about the difference between knowing and doing something. Individuals with impaired self-awareness may also underestimate the residual deficits and/or their implications for driving safety. At times, they may not fully understand or accept safety risks resulting from a post-injury functional impairment.

A neuropsychologist can work with them in individual and group sessions to help them not only to recognize their functional limitations and the associated risks for driving, but to also to anticipate when their impairments may affect driving performance as well as implement strategies to maximize success. In other words, a neuropsychologist is able to help individuals gain awareness and progress from ‘intellectual awareness’ to ‘emergent awareness’ and finally to the level of ‘anticipatory awareness’ (Crosson et al., 1989). Exercises based on “Predict-Perform” paradigms may be particularly helpful in facilitating self-awareness. Therapeutic techniques guided by principles of Acceptance and Commitment Therapy, Motivational Interviewing, as well as corrective feedback, strategy training, and family/caregiver education are usually highly effective.

Additionally, some individuals may clearly have significant obstacles, physical, or cognitive, or other to a safe return to driving. Those individuals may need to become emotionally ready for a possible long delay in getting back to driving and perhaps never being cleared to drive. Furthermore, they often benefit from considerable counseling and education. Rehabilitation neuropsychologists, with their unique knowledge and skillset covering broad bases, can contribute significantly to the preparation and facilitation of the process.

A rehabilitation neuropsychologist also plays a critical role as an educator and advocate. An individual planning to return to driving needs to have good self-awareness and critical information about the State regulations pertaining to driving after brain injury. To improve self-awareness and self-regulation, many clinicians have individuals fill out the Awareness Questionnaire (Sherer et al. 1998) and help them predict and compare their self-evaluation on many tasks with the evaluations made by the clinician or others (Toglia and Kirk, 2000; Goverover et al., 2007; Staley & Owsley, 2003). Gooden and others (2017) emphasized the importance of addressing self-awareness issues as they found that individuals with TBI who failed the on-road test significantly overestimated The driver regulation information is shared with patients during individual therapy sessions, but probably more effectively during a group therapy session. The group sessions are particularly helpful to patients especially those who lack self-awareness and don’t see any safety concerns with just returning to driving on their own. During these driving-focused group sessions, the safety minded individual’s opinions usually prevail and help others with building awareness, insight, and a sense of hope.

The objective of the present cross-sectional study is to examine the return-to-driving process and the variables affecting the outcomes in individuals with acquired brain injury treated in a neurorehabilitation setting. Specifically, we will look at; (1) performances on the in-office cognitive screening and on-road driving test, (2) the types of errors demonstrated on the on-road (BTW) test, (3) the intervention (education, training, counseling) offered, and 4) the role neuropsychology plays throughout the process.

2 Methods

2.1 Participants

The present study involves a retrospective examination of the return to driving process of 39 individuals, including 33 males and 6 females, who were attending an outpatient Post-acute Brain Injury Rehabilitation Program in a southern metropolitan city in the USA. The mean age for this participant group was 43.9 years, and mean education level was 13.4 years. The sample was composed of 30 Non-Hispanic White individuals, 4 Black individuals, 4 Hispanic individuals, and 1Asian individual.

With regard to the type of injury, most participants had sustained a stroke (21) or a TBI (17), while one participant was status post brain neoplasm. All the individuals with TBI had moderate or severe injuries (based on GCS) and nearly all individuals with strokes had large strokes involving the middle cerebral artery (MCA) territory. This is not a random sample of people with ABI, but perhaps is a sample of individuals with moderate-severe brain injuries and prominent residual impairments. Twenty participants had evidence of right hemisphere brain injuries, seventeen had left hemisphere pathology, whereas two patients had bilateral involvement. Post-injury interval ranged from 3 to 11months. Functional status revealed 16 individuals with residual hemiparesis, 5 with aphasia, and 3 with seizures (See Table 1 for further demographic and injury-related details).

Table 1
Demographic characteristics and injury-related variables

Demographic and injury-related variables Passed BTW Failed BTW

Age 49.2 38.2

Education 13.4 14.0

Ethnicity/race 10%B 80%W

10%L 20%B

77%W

3%A

Stroke 50% 60%

TBI 44% 40%

Right hemisphere injury 50% 60%

Left hemisphere injury 50% 40%

Time since injury 3.9 months 6.6 months

Demographic and injury-related variables	Passed BTW	Failed BTW
Age	49.2	38.2
Education	13.4	14.0
Ethnicity/race	10%B	80%W
	10%L	20%B
	77%W
	3%A
Stroke	50%	60%
TBI	44%	40%
Right hemisphere injury	50%	60%
Left hemisphere injury	50%	40%
Time since injury	3.9 months	6.6 months

Note: BTW = Behind the Wheel driving exam, Ethnicity (B = Black, W = White, L = Latino, A = Asian). Age and education are presented in years.

2.2 Procedure

2.2.1 Pre-driving assessment

Many rehabilitation programs use the pre-driving assessment as a way to screen out individuals who have too severe cognitive impairments to safely return to driving at that time. Passing a baseline pre-driving assessment, thus, is a first step toward returning to driving.

