On the Road Again: Return to Driving after Traumatic Brain Injury · 2017-02-07 · On the Road Again: Return to Driving after Traumatic Brain Injury Pamela Ross BAppSc OT (Hons),

On the Road Again: Return to Driving after

Traumatic Brain Injury

Pamela Ross

BAppSc OT (Hons), Driver Assessor

A thesis submitted for the degree of Doctor of Philosophy

at

Monash University in 2016

School of Psychological Sciences

Faculty of Medicine, Nursing and Health Sciences

ii

Copyright notice Notice 1

© The author (2016). Except as provided in the Copyright Act 1968, this thesis may not be reproduced in any form without the written permission of the author.

iii

ABSTRACT

Returning to driving following a traumatic brain injury (TBI) is often a key

rehabilitation goal, as the ability to drive enables return to independence and many previous

life roles. The ‘gold standard’ assessment of driving after TBI is considered to be the on-road

assessment, usually conducted by a specialised occupational therapy driver assessor (OTDA).

However there have been few studies investigating the patient characteristics and pre-injury

and injury related factors associated with passing or failing the on-road OT driver assessment

after TBI. In addition, little is known about the processes and goals of driver rehabilitation

provided to those who fail the initial on-road assessment. There has also been limited research

into the post-assessment driving behaviour and safety of individuals returning to driving after

driver rehabilitation.

Accordingly, the main aims of the PhD program of research were to a) examine

which patient characteristics and pre-injury and injury-related factors were associated with the

outcome of initial on-road driver assessment, b) describe the range of goals, processes, timing

and outcomes, including the use of restricted licensing and resources, associated with

providing on-road training to those who failed an initial OT driver assessment and c) examine

and compare the characteristics and self-reported pre- and post-injury driver safety and

patterns of driving behaviour of those drivers who returned to driving after one on-road

assessment with those who received on-road training and subsequent reassessments.

In Study 1, the results of all on-road driver assessments completed by patients with a

TBI (n = 207), in a rehabilitation setting, over an 8-year period were reviewed retrospectively.

Two outcome groups were identified: a ‘pass’ group who resumed driving after passing the

initial on-road assessment and a ‘rehabilitation’ group who failed and required on-road

training in the form of driving lessons.

iv

Key-findings; Post traumatic amnesia (PTA) duration proved to be more strongly associated

with driver assessment outcome than Glasgow coma scale (GCS) score. Participants, who

were male, had shorter PTA duration, faster reaction time and no physical or visual

impairment and were at least 3 months post-injury were more likely to pass the initial on-road

assessment. These variables correctly classified 87.6% of the pass group and 71.2% of the

rehabilitation group. On-road training, followed by subsequent on-road re-assessments were

associated with a high probability of return to driving after TBI.

Recommendations; Factors to consider when determining whether to refer for a practical

driver assessment include; ensuring that the client is at least 3 months post-injury, evidence of

moderate to severe TBI measured by PTA, slowed choice reaction times and presence of

physical or visual impairment that may impact on driver capacity. On–road training is an

important driver rehabilitation intervention and should be offered to drivers with TBI who fail

the initial on-road assessment.

From a sample of 340 participants, Study 2 examined the goals, outcomes, timing, use

of restricted licenses and number of on-road training lessons and OT driver reassessments

provided to the 94 participants who failed the initial on-road assessment.

Key-findings; The use of goal directed driving lessons to facilitate compensation for

cognitive, physical or visual impairment, improve confidence or enhance previously learned

driving skills and restricted licensing were found to be associated with return to driving

following moderate/severe TBI. An average of seven driving lessons (range 1 – 35) and 2.5

OT driver reassessments (range 1-6), were provided to participants, resulting in 93% (n=87)

of cases resuming driving and 7 (7%) failing to meet licensing standards. An open license

was recommended for 42 (45%) cases and 45 (48%) resumed driving with a restricted license.

The mean time for referral for driving assessment varied significantly between the pass (7.62

months) and rehabilitation groups (13.31 months).

v

Recommendation; Investment in on-road training lessons addressing individual goals,

followed by reassessment and use of restricted licenses, can achieve successful return to

driving following TBI. Although delaying driving by at least 3 months appears to be

appropriate, a much longer time frame is often required, particularly with severe TBI.

Finally, Study 3 examined self-report responses of 106 participants regarding post-

injury changes in driving behaviour and number of pre- and post-injury crashes.

Key findings: No significant differences were found in pre- and post-injury crash rates or in

crash rates between the pass (n= 74) and rehabilitation (n= 32) groups. Many drivers

reported changes to their driving behaviour: Compared to pre-injury, 36.8% of drivers

reported limiting driving time, 40.6% drove more slowly and 41.5% reported greater

difficulty with navigating. The rehabilitation group (with greater injury severity) was

significantly more likely to drive less frequently, shorter distances and avoid driving with

passengers, in busy traffic, at night and on freeways than the pass group.

Recommendation: As most of the study participants resumed driving and were safe to do so

in the longer term, the importance of offering driver assessment and rehabilitation following

moderate to severe TBI has been emphasized.

This PhD program of research, has also highlighted the complexity of the decision-

making process required by rehabilitation clinicians in determining fitness to drive after TBI.

Factors that were found to contribute to this situation included the wide variation in optimum

timing for resuming driving and the range of variables that may impact on the outcome of the

on-road assessment, such as injury severity, physical/visual issues, driver confidence, ability

to compensate for cognitive issues and driver experience. The findings and recommendations

of this PhD program may contribute to development of improved referral criteria and

guidelines for resuming driving after TBI.

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DECLARATION

This thesis contains no material which has been accepted for the award of any other degree or

diploma at any university or equivalent institution and that, to the best of my knowledge and

belief, this thesis contains no material previously published or written by another person,

except where due reference is made in the text of the thesis.

Signature: …… ………………

Print Name: …Pamela Ross……………….

Date: …26/8/16……………………….

vii

PUBLICATIONS AND CONFERENCE PROCEEDINGS

DURING CANDIDATURE

Publications

Ross, P. E., Ponsford, J. L., Di Stefano, M., & Spitz, G. (2015). Predictors of on-road driver

performance following traumatic brain injury. Archives of Physical Medicine and

Rehabilitation, 96(3), 440-446.

Ross P, Ponsford JL, Di Stefano M, Charlton J, Spitz G. (2015). On the road again after

traumatic brain injury: driver safety and behaviour following on-road assessment and

rehabilitation. Disability and Rehabilitation :1-12.

Ross P, Ponsford JL, Di Stefano M, Charlton J, Spitz G. (2016). Interventions for resuming

driving after traumatic brain injury. Accepted for publication-Disability and Rehabilitation.

McKay A, Liew C, Schönberger M, Ross PE, Ponsford J. (2015). Predictors of the on-road

driving assessment after TBI: Comparing cognitive tests, injury factors and demographics.

JHTR.

Gooden, J. R., Ponsford, J. L., Charlton, J. L., Ross, P. E., Marshall, S., Gagnon, S., . . .

Stolwyk, R. J. (2016). Self-awareness and self-ratings of on-road driving performance after

traumatic brain injury. Journal of Head Trauma Rehabilitation.


Stolwyk, R. J. (2016). The development and initial validation of a new tool to measure self-

awareness of driving after traumatic brain injury. Australian Occupational Therapy Journal,

ISSN1440-1630.


Stolwyk, R. J. (2016). Self-regulation upon return to driving after traumatic brain injury,

Neuropsychological Rehabilitation,DOI:10.1080/09602011.2016.1261716

Conference presentations during candidature

On the Road Again: Driver Assessment and Rehabilitation Outcomes after Traumatic Brain

Injury; Platform presentation at 7th World Congress for NeuroRehabilitation, Melbourne,

Australia, 16-19 May 2012

On-road driver rehabilitation following traumatic brain injury: Platform presentation at the 5th

INS/ASSBI Pacific Rim Conference, Sydney, Australia, 1-4 July, 2015. Awarded Special

Commendation in the category of oral presentation by a doctoral student.

viii

THESIS INCLUDING PUBLISHED WORKS GENERAL

DECLARATION

I hereby declare that this thesis contains no material which has been accepted for the award of

any other degree or diploma at any university or equivalent institution and that, to the best of

my knowledge and belief, this thesis contains no material previously published or written by

another person, except where due reference is made in the text of the thesis.

This thesis includes two original papers published in peer reviewed journals and one paper

currently under review. The core theme of the thesis is an investigation of return to driving

after traumatic brain injury. The ideas, development and writing up of all the papers in the

thesis were the principal responsibility of myself, the candidate, working within the School of

Psychological Sciences under the supervision of Professor Jennie Ponsford, Dr Marilyn Di

Stefano (La Trobe University) and Associate Professor Judith Charlton (Monash Injury

Research Institute)

(The inclusion of co-authors reflects the fact that the work came from active collaboration

between researchers and acknowledges input into team-based research.)

In the case of Chapters 2, 3 and 4 my contribution to the work involved the following: The

concept for the PhD program and design of each study was mine, with direction from my

supervisors. I completed the data collection for Study 2 alone but had some support from a

research assistant with data collection for Study 1 and Study 3. I received support with the

statistical analysis. I independently wrote each of the journal articles and completed the

revisions, however the co-authors contributed to the editing and made suggestions about

content and organization of the material. My supervisors made similar contributions to the

thesis. As a result of this research program I have become a member of a research group

based at Monash University and am currently involved with other driving related projects.

My estimated contribution to this PhD program is therefore outlined in the template required

by Monash University below:

Thesis

Chapter

Publication

Title

Status (published, in

press, accepted

or returned for revision)

Nature and %

of student

contribution

Co-author name(s)

Nature and % of Co-

author’s

contribution*

Co-

author(s),

Monash

student

Y/N*

2

Predictors of

on-road

driver

performance following

traumatic

brain injury

Published

70%

contribution by

the candidate.

This included

formulation of

the experimental design, data

collection, data

analysis and

writing the

manuscript

Jennie Ponsford

Marilyn Di Stefano

Gershon Spitz

No

3 Interventions

for resuming

Accepted

for

70%

contribution by

Jennie Ponsford

Marilyn Di Stefano No

ix

driving after

traumatic

brain injury

publication the candidate.

This included

formulation of

the experimental

design, data

collection, data

analysis and

writing the

manuscript

Judith Charlton

Gershon Spitz

4

On the road

again after

traumatic

brain injury:

driver safety

and

behaviour

following on-

road

assessment

and

rehabilitation

Published

70%

contribution by

the candidate.

This included

formulation of

the experimental

design, data

collection, data

analysis and

writing the

manuscript

Jennie Ponsford

Marilyn Di Stefano

Judith Charlton

Gershon Spitz

No

I have renumbered sections of submitted or published papers in order to generate a consistent

presentation within the thesis.

Student signature:

Date: 26/8/16

The undersigned hereby certify that the above declaration correctly reflects the nature and

extent of the student and co-authors’ contributions to this work.

Main Supervisor signature:

Date: 26/8/16

x

ACKNOWLEDGEMENTS

I had been working for over 20 years as an OT driver assessor when I embarked on the

journey of clinician to PhD student. My initial goal was to evaluate the outcomes of the

patients with TBI who had completed the OT driver assessment and rehabilitation program at

Epworth Rehabilitation. Having conducted at least 2000 on-road assessments, I was aware

that our program was effective in getting people back to driving but did not know how safe

they were or much about their post-assessment driving patterns. I was in the fortunate positon

in my role as return to work specialist, to follow up many of these patients for a further 6 to

12 months after their participation in the driving program. I was aware that most of them

continued to drive safely – but we had no data or evidence.

The first year of the study was completed with support from a scholarship from the

Royal Automobile Club of Victoria (RACV). In subsequent years I am grateful for the study

leave provided by Epworth Rehabilitation and for the resources that have been available to me

through the Monash Epworth Rehabilitation Research Centre (MERRC). I would especially

like to thank Professor Jennie Ponsford for her ongoing support and encouragement, spanning

from my initial discussions about the study, her assistance in applying for the RACV Sir

Edmond Herring Memorial Scholarship (around 7 years ago) and her invaluable guidance

over the past years as I have negotiated my way through the world of research. It would not

have been possible to complete the PhD program without her continued support, enthusiasm,

supervision, prompting and her involvement in linking me with the appropriate resources and

people to support the project. I can honestly say that without Jennie’s encouragement and

guidance, I would not have been able to complete the PhD program.

I would also like to express my gratitude to Dr Marilyn DiStefano for continuing to

supervise me after leaving La Trobe University and generously making the time for our

‘coffee catch-ups”, despite her health challenges and work commitments along the way. She

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provided me with wonderful advice from both the occupational therapy and driver licensing

perspectives. I am also very grateful for her suggestion to apply for and for supporting my

successful application for a Churchill Fellowship. It has been an amazing opportunity to

further my understanding of the area of driver assessment and rehabilitation. The knowledge

that I have gained from the PhD program provided me with an excellent basis for the trip.

Associate Professor Judith Charlton has also provided me with invaluable advice from

the road safety perspective, particularly in developing the questionnaire and guidance with the

articles and thesis. I have appreciated her expertise and contributions from her knowledge of

the research into older drivers and road safety.

A special mention must be made to Dr Gershon Spitz, co-author, whose help with the

‘dreaded statistical analysis’ has been immeasurable. I am extremely grateful for his patience,

support and wonderful advice and would have struggled to complete the PhD program

without his support. It has been a pleasure to watch him develop from PhD student to skilled

Research Fellow.

The OT department at Epworth Rehabilitation and in particular, the OT manager,

Anne Sutherland has supported me throughout the long process with study leave. Without

Anne’s ongoing support, encouragement and flexible work arrangements, it would not have

been possible to complete the PhD program. Lorraine Macmillan provided invaluable

support, efficiency and good humour particularly during the early data collection phase and in

solving many of the little administrative hurdles! Natalie Gracia from MERRC, provided me

with assistance with some of the follow up questionnaire telephone calls and for this I am

very grateful.

I would also like to thank my family for their support - At various stages, of the PhD

program I have studied alongside each of my children Dale, Lauren and Alastair at the kitchen

table and been proud to see them complete their qualifications. I tried to study each time my

xii

husband Murray was on one of his numerous trips to China, but more recently he has

patiently supported me during the hours spent in front of a computer. When he was away, I

often appreciated the company of my parents, Peg and Bruce, at Acheron who provided cups

of tea, meals and were happy to read and potter while I studied. I am also very grateful to the

participants who completed the questionnaires as their responses have contributed

significantly to my knowledge about driving after TBI.

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CONTENTS ABSTRACT .............................................................................................................................. iii

DECLARATION ...................................................................................................................... vi

PUBLICATIONS AND CONFERENCE PROCEEDINGS DURING CANDIDATURE ..... vii

THESIS INCLUDING PUBLISHED WORKS GENERAL DECLARATION ..................... viii

ACKNOWLEDGEMENTS ....................................................................................................... x

LIST OF TABLES .................................................................................................................. xvi

LIST OF TERMS ................................................................................................................... xvii

Preface .............................................................................................................................. xviii CHAPTER 1 ............................................................................................................................... 1

Chapter 1 Overview ............................................................................................................. 2

1.1 Traumatic Brain Injury and Driving ........................................................................... 3 1.1.1 Definition and mechanism of TBI ............................................................................. 3

1.1.2 Epidemiology ............................................................................................................ 4

1.1.3 Measuring injury severity of TBI ............................................................................. 6

1.1.3.1 Loss of consciousness ............................................................................................ 7

1.1.3.2 Glasgow Coma Scale ............................................................................................. 8

1.1.3.3 Post Traumatic Amnesia ........................................................................................ 8

1.1.3.4 Injury severity summary ....................................................................................... 10

1.1.4 Impact of TBI impairments on driving capacity .................................................... 10

1.1.5 Recovery following TBI ......................................................................................... 17

1.2 Models of Driving Behaviour ..................................................................................... 18 1.2.1 Applying models of driving to TBI ......................................................................... 21

1.3 Driving after TBI ......................................................................................................... 25 1.3.1 Incidence of driving after TBI ................................................................................. 25

1.3.2 Guidelines and timing for resuming driving after TBI ........................................... 26

1.3.3 Outcome measures for driving ............................................................................... 29

1.4 On-road Driver Assessment ........................................................................................ 30

1.5 Predictors of On-road Assessment Outcome ............................................................. 33 1.5.1 Medical predictors ................................................................................................... 34

1.5.2 Injury-related predictors ......................................................................................... 35

1.5.3 Pre-injury predictors ................................................................................................ 36

1.5.4 Post-injury predictors .............................................................................................. 37

1.5.5 Off-road assessments ............................................................................................... 37

1.5.5.1 Off-road screening assessments ........................................................................... 38

1.5.5.2 Neuropsychological tests ...................................................................................... 41

1.5.5.3 Driving simulator assessments ............................................................................ 43

1.6 Factors Influencing On-road Assessment Outcome ................................................. 46 1.6.1 Timing of On-Road Assessment ............................................................................ 47

1.6.2 Driver Rehabilitation .............................................................................................. 49

1.6.2.1 Driver rehabilitation interventions ...................................................................... 52

1.6.3 Restricted licensing ................................................................................................ 56

1.7 Driving Safety and Behaviour after Return to Driving ............................................ 57 1.7.1 Crash risk after TBI ................................................................................................ 58

1.7.2 Patterns of driving after TBI ................................................................................... 61

1.8 Summary and Study Rationale ................................................................................... 62 1.8.1 Aims and Hypotheses .............................................................................................. 64

Study 1: Predictors of On-Road Driver Performance following Traumatic Brain Injury 64

Study 2: Interventions for Resuming Driving after Traumatic Brain Injury .................... 65

xiv

Study 3: On the Road Again after Traumatic Brain Injury: Driver Safety and Behaviour

following On-road Assessment and Rehabilitation .......................................................... 65

1.9 Summary of Methods ................................................................................................... 66 CHAPTER 2 ............................................................................................................................. 69

Introduction to Study 1 ...................................................................................................... 70

2.1 Abstract ......................................................................................................................... 72

2.1 Introduction .................................................................................................................. 74

2.2 Methods ......................................................................................................................... 76 2.2.1 Participants .............................................................................................................. 76

2.2.2 Procedures ............................................................................................................... 78

2.2.3 Data analysis ........................................................................................................... 80

2.3 Results ........................................................................................................................... 81 2.3.1 On-Road Assessment Outcomes ............................................................................. 81

2.3.2 Predictive Models .................................................................................................... 82

2.4 Discussion ...................................................................................................................... 84 2.4.1 Study Limitations .................................................................................................... 86

2.4.2 Conclusions ............................................................................................................. 87

2.5 References .................................................................................................................... 88 CHAPTER 3 ............................................................................................................................. 94

Introduction to Study 2 ...................................................................................................... 95

3.1 Abstract ......................................................................................................................... 97

3.2 Introduction .................................................................................................................. 98

3.3 Method ......................................................................................................................... 102 3.3.1 Participants ............................................................................................................ 102

3.3.2 Measures ................................................................................................................ 102

3.3.3 Referral and driver assessment procedure ............................................................. 104

3.3.4 Assessment Outcome ............................................................................................ 105

3.3.5 On-road training and reassessment procedure....................................................... 105

3.3.6 Data Analysis ........................................................................................................ 109

3.4 Results ......................................................................................................................... 109 3.4.1 Assessment outcomes and participant characteristics ........................................... 110

3.4.2 Timing of assessment and return to independent driving ..................................... 110

3.4.3 Outcomes of on-road training................................................................................ 111

3.4.4 Restricted licensing ............................................................................................... 112

3.4.5 Resources measured by labour hours .................................................................... 113

3.4.6 Goals of on-road training ...................................................................................... 113

3.4.7 Relationship of participant characteristics with lesson goals ................................ 114

3.5 Discussion .................................................................................................................... 116 3.5.1 Addressing cognitive impairment ......................................................................... 116

3.5.2 Compensating for visual/physical impairment ...................................................... 116

3.5.3 Enhancing previously learned skills ...................................................................... 117

3.5.4 Lesson goal; confidence ........................................................................................ 117

3.6 Implications for Rehabilitation ................................................................................ 121

3.7 References .................................................................................................................. 122 CHAPTER 4 ........................................................................................................................... 129

Introduction to Study 3 .................................................................................................... 130

4.1 Abstract ....................................................................................................................... 132

4.2 Introduction ................................................................................................................ 133

4.3 Methods ...................................................................................................................... 137 4.3.1 Participants ............................................................................................................ 137

xv

4.3.2 Driver assessment and rehabilitation procedure .................................................... 138

4.3.3 Data collection ....................................................................................................... 139

4.3.4 Questionnaire ........................................................................................................ 140

4.3.5 Data analysis ......................................................................................................... 141

4.4 Results ......................................................................................................................... 142 4.4.1 Respondent and non-respondent characteristics.................................................... 142

4.4.2 Pass and rehabilitation group characteristics......................................................... 143

4.4.3 Comparison of self-reported pre- and post-injury driving behaviour ................... 144

4.5 Discussion .................................................................................................................... 151 4.5.1 Limitations ............................................................................................................ 155

4.6 Implications for Rehabilitation ................................................................................. 156

4.7 References ................................................................................................................... 157 CHAPTER 5 ........................................................................................................................... 165

5.1 Overview and Integration of Main Findings ........................................................... 166

5.2 Driving Program Outcomes ..................................................................................... 168 5.2.1 Driving resumption after completing driving program ........................................ 168

5.2.2 Resumption of Driving with License Restrictions ................................................ 172

5.2.3 Timing of return to driving .................................................................................... 175

5.3 Factors Influencing Initial Driver Assessment Performance ................................. 179 5.3.1 Injury related factors ............................................................................................. 181

5.3.1.1 Injury severity .................................................................................................... 181

5.3.1.2 Physical and visual impairment .......................................................................... 182

5.3.1.3 Slower brake reaction times ............................................................................... 183

5.3.1.4 Lack of recent driving experience ...................................................................... 184

5.3.1.5 Confidence ......................................................................................................... 185

5.3.2 Pre-injury related factors ....................................................................................... 186

5.3.2.1 Age and driving experience ................................................................................ 186

5.3.2.2 Gender ................................................................................................................ 188

5.3.2.3 Previously learned driving skills ........................................................................ 188

5.4 On-road Training Goals ............................................................................................ 189 5.4.1 Resources associated with driver rehabilitation .................................................... 192

5.5 Post-assessment Safety and Behaviour ..................................................................... 194 5.5.1 Total group safety and behaviour .......................................................................... 195

5.5.2 Comparison of safety and behaviour of pass and rehabilitation groups.............. 200

5.6 Limitations .................................................................................................................. 203

5.7 Strengths and Unique Contributions ........................................................................ 207

5.8 Directions for the Future ........................................................................................... 211

5.9 Personal Reflections .................................................................................................. 215

5.10 Conclusion .......................................................................................................... 217 REFERENCES ....................................................................................................................... 220

APPENDICES ........................................................................................................................ 252

Appendix A; Questionnaire for Current Drivers .......................................................... 253

Appendix B; Questionnaire for Non-Drivers ................................................................. 257

Appendix C; Participant Information and Consent Form ........................................... 259

xvi

LIST OF TABLES Chapter 1: Introduction

Table 1 Table 1 Consensus Statements for Screening and Assessment Tools……38

Chapter 2: Predictors of On-road Driver Performance after Traumatic Brain Injury

Table 1 Demographic and injury-related variables for Pass and Rehabilitation

Groups ……………………………………………………………………67

Table 2 On-road assessment outcomes…………………………………………...71

Table 3 Logistic regression models predicting Pass and Rehabilitation group

Outcome…………………………………………………………………..73

Chapter 3: Interventions for Resuming Driving after Traumatic Brain Injury

Table 1 Driver rehabilitation case studies………………………………………..94

Table 2 Characteristics of individuals who passed and failed initial driver

assessment……………………………………………………………….98

Table 3 On-road training outcomes and resources …………………………….100

Table 4 Relationship of on-road training goals with driver characteristics……..101

Chapter 4: On the Road Again after Traumatic Brain Injury: Driver Safety and

Behaviour following On-road Assessment and Rehabilitation

Table 1 Characteristics for respondents and non-respondents………………….128

Table 2 Characteristics for Pass and Rehabilitation groups……………………129

Table 3 Comparison of self-reported pre- and post-injury driving behaviour…..131

Table 4 Self-restriction of driving and navigation difficulties…………………..132

Table 5 Characteristics of participants who reported crashes and those who reported

no crashes………………………………………………………………..134

Table 6 Self-reported issues perceived to affect driving capacity ………………135

xvii

LIST OF TERMS

TBI Traumatic Brain Injury

PTA Post Traumatic Amnesia

GCS Glasgow Coma Scale

LOC Loss of Consciousness

FIM/FAM Functional Independence Measure/ Functional Assessment Measure

OT Occupational Therapist

OTDA Occupational Therapy Driver Assessor

DRS Driver Rehabilitation Specialist

CDRS Certified Driving Rehabilitation Specialist

DLA Driver Licensing Authority

DVLA Driver and Vehicle Licensing Agency (UK)

NHTSA National Highway Traffic Safety Administration

CDE Comprehensive Driver Evaluation

CVA Cerebral Vascular Accident

PTSD Post- traumatic Stress Disorder

ABI Acquired Brain Injury

HC Healthy Control

CBDI Cognitive Behavioural Driver’s Inventory

AIC Akaike Information Criterion

RCT Randomised Control Trial

CT Computed Tomography

xviii

Preface

To drive or not to drive: that is the question? (Apologies to Shakespeare)

This is the question that must be considered by clinicians working with patients who

hope to resume driving following a traumatic brain injury (TBI). For patients with a milder

injury, the answer may be ‘yes, return to driving is likely’. This will then raise a further

question; ‘Is a practical driver assessment required and when should this occur?’ For those

with a more severe TBI, the answer is likely to be less clear, due to the lasting sensory,

physical, cognitive, behavioural and emotional impairments after TBI which may affect

driving capacity.

Driving a car is a complex activity, that requires not only physical and perceptual

skills, but also the ability to self-monitor and make appropriate responses and decisions in a

constantly changing environment and with time demands (Mazer, Gelinas, & Benoit, 2004).

Driving contributes to self-esteem and sense of identity and feeling ‘normal’ (Liddle et al.,

2012). Following TBI, being able to drive is associated with higher life satisfaction (Novack

et al., 2010) and in a TBI group, surveyed one month after discharge, driving rated highly as

an activity they would like to perform (Johnston, Goverover, & Dijkers, 2005). Resuming

driving is therefore, frequently a key rehabilitation goal, as it signifies attainment of

independence and is a major step towards returning to pre-injury lifestyle (Rapport, Hanks, &

Bryer, 2006). Making the decision about when and if it is safe to return to driving is therefore

an important one, but can be very difficult and stressful for health professionals, the injured

person and their families (Hopewell, 2002; Liddle et al., 2012). The wide range of

impairments following TBI, combined with the lack of knowledge, detailed guidelines, and

uniform assessment and rehabilitation procedures for return to driving after TBI, contributes

to this situation (Hopewell, 2002; Tamietto et al., 2006).

xix

The present thesis comprises five chapters exploring return to driving after TBI.

Chapter 1 reviews the literature on topics associated with traumatic brain injury and driving,

with an emphasis on predictors for resuming driving after TBI, on-road assessment, driver

rehabilitation and driver safety. Based on this literature, the study rationale is discussed and

aims and hypotheses of this thesis are presented. A brief method section is also included to

provide an overview of the methods and participant overlap for each study and how the three

studies are linked. Chapter 2 comprises the first published study - ‘Predictors of on-road

driver performance following traumatic brain injury’. This study introduces the reader to the

methodology used in each of the studies, where participants are divided into two groups – the

‘pass’ group who resume driving after passing the initial on-road assessment and the

‘rehabilitation’ group who required driver rehabilitation. The second study, ‘Interventions for

resuming driving after traumatic brain injury’ (accepted for publication), forms Chapter 3 and

focuses specifically on the driver rehabilitation process for the ‘rehabilitation’ group who

failed the initial on-road assessment. Chapter 4 is comprised of the third study, ‘On the road

again after traumatic brain injury: driver safety and behaviour following on-road assessment

and rehabilitation’ and explores and compares the safety and changes in post-assessment

driving patterns of the ‘pass’ and ‘rehabilitation’ groups from pre-to post injury. Chapter 5

presents an integrated discussion and interpretation of the findings from the previous three

chapters and discusses clinical implications for return to driving following TBI. The

limitations of the thesis, future directions, conclusion and a personal reflection are also

presented in this chapter. As the present thesis includes published work (Chapters 2 and 4), a

degree of repetition was unavoidable.

CHAPTER 1

INTRODUCTION

Chapter 1 Introduction

2

Chapter 1 Overview

The main focus of Chapter 1 is to introduce and familiarize the reader to the causes and

sequelae of TBI and the range of issues that arise when assessing fitness to drive in this

population. A systematic review of each topic area was not performed. However a review of the

literature was conducted by searching relevant databases (PubMed, CINAHL Plus, PsycINFO,

Ovid MEDLINE, and Scopus) using a range of terms for each topic area and key textbooks were

referred to.

Chapter 1 is structured to initially provide an overview of traumatic brain injury including

its’ mechanism and epidemiology, followed by a description of the measurements of injury

severity. The range of impairments that may result following TBI and the possible impact on

driver capacity are presented. Models of driving behaviour and current guidelines for driving

after TBI are then discussed. As the main outcome measure used in this PhD program is passing

an OT on-road driver assessment, a more detailed review of the literature examining on-road

driver assessment is provided. The incidence, outcome measures, predictors and assessment

methods for fitness to drive following TBI is examined and provides background to Study 1. The

literature regarding factors that may affect the outcome of the on-road assessment such as the

timing of the on-road assessment, the availability of restricted licensing and driver rehabilitation

and interventions are then discussed and form an introduction to Study 2. The background

literature for Study 3 examining post-assessment driver safety and driving behaviour is then

provided. Finally the aims and hypotheses of the study will be presented and a brief method

section is included.


3

1.1 Traumatic Brain Injury and Driving

1.1.1 Definition and mechanism of TBI

TBI is caused by an external force applied to the head, usually resulting in a loss or

impairment of consciousness, with either temporary or permanent neurological impairment

(Khan, Baguley, & Cameron, 2003; Ponsford, Sloan, & Snow, 2013). The mechanisms of

neuronal damage are complex. Factors such as a closed or open head injury and the velocity of

impact when the injury occurred may result in different types of damage. For example, neuronal

damage may result from both the primary, focal effect where contact occurred, resulting in

lacerations, contusions and haematomas (epidural, subdural or intracerebral) and more

widespread microscopic damage, due to acceleration/deceleration injury types, resulting in

diffuse axonal injury or brain swelling (Cassidy, 1994; Ponsford et al., 2013; Silver, Hales, &

Yudofsky, 2010; Werner & Engelhard, 2007).

Contusions occur in site specific areas, resulting from the brain contacting the boney

protuberances within the skull and commonly result from low velocity injuries such as falls and

assaults. A coup injury occurs at the site of impact, whereas a contre- coup injury occurs opposite

the site of impact, as the brain strikes the skull. This type of injury can occur when there is a

sudden deceleration of the head. Diffuse axonal injury refers to the extensive white matter

damage that occurs when the axons are rapidly stretched as the brain rotates, as occurs in high

speed accidents (Cassidy, 1994; Smith, Meaney, & Shull, 2003). Shearing strains are greatest at

grey-white matter interfaces. Regardless of the site of impact, the frontal and temporal lobes in

particular, as well as the corpus callosum, basal ganglia, fornices, hypothalamus, brain stem and


4

cerebellum are most vulnerable to injury (Levin, Williams, Eisenberg, High, & Guinto, 1992;

Ponsford et al., 2013).

Neuronal damage can also result from a range of secondary effects. Cerebral ischaemia

can result in hypoxia due to insufficient cerebral blood flow. Damage can also result from

compression of brain tissue due to brain swelling or an increase in cerebral blood volume.

Infection, which may be associated with skull fractures, and raised intracranial pressure are

further examples of secondary mechanisms, of neuronal damage (Ponsford et al., 2013; Silver et

al., 2010).

1.1.2 Epidemiology

In Australia, the minimum age to hold a driver’s license may be 17 or 18 years of age,

depending on the state requirement. This PhD program examined return to driving in an adult

TBI population and will therefore only discuss the epidemiology of TBI in adults. It is difficult

to obtain accurate data regarding the incidence of TBI, due to variations in TBI definitions,

diagnostic criteria, sources of data such as emergency department presentations or hospital

admissions and methods of data collection (Andelic, 2013; Corrigan, Selassie, & Orman, 2010;

Ponsford et al., 2013). This was illustrated in a recent study examining the incidence of TBI per

100,000 person-years of TBI in New Zealand (Feigin et al., 2013). This study used a variety of

sources to obtain data and therefore captured cases of mild TBI that had not resulted in a hospital

admission. Most previous studies have only used hospital admissions as the main source of data

and therefore the rates of TBI, especially mild TBI, were much higher in this study than have

generally been reported in comparable high income countries in Europe and North America

(Andelic, 2013).


5

In Australia, the rate of hospitalizations due to TBI between 1999–00 and 2004–05 has

remained unchanged at approximately 107 per 100,000 population per year, with 2.5 times as

many males injured than females (Harrison, Helps, & Henley, 2008). However based on the

results of the study by Feigen and colleagues (2013 ), which reported 790 cases per 100,000

population per year, this rate is likely to be much higher (Feigin et al., 2013). Similarly the

reported rates are also lower in the US; an estimated 444 per 100,000 population presented to

hospital Emergency departments with diagnosis of TBI between 1992 and 1994 (Jager, Weiss,

Coben, & Pepe). It is estimated that an average of 1.4 million individuals sustain a TBI each year

in the US (Langlois, Rutland-Brown, & Wald, 2006) and for individuals under 45, TBI remains

the main cause of injury and death (Feigin et al., 2013; Werner & Engelhard, 2007).

When TBI is the primary diagnosis, the most common causes of TBI in Australia have

been identified as falls (42%), transport accidents (29%) and assault (14%). Falls are consistently

a leading cause of TBI (Feigin et al., 2013), however these proportions changed when TBI was

documented as an additional diagnosis. Transport accidents (42%) were the most common cause

of TBI, followed by falls (30%) and assault (16%) (Harrison et al., 2008). Higher numbers of

males sustain TBI due to assault, whereas females have been shown to be more likely to have

sustained TBI resulting from falls; and similar proportions of males and females sustain TBI

caused by transport accidents (Feigin et al., 2013). The highest incidence of TBI occurs in the

age-group 15–24 years, mainly due to their over representation in traffic accidents, followed by

the age group over 75 years, due to falls and pedestrian accidents (Harrison J, 2008). Sporting

and recreational injuries are the main cause of mild TBI, along with falls, motor vehicle

accidents, cycling accidents, and assaults (Heegaard & Biros, 2007).


6

For this predominantly young age-group, the loss of driving privileges can be one of the

most disabling consequences of TBI, as it affects participation in many aspects of daily life

(Liddle et al., 2012). Survivors of TBI who have not returned to driving show poorer community

integration, and a higher incidence of depression (Rapport et al., 2006). Employment outcomes

have also been shown to be influenced by driving status; individuals who were able to drive

independently were four times more likely to find stable employment than those who did not

drive (Kreutzer et al., 2003). Although this association is not necessarily causative, it is important

that support to gain licensure or return to driving is addressed as part of the rehabilitation process

to maximize outcomes in other areas of life (Brouwer & Withaar, 1997; Liddle et al., 2011).

1.1.3 Measuring injury severity of TBI

One of the immediate consequences of a TBI is a disturbance of consciousness reflecting

an alteration of brain function. This disturbance may range from a mild reduction in alertness to

a profound coma. The duration of the disturbance may be brief, as in the case of concussion, or a

prolonged period of coma (Russell & Smith, 1961). The measurement of injury severity

following TBI is useful for treatment planning and in long term prognosis and recovery, as it has

been found to be predictive of both cognitive and functional outcome (Brown et al., 2005; Spitz,

Ponsford, Rudzki, & Maller, 2012).

Internationally, there is a lack of consensus around which measures of injury severity to

use after TBI. There have been a variety of approaches to classifying injury severity, however the

three most commonly used indices of injury severity classify the disturbance of consciousness

and include: 1) Glasgow Coma Scale (GCS) score, which measures depth of coma, 2) Post

Traumatic Amnesia (PTA) duration defined as the length of altered consciousness, including the


7

period of coma and 3) duration of loss of consciousness (LOC). Each of these classifications has

advantages and disadvantages depending on the purpose for which they are being used.

