Driving after stroke

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Driving is considered one of the most important activities of daily living and is highly associated with maintaining quality of life post-stroke. Individuals who have had a stroke may experience difficulties that affect their ability to drive such as physical impairments, poor visual scanning, attention, information processing speed and psychomotor skills, which can also be impaired with aging (Crotty et al., 2003). It is therefore important to screen our stroke population who is often at-risk drivers. Driving cessation post-stroke often leads to social isolation and studies have shown higher rates of depression, comorbidities and lower functional independence than individuals who resume driving post-stroke (Devos et al., 2010). Post-stroke assessment of safety to drive is necessary for many patients, with figures showing that only 30% of stroke survivors are able to resume driving following stroke (Finestone et al., 2007). Because of the significant impacts of driving cessation, a growing importance has been developing on interventions to help individuals resume driving following an acute medical condition or prolong the ability to drive in the elderly.

A systematic review by Unsworth & Baker (2014) identified the types of interventions used by Occupational Therapists (OTs) to improve on-road fitness-to-drive and the effectiveness of these interventions. The review included participants with a range of conditions (TBI, older drivers, stroke, ABI, physical and intellectual disability, SCI, and younger drivers with information processing deficits) and included 16 studies*, 2 of which are included in this StrokEngine module. The most commonly-used interventions were bottom-up in nature (computer-based driving simulator training, off-road skill-specific training, off-road education programmes), whereas just one intervention used a top-down approach (car adaptations/modifications). There were inconsistencies in frequency, duration and total number of sessions among studies of each intervention type. The secondary aim of the systematic review was to determine effectiveness of driving interventions: 2 of the 4 types of interventions (computer-based driving simulator training, off-road skill-specific training) showed moderate (level 1b) evidence supporting effectiveness for regaining on-road fitness-to-drive.

* 5 RCTs, 4 pre-post tests,  2 case studies, 2 case control design, 2 cohort studies, and 1 cross-sectional design study.

Petzold et al. (2010) conducted a cross-sectional Canada-wide telephone survey of 480 Occupational Therapists (OTs) working in stroke rehabilitation to examine clinicians’ management of driving-related issues. Participants were recruited from both inpatient and community-based settings over an 18-month period. The survey used a clinical vignette to gather information from clinicians regarding their use of driving-related assessments and interventions. The frequency of use of driving-specific assessments was as low as 11% across the continuum of care with off-road driving screening the most common type of assessment. Non-driving-specific assessments (e.g. MVPT, Cognistat) were used by 59% of inpatient rehabilitation clinicians and 37% of community-based clinicians. In terms of interventions, less than 6% of respondents reported using general interventions in driving rehabilitation and only 3% of respondents used driving-specific intervention. No clinicians reported using computer game/virtual reality interventions in driving rehabilitation. Potential explanations for the lack of attention to driving-related issues post-stroke include the need for best practice standards in driving rehabilitation, clinicians’ need to prioritize post-stroke rehabilitation goals, as well as clinicians’ self-perceived lack of competence regarding driving retraining.

This module reviews evidence regarding interventions used in driving rehabilitation post-stroke and their effectiveness in regaining safe driving skills.

Please click here to see Authors’ Result Table

Acute stage of stroke recovery
No studies have reviewed driving training among patients in acute phase of stroke recovery

Subacute phase - Simulator-based driving training

Cognitive perceptual driving skillsNot effective1b

One high quality RCT (Akinwuntan, et al.,  2005) examined the effects of simulator-based driving training on cognitive-perceptual driving skills in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive simulator-based driving training or driving-related cognitive training, in addition to conventional rehabilitation. There were no significant between-group differences in cognitive-perceptual driving skills (evaluated using the Stroke Driver Screening Assessment dot cancellation, square matrix test direction and compass and road sign recognition subtests) at 5 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that simulator-based driving training is not more effective than driving-related cognitive training for improving cognitive perceptual driving skills in patients with subacute stroke.

On-road Driving PerformanceNot effective1b

One high quality RCT (Akinwuntan, et al.,  2005) and one fair quality follow-up study (Devos et al., 2010) examined the effects of simulator-based driving training on on-road driving performance in patients with subacute stroke.

The high quality RCT  (Akinwuntan, et al.,  2005) randomized patients with subacute stroke to receive simulator-based driving training or driving-related cognitive training, in additional to conventional rehabilitation. Driving performance was evaluated by an on-road driving evaluation that resulted in (i) a 3-class decision (fit to drive, temporarily unfit to drive, unfit to drive) and (ii) a pass/fail decision. There were no significant between-group differences in any measure of on-road driving performance at 5 weeks (post-treatment, when participants were 11-14 weeks post-stroke). However, there was a significant between-group difference in on-road driving performance at follow-up (when participants were 6-9 months post-stroke) in favour of simulator-based driving training compared to driving-related cognitive training.