In the present study, the pre-driving protocol included the following measures:

Motor Free Visual Perceptual Test (MVPT; Colorusso & Hammill, 2015), Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005), Trail Making Test (TMT-A and TMT-B, 1944), Road Signs Test, the Bells Test (Gauthier et al. 1989), and Visual Motor Reaction Time Test (VMR, 2017). The neuropsychologist was involved in administering the Trail Making Test, Montreal Cognitive Assessment, Motor Free Visual Perception Test, and helping with having individuals practice the road signs test, while an occupational therapist was responsible for administering the remaining measures.

This study used stringent cut-off scores for passing the pre-driving assessment in order to then take the road test. Specifically, individuals were required to score in the non-impaired range on the MoCA, perform in the average range or better on MVPT, complete TMT-A in 30 seconds or less and TMT-B in 120 seconds or less, have 80%accuracy on the Bells Test, exhibit a consistent 0.750 second response time or lower across four trails of the VMR, and pass five separate road signs tests. In terms of motor functioning, the person needs to be able to get into and out of the vehicle independently and manage their mobility device such as break down/fold and stow their wheelchair. Additionally, individuals were required to meet the State DPS criteria for vision. Thus, if the individuals had visual field loss, they were sent to a neuro-ophthalmologist and according to DPS regulations individuals were required to have 140 degrees of visual field at minimum and 20/40 or better visual acuity. Figure 1 outlines the steps in the pre-driving process.

Fig. 1

The sequential process from pre-driving assessment to the on-road examination. Notes. MoCA: Montreal Cognitive Assessment; MVPT: Motor-Free Visual Perception Test; TMT-A&B: Trail Making Test; VMR: Visual Motor Reaction time test program; UE: Upper Extremity; LE: Lower Extremity.

2.2.2 Behind-the-wheel driving assessment

All individuals who passed a pre-driving assessment protocol underwent a behind-the-wheel (BTW) driving assessment. Though the BTW is considered the “Gold Standard,” some research suggests it offers limited quantitative data (Schultheis & Mourant, 2001), Accordingly, a rating form was used to collect data in the current study (Pate Rehabilitation, 2015).

The therapeutic BTW driving evaluation offered through this rehabilitation program involved a one-hour assessment with a certified driver rehabilitation specialist (CDRS). A CDRS is required to have 1664 documented hours of driver rehab practice. The CDRS in this program completed a 91-item checklist (Pate Rehabilitation, 2015) during each BTW assessment for each participant. Items on the checklist were all related to DPS driver manual information (i.e., check mirrors, yield right of way, brakes smoothly, maintains lane position, performs lane change safely). All items were given one of three possible scores: (Performed Consistently, Performed 25–50%of the time, or Required Instructor Cues/Intervention). A copy of the Behind-the-Wheel Driving Rating Form can be found in the Appendix (Pate Rehabilitation, 2015).

3 Results

3.1 Pre-driving assessment

Of 200 individuals treated at the outpatient rehabilitation facility, only 39 individuals (approximately 20%) participated in and passed the pre-driving protocol and went on to attempt the BTW on-road driving test. In this sample the largest reasons for not passing the pre-driving protocol were significant attention/executive dysfunction (30%), hemiparesis resulting in very limited mobility (20%), and visual field impairment (10%). These issues are common in this population, with empirical research suggesting that 27–57%percent of people are with vision impairment after stroke (Zhang et al., 2006; Pollock 2011) and many people continue to exhibit executive dysfunction and mobility issues during the post-acute rehabilitation phase of recovery. Ten (5%) individuals were driving and opted to not be tested. So only 190 individuals participated in the pre-driving protocol and 39 (20%) passed. Of those 39 people only 34 (87%) passed the driving exam. Since empirical research suggests about 50%of people get re-licensed after a severe TBI, it may be that the pre-driving assessment being used is somewhat restrictive (Brouwer & Withaar, 1997). No one failed the pre-driving assessment purely based on residual aphasia though some individuals who failed due to significant motor impairments also had aphasia.

3.2 On-road driving assessment

Thirty four of the 39 (87%) of the individuals who successfully completed the in-office pre-driving assessment went on to pass the behind-the-wheel (BTW) road test. Eight of these patients required driving accommodations, involving a left foot accelerator pedal and steering wheel spinner knob, while three patients required a crossover bar for turn signals, and three were required to complete two hours of driver training.

Of the remaining five individuals who did not pass the road test, two patients failed the road test due to their inability to follow the examiner directions secondary to residual aphasia. Aphasia was not a significant obstacle for passing the pre-driving protocol, but did negatively affect the driving test performance in these two individuals. Another individual failed the road test as he was unable to correctly retain directions due to his severely impaired short-term memory skills secondary to bilateral ischemic strokes. Two other individuals failed the road test due to difficulty with attentional regulation, particularly demonstrating poor divided attention while dual tasking (i.e., driving and following instructions).

