Assessment for resumed driving in stroke patients via Functional Independence Measure 1

Abstract

BACKGROUND:

Some stroke survivors hope to resume driving after hospital discharge. For those who had driven frequently before their stroke, a normal daily life depends on being able to drive.

OBJECTIVE:

Our objective was to determine whether Functional Independence Measure (FIM) scores predict patient driving ability, which would make them a suitable index for determining if a stroke patient can resume driving.

METHODS:

This was a retrospective study of 71 patients who suffered from stroke. We divided them into three groups based on their driving status after discharge: (1) resumed driving (Driver), (2) wish to resume driving (Wisher), and (3) no wish to resume driving (Non-wisher). We compared total FIM scores and subcategories of FIM scores across groups.

RESULTS:

Scores on the Motor-FIM and Cognitive-FIM were highest in the Driver group, followed by the Wisher and Non-wisher groups. Moreover, scores on the ‘problem solving’ and ‘memory’ subcategories of the Cognitive-FIM were significantly higher in the Driver group than in the Wisher group.

CONCLUSIONS:

The FIM could be a useful assessment tool for determining whether or not stroke patients can resume driving. Moreover, among the Cognitive-FIM sub-categories, problem solving and memory ability might be the scores most relevant for this decision.

Keywords

Vehicle driving stroke functional independence measure cognitive function

1 Introduction

Some stroke survivors hope to resume driving after hospital discharge. For those who had driven frequently before their stroke, a normal daily life depends on being able to drive a vehicle. Being unable to drive again after stroke can thus limit social activities for these patients, leading to increased depression [1]. Because stroke survivors often suffer from cognitive, perceptual, visual, and motor deficits that eventually affect their driving performance, medical staff must evaluate driving ability precisely [2]. On-road evaluation is considered to be a reliable and valid method of assessing driving ability, and many researchers regard it as the gold standard [2 –6]. However, performing on-road evaluation for all stroke patients who wish to resume driving is difficult in terms of time and cost. Further, some patients refuse on-road evaluations because they fear collisions. Therefore, approximate guidelines that do not require on-road evaluation are needed for determining whether a patient should resume driving after stroke. In Japan, when such a patient wishes to resume driving, a certificate issued by a medical doctor is required. However, most medical doctors experience uncertainty about the decision because detailed standards are lacking.

Accurate prediction of driving ability is crucial to facilitating proper planning after discharge and determining the need for community support [7]. If patients had been driving to work by necessity before the stroke, the inability to drive might lead them to quit their jobs. In order to facilitate a successful return to work (RTW) after acquired brain injury, self-awareness of the person’s cognitive and social abilities is required [8, 9]. In terms of RTW, well-administered, simple, and easily available prediction standards are therefore needed for assessing whether driving can be resumed. Among the many tools available for evaluating the physical and mental status of stroke patients, for this study the Functional Independence Measure (FIM) was chosen. The FIM assesses performance in three categories: activities of daily living (ADL), mobility, and cognition. Its reliability, validity, and responsiveness have been reported extensively [10 –12]. Because driving a vehicle needs complex recognition and motor function, it was presumed that predicting driving ability with the FIM would be adequate as it reflects cumulative effects of motor, cognitive, and psychological performance. Several studies have validated off-road assessments for stroke patients, including the Occupational Therapy Driver Off-Road Assessment and the Stroke Drivers’ Screening Assessment [13, 14]. These assessments play an important clinical role in helping stroke patients decide to proceed with an on-road assessment [13]. However, it would be difficult that all rehabilitation facilities establish a system for providing off-road assessments. In Japan, only a few rehabilitation hospitals provide driving supports using off-road assessment tools for stroke patients because of lack of medical staff familiar with driving rehabilitation. On the other hand, the FIM is commonly used by medical staff in many facilities such as nursing homes and rehabilitation hospitals [15]. If the driving ability of stroke patients can be predicted by the FIM, both rehabilitation and other medical staff could set realistic goal and give beneficial support for driving resumption and RTW.