The fair quality follow-up study (Devos et al., 2010) conducted a 5-year follow-up to the study by Akinwuntan et al. (2005). Participants from the original study, now with chronic stroke, were assessed for fitness-to-drive (pass/fail) based on medical, visual, neuropsychological and on-road tests. No significant between-group differences in fitness-to-drive were found at 5 years follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that simulator-based driving training is not more effective than driving-related cognitive training for improving immediate (11-14 weeks post-stroke) or long-term (5 years post-stroke) on-road driving performance among patients with stroke.
NOTE: However, simulator-based driving training was more effective than driving-related cognitive training at 6-9 months post-stroke.

Visual attention skillsNot effective1a

Visual attention skills –  Useful Field of View (UFOV), Speed of processing, Divided attention, Selective attention

Two high quality RCTs (Akinwuntan et al., 2010Akinwuntan, et al., 2005) examined the effect of simulator-based driving training on visual attention skills in patients with subacute stroke.

The first high quality RCT (Akinwuntan et al., 2010) randomized patients with subacute stroke to receive simulator-based driving training or non-computerized cognitive training, in addition to conventional rehabilitation. There were no significant between-group differences in visual attention skills (speed of processing, divided attention and selective attention measured by the Useful Field of View) at 5 weeks (post-treatment) or 3 months (follow-up).

The second high quality RCT  (Akinwuntan, et al., 2005) randomized patients with subacute stroke to receive simulator-based driving training or driving-related cognitive training, in addition to conventional rehabilitation. There were no significant between-group differences in visual attention skills (measured using the Useful Field of View) at 5 weeks (post-treatment).

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that simulator-based driving training is not more effective than non-computerized cognitive training for improving visual attention skills in patients with subacute stroke.

Subacute phase - Useful Field of View (UFOV) training

AttentionNot effective1b

One high quality RCT (Mazer et al., 2003) examined the effects of Useful Field of View (UFOV) driving training on attention in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There was no significant between-group difference in attention (measured by the Test of Everyday Attention (TEA) after 20 sessions (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that UFOV driving training is not more effective than traditional computerized visual-perception training for improving attention in patients with subacute stroke.

On-road driving performanceNot effective1b

One high quality RCT (Mazer et al., 2003) examined the effects of Useful Field of View (UFOV) driving training on on-road driving performance in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There were no significant between-group differences in on-road driving skills (measured using a pass/fail functional driving evaluation) after 20 sessions (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that UFOV driving training is not more effective than traditional computerized visual-perception training for improving on-road driving performance in patients with subacute stroke.

Visual attentions skillsNot effective1b

Visual attention skills –  Useful Field of View (UFOV) Speed of processing, Divided attention, Selective attention

One high quality RCT (Mazer et al., 2003) examined the effects of driving training using the Useful Field of View (UFOV) on visual attention skills in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There was no significant between-group difference in visual attention skills (measured using the UFOV total score and visual processing speed, divided attention and selective attention subscores) after 20 sessions (post-treatment).

Conclusion: There is moderate evidence (level 2b) from one high quality RCT that UFOV driving training is not more effective than traditional computerized visual-perception training for improving visual attentions skills in patients with subacute stroke.

Visual-perceptual skillsNot effective1b

One high quality RCT (Mazer et al., 2003) examined the effects of Useful Field of View (UFOV) driving training on visual-perceptual skills in patients with subacute stroke. This high quality RCT) randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There were no significant between-group differences in visual perceptual skills (evaluated using the Complex Reaction Timer, Motor-Free Visual Perception Test, Single and Double Letter Cancellation Tests, Money Road Map Test of Direction Sense, Trail Making Test Parts A and B, Bells test and Charron Test) after 20 sessions (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that UFOV driving training is not more effective than traditional computerized visual-perception training for improving visual-perceptual skills in patients with subacute stroke.

Chronic phase - Dynavision training

Dynavision ParametersInsufficient evidence5

One non-randomized study (Klavora et al., 1995) examined the effects of Dynavision driving training on Dynavision assessment parameters in patients with chronic stroke. This pre-post study assigned patients with chronic stroke who had failed a Behind-the-Wheel (BTW) assessment to receive Dynavision training. At 6-weeks (post-treatment) 6 of 10 participants showed a significant improvement in Dynavision driving parameters of endurance and speed. Results remained significant at 3-month follow-up.