Few studies look at specific issues individuals have that result in the road test failure. In the current study, the driving performance was evaluated in terms of errors committed during a road test. Most drivers made very few errors. Most of those who passed either made no errors or one error. Individuals who failed tended to make 2 to three errors each. The most common driving errors made by the participants who failed the road test are summarized in Table 2. In addition, the five individuals who failed the road test will be described in some detail below to facilitate greater insight into the return-to-driving process, the roadblocks, and potential solutions.

Table 2
Errors committed on the Behind the-Wheel exam by individuals who failed

Types of driving errors Number of people who made the error

Not maintaining lane position, drifting across lanes 3

Missing turns 3

Difficulty following directions/processing information 3

Difficulty regulating speed 2

Trouble reading road signs 2

Maintains consistent speed 2

Comes to a complete stop when required 1

Checks mirrors or back window when backing up 1

Difficulty backing up around obstacles 1

Types of driving errors	Number of people who made the error
Not maintaining lane position, drifting across lanes	3
Missing turns	3
Difficulty following directions/processing information	3
Difficulty regulating speed	2
Trouble reading road signs	2
Maintains consistent speed	2
Comes to a complete stop when required	1
Checks mirrors or back window when backing up	1
Difficulty backing up around obstacles	1

Note: These results reflect the total number of errors made by the five individuals who failed the driving exam.

3.3 Individuals who passed the in-office pre-driving assessment, but failed the on-road driving test

Mr. S was a 38-year-old African American male, with 16 years of education, who was 10 months post left hemisphere cerebrovascular accident (CVA), with residual expressive aphasia and right dominant hemiparesis. On the pre-driving screening, he showed intact visual fields and exhibited no deficits in visual scanning, reaction time, or orientation. He was also able to follow and repeat simple two-step directions. He however failed the road test due to inability to follow verbal directions while driving. One month later, he completed another on-road evaluation using a Global Positioning System (GPS) to bypass the need to follow directions provided by the examiner but continued to experience similar difficulty using the GPS commands. Accordingly, he did not pass the second on-road examination either. He did well on all other aspects of the driving process. It appeared that driving consumed his cognitive resources to the extent that he was unable to process and follow any additional information while operating a vehicle. Before his second road test, a rehabilitation therapist had him practice dual tasking in an attempt to help facilitate processing verbal directions while consistently performing another task. Nonetheless, the benefit did not carry over to the driving situation.

Mr. L was a 24-year-old Caucasian male with 12 years of education and a pre-existing history of Attention Deficit Hyperactivity Disorder (ADHD), who was 4 months post a moderate TBI. He exhibited some distractibility and short attention span in the clinic, but was able to pass the pre-driving protocol. During his road test, he appeared somewhat impulsive and switched lanes too quickly before an upcoming turn. In addition to maintaining his position in the lanes, he also had difficulty with maintaining a constant speed. Thus, although he adequately and quickly completed all cognitive tasks of the pre-driving screening, including those having attentional component, his ability to regulate and alternate his attention was insufficient for driving at the time of his on-road assessment.

Mr. A was a 64-year-old Caucasian male with 16 years of education, who suffered bilateral posterior cerebral artery (PCA) strokes 9 months prior. Consistent with the location of his injury, he had a small visual field loss (of 20 degrees) but very efficient visual scanning, fully functional communication skills, and passed the entire pre-driving protocol despite exhibiting moderate short-term verbal and visual memory loss, which was apparent only to the clinicians that worked with him. He failed the or-road driver evaluation as he repeatedly forgot the directions the examiner was giving him and kept his driving speed consistently below the speed limit. Otherwise, he did not make any significant errors during the on-road testing.

Mr. T was a 56-year-old Caucasian male with 16 years of education, who was 7 months post a left middle cerebral artery (MCA) stroke resulting in severe expressive aphasia and a 30 degree right peripheral vision loss. He otherwise appeared cognitively intact and successfully completed the pre-driving screening protocol following the test instructions well. The only issue evidenced in the clinic was mild distractibility. He nevertheless failed the road test as he tended to get confused and mixed up in trying to follow the examiner directions, and also had difficulty with the left foot accelerator causing him to hit the gas and brakes.

Ms. S was a 46-year-old, Caucasian woman with 14 years of education, who was 6 months post right MCA stroke resulting in dense right hemiparesis. She had a left visual field loss of 20 degrees and had a high level of distractibility that was pre-existing due to ADHD but had worsened after her stroke. She took the BTW wheel test with a left foot accelerator, and spinner knob. On the BTW test, she made multiple errors largely related to poor attentional regulation and did not pass but was recommended to re-take the BTW test.

3.4 Neuropsychological intervention

In the current study, the rehabilitation neuropsychologist worked with participants individually and in a group. When individuals demonstrated impaired performance on any pre-driving measures and/or road testing, several disciplines worked on cognitive rehabilitation alongside the neuropsychologist. Quite commonly, the neuropsychologist worked on facilitating strategy usage for visual scanning, visual perception, attention, and awareness (Cicerone et al., 2000).