1.1.3.1 Loss of consciousness

The most common definition of loss of consciousness (LOC) is the interval from injury to

return of ability to follow commands (Malec et al., 2007) and is characterized by a lack of

response to external and internal stimuli (Ponsford et al., 2013). LOC is less commonly used as a

measure of injury severity, compared to GCS score and PTA duration, due to the lack of an

established classification system to describe injury severity (Sherer, Struchen, Yablon, Wang, &

Nick, 2008). In many cases, the duration of loss of consciousness cannot be established if the

injury was not witnessed. Additionally a loss of consciousness is not required for a diagnosis of

TBI, although evidence of a period of confusion or altered consciousness is required (Prevention

& Control, 2003).


8

1.1.3.2 Glasgow Coma Scale

The GCS measures depth of coma and is widely used as a measure of injury severity,

particularly in the acute management of TBI. Scores are assigned from clinical observations of

best performance of eye opening, motor response and verbal response and combined to provide a

total score ranging from 3 to 15. Severity is rated as a mild injury for a GCS score of 13-15,

moderate 9-12 and severe 3-8 (Jennett, 1976; Teasdale & Jennett, 1974). The GCS score can vary

according to when it is measured, and therefore the severity rating may change depending on the

time of measurement. It is commonly recorded at the accident scene or in the emergency

department and can also be documented as the highest or lowest score in a 24 hour period. It can

be difficult to measure due to some aspects of medical management, such as use of sedating

medication or other factors such as facial injuries, or the influence of alcohol or drugs. It has also

been proposed that it may not be the best measure of severity for mild TBI, where GCS score

ranges from 13 -15. Using the term mild, may underestimate the severity of impairments in

patients with a score of 13 or 14 (Teasdale, 1995). Furthermore, a study comparing severity

measures found that 33% of participants classified as mild using GCS score, would be classified

as severe using PTA criteria (Sherer et al., 2008). The authors concluded that results of studies

using GCS as a severity measure would not be consistent with those using PTA duration as the

measure of injury severity.

1.1.3.3 Post Traumatic Amnesia

PTA duration is defined as the period of time from injury until return of orientation and

continuous memory of events and includes the period of coma (Marosszeky, Ryan, Shores,

Batchelor, & Marosszeky, 1997; Sherer et al., 2008). PTA duration can be measured


9

retrospectively by asking the patient to recall their first memory upon regaining full

consciousness, however accuracy may be compromised using this method and prospective

measurement is preferred (Roberts, Spitz, & Ponsford, 2016). In Australia, the Westmead PTA

scale is commonly used to evaluate whether a patient is out of PTA. Assessment of PTA duration

is based on the accuracy of patient responses to a pre-determined set of questions, which are

asked each day until a perfect score of 12 is achieved on three successive days. The patient is

deemed to be out of PTA from the first day that a perfect score was achieved on three

successive days (Shores, Marosszeky, Sandanam, & Batchelor, 1986). In the US and Canada, the

Galveston Orientation and Amnesia Test (GOAT), a scale measuring orientation to person, place

and time and pre and post injury memory of events (Levin, O'Donnell, & Grossman, 1979), is

generally used to evaluate patients in PTA.

Classifications of injury severity measured by PTA duration that have been used

extensively in the past - (less than 5 minutes = very mild, 5 to 60 minutes = mild, 1-24 hours =

moderate, 1-7 days = severe, 1 week - 4 weeks = very severe and greater than 4 weeks =

extremely severe) or more recently - (less than 24 hours = mild, 1-7 days = moderate, 1-4 weeks

=severe and greater than 4 weeks = very severe), may not differentiate the severity of those

patients with greater PTA duration. More recent studies have identified that cut-offs at 28 days or

70 days are more meaningful, but it is also argued that PTA can be most accurately used to

predict outcome when measured continuously (Ponsford, Spitz, & McKenzie, 2016).

A number of studies that have found that PTA duration is a strong predictor of both short

and long term functional outcomes using a range of measures including Functional Independence

Measure (FIM), the Disability Rating Scale (Brown et al., 2005) and return to employment

(Schönberger, Ponsford, Olver, Ponsford, & Wirtz, 2011). Furthermore, PTA duration has been


10

recommended as a standard measure of injury severity for use in TBI research (Brown et al.,

2010; Walker et al., 2010).

1.1.3.4 Injury severity summary

In summary, injury severity may be categorized by different methods using the terms

mild, moderate and severe. Mild TBI has been defined as an injury presenting with confusion or

loss of consciousness for less than 30 minutes, PTA duration of less than 24 hours and a GCS

score of 13-15 (Carroll, Cassidy, Holm, Kraus, & Coronado, 2004). Moderate and severe TBI,

include cases where coma duration is longer than one hour and PTA duration persists for more

than 24 hours (Ponsford et al., 2013), resulting in behavioural and cognitive impairments. This

discussion has highlighted some of the difficulties in classifying mild, moderate and severe TBI

and the need to define which measure of injury severity has been used, when reporting results of

TBI research.

1.1.4 Impact of TBI impairments on driving capacity

The wide variability in the long and short term sensory, physical, cognitive and

behavioural changes following TBI is dependent on the severity, mechanism and location of the

injury (Ponsford et al., 2013). Hence, sustaining a TBI may result in a multi-faceted disability.

The cognitive and functional consequences of the injury have been found to be associated with

injury severity (Brown et al., 2005; Bush, 2003). Cognitive function, measured by

neuropsychological tests, has been found to be a stronger predictor of functional outcome in the

first year post-injury, than injury severity (Spitz et al., 2012). Therefore in addition to injury

severity, it is important to consider both cognitive and functional impairments following TBI.

Impairments may be categorized as sensorimotor and cognitive/behavioural sequelae (Ponsford et


11

al., 2013). For the purposes of this review, only the impairments that are likely to have an impact

on the ability to drive will be discussed.

Sensorimotor impairments may include changes to vision, hearing, sense of smell,

speech, swallowing, vertigo, motor function and sensation. Visual disturbances are particularly

common following TBI and may have significant ramifications for resuming driving. They can

be caused by damage to cranial nerves, the optic nerve and occipital lobes (Ventura, Balcer, &

Galetta, 2014). The prevalence of visual disturbances after TBI is not known, however it has

been informally estimated that they are present in one third (Hawley, 2001), 30-50% (Kowal,

1992) and 56.7% (Van Stavern, Biousse, Lynn, Simon, & Newman, 2001) of individuals

following TBI. A range of visual disturbances have been identified, including reduced acuity,

blurred vision, diplopia, photophobia (sensitivity to light), visual field deficits and blindness

(Ventura et al., 2014). Eye movements may also be affected by TBI. These include abnormal

saccades (the quick, simultaneous movement of both eyes between two points of fixation in the

same direction), pursuit (the ability to follow slow moving objects) and convergence (the ability

of the eyes to adduct to maintain focus on near objects) (Kowal, 1992; Ventura et al., 2014).

Hearing loss is less common, however tinnitus occurs more frequently after mild TBI

particularly after blast related injury (Lew & Guillory, 2007), but does not generally preclude

return to driving. Changes to hearing may necessitate the learning of compensatory techniques to

increase observation of the traffic environment (DiStefano, 2006). Dizziness or vestibular

disturbances are also common following TBI, and are frequently early symptoms (Alexander,

1995), due to involvement of the vestibular branch of the eighth cranial nerve. They have also

been found to be associated with some visual disturbances (Ventura et al., 2014). Driving can


12

require rapid head turning, which may then elicit symptoms of dizziness, thus affecting driving

capacity (Cohen, Wells, Kimball, & Owsley, 2003).

Motor impairment is also common after TBI, particularly in the early stages of recovery,

and may affect one or both sides of the body including either or both upper or lower limbs and

reduced balance. Physical function may be affected by paralysis, weakness, endurance, poor

balance, postural control, incoordination, reduced range of movement or poor gross and fine

manipulative skills (Walker & Pickett, 2007). Driving capacity may also be affected by changes

in sensation, such as reduced kinesthetic awareness or proprioception, defined as the inability to

sense movement or locate the position of limbs in space. Whilst most patients with TBI do not

experience long term motor impairment (Ponsford et al., 2014), following severe TBI, around

one third have been found to have at least one persisting physical impairment at 2 year follow up

(Walker & Pickett, 2007). The importance of assessing the influence of physical impairment on

driving performance has been outlined in a number of studies (Brouwer & Withaar, 1997;

Hawley, 2001; Jones, Giddens, & Croft, 1983; Mazer et al., 2004) and in the Australian fitness to

drive guidelines (Austroads, 2012).

Chronic pain may also be associated with TBI and any accompanying orthopaedic

injuries (Lahz & Bryant, 1996). Headaches were found to be the most commonly reported type of

pain post-TBI, with one third of patients experiencing headaches almost daily in the first year

post-injury (Walker, Seel, Curtiss, & Warden, 2005).

There are a range of cognitive and behavioural impairments that may be present after TBI.

Greater injury severity has been associated with more impaired cognitive functioning (Borgaro

& Prigatano, 2002; Draper & Ponsford, 2008) and therefore, the potential impact of cognitive

impairment on driving will depend on injury severity. One of the most common symptoms


13

experienced after TBI across the range of severity and reported in the longer term is fatigue

(Olver, Ponsford, & Curran, 1996; Ponsford et al., 2014). Fatigue after TBI is thought to be due

to a number of factors including disturbed sleep patterns and the additional cognitive effort that

is required to compensate for cognitive impairments, such as slowed information processing and

reduced attention (Ouellet & Morin, 2006; Ponsford & Sinclair, 2014). In addition, fatigue may

be exacerbated by the presence of pain, depression and anxiety (Ponsford & Sinclair, 2014).

Deficits in attention, memory and executive functioning are the most commonly reported

cognitive sequelae after TBI (Dikmen et al., 2009; Ponsford et al., 2013). Attention refers to both

the ability to sustain attention or concentration over time and to selectively focus or divide

attention and screen out irrelevant information (Ziino & Ponsford, 2006). Reduced speed of

information processing is an attentional difficulty that is commonly reported after TBI. Slowness

in processing leads to a reduced capacity to take in information and to divide attention (Ponsford

et al., 2013). A study assessing ten participants with TBI on a complex selective attention task,

required participants to monitor a speedometer and ignore other environmental changes.

Performance in the TBI group, who ranged from 2 to 19 month post injury, was significantly

worse than in a control group (Masson et al., 2013). Similar results were found in a study

examining the impact of impaired divided attention and slowed processing on driving tasks, using

a driving simulator (Cyr et al., 2009). The TBI group, were found to crash significantly more

often than a control group. Attentional difficulties are therefore a significant concern for

resuming the complex task of driving, where both maintenance of attention and the ability to

focus and divide attention are vital (Brouwer, Withaar, Tant, & van Zomeren, 2002).

Memory and learning problems are also common after TBI (Azouvi, Vallat-Azouvi, &

Belmont, 2009). Procedural memory has been found to be relatively resistant to the impact of


14

TBI. For many experienced drivers, the skills required for driving are considered to rely largely

on procedural knowledge and may be relatively well preserved after severe TBI (Brouwer et al.,

2002). The impact of memory and learning issues is therefore likely to be greater for

inexperienced or learner drivers where the skills required for driving have not been well

established (Brouwer et al., 2002).

Executive functions refer to the higher level abilities of reasoning, planning, problem

solving, mental flexibility, initiation, inhibition, organisation, sequencing and self- regulation.

Impairments in these areas have been associated with damage to the frontal lobes and their

associated networks (Asimakopulos et al., 2012; Azouvi et al., 2009). Executive dysfunction may

also be associated with behavioural changes. These may include impulsivity, difficulty with

control of anger or frustration, a lack of initiation and poor self- monitoring and awareness

(Ponsford et al., 2013). Patients with lack of insight and reduced awareness of their limitations

have poor judgment and decision making skills and difficulty learning from experience to change

behaviour (Hart, Seignourel, & Sherer, 2009). Executive dysfunction and in particular lack of

insight therefore has the potential to have a significant impact on driving capacity (Coleman et

al., 2002; Griffen, Rapport, Bryer, Bieliauskas, & Burt, 2011; Lundqvist & Alinder, 2007).

Comprehension can be impacted by ‘concrete thinking’ and mental inflexibility and can

result in a rigid pattern of thinking or interpretation being applied to a situation (Ponsford et al.,

2013). In the context of driving, there may be reduced ability to interpret or judge an appropriate

or ‘common sense’ approach to a road safety issue, resulting instead in a rigid and potentially

unsafe approach to a traffic situation (Brouwer et al., 2002).

Visuospatial deficits are less common after TBI, however the presence of a unilateral

neglect or inattention will preclude driving due to the difficulty in maintaining road position and


15

reduced awareness of hazards in the peripheral visual fields (Coleman Bryer, Rapport, & Hanks,

2005). There is limited evidence to support the effectiveness of retraining of visual scanning for

drivers with these deficits (Cicerone et al., 2005). Way-finding or the ability to navigate, has been

described as a spatial problem-solving process, requiring the ability to form, remember and then

use cognitive maps (Livingstone & Skelton, 2007). A study, comparing the way-finding ability

of 18 participants with TBI to a control group, found that the TBI group made more errors along

the route (Lemoncello, Sohlberg, & Fickas, 2010). The ability to plan-routes and then follow and

monitor the route, is a requirement for driving. A deficit in this domain is likely to present a

challenge for drivers with TBI. It is a relatively under-researched area, with few studies in the

TBI literature.

The influence of co-morbid conditions including, musculo-skeletal impairment,

psychiatric or substance abuse history and the effects of medication on driving performance have

also been highlighted as areas to consider when assessing fitness to drive (Hopewell, 2002). A

medical complication that can affect driving is the presence of post-traumatic epilepsy. It has

been estimated that post-traumatic epilepsy can occur in between 4.4% and 53% of individuals

following TBI, depending on the age range of the study population and time of data collection

post-injury (Frey, 2003). Guidelines for the seizure free period required before resuming driving

after post-traumatic epilepsy vary throughout the world (Bushnik, Englander, & Duong, 2004). In

Australia an assessment by a specialist neurologist is usually required regarding fitness to drive

following post-traumatic epilepsy (Austroads, 2012).

In summary, the skills required for driving have been divided into three domains; namely

psychomotor (e.g., strength, coordination, reach, postural control, tone, endurance),

sensory/perceptual (e.g., vision, sensation, audition, proprioception, visual perception) and


16

cognitive (e.g., attention, memory, learning ability, executive functions) (Mazer et al., 2004). As

TBI may cause impairments in any or all of these domains, each needs to be considered when

determining capacity of an individual with TBI, to resume driving (Brouwer & Withaar, 1997;

Hawley, 2001).


17

1.1.5 Recovery following TBI

Recovery has been found to be most rapid in the first 5 to 6 months following TBI

(Christensen et al., 2008; Dikmen et al., 2009) and the rate and extent of recovery have been

found to be related to PTA duration (Kosch, Browne, King, Fitzgerald, & Cameron, 2010). Most

improvement occurs over the first two years post injury (Christensen et al., 2008), however,

improvements in function have been found to continue to occur in the years following TBI

(Ponsford et al., 2014; Spitz et al., 2012). Although cognitive impairment may still be present in

the longer term, some individuals with TBI can benefit from strategy training to learn to

compensate for impairment, thereby reducing the functional effect on everyday activities

(Cicerone et al., 2005; Ponsford et al., 2013).

The extent of cognitive impairments has been found to be associated with the severity of

the injury (Draper & Ponsford, 2008). The majority of TBI cases are classified as mild: in an

Australian study of hospital treated TBI, 62.2% of cases were mild, 20.3% were moderate and

13.6% were severe. The remaining 3.9% of cases died (Tate, McDonald, & Lulham, 1998). It is

widely accepted that following mild TBI, most cognitive symptoms have resolved by three

months post-injury (Ettenhofer & Abeles, 2009; Ponsford et al., 2000) and driving capacity is

generally not affected (Brouwer & Withaar, 1997). For those with a moderate to severe TBI,

cognitive impairments have been found to persist in the longer term (Ponsford et al., 2014),

thereby potentially affecting driving capacity.


18

1.2 Models of Driving Behaviour

Driving is a complex activity that is influenced by a range of factors, including the

environment in which driving takes place. There are a wide range of different models of driving

that have been developed by various professional disciplines to describe the complexity of the

driving task. They aim to describe the skills and behaviours required for driving and provide a

framework for driver competencies, attributes and capacity. It is important in the field of driver

rehabilitation, to have a framework or model, on which to base referral and assessment criteria

(Dickerson & Bedard, 2014; MacDonald, Perrerito, & Di Stefano, 2006). George and colleagues

(2009) reviewed 10 models of driving and identified the need for one model or framework of

driving for occupational therapy driver assessors (OTDAs), to guide selection of interventions for

driver rehabilitation (George, May, & Crotty, 2009). A detailed description of driving models

that support driver rehabilitation has been provided by MacDonald and colleagues (2006)

(MacDonald et al., 2006). An examination of these models of driving is beyond the scope of this

review; however two models for driving have been more frequently cited in both the TBI and

driver rehabilitation literature. These included Keskinen’s model for driving (Laapotti, Keskinen,

Hatakka, & Katila, 2001) and Michon’s model for driving (Michon, 1985).

Michon’s model of driving provides a hierarchy of three levels of decision making

(strategic, tactical, operational), each entailing different time pressures for tasks related to

driving. As response times are frequently impaired after TBI, this model provides a framework

for assessing capacity to make driving related decisions within a limited timeframe (Brouwer et

al., 2002; Preece, Horswill, & Geffen, 2012). Van Zomeren and colleagues (1987) provided an

analysis of the skills required for various driving tasks based on Michon’s model (Van Zomeren,

Brouwer, & Minderhoud, 1987). The highest level of the model involves strategic decisions,


19

which are often made prior to driving and require planning and judgment. Generally the amount

of time taken to make these decisions is not as ‘pressured’ as decisions made at the other levels.

Examples of these less time dependent decisions include which route to take, when and whether

to drive, such as at night or in poor weather conditions and when to attend to tasks such as car

maintenance (checking tyre pressure, oil etc). At times faster decision making can be required at

this level, such as unexpected road works or a rash requiring alternative route planning. The

tactical level involves actions taken while driving, such as adjusting speed or road position in

response to traffic conditions (deciding to slow down for an intersection or overtake another car),

switching on headlights or wipers. These need to be completed within a short timeframe. The

operational level involves the constant, ‘split second’ responses required to monitor and adjust

speed. It includes gap selection by accelerator and brake use and steering adjustments to maintain

accurate road position. Dickerson and Bedard (2014) have provided a framework, based on

Michon’s model, to assist OTs to determine whether their clients may require specialist driver

assessment (Dickerson & Bedard, 2014). This framework also provides a useful checklist of

motor, cognitive, visual and perceptual skills at each level of the model for driver rehabilitation

specialists (DRS) to consider when assessing driver capacity. This is particularly useful for TBI

clients, who may have impairment in any of these areas.

Keskinen’s model also proposes a hierarchical structure, but provides an additional fourth

level. It has also been described as the Gadget Matrix model (MacDonald et al., 2006). Similar to

Michon’s operational level, the first level is concerned with basic vehicle handling such as speed

control and steering. Level two is related to negotiating various traffic situations (tactical level)

and level three is concerned with the context and goals of driving and includes the ability to

navigate and plan routes, similar to Michon’s strategic level of driving. The fourth level identifies


20

further skills required for driving and includes the personal characteristics, motivations, life goals

and attitudes of the individual, which determine the decisions made while driving (Laapotti et al.,

2001). In the context of TBI and driver rehabilitation, life roles and the specific need and value

of driving to an individual’s lifestyle, are also important factors to consider.

Both models are therefore useful for describing some of the possible functional impacts of

impairment after TBI on driving capacity. For example the operational level may be impacted by

poor pedal or steering control due to lower or upper limb motor impairment. Keskinen’s model

provides the additional level, enabling lifestyle and personal characteristics to be considered

when decisions about driver evaluation and fitness to drive are made.

Hopewell (2002) provided a simple graded, multi-stage model for clinicians to use when

considering a client’s capacity to return to driving. It recommended that an assessment for

adequate vision and motor function, medical contraindications, such as seizure risk, medication

effects and psychiatric instability, be completed before proceeding to assessment, followed by

driver rehabilitation if required, to remediate driving skills or learn to compensate for impairment

(Hopewell, 2002)

A more recent model, less cited in the TBI literature, is called the Multifactorial Model

for Driving. It was proposed by Anstey and colleagues (2005) and addresses the potential effect

on driving capacity of visual, cognitive, and physical impairments. In addition, the model

incorporates the influence of ability to self-monitor, beliefs about driving skills, the driving

environment and previous driving experience and skills, on driving capacity (Anstey, Wood,

Lord, & Walker, 2005). This model is very useful when considering driving after TBI as it also

encompasses insight and ability to self-regulate, in addition to impairments in the areas of vision,

cognition and physical requirements for driving, which are commonly associated with TBI.


21

1.2.1 Applying models of driving to TBI

One of the earliest reviews of driving after TBI was written by van Zomeren and

colleagues in 1987 (Van Zomeren et al., 1987). This review discussed seven earlier works which

had based their findings on the results of World War II veterans who had sustained a TBI. From

their review of these studies, the authors found that around half of the study participants were still

licensed and they did not appear to be at greater risk of crashes. However, visuospatial problems,

poor judgment and impulsivity were frequently reported issues. As such, they surmised that

neuropsychological assessments don’t assess all of the skills required for driving and are

therefore not predictive of fitness to drive. Their review also provided a discussion of the effect

of TBI impairments on each of the levels of Michon’s model. They recommended that

assessment and retraining procedures should be developed to address the cognitive skills required

at the strategic level and that further research into driving after TBI was required.

Since this time, both the volume and speed of traffic and complexity of the driving

environment have significantly increased. This reinforces the importance of using appropriate

assessment and retraining techniques to assess capacity to drive safely in a range of traffic

environments. Additionally, driving has become a routine and necessary aspect of the modern

lifestyle. A number of studies have reported an association between enhanced quality of life and

driving after TBI (Johnston et al., 2005; Novack et al., 2010). Returning to driving is therefore

often an important rehabilitation goal for drivers with TBI, which may require careful assessment

(Liddle et al., 2011; Rapport et al., 2006), due to the possible range of physical, cognitive or

behavioural impairments. Limitations in any of these areas may compromise driving capacity.

Driver licensing authorities, health care professionals and caregivers have recognized the

possible safety risk that drivers with a TBI may pose to themselves and the community. In one


22

US study, nearly half of the caregivers of an individual with TBI, reported great concerns about

that individual’s driving behaviour (due to fatigue, distractibility and slowness) (Kreutzer et al.,

2009). Licensing authorities have attempted to implement guidelines for resuming driving after

TBI (Austroads, 2012) and internationally, health care professionals have recognized the need for

consistent methods and guidelines for evaluating fitness to drive (Devos et al., 2012; Di Stefano

& Macdonald, 2010; Hopewell, 2002; Vrkljan, Myers, Crizzle, Blanchard, & Marshall, 2013).

To improve assessment methods and guidelines for driving after TBI, an understanding is

required of the potential effects on driving skills of the range of sensory, physical, cognitive, and

behavioural impairments that may be present after a TBI. Using Keskinen’s model, Lane and

Benoit (2011) provided a framework to describe the possible impact of TBI related impairments

on driving skills and functional techniques to compensate (Lane & Benoit, 2011). A similar

framework was provided by Van Zomeron et al 1987, using Michon’s model (Van Zomeren et

al., 1987).

The operational level (vehicle maneuvering) is concerned with car control and requires

the physical ability to steer the car and operate brake and accelerator pedals. After TBI this may

be impacted by residual motor or sensory impairment in upper or lower limbs. Assuming no

other impairments (e.g., cognitive) are present, deficits in these areas can generally be

compensated for by the use of adaptive equipment (Lane & Benoit, 2011). In the case of reduced

function in one upper limb, a steering or spinner knob can be fitted to the steering wheel, to

enable steering with one arm. If the right lower limb is significantly impaired, a left foot

accelerator can enable safe operation of accelerator and brake pedals, or hand controls can

compensate for loss of function in both lower limbs (VicRoads, 2008).


23

The second or tactical level (mastery of traffic), is concerned with safe decision-making

in traffic and cognitive impairments may affect driving capacity at this level. The ability to

maintain and/or divide attention, monitor and regulate speed in response to changes in traffic

conditions, maintain lane position and adequate space between vehicles and respond in a timely

manner, may all be impacted by deficits in visuo-spatial skills, planning and attention, including

speed of processing (Brouwer et al., 2002; Preece et al., 2012). It is more difficult to learn to

compensate for these deficits than a motor impairment and requires some degree of insight. Van

Zomeran et al (1987) recommended that training in defensive and anticipatory skills can be

useful compensatory interventions at the tactical level (Van Zomeren et al., 1987). Some of the

sophisticated driving technology that is now available, such as adaptive cruise control and lane

departure warning systems, may assist both drivers with and without cognitive impairment to

drive safely (Charron, Hoc, & Milleville-Pennel, 2010; Lane & Benoit, 2011; Stanton & Salmon,

2009).

The highest or strategic level is concerned with goals made in the context of driving such

as route-planning and avoidance of certain driving conditions. This level can also be affected by

cognitive or behavioural sequelea, resulting from executive dysfunction, as it relies on judgment

and planning, and is difficult to assess during a structured and directed on-road assessment. For

example, the ability to monitor level of fatigue and selectively choose not to drive or to self-

regulate by taking rest breaks may only be assessed over time and may be better addressed during

on-road training (Van Zomeren et al., 1987). As the three levels are interdependent, abilities may

be limited by impairments in any of the other levels (George et al., 2009).

Novack and Lopez (2015) provided a brief overview of driving after TBI and listed some

of the skills necessary for safe driving that may be affected by impairment following TBI. These


24

included the ability to maintain constant lane position, concentrate over long periods of time,

have accurate vision, adequate eye/hand coordination, reaction times, safety awareness, judgment

and memory function to recall directions, and the planning ability to work out solutions to

problems (Novack & Lopez, 2015). The Multifactorial Model for Driving, discussed earlier,

considers the visual, physical, cognitive skills for driving as well as the ability to self-regulate

and is able to accommodate all of these driving behaviours described above.


25

1.3 Driving after TBI

1.3.1 Incidence of driving after TBI

Determining the incidence of driving after TBI is difficult, as it will vary according to the

interval post-injury of follow- up (Tamietto et al., 2006). However several studies have estimated

that between 30 and 50% of TBI survivors return to driving (Brouwer & Withaar, 1997;

Coleman et al., 2002; Priddy, Johnson, & Lam, 1990; Rapport, Bryer, & Hanks, 2008; van

Zomeren, Brouwer, Rothengatter, & Snoek, 1988). There is limited information about the

incidence of return to driving following TBI in Australia, or for the number who completed a

formal OT driver assessment. However a follow-up study of a cohort of 141 individuals with

predominantly moderate to very severe TBI (mean PTA 35 days), who had access to driver

assessment and rehabilitation, revealed that 50% reported returning to driving without restrictions

at two years post-injury, with this increasing to approximately 70% at the five-year and 10 year

post-injury time-points (Ponsford et al., 2014). In the US, a survey of 423 patients with TBI seen

in a rehabilitation service, found that around two thirds of participants did not receive a formal

evaluation and 18.1% reported receiving no advice about driving (Fisk, Schneider, & Novack,

1998). This number was higher in the UK (Hawley, 2001). Of the 381 participants in Hawley’s

(2001) study, only 16% had received formal advice about driving. A contributing factor was the

limited access to driver assessment programs in the UK at that time (Brooks & Hawley, 2005).

A study examining barriers to driving and community integration after TBI, found that

over half of the individuals who returned to driving, had sought a formal driving evaluation,

whereas less than 6 % of the participants who had not returned to driving had sought a driving

evaluation (Rapport et al., 2006). Coleman et al. (2002) found that in the absence of professional

advice, the decision to drive was strongly influenced by the opinion of a significant other, with


26

regard to competence to return to driving (Coleman et al., 2002). The research shows that access

to a driver assessment program may influence return to driving (Rapport et al., 2006; Schultheis,

Matheis, Nead, & DeLuca, 2002) but the prevalence of resuming driving after receiving on-road

training, for those who fail an initial assessment, has not been well documented for the TBI

population.

1.3.2 Guidelines and timing for resuming driving after TBI

The term ‘fitness to drive’ refers to the ability to drive safely (Bryer, Rapport, & Hanks,

2006). The aim of determining fitness to drive has been defined as “achieving a balance between

minimising any driving-related road safety risks for the individual and the community, posed by

the driver’s permanent or long-term injury or illness, and maintaining the driver’s lifestyle and

employment-related mobility independence”, page 16 (Austroads, 2012).

Determining fitness to drive following TBI is a complex and much debated issue.

Publications discussing issues and procedures around returning to driving have come from the

US, (Devos et al., 2012; Dickerson, Davis, & Staplin, 2014; Galski, Bruno, & Ehle, 1992;

Hopewell, 2002) Spain, (Leon-Carrion et al., 2005), France (Debellieux.X, 2001), the UK

(Brooks & Hawley, 2005; Christie, 2001; Hawley, 2015) and Canada, (Marshall & Gilbert, 1999;

Vrkljan et al., 2013). Common themes in these studies included the lack of knowledge of doctors

and clinicians regarding laws and potential legal issues around return to driving, inconsistent

advice provided by health practitioners and the lack of a shared understanding of driving related

terminology between driver licensing authorities (DLAs) and clinicians. These studies have also

highlighted the complexities involved in determining fitness to drive and the need for better

guidelines.


27

A recent study examining the quality of national level guidelines on driving with medical

illness found that there was a lack of rigour in their development and that they were difficult to

apply due to the challenge in describing the functional impact of medical conditions on driving

(Rapoport et al., 2015). The study also reported that the guidelines were difficult to locate which

created a barrier for clinicians to access them. An additional issue is the variability between

countries in requirements for mandatory reporting of medical conditions. In a number of

countries, including Australia, it is the individual’s responsibility to notify the DLA of any

medical condition that could impact on driving performance (Austroads, 2012). As self-

awareness can be affected after a TBI, particularly with regard to driving ability (Coleman et al.,

2002; Gooden et al., 2016), it is not realistic to expect that all individuals who have sustained a

TBI, will be aware of possible cognitive or behavioural impediments to driving. Treating

clinicians therefore have a responsibility to advise the individual and their significant others

about their capability for driving (Austroads, 2012; Hopewell, 2002; Marshall & Gilbert, 1999).

Australian medical and allied health professionals can refer to the Austroads publication

‘Assessing Fitness to Drive - medical standards for licensing and clinical management’

guidelines, which provides recommendations for a range of medical conditions (Austroads,

2012). With regard to timing of return to driving, the guidelines for head /brain injury state (page

90): “A head injury will only affect driver licensing if it results in chronic impairment or seizures

….any person who has had a traumatic injury causing loss of consciousness should not drive for

a minimum of 24 hours. Minor head injuries involving a loss of consciousness of less than one

minute with no complications do not usually result in any long-term impairment” (Austroads,

2012). The guidelines do not provide specific advice about timing for resuming driving

following a more severe TBI, but do state that “Neurological recovery from a traumatic brain


28

injury may occur over a long period and some people who are initially unfit may recover

sufficiently over many months such that driving can eventually be resumed”. This statement has

been supported by the results of a study that found 42% of a sample with TBI (with less severe

injuries) had resumed driving within the first year and by the fifth year, 53% of the sample had

resumed driving (Novack et al., 2010).

The guidelines also provide a checklist of possible impairments associated with

neurological disorders and consideration of co-morbidities. These include possible physical,

visual and cognitive issues including lack of insight and behaviour changes and potential co-

morbidities such as musculoskeletal or psychiatric conditions; anxiety or post-traumatic stress

disorder (PTSD). They recommend further assessment if any of these are present and state that

“Clinical, neuropsychological or practical driver assessments may be helpful in determining

fitness to drive”.

In Australia, it is currently the primary responsibility of the doctor to determine medical

fitness to drive, and whether further assessment in the form of an OT driver assessment is

indicated. The DLA will inform the individual that they must be assessed by an OTDA, if it is

requested by the doctor. It can be challenging for doctors to use these guidelines to make a

decision about fitness to drive, as it may be difficult to define whether chronic impairment exists,

and no useful guidance is provided, regarding timing of return to driving after TBI. Whilst the

Australian guidelines provide general recommendations, there is a need for a more solid evidence

base regarding predictors of fitness to drive, as a basis for development of more reliable and

consistent guidelines and assessment methods following TBI (Devos et al., 2012; Ortoleva,

Brugger, Van der Linden, & Walder, 2012; Pietrapiana et al., 2005).


29

1.3.3 Outcome measures for driving

In order to examine which factors are associated with prediction of fitness to drive, the

outcome measures for successful return to driving need to be defined. Measures used in studies to

date have included driving status (driving vs not driving ), passing or failing off-road screening

and/or on-road tests, number of miles driven and driving safety measured by crash rates and

traffic infringements (Coleman et al., 2002; Ortoleva et al., 2012; Pietrapiana et al., 2005;

Tamietto et al., 2006). As return to driving in itself does not indicate quality of driving or reflect

any changes in driving behaviour, it is important when investigating driving outcomes, to ensure

that safety record and driving frequency are also measured (Coleman et al., 2002; Schultheis et

al., 2002). Most of the research has related to predicting the outcome of the on-road assessment.

A major flaw in using on-road assessment outcome as the measure of driver safety is the lack of

standardization and consistency between assessments, due to variability in pass/fail criteria,

design of assessment routes, traffic conditions and experience of the assessor (Fox, Bowden, &

Smith, 1998) (see section 1.4). Despite these issues, on-road assessment continues to be the

‘Gold Standard’ and most commonly accepted method for assessing driver performance. It has

therefore been the main outcome measure used in studies examining predictors for fitness to

drive (Fox et al., 1998; Tamietto et al., 2006).


30

1.4 On-road Driver Assessment

A test of driving capacity must be able to reliably assess key driving competencies and

behaviours. In the context of driver rehabilitation, an evaluation should be sufficiently complex to

assess the impact of individual impairments/capacities on specific driving related skills (Di

Stefano, 2006). Closed course assessments such as in a parking lot, have been found to be useful

for determining fitness and readiness to undertake an on-road evaluation in terms of ability to

operate a vehicle, but are not sufficiently complex to test the skills required for open road driving

(Fox et al., 1998). Similarly, a driving test designed for learner drivers is not designed to assess

whether an impairment has affected driving capacity and is therefore not a valid method of

assessing medically impaired drivers (Di Stefano, 2006).

Di Stefano and McDonald (2012) have classified the two main competencies for driving as

vehicle control competencies and perceptual-cognitive competencies (Di Stefano & MacDonald,

2012). Driving tests must therefore assess whether the individual has the motor control to steer

accurately and operate foot pedals in a timely manner, at the operational level of driving, in order

to complete the range of driving behaviours that are required for safe driving. The tactical level

of driving which includes the ability to change and maintain lanes safely, perceive and respond to

potential hazards and monitor and adjust speed are all important aspects of driver performance

and are relatively easy to assess during an on-road assessment. The perceptual and cognitive

skills required for safe, consistent driving, are more difficult to assess and rely on the assessor’s

knowledge of how impairment may affect driver performance (Di Stefano, 2006). The off-road

component of the driver assessment can screen for potential cognitive and perceptual impairment

and in combination with the on-road assessment can contribute to the fitness to drive

determination.


31

This combination of clinical off-road and on-road assessment is known as a comprehensive

driver evaluation (CDE) in the US and as an OT driver assessment in Australia. OT driver

assessment will be the term used throughout this thesis. Such assessments have been regarded as

the ‘gold standard’ for driver evaluation as both the tactical and operational aspects of real world

driving are assessed (Classen et al., 2009; Fox et al., 1998).

In the USA and Canada, these assessments are conducted by driver rehabilitation specialists

(DRS) or Certified Driver Rehabilitation Specialists (CDRS) who have completed an additional

exam and are drawn from a range of disciplines, including OTs and driving instructors

(Dickerson, 2013). In Australia, these assessments are conducted by OTs who have received

specialised training and are called occupational therapy driver assessors (OTDAs) (Di Stefano &

MacDonald, 2012).