The objective of this study was to determine whether FIM scores predict patient driving ability, which would make them a suitable index for determining if a stroke patient can resume driving.

2 Methods

2.1 Participants

This survey included 525 stroke patients who were admitted to the Tokyo Metropolitan Rehabilitation Hospital between April 2006 and February 2008 and who eventually returned home. At discharge, their doctors asked them if they wished to resume driving. After discharge, driving status and the desire to resume driving were investigated by questionnaire. In May 2008, questionnaires were sent to all patients, enquiring about their driving status after discharge. Those who were not driving were asked whether they wished to resume driving. Valid responses were received from 216 patients. Among them, 71 stroke patients who had been driving to work every day before stroke were chosen for analysis. The other 145 stroke patients were excluded from this analysis because they had not always driven to work before the stroke. These participants were initially divided into 2 groups based on their desire to resume driving at discharge: want to resume and does not want to resume. After discharge, participants were re-divided into 3 groups based on their answers to the questionnaire: resume driving (Driver), wish to resume (Wisher), and no wish to resume driving (Non-wisher). Written informed consent was obtained from all participants before discharge. This study was approved by the Ethical Committee of the Tokyo Metropolitan Rehabilitation Hospital.

2.2 Measurements

For all patients, motor functions and the degree of ADL independence were assessed at discharge. Brunnstrom stage (BS) was used to assess motor function of upper (UE-BS) and lower (LE-BS) extremities before discharge. BS is classified into 6 stages (stages 1-6). Lower stages exhibit flaccid or low muscle tone, middle stages include spasticity and a synergic pattern, higher stages demonstrate movements without synergic patterns, or separate movements [16].

The FIM was used as an assessment of ADL before discharge. The FIM is composed of 18 items and divided into 13 motor components (Motor-FIM) and 5 cognitive components (Cognitive-FIM) [17]. The Motor-FIM assesses eating, grooming, bathing, dressing upper body, dressing lower body, personal hygiene, bladder control, bowel control, transfer to bed/chair/wheelchair, transfer to toilet, transfer to tub/shower, walk or wheelchair, and stairs. The Cognitive-FIM is assessed by 5 sub-category items: ‘comprehension’, ‘expression’, ‘social interaction’, ‘problem solving’, and ‘memory’. Each item is assessed with 7 grades ranging from 1 (total dependence) to 7 (independence). The maximum FIM score is 126, with the Motor-FIM score ranging from 13 to 91 and Cognitive-FIM score ranging from 5 to 35.

2.3 Statistical analysis

First, the UE-BS, the LE-BS, the Motor-FIM, and the Cognitive-FIM scores were compared between the two groups (Desire to drive vs. No desire to drive) with an unpaired t-test. Next, these values were compared between the 3 groups that were based on the post-discharge questionnaire (Driver, Wisher, Non-wisher) with a one-way analysis of variance (ANOVA) and a Tukey-Kramer post-hoc test. In all statistical analyses, P values <0.05 were considered significant.

3 Results

Participants comprised 67 men and 4 women (age of 59.5±10.0 years; range: 36–81 years). The average time between patient discharge and administration of the questionnaire (questionnaire time) was 393±180 days (range: 91–731 days). Among these 71 patients, 16.9% (12 patients) were taxi or limousine drivers, 15.5% (11 patients) were common carrier drivers. Other participants used vehicles for work, but were not professional drivers (67.6%, 48 patients). According to the initial inquiry at discharge, patients were divided into 2 groups: those who wished to resume driving (n = 49) and those who did not (n = 22). Responses to the questionnaire yielded 22 (Driver), 27 (Wisher), and 22 (Non-wisher) (Fig. 1). Patient characteristics are shown in Table 1.

Fig.1

Number of patients who wished to drive at discharge and number of patients who were driving or wished to drive after discharge.