Many different cognitive rehabilitation tools can be helpful in improving relevant cognitive skills. Attention Process training (APT-II) can help improve higher level attention skills and numerous exercises can improve visual scanning (cancellation tasks, mazes, tracking moving objects and moving the head while maintaining fixed gaze on objects. This program uses the Sanet Vision Integrator with a 50-inch touch screen that measures visual scanning and reach time in each quadrant. Errors made during pre-driving and road test were examined and strategies to minimize them were explained and rehearsed under the neuropsychologist’s guidance.

The neuropsychologist also communicated on a regular basis with the occupational therapist and other disciplines involved in this process to emphasize a collaborative effort in helping individuals succeed. For example, in the pre-driving protocol, one of the measures (VMR) was significantly difficult and often required participants to work on the task an hour each day for several weeks. This task became an ongoing stressor for many participants and many benefitted from discussing and processing their frustrations and learning to cope with this necessary part of treatment in pursuing their driving goal. The neuropsychologist provided a safe environment and helped facilitate compliance by reframing it as a needed mental exercise that will allow them to respond more quickly in challenging driving situations.

The neuropsychologist also aimed to help patients build and maintain their self-esteem and a sense of self-efficacy despite frustrating circumstances. Some individuals benefit from counseling to reconceptualize their circumstances and trying to problem solve short-term and perhaps long-term transportations issues if they cannot drive. Also provided was psychoeducation relevant to return to driving. Some of the topics discussed included: driving as a privilege and as the single most dangerous thing individuals do, review of the state DPS regulations about driving after brain injury. In Texas the regulations have several brain injury specific criteria that must be adhered to such as no driving within 90 days of a seizure, the necessity of 140 degrees in visual field (either binocular or monocular), and visual acuity of 20/40 or better corrected vision.

4 Discussion

Driving is an important activity of daily living with inherent public safety risks. It also requires the coordination of several efficient cognitive skills in a manner that is difficult to assess with in-clinic tasks and tests. Many individuals seeking to resume driving after ABI may lack full awareness of their relevant cognitive impairments and an adequate and accurate understanding of the DPS medical regulations. Driving helps facilitate community integration and increases employment potential (Klonoff et al., 2006). Return to driving after brain injury is one of the most complex rehabilitation goals. Safe return to driving often requires a coordinated effort of a multi-disciplinary treatment team. This goal also often requires good communication and coordination with the person family.

Not uncommonly a spouse or family member will have strong opinions or feedback that should be discussed and processed throughout this process. Additionally, families have varied abilities to provide transportation and often need to problem solve this issue and to learn about community supports and transportation services. The data in this study suggests that there are perhaps several reasons why individuals may not actually have a therapeutic evaluation even in programs that offer that service. At times such an evaluation is not possible because the individual may exhibit impairments that are deemed too significant to safely drive. Sometimes individuals choose not to be tested likely due to diverse reasons. For example, people may find on-road testing to be expensive, daunting, or unnecessary. The screening process to determine if someone is appropriate for a BTW road test can vary dramatically as well, but at the very least, should involve tests that measure aspects of attention, executive functions, processing speed, reaction time, and issues relevant to DPS regulations such as visual fields, visual acuity, absence of seizures, and others. In-office assessment and training may also be supplemented by ecologically valid experiences such as those involving driving simulators.

Many participants in this program and likely many persons who suffer moderate to severe brain injuries have various impairments that preclude taking the BTW test earlier in their recovery period. The participants in this study who passed the in-clinic cognitive screen conducted between 3.9 to 6.6 months post-injury were highly successful in the BTW exam. Earlier in treatment it appeared unlikely that many of these individuals would return to driving. It appears likely that some of the individuals who did not pass the pre-driving assessment may pass it at some future time.

In this study, demographic variables, as well as injury parameters such as type of brain injury, severity of injury, and injury lateralization did not play a significant role in the return-to-driving process. Consistent with previous research (Stolwyk et al., 2019) the people who failed the BTW evaluation made more errors than those who passed (who had what appeared to be normal driving skills). The errors made by those who failed appeared to be consistent with inefficiencies within the attention system and what primarily appeared to reflect difficulty with dual tasking (especially when one of the tasks is dynamic and fast moving, such as driving).

The attentional dysregulation also appeared to interfere with information processing. These results appear consistent with other research validating the importance of attention and executive functioning in driving safety (Ortoleva et al., 2012; Leon-Dominguez et al, 2017). An analysis of failures on the BTW examination in the current study suggest that impaired ongoing attention regulation and information processing essentially accounted for all failures. There has been a strong evidence that reduced speed of information processing is the most consistent attention deficit in individuals with moderate-severe TBI (Azouvi et al., 2009; Beaulieu-Bonneau et al., 2017;Ross and colleagues, 2016; McCullagh & Feinstein, 2011).