A survey to determine the off- and on-road practices of clinicians in the US and Canada

found that OTs were the main discipline involved in these assessments, but there was variation in

the assessment practices used. For example, 94% of clinicians reported that they conducted an

on-road assessment. When asked whether all clients completed an on-road assessment

irrespective of the off-road results, 61% reported yes and 37% said no and 2% responded

sometimes (Korner-Bitensky, Bitensky, Sofer, Man-Son-Hing, & Gelinas, 2006).

The main criticisms which may apply to on-road assessments used for rehabilitation or

research purposes, include the lack of standardization regarding the duration and pass/fail criteria

of the assessment, the complexity and variability of traffic conditions included and the variation

in the manouvres required (Pietrapiana et al., 2005). In a survey of Australian OTDAs, most

routinely used a documented, standard assessment route (Di Stefano & MacDonald, 2012)

designed to comply with Victorian Competency Standards (OT-Australia, 1998). The


32

competency standards were designed to ensure a high level of consistency in assessment routes

used by OTDAs. When assessing for an unrestricted license (see section 1.6.3), the assessment

route should include a range of traffic conditions (e.g., different types of intersections,

single/multi-laned roads), driving manouvres (e.g., parking, lane changing, locating a street sign)

and environmental inclusions (e.g., low/high density traffic, high speed driving, in car and

external distractions) (OT-Australia, 1998).

The criteria for passing an on-road assessment vary and can be subjective and dependent on

the experience of the assessor. Pass/fail criteria may be based on number of driver errors,

evidence of critical incidents where safety was compromised and/or achievement of a pre-

specified score (Di Stefano & Macdonald, 2003). A number of scoring methods have been

developed for behind-the-wheel assessments (Justiss, Mann, Stav, & Velozo, 2006). To address

this variability in methods, guidelines for scoring the on-road assessment have been outlined (Di

Stefano, 2006). These included a procedure where specified behaviours are observed and

recorded during the on-road assessment, either as appropriate/inappropriate or rated on a scale

according quality. The Test Ride for Investigation of Practical fitness to drive (TRIP) has been

developed to provide a method of scoring the on-road assessment using these guidelines. The

TRIP has also been commonly used in research studies to provide a consistent method of on-road

scoring (De Raedt & Ponjaert-Kristoffersen, 2001; Devos et al., 2007; Withaar, Brouwer, & Van

Zomeren, 2000). More recently another on-road scoring method has been developed, called the

Driver Observation Schedule (DOS) (Vlahodimitrakou et al., 2013), however it was developed

for research with healthy older drivers and may not be valid for use with a medically impaired

population. It can also be difficult to establish a pass/fail outcome with one on-road assessment.

For example the driving performance of an individual with TBI may fluctuate during the day,


33

according to the degree of fatigue. It is also difficult to evaluate the many strategic aspects of

driving, such as route planning or deciding to take a rest when fatigued, based on driver

performance during one on-road assessment (Korteling & Kaptein, 1996).

Despite these criticisms, the authors of a review of the literature of driving assessment and

TBI, surmised that the outcomes of OT driver assessments are potentially predictive of real-world

driving, although the need for more longitudinal studies was identified (Classen et al., 2009).

On-road assessment has been found to be a significant predictor of return to driving (Rapport et

al., 2006; Schultheis et al., 2002; Shechtman, Classen, Awadzi, & Mann, 2010) but there is a

lack of research about whether such assessments predict post-assessment driver safety (Coleman

et al., 2002; Pietrapiana et al., 2005; Tamietto et al., 2006) or who will benefit from driver

rehabilitation for those who fail the initial on-road assessment.

1.5 Predictors of On-road Assessment Outcome

A review of the literature has revealed a number of variables have been investigated as

predictors for return to driving. These have included medical and injury-related information such

as injury severity and impairment scales, pre-injury factors such as driving style, driving

experience and personality, and post-injury factors such as results from neuropsychological and

simulator tests, injury-related self-awareness, years post-injury and the opinions of significant

others (Ortoleva et al., 2012; Pietrapiana et al., 2005). The research regarding each of these

variables has produced mixed results, possibly influenced by the wide range of methodological

differences (Ortoleva et al., 2012; Tamietto et al., 2006). For example, many studies examining

predictors for driving after TBI, have used neurological samples which have included other

diagnoses such as stroke and multiple sclerosis. It is therefore difficult to generalize results about

driving performance from these studies to the TBI population. Injury severity of the sample and


34

time post-injury have frequently not been reported and different outcomes measures have been

used to determine fitness to drive, making comparisons between studies difficult (Tamietto et al.,

2006). Evidence for each of the predictors will be examined separately.

1.5.1 Medical predictors

Injury severity has been investigated as a predictor for resuming driving after TBI however it

is difficult to compare studies due to the different severity measures that have been used. For

example, in Australia, both GCS score and PTA duration are commonly documented, whereas in

the US, duration of coma and GCS score have historically been the most widely used measures of

injury severity. Most studies have investigated GCS score and coma duration as predictors for

return to driving, however the results have been inconsistent. A number of studies have found no

correlation between GCS score and return to driving (Fisk et al., 1998; Hawley, 2001; Priddy et

al., 1990; Rapport et al., 2006). One study found that coma duration was a good predictor for

return to driving but not for predicting driving safety (Pietrapiana et al., 2005). In contrast

patients with coma duration over 48 hours were more likely to be involved in a traffic accident

(Formisano et al., 2005). Another study found no relationship between driving outcome and

coma duration (Priddy et al., 1990). The range of findings in these studies may reflect the

different methodologies and outcome measures used and as a result, it is difficult to draw any

conclusions.

Brouwer, Withaar, Tant and van Zomeren (2002) cited a number of early studies that used

PTA as a measure for injury severity. In particular, a study that compared the average PTA

duration (5.3 weeks) in a relicensed group with a non- relicensed group (13.6 weeks), found an

association between a lower PTA duration and return to driving (Brouwer et al., 2002). Based on

these earlier works, PTA duration was identified as a possible predictor for resuming driving


35

(Van Zomeren et al., 1987). More recently, in a study of driving after TBI, PTA duration has

been recorded as the preferred measure of injury severity (Labbe, Vance, Wadley, & Novack,

2013), however no studies were identified that examined the association between PTA duration

and successful return to driving following driver assessment and rehabilitation.

1.5.2 Injury-related predictors

With regard to measures of injury-related impairment or disability, a number of studies have

found a correlation between high discharge FIM-FAM scores and return to driving (Cullen,

Krakowski, & Taggart, 2014; Fisk et al., 1998; Hawley, 2001; Pietrapiana et al., 2005). Some

studies have investigated whether site of injury, as measured by Computed Topography (CT)

results, influenced return to driving, however the results are inconclusive. Brooks and Hawley

(2005) classified groups according to the presence of right, left, bilateral and no haematomas

from the results of CT scans of 229 previous drivers and found no significant differences between

the groups in terms of problems with driving, behaviour and anger management (Brooks &

Hawley, 2005). Another study cited a small number of case studies and described the effect of

the patients’ lesions on driving capacity (Brouwer et al., 2002) but these results may not

generalise to the wider TBI population.

Most studies have not recorded the influence of injury-related physical or visual

impairment on driving after TBI. They have been identified as important areas to consider in

research investigating driving following TBI, as adequate visual and physical capacity are

required for safe driving (Brouwer et al., 2002; Hopewell, 2002). Similarly, co-morbid medical

conditions which are unrelated to TBI, such as the effects of medication, substance abuse, or a

psychiatric history can also affect driving performance and should be considered as risk factors

when assessing medical fitness to drive (Austroads, 2012; Hopewell, 2002). Furthermore,


36

participants involved in research that examines fitness to drive after TBI, should be screened for

and excluded, if co-morbid conditions are present that contraindicate driving (Sommer et al.,

2010).

1.5.3 Pre-injury predictors

Few studies have examined pre-injury driving experience as a predictor for driving after TBI.

Given the over-representation of younger, inexperienced drivers in the crash statistics, it would

be expected that pre-injury driving experience may be a predictor for resuming driving after TBI.

One study observed that for experienced drivers, the skill of driving is related to procedural

memory so that following a severe TBI, an inexperienced driver would be more likely to have

difficulty, as driving is not a well learned skill (Brouwer & Withaar, 1997). A significant

correlation has been found between driving experience, traffic perception and insight judgments

(Van Zomeren et al., 1987). Furthermore, when driving experience, coma duration and

performance on the Perceptual Speed task and the Time Estimation task were combined, an

association was found with on-road assessment outcome (Korteling & Kaptein, 1996). These

results suggest that pre-injury driving experience should be taken into account in research

investigating driving after TBI.

The influence of pre-injury driving behaviour and personality on post-injury safety has not

been conclusively demonstrated. Years post-injury and pre-injury driving behaviour, measured

by self-report and opinions of significant others, regarding number of crashes and traffic

violations, were found to be the strongest predictors of post-injury driving safety in a sample of

drivers with TBI (n=35) (Pietrapiana et al., 2005). In contrast, another study, also examining

post-TBI drivers, did not find a relationship between pre-injury driving habits and DLA recorded

post-injury crash rates (Coleman et al., 2002). DLA driving records may not be an accurate


37

measure of post-injury crashes, as they only reflect crashes that have been reported and not minor

unreported crashes (Schultheis et al., 2002). Both pre-injury personality traits and cognitive

ability were found to be important predictors of driver performance after TBI, measured by on-

road evaluation (Sommer et al., 2010), however no conclusion can be drawn about post-

assessment safety in the longer term as post-assessment crash involvement was not examined.

1.5.4 Post-injury predictors

Two post-injury factors have been examined as predictors for return to driving. Firstly, the

opinion of significant others, particularly in the absence of more formal advice, has been found to

be a predictor of resuming driving after TBI (Coleman et al., 2002; Rapport et al., 2006).

Secondly, the number of years post-injury has also been found to significantly predict resumption

of driving after TBI (Novack et al., 2010; Sommer et al., 2010). Novack et al (2010) investigated

return to driving at one and five years post-injury and found that the odds of returning to driving

increased over time, with 42% of participants driving after the first year, and 53 % in the fifth

year post-injury. Not surprisingly, the authors found that people with less severe injuries returned

to driving earlier, but injury severity was not a factor at 5 years post-injury. Factors that weren’t

injury-related also contributed to the timing of return to driving, such as age, access to a car,

employment status and financial constraints (Novack et al., 2010).

1.5.5 Off-road assessments

Many studies have attempted to identify off-road methods for predicting fitness to drive,

due to the perception that on-road assessment is more time consuming, potentially dangerous,

costly and difficult to organize. These methods have included specific driving related off-road

tests, neuropsychological tests and driving simulators (described in the sections below). There are


38

a wide range of assessments available, with varying relevance and validity for prediction of

driving capacity. For example, a review of tests of executive function that have been used in

driving research, identified 53 assessments. Of these, 27 were tests of cognition, 19 were specific

driving-related assessments and 7 were activities of daily living assessments and not surprisingly,

none measured all aspects of executive function (Asimakopulos et al., 2012).

1.5.5.1 Off-road screening assessments

The purpose of screening assessments is to provide a quick method of differentiating drivers

without impairment from those with impairment, who may require more detailed assessment

(Bedard & Dickerson, 2014). In contrast to a screening assessment the evaluation assessments

are used to obtain data which may then comprise part of the formal assessment process regarding

the capacity of the driver to resume driving. In Australia these tests are referred to as ‘off-road’

assessment as they are conducted in a clinical environment. They comprise a range of clinical

assessments and are used in combination with on-road assessment to provide a comprehensive

driver evaluation (CDE). Twelve consensus statements regarding screening and assessment tools

used to determine fitness to drive in the occupational therapy context have been developed

(Bedard & Dickerson, 2014) and are reproduced in Table 1.

Table 1 Consensus Statements for Screening and Assessment Tools

Statement 1: A decision about continued, restricted, or cessation of driving should never be made

on the results of one tool in isolation, as there is not enough evidence provided by any one tool to

make a decision.

Statement 2: Measurement tools must be administered according to the protocol under which

they were tested in order to use the norms and/or evidence.

Statement 3: Measurement tools that are developed specifically for a diagnostic group should be

interpreted carefully when used with other diagnostic groups unless there is sufficient evidence


39

supporting the use of the tool with another group.

Statement 4: Results from measurement tools that are developed based upon specific outcomes

(e.g., crashes) should be interpreted carefully when used to predict another outcome (e.g., driving

performance).

Statement 5: The ethical application of research knowledge depends on the critical appraisal of

the research, its replication, and adequate synthesis.

Statement 6: Some screening tools appear to hold more promise than others. Therapists should

use evidence-based tools in making decisions.

Statement 7: Occupational Therapists need to apply a framework to identify the criteria required

to select the tools best suited to their needs and practices.

Statement 8: In the hands of a general practice occupational therapist, results from

screening/assessment tools serve as criteria for referral and action. In the hands of the driver

rehabilitation specialist, the same tools can contribute to a decision for fitness-to-drive.

Statement 9: Processes should be followed for occupational therapy generalists to start the

driving discussions with sufficient clinically related evidence.

Statement 10: If the client is determined to be unfit to drive, the occupational therapist should

provide intervention or an appropriate referral for intervention and planning to address

transportation options and community mobility.

Statement 11: Occupational therapy generalists should consider the multi-factorial nature of

someone’s condition and potential for improvement.

Statement 12: If the client is determined to be fit to drive the occupational therapist needs to

address future community mobility issues including enhancing safe driving as well as

transitioning to non-driver status over time.

The first statement proposes that fitness to drive decisions should not be made on the results

from one tool alone. In a US based review of clinical assessments used by driver rehabilitation

specialists (DRS), 114 specific tools were identified (Dickerson, 2013). Despite the large number

of tools used, 80% of DRS reported assessing visual acuity and physical function. The most

commonly used cognitive assessments included the Trail Making Test and Motor-Free Visual


40

Perception Test-Revised (Dickerson, 2013). Three of the consensus statements relate to the

methods for administering these tools and other statements included recommendations about who

should administer the tools and the importance of using evidence-based tools.

In contrast, Australian occupational therapy driver assessors (OTDAs) use two main off-road

evaluations to assess patients prior to on-road testing. The OT-DORA (Occupational Therapy -

Driver Off-road assessment) is a standardized battery of tests, designed to provide a

comprehensive assessment of competencies required for driving including, vision, physical and

cognitive capacity (Unsworth et al., 2012). It is not intended to replace on-road testing and relies

on the clinical reasoning of the OTDA to decide whether on-road testing is appropriate.

The second assessment is the Drive Safe/ Drive Aware assessment. It is an off-road computer

based test, designed to assess awareness of the driving environment and of an individual’s

abilities to respond in a timely manner to the environment. Based on performance score, clients

are categorized according to whether they are likely to pass or fail an on-road assessment, or

require further testing (Kay, Bundy, & Clemson, 2009). The test was developed for an older

population and may not be valid for determining who should proceed to on-road assessment in a

predominantly younger TBI population

There are a variety of other specific driving-task off-road pencil and paper tests that have

been developed, such as the Driver Behaviour Questionnaire (Reason, Manstead, Stradling,

Baxter, & Campbell, 1990). However, one of the main criticisms of these types of assessments is

that they do not assess the functional competencies for driving, such as physical and visual

capacity and have been found to be poor predictors of on-road driving ability (Hopewell, 2002).

As driving is an activity that requires a complex range of tasks and behaviours, these assessments


41

are therefore most useful to screen for impairment, prior to on-road assessment and should not be

used alone to assess driver capacity.

1.5.5.2 Neuropsychological tests

Many studies have investigated the potential of neuropsychological tests to predict

driving performance after TBI, but have found that they do not reliably predict on-road driving

assessment outcomes (Korner-Bitensky et al., 2006; Lundqvist & Alinder, 2007; McKay, Liew,

Schönberger, Ross, & Ponsford, 2015; Pietrapiana et al., 2005; Schanke & Sundet, 2000; van

Zomeren et al., 1988). In a review of the literature examining the association between

neuropsychological tests and prediction of driving after TBI, only two class II studies (level of

evidence was rated from Class1-highest to class IV – lowest ) were found (Classen et al., 2009).

Neither study provided injury severity of the sample and although one study found that

performance on the Perceptual Speed test and the Time Estimation task were significantly

correlated with driving performance, it was concluded that these tests could not replace the on-

road driving assessment (Korteling & Kaptein, 1996). Tests of speed of processing, divided

attention, working memory, perception, motor skills and reaction times have shown promise as

predictors of driving assessment outcomes (Tamietto et al., 2006). However, the authors of this

review concluded that comparison of the study results was not possible, due to the

inconsistencies in the outcome measures used, variable study samples and differing study

designs. The Useful Field of View (UFOV®) is a measure of visual information processing and

attention (Ball & Owsley, 1993). Two studies have found that it is helpful in assessing readiness

to return to driving, but not for assessing real world driving performance (Fisk, Novack,

Mennemeier, & Roenker, 2002; Novack et al., 2006). It is frequently used by driver rehabilitation

specialists during off-road screening rather than by neuropsychologists as part of their battery of


42

cognitive assessments. The Attention Network Test, which measures the three distinct functions

of attention (alerting, orienting, and executive function) was found to be similar to the UFOV in

its’ ability to predict road scores on a simulated drive (Weaver, Bedard, McAuliffe, & Parkkari,

2009).

The Cognitive Behavioural Driver’s Inventory (CBDI) is used to assess the cognitive and

behavioural skills required for safe driving (Engum, Cron, Hulse, Pendergrass, & et al., 1988).

Although the scores on the CBDI were worse in a group who failed the on-road test, the results

obtained on this test were not able to reliably predict performance outcome of an on-road

evaluation and therefore could not replace the behind the wheel assessment (Bouillon, Mazer, &

Gelinas, 2006).

More recently, a study by Alaskan and colleagues (2013) has found that when combined,

cut-off scores on 3 tests – simple reaction time (395ms) measured by the California

Computerised Assessment Package (CalCap) (Miller, 2002), 45 seconds on Trail-Making A

(visuo-motor tracking) and 97.5 seconds on a fine motor task using a Grooved Pegboard with

dominant hand, correctly predicted passing an on-road test in 82.1% of cases (Aslaksen, Ørbo,

Elvestad, Schäfer, & Anke, 2013). Concerns have been raised about self-selection bias in the

sample, and with this approach, one in five patients would be screened as unfit to drive and not

have the opportunity to have their driving assessed (Devos & Hawley, 2013). Another recent

study found that neuropsychological tests were not reliable predictors of on-road performance

and that injury related factors such as injury severity were stronger predictors of on-road

assessment outcome (McKay et al., 2015). In addition, driver self-confidence and pre-injury

driving style/ skills, may influence post-injury driver performance and these cannot be measured


43

by neuropsychological tests (Allegri N, 2001) and nor can driver experience (Withaar et al.,

2000).

In summary, most studies acknowledge that neuropsychological tests can make a

contribution to the decision-making process of determining fitness to drive, particularly tests of

working memory, divided attention, reaction time, planning and speed of processing. They can be

used to screen for these issues but on-road assessment is required to determine their effect on

driver capacity and the effect of other factors such as the influence of previous driving experience

on driver performance. A number of studies have concluded that on-road assessment remains the

preferred method for assessing driver performance, whilst neuropsychological test results may

have a role in providing guidance about which TBI drivers may benefit from driver retraining

(Brouwer et al., 2002; Lundqvist, 2001; Schanke & Sundet, 2000) .

1.5.5.3 Driving simulator assessments

Driving simulation refers to the use of technology to replicate both the behaviours and

physical requirements of driving a vehicle. Driving simulators may range from simple, low cost

desk-top models with a single screen to mid-level fixed based simulators usually with three to

five screens, to high cost simulators on motion platforms with 360 degree field of view, housed in

a full car body (Lemieux, Stinchcombe, Gagnon, & Bédard, 2014). The degree of realism or

validity of the simulator varies between types of driving simulators and the scenarios used

(Mullen, Charlton, Devlin, & Bedard, 2011). Driving simulators have been used extensively in

road safety research, but more recently, there is a great deal of interest amongst doctors and

clinicians in using driving simulators to assist in determining fitness to drive (Crisler et al., 2012).

They provide a safe and controlled environment where driving errors do not pose a risk to safety.


44

The protocols for using a simulator to assess driving ability of individuals with impairments have

not been adequately established. However, an assessment tool called P-Drive, that uses 20 items

to assess the quality of driving, has been found to be a valid tool for assessing driver ability after

stroke on a driving simulator and may eventually be validated for use in other populations

(Patomella, 2008).

Despite the lack of protocols for their use as an assessment tool of driving ability, driving

simulators can contribute to the screening process prior to on-road assessment. They provide a

suitable method for observing physical ability to control a vehicle or use adaptive equipment and

to determine responses to potential hazards. In addition, they have been found to assist in

retraining of driving skills and behaviours (Stern & Schold Davis, 2006). This will be discussed

in the section on driver rehabilitation interventions (section 1.6.2) below. In a review of driving

assessment tools conducted in the US, very few DRS used driving simulators as part of the driver

assessment process. This was attributed to cost, the lack of protocols and evidence for their use in

assessment of driving capacity and the risk of simulator sickness (Dickerson, 2013).

Simulator sickness has been reported as one of the main limitations in using driving

simulators. It has been described as physical discomfort that may include nausea, headaches,

sweating, visual and vestibular symptoms, sometimes resulting in vomiting (Brooks et al., 2010;

Milleville-Pennel & Charron, 2015; Schultheis, Rebimbas, Mourant, & Millis, 2007). It is

thought to occur due to the mismatch between the anticipated and actual sensations associated

with driving. A review of the driving simulator literature found that a proportion of the

participants in most driving simulator studies experienced simulator sickness (Classen,

Bewernitz, & Shechtman, 2011). Estimates of the incidence of simulator sickness varied

between 12% and 52% (Milleville-Pennel & Charron, 2015) and a review of the literature


45

concluded that it was more common in older drivers over 70 probably more common in women

than men (Classen et al., 2011). Protocols have been recommended to minimise the likelihood of

clients experiencing simulator sickness. These have included using shorter (5 to 10 minutes)

familiarization drives on straight roads initially and gradually lengthening the exposure and

driving demands on subsequent drives (Stern & Schold Davis, 2006). The use of the Simulator

Sickness Questionnaire has also been recommended to monitor development of simulator

sickness while using the simulator (Kennedy, Lane, Berbaum, & Lilienthal, 1993).

Researchers have explored the application of driving simulators with a variety of

diagnoses. These have included stroke, multiple sclerosis, Parkinson’s disease, cerebral palsy,

autism spectrum disorder, epilepsy, hemianopia, post-traumatic stress disorder and dementia

(Classen & Brooks, 2014). Only a few studies have examined their use in driver assessment in a

TBI population: One study found that the driving simulator performance of a group of 11

patients with TBI was worse than that of a healthy control group (n = 16), particularly in the

areas of speed regulation, steering control and following traffic rules (Lew et al., 2005). The

study also concluded that further research in this area was required. Another study found that a

group with TBI crashed significantly more than a control group on a divided attention task using

a simulator, but concluded that the findings may not be generalized to real-world driving (Cyr et

al., 2009). A study that used a small clinical sample, found that simulators have the potential to

facilitate assessment of driving capacity (Bédard, Parkkari, Weaver, Riendeau, & Dahlquist,

2010), however there is a lack of evidence that they provide a valid assessment of driving

capacity. Currently, there is a lack of evidence to support the use of driving simulators to predict

real-world driving in a TBI population.


46

In their 2014 review of the use of driving simulators in occupational therapy for

screening, assessment and intervention, Classen and Brooks (2014), outlined five statements to

guide simulator use, provided by an expert panel after a thorough review of the literature. These

are summarized as; 1) Driving simulators should not be the only method used when assessing

driving capacity in older drivers; 2) OTs using simulators require the knowledge to minimize

simulator sickness; 3) Simulators can also be used to provide training interventions and practice

of skills as part of driver rehabilitation; 4) Simulators may contribute to a comprehensive driver

assessment; 5) OTs using simulators should have appropriate training and knowledge and they

may then use simulators to assess for physical, cognitive or visual impairment that may impact on

driving skills (Classen & Brooks, 2014).

In summary, off- road and driving simulator assessments have been found to be useful for

determining potential driving-related impairments and readiness to complete an on-road

assessment, but have generally not been shown to be predictive of driver safety. They therefore

do not replace the on-road assessment of driving. A study undertaken 33 years ago found that off-

road testing should complement rather than replace on-road testing (Jones, et al, 1983) and this

still applies today.

1.6 Factors Influencing On-road Assessment Outcome

The outcome of the OT driver assessment may include; a pass and to resume driving, or a

‘fail’ with recommendations for on-road training, not yet ready for driver training or

disqualification from driving (Schultheis, DeLuca, & Chute, 2009). A number of behaviours

exhibited by drivers post-TBI have been identified as reasons for failing an on-road driver

assessment. These have included anxiety, confusion, impulsivity, slowness, distractibility


47

inattention and following directions (Galski et al., 1992). Being assessed too early in recovery

(Brooks & Hawley, 2005; Hopewell, 2002), lack of recent driver experience or reduced

confidence have also been identified as reasons for failing an on-road assessment (Di Stefano &

McDonald, 2006). Any of these factors may result in driver errors or poor quality of driving. To

remediate errors and plan further driver rehabilitation, it is important for OTDAs to have

knowledge of goals of on-road training. From a review of the literature, no studies were identified

that examined the goals of on-road training in a TBI population for those individuals who failed

the initial on-road assessment.

1.6.1 Timing of On-Road Assessment

The outcome of the initial driver assessment may be influenced by the timing of the

assessment, if it is completed too early after injury. A description of the course of recovery

following TBI has been provided above in section 1.1.5. The timing of resuming driving after

mild TBI (Baker, Unsworth, & Lannin, 2015), and in a moderate to severe TBI sample (Novack

et al., 2010) has been described, but there is a lack of information about what factors need to be

considered in determining readiness to return to driving after TBI.

In the case of mild TBI, the Australian medical guidelines for fitness to drive (Austroads,

2012), a Canadian study (Marshall, Bayley, McCullagh, Velikonja, & Berrigan, 2012) and two

Australian studies (Baker et al., 2015; Preece, 2010) all recommended that driving should be

avoided in the first 24 hours post-injury. However no guidance is provided about when to resume

driving after this period following a mild, moderate or severe TBI. Despite this guideline, one of

the Australian studies found that only 26 drivers from a sample of 60 drivers with mild TBI had

resumed driving at 2 weeks post injury (Baker et al., 2015). Reasons provided for not driving

included headaches, pain, dizziness and ‘not feeling right’.


48

The guidelines from other countries vary with regard to specific advice about timing for

resuming driving following TBI. For example, the medical fitness to drive guidelines from the

New Zealand Transport Agency differentiate between mild TBI (no driving for 3 hours or 24

hours if LOC has occurred ) and severe TBI and those with post-concussion syndrome (no

driving for a minimum of 6 months) (NZTA, 2009). The Driver and Vehicle Licensing Agency

guidelines (UK) state that ‘Relicensing may be considered usually after 6 to 12 months dependent

on features such as seizures, post-traumatic amnesia, dural tear, haematoma and contusions’

(DVLA, 2013 ). Although post traumatic amnesia duration is mentioned, there is no guidance as

to how this may affect the timing for resuming driving. In contrast, US guidelines provide no

recommendations with regard to timing for return to driving following TBI (NHTSA, 2009). The

question of accuracy is raised by the discrepancies between the guidelines from each country and

highlights the need for more specific guidelines about when to resume driving after TBI.

Jones et al (1983) found that a number of participants who had completed the driver

assessment program and failed, had done so too early in their recovery. However timing was not

discussed and the study sample included a range of aetiologies other than TBI (Jones et al.,

1983). The Austroads guidelines recommend that driving should be avoided for a minimum of

one month after a stroke or three months after a subarachnoid haemorrhage (Austroads, 2012). It

is understood that these guidelines are based on the possible cognitive changes that occur due to

significant brain trauma and the time frame allows for some recovery to take place. A similar

guideline for a time frame for driving assessment after TBI has not been provided, possibly

reflecting the wide variability in severity and the lack of evidence-based research on which to

draw.


49

A relationship has been found between TBI injury severity and time of return to driving

(Novack et al., 2010). Those with a less severe injury resumed driving earlier. In addition, it has

been found that drivers who had sustained a mild TBI generally returned to driving without any

issues (Brouwer & Withaar, 1997). This study specified that the study sample comprised very

severe TBI but did not provide the number of or participant details for the mild TBI participants.

Whilst many impairments following TBI were found to improve during the first 6-12 months

after TBI, the longitudinal research has found that many changes persist in the longer term

(Ponsford et al., 2014). The relationship between timing of return to driving, injury severity and

longer term post-assessment safety has not been examined. There is also a lack of research

examining what factors affect timing of return to driving after TBI, such as co-morbidities and

how to determine the optimal timing for resuming driving.

1.6.2 Driver Rehabilitation

The availability of driver rehabilitation may also influence on-road assessment outcome.

The option to improve driving skills after failing an initial on-road assessment followed by a

subsequent reassessment is an alternative outcome to failure and license cancellation. Driver

rehabilitation aims to provide training to improve driving skills, change behaviour and develop

compensatory strategies to assist the driver cope with impairments. The two main goals of driver

rehabilitation have been categorised as remediation, where training is provided to change

behaviour to improve driving skills and compensation, where strategies are provided to assist the

driver to cope with impairment (Di Stefano, 2006). Both goals aim to help drivers with an

impairment self-manage on-road driving behaviour to reduce risk and optimise safety in the

longer term (MacDonald et al., 2006). Driver rehabilitation refers to re-training of an experienced

driver rather than training provided to a learner driver. It is provided after areas of impairment


50

have been identified during the on-road driver assessment, so that the goals of driver

rehabilitation can then be established.

A number of studies have reported that driver retraining is required for those with

physical impairment, needing to learn to use adaptive equipment (Benoit, 2008; Jones et al.,

1983; Korteling & Kaptein, 1996). Other goals of driver rehabilitation have been identified as re-

building confidence, improving knowledge of road law and safe driving procedures and learning

to compensate for cognitive impairments (Di Stefano, 2006; Jones et al., 1983).

Insight and the subsequent ability to compensate for impairment were found to be key

factors in safe driving after TBI (Coleman et al., 2002; Griffen et al., 2011; Lundqvist & Alinder,

2007; Lundqvist, Alinder, & Rönnberg, 2008). A study by Reason (1990) found that in a healthy

population (of drivers recruited randomly on the street or in supermarket car parks), the drivers

who reported the most driving violations (categorized as slips or lapses, mistakes or unintentional

or deliberate violations), also tended to rate themselves as good drivers (Reason et al., 1990).

This finding of overestimating driving ability is consistently reported for ‘normal’ drivers without

medical impairment, and generally does not present any issues. However studies have found that

individuals with a severe TBI tended to over-estimate their driving abilities compared to those

with a less severe TBI (Griffen et al., 2011; Rapport et al., 2008) and those drivers with TBI with

reduced self-awareness of driving abilities were more likely to have failed an on-road assessment

( Gooden et al., 2016). It could be argued that the drivers who failed the on-road assessment in

this sample, had not had the opportunity to drive prior to being assessed. Therefore, they had not

had the opportunity to experience how injury-related deficits may affect driving performance and

would not have developed insight. Driver rehabilitation that offers real-world in car driving, may

provide an opportunity for drivers with TBI, who present with impairment impacting on driving


51

performance, to learn from mistakes and incidents (Brenner, Homaifar, & Schultheis, 2008; Katz

et al., 1990) and gain insight. No studies were identified that examined change in awareness of

driving performance, from pre-assessment to post-on-road training.

Another potential benefit of driver rehabilitation is to provide an opportunity to develop

the ability to self-regulate. This includes a variety of driving behaviours such as pre-planning

routes and rest periods and avoiding certain driving conditions (Gwyther & Holland, 2012).

According to Michon’s model, navigation and route planning would be considered strategic

aspects of driving and may be affected by TBI (Lemoncello et al., 2010). From the results of a

study where half of the sample were considered safe drivers after retraining, Brouwer and

Withaar (1997) recommended that all severely injured TBI patients (PTA over one month) should

be offered a driver training program to focus on improving skills at both the operational and

tactical levels. It was also recommended that the training of compensatory behaviours at the

strategic level, such as avoiding driving in unfamiliar areas, night- time driving and avoiding

peak hour, should also be provided (Brouwer & Withaar, 1997). This is one of the few studies to

have reported the incidence of resuming driving after providing driver retraining in a TBI

population.

There has also been little attention given to the effectiveness of driver

rehabilitation/retraining following TBI or the outcomes of comprehensive OT driver assessment

and training programs (Brouwer & Withaar, 1997; Classen et al., 2009; Devos et al., 2012). A

very early study that reported the results of a driver assessment and training program included a

mixed sample of TBI and stroke patients, and included both learner and experienced drivers

(Jones et al., 1983). The program included off- and on-road assessment, followed by a mean of

5.5 driving lessons of 60 to 90 minute duration (range 1- 30), but did not examine driver safety


52

(crash involvement) after the intervention, in the longer term. Of the 38 patients who failed the

initial assessment and then received driver retraining, 23 were able to resume driving. It is

difficult to generalize these results to a TBI population due to the mixed sample and the inclusion

of learner drivers. However a more recent study of drivers with a TBI, who had successfully

passed a driver assessment and training program, returned to driving with few issues and did not

appear to be at greater risk of crash involvement (Schultheis et al., 2002).

Driver rehabilitation may therefore be an important intervention for resuming driving

after TBI, however very few studies have examined the relevance and effectiveness of

rehabilitation goals and types of interventions in a TBI population.

1.6.2.1 Driver rehabilitation interventions

Driver rehabilitation may include a range of different interventions for improving driver

performance. It includes the term ‘driver retraining’, which may refer to on-road driving lessons

or clinical remediation sessions with a clinician (Di Stefano & McDonald, 2006). Sixteen studies

were examined in a systematic review of types and effectiveness of interventions used by OTs to

improve on-road fitness to drive as part of driver rehabilitation (Unsworth & Baker, 2014). The

review found that the three most commonly reported interventions were computer based driving

simulator training (n=8), off- road skill specific training such as cognitive retraining (n=4) and

off- road education programs (n=3) and only one study reported the use of adaptive equipment.

These studies were conducted in North America and may not reflect the practices in other

countries. The results for the effectiveness of these interventions with different diagnoses were

inconclusive, as the authors reported that it was difficult to compare the studies for a variety of

reasons: the study samples included a range of diagnoses, pass/fail criteria and injury severity

were difficult to compare as they weren’t always reported, the delivery of the interventions varied


53

in frequency and duration, and it was not always possible to control for driver experience, age

and co-morbidities.

A review of driver rehabilitation interventions for individuals with neurological

conditions also identified a range of retraining programs (Devos et al., 2012). Specific cognitive

functions such as visual processing (Crotty & George, 2009), attention, speed of information

processing or perceptual/cognitive skill (Klonoff et al., 2010; Sivak, Olson, Kewman, Won, &

Henson, 1981) were targeted. A significant limitation of this approach is the assumption that

improvements in these domains will transfer to improved driver performance. Hence, the results

from these studies were also mixed.

Evidence is emerging that training of driving-related skills in the relevant context, such

as on-road training or driving simulator training, is more effective than a cognitive- remediation

based approach (Classen, 2014; Devos et al., 2012; Korner-Bitensky, Kua, von Zweck, & Van

Benthem, 2009). A study comparing simulator retraining of driving skills, that included playing

commercially available games to a cognitive training program after stroke, found that on-road

assessment scores of the simulator group were better than the cognitive training group (Devos et

al., 2009). Similarly, a review of the effectiveness of rehabilitation interventions, such as driving

simulators and clinical remediation tasks to improve driving skills after stroke, identified only

four studies that met the study’s selection criteria (George, Crotty, Gelinas, & Devos, 2014). The

authors reported that there was insufficient evidence to draw any conclusions, although driving

simulators may be useful in remediating visuo-cognitive abilities. They also documented the lack

of randomized control trial (RCT) studies for a stroke population, that evaluated on-road

training in the form of driving lessons.


54

A systematic review of the effectiveness of interventions for older driver retraining found

four studies that met the study’s selection criteria (Korner-Bitensky et al., 2009). The authors

found strong evidence to conclude that education programs, combined with on-road training,

improved driver performance. However, the systematic review examining interventions used by

OTs to improve driving performance, described above, did not find any studies evaluating on-

road training (Unsworth & Baker, 2014). Furthermore, a review of the driver assessment

practices of DRS in the US and Canada, found that most clinicians reported offering driver

retraining to clients who fail; however the types of interventions and results of the retraining were

not reported (Korner-Bitensky et al., 2006).