Table 1

Characteristics of patients by group after discharge

Driver	Wisher	Non-wisher
Subject Number	22	27	22
Age (mean±SD)	56.4±10.1	58.9±10.6	63.1±8.5
Sex (male/female)	20/2	26/1	21/1
Paralysis (Rt/Lt, ratio)	1.4	1.4	1.7

3.1 Comparison of measurements at discharge (Table 2)

Table 2
Comparison of motor function and ADL between groups at discharge

UE-BS LE-BS Motor-FIM Cognitive-FIM

Wish to resume 4.8±1.3 5.0±1.1 80.1±8.8 30.5±5.7

driving

Not wish to 4.8±1.4 4.7±1.4 74.3±15.6 28.2±5.8

resume driving

P value 0.89 0.41 0.16 0.17

UE-BS	LE-BS	Motor-FIM	Cognitive-FIM
Wish to resume	4.8±1.3	5.0±1.1	80.1±8.8	30.5±5.7
driving
Not wish to	4.8±1.4	4.7±1.4	74.3±15.6	28.2±5.8
resume driving
P value	0.89	0.41	0.16	0.17

Values are represented as means±SD. ADL: activities of daily living; UE: upper extremity; LE: lower extremity; BS: Brunnstrom stage; FIM: Functional Independence Measure.

The UE-BS, the LE-BS, the Motor-FIM, and the Cognitive-FIM scores were compared between the patients who wished to resume driving at discharge and those who did not. None of the comparisons were significantly different (all Ps > 0.05).

3.2 Comparison of measurements based on driving status after discharge

Measurements between the 3 groups that were determined from the post-discharge questionnaire were compared. No significant differences were observed in age (Driver: 56.4±10.1 years; Wisher: 58.9±10.6 years; Non-wisher: 63.1±8.5 years; ANOVA, P > 0.05) or in questionnaire time (Driver: 454±172 days; Wisher: 359±172 days; Non-wisher: 359±180 days; ANOVA, P > 0.05). Further, the ratios of Rt/Lt hemiplegia were similar across groups (1.4, 1.4, and 1.7, respectively).

No significant differences were observed across groups for either the UE-BS (5.1±1.2, 4.6±1.5, and 4.7±1.3; ANOVA, P > 0.05) or the LE-BS (5.2±0.9, 4.8±1.3, and 4.7±1.3; ANOVA, P > 0.05) (Fig. 2). In contrast, significant differences were found across groups on both the Motor- and Cognitive-FIM (Figs. 3 and 4). The Motor-FIM scores were highest for the Driver group (81.8±10.4), followed by the Wisher group (79.9±6.3) and then the Non-wisher group (72.6±15.1). Values for the Cognitive-FIM showed a similar pattern (scores: 33.4±2.7, 29.1±5.4, and 26.8±6.9, respectively). After adjusting for multiple comparisons, the Tukey-Kramer post-hoc test revealed that the Driver group scored significantly better than the Non-wisher group for both the Motor-FIM (P = 0.03) and the Cognitive-FIM (P = 0.0007). For the Cognitive-FIM, statistical significance was also found between the Driver and Wisher groups (P = 0.02).

Fig.2

BS score for each group. Open bars, upper-BS; Filled bars, lower-BS. Error bars are standard deviation. No significant differences were found across groups (ANOVA, upper-BS: P = 0.47, lower-BS: P = 0.34).

Fig.3

Motor-FIM for each group. Error bars are standard deviation. post hoc test,* P = 0.03.

Fig.4

Cognitive-FIM for each group. Error bars are standard deviation. post hoc test, * P = 0.02; ** P = 0.0007.

Next, items of the Cognitive-FIM (‘comprehension’, ‘expression’, ‘problem solving’, ‘memory’, and ‘social interaction’) were compared across groups (Table 3). For all items, values were highest for the Driver group, followed by the Wisher group and then the Non-wisher group. The Driver group scored significantly higher than the Wisher group on ‘problem solving’ (P = 0.03) and ‘memory’ (P = 0.009), and significantly higher than the Non-wisher group on ‘comprehension’ (P = 0.007), ‘expression’ (P = 0.004), ‘problem solving’ (P = 0.003), and ‘memory’ (P = 0.003). ‘Social interaction’ did not differ across groups.