The rehabilitation program’s neuropsychologist played a role throughout the process, performing the in-clinic cognitive evaluation prior to the BTW road test, addressing during individual and group therapy sessions barriers to driving and facilitating implementation of appropriate strategies to minimize driver risks and maximize driving performance. Providing patients with additional knowledge of Defensive driving strategies such as the Smith Systems five keys to safe driving is helpful.

While brain-injury rehabilitation programs may differ in their approach to driving rehabilitation, neuropsychology may help the team establish a well-integrated process to optimize the return-to- driving outcome. For example, a neuropsychologist may 1) provide recommendations for standardizing the neurocognitive screening procedure and cut-scores to the extent possible, and 2) identify and present key psychoeducation components such as vision requirements, seizure-free time periods, road safety rules, and DPS rules and regulations that are state specific. Moreover, some neuropsychologists educate patients about transportation options for disabled individuals (e.g., Metro-Lift) available to individuals who are ultimately unable to resume driving.

4.1 Limitations and future research

This research had some weaknesses including the fact that it was retrospective, has a relatively small sample, mixed participants with different types of injury (TBI and stroke), and there was no knowledge of their pre-injury driving other than that they had a valid driver’s license. Despite the aforementioned limitations, the current study supports the role of select cognitive functions and adds to the existing evidence that difficulties with attention regulation and information processing can adversely effect on-road driving performance and driving safety. Additionally, the study also reiterates the benefits of both in-office pre-driving and on-road driving assessments, as well as comprehensive intervention, highlighting the role of a neuropsychologist within a multidisciplinary rehabilitation team.

Future studies may attempt to determine good predictors of safe driving using larger, samples, develop standardized protocols for both in-office and on-road assessment and re-assessment, along with clear guidelines for training and retraining practices. Longitudinal studies may also add to the clinical knowledge and practice as such efforts will monitor driving behaviors in individuals with ABI over a longer time and potentially provide cues for enhancing outcomes.

Conflict of interest

None to report.

Footnotes

The appendix is available in the electronic version of this article: .

References

Alexandersen,

, Dalen,

, & Brønnick,

(2009). Prediction of driving ability after inconclusive neuropsychological investigation. Brain Injury, 23(4), 313–321. https://doi.org/10.1080/02699050902788428

Akinwuntan,

A. E.

, De Weerdt,

, Feys,

, Baten,

, Arno,

, & Kiekens,

(2005). The validity of a road test after stroke. Archives of Physical Medicine and Rehabilitation, 86(3), 421–426. https://doi.org/10.1016/j.apmr.2004.04.047

Andelic,

(2013). The epidemiology of traumatic brain injury. Lancet Neurology, 12(1), 28–29. https://doi.org/10.1016/S1474-4422(12)70294-6

Anschutz,

J. R.

, Luther-Krug,

, & Seel,

R. T.

(2010). A verbal cuing device for persons with brain injury: development and proof-of-concept case study. Topics in Stroke Rehabilitation, 17(5), 337–344. https://doi.org/10.1310/tsr1705-337

Arnould,

, Dromer,

, Rocha,

, Van der Linden,

, & Azouvi,

(2016). Neurobehavioral and self-awareness changes after traumatic brain injury: Towards new multidimensional approaches. Annals of Physical Rehabilitation Medicine, 59(1), 18–22. https://doi.org/10.1016/j.rehab.2015.09.002

Azouvi,

, Vallat-Azoouvi,

, & Belmont,

(2009). Cognitive deficits after traumatic coma. Progress in Brain Research, 177, 89–110.

Ball,

, & Owsley,

(1993). The useful field of view test: a new technique for evaluating age-related declines in visual function. Journal of the American Optometric Association, 64(1), 71–79.

Ball,

, Owsley,

, Sloane,

M. E.

, Roenker,

D. L.

, & Bruni,

J. R.

(1993). Visual attention problems as a predictor of vehicle crashes in older drivers. Investigative Ophthalmology and Visual Science, 34(11), 3110–3123.

Barrash,

, Stillman,

, Anderson,

, UC,

, Dawson,

, & Rizzo,

(2010). Prediction of driving ability with neuropsychological tests: Demographic adjustments diminish accuracy. Journal of the International Neuropsychological Society, 16(4), 679–686. doi: 10.1017/S1355617710000470

10.

Beaulieu-Bonneau,

, Fortier-Brochu.

É.

, Ivers,

, & Morin,

C. M.

(2017). Attention following traumatic brain injury: Neuropsychological and driving simulator data, and association with sleep, sleepiness, and fatigue. Neuropsychological Rehabilitation, 27(2), 216–238. https://doi.org/10.1080/09602011.2015.1077145

11.

Bivona,

, et al. (2012). Return to Driving After Severe Traumatic Brain Injury: Increased Risk of Traffic Accidents and Personal Responsibility. Journal of Head Trauma Rehabilitation, 27, 210–215.

12.

Bliokas,

V. V.

, Taylor,

J. E.

, Leung,

, & Deane,

F. P.

(2011). Neuropsychological assessment of fitness to drive following acquired cognitive impairment. Brain Injury, 25(5), 471–487. https://doi.org/10.3109/02699052.2011.559609

13.