A number of studies have identified on-road training as a key intervention for driver

rehabilitation (Di Stefano & McDonald, 2006; Mazer et al., 2004; Schultheis et al., 2009). In

Australia, on-road training comprises a series of driving lessons provided by driving instructors

under the supervision of an OT and is a common intervention for improving driver performance

in driver rehabilitation programs (VicRoads, 2008). It is therefore surprising to find such a lack

of research into the outcomes and effectiveness of using this intervention to improve the

performance of medically impaired drivers (George et al., 2014; Mazer et al., 2004; Unsworth &

Baker, 2014).

In contrast, there have been an increasing number of studies examining the effectiveness

of driving simulators for driver retraining with a range of diagnoses. In addition to on-road

training, driving simulators provide a contextual, driving-related approach to retraining driving

skills. For stroke patients there is evidence that graded simulator interventions and on-road

training can improve on-road performance (Akinwuntan et al., 2005). Training sessions on a

simulator may have the potential to improve visual, cognitive and on-road skills in patients with


55

relapsing-remitting MS (Akinwuntan et al., 2014). In the field of older driver research, one study

found that driver performance can be improved by offering programs (such as simulator training)

that focused on self-awareness of driving skills (Hunt & Arbesman, 2008) and can result in

improved on-road performance (Casutt, Theill, Martin, Keller, & Jäncke, 2014).

Within a TBI population, simulator training has been used as an intervention for returned

combat veterans with diagnoses of mild TBI, PTSD and orthopaedic injuries and has

demonstrated a reduction in driving errors and improved lane maintenance (Classen et al., 2014)

and in driver performance and behaviour (Cox et al., 2010). However, a recent study using a

mixed sample of TBI and stroke patients did not find a significant difference in on-road pass rates

in a group who received 16 sessions of simulator training, compared to a control group who

received no intervention (Mazer et al., 2015). There is limited evidence at this stage to support

the use of driving simulators to retrain drivers with TBI. Further research is needed to examine

the effectiveness of using driving simulators to retrain driving ability and in particular, specially

designed simulator scenarios are required to target specific driving behaviours, to improve

assessment and retraining options (Crisler et al., 2012; Yuen, Brooks, Azuero, & Burik, 2012).

In summary, the majority of studies in the area of return to driving following TBI have

focused on driver assessment, predictors of driving capacity and prevalence of resuming driving.

Most studies to date have not specified whether their results are based on one on-road assessment

or whether participants have had access to driver retraining and if so, what interventions were

provided. Failing to provide driver rehabilitation for those who do not pass an initial on-road

assessment, may result in many drivers who have the potential to resume driving, being excluded

(Bliokas, Taylor, Leung, & Deane, 2011; Brouwer & Withaar, 1997). A number of studies have


56

therefore highlighted the need for research into successful resumption of driving after contextual

based driver training and the costs and time associated with providing this type of intervention

(Brenner et al., 2008; Devos et al., 2012; Unsworth & Baker, 2014) .

1.6.3 Restricted licensing

Restricted licensing refers to the practice of a restriction or condition being placed on an

individual’s license by the driver licensing authority (DLA). This practice has been defined as “a

mechanism for optimising driver and public safety, while maintaining driver independence when

a driver has a long-term or progressive health condition or injury that may impact on their ability

to drive safely” (Austroads, 2012). Examples of possible license conditions include; not to drive

at night, limiting numbers of passengers, to drive with adaptive equipment or to be restricted to

drive within a specific geographic area (VicRoads, 2008).

The use of restricted licensing varies between countries and jurisdictions. For example, it

is available in Canada and most US states but frequency of use varies (Nasvadi & Wister, 2009).

It is available in all Australian states and is frequently used as a method of enabling continuation

of driving in older drivers (Langford & Koppel, 2011). A Canadian study found that the

availability of restricted licensing made physicians more comfortable with reporting medical

conditions (Marshall & Gilbert, 1999). The availability of restricted licensing can also effect on-

road assessment outcome. For example, an individual may fail a standard on-road assessment,

conducted in the area around a rehabilitation centre, but may pass a reassessment conducted in

their local familiar area. The individual would then be issued with a restricted license, with the

condition that they only drive within a local specified area, rather than license cancellation and

being precluded from driving.


57

No studies have been found that have examined the use of restricted licenses in a TBI

population. There is limited evidence to support their use in older drivers with visual, physical

and cognitive impairment, to provide additional driving time to maintain mobility and

independence (Braitman, Chaudhary, & McCartt, 2010; Langford & Koppel, 2011) and for

lowering the risk of crashes in older drivers (Nasvadi & Wister, 2009). Compliance has been

identified as a possible issue if insight and/or memory are poor and it has been recommended that

they should be issued with caution in a cognitively impaired population (Classen, 2014).

1.7 Driving Safety and Behaviour after Return to Driving

One of the challenging issues for clinicians in assessing driver performance, is to balance

the need to manage crash risk with the client’s need to maintain community mobility

(MacDonald et al., 2006). Driving a vehicle in itself can be a risky activity for all drivers and the

OT driver assessment has been developed to evaluate the additional risk that a medical

impairment may contribute to driver performance. However there has been a lack of research

examining the association between the on-road test outcome and safety in the longer term, in a

TBI population (Coleman et al 2002). Furthermore, the aim of driver rehabilitation is to assist

drivers to change or manage their driving behaviour to optimise safety (MacDonald et al., 2006).

Patterns of driver behaviour in individuals with TBI who have resumed driving after driver

rehabilitation have also received scant attention. A summary of the research for crash risk and

patterns of driving behaviour after TBI is outlined below.


58

1.7.1 Crash risk after TBI

It has been argued that the best measure of fitness to drive is the absence of crashes in the

longer term (Brouwer & Withaar, 1997; Tamietto et al., 2006). To evaluate the validity of on-

road assessment in determining fitness to drive, driver safety following resumption of driving

should be examined (Coleman et al., 2002). Three methods of assessing driver safety after TBI

have been identified as; self-report, the report of a significant other and examination of Driver

Licensing Authority (DLA) records for number of crashes and traffic infringements (Coleman et

al., 2002; Pietrapiana et al., 2005). Questionnaires and telephone interviews have been used to

obtain views of significant others and self- report of driving behaviours, such as frequency of

driving or self- imposed restrictions. Whilst none of the methods are perfect, self-report of

crashes has been identified as an adequate option for obtaining crash data (Anstey, 2009)

although a combination of both DLA and self-reported data is preferred (Finestone et al., 2011).

Crashes occur in the non-brain injured population and many risk factors have been

identified, including intoxication, driver distractions, reckless driving behaviour, environmental

factors and fatigue. Driver speed has been identified as the major determinant of crash risk

(Kloeden, McLean, & Glonek, 2002). This risk is increased as the complexity of the driving

environment increases (Edquist, Rudin-Brown, & Lenné, 2011) and by greater driving exposure,

with increased driving frequency (Coleman et al., 2002). It is therefore difficult to attribute the

cause of crashes to the presence of a TBI alone. In addition, it has been acknowledged that

crashes are relatively rare events and therefore it is difficult to obtain accurate estimates of driver

safety after TBI using frequency of crashes alone (Schultheis et al., 2002; Tamietto et al., 2006).


59

A US study, compared self-reported crash rates with DLA records in a TBI group with

those of a Healthy Control (HC) group and found that both groups reported more crashes than

were recorded by the DLA. The TBI group was not at significantly greater risk of crashes

(Schultheis et al., 2002). The limitations of this study included the small and non-random

sample, of drivers who had passed a formal driving assessment. Additionally, injury severity of

the sample was not reported. Another study reviewed the DLA records of four different cohorts

of patients (CVA n=1, 910, TBI n=896, extremity fractures n=4,369, and appendicitis n=2,409)

and found that the crash risk after TBI was not greater than that of cohorts of non-TBI patients in

the 12 months following hospitalization. The TBI and fracture groups were however, more likely

to incur traffic infringements than the CVA and appendicitis groups. The authors concluded that

this may be related to risk-taking behaviour (Haselkorn, Mueller, & Rivara, 1998). As injury

severity of the TBI group was not recorded, it is difficult to generalize these results to the wider

TBI population. Priddy et al (1990) found that 73% of drivers in their sample had not had any

crashes or traffic infringements according to their DLA driving records. None of the sample had

received a formal driving assessment. The sample comprised 80% TBI and the remaining 20%

other neurological conditions. Injury severity measured by duration of loss consciousness was

recorded, but was not found to be associated with driving outcome (Priddy et al., 1990).

Similarly, another study did not find an increased crash rate in 103 TBI drivers, reviewed 12

months after resuming driving (Dimarco & Cantagallo, 2001), nor in an early study, with a small

sample (n= 22) of drivers with TBI and CVA (Katz et al., 1990), who had completed a

comprehensive driver evaluation on average 10 months post-injury and were followed up a mean

of 2.67 years post injury.


60

In contrast, a number of studies have found that the presence of brain injury increased the

risk of crashes compared to pre-injury (Bivona et al., 2012) and population based crash data

(Formisano et al., 2005; Schanke, Rike, Molmen, & Osten, 2008). As some of these studies had

mixed samples including other neurological conditions such as stroke, the results for crash risk in

a TBI population are inconclusive. A more recent study of individuals who had sustained a TBI

from car, motorbike and cycling injuries, merged the DLA database of police reported crashes

with a data-base of hospital admissions with TBI. Drivers with a TBI were found to be more

likely to be involved in multiple crashes, than drivers who had not had a TBI (Neyens & Boyle,

2012). The authors did not have access to information about whether the drivers had been

assessed or received any driver rehabilitation. Few studies have investigated the value of on-road

testing for predicting crash risk in the longer term (Tamietto et al., 2006).

Although many studies have examined the frequency of return to driving after TBI, the

findings of research investigating subsequent driver safety have been inconclusive and

contradictory. Methodological differences have been identified, such as the time post-injury of

follow-up, and the timing of when the number of post-injury crashes was measured (Tamietto et

al., 2006). Frequency of driving and distance driven may vary and should also be recorded, as

greater driving exposure may increase the risk of a crash or traffic infringement (Coleman et al.,

2002). Based on the mixed results of studies to date, it is difficult to draw any conclusions about

driver safety after TBI. The various methodologies used and lack of information about injury

severity of the study samples, whether they have received formal driver assessment and

rehabilitation and time post- injury when the data was obtained contribute to this situation.


61

1.7.2 Patterns of driving after TBI

Patterns of driving behaviour may encompass driving frequency, distances driven and

avoidance of specific types of manouvres or driving conditions, such as driving in unfamiliar

areas, night driving, high speed driving, with passengers and busy traffic (MacDonald et al.,

2006). A primary goal of driver rehabilitation is to assist drivers to change their driving patterns

to compensate for impairment and reduce crash risk, and it is therefore important to evaluate

whether this goal is achieved. In the literature examining patterns of driving after TBI,

methodological differences between studies, contributed to a range of findings.

A study that interviewed 184 individuals with TBI, who had driven in the previous month,

found that those with shorter duration of PTA were more likely to drive with higher frequency

and distance (Labbe et al., 2013). Individuals who were male and had a more severe injury were

less likely to avoid difficult driving situations or modify their driving behaviour. It is therefore

important to document injury severity and gender when examining driving patterns in a TBI

population. Two studies found that drivers with a TBI who received a formal assessment of

driving, frequently modified their driving behaviour in response to changes or difficulties they

were experiencing, however injury severity was not reported (Priddy et al., 1990; Schultheis et

al., 2002) .

In contrast, another study found that TBI drivers did not change their driving patterns

post-injury, compared to stroke patients, who had reduced frequency of driving. It is noted that

the CVA group comprised an older population which had different requirements for driving than

the younger TBI group and again no information was provided regarding injury severity

(Schanke et al., 2008).


62

Changes to driving patterns may occur due to improved self-awareness and the

subsequent implementation of compensatory strategies or avoidance of challenging traffic

situations. The use of compensatory strategies has been found to increase as self- awareness

increases (Lundqvist & Alinder, 2007; Rapport et al., 2008) and, combined with driver

experience (Brouwer & Withaar, 1997), is an important factor in resuming driving after TBI.

The processes of driver assessment and rehabilitation may influence post-injury driving

behaviour; however this has not been extensively examined in a TBI population. In addition the

post-injury driving behaviour of a group that passed an initial on-road assessment and a group

that had received driver rehabilitation has not been compared.

1.8 Summary and Study Rationale

This literature review has highlighted the difficulties in comparing the results of studies

examining return to driving following TBI, due to the lack of consistency in study design: There

has been variability in the type of outcome measure for resuming driving (driving license status,

pass/fail driving assessment, post-injury safety record), which measure of injury severity was

recorded (if at all), pre-and post-injury driving patterns, the nature and extent of impairments and

length of follow up from time of injury. Many study samples have comprised a mix of

neurological conditions, which has contributed to difficulty in obtaining useful results for a TBI

population. There has not been a comprehensive examination of the relative contribution of a

range of pre-injury, injury-related and post-injury factors, in an exclusively TBI sample. Nor

have the driver assessment and rehabilitation outcomes for those who pass the initial OT driver

assessment and those who resume driving following on-road training, been described.

Pre-injury factors that have emerged from the review of the literature as worthy of further

research include the influence of past driving experience and driver behaviour (measured by pre-


63

injury crash rate and driving exposure) on driver assessment outcomes. The influence of injury-

related factors, such as presence of visual or physical impairment, on driving capacity has not

been well described in the TBI literature. Whilst injury severity measured by GCS score has not

been shown to be predictive of driving capacity, the association of PTA duration with on-road

performance has not yet been assessed. It’s emergence as a stronger predictor of functional

outcome across a range of domains, renders it worthy of investigation as a predictive factor.

Although past research found that simple reaction time is not predictive of on-road assessment

outcome, choice reaction time is. The off-road assessment included both simple and choice

reaction time as a screening tool for evidence of slower processing and it would be important to

include this injury-related factor when examining possible predictors for return to driving.

The issue of timing or readiness to return to driving has also received scant attention and

little is known about the association of injury severity with timing of return to driving and what

factors influence this. It is known that years post-injury is a predictor of return to driving,

however clearer guidelines and appropriate and relevant impairment status criteria for timing of

return to driving after TBI are required.

Previous studies have not examined the effectiveness of OT driver assessment and

rehabilitation programs where long term driver safety and behaviour have been used as the

measure for confirming fitness to drive. The prevalence of using license restrictions and

providing driver training and reassessment following TBI has not been examined. Although the

literature indicated that TBI drivers can and do modify their driving, little is known about how

they change their driving behaviour and which injury-related or other factors cause them to do

this. As long term follow up is required to measure both safety record of TBI drivers and


64

changes in driving behaviour, this information may be captured by self-report and a retrospective

study design.

The literature review has identified the need for clearer and more comprehensive evidence

based guidelines for return to driving, in order to improve rehabilitation care and outcomes for

this cohort. It has highlighted why it is so difficult for clinicians to answer the simple question

from patients; ‘When can I drive?’ and to provide information to carers about likely driving

behaviour and safety. A significant gap in the literature about the lack of knowledge regarding

on-road training, as a rehabilitation intervention, for those who fail the initial driver assessment,

has also been identified. Therefore the overall objective of this PhD program of research was to

contribute to current knowledge about resuming driving after TBI, to assist in clinical decision-

making and optimise the driver assessment and rehabilitation process for individuals with TBI.

1.8.1 Aims and Hypotheses

The PhD program comprised three studies, each examining a different aspect of driving after

traumatic brain injury;

Study 1: Predictors of On-Road Driver Performance following Traumatic Brain Injury

The aims of the first study were to document the patient characteristics and outcomes of

an occupational therapy driver assessment and rehabilitation program and to examine pre-injury

and injury-related factors and their association with the outcome of the initial on-road driver

assessment. It was hypothesized that patients with less pre-injury driving experience, greater

injury severity in terms of longer PTA duration or lower GCS, slower reaction times, and

physical impairments would be less likely to pass the driving assessment.


65

Study 2: Interventions for Resuming Driving after Traumatic Brain Injury

The main aim of the second study was to describe the range of goals, processes, outcomes

and resources associated with providing on-road training and use of restricted licensing, in a

group of drivers with TBI who failed an initial OT driver assessment. A subsidiary aim was to

describe the practical application of the driver assessment and rehabilitation process and use of

restricted licensing, as interventions for grading return to driving after TBI.

Study 3: On the Road Again after Traumatic Brain Injury: Driver Safety and Behaviour

following On-road Assessment and Rehabilitation

The aims of the third study were firstly to examine self-reported pre- and post-injury

driver safety and patterns of driving behaviour amongst individuals with a TBI, who had

completed an OT driver assessment and rehabilitation program. The second aim was to compare

the characteristics and subsequent self-reported driver behaviour of those drivers who returned to

driving after one on-road assessment, with those who received on-road training prior to

subsequent assessments. It was hypothesized that participants would report more crashes or near-

crashes, and would report more modifications to their driving behaviour relative to pre-injury. It

was also hypothesized, that if participants did not pass the initial driver assessment and required

on-road training, then they would have sustained a more severe TBI and would be more likely to

have modified their driving behaviour.


66

1.9 Summary of Methods

In Chapters 2, 3 and 4 a methods section is included for each study, however the

following summary is provided to enable the reader to understand how the three studies and their

participants overlap and combine to form the PhD program.

Exclusion criteria for the PhD program included individuals with no pre-injury driving

history and learner drivers, as the purpose of the study was to examine return to driving, not

learning to drive following TBI. In addition, patients who had only completed the off- road

component of the driver assessment were also excluded, as the focus of the study was to examine

on-road assessment and driver rehabilitation outcomes and the safety and patterns of driving

behaviour in those who had successfully resumed driving after completing the driving program.

For Study 1, a retrospective design was used to collect data from driving and medical

records on all patients (n= 207: 156 male, 51 female) who had sustained a TBI and completed an

occupational therapy on-road driver assessment at Epworth Rehabilitation between 2002 and

2009 inclusive. The data for Study 1 was collected in 2010; participant details and off and on-

road assessment data and outcomes were extracted from medical and OT driving records for all

207 participants and used to examine which pre-injury and injury-related factors were associated

with the outcome of the initial on-road driver assessment. The participants were divided into two

groups according to the outcome of the OT driver assessment. The ‘pass’ group (n= 137) was

defined as those who returned to driving after passing the initial on-road assessment. The

‘rehabilitation’ group (n = 70) required driving lessons and/or further on-road assessments.

The focus of Study 2 was to describe the goals and processes of driver rehabilitation for

those patients who failed the initial on-road assessment and required driving lessons (the

rehabilitation group). In 2014, further data was collected on all patients with TBI who had


67

completed the driving program between 2010 and 2014 inclusive. This sample was combined

with the sample from Study 1 making a total of 340 participants and of this group, 94 participants

failed the initial on-road assessment and required driver rehabilitation. The OT driver evaluation

reports for these 94 participants were then examined to extract the number and goals of driving

lessons and number and types of restricted licenses that were recommended by the OTDA.

The data for Study 3 was collected during 2010, in the same period of time as Study 1 and

the questionnaire (Appendix A) was also developed at this time, to investigate post assessment

driver safety and patterns of behaviour. In 2010, it was sent to all patients who had successfully

returned to driving after completing the driving program, between 2002 and 2009. There was

overlap in the samples of Study 1 and Study 3 as the 106 participants who responded to the

questionnaire were drawn from the sample used in Study 1.

The Methods section for each of the three studies describes participant characteristics,

including injury severity measured by PTA duration and GCS score, date of injury, date of birth,

gender, cause of TBI, obtained from patient medical files.

Driving related data was collected from a number of sources. The mean choice reaction

time, presence of physical or visual impairment and driver experience measured by years licensed

were obtained from the OT records documenting the off-road assessment results. Date of off-road

assessment, initial on-road assessment and subsequent reassessments and assessment outcome

including restricted licenses were obtained from the OT car evaluation report that was sent to the

driver licensing authority. This data was used to calculate time from injury to independent

driving with or without license restrictions. Number of and goals of driving lessons were

obtained from the detailed report written by the OTDA after an unsuccessful driver assessment.


68

A description of both the off and on-road driver assessment procedures completed by all

participants has been described in each study and will not be reiterated.

CHAPTER 2

Predictors of On-Road Driver Performance following Traumatic

Brain Injury

This Chapter constitutes a manuscript published in Archives of Physical Medicine and

Rehabilitation

Ross, P. E., Ponsford, J. L., Di Stefano, M., & Spitz, G. (2015). Predictors of on-road driver

performance following traumatic brain injury. Archives of Physical Medicine and Rehabilitation,

96(3), 440-446.

This chapter was formatted in accordance with requirements set by Archives of Physical

Medicine and Rehabilitation.

Chapter 2 Predictors of On-road Assessment

70

Introduction to Study 1

Determining whether an individual with TBI should be referred for a practical driver

assessment prior to return to driving can be challenging for most health care professionals. The

literature review has discussed various factors that may influence this decision such as severity of

the TBI, time post-injury and perceived potential impact of physical or cognitive impairment on

driver capacity. Neuropsychological tests have been used to assist in identifying potential

cognitive impairment but have been found to be poor predictors of on-road driver performance.

There is a lack of documentation about the impact on driver performance after TBI of other

factors that are routinely assessed during the off-road assessment, such as physical and visual

impairment, reaction time and injury severity.

A driver assessment and rehabilitation program, specializing in return to driving

following TBI, has operated at Epworth Rehabilitation where this study was conducted since

1987 however the outcomes of the program had never been examined. It was anticipated that an

examination of the patient characteristics and driver assessment outcomes may contribute to

current knowledge in this field of research and improve referral processes. The standard referral

procedure at the centre where the study was conducted was to refer all patients with TBI who

were at least 3 months post-injury and were assessed by their treating doctor and team as having

the potential to resume driving, following an eyesight clearance and neuropsychological

assessment. Based on clinical observation, most patients who had sustained a less severe TBI

passed the assessment, but little was known about the characteristics of those who passed the

initial on-road assessment compared to those who failed and required driver rehabilitation. By

documenting the patient characteristics and examining the outcomes of the driver assessment

program the aim of Study 1 was to identify which factors were predictive of passing/failing the


71

initial on-road driver assessment. Some repetition will be apparent with regard to the literature

reviewed and methods described and some formatting will be different in accordance with the

journal’s submission requirements.


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2.1 Abstract

Objective: To examine assessment outcomes and factors associated with passing an occupational

therapy (OT) on-road driver assessment, after traumatic brain injury (TBI).

Design: Retrospective analysis of outcomes of on-road driver assessments completed by persons

with a TBI over an eight year period.

Setting: Inpatient and outpatient rehabilitation hospital.

Participants: A consecutive sample of 207 individuals with mild to severe TBI, who completed

an on-road driver assessment and were assessed at least 3 months post injury.

Intervention: Not applicable

Main Outcome Measures: Outcome of on-road driver assessment

Results: Sixty-six percent of TBI drivers (n=137) passed the initial on-road driver assessment

(pass group), while 34% (n=70) required on-road driver rehabilitation and/or one or more on-

road assessments (rehabilitation group). After driver rehabilitation, only 3 of this group did not

resume driving. Participants who were male, had shorter posttraumatic amnesia (PTA) duration,

no physical and/or visual impairment, as well as faster reaction times were significantly more

likely to be in the pass group. In combination, these variables correctly classified 87.6% of the

pass group and 71.2 % of the rehabilitation group.

Conclusions: PTA duration, proved to be a better predictor of driver assessment outcome than

Glasgow coma scale score and in combination with the presence of physical/visual impairment

and slowed reaction times, could assist clinicians to determine referral criteria for OT driver

assessment. On-road driver rehabilitation, followed by on-road re-assessments were associated

with a high probability of return to driving after TBI.


73

Key Words: brain injury: automobile driving: on-road assessment: driver rehabilitation:

posttraumatic amnesia: Glasgow coma scale


74

2.1 Introduction

Driving is an important daily life skill, and returning to driving following traumatic brain

injury (TBI), has been associated with greater life satisfaction,(T. A. Novack et al., 2010)

community integration (Rapport et al., 2006) and employment.(Kreutzer et al., 2003) Driving a

car is a complex activity, impacted in many ways by the sensory, physical, cognitive, behavioral

and emotional effects of TBI. (Ponsford et al., 2013) It is therefore essential to assess the impact

of such impairments on capacity for safe driving. This represents an important but challenging

task, due to the lack of validated guidelines and procedures for returning to driving after TBI.

(Hopewell, 2002; Marshall & Gilbert, 1999; Ortoleva et al., 2012; Tamietto et al., 2006)

Methodological issues and contradictory results of previous studies investigating predictors of

driving capacity have contributed to this situation. (Classen et al., 2009; Ortoleva et al., 2012;

Tamietto et al., 2006)

Injury severity has been acknowledged as an important predictor for return to driving after

TBI. Both coma and posttraumatic amnesia (PTA) duration have been associated with safe

driving outcome (Dimarco & Cantagallo, 2001; Pietrapiana et al., 2005), and Glasgow coma

scale (GCS) score, and Functional Independence Measure and Functional Assessment Measure

(FIM/FAM) scores have been investigated as predictors of driving capacity, but with mixed

findings.(Dimarco & Cantagallo, 2001; Fisk et al., 1998; Formisano, Bivona, Brunelli, Giustini,

& Taggi, 2001; Hawley, 2001; Korteling & Kaptein, 1996; Pietrapiana et al., 2005; Rapport et

al., 2006) PTA duration has emerged as a stronger predictor of short and long term functional

outcome after TBI than other injury severity measures,(Brown et al., 2005; Kosch et al., 2010)

however the relative association of PTA duration and GCS score with driver assessment

outcome has not been extensively studied.


75

Assessments of fitness to drive include off-road tests, such as neuropsychological tests

and simulator assessments and on-road tests.(Classen et al., 2009) However, many studies have

found that off-road tests do not reliably predict real-world driving outcomes.(Bliokas et al., 2011;

Brouwer & Withaar, 1997; Coleman et al., 2002; Cyr et al., 2009; Duquette et al., 2010;

Hopewell, 2002; Korner-Bitensky et al., 2006; Lew et al., 2005; Pietrapiana et al., 2005; van

Zomeren et al., 1988) Despite varying degrees of standardization, (e.g., of route complexity,

traffic conditions, assessment duration) (Di Stefano & Macdonald, 2010; Korner-Bitensky et al.,

2006; Pietrapiana et al., 2005) on-road driver assessment is regarded as the more accurate means

of assessing fitness to drive, by assessing the effects of physical, visual, and cognitive

impairments on real-world driving. (Di Stefano, 2006; Di Stefano & McDonald, 2006; Fox et al.,

1998; Jones et al., 1983; Tamietto et al., 2006)

Other factors shown to influence driving after TBI include physical or visual impairment, (Fisk

et al., 1998; Hawley, 2001; Hopewell, 2002; Jones et al., 1983; Korteling & Kaptein, 1996; Shute

& Woodhouse, 1990; van Zomeren et al., 1988) pre-injury driving experience,(van Zomeren et

al., 1988) years post- injury,(T. A. Novack et al., 2010) views of significant others,(Coleman et

al., 2002; Rapport et al., 2006) and provision of on-road driver rehabilitation,(Jones et al., 1983)

which includes in-car training using remediation and compensatory techniques. (Di Stefano,

2006) Whilst Jones et al.(Jones et al., 1983) and Brouwer and Withaar(Brouwer & Withaar,

1997) have highlighted the importance of on-road driver retraining programs, few studies have

examined outcomes following on-road driver rehabilitation after TBI. (Brouwer & Withaar,

1997; Bush, 2003; D’apolito, Massonneau, Paillat, & Azouvi, 2013)

In Australia, physicians establish medical fitness to drive and requirements for practical

driver assessment based on guidelines for assessing fitness to drive. (Austroads, 2012) Following


76

driver assessment, occupational therapists (OTs), trained in a standard assessment protocol, are

responsible for providing license recommendations to the Driver Licensing Authority (DLA),

VicRoads.(Di Stefano & Macdonald, 2010) The guidelines do not specify referral criteria for on-

road assessment or a period of abstinence from driving after TBI. However, individuals with TBI

are advised against resuming driving for at least 3 months post-injury to allow for recovery of

motor and cognitive sequelae, including reaction times, which are routinely assessed as part of

off -road screening. A greater understanding of factors associated with passing an on-road

assessment, could assist clinical decision-making with regard to referral criteria and optimize

driver rehabilitation for individuals with TBI. (Classen et al., 2009)

The present study therefore had two aims:

1. To document the patient characteristics and outcomes of an occupational therapy driver

assessment and rehabilitation program.

2. To assess the relative contribution of injury severity measured by PTA duration, GCS

score, age, physical impairment, driving experience and reaction times with the outcome

of the initial on-road driver assessment.

It was hypothesized that patients with less pre-injury driving experience, lower GCS score,

longer PTA duration, slower reaction times, and physical impairments would be less likely to

pass the initial driver assessment.

2.2 Methods

Ethics approval was obtained from Monash University and Epworth Human Research and

Ethics Committees. Data were collected retrospectively.

2.2.1 Participants


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The convenience sample was drawn from both urban and rural areas and included patients

with TBI, n=207 (156 male, 68.4%) who consecutively completed the same driver assessment

procedure at Epworth Rehabilitation, Victoria, Australia between 2002 and 2009. Prior to 2002, a

different brake reaction tester was used. Cause of TBI included vehicle accidents (45%),

pedestrian (15%), motor-bike (12%), fall (10%), bicycle (5%), work-related (6%), assault (1%)

and unknown (6%). All participants had sustained a loss of consciousness. Average PTA duration

was 23.34 (SD = 25.51, range = .1 – 140), with 2.0% of the sample classified as mild (PTA< 24

hours), 31.3% as moderate (PTA 1-7 days), 35.3% as severe (8-28 days) and 31.3% as very

severe (> 28 days). The mean GCS score was 9.60 (SD = 4.32, range = 3 – 15), whereby 42%

were classified as mild (GCS 13-15), 14.9% as moderate (GCS 9-12), and 43.1% as severe (GCS

3-8). Only 1% (n=2) were classified as mild on both PTA and GCS score, resulting in a sample

comprised predominantly of moderate to severe injuries.

Prior to referral, participants received medical and visual clearance and had completed a

neuropsychological assessment. Learner drivers and those completing only off-road assessment

were excluded. In order to determine factors associated with the outcome of the initial on-road

assessment, participants were classified for analyses according to on-road assessment outcome: a

pass group, including those who returned to driving after one on-road assessment without driving

lessons and a rehabilitation group which required driving lessons and/or more than one on-road

assessment. Table 1 summarizes the demographic and injury-related characteristics of both

groups.

Table 1 Demographic and injury-related variables for Pass and Rehabilitation Groups

Variable Pass Group n = 137 Rehabilitation Group n = 70 Significance p

Age (years)a 36.86 ±14.69 36.76±17.10 .800


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GCS score a 10.47±4.06 8.05±4.37 <.001

PTA duration (days) a

<24 hours PTA

<7 days PTA

<14 days PTA

<28 days PTA

15.52±16.24

3.0 (4)

41.5 (56)

60.8 (82)

81 (111)

38.96±32.69

1.5 (1)

17.9 (12)

28.3 (19)

47.1 (33)

<.001

Years Licensed a 17.80±14.30 15.88±15.63 .279

Reaction Time (ms) a 730.70±127.89 825.59±226.47 .002

Gender (Male)b

Physical Impairment

83 (110) 65.7 (46) .021

Visual b 8.8 (12) 29.6 (21) <.001

Upper Limbb 8.1 (11) 29.6 (21) <.001

Lower Limbb 7.4 (10) 18.3 (13) .015

Back/Neckb 5.1 (7) 8.5 (6) .331

NOTE: Values are % (n), mean ± SD (range) or as otherwise indicated. aIndependent sample t-test

undertaken, bChi-square test for independence was used. (ms =milliseconds)

2.2.2 Procedures

Participant details and off and on-road assessment data and outcomes were extracted

from medical and OT driving records, including gender, age at injury, date of injury, medication,

other diagnoses, lowest pre-intubation GCS in the first 24 hours and PTA duration, as measured

prospectively using the Westmead PTA Scale.(Marosszeky et al., 1997)

All participants completed the same off- road assessment, conducted and reported by the

assessing OT prior to on-road assessment. This assessment included: driver experience (years

licensed), road law knowledge and mean reaction time (milliseconds) over 3 trials on a Servicing


79

Optics Model 30P brake reaction tester. Although validated normative data were not available for

this apparatus, it was used to screen for gross evidence of slowed processing and capacity to

perform movements required for driving (turning a steering wheel or transferring the foot from

accelerator to brake in response to a randomly presented stimulus light). Drivers were generally

not excluded from on-road assessment based on these results. Injury-related visual impairment

was recorded as Yes/No on the basis of an eye-specialist’s report. Upper and lower limb range of

movement, strength, coordination, tone and sensation were assessed. Impairment, including

presence of pain or reduced spinal column range of movement, was recorded as Yes/No.

The on-road assessments were conducted by six experienced Occupational Therapists

who had completed the same driver assessor training course, with two completing the majority of

tests (66%). In 90% of assessments, the same experienced driving instructor, accompanied the

OT and provided standard verbal directions for the pre-determined route and was responsible for

maintaining safety in a dual-controlled car. All participants attempted the initial 10 minute low-

demand driving route, to enable vehicle familiarization and to assess capacity to proceed with

more demanding route segments. A few participants, who were assessed as incapable of

progressing, were offered driving lessons or reassessment at a later time to allow for further

recovery. Most participants completed the remaining 45-50 minutes on a standard route designed

to comply with Competency Standards for Occupational Therapy Driver Assessors,(OT-Australia,

1998) (Di Stefano, 2006) including manouvres, such as lane-changing, merging, parking,

negotiating controlled and uncontrolled intersections, low to high density traffic conditions,

freeway driving and distractions (talking while driving).

An on-road assessment checklist was used to record appropriate/inappropriate driver

behavior and the OT and driving instructor discussed the results. Pass/fail criteria were based on


80

the Competency Standards (OT-Australia, 1998) and jurisdictional license test performance

criteria (POLA criteria, 1999) including automatic fail for critical incidents requiring

intervention by the driving instructor. Assessment outcome was also influenced by evidence of

fatigue, cognitive difficulties, anxiety, driving inexperience, poor driving habits or training to use

adaptive equipment or implement compensatory techniques. Outcomes included unconditional

pass, driving lessons with an experienced driving instructor, license suspension, license

restrictions and/or requirement for further on-road assessments. The time from injury, number of

driving lessons and on-road assessments was recorded until a final outcome was achieved of

either license suspension or independent driving with or without license restrictions: automatic

transmission, adaptive equipment or restriction of driving within a specified area.

2.2.3 Data analysis

The pass and rehabilitation groups were compared on gender, age at injury, GCS score, PTA

duration, time from injury to resuming independent driving, reaction time, years of driving

experience and presence/absence of physical or visual impairment, using Chi-square and

independent samples t-tests. Variables on which the groups significantly differed were entered in

logistic regression models to determine how, in combination, they predicted likelihood of passing

an on-road assessment. No significant multicolinearity of independent variables was identified.

Pearson correlations ranged between -.07 and -.55 for the continuous variables included in the

logistic regression. Duration of PTA and GCS displayed a moderate correlation of -.55.

Significant demographic variables were sequentially added to the logistic model, followed by

injury severity, reaction time, and the significant physical variables. The step that entered injury

severity into the model included PTA and GCS as both of these variables significantly


81

differentiated individuals in the pass and rehabilitation groups. Entering both of these variables

provided the ability to examine their relative predictive strength.

Subsequently, the Akaike Information Criterion (AIC) corrected for the number of predictors

included in the model, was used to simultaneously assess each of the models against one another,

to determine their support for the observed data, using the steps outlined by Johnson and Omland

(2004).(Johnson & Omland, 2004) Difference scores were calculated by subtracting the AIC of

each model from the best model—defined as the model with the lowest AIC. Based on these

difference scores, the likelihood of each model was calculated, before normalizing these model

likelihood values so they summed to unity. Subsequently, a probability for each model could be

derived, indicating the likelihood of being ‘the best model.’

2.3 Results

2.3.1 On-Road Assessment Outcomes

Of the 207 participants, 137 were in the pass group and 70 in the rehabilitation group.

Sixty-seven (94%) of the rehabilitation group eventually returned to driving following driver

rehabilitation; of these, 12 returned to driving following only a second on-road assessment. Three

participants, aged 64, 70 and 73, from the rehabilitation group were recommended for license

cancellation. Table 2 summarizes outcomes for both groups.