Conclusion: There is insufficient evidence (level 5) regarding the effect of Dynavision driving training on Dynavision assessment parameters among patients with chronic stroke. However, one non-randomized study reported a significant improvement in Dynavision assessment performance.

On-road Driving PerformanceInsufficient evidence5

One non-randomized study (Klavora et al., 1995) examined the effects of Dynavision driving on on-road driving performance in patients with chronic stroke. This pre-post study assigned patients with chronic stroke who had failed a Behind-the-Wheel (BTW) assessment to receive Dynavision driving training. There was a significant improvement in BTW performance (measured using a subjective on-road evaluation of driving skills) among 6 of 10 participants* at 6 weeks (post-treatment). Results remained significant at 3-month follow-up.
* Participants were deemed “safe to resume driving and/or to receive on-road driving lessons”.

Conclusion: There is insufficient evidence (level 5) regarding the effect of Dynavision driving training on on-road driving performance among patients with chronic stroke. However, one non-randomized study reported significant improvement in on-road driving performance following Dynavision training.

Pre-driving skillsInsufficient evidence5

One non-randomized study (Klavora et al., 1995) examined the effects of Dynavision driving training on pre-driving skills (visual processing skills, visual reaction and movement time and anticipation time) in patients with chronic stroke. This pre-post study assigned patients with chronic stroke who had failed a Behind-the-Wheel (BTW) assessment to receive Dynavision driving training. There was a significant improvement in most pre-driving skills (measured by the Simple and Choice Response Timers – response time, visual reaction time and movement time) at 6 weeks (post-treatment). Results remained significant at 3-month follow-up. There were no significant improvements in other measures of pre-driving skills (Choice Response Timer – Choice Visual Reaction Time, Bassin Anticipation Timer – anticipation time) at either time point.

Conclusion: There is insufficient evidence (level 5) regarding the effect of Dynavision driving training on pre-driving skills among patients with chronic stroke. However, one non-randomized study reported significant improvements in pre-driving skills following Dynavision training.

Chronic phase - Visual Restorative Function Training

Driving safetyInsufficient evidence5

One pre-post study (Bergsma et al., 2011) examined the effects of visual Restorative Function Training (vRFT) on driving safety in patients with chronic stroke. This pre-post study assigned patients with chronic stroke and homonymous Visual Field Defect (VFD) to receive vRFT intervention using custom-built computer software. After 15 sessions (post-treatment) participants showed a significant improvement in average speed (measured using the STISIM driving simulator), but there was no significant change in other STISIM simulator measures of driving safety (number of collisions, number of pedestrians hit, number of times speed was exceeded, percentage of total distance driving out of lane).

Conclusion: There is insufficient evidence (level 5) regarding the effect of visual Restorative Function Training on driving safety in patients with chronic stroke. One non-randomized study reported improvements in driving speed following visual Restorative Function Training, but no significant change in other measures of driving safety.

Oculomotor behaviourInsufficient evidence5

One pre-post study (Bergsma et al., 2011) examined the effects of visual Restorative Function Training (vRFT) on oculomotor behaviour (eye movements/saccades) in patients with chronic stroke. This pre-post study assigned patients with chronic stroke and homonymous Visual Field Defect (VFD) to receive vRFT intervention using custom-built computer software. Two of nine patients showed significant increase in saccades in the direction of the visual field defect after 15 sessions (post-treatment).

Conclusion: There is insufficient evidence (level 5) regarding the effect of visual Restorative Function Training on oculomotor behaviour in patients with chronic stroke. One non-randomized study reported improvements in 2 of 9 patients following visual Restorative Function Training.

Visual field defect border shiftInsufficient evidence5

One pre-post study (Bergsma et al., 2011) examined the effects of visual Restorative Function Training (vRFT) on Visual Field Defect (VFD) border shift in patients with chronic stroke. This pre-post study assigned patients with chronic stroke and homonymous Visual Field Defect (VFD) to receive vRFT intervention using a custom-built computer software program. Two of nine patients showed significant improvement after 15 sessions (post-treatment) with VFD border shift of ≥ 5 degrees towards the affected visual field, and four patients showed average shifts of 2-5 degrees towards the affected visual field at post-treatment.

Conclusion: There is insufficient evidence (level 5) regarding the effect of visual Restorative Function Training on visual field defect border shift in patients with chronic stroke. One non-randomized study reported improvements in 6 of 9 patients following visual Restorative Function Training.

Phase of stroke not specified - Dynavision training

Driving Self-EfficacyNot effective1b

One high quality RCT (Crotty et al., 2009) examined the effects of Dynavision driving training on driving self-efficacy in patients with stage of stroke not specific to one period. This high quality RCT randomized patients to receive driving training using the Dynavision or no intervention. There were no significant between-group differences in driving self-efficacy (measured by the Adelaide Driving Self-Efficacy Scale) at 6 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that Dynavision training is not more effective than no intervention for improving driving self-efficacy in patients with stage of stroke not specific to one period.