Braga,

M. M.

, Nickel,

, Lange,

, Piovesan,

É. J.

(2018). Driving and visual deficits in stroke patients. Arquivos de Neuro-psiquiatra, 76(2), 85–88. https://doi.org/10.1590/0004-282X

14.

Brouwer,

W. H.

, & Withaar,

F. K.

(1997). Fitness to drive after traumatic brain injury. Neuropsychological Rehabilitation, 7, 177–93.

15.

Brouwer,

W. H.

, Withaar,

F. K.

, Tant,

M. L.

, & van Zomeren,

A. H.

(2002). Attention and driving in traumatic brain injury: a question of coping with time-pressure. Journal of Head Trauma and Rehabilitation, 17(1), 1–15. https://doi.org/10.1097/00001199-200202000-00003

16.

Cicerone,

K. D.

, Dahlberg,

, Kalmar,

, Langenbahn,

D. M.

, Malec,

J. F.

, Bergquist,

T. F.

, et al. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Arch Phys Med Rehabilitation, 81, 1596–615.

17.

Colarusso,

, & Hammill,

D. D.

(2015). Motor-Free Visual Perception Test - 4. Novato, CA: Academic Therapy Publications.

18.

Coleman,

R. D.

, Rapport,

L. J.

, Ergh,

T.C.

, Hanks,

R. A.

, Ricker,

J. H.

, & Millis,

S. R.

(2002). Predictors of driving outcome after traumatic brain injury. Archives of Physical Medicine & Rehabilitation, 83(10), 1415–1422.

19.

Crosson,

, Barco,

P. P.

, Velozo,

C. A.

, Bolesta,

M. M.

, Cooper,

P. V.

, Werts,

, & Brobeck

T. C.

(1989). Awareness and compensation in postacute head injury rehabilitation. Journal of Head Trauma Rehabilitation, 4, 46–54.

20.

Cyr,

A. A.

, Stinchcombe,

, Gagnon,

, Marshall,

, Hing,

M. M.

, & Finestone,

(2009). Driving difficulties of brain injured drivers in reaction to high-crash-risk simulated road events: a question of impaired divided attention?Journal of Clinical and Experimental Neuropsychology, 31(4), 472–482. https://doi.org/10.1080/13803390802255627

21.

de Haan,

G. A.

, Melis-Dankers,

B. J.

, Brouwer,

W. H.

, Bredewoud,

R. A.

, Tucha,

, & Heutink,

(2014). Car driving performance in hemianopia: an on-road driving study. Investigative Ophthalmology and Visual Science, 55(10), 6482–6489. https://doi.org/10.1167/iovs.14-14042

22.

D’Apolito,

A. C.

, Massonneau,

, Paillat,

, & Azouvi,

(2013). Impact of brain injury on driving skills. Annals of Physical Rehabilitation Medicine, 56, 63–80. https://doi.org/10.1016/j.rehab.2012.12.002

23.

Devos

, Nieuwboer,

, Vandenberghe,

, Tant,

, DeWeerdt,

, & Uc.

E. Y.

(2014). On-road driving impairments in Huntington disease. Neurology, 82(11), 956–962.

24.

Dobbs,

B. M.

(2005). Medical conditions and driving: A review of the scientific literature (1960-2000).

25.

Donofio,

L. K., M.,

, D’Ambrosio,

L. A

, Coughlin,

J. F

, & Mohyde,

(2009). To drive or not to drive, that isn’t the question-the meaning of self-regulation among older drivers. Journal of Safety Research, 40, 221–226.

26.

Duchek,

J. M.

, Hunt,

, Ball,

, Buckles,

, & Morris,

J. C.

(1998). Attention and driving performance in Alzheimer’s disease. The Journals of Gerontology. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 53(2), P130–141. https://doi.org/10.1093/geronb/53b.2.p130

27.

Edwards,

J. D.

, Lunsman,

, Perkins,

, Rebok,

G. W.

, Roth,

D. L.

(2009). Driving cessation and health trajectories in older adults. Journal of Gerontology Psychology Science, 64A, 1290–1295.

28.

Egeto,

, Badovinac,

S. D.

, Hutchison,

M. G.

, Ornstein,

T. J.

, & Schweizer,

T. A. A

(2019). Systematic review and meta-analysis on the association between driving ability and neuropsychological test performances after moderate to severe traumatic brain injury. Journal of the International Neuropsychological Society, 25(8), 868–877. https://doi.org/10.1017/S1355617719000456

29.

Fisk,

G. D.

, Schneider,

J. J.

, & Novack,

T. A.

(1998). Driving following traumatic brain injury: prevalence, exposure, advice and evaluations. Brain Injury, 12(8), 683–695.

30.

Fueger,

, & Huddleston,

W. E

(2018). Effects of concussions on visually guided motor actions: A literature review. Journal of Clinical and Experimental Neuropsychology, 40(10), 1074–1080. https://doi.org/10.1080/13803395.2018.1458823

31.