Table 2 On-road assessment outcomes

Assessment Outcome Pass Group ( n=137) Rehabilitation Group (n=70)

License Suspension 0 3 (4.3)

Total Restricted Licenses 10 (7.3) 30 (42.6)

- Area Restriction 0 13 (18.1)


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- Automatic Restriction 8 (8) 24 (33.8)

- Adaptive Equipment 2 (1.5) 6 (8.5

Number of Lessons 0 5.06± 4.98 (1-22)

Number of On-Road Assessments 1 2.39 ± 1.35 (1-6)

Months to Final On-Road Assessment 5.72 ±7.75 (1-73)

Median = 4.00

22.74± 27.01(3-195)

Median = 13.00.

NOTE: Values are n (%), mean ± SD (range) or as otherwise indicated.

As shown in Table 1, individuals in the rehabilitation group were more likely to be

female, had significantly lower GCS scores, longer PTA duration, slower reaction times, and

more physical injuries compared to the pass group. However, age at injury, number of years

licensed, and back/neck impairment did not significantly differentiate the two groups. To reduce

the number of parameters in regression models, a physical/visual variable was created, including

individuals with visual, upper or lower limb difficulty. Back/neck difficulties were not included

in this variable as they did not significantly differentiate the groups. This new physical/visual

variable significantly differentiated the groups (χ2 (208) = 38.59, p< .001), with individuals in the

rehabilitation group reporting more physical issues (64.8%) than participants in the pass (21.2%)

group.

2.3.2 Predictive Models

Four logistic regression models were compared. These models are presented in Table 3.

The first model, which only included gender as a predictor variable, was not significant overall,

χ2 (1, N=164) =3.25, p=.07. Gender alone was a poor predictor of group status, being unable to

correctly classify any individuals into the rehabilitation group.


83

The second model, which included GCS and PTA, resulted in a significant overall model

relative to Model 1, χ2 (2, N=164)=38.52, p< .001. However, only PTA was a unique significant

predictor: for every additional day of PTA, individuals were 4% more likely to be in the

rehabilitation group - 81% of the pass group had a PTA duration of less than 28 days compared

to 47% of the rehabilitation group. This model, which included gender, GCS, and PTA, correctly

classified 91.4% of the pass group and 47.5% of the rehabilitation group.

The third model examined the contribution of reaction time. Its addition resulted in a

significantly better model relative to Model 2, χ2 (1, N=164) =5.61, p = .02. Reaction time was a

unique significant predictor; for every additional millisecond, participants were 0.3% more likely

to be in the rehabilitation group. This model correctly classified 89.50% of the pass group and

50.80% of the rehabilitation group.

The presence of physical/visual impairment was entered into the fourth model. This

model was statistically superior, relative to Model 3, χ2 (1, N=164) =25.68, p< .001. The presence

of physical/visual difficulties was a highly significant predictor, and individuals were eight times

more likely to be in the rehabilitation group. This model correctly classified 87.6% of the pass

group and 71.2% in the rehabilitation group.

Simultaneous comparison of the candidate set of models suggested that Model 4, which

included gender, GCS score, PTA, reaction time and physical/visual impairment, was 99.9%

likely to be the best of the models investigated. GCS was the only individual predictor that did

not significantly contribute to the model.

Table 3 Logistic regression models predicting Pass and Rehabilitation group outcome

Model B S.E Wald df Sig. Exp(B) 95% CI for Exp(B) AIC


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Lower Upper

1 Gender -0.66 0.37 3.27 1.00 0.07 0.52 0.25 1.06 215.03

Constant -0.10 0.31 0.10 1.00 0.76 0.91

2 Gender -1.29 0.44 8.60 1.00 0.00 0.28 0.12 0.65 180.50

GCS -0.08 0.05 2.37 1.00 0.12 0.93 0.84 1.02

PTA 0.04 0.01 13.76 1.00 0.00 1.04 1.02 1.06

Constant 0.11 0.72 0.02 1.00 0.88 1.12

3 Gender -1.22 0.45 7.45 1.00 0.01 0.29 0.12 0.71 176.90

GCS -0.08 0.05 2.54 1.00 0.11 0.92 0.83 1.02

PTA 0.04 0.01 11.23 1.00 0.00 1.04 1.02 1.06

RT-Milliseconds 0.00 0.00 4.82 1.00 0.03 1.00 1.00 1.01

Constant -2.25 1.29 3.02 1.00 0.08 0.11

4 Gender -1.03 0.48 4.69 1.00 0.03 0.36 0.14 0.91 153.22

GCS -0.09 0.06 2.33 1.00 0.13 0.92 0.82 1.03

PTA 0.04 0.01 11.41 1.00 0.00 1.04 1.02 1.07

RT-Milliseconds 0.00 0.00 6.94 1.00 0.01 1.00 1.00 1.01

Physical 2.11 0.45 21.80 1.00 0.00 8.23 3.40 19.95

Constant -4.08 1.45 7.93 1.00 0.01 0.02

Abbreviations: CI, confidence interval; Exp,exponentiation; RT reaction time; Sig, significance

2.4 Discussion

The current study achieved its first aim, in documenting the driver assessment and

rehabilitation outcomes and characteristics of 207 participants with TBI. Over the 8-year period,

only three individuals were recorded as having their license cancelled. The remaining 204

participants returned to driving. Of these, 34 % required driving lessons and of this group, 19%

returned to driving with a restricted license. To our knowledge, this is one of the few studies to

have examined the incidence of license restrictions and driver rehabilitation outcomes in the TBI


85

population. It supports the contention that after failing an initial driver assessment, driving

lessons followed by reassessment are associated with a high probability of return to driving after

TBI.(Brouwer & Withaar, 1997; Jones et al., 1983; Korteling & Kaptein, 1996) This process of

driver rehabilitation may have contributed to the higher incidence of relicensing compared with

other studies, however the current study did not specifically test this premise. (T. A. Novack et

al., 2010) (Fisk et al., 1998) (Dimarco & Cantagallo, 2001; Labbe et al., 2013) Similar to the

findings of Novack and colleagues,(T. A. Novack et al., 2010) drivers with less severe TBI

generally returned to driving within the first year post injury.

The second aim was also achieved. This study assessed the relative contribution of PTA

duration, GCS score, reaction times, age, gender, driver experience and physical/visual

impairment to the outcome of the initial on-road driver assessment. When considered in

combination, gender, PTA duration, presence of physical/visual impairment and reaction times

could predict the likelihood of passing an OT driver assessment in 87.6% of cases. PTA duration

emerged as a more significant predictor of driver assessment outcome than GCS score. The

results provided support for Brouwer and Withaar’s (Brouwer & Withaar, 1997)

recommendations, that TBI drivers with PTA duration of less than 28 days generally return to

driving with few issues, but also demonstrated that driving capacity cannot be assessed by injury

severity alone. Model 2, using gender, PTA and GCS correctly classified 91.4% of the pass

group compared to less than half (47.5%) of the rehabilitation group.

The addition of reaction time to the model improved the number of individuals correctly

classified into the rehabilitation group to 50.8%. The brake reaction test results were consistent

with the findings of Sommer and colleagues,(Sommer et al., 2010) that simple reaction time, was

predictive of driver assessment outcome.


86

The addition of physical/visual impairment into the model significantly improved the

accuracy of classification into the rehabilitation group to 71.2%. As discussed in previous

studies,(Hopewell, 2002; Korteling & Kaptein, 1996; Priddy et al., 1990; Schulte, Strasburger,

Muller-Oehring, Kasten, & Sabel, 1999) the presence of physical or visual impairment may

affect fitness to drive and require driver training to use adaptive equipment or learn compensatory

techniques .(Jones et al., 1983)

Inexperienced and older drivers are more highly represented in road trauma

statistics.(TAC, 2010) It was therefore surprising to find that neither age nor pre-injury driving

experience were associated with passing an initial driver assessment. Age was not found to

significantly differentiate between individuals in the pass and rehabilitation groups. This result

may have been influenced by the small number of older drivers in the study: only nine drivers

were aged 70-79 and although 6 failed their initial assessment, license suspension was

recommended in only 2 cases. Years licensed was used to measure driving experience, however

estimates of distances driven per year, (Dimarco & Cantagallo, 2001) and type of driving

experience might be more sensitive variables to use in future studies.

Although Model 4 correctly classified 71.2% of participants in the rehabilitation group, a

more detailed examination of the cases for whom the model did not fit well, revealed other

factors that may influence assessment outcomes. Driving lessons were recommended to address

cognitive impairment for 65% of the rehabilitation group, but driver anxiety, poor driving

habits, compensatory training for adaptive equipment/techniques, limited recent driving

experience or city versus rural experience were also addressed during driver rehabilitation.

2.4.1 Study Limitations


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The study sample was drawn from participants in a multidisciplinary rehabilitation

program and results may not generalize to individuals not receiving rehabilitation or with co-

morbid conditions such as psychiatric/substance abuse disorders. It was also not possible to

assess inter-rater reliability between the 6 OTs conducting on-road assessments and individuals

who only completed off-road assessment were excluded. A true measure of fitness to drive has

been defined as the absence of crashes. (Brouwer & Withaar, 1997; Galski, 2000; Schanke et al.,

2008; Schultheis et al., 2002; Tamietto et al., 2006) The current study, used passing an on-road

driver assessment as a measure of fitness to drive, which does not necessarily equate to driver

safety over time. Similar to recommendations in other studies (Bivona et al., 2012; Schanke et al.,

2008; Schultheis et al., 2002) investigation of driver safety and exposure following driver

rehabilitation is required. There was a higher representation of females in the rehabilitation

group. The reason for this is unclear and also warrants further investigation.

Future research examining types of driver errors/behaviors resulting in a ‘fail’ or a

restricted license and goals and outcomes of driver rehabilitation could provide useful

information to guide driver assessment and rehabilitation.

2.4.2 Conclusions

The results from the study demonstrated that PTA duration is a better predictor of driver

assessment outcome than GCS score and in combination with gender, presence of physical/visual

impairment and reaction times, could assist clinicians to determine referral criteria for OT driver

assessment. Future studies and clinical guidelines concerning return to driving after TBI, should

consider using PTA duration rather than GCS score in consideration of suitability for driver

assessment. The availability of on-road driver rehabilitation, using driving lessons, allowing

more than one on-road assessment and restricted licenses, contributed to the high relicensing rate


88

(94%) and highlights the importance of offering driver rehabilitation to drivers who fail the initial

on-road assessment. Given the association between driving, participation and quality of life, (T.

A. Novack et al., 2010; Rapport et al., 2008) it is important that all individuals with TBI have

their potential to resume driving assessed.

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CHAPTER 3

INTERVENTIONS FOR RESUMING DRIVING AFTER

TRAUMATIC BRAIN INJURY

This Chapter constitutes a manuscript accepted for publication in Disability and Rehabilitation.

Ross PE, Ponsford JL, Di Stefano M, Charlton J, Spitz G. (2016). Interventions for resuming

driving after traumatic brain injury. Under review with Disability and Rehabilitation.

This chapter was formatted in accordance with requirements set by Disability and Rehabilitation,

which included the use of the Council of Science Editors citation and sequence format for

referencing.

Chapter 3 Interventions for Resuming Driving after TBI

95


The results of Study 1 found that 66% of drivers resumed driving after passing the initial

on-road assessment (the pass group). The remaining participants (the rehabilitation group)

received on-road training and most resumed driving following a series of driving lessons and

reassessments. Only three of this group were assessed as unsafe to resume driving and had their

driving license cancelled. The number and goals of the driving lessons were recommended by the

OTDA based on the results of the off and on-road assessments. The on-road training was

provided as a series of driving lessons by an experienced driving instructor under the direction of

an OTDA. A subsequent on-road reassessment was conducted by the OTDA at the conclusion of

the driving lessons. On-road training proved to be a successful and important driver rehabilitation

intervention after TBI. However, no studies have described this type of driver rehabilitation

intervention (George et al., 2014; Unsworth & Baker, 2014).

Therefore, the primary aim of Chapter 3 (Study 2) was to provide a detailed description of

on-road training including the goals that were addressed, average number of driving lessons

required and timing of return to independent driving. To assist clinicians with treatment

planning, the resources that were required to deliver the intervention were also examined.

Study 1 also found that drivers in the rehabilitation group were significantly more likely

to resume driving with a restricted driving license than those in the pass group. The use of

restricted licensing has not been widely researched and no studies were identified in the literature

review describing its use in a TBI population. A further goal of Study 2 was therefore to

investigate the use of restricted licensing in a TBI population. Another important and unexpected

finding from Study 1 was the fact that women were significantly more likely to be in the


96

rehabilitation group than men. By examining the goals of driving lessons, it was expected that

the reason for this finding may be identified in Study 2.

The data collection for Study 2 was completed early in 2015, and therefore the data from

all patients who had completed the driving program since Study 1 (2002-2009) was added to the

original sample. The new sample for Study 2 therefore comprised a total of 340 participants and

included 94 participants who had failed the initial on-road assessment and required on-road

training.

Some repetition will be apparent with regard to the literature reviewed and methods

described, and as noted, some formatting will be different in accordance with the journal’s

submission requirements.


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3.1 Abstract

Purpose: To describe the goals, processes, resources and outcomes of on-road training lessons

provided to drivers with traumatic brain injury (TBI) who failed an initial occupational therapy

(OT) driver assessment.

Method: Descriptive cohort study using file audit design of 340 drivers with mild to severe TBI.

Measures included; number and goals of on-road training lessons and reassessments, time from

injury to independent driving, license restrictions, years licensed, physical/visual impairments

and injury severity.

Results: Initial OT driver assessment was passed by 72% (n= 246) cases. Of the 28% (n=94) who

failed, 93% (n=87) resumed driving following on-road training; 42 (45%) with an open license,

45 (48%) with restricted license and 7 (7%) failed to meet licensing standards. Individuals

required, on average, 7.0 driving lessons (14 driving instructor hours) and 2.5 on-road

reassessments, (9.8 OT and 3.8 driving instructor hours). Lesson goals were recommended to

develop compensatory strategies for cognitive impairments (64%), improve previously learned

driving skills (57%), improve confidence (53%), and address physical (26%) or visual

impairment (16%).

Conclusions: Investment in on-road training lessons addressing individual goals, followed by

reassessment and use of restricted licenses, can achieve successful return to driving following

TBI.


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3.2 Introduction

The inability to return to driving following a traumatic brain injury (TBI) can have a

devastating impact on quality of life (Fleming, Liddle, Nalder, Weir, & Cornwell, 2014; Kreutzer

et al., 2009; Liddle et al., 2011). Resuming driving is seen as a sign of recovery, whereas driving

cessation impacts participation in work, social, leisure and other activities and is associated with

loss of identity (Liddle et al., 2011, 2012). A comprehensive driver evaluation that includes off-

and on-road driver assessment is the accepted process for resuming driving after moderate or

severe TBI (Korner-Bitensky et al., 2006; Korteling & Kaptein, 1996). It has been recommended

that all severely injured individuals with TBI, who have potential to resume driving, should have

access to driver assessment and rehabilitation (Brouwer & Withaar, 1997; Ross, Ponsford, Di

Stefano, & Spitz, 2015). Many studies have investigated predictors of driving capacity,

prevalence of driving, and outcomes of on-road driver assessment following TBI (Griffen et al.,

2011; P. E. Ross et al., 2015; Schultheis et al., 2002; Van Zomeren et al., 1987). However, few

studies have described driver rehabilitation programs for individuals with TBI who fail the initial

on-road assessment (Di Stefano & McDonald, 2006; Unsworth & Baker, 2014).

The term driver rehabilitation may refer to a range of interventions to assess and

remediate driver ability (Lane et al.; Mazer et al., 2004). In the current study, it refers to the

practice of providing on-road training to improve driving skills, change behaviour and develop

compensatory strategies to maximise driving competence (Di Stefano & McDonald, 2006).

Internationally, differences exist in the professions responsible for driver rehabilitation. In the

US, driver rehabilitation specialists (DRS) are mainly occupational therapists (OTs), but may also

be physiotherapists, psychologists, kinesiotherapists and driving instructors (Devos et al., 2012;

Dickerson, 2013). Many DRS also achieve the qualification of certified driver rehabilitation


99

specialist (CDRS) after gaining experience and passing an exam (Dickerson, 2013). Both OTs

and driving instructors provide driver rehabilitation in specialised Mobility Centres in the UK

(Brooks & Hawley, 2005). In Australia, qualified occupational therapy driver assessors

(OTDAs) registered with the local driver licensing authority (DLA), conduct driver assessments

and develop individualised goals of driver rehabilitation based on results from the off- and on-

road driver assessments (Di Stefano, 2006).

In a review of driver rehabilitation interventions delivered by OTs, the most commonly

provided interventions were driving simulator training, off-road driver education programs and

off-road training designed to target specific skills, such as attention, speed of information

processing, or perception (Unsworth & Baker, 2014). There is an emerging view that functional

re-training of driving skills in a real-driving context, such as on-road training or driving simulator

training, targets the skills required for driving and is therefore more effective than an off-road

cognitive based approach (Devos et al., 2012; George et al., 2014; Korner-Bitensky et al., 2009).

For example, driving simulators are being used in some driver rehabilitation programs, mainly in

North America, to assist with pre-driving assessment and driver retraining (Akinwuntan et al.,

2005; Akinwuntan et al., 2014; Classen & Brooks, 2014; Mazer et al., 2015). Current limitations

of driving simulators include the possibility of simulator sickness (Brooks et al., 2010; Classen et

al., 2011; Classen & Brooks, 2014), and variability in scenarios and the training and experience

of the DRS (Classen & Brooks, 2014).

On-road training, conducted in real traffic conditions, has been identified as an important

aspect of driver rehabilitation (Di Stefano & McDonald, 2006; George et al., 2014; Schultheis et

al., 2009). In Australia, on-road training, comprises a series of driving lessons provided by

driving instructors experienced in driver rehabilitation, working under OTDA supervision


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(VicRoads, 2008). Although on-road training is a common rehabilitative intervention for

medically impaired drivers, no studies examining this approach have been identified (George et

al., 2014; Unsworth & Baker, 2014). Moreover, the resources required to provide such

interventions have not been reported, making cost-benefit comparisons with other types of

interventions difficult.

Driver rehabilitation interventions should address driving skills at the three hierarchical

levels of decision making described in Michon’s (1985) model (Brouwer & Withaar, 1997;

Dickerson & Bedard, 2014; Michon, 1985). Lower level decisions are made at the operational

level of driving, involving immediate reactions such as braking speed, lane position and gap

judgement. More demanding tactical decisions include anticipatory manoeuvres and risk

avoidance. Higher level strategic decisions involve planning and selective decision-making with

low time pressure, such as taking rest periods, avoiding certain driving conditions or tasks to

improve poor navigation (way-finding) and difficulty in route-planning. On-road training can

address individualised goals to improve self-regulation on any or all of these levels.

A number of factors may contribute to an individual failing an on-road driver assessment:

confusion, impulsivity, slowness, distractibility, inattention, anxiety (Galski et al., 1992), poor

driving habits, lack of recent driver experience or confidence (Di Stefano & McDonald, 2006) or

being assessed too early following injury (Hopewell, 2002; Jones et al., 1983). Poor visuo-spatial

skills, physical or psychological problems and lack of on-road practice have been associated with

non-readiness to drive (Klavora, Young, & Heslegrave, 2000). Driver rehabilitation may

therefore be required to address a range of issues in the following categories: improving low pre-

injury skills, improving previously learned driving skills, compensating for impairments, learning


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to use adaptive equipment for physical impairment, or addressing psychological issues (e.g.,

anxiety) (Di Stefano & McDonald, 2006).

Driver self-awareness and the associated ability to compensate for injury-related

impairments have been found to be key factors in safe driving after TBI (Gooden et al., 2016;

Lundqvist et al., 2008; Ross, Ponsford, Di Stefano, Charlton, & Spitz, 2015; Van Zomeren et al.,

1987). Drivers who received on-road training, were followed up an average of 4.5 years after

resuming driving. Many reported that relative to pre-injury, they had modified their driving

behaviour in response to perceived ongoing impairments (P. Ross et al., 2015). This suggests the

development of some degree of self-regulation. Additionally, drivers who lack self-awareness,

and present for assessment too early in the recovery process, may find supervised driving

experience helpful in transitioning to independent driving (Brooks & Hawley, 2005; Jones et al.,

1983) . On-road training offers the opportunity to improve awareness of driving capacity by

providing immediate performance feedback (Di Stefano & McDonald, 2006).

In Australia, restricted licensing can offer an alternative to license withdrawal by

providing a graded approach, in the transition to independent and safe driving. License conditions

can include the need for medical treatment, vehicle modifications or adaptive equipment and

driving restrictions, such as driving within a specified geographical area (Austroads, 2012). One

study reported that 94% of participants with TBI, resumed independent driving, using an

approach that combined on-road training and restricted licensing (P. E. Ross et al., 2015).

However very few studies have investigated the use of restricted licensing in a TBI population.

Whilst on-road training provides a potentially effective real-world means of addressing

individual client goals for resumption of driving, the associated processes, outcomes and

resources have not been examined in detail in a TBI population (Devos et al., 2012; Marshall &


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Gilbert, 1999; Unsworth & Baker, 2014). The aims of the current study were therefore to

describe the goals, processes, outcomes, and resources associated with providing on-road

training, for patients with TBI who failed an initial OT driver assessment.

3.3 Method

3.3.1 Participants

The sample comprised a consecutive group of 340 participants with TBI, completing off

and on-road OT driver assessment between 2002 and 2014 at Epworth Rehabilitation, Melbourne

Australia. All participants had sustained a TBI, based on clinical evidence of loss of

consciousness and documented Glasgow Coma Scale (GCS) score and Post Traumatic Amnesia

(PTA) duration. The sample was divided into 2 groups: 1) those who passed the initial or a

subsequent (where the initial assessment result was uncertain) on-road assessment without

requiring driver rehabilitation: 2) those who received one or more on-road training lessons after

the initial assessment. Exclusion criteria included patients who did not meet Austroads medical or

eyesight standards. Learner drivers were excluded, as the aim of the study was to investigate an

intervention for resuming driving, not learning to drive after TBI. Drivers aged 65 or over were

not excluded, as they form a significant proportion of the TBI population and many wish to

return to driving post-injury.

3.3.2 Measures

A file audit of medical and OT records at a single study site was used to achieve the aims

of this descriptive cohort study. Ethics approval was obtained from the appropriate hospital and

university ethics committees.


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Participant details extracted from records included date of injury, gender, age at injury,

driver experience—measured by years licensed, medications, other diagnoses, PTA duration

(measured prospectively using the Westmead PTA Scale) (Marosszeky et al., 1997), and lowest

pre-intubation GCS score in the first 24 hours. Assessment outcome, license restrictions and

months from injury to off-road assessment and independent driving, were extracted from OTDA

reports sent to the DLA.

The number and goals of on-road training lessons were obtained from the

recommendations section of the detailed report written by the OTDA after each on-road

assessment. Goals of on-road training were assigned according to the categories described by Di

Stefano and MacDonald (2006) (Di Stefano & McDonald, 2006). The goal of learning to

compensate for impairment was divided into three types of impairment: cognitive, physical, and

visual. Each driver could therefore have up to 5 goals (cognitive, physical, visual, improve

previous skills or confidence) as defined below:

Cognitive goals to compensate for impairments in attention, memory, planning, speed of

processing, navigation skills or fatigue.

Physical goals included learning to use adaptive equipment or compensate for physical

impairment without adaptive equipment.

Visual goals included learning to compensate for impairments such as visual field loss or

reduced binocular vision.

Improvement of previously learned skills included, remediating poor driving habits,

updating road law knowledge, adapting to a new driving environment (eg. rural to urban,

cultural differences) or practice for lack of recent driving experience.

Addressing psychological issues, i.e., improving confidence or reducing anxiety.


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3.3.3 Referral and driver assessment procedure

Participants in this study followed a standard referral procedure for driver assessment

following TBI. This procedure had been followed over many years by staff at this rehabilitation

centre. Patients were referred at least 3 months post- injury following team discussion,

considering medical and eyesight clearances and neuropsychological assessment results. Costs

were covered by private health insurance, worker’s compensation or the no-fault compensation

system for people injured in transport accidents. All drivers had completed the same off-road

assessment, conducted by the OTDA, which complied with the Competency Standards for

Occupational Therapy Driver Assessors (OT-Australia, 1998). This included assessment of

physical impairments likely to affect driving capacity (e.g., reduced range of movement, strength,

coordination, speed of movement, sensation), visual impairment, road law knowledge, reaction

times and driving experience. During the period of data collection, seven experienced OTDAs,

who had completed the same OT driver assessor training, were involved in the driver

rehabilitation program. The specialist driving instructors who supervised the assessments were

experienced in working with medically impaired drivers.

The standard on-road assessment route of 50 to 60 minutes duration, was conducted in a

dual-controlled automatic vehicle, accompanied by a driving instructor. The OTDA was seated in

the rear of the vehicle. The assessment commenced in a low demand area for 10 – 15 minutes to

allow familiarisation with the vehicle and for the OTDA to judge whether it was safe to proceed

with the open road route in more complex traffic conditions. The assessment route complied with

standard agreed test and route criteria, outlined in Competency Standards for Occupational

Therapy Driver Assessors (OT-Australia, 1998) and Guidelines for Occupational Therapy Driver

Assessors (VicRoads, 2008). Driver performance and errors in observation, speed control,


105

signaling, lane position, adherence to road rules and vehicle control were recorded by the OTDA

on the pre-defined on-road checklist, as appropriate or inappropriate. The various driving

situations along the route included intersection negotiation, merging, lane changing, low speed

manoeuvres and manoeuvre-free driving (Di Stefano & MacDonald, 2012). The traffic

complexity, speed zone, type of driving manoeuvre and driver distractions were recorded for any

critical errors, where the driving instructor intervened either physically or verbally to avoid a

crash or unsafe situation.

3.3.4 Assessment Outcome

Feedback was provided to the driver immediately after the assessment. This included

discussion of non-critical errors, reflecting poor driving habits (e.g., rolling over Stop- line),

common to many ‘experienced’ drivers (Dobbs, Heller, & Schopflocher, 1998) and critical errors

where safety was threatened. Pass/fail determination included: ‘unconditional pass’ if no critical

driver instructor interventions were recorded, ‘fail - driver training required’, or a further on-road

assessment if the result was unclear. The assessment outcome was also influenced by

observations of fatigue, slow responses/decision making or evidence of anxiety or lack of

confidence.

3.3.5 On-road training and reassessment procedure

Specialist driving instructors conducted on-road training lessons under supervision from

the OTDAs. The goals of the lessons had been developed by the OTDA, based on errors/ issues

identified during the off- and on-road assessments. Participants’ progress during on-road training

was discussed with the OTDA, to provide opportunity for advice and recommendations for


106

interventions. For example, to compensate for slower processing, training to slow down earlier

prior to intersections and increase following distance may be recommended by the OTDA.

An on-road reassessment, was conducted at the conclusion of the on-road training using

the same standard route. If a restriction to drive within a specified area was considered more

appropriate, the reassessment was conducted in the local area. The DLA was then notified of the

assessment outcome by the OTDA. Recommendations included: license cancellation if no

improvement in driving performance was observed, further on-road training followed by another

on-road reassessment for those demonstrating improvement but still considered unsafe, or

resumption of driving with or without license restrictions. These included requirement to drive

within a specified area, use automatic transmission or vehicle modifications (eg., spinner knob,

left foot accelerator pedal or hand controls). Return to driving could therefore, be graded from

driving in familiar, less complex traffic conditions, to more complex open licence conditions. The

licence restriction could be removed after successful reassessment in the future.

The resources associated with providing driver rehabilitation were based on two hours for

each driving lesson. This included a one-hour lesson and an hour for driving instructor travel and

administrative/liaison time. For each OT driver reassessment, one and a half hours of driving

instructor time and four hours of OT time was allowed. The OT time included one and a half

hours for reassessment, one and a half hours for report writing/ liaison and one hour of travel, for

reassessments conducted in a patient’s local area.

In table 1, two case studies illustrate the driver rehabilitation process, using customized lesson

goals, reassessments and license restrictions, to grade return to driving.

Table 1 Driver rehabilitation case studies


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Case Study 1

33 year old cyclist, TBI (GCS-4, PTA 70 days) 15 years of driving experience. Off and

on-road assessments completed 13 months post-injury, but advised to wait 4 months for

further recovery, due to left upper limb incoordination, slow cognitive processing and

reaction times. On reassessment, response speed and steering accuracy improved, but

failed assessment due to reduced mirror use, signalling errors, poor lane maintenance at

higher speeds, slowness in observation and planning as traffic complexity increased.

Eight weekly driving lessons provided (automatic car to reduce physical effort and

complexity of driving task), to learn compensatory strategies for cognitive (slower

processing) and physical impairment (left upper limb) and improve previously learned

skills (mirror use, signalling). Driving instructor provided immediate feedback to increase

awareness when drifting out of lane. Commentary (verbalising hazard perception and

decision making) was used to improve forward observation and planning.

On reassessment, improvement observed in steering control, mirror use, signalling,

awareness of injury related driving issues. Failed due to instructor intervention on three

occasions to correct drifting to left to avoid colliding with parked cars when attention was

diverted to a potential hazard, speed slowed significantly when talking and fatigue

observed after 20 minutes. Patient’s goal was to drive to and from work. Six driving

lessons provided to practise route to work and learning of compensatory strategies such

as no talking when driving and incorporating a rest break.

Reassessed using route from home to work; significant improvement observed in divided

attention and self-monitoring of fatigue – initiated rest break after 20 minutes.

Resumed independent driving on restricted license within 15km radius of home in


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automatic vehicle, no freeway driving. Returned to work and incorporated a coffee

break, after 20 minutes of driving.

Requested review of license restriction 8 months later (2 years 8 months post injury); no

crashes or speeding violations reported. Required six driving lessons in unfamiliar areas

including freeways with goal to compensate for slower processing by improving forward

observation and braking earlier prior to corners to improve steering accuracy. On

reassessment, 15km and ‘no freeway’ driving restrictions removed, automatic restriction

maintained.

Case study 2

21 year old jockey TBI (GCS -3, PTA 107 days), 2.5 years driving experience. Partial

visual field loss in right eye (Cleared by ophthalmologist as meeting Australian fitness to

drive guidelines). Off and on-road assessment completed 3 years post-injury.

Initial assessment did not proceed to complex road environment due to reduced visual

scanning to right, slow response times and low confidence due to lack of recent driving

experience. Ten lessons provided in familiar, low demand, rural town (living with

parents) to learn to compensate for visual and cognitive impairment, improve previously

learned skills and confidence. Reassessed in rural town. Drove safely; response speed,

visual scanning to right and confidence improved. Resumed independent driving with

license restriction to drive only in familiar, rural town in automatic vehicle.

Reassessment requested three years later (had moved to independent living in familiar

pre–injury urban area). Mother reported no post-injury crashes in rural area but

occasionally became lost due to poor memory. Six driving lessons were provided in new

area prior to reassessment with goals to improve previous memory of this area and


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practise desired driving routes. License restriction extended to include 30km radius of

new address and automatic restriction.

Review of license restrictions requested, three years later due to move to unfamiliar area.

Reported one crash during previous three years. Reassessed, but unable to plan and

remember routes in new area. Five driving lessons provided to identify and learn to use

the most suitable Global Positioning System (GPS) – three different GPS trialled. On

reassessment, responded to GPS instruction without adequate checking of road

environment on two occasions, resulting in instructor intervention. Six lessons provided

to improve observation of road environment while using GPS. On reassessment, drove

safely; license restrictions extended to include 25km radius from new address and to

drive a vehicle with a GPS. After 6 months of safe and independent driving using GPS

within restricted area, requested reassessment; area restriction removed but restricted to

automatic vehicle and to drive a vehicle with a GPS.

3.3.6 Data Analysis

Data were analyzed using the Statistical Package for Social Sciences Version 20.0 (SPSS

Inc., Chicago). Characteristics of the sample, on-road training goals, and costs were examined

using descriptive statistics. Independent samples t-tests and Chi-square statistics were conducted

to compare characteristics of the group who passed the initial OT driver assessment with those

who required on-road training as well as to explore any group differences between each

participant characteristic and each lesson goal.


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3.4 Results

3.4.1 Participant characteristics and assessment outcomes

The causes of TBI in the sample included: motor vehicle occupant crash 50.1% (n = 171),

pedestrian 14.1% (n=48), motorcycle crash 14.1% (n = 48), cyclist 7.0% (n= 24), work injury

5.3% (n=18), fall 7.3% (n =25) and assault 1.2% (n=4). Cause of TBI was missing for two

participants (0.6%).

Of the 340 participants 72.3% (n=246) resumed driving without on-road training. This

comprised 66.8% (n=227) of drivers who passed the initial on-road assessment and a further 19

drivers who passed after a subsequent on-road assessment which was offered in cases where the

initial assessment result was uncertain. The remaining 27.6% (n=94) failed the initial

occupational therapy driver assessment and required on-road training.

The characteristics of those who passed and those who required on-road training are

summarised in table 1. Whilst the groups did not differ on age at injury (p = .67) or driving

experience measured by number of years licensed (p =.52), a significant difference was found in

injury severity, with those requiring on-road training having lower GCS scores (t(308)=3.44,

p<.001) and longer PTA duration (t(324)=6.35, p<.001).

3.4.2 Timing of assessment and return to independent driving

As shown in table 1, a significant difference was found between the groups from time of

injury to off-road assessment (t(338)=5.42, p<.001), and to independent driving (t(331)=7.20,

p<.001). The results for one outlier for time from injury to off-road assessment and independent

driving were removed, as this participant had completed the driver assessment 15 years post-


111

injury, when his hemianopia had resolved. A significantly greater percentage of women required

on-road training than men (Χ2(1,340)=10.21 p=.001).

Table 2 Characteristics of individuals who passed and failed initial driver assessment

Passed – no lessons

N=246

Driving lessons

N=94

Mean

±SD

Median Range Mean

±SD

Median Range t/Χ2 p

value

Age at

Injury

(years)

38.65±15.52 35 17-82 39.50±18.88 32 18-91 .42 .673

GCS score

(3-15)

9.55 ± 4.37 11 3-15 7.69 ±4.36 7 3-15 3.44 <.001

PTA

duration

(days)

19.52±

20.49

14 .1-140 37.60± 28.89 31 .2-107 6.35 <.001

Years

Licensed

19.57±15.07 16 .2-60 18.34± 17.32 10.5 .3-61 .65 .518

Injury to

off-road

assessment

(months)

7.62 ±7.79 4.73 1.54-63.21 13.31 ±27.37 11.07 2.76-79.00 5.42 <.001

Injury to

resuming

driving

(months)

8.21 ±8.62 5.19 1.81-73.36 21.49 ±36.14 13.93 3.84-101.59 7.20 <.001

Gender

(Male)

82.9%

(204)

67%

(63)

10.21 .001

Note: Values are mean, ±SD = standard deviation, %, (n) or as otherwise indicated, GCS =

Glasgow Coma Scale score (3 = most severe), PTA = Post traumatic amnesia, t=independent

sample t-test was used, Χ2 = Chi-square test for independence was used

3.4.3 Outcomes of on-road training

Of the 94 participants who received on-road training and reassessments, licence

suspension was recommended in only seven cases. Five of these participants were aged 65 or

over. The remaining two, who were under 65 and failed, had co-morbid psychiatric conditions.


112

There were 33 (9.7%) participants aged 65 or over in the entire sample. They comprised 13.8%

(n=13) of the on-road training group and 8.1% (n=20) of the group that passed the initial

assessment. No statistically significant difference was found in the proportion of older drivers in

each group (Χ2 (1,340)=1.39, p=.24).


Following on-road training, 44.6% (n=42) of drivers resumed driving with an

open/unrestricted license and 47.8 % (n=45) required a restricted license. A number of drivers

had more than one of the restrictions, outlined in table 3.3, imposed on their license. For

example, if required to drive with a spinner knob, left foot accelerator pedal or hand controls,

drivers are also restricted to driving an automatic car. Of the 18 drivers assessed as safe to drive

with a restricted license within a designated area, six returned at various times after their driver

rehabilitation, to have the restriction reviewed and were subsequently granted an

open/unrestricted license.