Table 3

Comparison of Cognitive-FIM sub-categories by group

Driver	Wisher	Non-wisher	P-value^*
Comprehension	6.7±0.8^†1	5.9±1.1	5.5±1.7^†1	0.009
Expression	6.7±0.7^†,2	5.9±1.4	5.2±1.8^†2	0.006
Social interaction	7.0±0.0	6.6±1.1	6.3±1.5	>0.05
Problem solving	6.3±1.0^{†3, ‡1}	5.3±1.4^‡1	4.9±1.3^†3	0.003
Memory	6.8±0.6^{†4, ‡2}	5.4±1.7^‡2	5.2±1.6^†4	0.002

^*one-way analysis of variance (ANOVA). ^†and ^‡post hoc test between 3 groups; ^†1P = 0.007, ^†2P = 0.004, ^†3P = 0.003,^†4P = 0.003, ^‡1P = 0.03, ^‡2P = 0.009.

4 Discussion

In this study, all participants had been driving a vehicle every day at work before suffering from stroke. Because driving was required to return to the same job, 69.0% of patients wished to resume driving at discharge. However, only 31.0% of patients were actually able to do so. This prevalence of resumed driving is quite similar to that found in other studies. One study in the United States reported that approximately 30% of moderate to severe stroke patients were able to resume driving [18], while another found that 36% of ischemic stroke patients resumed driving within 1 month of their strokes [19]. Considering these findings with a previous survey in Japan, even in developed countries nearly two-thirds of patients suffering from stroke cannot resume driving [18 –20]. As a major reason for this trend, Hitosugi et al. suggested that medical staff did not provide sufficient information to stroke patients about resumption of driving [20]. Fisk et al. also found that 87% of stroke patients who resumed driving had not received any formal evaluation of driving ability [18]. Because the likelihood of passing driving assessments was higher for those who had received driving therapy, medical intervention for patients who wish to resume driving is required [21]. Moreover, appropriate intervention has led to the development of programs that support people who wish for RTW [8, 22].

Studies have indicated that well-planned and well-administered pre-driving assessments are helpful to identify stroke survivors who can safely resume driving. Physicians and therapists have tried to predict driving ability with many tools and concluded that the Motor-Free Visual Perception Test— a measure of visual perceptual skills— and the Trail-Making Test B— an assessment of multi-conceptual tracking, sequencing, and alternating divided attention— emerged as the best predictors of road driving [5]. However, performing all these tests requires specialists and time. Further, the precise cut-off values for each test have not been defined. Therefore, a simple and widely used tool to predict driving ability is required. In this study, to develop a screening measure, the FIM was the point of focus. The FIM was designed to measure degree of disability and to provide a consistent data collection tool for comparing rehabilitation outcomes across the healthcare continuum [15, 23]. Ratings are accumulated across items and are also used to determine the amount of help that is required for the patient to accomplish basic and routine daily tasks. The degree of dependency ranges from ‘no help’ to ‘complete dependence on a helper’. Although limited, evidence exists that the FIM scores can be used to accurately predict outcomes in stroke patients across civilian and veteran populations [15]. Because independence in daily activities is essential for vehicle driving, the FIM is preferable as a tool to predict driving resumption.

Here, scores on both the Motor- and the Cognitive-FIM were well correlated to the driving status: higher scores were associated with resumed driving and lower scores were associated with patients who quit driving. These results agree with a previous study that reported drivers were less impaired than non-drivers on the composite FIM score. In that study, a 1-point increase in the composite FIM score increased the likelihood of being a driver by 5% [18].

Most patients in the current study suffered from mild to moderate motor impairment (with a mean BS ≥ 4). Additionally, no significant differences in BS were found across the 3 groups. Therefore, the possibility of resuming driving relies on cognitive function.