Gauthier,

, Dehaut,

, & Joanette,

(1989). The Bells Test: a quantitative and qualitative test for visual neglect. International Journal of Clinical Neuropsychology, 11, 49–54.

32.

Gooden,

J. R.

, Ponsford,

J. L.

, Charlton,

J. L.

, Ross,

P. E.

, Marshall,

, Gagnon,

, & …Stolwyk,

R. J.

(2017). Self-awareness and self-ratings of on-road driving performance after traumatic brain injury. Journal of Head Trauma Rehabilitation, 32(1), E50–E59. https://doi.org/10.1097/HTR.000000000000021

33.

Goverover,

, Johnston,

M. V.

, Toglia,

, & Deluca,

(2007). Treatment to improve self-awareness in patients with acquired brain injury. Brain Injury913–23.

34.

Griffen,

J.A.

, Rapport,

L.J.

, Coleman Bryer,

, Bieliauskas,

L.A.

, & Burt.

(2011). Awareness of Deficits and On-Road Driving Performance. The Clinical Neuropsychologist, 25(7), 1158–1178.

35.

Hargrave,

D. D.

, Nupp,

J. M.

, & Erickson,

R. J.

(2012). Two brief measures of executive function in the prediction of driving ability after acquired brain injury. Neuropsychological Rehabilitation, 22(4), 489–500. https://doi.org/10.1080/09602011.2012.662333

36.

Jayagopal,

L. A.

, Samson,

K. K.

, & Taraschenko,

(2018). Driving with drug-resistant and controlled seizures from a patient’s perspective: Assessment of attitude and practices. Epilepsy Behavior, 81, 101–106.

37.

Klonoff,

P. S.

, Watt,

L. M.

, Dawson,

L. K.

, Henderson,

S. W.

, Gehrels,

, & Wethe,

J. V.

(2006). Psychosocial outcomes years after comprehensive milieu-oriented neurorehabilition: The role of pre-injury status. Brain Injury, 20, 601–612.

38.

León-Domínguez,

, Solís-Marcos,

, Barrio-Álvarez,

, Barroso,

, Martín,

J. M.

, & León-Carrión,

(2017). Safe driving and executive functions in healthy middle-aged drivers. Applied Neuropsychology: Adult, 24(5), 395–403. https://doi.org/10.1080/23279095.2015.1137296

39.

Lundqvist,

(2009). Neuropsychological aspects of driving characteristics. Brain Injury, 15(11), 981–994.

40.

McKay,

, Liew,

, Schönberger,

, Ross,

, & Ponsford,

(2016). Predictors of the On-Road Driving Assessment After Traumatic Brain Injury: Comparing Cognitive Tests, Injury Factors, and Demographics. J Head Trauma Rehabilitation, Nov/Dec;31(6)

41.

Marshall,

S. C.

, Molnar,

, Man-Son-Hing,

, Blair,

, Brosseau,

, Finestone,

H. M.

, & …Wilson,

K. G.

(2007). Predictors of driving ability following stroke: A systematic review. Topics in Stroke Rehabilitation, 14, 98–114. https://doi.org/10.1310/tsr1401-98

42.

McCullagh,

, & Feinstein,

(2011). Cognitive changes. In J.M. Silver, T.W. McAllister, S.C. Yodofsky (Eds.). Text book of traumatic brain injury (2nd edition)) pp. 279-294. Arlington VA: American Psychiatric Association Publishing INC.

43.

McKerral,

, Moreno,

, Delhomme,

, & Gélinas,

(2019). Driving behaviors 2-3 years after traumatic brain injury rehabilitation: A multicenter case-control study. Frontiers in Neurology, 10, 144. https://doi.org/10.3389/fneur.2019.00144

44.

Nasreddine,

Z. S.

, Phillips,

N. A.

, Bédirian,

, Charbonneau,

, Whitehead,

, Collin,

I….

, Chertkow,

(2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatric Society, 53(4), 695–699. https://doi.org/10.1111/j.1532-5415.2005.53221.x

45.

Novack,

T. A.

, Zhang,

, Kennedy,

, Rapport,

L. J.

, Watanabe,

T. K.

, Monden,

K. R.

, Dreer,

L. E.

, Bergquist,

, Bombardier,

, Brunner,

, Goldin,

, Marwitz,

, & Niemeier,

J. P.

Return to Driving Following Moderate-to-Severe Traumatic Brain Injury, Archives of Physical Medicine and Rehabilitation, 2021,

46.

Ortoleva,

, Brugger,

, Van der Linden,

, & Walder,

(2012). Prediction of driving capacity after traumatic brain injury: A systemic review. Journal of Head Trauma Rehabilitation, 27, 302–313.

47.

Palubiski,

, & Crizzle,

A. M.

(2016). Evidence Based Review of Fitness-to-Drive and Return-to-Driving Following Traumatic Brain Injury. Geriatrics (Basel, Switzerland), 1(3), 17. https://doi.org/10.3390/geriatrics1030017

48.