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Table 3 On-road training outcomes and resources

Reassessment Outcome On-Road Training Group N=94

N %

Open/unrestricted license 42 44.6

Fail/License suspension 7 7.5

Total restricted licenses 45 47.8

Area restriction 18 19.1

Automatic restriction 39 41.5

Adaptive equipment 16 17.0

Resources required Mean (±SD) Median Range

Number of lessons 7.1 ± 5.6 5.5 1 – 35

Instructor hrs (2/lesson) 14.1 ± 11.2 11.0 2-70

No. of re-assessments 2.6 ±1.7 2.00 1- 6

OT hrs (4/reassessment) 9.8 ± 4.9 8.0 4.0 – 24.0

Instructor hrs

(1.5/reassessment)

3.7 ± 1.8 3.0 1.5- 9.0

Note : SD = standard deviation

3.4.5 Resources measured by labour hours

As shown in table 3, an average of seven on-road training lessons, equivalent to 14 hours of

driving instructor time were required to deliver the intervention. Following on-road training, an

average of 2.6 on-road reassessments, equivalent to 9.8 OT hours and 3.7 driving instructor hours

were required. Although the maximum number of driving lessons provided was 35, ten or less

driving lessons were provided in 85.1 % of cases. In 87.2 % of cases, twelve or less OT hours

were required, for the reassessments.

3.4.6 Goals of on-road training

In 23.4% (n=22) of cases, only one goal was recommended for the on-road training,

42.6% (n= 40) had two goals, 28.7% (n= 27) had three goals and 5.3% (n=5) had four goals. The


114

frequency of recommendation for each goal was: learning compensatory strategies for cognitive

impairment - 63.8% (n=60), for physical impairment - 25.5% (n=24) (including 17% (n=16) who

learnt to use adaptive equipment), for visual impairment - 16.0% (n=15), for improvement of

previously learned driving skills - 57.4% (n=54) and to improve confidence or reduce anxiety -

53.2% (n= 50).

3.4.7 Participant characteristics and lesson goals

We explored whether there were any group differences for each of the participant

characteristics (gender, age, PTA duration, GCS score and years licensed) with any of the five

on-road training goals (compensating for cognitive, physical or visual impairment, improving

previously learned skills or confidence). As shown in table 3, a greater percentage of women

received driving lessons to address confidence than men (Χ2 (1,94)=8.19, p = .004), whereas

males were significantly more likely to require driving lessons to address cognitive issues (Χ2

(1,94)=4.78, p=.029) than women. Participants requiring driving lessons to address cognitive

issues had significantly longer PTA duration (t(90)=3.85, p < .001) than the 36.2% (n=34) who

required lessons for other reasons and lower GCS scores (t(92)=2.24, p=.028). No other

characteristics examined were associated with any of the five driver rehabilitation goals.

Table 4 Relationship of on-road training goals with driver characteristics

Training goal Gender Age PTA GCS Years licensed

Male

% (n)

Female

% (n)

M (SD) M (SD) M (SD) M (SD)

Improve

Confidence

Required 42.9

(27)

74.2

(23)

39.4 ±

(18.40)

33.7 ±

(28.04)

8.4 ±

(4.56)

17.6 ±

(17.09)

Not 57.1 25.8 39.6 ± 42.2 ± 6.9± 19.2±


115

required (36) (8) (19.63) (29.55) (4.02) (17.72)

Χ2/t 8.19 .04 1.41 1.65 .45

p .004 .965 .162 .103 .652

Cognitive

compensatory

strategies

Required 71.4

(45)

48.4

(15)

41.5±

(20.90)

45.9 ±

(29.72)

7.0 ±

(4.14)

19.9±

(18.89)

Not

required

28.6

(18)

51.6

(16)

35.9±

(14.24)

23.5 ±

(21.22)

9.0±

(4.48)

15.6±

(13.96)

Χ2/t 4.78 1.39 3.85 2.24 1.16

p .029 .167 <.001 .028 .250

Improve

driving skills

Required 61.9

(39)

48.4

(15)

41.2±

(20.33)

35.7±

(28.75)

7.8±

(4.29)

18.9±

(18.49)

Not

required

38.1

(24)

51.6

(16)

37.2 ±

(16.71)

40.2 ±

(29.24)

7.5±

(4.50)

17.6±

(15.80)

Χ2/t 1.55 1.02 .75 .37 .34

p .213 .312 .456 .716 .736

Physical

compensatory

strategies

Required 27.0

(17)

22.6

(7)

35.1±

(14.81)

38.8 ±

(25.87)

7.3±

(4.59)

16.3 ±

(14.75)

Not

required

73.0

(46)

77.4

(24)

41.0 ±

(19.96)

37.2±

(30.06)

7.8 ±

(4.30)

19.0±

(18.16)

Χ2/t .21 1.32 .23 .57 .67

p .645 .190 .822 .568 .508

Visual

compensatory

strategies

Required 14.3

(9)

19.4

(6)

42.5 ±

(18.60)

33.4 ±

(32.27)

8.9 ±

(4.29)

22.1±

(19.26)

Not

required

85.7

(54)

80.6

(25)

38.9±

(19.00)

38.4 ±

(28.35)

7.5 ±

(4.36)

17.6 ±

(16.96)

Χ2/t .40 .66 .61 1.14 .93

p .528 .510 .543 .256 .357

Note: Values are M= mean, ±SD = standard deviation, %, (n) or as otherwise indicated, GCS =

Glasgow Coma Scale score (3 = most severe), PTA = Post traumatic amnesia, p=p value,

t=independent sample t-test was used, Χ2 = Chi-square test for independence was used


116

3.5 Discussion

This study aimed to describe the goals, processes, outcomes and resources required for a

rehabilitation intervention for resuming driving after TBI. The number of lessons, reassessments,

restricted licenses and characteristics of drivers with TBI who received on-road training after

failing an initial on-road assessment were investigated. An average of 7.0 driving lessons and

2.5 on-road reassessments were required to address lesson goals related to cognitive, physical and

visual impairment, reduced confidence and improvement of previously learned driving skills.

3.5.1 Addressing cognitive impairment

Of the 94 drivers requiring on-road training (27.6% of the total sample of 340

participants), learning to compensate for cognitive impairment was recorded as a goal of lessons

in 63.8% (n=60) of cases. The drivers who required lessons to address cognitive issues had

significantly more severe injuries than the remaining 36.2% (n=34), requiring lessons for other

reasons. Interestingly, 16% (n=55) of participants in the total sample (n=340) had long PTA

duration exceeding 28 days, but passed the initial on-road assessment without requiring on-road

training. This finding implies that not all individuals with TBI will require driver rehabilitation

and of those who do, the goals of the on-road training may not be related to cognitive

impairment.

3.5.2 Compensating for visual/physical impairment

A range of visual disturbances such as visual field loss, ocular motor palsies or

abnormalities in saccades or convergence (Ventura et al., 2014) may be experienced following

TBI. This study found that a proportion of drivers with TBI, required a behind the wheel

approach for learning to compensate for visual changes after TBI. Physical impairment was


117

found to affect driving capacity in a quarter of the sample. On-road training was found to be a

successful intervention to learn to compensate for physical impairment and/or learn to use

adaptive equipment.

3.5.3 Enhancing previously learned skills

As with other studies, (Jones et al., 1983; Klavora et al., 2000) a proportion of drivers

(57.4%) required on-road training to enhance previously learned driving skills, such as improving

poor driving habits, or addressing a lack of recent or relevant driving experience. Although the

numbers were small, the proportion of older drivers (aged 65 and over), was higher in the group

requiring on-road training than in the group who passed the initial on-road assessment. Whilst

this could indicate that older drivers with a TBI may be more likely to require on-road training,

no such conclusion can be drawn from these data: the sample was small and the group difference

was not significant.

3.5.4 Lesson goal; confidence

Improving confidence was a goal for around half of those who required on-road training

(53.2%). Women were significantly more likely to require lessons to improve confidence than

men. This finding is consistent with the older driver literature, where older females were more

likely to avoid some driving situations, possibly due to anxiety or lack of confidence (Oxley,

Charlton, Scully, & Koppel, 2010). From the total sample of 340 participants, 19 drivers were

cleared to drive after a subsequent assessment without on-road training. Of the 94 drivers

requiring on-road training, 9% required only one or two lessons. One driving instructor reported

anecdotally that improved driving performance was frequently observed during the first lesson,

when the stress associated with being assessed was removed. Where lesson goals are not


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impairment related, but focused on improving confidence or previously learned driving skills,

providing feedback and offering a second on-road assessment may reduce the requirement for on-

road training.

It has been found that awareness of impairments could aid in adjustment and modification

of driving behaviour after brain injury (Lundqvist & Alinder, 2007). On-road training that

provides real world driving experience and timely feedback, may be a useful intervention to aid

insight development into the effect of impairment on driving. It could therefore be another

potential goal of on-road training, but was not examined in the current study.

In summary, OTDA directed on-road training was needed for a broad range of factors

which contributed to poor driving performance after TBI. This may explain why

neuropsychological assessments alone have limited predictive value for on-road assessment

outcome (Classen et al., 2009; McKay et al., 2015) . Such assessments do not capture the full

range of skills (e.g., physical/motor skills, relevant driving experience) required for resumption of

driving. Future studies investigating the association between neuropsychological assessments and

on-road assessment outcome, should also identify the reasons for failing the on-road assessment.


A number of studies have recommended a model of driver rehabilitation where return to

driving is graded, using on-road training, employing a functional /contextual approach, restricted

licenses and providing opportunities for driver education and relearning of skills (Brouwer &

Withaar, 1997; Brouwer et al., 2002; Devos et al., 2012; Hopewell, 2002). Furthermore,

Marshall (1999) found that the availability of restricted licensing and adopting a graded approach

to driving after TBI, made physicians more comfortable with reporting medical conditions

(Marshall & Gilbert, 1999). Another aim of the current study was to describe a graded approach


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to return to driving using restricted licenses and multiple reassessments over time. This graded

approach is supported by the findings of this study; 92.5% (n=87) of participants resumed driving

after on-road training and approximately half (n=45) with a restricted license. Only 7 of the 94

drivers did not return to driving following driver rehabilitation. In contrast to the high success

rate reported here, another study, has found that despite providing on-road training there was a

high failure rate of 46%. It is difficult to directly compare results, as this sample comprised

diagnoses of stroke, TBI and cerebral palsy and included learner drivers (Jones et al., 1983). The

timing of the driver assessments and number and content of driving lessons may also have

influenced the pass/fail rates.

3.5.6 Timing of return to driving

At the rehabilitation centre from which this sample was derived, the timing of referral for

driver assessment was determined by experienced medical and therapy staff. Readiness to

resume driving was generally not considered until 3 months post-injury, to allow time for some

recovery of motor and cognitive sequelae. The average time from injury to off –road assessment

was significantly shorter for the group that passed the initial assessment, compared to the more

severe group that required on-road training (table1). In addition there was a significant difference

in average time from injury to resuming driving (21.5 months), compared to the group who

passed the initial assessment (8.2 months). This is consistent with results from another study,

where those with less severe injuries returned to driving more quickly, often within the first year

post-injury(T. A. Novack et al., 2010). The time required to complete driving lessons and

subsequent reassessments would have contributed to the time taken for to resume independent

driving.

3.5.7 Resources


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A further aim of this study was to provide a description of the resources associated with

on-road training and reassessments. Labour hours rather than cost, was considered to be the most

generalizable measure of resources, as cost of service delivery varies between countries, whereas

labour hours remain consistent. No studies were found that had examined resources associated

with other driver rehabilitation interventions, such as driving simulator sessions, in a TBI

population. A cost comparison is therefore not possible, however the study results provide a

useful basis for treatment planning after TBI.

3.5.8 Limitations

As this was a descriptive cohort study without a comparison group, it is not possible to

draw conclusions regarding the efficacy of on-road training compared to no intervention or any

other form of intervention. However, it was considered both unethical and unsafe, to have a

comparison group who did not receive driver rehabilitation. The study was conducted at a single

site, including patients receiving comprehensive rehabilitation and therefore results may not

generalise to other TBI populations.

Passing the on-road assessment was the outcome used to measure driver competence. The

absence of crashes in the longer term, is arguably a more accurate measure of driving capacity.

This was not measured in the current study but our previous research, which included many of

the same participants, found that drivers followed up an average of 4.5 years post injury, did not

report more crashes compared to pre- injury (P. Ross et al., 2015). They had completed the same

OT driver assessment and rehabilitation process.

3.5.9 Future research

This study provides descriptive background to enhance knowledge in this important and

relatively under-researched area of driver rehabilitation after TBI. Future studies might examine


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more directly the relationship between on-road training and driver self-awareness. Learner

drivers with a TBI were excluded from the current study, but the needs of this group should be

examined. In a study conducted by Kreutzer (2009) nearly half of the caregivers of individuals

with TBI reported that driving behaviour was a key area of concern (Kreutzer et al., 2009). Future

research could investigate whether participation in a driver assessment and rehabilitation program

for individuals with TBI could reduce carer stress.

3.5.10 Conclusion

Many studies have based fitness to drive determinations on the pass/fail outcome of on-

road assessment, without considering the potential benefits of on-road driver re-training (Bliokas

et al., 2011). With this approach there is the risk that many people who fail an initial on-road

assessment following TBI, may be excluded from the opportunity to resume driving. This study

has demonstrated that there may be a number of reasons for failing an initial on-road assessment,

which do not preclude successful return to driving after TBI. Individualised goals for on-road

training, reassessments and restricted licensing may assist individuals with TBI to develop the

confidence, driving skills and compensatory strategies to return to driving.

Declaration of Interest

The corresponding author was awarded an RACV Sir Edmond Herring Memorial Scholarship in

2009.

The remaining authors report no declarations of interest.

3.6 Implications for Rehabilitation

Driver rehabilitation specialists should offer on-road driver training to individuals with

moderate to severe TBI who fail an initial driver assessment.


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Goal directed driving lessons can train individuals with moderate to severe TBI to

compensate for cognitive, physical, visual and psychological barriers to driving, enabling

them to pass a reassessment and return to driving.

Restricted licences may enable some drivers with TBI to meet their driving needs and

achieve safe return to driving.

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CHAPTER 4

ON THE ROAD AGAIN AFTER TRAUMATIC BRAIN INJURY:

DRIVER SAFETY AND BEHAVIOUR FOLLOWING ON-ROAD

ASSESSMENT AND REHABILITATION

This Chapter constitutes a manuscript published in Disability and Rehabilitation.

Ross PE, Ponsford JL, Di Stefano M, Charlton J, Spitz G. (2015). On the road again after


rehabilitation. Disability and Rehabilitation :1-12.

This chapter was formatted in accordance with requirements set by Disability and Rehabilitation,

which included the use of the Council of Science Editors citation and sequence format for

referencing.

Chapter 4 Driver Safety and Behaviour after TBI

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The purpose of driver assessment and rehabilitation is to facilitate and optimise a safe

return to driving. Study 1 and Study 2 examined and described the predictors and processes for

resuming driving after TBI based on passing an on-road assessment. However, the most accurate

measure of a safe return to driving is the absence of crashes and traffic infringements in the

longer term. The focus of the final study was therefore, to examine driver safety by investigating

crash rates and patterns of driving compared to pre-injury in both the group who passed the initial

assessment and the group who resumed driving after on-road training and subsequent

assessments.

Accurate data about crash involvement can be difficult to obtain. The limitations for each

of the three data collection methods (self–report, data from driver licensing authority records and

the report of a significant other) are discussed in Study 3. The original design for this study was

to combine self-report using a questionnaire with information about police reported crashes and

traffic infringements from the VicRoads the local driver licensing authority, however due to lack

of resources and the high cost of obtaining this data this method was deemed to be impractical.

The questionnaire was the sole method used to obtain data about crash involvement and

information about pre and post –injury patterns of driving. The questionnaire was sent to all of

the participants who could be contacted from the sample used in Study 1. Of this group 106

participants or 52% of the sample responded.

As discussed in 1.7.2, the results of research into whether drivers with TBI modify their

driving behaviour to compensate for impairment have been mixed. Study 1 found that

participants in the rehabilitation group had sustained a significantly more severe TBI than those

in the pass group. One of the goals of Study 3 was therefore to examine whether there were


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differences between the pass group and rehabilitation group with regard to post- assessment

driving patterns and whether either group had modified their driving in response to perceived TBI

related impairment.

Some repetition will be apparent with regard to the literature reviewed and methods

described, and as noted, some formatting will be different in accordance with the journal’s

submission requirements.


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4.1 Abstract

Purpose: To examine pre- and post-injury self-reported driver behaviour and safety in

individuals with traumatic brain injury (TBI) who returned to driving after occupational therapy

driver assessment and on-road rehabilitation.

Method: A self-report questionnaire, administered at an average of 4.5 years after completing an

on-road driver assessment, documenting pre- and post-injury crash rates, near-crashes, frequency

of driving, distances driven, driving conditions avoided, and navigation skills, was completed by

106 participants, who had either passed the initial driver assessment (pass group n=74), or

required driver rehabilitation, prior subsequent assessments (rehabilitation group n =32).

Results: No significant difference was found between pre- and post-injury crash rates. Compared

to pre-injury, 36.8% of drivers reported limiting driving time, 40.6% drove more slowly, 41.5%

reported greater difficulty with navigating and 20.0% reported more near-crashes. The

rehabilitation group (with greater injury severity) were significantly more likely to drive less

frequently, shorter distances, avoid: driving with passengers, busy traffic, night and freeway

driving than the pass group.

Conclusions: Many drivers with moderate/severe TBI who completed a driver assessment and

rehabilitation program at least 3 months post-injury, reported modifying their driving behaviour,

and did not report more crashes compared to pre-injury. On-road driver training and training in

navigation may be important interventions in driver rehabilitation programs.


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4.2 Introduction

Traumatic brain injury (TBI) results in a range of physical, cognitive, sensory, emotional

and behavioural changes that may affect driving capacity (Ponsford et al., 2013). Resuming

driving after TBI represents a major step towards independence and return to pre-injury lifestyle

(Liddle et al., 2012; Rapport et al., 2006). Assessment of fitness to drive should therefore be

addressed as part of the rehabilitation process (Brouwer & Withaar, 1997; Liddle et al., 2011;

Rapport et al., 2008; Schultheis et al., 2009).

Methods for assessing clinical fitness to drive have included off-road tests (eg

DriveAware (Kay et al., 2009), Cognitive Behavioural Driver’s Inventory (Engum et al., 1988),

Useful Field of View (Fisk et al., 2002)), neuropsychology tests (Bliokas et al., 2011) and

driving simulator assessments.(Classen & Brooks, 2014) (Lew et al., 2005). Some of these

methods have been found to be useful for identifying potential issues for driving (Asimakopulos

et al., 2012), but not as useful for assessing the impact of other factors, such as physical, sensory

impairment and past driving experience on driving capacity and have generally proved to be

unreliable predictors of real-world driving (Classen et al., 2009). The most commonly accepted

and recommended method for determining fitness to drive following TBI includes on-road driver

assessment (Bouillon et al., 2006; Classen et al., 2009; D’apolito et al., 2013; Fox et al., 1998;

Korner-Bitensky et al., 2006).

In Australia, Occupational Therapist Driver Assessors (OTDAs), who have completed

additional training in driver assessment, have been conducting fitness to drive assessments since

1987. There is no mandatory reporting of medical conditions in the state of Victoria, Australia;

however, OTDAs are responsible for providing recommendations to the Driver Licensing

Authority (DLA), VicRoads, regarding fitness to resume driving (Di Stefano & Macdonald,


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2010). More than 70 percent of individuals with moderate to severe TBI who have received

rehabilitation, and been followed up over a ten year period, have resumed driving following such

an assessment (Ponsford et al., 2014). Whilst the Australian medical guidelines for fitness to

drive (Austroads, 2012), do not prescribe a non-driving period, common practice in some

hospitals in Australia has been to delay driver assessment for at least three months post-TBI.

Following a mild TBI, cognitive sequelea can still be present in some cases 3 months post-injury

(Ponsford et al., 2000), however little is known, about the optimum timing for resuming driving

or the crash rates, driving experiences and behaviour following on-road assessment and

rehabilitation.

To establish the validity of on-road driver assessment and rehabilitation programs, it is

important to obtain longer-term follow-up information regarding driver behaviour, crash

involvement, and traffic infringements (Fox et al., 1998; Schanke et al., 2008; Schultheis et al.,

2002). Methods used to examine crash- rates and traffic infringements include: self-report, report

of a significant other, and examination of DLA records. It has been acknowledged that reports of

pre-injury driving patterns by significant others are subjective and difficult to validate

(Pietrapiana et al., 2005). It is also difficult to compare crash-rates between studies due to

variability in follow-up periods, and inconsistent reporting of crashes to authorities. Studies

comparing self-reported crash-rates with those of DLA records in TBI (Schultheis et al., 2002)

and stroke (Finestone et al., 2011) populations have found discrepancies: DLA databases record

police-reported crashes and do not include minor crashes or fault status. Although self-report

may be affected by memory or response bias, particularly in a cognitively impaired population,

an Australian study of older drivers found that retrospective self-report of crash history was a

preferable method of measurement to obtaining data from DLA records (Anstey, 2009).


135

One study in a TBI group, using an un-validated questionnaire, found a high correlation

between self- report of driving behaviour and that of a significant other (Labbe et al., 2013),

however, there are limited validated tools to measure self- reported driver behaviour and crash-

rates in the TBI driving literature. There have been promising results regarding validation of the

Safe Driving Behaviour Measure, which uses self- and significant -other report to screen for

risky driving behaviour in older drivers. This may also be useful for future use with the TBI

population (Classen et al., 2013).

Reviews examining research into driver behaviour and safety following TBI have

concluded that findings have been inconclusive and contradictory due to methodological issues

(Charlton et al., 2010; Classen et al., 2009; Ortoleva et al., 2012; Tamietto et al., 2006). These

have included small or poorly defined samples (injury severity, years licensed), with mixed

diagnoses and use of various outcome measures of driving capacity, such as driving status

(driving vs not driving), passing or failing an off and/or on-road test, and driving safety,

measured by crash-rates and traffic violations. Several studies have found that drivers with a TBI

are not significantly more likely to crash compared to the general population (Haselkorn et al.,

1998; Priddy et al., 1990; Schultheis et al., 2002) whilst others suggest that crash-risk is increased

(Bivona et al., 2012; Formisano et al., 2005; Lundqvist, Alinder, & Ronnberg, 2008; Schanke et

al., 2008).

Similarly some studies have found that many individuals with TBI modified their driving

behaviour in response to perceived driving difficulties (Labbe et al., 2013; Priddy et al., 1990;

Schultheis et al., 2002). However, in a study comparing driving behaviour of a Cerebral Vascular

Accident (CVA) and TBI group, the CVA group modified their behaviour and drove less

frequently, whereas the TBI group did not (Schanke et al., 2008). Furthermore, it is difficult to


136

ascertain whether successful completion of a driver assessment and rehabilitation program

influenced crash-rates or driver behaviour.

The results of studies examining the association between pre-injury driver behaviour and

post-injury safety are also inconclusive. Pre-injury risky driving behaviour, crash-rates and traffic

violations, reported by a significant other, were found to be associated with post-injury driver

safety (Pietrapiana et al., 2005). In contrast, Coleman (2002) did not find a relationship between

pre-injury driving record and post-injury crash-rate.

The ability to modify driving behaviour has been found to be a key indicator of safe

driving following TBI (van Zomeren et al., 1988), and is also a goal of driver rehabilitation,

where training is provided to compensate for impairment and remediate specific driving skills (Di

Stefano & McDonald, 2006). The lack of knowledge about the outcomes of on-road driver

rehabilitation was highlighted in a systematic review of interventions used by occupational

therapists to improve on-road fitness to drive [41]. The reviewers were unable to find any studies

examining the outcomes of providing a series of on-road driver rehabilitation lessons. However, a

more recently published study (P. E. Ross et al., 2015), documented the outcomes of a driver

rehabilitation program provided to drivers with TBI who had failed the initial on-road

assessment, and found a high probability of return to driving. An older study by Jones (1983)

also examined the outcomes of an on-road driver rehabilitation program, but the sample

comprised mixed diagnoses (Jones et al., 1983).

The review presented here highlights a gap in knowledge about the characteristics, crash

rates and driving behaviour of individuals with TBI, the efficacy of driver rehabilitation, and the

extent to which drivers with a TBI modify their driving behaviour relative to pre-injury.


137

Therefore, the goals of the current study were:

1. To examine self-reported pre- and post-injury driver safety and patterns of driving

behaviour amongst individuals with a TBI, who had completed a driver assessment

program. It was hypothesized that drivers would report more crashes or near-crashes, and

would report more modifications to their driving behaviour relative to pre-injury.

2. To compare the characteristics and subsequent self-reported driver behaviour of those

drivers who returned to driving after one on-road assessment with those who received on-

road driver rehabilitation prior to subsequent assessments. It was hypothesized that

drivers who did not pass the initial driver assessment and required driver rehabilitation

would have sustained a more severe TBI and would be more likely to have modified their

driving behaviour.

4.3 Methods

Ethics approval was obtained from the Human Research and Ethics Committees of both

Epworth HealthCare and Monash University and all participants provided informed consent.

Participants were assured that the information, provided in a mailed questionnaire, would remain

confidential and would not be passed on to VicRoads, the DLA in Victoria, Australia.

4.3.1 Participants

This study drew on a sample of 209 patients with a TBI, from a previous study (Ross,

Ponsford, Di Stefano, & Spitz) who were consecutively assessed as fit to resume driving

following a driver assessment and rehabilitation program at Epworth Rehabilitation, Australia,

between 2002 and 2009. Following common local practice, all drivers were assessed at least 3


138

months post-injury and had received medical clearance and completed a neuropsychology

assessment. Learner drivers and those who did not pass the driver assessment and rehabilitation

program were excluded.

The final study sample comprised 106 participants (81 male = 76 %) who responded to a

postal questionnaire. Cause of TBI included motor vehicle (36%), pedestrian (14%), motor-bike

(16%) and bicycle (7%) crashes, falls (12%), work-related (6%), assaults (1%) and missing data

(8%). Drivers completed the questionnaire between 8 months and 10 years after passing their

most recent driver assessment, with a mean time since driver assessment of 4.5 years.

All respondents had sustained a loss of consciousness, with 2.0% classified as mild

(PTA< 24 hours), 25.5% as moderate (PTA 1-7 days), 36.3% as severe (PTA 8-28 days) and

36.3% as very severe (PTA> 28 days). When measured by GCS score, 39.1% were classified as

mild (GCS 13-15), 17.5% as moderate (GCS 9-12), and 43.4% as severe (GCS 3-8). Only one

person was classified as mild on both PTA duration and GCS score, resulting in a sample

comprised predominantly of moderate to severe injuries.

4.3.2 Driver assessment and rehabilitation procedure

All drivers had completed the same driver assessment process, which complied with the

Competency Standards for Occupational Therapy Driver Assessors guidelines. In 90% of

assessments, the same experienced driving instructor provided standard directions and maintained

vehicle safety. The assessments were conducted by one of four OTDAs, who had all attended the

same training course (OT-Australia, 1998). The test comprised an off-road evaluation followed

by an on-road assessment of 50 to 60 minutes duration, conducted in a dual-controlled vehicle on

a standard route, designed to include a variety of driving manoeuvers and traffic conditions.

Driver behaviour was recorded as appropriate/inappropriate using a defined checklist. An


139

unconditional pass included demonstration of independent driving without requirement for

driving instructor intervention.

For those who did not pass at the first attempt, driver rehabilitation lessons were

conducted with the same driving instructor involved in the assessment. The OTDA provided a

written report to the driving instructor. This documented the problems that were observed and

recommendations regarding the number and focus of the lessons, which included teaching

compensatory and remediation strategies and skill development. Following the prescribed

number of driving lessons, an on-road reassessment was completed to assess whether the driver

was considered safe to resume driving.

Recommendations regarding fitness to drive, based on the pass/fail criteria included in

the Competency Standards (OT-Australia, 1998) and the Victorian license test performance

criteria relevant at the time (POLA criteria, 1999) were provided by the OTDA to the

DLA(VicRoads) and included unconditional pass, license suspension or license restrictions. The

latter included a condition to drive with: automatic transmission, adaptive equipment (e.g.

spinner knob, left foot accelerator pedal), or restriction of driving within a defined area.

The cost of the driver assessment and rehabilitation program for all participants was

covered by private health or Worker’s compensation insurance, or the Transport Accident

Commission, a no fault compensation system providing medical benefits to people injured in

transport accidents in Victoria, Australia.

4.3.3 Data collection

Data for the 209 potential participants was extracted from medical and OT driver

assessment records and included age at injury, gender, diagnosis and details of TBI, lowest pre-

intubation Glasgow Coma Scale (GCS) score in the first 24 hours and Post Traumatic Amnesia


140

(PTA) duration, measured prospectively using the Westmead PTA Scale (Marosszeky et al.,

1997; Ponsford, 2014), number of years licensed and driver assessment outcome. Participants

were classified into two groups according to the outcome of the initial driver assessment: The

pass group included those who returned to driving after one on-road assessment without driving

lessons and the rehabilitation group which required driving lessons and/or more than one on-road

assessment. Of the methods discussed in the introduction, self-report was considered to be the

most reliable method of data collection for the current study as the alternatives, were judged to

have greater limitations. Accessing DLA records and/or infringement data were considered but

proved to be impractical due to limited resources.

4.3.4 Questionnaire

In the absence of a suitable existing instrument, a questionnaire was developed to

document self-reported pre- and post-injury safety record, as well as driver behaviour. The design

and item content of the questionnaire was based on instruments used in previous studies

(Charlton et al., 2006; Fisk et al., 1998; Lundqvist et al., 2008; Rapport et al., 2006; Schanke et

al., 2008; Schultheis et al., 2002).

The questionnaire (Appendices A and B) was mailed to the 209 potential participants

with a reply paid envelope, consent form, and participant information sheet and was therefore not

completed anonymously. Many of the participants had been medically reviewed at three, five and

ten years post injury and contact details had been updated. Of those who did not return the

questionnaire by post, some were able to be contacted by telephone and given the option of


141

responding via telephone interview. In total, 60 potential participants (28.7%) were not able to be

contacted.

Questionnaire items prompted participants to compare driving behaviour and safety

across two points in time: in the five years prior to injury, and after resuming driving post-injury,

with regard to frequency of driving, distances driven, perceived importance of driving to lifestyle,

driving conditions avoided, number of minor or major crashes in which they were the driver,

near-crashes, defined as a ‘near-miss’ or ‘close call’, traffic infringements, measured by number

of speeding fines, license suspensions, and employment status. Modifications made to driving

behaviour with regard to duration of driving time, driving in unfamiliar places and driving speed

were explored. Participants were asked whether they had more difficulty planning and

remembering routes post-injury and to identify from a checklist, any issues they had continued to

experience with regard to driving. In addition, comments were sought regarding the helpfulness

of the program in returning to driving.

4.3.5 Data analysis

Data were analyzed using the Statistical Package for Social Sciences Version 20.0 (SPSS

Inc., Chicago). Sample characteristics and driving behaviours were examined using descriptive

statistics. Independent samples t-tests and Chi-square statistics were used to compare variable

mean scores and differences in frequency of questionnaire responses between the pass and

rehabilitation groups. The relationships between the study variables were identified using

Pearson’s correlations. Pre- and post-injury driving behaviour and safety record were compared

using McNemar’s Test. Pre-injury crash rates were calculated for each individual by taking the

lower number of crashes reported and dividing this by the 5 years preceding their accident. Post-


142

injury crash rates were calculated for each individual by dividing the lower number of crashes

reported by length of time from the date of the final assessment to completion of questionnaire.

4.4 Results

4.4.1 Respondent and non-respondent characteristics

Of the 209 potential participants, 149 drivers were able to be contacted and received the

questionnaire and of these, 26.8% (n=40) declined to participate. Three respondents reported that

they were no longer driving, and were excluded. Of the total pass group, 54% (n=74) and 46% of

the total rehabilitation group (n=32) responded to the questionnaire. As shown in table 1, the

non-participating group, comprising those unable to be contacted, declining to participate, or not

driving, did not differ significantly from the study sample with regard to: age (t (207) = -1.29:

p=0.20), injury severity measured by PTA duration (t (200) = -1.26: p=0.21) and GCS score (t

(180) = 1.126: p=0.21), years licensed (t (207) = -1.84: p=0.07), or gender (χ2 (1, N=209) =0.08,

p =0.78).

Table 1 Characteristics for respondents and non-respondents

Respondents N=106 Non-respondents N=103

M SD Range M SD Range

Age at injury (years) 37.81 14.82 18-73 35.12 15.35 17-79

Age at questionnaire

completion

43.62 14.85 21-78 41.92 15.47 21-86

GCS score 9.13 4.47 3-15 9.90 4.22 3-15


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PTA duration (days) 25.63 26.95 0.1-140 20.41 22.76 0.5-107

Years Licensed 18.73 14.89 0.2-55 15.02 13.85 0.2-61

Gender (Male) 76.4 (81) 75 (75)

NOTE: M = mean, SD =standard deviation, %, (n)

4.4.2 Pass and rehabilitation group characteristics

As shown in table 2, no significant differences were found between the groups with

regard to: age at injury, age at questionnaire completion or years licensed. When compared on

PTA duration and GCS score, participants’ injuries in the rehabilitation group were significantly

more severe than in the pass group. Pre-injury, 95.2% of participants reported that they were

engaged in work, compared to 60.4% at completion of questionnaire and of these, eight of the ten

aged over sixty-five had retired. Not surprisingly, a significant group difference was found in

employment status, with 70.3% of the pass group and only 40.6% of the more severe

rehabilitation group engaged in work or study post-injury: (χ2(1, N=106) = 11.43, p = 0.02). No

significant difference was found in perceived importance of driving to lifestyle, either between

the groups or pre- and post-injury. Five drivers (15.6%) from the rehabilitation group drove with

adaptive equipment compared to 3 (4.1%) in the pass group.

Table 2 Characteristics for pass and rehabilitation groups

Pass Group N=74 Rehabilitation Group N=32

M SD Range M SD Range p

Age at injury (years) 38.74 14.99 18-72 35.66 14.43 19-72 0.33

Age at questionnaire 43.40 14.97 22-78 44.12 14.78 21-75 0.78


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completion

GCS score 10.06 4.15 3-15 7.10 4.52 3-15 0.003

PTA duration (days) 18.08 17.97 <1-84 44.64 35.60 <1-140 <0.001

Years Licensed 19.93 14.94 0.2-54 15.95 14.63 1-55 0.21

Gender (Male) 78.38(58) 71.88 (23) 0.47


4.4.3 Comparison of self-reported pre- and post-injury driving behaviour

As shown in table 3, a significant difference was found between pre- and post- injury

frequency of driving for; 1) the whole group (n=106); 92.5% of drivers reported driving nearly

every day pre-injury compared to 78.3% post-injury and 2) in the post-injury driving frequency

between the groups, with 83.8% of the pass group (n=74) reporting that they drove nearly every

day compared with 65.6% of the rehabilitation group (n=32).

At the time of questionnaire completion, 99 drivers had been driving between 12 months

and 10 years post-assessment. Of the remaining 7 drivers who had been driving between 8 and 12

months, 5 were in the pass group, 6 reported that they drove nearly every day and 1 reported

driving one to three times per week.

A significant difference was also found between pre- and post-injury distances driven

(table 3); 86.9% of participants reported driving anywhere pre-injury compared to 69.8% post-

injury and 30.2% drove mainly within 10km of home. Most of the pass group (78%) continued

to drive anywhere compared to only 50% of the rehabilitation group. In addition, 25.0% of the

rehabilitation group reported driving mainly within 5km from home, compared to 6.8% of the

pass group. Only 7 of the 106 respondents, all in the rehabilitation group, had a restricted license,

limiting driving within a defined geographical area.


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Both groups reported having modified their driving with regard to avoiding busy traffic,

taking passengers, night driving and driving on freeways. Statistically significant differences

were found for both groups in avoiding busy traffic and night driving and for taking passengers in

the rehabilitation group only (table 3). It is noted that at the time of questionnaire completion,

eight of the pass group (n=74) and two of the rehabilitation group (n=32) were aged over sixty-

five and may have modified driving behaviour due to age-related changes.