Here, the mean Cognitive-FIM for the Wisher group was 29.1±5.4. According to a previous study in the United States, the mean Cognitive-FIM score of post-stroke patients who had resumed driving was 26±7 [18]. Although traffic conditions between areas and countries might be somewhat different, some of the patients in our Wisher group might be able to resume driving as their mean Cognitive-FIM was higher than that found in the other study. Taking the mean Cognitive-FIM of the Driver (33.4±2.7) and Wisher (29.1±5.4) groups into account, we concluded that the cutoff for resumed driving should be a Cognitive-FIM score between 29 and 33. However, in order to get a more precise fix for the cutoff, and considering the whole Cognitive-FIM score as well as scores for each sub-category, further prospective studies with appropriate sample sizes are needed.

Importantly, the current study expands on these results by looking at the Cognitive-FIM sub-categories. Analysis showed that ability in both problem solving and memory influenced whether or not a patient resumed driving. In some cognitive skills, problem solving and memory are important. At present, it is unclear which impairments that influence driving ability after stroke are amenable to rehabilitation and which aspects of the intervention are the most valuable for individuals who need to resume driving [24]. Our result regarding cognitive skills might give a new insight into these unsolved problems. When judging patient fitness to drive, if a patient lacks enough of such functions as problem solving and memory, medical staff must deeply consider whether they should be allowed to resume driving. This study is the first to compare the values of the Cognitive-FIM subcategories based on driving status.

In this study, measurements were first compared based on the patient’s wish at discharge, and then compared based on the actual driving status after discharge. Many patients changed their minds after discharge, as shown in Fig. 1. Although all measurements were well associated with the real driving status after discharge, they did not differ at discharge based on the desire to resume driving. Therefore, it is assumed that it is better not to make an immediate decision. Rather, the decision to resume driving should be made some time after the return to daily life with family members.

This study had a few limitations. First, the sample size was small. However, although the study only included 71 patients, statistical analysis could provide useful information and showed that driving resumption could be roughly predicted by the FIM. Therefore, this study can be regarded as a pilot study, and further prospective studies are needed to confirm the results. Second, detailed results of neuropsychological assessments were lacking. However, the objectives of the study were to establish a simple and widely used measure to predict ability to resume driving. Although neuropsychological examinations were not used in this study, in the future, assessments via the FIM and neuropsychological examinations should be compared. Third, we did not include other off-road assessments. As the FIM and driving ability have been described in some previous studies, results of off-road assessments have not included and compared with the FIM [18 , 25–27]. Therefore, in the future, the validity of using FIM scores as an index for driving fitness must to be verified by assessing how well it performs relative to existing off-road assessments.

5 Conclusions

The FIM has the possibility to be a useful assessment tool for determining whether stroke patients can resume driving. Moreover, the analysis of the Cognitive-FIM sub-categories suggested that problem solving and memory ability might be the scores most relevant for the decision to resume driving. Clinically, this decision should be made a certain amount of time after the return to daily life.

Conflict of interest

None to report.

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Assessment for resumed driving in stroke patients via Functional Independence Measure 1

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

2 Methods

2.1 Participants

2.2 Measurements

2.3 Statistical analysis

3 Results

Table 2 Comparison of motor function and ADL between groups at discharge UE-BS LE-BS Motor-FIM Cognitive-FIM Wish to resume 4.8±1.3 5.0±1.1 80.1±8.8 30.5±5.7 driving Not wish to 4.8±1.4 4.7±1.4 74.3±15.6 28.2±5.8 resume driving P value 0.89 0.41 0.16 0.17

5 Conclusions

Conflict of interest

References

Table 2
Comparison of motor function and ADL between groups at discharge

UE-BS LE-BS Motor-FIM Cognitive-FIM

Wish to resume 4.8±1.3 5.0±1.1 80.1±8.8 30.5±5.7

driving

Not wish to 4.8±1.4 4.7±1.4 74.3±15.6 28.2±5.8

resume driving

P value 0.89 0.41 0.16 0.17