Parasuraman,

, & Nestor,

P. G.

(1991). Attention and driving skills in aging and Alzheimer’s disease. Human Factors, 33(5), 539–557.

49.

Pate Rehabilitation. (2017). Visual Motor Reaction Time (VMR) Test Software. Anna, Texas Pate Rehabilitation. (2015). Behind-the-Wheel Driving Evaluation Form, Anna, Texas.

50.

Patomella,

A. H.

, Kottorp,

, & Tham,

(2008). Awareness of driving disability in people with stroke tested in a simulator. Scandinavian Journal of Occupational Therapy, 15(3), 184–192. https://doi.org/10.1080/11038120802087600

51.

Parasuraman,

, & Nestor,

P. G.

(1991). Attention and driving skills in aging and Alzheimer’s disease. Human Factors, 33(5), 539–557. https://doi.org/10.1177/001872089103300506

52.

Pollock,

, Henderson,

C. A.

, Angilley,

, Dhillon,

, Langhorne,

, et al. (2011). Interventions for visual field defects in patients with strokes. Cochrane Database of Systemic Reviews, 10(2), CD008388.

53.

Rabadi,

M. H.

, Akinwuntan,

, & Gorelick,

(2010). The safety of driving a commercial motor vehicle after a stroke. Stroke, 41, 2991–2996.

54.

Rapport,

L. J.

, Bryer,

R. C.

, & Hanks,

R. A.

(2008). Driving and community integration after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89(5), 922–930. https://doi.org/10.1016/j.apmr.2008.01.009

55.

Rapaport,

M. J.

, Cameron,

D. H.

, Sanford,

, & Naglie,

(2017). A systematic review of intervention approaches for driving cessation in older adults. International Journal of Geriatric Psychiatry, 32(5), 484–491.

56.

Rapport,

L. J.

, Hanks,

R. A.

, & Bryer,

R. C.

(2006). Barriers to driving and community integrations after traumatic brain injury. Journal of Head Trauma Rehabilitation, 21(1), 34–44.

57.

Rike,

P. O.

, Ulleberg,

, Schultheis,

M. T.

, Lundqvist,

, & Schanke,

A. K.

(2014). Behavioural ratings of self regulatory mechanisms and driving behaviour after an acquired brain injury. Brain Injury, 28(13-14), 1687–1699. https://doi.org/10.3109/02699052.2014.947632

58.

Ross,

, Ponsford,

JL.

, Di Stefano,

, Charlton,

, & Spitz,

(2016). On the road again after traumatic brain injury: Driver safety and behaviour following on-road assessment and rehabilitation. Disability Rehabilitation, 38(10).

59.

Ross,

P. E.

, Di Stefano,

, Charlton,

, Spitz,

, & Ponsford,

J.L.

(2018). Interventions for resuming driving after traumatic brain injury. Disability Rehabilitation, 40(7), 757–764.

60.

Schanke,

A. K.

, Rike,

P. O.

, Mølmen,

, & Osten,

P. E.

(2008). Driving behaviour after brain injury: a follow-up of accident rate and driving patterns years post-injury. Journal of Rehabilitation Medicine, 40(9), 733–736.

61.

Schultheis,

M. T.

, & Whipple,

(2014). Driving after traumatic brain injury: Evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Report, 2(3), 176–183.

62.

Sherer,

, Oden

, Bergloff,

, Levin,

Jr. , & High,

W. M.

(1998). Assessment and treatment of impaired awareness after brain injury: implications for community reintegration. NeuroRehabilitation, 10(1), 25–37.

63.

Silverberg,

, & Millis,

(2009). Impairment versus deficiency in neuropsycholgical assessment: Implications for ecological validity. Journal of the International Neuropsychological Society, 15(1), 94–102.

64.

Stalvey,

B. T.

, & Owsley,

(2003). The development and efficacy of a theory-based educational curriculum to promote self-regulation. Health Promotion Practice, 4(2), 109–119.

65.

Stolwyk,

R. J.

, Charlton,

J. L.

, Ross,

P. E.

, Bédard,

, Narshall,

, Gagnon,

, Gooden,

J. R.

, & Ponsford,

J. L.

(2019). Characterizing on-road driving performance in individuals with traumatic brain injury who pass or fail an on-road driving assessment. Disability Rehabilitation, 41(11), 1313–1320.

66.

Tamietto,

, Torrini,

, Adenzato,

, Pietrapiana,

, Rago,

, & Perino,

(2006). To drive or not to drive (after TBI)? A review of the literature and its implications for rehabilitation and future research. NeuroRehabilitation, 21(1), 81–92.

67.

Toglia,

, & Kirk,

(2000). Understanding awareness deficits following brain injury. NeuroRehabilitation, 15(1), 57–70.

68.

Vickers,

K. L.

(2018). Clinical considerations for older adult drivers with a history of traumatic brain injury. Brain Injury Professional, 17(1), 12–14.