Table 3 Comparison of self-reported pre- and post-injury driving behaviour

Behavior Total Group N=106 Pass Group N= 74 Rehabilitation Group N=32

Pre-

injury

%

Post-

injury

%

p

Pre-

injury

%

Post-

injury

%

p

Pre-

injury

%

Post-

injury

%

p

Driving nearly

every day

92.5 78.3 <.001 90.5 83.3 .23 96.9 65.6 .002

Driving

anywhere

86.8 69.8 .001 86.5 78 .21 87.5 50.0 .002

Avoid busy

traffic

15.1 37.7 <0.001 16.2 32.4 < 0.001 12.5 50.0 <0.001

Avoid

passengers

2.8 16 0.001 2.7 10.8 0.07 3.1 28.1 0.008

Avoid night

driving

1.9 24.5 <0.001 1.4 20.3 <0.001 3.1 34.4 0.002

Avoid

freeway

3.8 14.2 .003 1.4 8.1 0.06 9.4 28.1 0.07


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4.4.4 Self- restriction of driving and navigation

Compared to pre-injury, 36.8% (n=39) of participants reported that they limited the time

they drove for, 19.8% (n=21) avoided unknown places, 40.6% (n=43) drove more slowly and

41.5 % (n=44) reported more difficulty with planning and remembering routes. Significant

differences were found between the groups for these variables with the exception of planning and

remembering routes post-injury. (table 4) Both groups reported fatigue as the main reason for

limiting driving time and increased caution and awareness of safety was the main reason for

driving more slowly. Avoidance of unknown places was attributed to poor memory and lack of

confidence .

Table 4 Self-restriction of driving and navigation difficulties

Driving

Behavior

Total Group

N = 106

Pass Group

N = 74

Rehabilitation Group

N = 32

n % n % n % p

Limit driving time 39 36.8 22 29.7 17 53.1 .02

Due to:

Pain 6 8.1 0 0

Fatigue 10 13.5 10 31.3

Anxiety 2 2.7 5 15.6

Avoid unknown places 21 19.8 8 10.8 13 40.6 <.001

Due to:

Memory 3 4.1 8 25.0

Confidence 3 4.1 4 12.5

Drive more slowly 43 40.6 25 33.8 18 56.3 .03

Due to:


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Anxiety 3 4.1 1 3.1

More cautious 15 20.3 8 25.0

Safety awareness 2 2.7 5 15.6

Time to respond 1 1.4 3 9.4

Speed cameras 1 1.4 1 3.1

Difficulty navigating 44 41.5 28 37.8 16 50.0 .24

4.4.5 Crash rates, speeding fines, license suspensions and near crash events

Crashes were reported pre-injury by 31.1% of participants and post injury by 28% of

participants. No significant difference was found in the proportion of post-injury crashes reported

between the rehabilitation group (n= 9 - 28%) and the pass group (n= 21 -28%) Although this

data was not able to be verified, as access to DLA records was precluded due to funding

limitations, and the sample size was small, no significant difference was found between pre- and

post-injury crash-rates, t(105)=1.03,p=.30. As shown in table 5, no significant difference was

found between the characteristics of participants who reported crashes post-injury and those who

did not.

Speeding infringement data were obtained by self-report but assessed as unreliable due to

inconsistent operation and number of speed cameras in the region during the period of data

collection. However, as would be expected, those who reported speeding fines had been driving

for longer (M=64.42, SD=29.29) than those who had not received any speeding fines (M=46.50,

SD=29.19): t(104)=-3.09, p = .003.

Of the pass group, 9.5 % (n=7) reported that their driver’s license had been suspended post-

injury, compared to 15.6% (n=5) of the rehabilitation group. Although 19% (n=20) of


148

participants;14.9% (n=11) of the pass group and 29% (n=9) of the rehabilitation group) reported

that compared to pre-injury, they had experienced more near-crashes since resuming driving, than

pre-injury, no significant difference in proportions of near crashes was found between the pass

and rehabilitation groups, X2(1,N= 105) = 2.84, p= .09.

Table 5 Characteristics of participants who reported crashes and those who reported no crashes

Crashes reported N=30 No crashes reported N=76

M SD Range M SD Range p

Age at injury

(years)

34.23 14.51 18-64 39.22 14.80 19-73 .12

Age at

questionnaire

completion

40.50 15.75 22-69 44.85 14.39 21-78 .19

GCS score 8.54 4.89 3-15 9.39 4.28 3-15 .40

PTA (days) 22.16 20.56 0.5-69 26.95 29.02 0.1-140 .43

Years Licensed 15.55 14.45 0.2-49 19.98 14.97 1-55 .17

Gender (Male) 74(22) 79 (60) .33

Months driving

since

assessment

61.03 30.41 9.36 –

121.86

49.14 29.35 7.99-

106.81

.07



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4.4.6 Self-reported issues perceived to affect driving capacity

Participants were asked to select from a checklist what factors they felt affected their

current driving capacity (table 6). Fatigue was the most frequently reported issue for both groups

followed by concentration and memory for the pass group, whereas the rehabilitation group

reported slowness, followed by memory issues. A greater proportion of drivers (34%) from the

rehabilitation group felt that their driving ability was not as good as pre-injury compared to

18.9% of the pass group, however the difference was not statistically significant χ2(1, N=104) =

5.02, p = 0.08. Finally, participants were asked to rate the driver rehabilitation process and 92%

stated that it was helpful.

Table 6 Self-reported issues perceived to affect driving capacity

Total Group

N=106

Pass Group

N=74

Rehabilitation

Group

N=32

Issue n % n % n % p

Anxiety 22 20.8 15 20.3 7 21.9 0.85

Concentration 31 29.2 19 25.7 12 37.5 0.22

Fatigue 43 40.6 28 37.8 15 46.9 0.38

Memory 32 30.2 18 24.3 14 43.8 0.046

Slowness 22 20.8 10 13.5 12 37.5 0.005

Distractible 22 20.8 12 16.2 10 31.2 0.08

Anger 19 17.9 11 14.9 9 28.1 0.11

Confidence 19 17.9 11 14.9 8 25.0 0.21

Vision* 5 4.7 3 4.1 2 6.2 0.62


150

Pain*

6 5.7 6 8.1 0

0 0.10

None of the

above issues

27 25.5 21 28.4 6 18.8 0.30


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4.5 Discussion

The first aim of the study was to examine self-reported safety and patterns of driver

behaviour amongst individuals, who had resumed driving after successful completion of a driver

assessment and rehabilitation program at least 3 months post-TBI. It was hypothesized that

drivers would report more crashes and near-crashes following injury and more modifications to

their driving behaviour relative to pre-injury. This hypothesis was partially supported by the

results, as many participants reported modifying their driving behaviour, however no significant

difference was found for self-reported crashes or near-crashes relative to pre-injury,

Our results support those of Schultheis (2002),(Schultheis et al., 2002) who found no

evidence for an increased crash-rate, in drivers with TBI (N=47) who had completed driver

assessment and retraining when compared to a control group. Caution should be applied when

comparing these study results to the current study, as a control group was not used. Similarly,

although Schanke (2008)(Schanke et al., 2008) found that the crash-rate for drivers with TBI who

had received a formal driver assessment, was higher when compared with rates for the general

population in Norway, and the TBI group were less likely to modify driving behaviour compared

to a CVA cohort, it is not possible to make comparisons due to the different methodologies

used.

Whilst the drivers in the current study have continued to drive and have not reported an

increased crash-rate compared to pre-injury, the reliance on self-report and accuracy of memory

in a cognitively impaired population over lengthy intervals of time is acknowledged as a

limitation, and therefore conclusions about driver safety are difficult to draw from this data.

Schulheis (2002) also acknowledged the difficulty in using crashes as a measure of driver safety

as they are relatively rare occurrences.(Schultheis et al., 2002)


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Over 78% of the respondents reported driving on a daily basis, similar to the figure

(81.5%) reported by Schanke (2008). (Schanke et al., 2008) This frequency is higher than

reported in other studies, where 25% (Coleman et al., 2002) and 64% (Fisk et al., 1998) of

participants reported driving each day. This may reflect differences in regional driving patterns or

their samples may have included more severe injuries, as driving frequency in the more severe

rehabilitation group was significantly lower than that in the pass group. Additionally, these

participants were of similar age to those in this study, but did not have access to a driver

rehabilitation program. Whilst not possible to substantiate this in the current study, it may be

conjectured that post-injury driving frequency may be influenced by the driver assessment and

rehabilitation process, as 92% of participants reported that it was a helpful process. Some

participants commented that it was good to be given a formal clearance to resume driving and it

improved their confidence and awareness of driving responsibly.

Many drivers reported modifying aspects of their driving behaviour in response to

recognition that their driving skills had changed: Compared to pre-injury, 36.8% of drivers

limited the time driven, 40.6% drove more slowly and 19.8 % avoided unknown places and were

significantly more likely to avoid busy traffic, night driving, passengers and freeways. These

findings are consistent with those of Schultheis (2002) (Schultheis et al., 2002) and Priddy

(1990),(Priddy et al., 1990) who found that approximately one third of the drivers in their studies

had made voluntary restrictions to their driving, including avoiding unfamiliar routes, night

driving or busy traffic. It is acknowledged that many older drivers modify their driving

behaviour (Molnar, Charlton, et al., 2013; Molnar & Eby, 2008; Molnar, Eby, et al., 2013), and

age-related changes may have contributed to this finding. However, less than 10% of participants

were older drivers, with 6 aged 65- 69 and 4 aged 70 – 78 at the time of questionnaire


153

completion. Fatigue was the main reason for limiting driving time and was reported by 40.6% of

the group as continuing to affect driving. Being more cautious was reported as the main reason

for driving more slowly than pre-injury. Lack of confidence and poor memory were the main

reasons given for limiting driving to familiar areas. This finding suggests that lack of confidence

and strategies to address navigation skills should be addressed during driver rehabilitation.

A unique finding of this study was the high proportion of participants (41.5%) who

reported difficulty with remembering and planning routes: (51.9% of the rehabilitation group and

37.5% of the pass group). Michon’s model of driving (Michon, 1985) describes 3 levels of

decision making: operational decisions involving immediate reactions, tactical decisions

requiring anticipatory manouvres and strategic decisions involving planning, with low time

pressure. Route-planning and navigation would be regarded as strategic aspects of driving and

are amongst the most difficult and time-consuming to assess during on-road assessment. Further

investigation is warranted to determine whether this problem could be predicted by

neuropsychological assessment and whether compensatory strategies, such as training to use a

Global Positioning System (GPS) while driving, would be of benefit.

The practice of delaying the initial driver assessment for at least 3 months post- injury,

combined with the process of driver assessment and retraining, may have provided time and

opportunity for improved driver skills and development of self-awareness of the effects of the

TBI on driving capacity. Interestingly, 74% of respondents felt that issues related to their injury

continued to affect their driving, 25% of respondents considered their driving ability to be worse

and 59% about the same as pre-injury. This contrasts with Rapport’s (2006) (Rapport et al., 2006)

findings, that drivers with a TBI rated their driving abilities as better than average. Driver

assessment and rehabilitation may have contributed to the development of self- awareness and


154

subsequent post-injury modifications to driving behaviour, however, the current study did not test

this premise.

The second aim of the study was to compare the characteristics and subsequent self-

reported driver behaviour of those drivers who returned to driving after one on-road assessment

with those who required driver rehabilitation prior to subsequent assessments. It was

hypothesized that drivers who did not pass the initial driver assessment and required driver

rehabilitation would have sustained a more severe TBI and would be more likely to have

modified their driver behaviour.

This hypothesis was supported by the results: the rehabilitation group included a higher

proportion of individuals with severe TBI than the pass group. This finding is consistent with

results from previous research, that driver rehabilitation is likely to be required by individuals

with a severe TBI to enable a safe return to driving.(Brouwer & Withaar, 1997; Ross et al.; P. E.

Ross et al., 2015) Drivers in both groups reported modifications to their driving behaviour

compared to pre-injury, however, the rehabilitation group was significantly more likely to avoid

driving with passengers, busy traffic, night and freeway driving. Similar to the findings of Labbe

(2013), (Labbe et al., 2013) the more severely injured drivers, were also more likely to drive less

frequently and limit the distance driven. The rehabilitation group was four times more likely to

be driving within 5 km of home than the pass group (only one participant was restricted to

driving within 5 km of home on a conditional license). Factors such as employment status, poor

memory or lack of confidence may have influenced driving frequency and distance driven, in

addition to self-awareness: 40.6% of the rehabilitation group reported that they drove more

cautiously and were more aware of risks compared to 23% of the pass group,


155

The rehabilitation group was twice as likely to report more post-injury near-crashes than

the pass group. A significant difference was found between the groups with regard to self-

reported slowness in thinking, which may have been a contributing factor to the greater frequency

of near-crashes reported by the rehabilitation group and supports Preece (2012) finding, of an

association between hazard perception response speed and PTA duration (Preece et al., 2012).

4.5.1 Limitations

The study findings should be interpreted with reference to several limitations. The

absence of a comparison group who did not undergo the driver assessment and rehabilitation

process limits conclusions regarding the effects of those processes on driver behaviour. However,

such a comparison was not deemed practically or ethically possible. Additionally, care must be

taken in interpreting the results for the rehabilitation group, due to the small sample size.

The study data were based on self-report, which may be associated with memory or

response bias and the accuracy of pre- and post-injury self-reported crash- rates and traffic

infringements may have been affected by 1) the perception that by completing the questionnaire,

the participant’s right to drive might be at risk, due to the lack of anonymity, 2) the time elapsed

between returning to driving and questionnaire completion, 3) the fact that many of the TBI

drivers continued to experience memory difficulties, and 4) the questionnaire did not evaluate

crash fault status or provide a clear definition of a minor or major crash. In future studies, seeking

a corroborative opinion from a significant other regarding crash involvement and traffic

violations, and access to DLA records might improve the accuracy of data. (Classen et al., 2013)

However, information regarding near-crashes, minor crashes or fault status cannot be accessed

from DLA records.


156

Although no significant differences were found in demographic or injury-related

characteristics between the respondents and non-respondents, it cannot be assumed that the

information provided by the group of respondents was representative of the total sample.

Reasons for declining to participate may have included a fear of disclosing a poor pre- or post-

injury driving record. Most drivers in this study continued to drive with few issues, however,

OTDAs involved in the driver assessment program have provided feedback, that at least four

males belonging to the original rehabilitation group, all of whom also had a history of substance

misuse, had license suspensions following return to driving. None of these individuals responded

to the questionnaire. Further research to investigate risk factors for drivers who have passed

driver assessment and then subsequently been banned from driving is warranted.

4.5.2 Conclusion

The current study found, that based on self-report, many drivers with a moderate to severe

TBI, who passed an on-road assessment with or without on-road driver rehabilitation and were

at least 3 months post-injury, reported modifying their driving behaviour to compensate for

ongoing impairment and continued to drive safely in the longer term. This study also highlighted

that navigational difficulties were commonly experienced post-TBI, suggesting that inclusion of

training in navigation may be an important aspect of driver rehabilitation.

Declaration of Interest

Pamela Ross was awarded an RACV Sir Edmond Herring Memorial Scholarship in 2009.

The remaining authors report no declarations of interest.

4.6 Implications for Rehabilitation

Driver assessment and on-road retraining are important aspects of rehabilitation following

traumatic brain injury.


157

Many drivers with moderate/severe TBI, reported modifying their driving behaviour to

compensate for ongoing impairment and continued to drive safely in the longer term.

Navigational difficulties were commonly experienced following TBI, suggesting that

training in navigation may be an important aspect of driver rehabilitation.

4.7 References

1. Ponsford, J., S. Sloan, and P. Snow, Traumatic brain injury: rehabilitation for everyday

adaptive living 2nd Edition(2013): Psychology Press.

2. Rapport, L.J., R.A. Hanks, and R.C. Bryer, Barriers to driving and community integration

after traumatic brain injury. Journal of Head Trauma Rehabilitation, 2006. 21(1) p 34-44.

3. Liddle, J., Fleming, J., McKenna, K., Turpin, M., Whitelaw, P., & Allen, S., Adjustment

to loss of the driving role following traumatic brain injury: a qualitative exploration with

key stakeholders. Australian Occupational Therapy Journal, 2012. 59(1): p. 79-88.

4. Rapport, L.J., R.C. Bryer, and R.A. Hanks, Driving and community integration after

traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 2008. 89(5): p.

922-30.

5. Brouwer, W.H. and F.K. Withaar, Fitness to drive after traumatic brain injury.

Neuropsychological Rehabilitation, 1997. 7(3): p. 177-193.

6. Liddle, J., Fleming, J., McKenna, K., Turpin, M., Whitelaw, P., & Allen, S.., Driving and

driving cessation after traumatic brain injury: processes and key times of need. Disability

and Rehabilitation, 2011. 33(25-26): p. 2574-86.

7. Schultheis, M.T., J. DeLuca, and D. Chute, Handbook for the assessment of driving

capacity 2009: Academic Press.


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8. Kay, L.G., A.C. Bundy, and L.M. Clemson, Predicting Fitness to Drive in People With

Cognitive Impairments by Using DriveSafe and DriveAware. Archives of Physical

Medicine and Rehabilitation, 2009. 90(9): p. 1514-1522.

9. Engum, E. S., Cron, L., Hulse, C., Pendergrass, T. M., & et al., Cognitive Behavioral

Driver's Inventory. Cognitive Rehabilitation, 1988. 6(5): p. 34-50.

10. Fisk, G. D., Schneider, J. J., & Novack, T. A., Useful field of view after traumatic brain

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CHAPTER 5

PhD PROGRAM -GENERAL DISCUSSION

Chapter 5 General Discussion

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5.1 Overview and Integration of Main Findings

Research has identified that driving is one of the most important daily living activities for

many people after TBI (Hopewell, 2002; Liddle et al., 2012). Not surprisingly, it has been

identified as a key rehabilitation goal. Potential sensory, physical, cognitive, behavioural and

emotional sequelae that may be prevalent following TBI, are known to impact on driving

capacity. As such, it is essential that advice and clinical interventions to assist in resuming

driving after TBI are consistent and informed by evidence (Liddle et al., 2011).

There has been considerable variability in results of studies investigating driving after

TBI, likely reflecting their different samples, study settings, licensing contexts and designs.

Studies to date have investigated predictors of passing/ failing on-road assessment, prevalence of

driving after TBI, types of driver errors, post-injury patterns of driving and some studies have

examined driver safety measured by crash rates. Only a small number of these studies have

reported whether participants were offered driver rehabilitation and on-road training after failing

the initial on-road assessment. No studies were identified that examined the characteristics,

interventions provided and outcomes of those individuals with TBI, who received on-road

training after failing initial on-road assessment. Additionally, the use of restricted licensing,

goals of on-road training and longer term safety and driving patterns have not been examined in a

TBI population

The overall objective of this PhD program, was therefore to contribute to current

knowledge about resuming driving after TBI, by examining characteristics of participants,

processes, interventions and outcomes of a driver assessment and rehabilitation program. The

intention of obtaining this knowledge, was to assist in clinical decision-making and to identify

methods to optimise the driver assessment and rehabilitation process for individuals with TBI.


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Study 1 sought to; 1) document the patient characteristics and outcomes of an OT driver

assessment and rehabilitation program and 2) to examine which pre-injury and injury-related

factors were associated with the outcome of the initial on-road driver assessment. The results of

this study found that PTA duration, gender, choice reaction time and the presence of physical and

visual impairments were useful variables in predicting the likelihood of failing the on-road

assessment. They are important referral criteria when deciding whether an OT driver assessment

is indicated. Although 66% of drivers passed the initial assessment and resumed driving, the

remaining 34% required on-road training. No studies have been identified in the literature that

examined and described how this intervention is provided. As such, the aims of Study 2, were to

describe the range of goals, processes, outcomes and resources associated with providing on-road

training in a group of drivers with TBI who failed an initial OT driver assessment. A further

subsidiary aim of the second study was to describe the practical application of the driver

assessment and rehabilitation process and use of restricted licensing as interventions for grading

return to driving after TBI. Only three of the 207 participants in Study 1 did not resume driving.

Given the high rate of relicensing after completing the driving program (with or without lessons),

it was important to examine the longer term safety of this group. This was the focus of Study 3

which addressed two aims; 1) to examine self-reported pre- and post-injury driver safety and

patterns of driving behaviour amongst individuals with a TBI who had completed an OT driver

assessment and rehabilitation program and 2) to compare the characteristics and subsequent self-

reported driver behaviour of those drivers who returned to driving after one on-road assessment,

with those who received on-road training and subsequent reassessments. The study found that

many drivers with a moderate to severe TBI who passed an on-road assessment with or without

on-road training and were at least 3 months post-injury continued to drive safely in the longer


168

term. Many participants also reported modifying their driving behaviour to compensate for

ongoing impairment

The following discussion will integrate the findings across the studies, by considering

each of the aims of the PhD program and highlighting key issues and implications for clinical

practice in the area of driver assessment and rehabilitation following TBI.

5.2 Driving Program Outcomes

To demonstrate how the first aim - to document the patient characteristics and assessment

outcomes of an OT driver assessment and rehabilitation program in a TBI population -was

achieved, the discussion will focus initially on the assessment outcomes, including pass/fail rates,

prevalence of recommended license restrictions and timing of return to driving. Patient

characteristics will be discussed in the next section entitled ‘Factors influencing initial driver

assessment performance’. To examine and compare the characteristics of the participants in each

of the three studies, they were divided into two groups; the pass group who did not require any

on-road training and the rehabilitation group who received one or more driving lessons.

5.2.1 Driving resumption after completing driving program

Of the 340 participants in Study 2, all of whom had been deemed suitable to be

considered for driver rehabilitation, only seven were recorded as having their license suspended

and did not return to driving. No studies were identified that recorded relicensing rates following

driver rehabilitation in a TBI population; however the findings from this study, support Brouwer

and Withaar’s (1997) observation, that relicensing rates can be improved after TBI with access to

a driver rehabilitation program (Brouwer & Withaar, 1997).


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Previous studies have reported that the prevalence of resuming driving after TBI, mostly

without any formal clearance to drive, is estimated to be between 37% and 60 % (Bivona et al.,

2012; Brouwer & Withaar, 1997; Fisk et al., 1998; Hawley, 2001). A higher rate of driving

resumption of 85%, was found in a study where the sample included only drivers with TBI, of

unknown injury severity, who had successfully completed a comprehensive driver evaluation

(Schultheis et al., 2002). It is not known whether any of this sample had required driver

rehabilitation prior to being clear to drive. It is difficult to ascertain whether formal driver

assessment and rehabilitation influences the rates of resuming driving after TBI. There is a lack

of recent literature, reporting numbers of drivers with TBI who receive a formal driving

evaluation and how many are not able to resume driving after driver rehabilitation.

An older study, conducted in the US, found that two thirds of participants had not

received an assessment of their driving (Fisk et al., 1998) and a UK based study published in

2001 found that only 16% of participants who resumed driving, reported receiving advice about

returning to driving (Hawley, 2001). Access to driving programs and the clinical practices for

resuming driving after TBI vary widely between rehabilitation centres and countries. The

rehabilitation facility where the studies were conducted had a well-established in-house driving

program with the costs of driving assessments routinely covered by no-fault accident or workers

compensation insurance. Driving and community mobility issues were routinely considered by

all staff and may have influenced numbers of referrals to the driving program.

Following on-road training and reassessment, the pass rate of 98% of participants referred

to the driving program was very high. It is difficult to compare this relicensing rate with those of

other studies for a number of reasons. The relicensing rate may not be representative of the wider

TBI population that attended this rehabilitation centre as only those individuals who were


170

referred to the driving program were included in the sample. Other rehabilitation centres may use

different referral criteria. For example, some individuals with mild TBI were referred to the

driver rehabilitation program however, at another centre only patients with moderate/severe TBI

may be referred for driver assessment. In addition, the professional disciplines and experience of

those who refer to these programs may differ.

At the centre where this study was conducted, the decision to refer for driver assessment

was made by the doctor after a patient review. In making this decision, the doctor often sought

the opinion of the community based multi-disciplinary team, which may have included

neuropsychologist, occupational therapist, specialist OTDA, speech pathologist, physiotherapist

and social worker. Each case was considered on an individual basis, however the referral criteria

included; meeting the medical and eyesight licensing requirements outlined in the Austroads

Medical Fitness to Drive publication (Austroads, 2012). There are no Australian guidelines

examining timeframes for resuming driving after moderate to severe TBI. The established

procedure based on clinical experience at the centre, was to advise patients not to drive for at

least three months from date of injury. They were also advised that an assessment of readiness to

drive and whether an OT driver assessment was required would be conducted at the review with

their doctor. The results of the neuropsychological assessment, functional occupational therapy

assessment and physiotherapy advice for patients with physical impairment were also considered,

as well as the known driving experience and history and wishes of the patient.

In other centres this decision may rest solely with the doctor. Finally, the sample

included both the drivers who passed after one on-road assessment and those who had passed

after receiving on-road training. Most studies do not specify whether and how much on-road

training was provided. It is to be hoped that a body of knowledge around return to driving can be


171

built up that includes consistent reporting of referral criteria and whether participants have been

offered driver rehabilitation.

From the results of Study 2, it is not possible to conclude that return to driving rates may

be influenced by offering both driver assessment and on-road training, as there was no

comparison group, who did not complete the driving program. However, a longitudinal study of

outcomes after TBI, conducted at the same rehabilitation centre, where patients with potential to

resume driving were routinely referred to the driving program, found that 70% of participants

reported they were driving by ten years post-injury (Ponsford et al., 2014). This rate of returning

to driving is likely to be higher, as the 30% who reported that they were not driving, may also

include people who had never held a driving license or were no longer driving. It may be

surmised, therefore, that at this rehabilitation centre, where a comprehensive driving program is

offered, the prevalence of driving after TBI is greater than 70% and is generally higher than the

rates reported in the literature. In addition, the questionnaire responses from Study 3, indicated

that the majority of individuals who completed the driving program, had continued to drive in the

longer term. Only three of the 106 respondents, reported that they had stopped driving, despite

being cleared to drive after successfully completing the OT driver assessment.

The results of Study 1 were based on data collected from the OT driver assessments of

207 participants conducted between 2002 and 2009. The data from Study 2, included this earlier

data and the results from a further 133 OT driver assessments conducted between 2010 and 2014,

making a total sample of 340 participants. There was a difference in the initial assessment pass

rates between the first (66%) and second studies (72%), as 19 participants in the first study had

received one or two subsequent assessments because their initial assessment result was not clear.

In Study 2, these 19 participants were included in the pass group, as the goal of this study was to


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examine only the participants who had received on-road training. If these 19 participants are

removed from the rehabilitation group in the first study, then the proportion of individuals

requiring on-road training is similar across the studies; 25% in the first study and 28% in the

second study.

5.2.2 Resumption of Driving with License Restrictions

In Victoria, Australia, where this program of research was conducted, OTDAs can

recommend a range of license conditions and restrictions (VicRoads, 2008). In making such a

recommendation, the OTDA will consider the cognitive ability and willingness of the driver to

comply with the restrictions. The conditions must be able to be enforced by police and complied

with by the driver and the occurrence of unexpected situations must be considered(VicRoads,

2008). Examples of inappropriate restrictions would be to limit a driver to a fixed route (what

happens if a detour is required due to road-works or an accident?) or certain weather conditions

(no driving in wet weather) which may change during the journey.

The decision to assess for a restricted license is made by the OTDA after the driver has

failed the standard on-road driving route and usually after completion of driver rehabilitation.

Feedback about driver performance is obtained from the driving instructor and the option of a

restricted license is discussed with the driver and significant others prior to reassessment. When a

restriction to drive within a specified area is likely to be recommended, the on-road assessment is

always conducted in that area. The ability of the driver to navigate in the area is always assessed

by the OTDA. After the assessment the area restriction is discussed with the driver and often a

map is provided. This is also confirmed in writing by the DLA. It is difficult to monitor or

enforce a restricted license, however often a significant other may monitor the driver. In addition,


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an incentive to comply with the restriction is the risk of a fine, conviction or the prospect of loss

of license for failure to comply.

The use of license conditions recommending the use of adaptive equipment, such as

steering aids, left foot accelerator pedals and hand controls to compensate for physical

impairment, is necessary and widely accepted. However, the practice of placing a license

restriction to drive within a specified area is less common. To our knowledge, this is the only

study to have documented the prevalence and use of license restrictions in a TBI population,

within a licensing context, where such restrictions are available.

Of the 94 drivers, in Study 2, who required on-road training, almost half (47.8 %),

resumed driving with a restricted license. Of those requiring a restricted license, 41.5 % required

an automatic license restriction. This included 17% of participants, requiring both the restriction

to drive with automatic transmission and adaptive equipment, to compensate for physical

impairment. Similarly, 19.1% of the group were restricted to driving within a specified area and

may also have been restricted to driving an automatic vehicle. Some participants therefore had

more than one license restriction recommended; three participants had all three restrictions placed

on their license, 33 participants had two restrictions and nine had one restriction.

One of the concerns raised about using restricted licensing in a cognitively impaired

population, was the possibility of non-compliance (Classen, 2014). This may be due to the

presence of poor insight or self-monitoring and memory impairment. In Study 2, it was not

possible to evaluate whether the study participants complied with the conditions on their licenses,

or to measure how safely they drove in the longer term as this was not part of the study design.

The question of compliance with license conditions is difficult to investigate, due to the need to

rely on self-report, the report of a significant other or police report to the DLA. It may have been


174

useful to include a question about license compliance on the questionnaire used in Study 3, but

this was not considered in the study design.

The availability of restricted licensing improved the rates of return to driving in this

group. Without the option to apply a license restriction, the drivers in this group would have been

assessed as unsafe to resume driving at that time. With further recovery or additional driver

rehabilitation they may have eventually been assessed to resume driving with an unrestricted

license. In jurisdictions where restricted licensing is not widely used, these participants would

have been assessed as not fit to hold a license, would not have resumed driving, and would

potentially have experienced reduced participation in a range of activities of daily living.

Although the use of restricted licensing has not been previously investigated in a TBI

population, one study found that the use of restricted licensing, enabled many older drivers to

avoid license withdrawal and thereby maintain independence (Nasvadi & Wister, 2009).

Additionally, crash risk was found to be lower for older drivers with a restricted license,

compared to those with an open license and was found to be a useful method for grading

reduction in driving (Langford & Koppel, 2011).

Study 2, demonstrated how the use of restricted licensing can facilitate a graded return to

driving in a TBI population. The demands of the driving environment can be reduced, by

restricting exposure to more challenging driving conditions, such as busy peak hour or driving on

roads with a high speed limit and driving in unfamiliar areas. For example, a geographical

restriction, can limit drivers to familiar local areas, thereby avoiding the additional demands of

planning and monitoring driving routes, required when driving in unfamiliar areas. By offering

the opportunity to have the license restriction reviewed and eventually removed or modified,

some drivers with TBI can resume unrestricted driving. The process of license restriction review


175

in Victoria, Australia can occur in a number of ways. The OTDA can specify that the driver

should drive within the confines of the license restriction for a period of time (such as 6 months)

and then request an OT driver reassessment to review the restriction. Alternatively the OTDA can

specify to the DLA that the license restriction should be reviewed within a specified time frame

and the DLA will then notify the driver of the need for a reassessment at that time.

Whilst the results of Study 3 found that many drivers with a TBI modified their driving

behaviour and did not appear to be at greater risk of crashes compared to pre-injury, it was not

possible to investigate the safety of the group using restricted licenses. The questionnaire used in

Study 3 did not ask drivers whether they held an open or restricted license. It was therefore not

possible to compare crash risk or traffic violations in the group who had resumed driving with a

restricted license after on-road training, with the group who resumed driving with an open

license. Determining the effectiveness of restricted licensing for maintaining driver safety in a

TBI population, is an area in need of further research.

5.2.3 Timing of return to driving

Whilst the focus of this PhD program of research has been to describe and examine the

processes involved in returning to driving after TBI, the simple question ‘When can I return to

driving?’ remains difficult to answer, particularly for those who have sustained a more severe

TBI. The Austroads medical guidelines for Fitness to Drive (2012), specify a non-driving period

of a minimum of 24 hours when loss of consciousness has occurred, but provide no guidance

about timing of resuming driving for those with a more severe TBI (Austroads, 2012). The

findings from two Australian studies examining fitness to drive status after mild TBI supported

this guideline not to drive for 24 hours post injury (Baker et al., 2015; Preece, 2010), but


176

concluded that better guidance is required about which factors facilitate return to driving after the

24 hour period.

A US study found a relationship between timing of return to driving and injury severity;

those with less severe injuries returned to driving earlier, usually in the first year post-injury

(Novack et al., 2010). However there is a lack of knowledge about timing of resuming driving

following moderate/severe TBI, as time from injury to resuming driving, has not generally been

documented in studies examining resumption of driving following TBI.

Participants in this program of research were not usually referred for OT driver

assessment until at least three months post-injury, to allow time for some recovery of motor and

cognitive impairment. This timeframe is not a documented guideline in Australian fitness to

drive guidelines, but was a standard procedure at the rehabilitation hospital from where the

sample was drawn and was based on clinical experience and previous research. In an Australian

study of recovery following mild TBI, cognitive symptoms that were reported at one week post-

injury had resolved in 76% of participants when assessed at three months post-injury (Ponsford

et al., 2000). Additionally, self-awareness of impairment has been shown to improve over time

(Hart et al., 2009), providing further support for the practice of delaying resumption of driving

and referral to driver assessment for at least three months, for patients with a more severe injury.

Despite this practice, the results from the current PhD program, found that the timing of

the off-road assessment varied considerably. The average time from injury to the off-road

assessment for drivers who subsequently passed the initial on-road assessment was 7.6 months,

with a median of 4.7 months. However the range was from 1.5 months to 5 years post injury.

There was a significant difference between the mean time from injury to off-road assessment for

the pass group and the group that received on-road training. The average time from injury to off-


177

road assessment for the rehabilitation group was 13.3 months post–injury, with a median of 11

months and a wide range, from 2.7 months to around 8 years post-injury. The differences in

delay of the driver assessment for the group requiring driver rehabilitation, were consistent with

having sustained a more severe TBI and/or physical/visual issues affecting driving capacity. This

finding supports results from previous studies, that identified a relationship between injury

severity and time to return to driving (Fleming et al., 2014; McKay et al., 2015; Novack et al.,

2010).

The wide variability that was found in the timing of return to independent driving

illustrates the complexity in assigning a time frame for medical fitness to drive guidelines

following TBI. As discussed in Chapter 1 in section 5.2.3 the UK medical guidelines specify that

relicensing may be considered 6 to 12 months post-injury. The guidelines from New Zealand,

recommend no driving for a minimum of 6 months for a moderate to severe TBI and the US

guidelines do not provide any time frames for resuming driving after TBI. Based on the results

of this PhD program, many drivers with moderate to severe TBI were assessed as fit to resume

driving prior to six months post-injury. This would indicate that improved guidelines are required

the timing of resuming driving after TBI and is an area that warrants further research.

Devos and colleagues (2012) have also identified the need for further research

investigating the optimal or most beneficial time for resuming driving after acute neurological

conditions, in order to improve current fitness to drive guidelines (Devos et al., 2012). Making

the decision about when to refer for driver assessment can be complex and may be dependent on

an individual’s circumstances and need for driving. It is usually based on predicted likelihood of

a successful outcome, as referring too early may result in failure of an on-road assessment (Jones

et al., 1983). However this may also be a desirable outcome; if a driver is at risk of driving,


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despite having been advised not do so, the provision of on-road training may delay resumption

of driving, thereby allowing time for further recovery and potential for improvement of self-

awareness (Brooks & Hawley, 2005).

At the centre where this program of research was conducted, patients were advised by

their doctor not to drive. They were advised that readiness to return to driving would be

considered by their doctor at least three months post injury. Therefore none of the participants

should have been driving prior to the initial on-road assessment.

In the state of Victoria, Australia, mandatory reporting to the DLA is not required.

Therefore unless the doctor and treating team were concerned about non-compliance, patients

still hold a license to drive (although many are under the impressions that their license is

suspended). Where non-compliance is a risk, the doctor can notify the DLA reporting that the

patient does not meet the national medical standards to drive. The DLA will then notify the

patient of license suspension, however there is always the risk that the driver will both ignore

medical advice not to drive and license suspension and continue to drive. This is also a problem

in countries where mandatory reporting of traumatic brain injury is required (DVLA, 2013 ). It is

difficult to enforce a non-driving period in patients with severe cognitive impairment who lack

insight and presents a significant safety risk to the community.

Strategies to minimize this risk, employed by staff at the rehabilitation centre where the

study was conducted included: seeking the cooperation of significant others usually at a pre-

discharge family meeting, informing the patient that their vehicle insurance would be void if they

had a crash or that they risked a conviction, a fine or loss of license for driving unlicensed and an

early referral to the driver rehabilitation program. The referral enables the patient to feel that they


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may legally be able to drive in the near future and sometimes a poor result on the brake reaction

test, conducted during the off-road assessment can assist in delaying driving.