On-road Driving PerformanceNot effective1b

One high quality RCT (Crotty et al., 2009) examined the effects of Dynavision driving on-road driving performance in patients with stage of stroke not specific to one period. This high quality RCT randomized patients to receive Dynavision driving training or no intervention. There were no significant between-group differences in on-road driving performance (measured using a standardized pass/fail on-road driving test) at 6 weeks (post-treatment).

 Conclusion: There is moderate evidence (level 1b) from one high quality RCT that Dynavision training is not more effective than no intervention for improving on-road driving performance in patients with stage of stroke not specific to one period.


Reference list:

References:

Akinwuntan, A.E., De Weerdt, W., Feys, H., Pauwels, J., Baten, G., Arno, P., & Kiekens, C. (2005). Effect of simulator training on driving after stroke: A randomized controlled trial. Neurology, 65(6), 843-850.  http://www.ncbi.nlm.nih.gov/pubmed/16186521

Akinwuntan A.E., Devos H., Verheyden, G., Baten, G., Kiekens, C., Feys, H. & De Weerdt, W. (2010). Retraining moderately impaired stroke survivors in driving-related visual attention skills. Topics in Stroke Rehabilitation, 17(5), 328-36.  http://www.ncbi.nlm.nih.gov/pubmed/21131257

Bergsma, D. P., Leenders, M. J. A., Verster, J. C., van der Wildt, G. J., & van den Berg, A. V. (2011). Oculomotor behavior of hemianopic chronic stroke patients in a driving simulator is modulated by vision training. Restorative Neurology and Neuroscience, 29(5), 347-359.  http://www.ncbi.nlm.nih.gov/pubmed/21811023

Crotty M. & George S. (2009). Retraining visual processing skills to improve driving ability after stroke. Archives of Physical Medicine & Rehabilitation, 90(12), 2096-102. http://www.ncbi.nlm.nih.gov/pubmed/19969174

Devos, H., Akinwuntan, A. E., Nieuwboer, A., Ringoot, I., Van Berghen, K., Tant, M., … & De Weerdt, W. (2010). Effect of simulator training on fitness-to-drive after stroke: A 5-year follow-up of a randomized controlled trial. Neurorehabilitation and Neural Repair, 24(9), 843-850.  http://www.ncbi.nlm.nih.gov/pubmed/20656965

Finestone, H. M., Guo, M., O’Hara, P., Greene-Finestone, L., Marshall, S. C., Hunt, L., … & Jessup, A. (2010). Driving and reintegration into the community in patients after stroke. PM&R, 2(6), 497-503.  http://www.ncbi.nlm.nih.gov/pubmed/20630436

Klavora, P., Gaskovski, P., Martin, K., Forsyth, R. D., Heslegrave, R. J., Young, M., & Quinn, R. P. (1995). The effects of Dynavision rehabilitation on behind-the-wheel driving ability and selected psychomotor abilities of persons after stroke. American Journal of Occupational Therapy, 49(6), 534-542.  http://www.ncbi.nlm.nih.gov/pubmed/7645666

Mazer, B.L., Sofer, S., Korner-Bitensky, N., Gelinas, I., Hanley, J., & Wood-Dauphinee, S. (2003). Effectiveness of a visual attention retraining program on the driving performance of clients with stroke. Archives of Physical Medicine and Rehabilitation, 84(4), 541-50.  http://www.ncbi.nlm.nih.gov/pubmed/12690593

Marshall, S. C., Molnar, F., Man-Son-Hing, M., Blair, R., Brosseau, L., Finestone, H. M., … & Wilson, K. G. (2007). Predictors of driving ability following stroke: A systematic review. Topics in stroke rehabilitation, 14(1), 98-114.  http://www.ncbi.nlm.nih.gov/pubmed/17311796

Petzold, A., Korner-Bitensky, N., Rochette, A., Teasell, R., Marshall, S., & Perrier, M. J. (2010). Driving poststroke: Problem identification, assessment use, and interventions offered by Canadian occupational therapists. Topics in stroke rehabilitation, 17(5), 371-379.  http://www.ncbi.nlm.nih.gov/pubmed/21131262

Unsworth, C. A., & Baker, A. (2014). Driver rehabilitation: A systematic review of the types and effectiveness of interventions used by occupational therapists to improve on-road fitness-to-drive. Accident Analysis & Prevention, 71, 106-114.  http://www.ncbi.nlm.nih.gov/pubmed/24906164