‘Neurological recovery from a traumatic brain injury may occur over a long period and

some people who are initially unfit may recover sufficiently over many months such that driving

can eventually be resumed’ (Austroads, 2012). This statement from the Australian medical fitness

to drive guidelines recognises that readiness to drive may vary after TBI, but that driver’s with a

TBI should be reviewed regularly and given the opportunity to eventually resume driving.

Whilst general guidelines about timing of resuming driving may be provided for many

different medical conditions, the decision to refer for assessment after TBI is likely to be based

on individual factors. From the results of this PhD program of research, these factors would

include severity of injury, cognitive impairments, presence of physical/visual impairment and

psychological factors such as confidence. While the medical and therapy teams are likely to be

the key decision makers as to the timing of referral for OT driver assessment, the wishes of the

individual and their family and risk to the community, may also be contributing factors (Coleman

et al., 2002). Based on the results of this study, the practice of delaying driving for at least 3

months following moderate and severe TBI, appears to be appropriate. The study has highlighted

the complexity of determining timing for resuming driving after TBI and the importance of

considering individual factors during the decision-making process.

5.3 Factors Influencing Initial Driver Assessment Performance

The second aim of Study 1, to examine which pre-injury and injury related factors were

associated with passing a driver assessment, was achieved. The results supported the hypothesis

that patients with greater injury severity, in terms of longer PTA duration or lower GCS score,


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slower brake reaction times and/or physical impairments were less likely to pass an OT driver

assessment. It was also hypothesized that years of driving experience may be associated with

passing a driver assessment; however the results did not support this premise as discussed below.

Examination of neuropsychological assessment results for the sample, may have enriched

the understanding of the driver characteristics. However another study undertaken by our

research group examined the neuropsychological assessment results of 99 participants who were

drawn from the sample used in Study 1 (McKay et al., 2015). It concluded that

neuropsychological assessments are generally poor predictors of on-road assessment outcome

after TBI. This finding is supported by a review of the literature examining neuropsychological

tests as predictors for on-road performance (Classen et al., 2009). The results of Study 2 also

provide support for this finding: Whilst 64% of drivers in the rehabilitation group primarily

required driving lessons to learn to compensate for cognitive issues, 36% required driver

rehabilitation for other reasons, such as lack of confidence or need to address physical or visual

impairment or improve previously learned driving skills. This may, in part, explain the poor

performance of neuropsychological assessments in predicting on-road assessment outcome. The

presence of cognitive issues is therefore a contributing factor related to on-road assessment

outcome, along with a range of other factors.

In order to identify the range of factors associated with failing the initial on-road

assessment, the reasons for an OTDA recommendation of on-road training were required. This

information was obtained by examining the documented goals of on-road training lessons. Study

1 found that in combination, being male, having a shorter PTA duration, faster reaction times and

presence of physical/visual issues correctly classified 87.6% of the pass group but only 71.2% of

the rehabilitation group. By examining the rehabilitation group who had failed the initial


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assessment, Study 2 provided a more detailed description of the cases for whom the predictive

model did not fit well. The findings of Studies 1 and 2 have been integrated to describe the

factors that influenced the outcome of the initial on-road assessment and are discussed below.

5.3.1 Injury related factors

5.3.1.1 Injury severity

Study 1 was the first published study to examine the relationship between PTA duration

and driver assessment outcomes. PTA duration was found to be a stronger predictor of driving

assessment outcome than GCS score. A study by our research group, published subsequently, has

also reported such an association (McKay et al., 2015). In Study 1, most of the pass group

(81%) had shorter PTA duration of less than 28 days and almost half (52%) of the rehabilitation

group requiring on-road training lessons, had PTA duration of greater than 28 days. This result is

not surprising, given the positive association between PTA duration and functional outcome

(Brown et al., 2005). The results also provide support for the early findings, reported by Brouwer

and Withaar (1997), that drivers with shorter PTA duration generally return to driving with few

issues (Brouwer & Withaar, 1997).

However, 16% of the sample in Study 1 had sustained a very severe TBI, with PTA

duration exceeding 28 days and also passed the initial assessment without on-road training.

Therefore, it cannot be assumed that all individuals with a long PTA duration, will fail the initial

assessment. This result supports the recommendation that injury severity alone should not

preclude a driving assessment. There is a need to further study driving performance among

people recovering from differing severity of TBI (Classen et al., 2009).

The second logistic regression model that was examined in Study 1, using gender, PTA

duration and GCS scores, correctly classified 91.4% of the pass group but only 47.5% of the


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rehabilitation group. Whilst the final model using gender, PTA duration, physical/visual

impairment and reaction times, correctly classified slightly less of the pass group (87.6%), it was

significantly better at predicating the rehabilitation group membership (71.2%). Although these

variables accounted for 71.2% of the rehabilitation group, there were other factors associated

with failing the initial on-road assessment for the remaining 28.8%. These factors were identified

in Study 2, examining the goals of the on-road training that was provided to the rehabilitation

group and will be discussed in section 5.4 entitled ‘On-road training goals’.

5.3.1.2 Physical and visual impairment

Study 1 found that individuals who had physical and/or visual impairment were eight

times more likely to be in the rehabilitation group than the pass group. As discussed in a number

of studies examining driving related issues following TBI (Hopewell, 2002; Korteling &

Kaptein, 1996; Priddy et al., 1990), the presence of physical impairment can affect fitness to

drive. It was therefore, not surprising to find that an upper or lower limb impairment, which had

the potential to negatively affect ability to steer a car or operate accelerator and brake pedals, was

associated with a delayed driver rehabilitation outcome. Training is usually required when any

adaptive equipment is recommended to compensate for a physical impairment (Jones et al.,

1983). Therefore, the group requiring adaptive equipment, would not be in the pass group,

although they may have sustained only a mild TBI. In fact 17% of participants required on-road

training to use adaptive equipment, such as left foot accelerator pedal, a steering aid or hand

controls.

Visual disturbance is relatively common after TBI and a range of visual issues including

diplopia and visual field deficits have been reported (Kowal, 1992; Ventura et al., 2014). Some

of these visual issues are permanent and may preclude resumption of driving. Others are


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temporary and may delay return to driving, until they have resolved. In a study of characteristics

and problems reported by individuals who had returned to driving after TBI, 28.1% reported that

vision was an ongoing issue, but very few had received a formal eyesight examination (Hawley,

2001). In comparison, all participants of this study had received an eye sight clearance

recommending that their eyesight met national standards for driving. Nevertheless, 16% of the

rehabilitation group, required on–road training to address visual issues. This included learning to

compensate for minor visual field loss or the loss of binocular vision and field loss, after losing

the sight in one eye. This finding has not previously been described in the TBI driving literature,

and provides evidence that visual issues should also be considered as a potential reason to refer

for a practical driver assessment after TBI.

5.3.1.3 Slower brake reaction times

In Study 1, a significant difference was found between the pass and rehabilitation groups

in brake reaction scores. The brake reaction test was part of the standard off-road procedure and

was used to screen for slower processing and whether the driver could physically complete the

required movements for driving. It tested choice reaction time, by requiring the driver to choose

on 15 occasions, whether to turn the steering wheel to the right or left or place their foot on the

brake in response to one of three lights. The test consisted of a practice trial followed by two

more trials and in the third trial, the additional demand of dividing attention was required when

the driver was distracted by conversation. This is consistent with results from other studies that

have found an association between greater reaction times and poorer driver performance, both

on-road in real traffic (Sommer et al., 2010), and using a driving simulator (Cyr et al., 2009).

This would be expected, as the ability to respond in an appropriate time frame and to cope with


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time pressure, when undertaking driving behaviours at the operational level such as braking

speed, is essential for safe driving (Brouwer et al., 2002).

From the questionnaire responses in Study 3, 37.5% of the rehabilitation group, reported

that slowness in thinking continued to affect their driving in the longer term. Interestingly, 40.6%

of the total group of respondents (n =106) in Study 3, reported that they drove more slowly than

pre-injury. It would have been interesting to re-evaluate reaction times in this group of

individuals to compare with earlier results, however this was not part of the study design. It is

therefore not possible to determine, whether these respondents had changed their driving patterns

by driving more slowly, to compensate for slower reaction times, thereby allowing additional

response time.

Although participants with slower reaction times, were significantly more likely to be in

the group that failed the initial on-road assessment, reaction time cut-points cannot be used to test

who is likely to fail a driver assessment. There are a wide range of other factors that contribute to

competent driving (Hatakka, Keskinen, Gregersen, Glad, & Hernetkoski, 2002) such as the

ability to perceive hazards, and employ driving behaviours that reduce crash risk, including

maintaining a safe following distance or appropriate gap selection. However, reaction times are

useful as part of the off-road screening process prior to referral for on-road assessment, to screen

for both slower processing speed and physical capacity to respond in a timely manner.

5.3.1.4 Lack of recent driving experience

None of the drivers in this group of studies had driven since at least the day of their

injury, as they had all been advised not to drive until they had been medically cleared to do so. It

cannot be verified that they had all complied with this advice, however it is assumed that the

majority of patients did comply and had not driven until the day of their initial on-road


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assessment. For drivers requiring on-road training, the mean time from injury to the initial on-

road assessment was 18 months. They therefore, had not had any recent driving experience.

Study 2 did not examine the direct association of lack of recent driving experience with

assessment outcome, however the need for further driving practice prior to resuming driving ,

was identified as a goal of driver rehabilitation in a number of cases. It may therefore be

conjectured that some drivers who pass the initial on-road assessment, but have not driven for a

long period of time, could benefit from further supervised on-road experience, prior to resuming

independent driving.

5.3.1.5 Confidence

Study 2 identified that lack of confidence was an impediment to return to driving for a

proportion of drivers. The study did not differentiate between pre-injury and post-injury lack of

driving confidence as this was not formally measured and is a limitation of the study. Nor did it

measure the presence of anxiety about returning to driving or a diagnosis of PTSD. However,

improving confidence was recorded as a goal of driving lessons, in 53% of the cases who

required on-road training (n=94). Women were significantly more likely to require driving

lessons to improve confidence than men. This finding is consistent with other driving- related

research where women with TBI who responded to a telephone survey within five years of injury,

reported avoiding challenging traffic situations more frequently than men (Labbe et al., 2013;

Vance et al., 2006) perhaps reflecting reduced confidence.

Lack of confidence was found to be a factor that influenced the on-road assessment

outcome and needed to be addressed during on-road training. Whilst it cannot be proven that

participating in the driving program contributed to an increase in confidence, 92% of

questionnaire respondents reported that the driving program was helpful. Some respondents


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reported that it improved confidence and was good to be given a formal clearance to drive.

Another study reported a similar finding, that improved confidence can be an outcome, following

completion of a formal driving assessment after TBI (Hawley, 2001).

5.3.2 Pre-injury related factors

5.3.2.1 Age and driving experience

Inexperienced and older drivers are over-represented in the road trauma statistics supplied

by the Transport Accident Commission of Victoria, Australia (TAC, 2010) and both areas,

experience and age, have been extensively researched in an effort to reduce road trauma amongst

these groups. Older drivers are over represented in serious injury and fatal crashes due to the

frailty factor. Evidence suggests that their increased risk of dying in a motor vehicle crash is due

to age related frailty, rather than age-related functional changes affecting driver performance

(Eberhard, 2008). However a review of the literature examining driving, aging and TBI has found

that older adults with a TBI may be more at risk for driving related issues, such as

fatigue/sleepiness, visual and cognitive changes (Brenner et al., 2008). This is a relatively under-

researched area and the specific effects of TBI on the aging process remain unclear, however the

authors recommended further research into driver assessment and rehabilitation for this group.

Novice drivers are more at risk of crash involvement, particularly in the first months

following licensure, due to a range of factors, such as night driving, alcohol consumption, driving

with passengers and driver inexperience (Williams, 2003). There is a lack of recent research into

the association between driving experience and on-road driving assessment outcome following

TBI. An early study, examining issues related to fitness to drive after TBI, reported that

experienced drivers with TBI, are more likely to resume driving than those with less experience.


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The authors concluded that this is due to the preservation of many of the automatic, skilled

behaviours associated with driving (Brouwer & Withaar, 1997). It was therefore expected that

drivers with less driving experience, measured by number of years licensed, would have been

more likely to fail the initial on-road assessment.

The results of Study 1 did not support this premise, as driving experience was not

significantly associated with the outcome of the initial on-road assessment. One previous study

did find that driving experience is a significant predictor of on-road assessment outcome in a TBI

population (Korteling & Kaptein, 1996). This study used self-reported total number of miles

ever driven, as the measure of driving experience. Comparison of results, between studies is

therefore not possible due to the different measures of driving experience that have been used.

Another study investigating the post-injury driving patterns and safety of 47 individuals with

TBI, who resumed driving after completing a comprehensive driver evaluation, measured driving

experience by numbers of years licensed. However this study did not examine the relationship of

driving experience with passing the on-road assessment, as this was not a goal of the study

(Schultheis et al., 2002).

A possible reason for the lack of association between driving experience and on-road

assessment outcome, is the small number of drivers in this sample with less than 12 months’

driving experience since gaining licensure. Similarly, there were only small numbers of older

drivers aged over 65 in the sample. Although there were a greater proportion of older drivers in

the rehabilitation group than the pass group, the difference was not found to be significant and

no conclusion about the effect of age on assessment outcome could be made.


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5.3.2.2 Gender

Consistent with other TBI research, males were over represented in each study sample

compared to females. In Study 1, 24.6 % (n = 51) of the total sample (n =207) were female.

When combined with other variables, gender was found to be a significant predictor of

assessment outcome; being female was associated with requiring on-road training. Study 2,

which examined the goals of on-road training, found that women were significantly more likely

to have driving lessons to address confidence than men, and as already discussed, this may

explain why women were more likely to be in the rehabilitation group than men. Of the 94

participants in the rehabilitation group in Study 2, 33% (n= 37) were female.

The mean age of the women requiring on-road training in Study 2 was found to be

significantly higher than the mean age of those who passed the initial on-road assessment. Older

age combined with gender was therefore associated with requiring on-road training in Study 2.

This finding is supported by evidence from the older driver literature. Older women have been

found to be less confident drivers than older men (Oxley et al., 2010). Additionally a study of

driving patterns after TBI, found that older women were more likely to avoid challenging driving

situations than men (Labbe et al., 2013).

5.3.2.3 Previously learned driving skills

Study 2 examined goals of on-road training, and revealed that 57% of drivers required

driving lessons to address factors related to pre-injury driving skills. The on-road assessment

outcome was based on successful demonstration of a number of key driving behaviours (OT-

Australia, 1998; VicRoads, 2008). The driver may not have demonstrated competency in these

areas for a number of reasons, which may or may not be associated with injury-related


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impairment. Other reasons for failing the initial on-road assessment that resulted in a

recommendation for on-road training, included reduced road law knowledge, limited driving

experience in Australia or in city areas for rural patients or poor driving habits. For example

many experienced drivers have poor driving habits, that may not pose a safety risk, such as

rolling over a Stop line instead of coming to a complete stop at a Stop sign. However, if it is

considered that the habit poses a threat to driver and community safety, such as poor lane

changing technique, due to absent or inconsistent blind spot and mirror checks, then on-road

training would be recommended.

5.4 On-road Training Goals

The PhD program of research achieved its third aim, which was to describe the range of

goals, processes, outcomes, and resources associated with providing on-road training and use of

restricted licensing, in a group of drivers with TBI who failed an initial OT driver assessment.

The goals of driving lessons and the subsequent outcomes after on-road training, have not

previously been reported in a TBI population. The goals of on-road training were identified by

the OTDA during on the on-road assessment and were classified according to the five training

goal categories described by DiStefano and MacDonald (2006); to learn to compensate for 1)

cognitive, 2) physical, 3) visual impairment or to improve 4) previously learned driving skills or

5) confidence (Di Stefano & McDonald, 2006).

A common approach to driver rehabilitation has been to examine the range of driving

errors that were recorded during on-road assessment and then provide off-road interventions to

target specific errors (Crotty & George, 2009; Klonoff et al., 2010; Mazer et al., 2004). There

have been mixed results with this approach. Study 2 has described an alternative approach to

driver rehabilitation. By identifying the range of goals of driver rehabilitation, then providing a


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functional real-world intervention, in the form of on-road training, individual goals can be

addressed. In Study 2, most participants (42.6%), required driving lessons to address at least two

goals, however the number of goals ranged from one to four. One of the benefits of this

intervention is the flexibility of driving lessons to assess and address other functional abilities

that may not have been able to be observed during the on-road assessment. For example,

evidence of fatigue at different times of day and some of the ‘strategic’ aspects of driving, such

as route planning and navigation difficulties, can be further assessed and addressed during on-

road training. Case study examples of driver rehabilitation were provided in table 1 in Study 2.

For ethical reasons, Study 2 was not able to use comparison groups to enable other types

of driver rehabilitation interventions, such as driving simulator training, to be compared with on-

road rehabilitation. Therefore it is not possible to conclude that this approach is more effective

than other approaches. However the high relicensing rate after completing on-road training and

subsequent reassessments suggested that this form of intervention can be effective in ensuring

successful return to driving in a significant proportion of cases. In comparison, another study

found that despite providing on-road training to 38 participants, there was a high failure rate of

46% (Jones et al., 1983). It is not possible to compare this result with findings from Study 2, as

only nine drivers with TBI were included in their on-road training group. The remainder of the

sample comprised a mix of neurological diagnoses, and also included five learner drivers with

cerebral palsy.

Although there are no studies comparing the effectiveness of on-road training with

simulator training of driving skills, one of the disadvantages of simulator training is the

occurrence of simulator sickness. This issue therefore limits the population who can use driving

simulators and this type of intervention for retraining driving skills. There is evidence that


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simulator sickness is more common in older drivers over 70 (Classen et al., 2011), however it is

not known whether the sensory symptoms often associated with TBI such as dizziness, light

sensitivity or oculo-motor symptoms increase the likelihood of simulator sickness in individuals

with TBI. In a study that provided simulator training to eleven men with TBI, none of the

participants reported simulator sickness (Cox et al., 2010), and similarly it was not reported as an

issue in a sample of three participants with TBI who received simulator training (Mazer et al.,

2015). Both studies have very small samples and no conclusion can be drawn about whether the

incidence of simulator sickness is higher in the TBI population than the general population. In

contrast, on-road training provides an intervention that can be provided to all drivers with TBI

who have been assessed, as having the potential to benefit.

There is some evidence in the older driver literature that driver rehabilitation can improve

self-awareness relating to driving skills (Hunt & Arbesman, 2008). However, there is very little

literature on rehabilitation techniques, to help patients with TBI develop awareness of the effect

of injury-related impairment on their capacity to drive (Brooks & Hawley, 2005). In a study that

assessed self-awareness of deficits in participants with TBI, at one and a half months post-injury

and one year post-injury, awareness was found to improve over time (Hart et al., 2009). The

authors recommended that effective interventions are required for individuals with TBI with

impaired insight. In Study 2, development of insight was not listed as a specific goal of driver

rehabilitation in the OT driving reports, following the initial on-road assessment. However, it

could be argued that some development of awareness is likely to take place during on-road

training in order for behaviour change to occur and would therefore always be an intrinsic, if not

explicitly articulated, goal of driver rehabilitation.


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A recent study, which was drawn from the sample in Study 2, found that poor self-

awareness of driving capability was significantly associated with failing the initial on-road

assessment (Gooden et al., 2016). Unfortunately, self-awareness was not measured after on-road

training, however this issue is currently the focus of a new study by our research group. Based on

the results of Study 2, the effectiveness of on-road training to change behaviour and improve self-

awareness cannot be proven. However, it could be argued that driver rehabilitation contributed to

behaviour change, as demonstrated, by the ability of drivers to modify their driving patterns in

order to pass the subsequent on-road reassessments and to continue to drive safely in the longer

term.

5.4.1 Resources associated with driver rehabilitation

It is important for health care planners to have information about the resources required to

deliver rehabilitation interventions. This has been identified as a specific area requiring further

research in relation to driver rehabilitation (Devos et al., 2012). The financial cost of providing

on-road training and reassessments may vary between countries. Number of driving lessons and

reassessments were therefore determined to be a more objective measure of resources required to

deliver the intervention than financial cost.

Study 2 found that 85% of individuals required 10 driving lessons or fewer and an

average of 2.5 on-road reassessments. The mean number of driving lessons provided was 7, with

a median of 5.5 and range of 1-35 lessons, which is consistent with the study by Jones et al

(1983) where a mean of 5.5 driving lessons, with a range of 1-30 driving lessons were provided

(Jones et al., 1983). As discussed previously, a valid comparison cannot be made with this study,

due to the mixed sample and inclusion of novice drivers. No other studies have examined or

reported the resources required to deliver on-road training as an intervention for resuming driving


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after TBI. These findings may be useful in future studies, examining the cost benefit of different

types of driver rehabilitation interventions following TBI.

A key resource that is required to provide this type of practical real-world intervention, is

the availability of skilled OTDAs and driving instructors with appropriate training or experience

in the area of TBI. Although the goals of driving lessons are identified by the OTDA, the success

of the intervention is likely to be dependent on the driving instructor delivering the intervention.

In Study 2, approximately 90% of the driving lessons were provided by the same experienced

driving instructor and therefore the results of this study may not apply to other driving programs

using less experienced driving instructors.

One of the criticisms of using driving instructors to provide retraining to neurological

patients is their lack of medical training (Devos et al., 2012). In Australia, the role of the

supervising OTDA during on-road training, is to discuss patient progress with the driving

instructor, after every 2-3 lessons. Feedback from the instructor is obtained and recommendations

from the OTDA can be provided. Whilst there is clearly a need for controlled examination of this

question, the high relicensing rates in this study demonstrated that the use of on-road training

under OT direction may be a useful intervention for resuming driving after TBI. The driving

instructors who provided most of the on-road training were experienced in working with

medically impaired drivers, however this method may not be as effective with less specialized or

experienced driving instructors.


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5.5 Post-assessment Safety and Behaviour

The results from Study 1 and Study 2, demonstrated that most drivers with TBI, who had

been referred to the driving program resumed driving. However it was not known whether these

individuals continued to drive in the longer term, whether they had modified their patterns of

driving and whether they drove safely. This knowledge was required to determine whether the

driver assessment and rehabilitation program that was offered, provided a valid intervention for

resuming safe driving after TBI.

For those in the pass group, an assessment of driving was made over one 50 - 60 minute

on-road assessment, conducted in a real-world environment. Some of the criticisms of on-road

assessments have included that traffic conditions can vary considerably in complexity from one

assessment to another, drivers are likely to be ‘on their best behaviour’ and the effect of

impairments such as fatigue on driving skills may vary, depending on the time of day that the

assessment was conducted. Therefore, a true representation of an individual’s driving ability may

not be obtained. Although the traffic conditions may vary from one assessment to another, the

route design, tasks assessed and criteria on which the participants were assessed, complied with

the Australian Competency Standards for Occupational Therapists (OT-Australia, 1998).

Additionally the protocol that was followed, including pass/fail criteria, was similar to that

applied in other studies, where on-road assessment protocols were evidence-based (Di Stefano &

Macdonald, 2010; Shechtman et al., 2010).

For those in the rehabilitation group, it may be argued that a more accurate assessment of

driver capacity could be obtained. By undertaking more than one on-road assessment and driver

rehabilitation interventions, a greater sampling of behaviours was afforded. Driving lessons were

often conducted in a variety of traffic conditions and at different times of day. Feedback from the


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driving instructor, regarding an individual’s driving ability and behaviour over the course of the

on-road training program, was taken into account by the OTDA. Information, such as the ability

of the driver to drive independently without driving instructor intervention, evidence of fatigue or

navigation difficulties and degree of insight into the need to compensate or modify driving

patterns, would have been provided to the OTDA by the driving instructor . This information

would therefore have contributed to the clinical decision making process regarding fitness to

resume driving and licensing conditions.

Study 1 examined predictors for passing the on-road assessment and Study 2 described

the process of driver rehabilitation for those who failed the initial on-road assessment. The best

measure of driving capacity is the ability of an individual to drive safely in the longer term and

this was the focus of Study 3, discussed in the section below.

5.5.1 Total group safety and behaviour

The aim of Study 3 was to examine the self-reported pre- and post-injury driver safety and

patterns of driving behaviour amongst individuals with a TBI, who had completed an OT driver

assessment and rehabilitation program. It was hypothesized that drivers would report more

crashes and near crashes following injury and more modifications to their driving behaviour

relative to pre-injury. Based on responses to a questionnaire, participants with moderate/severe

TBI who completed a driver assessment and rehabilitation program at least 3 months post-injury,

reported modifying their driving behaviour, and did not report more crashes compared to pre-

injury.

The hypothesis was therefore only partially supported by the results; participants did not

report more crashes but did report more near crashes and more modifications to their driving

behaviour, relative to pre-injury. This finding was consistent with the results of Schultheis et al


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(2002), which compared both self-reported crash rates and traffic violations with DLA records of

47 drivers with TBI, and 22 healthy control participants, for the 5 years prior to the survey

(Schultheis et al., 2002). The drivers with TBI had all successfully completed a comprehensive

driver evaluation, however injury severity of the sample, was not reported. No statistically

significant difference was found between the TBI drivers and HC group in terms of number of

crashes or traffic violations, as obtained either by self-report or DLA records.

Another study compared self-reported crash rates and changes in driving patterns, 6 – 9

years post-injury, of drivers with TBI (n=28) with a CVA group (n=65). Both groups had

returned to driving following a practical driving assessment. The self-reported crash rate of TBI

drivers was found to be 2.5 times that of the CVA group (Schanke et al., 2008). Crash rates in

this study may have been impacted by injury severity of the small TBI sample (which was not

recorded) and driving exposure of the participants.

It is acknowledged that there is a risk that with self-report of crash rate, inaccurate

information may have been provided, particularly if participants perceived that their right to drive

may be affected by completing the questionnaire, which was not anonymous. The questionnaire

response rate was 52% and it is noted that 30% of the rehabilitation group declined to respond to

the questionnaire, compared to 16% of the pass group. Reasons for declining may have been

related to concerns about reporting a poor driving record or license suspensions. The results from

this study may therefore not be representative of the entire sample – the ‘better’ drivers may have

chosen to respond and those with a poor driving record may have declined to respond.

Accuracy of crash history may have been improved by obtaining data from DLA records.

However, only crashes that have been reported are documented, and information about driving

exposure or ‘at fault’ information is not recorded (Coleman et al., 2002; Schultheis et al., 2002).


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Additionally, crashes are relatively rare events and do not provide a definitive or qualitative

description of an individual’s driving behaviour. Caregivers often have some knowledge of an

individual’s crash history and traffic infringements (Coleman et al., 2002; Liddle et al., 2011).

Obtaining information from a significant other would have provided more qualitative information

about a participant’s driving behaviour for the current study.

Although a range of factors have been found to increase likelihood of crash involvement

(e.g., inexperience, consumption of alcohol), greater driving exposure, measured by frequency of

driving and distances driven, may also increase the chance of crash involvement (Williams,

2003). Most of the questionnaire respondents (78%) reported that post-injury, they drove on a

daily basis and 70% reported that they drove anywhere and did not restrict the distances that they

drove. This high frequency of daily driving contrasts with lower proportions of regular driving

reported in other studies. A study by Coleman et al (2002) reported that only 28% of a sample of

71 patients with TBI reported driving on a daily basis, however 54% of the sample had not

returned to driving (Coleman et al., 2002). This sample, therefore cannot be compared with

Study 3, where all of the respondents were driving

Another study by Fisk et al (1998), reported that 60 % of a sample of 423 TBI patients

reported that they were currently driving and 60 % of this group reported driving every day (Fisk

et al., 1998). It is noted that the participants in this study had not had access to a driver

rehabilitation program and although it cannot be proven by the results of this study, driving

frequency may be influenced by the driver assessment process. However other factors, may have

contributed to the frequency of driving amongst participants, such as employment status, time

post-injury and injury severity of the sample. Although it is difficult to compare driving


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exposure of participants in Study 3 with other studies, they did not appear to be at greater risk of

crashes compared to pre-injury, at least based on self-reported data.

A number of studies of drivers with TBI who resumed driving without assessment,

found higher post-TBI crash rates, when compared to the healthy population (Bivona et al., 2012;

Formisano et al., 2005; Leon-Carrion et al., 2005) and a CVA group (Schanke et al., 2008). In

contrast, drivers who had successfully completed a driver assessment program and had resumed

driving, were not found to be at greater risk of crashes (Haselkorn et al., 1998; Schultheis et al.,

2002). From the results of this study, it is not possible to determine whether a relationship exists

between crash rates and driver assessment and rehabilitation. However it may be conjectured that

involvement in a driving program, may improve awareness of driving competence prior to

resuming independent driving and provide opportunity to change driving behaviour, thereby

potentially improving on-road safety.

In Study 3, around 19% of respondents reported more near-crashes relative to pre-injury.

It is equally important to acknowledge that the majority of drivers (80%), did not report more

near-crashes. In light of this finding, further studies investigating whether there is a relationship

between reporting of near-crashes and pre-driver rehabilitation or post-driver rehabilitation

performance on neuropsychological tests of attention, processing speed and executive function

may be helpful. Notwithstanding the aforementioned limitations of neuropsychological tests in

predicting real-world driving behaviour, if a relationship were found, it may be worth exploring

the potential benefit of driver rehabilitation interventions to learn to compensate for specific

deficits in attention, by improving forward observation, slowing down and avoiding

busy/complex traffic areas.


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The findings partially supported the hypothesis that drivers with a TBI would report more

modifications to driving behaviour post-TBI relative to pre-injury. Whilst many drivers reported

modifying their driving patterns post-injury, over half of the participants who responded to the

questionnaire did not report any changes in their driving patterns. As such, there is a group of

drivers with TBI who do modify their driving behaviour in response to recognition that their

driving skills have changed, which is similar to the findings of other studies investigating the

same issues (Priddy et al., 1990; Schultheis et al., 2002). Consistent with the results of another

study (Labbe et al., 2013), those TBI patients with a more severe injury (the rehabilitation

group), were more likely to modify their driving patterns compared to those in the pass group.

This is discussed in more detail in the next section.

One of the more surprising results of Study 3, was the high proportion of people in both

the pass and rehabilitation groups, who reported difficulty with route-planning and navigation

(51.9% of the rehabilitation group and 37.5% of the pass group reported this problem). This

issue has not been examined or reported in the driving literature following TBI, although it has

been reported in one study, examining way-finding when walking; 18 individuals with acquired

brain injury (ABI) were found to have greater difficulty in finding their way on foot, using a set

of written instructions, than a matched control group (Lemoncello et al., 2010). The study did not

define the term ABI, nor describe injury severity of the sample, so is difficult to establish whether

the sample had sustained a TBI.

The questionnaire data for the current study were collected in 2010. Participants were

asked to comment specifically about whether they used street directories and GPS more, less, the

same or never since resuming driving. Of the 106 participants who responded to the

questionnaire, 38% reported using GPS and 73% of the group reported using a street directory.


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Over the past few years there has been a significant increase in the use of GPS in the general

population. If the same question about GPS use was repeated in a study today, it would be

interesting to see whether greater use of GPS compared to street directories would be reported.

Approximately 21% of the group reported using a navigation aid (street directory or GPS) more

than pre-injury, which is consistent with the self-report of increased post-injury difficulty in

navigation reported in Study 3.

Whilst GPS have potential to assist individuals with TBI to cope with route-finding

difficulties, no research has been identified examining their use with drivers with TBI. One study

reported that they should be used with caution due to the possibility of driver distraction or the

driver not taking into account the road environment (Lane & Benoit, 2011).An example of the

need to trial and train a driver with TBI to use a GPS, was provided in Box 1, case Study 2. One

of the goals of driving lessons for this individual was to improve observation of the road

environment prior to following GPS direction, as on an early assessment he had intended to turn

right into the off ramp of a freeway, because the GPS direction was to turn right. He had not

observed the ‘No Right Turn’ sign onto the off- ramp or the ‘Right Turn’ sign further along the

road indicating where to turn right. It is therefore important to provide relevant instruction and

supervision in the use of such devices, due to the possibility of driver distraction or difficulties

with information processing of instructions. The ability of a driver to use a GPS competently is

an aspect of strategic driving that should be considered in the design of the on-road assessment

following TBI.

5.5.2 Comparison of safety and behaviour of pass and rehabilitation groups

The final aim of the PhD program completed in Study 3, was to compare the

characteristics and subsequent self-reported crash rates and driver behaviour of those drivers who


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returned to driving after one on-road assessment (pass group), with those who received on-road

training prior to subsequent assessments (rehabilitation group). It was hypothesized that patients

who did not pass the initial driver assessment would show higher rates of crashes and/or near-

crashes and would report more modifications to their driving behaviour relative to pre-injury.

This hypothesis was partially supported. Whilst there were no significant differences in

the self-reported crash rates between the groups, the rehabilitation group was more than twice as

likely to report near-crashes, than the pass group. Although we do not have corroborating data to

confirm the findings, this could be related to slowed processing speed and/or reduced attention:

The rehabilitation group were significantly more likely to report that slowness in thinking

continued to affect their driving than the pass group. Additionally, a recent study using

participants from the same rehabilitation centre, who had completed the same driver assessment

and rehabilitation process, found a significant difference in psychomotor speed, when measured

by the Symbol Digit Modalities Test, between those who passed and those who required on-road

training (Gooden et al., 2016). Another study found that 17 TBI drivers crashed significantly

more often than a control group on a divided attention task, using a driving simulator, and found

a relationship between slower reaction times and crash rates in a moderate to severe TBI group

(Cyr et al., 2009). Two limitations of this study include the small sample size and fact that driver

performance on a driving simulator may not generalize to real world on-road performance.

Whilst the rehabilitation group, with greater injury severity, reported more near-crashes

than the pass group, they were also significantly more likely to modify their driving behaviour

than the pass group. This may explain why they did not report more crashes. The modifications

to their driving behaviour may have provided protection and placed them at lower risk of crash

involvement, as overall they had less driving exposure. Similar to another study, (Labbe et al.,


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2013) they were found to drive less frequently and shorter distances, but unlike this study, the

respondents of Study 3 were significantly more likely to avoid driving with passengers, at night,

in busy traffic and on freeways than the pass group and relative to pre-injury. Labbe and

colleagues (2013) found that young men were a particular risk group as they did not avoid

challenging driving situations (Labbe et al., 2013) . Study 3 did not compare the gender or age of

the respondents who reported modifying their behaviour with those who didn’t and is a limitation

of the current study.

In contrast, a study of 38 drivers with a TBI followed up six to nine years post-injury

found that they had not made modifications to their driving behaviour and were at increased risk

of accident compare to normative data (Schanke et al., 2008). Similarly, another study reported

that participants with TBI were less likely to avoid challenging traffic situations than a control

group ( Lundqvist et al., 2008). It is difficult to compare the results of these studies with the

current study as they included small samples of TBI, the severity of which was not reported, and

it is not known whether the drivers had completed a driver rehabilitation program.

The driving ability of the pass group participants was assessed as competent to resume

driving. It would therefore not be expected that they would need to modify their patterns of

driving in the longer term. Although, the pass group was significantly more likely to avoid busy

traffic and night driving compared to pre-injury, significant differences were not found, for

reductions in driving frequency, distances driven or avoiding other challenging situations.

Another study found that individuals with more severe injuries (measured by PTA duration) were

not more likely to avoid challenging situations, but were more likely to drive less frequently and

shorter distances (Labbe et al., 2013).


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Self- awareness of deficits has been found to improve over time after TBI (Hart et al.,

2009) and although self-awareness was not measured during this study, it is reasonable to assume

that the modifications made to driving behaviour were in response to improved awareness of the

ways in which ongoing impairment affected driving performance.

It was interesting to find that most participants in the current study reported that they had

continued to drive in the longer term. At follow up in Study 3, only three participants reported

that they were not driving; two had stopped temporarily, due to license suspensions resulting

from traffic infringements, and one reported that his wife preferred him not to drive. It is difficult

to draw any conclusions about longer term driving status amongst the total group as the results

are based on the responses of only 106 participants. No significant differences with regard to age,

injury severity, gender or driving experience, were found between those who responded to the

questionnaire and those who did not respond. As discussed previously, some of the non-

respondents may have ceased driving due to license suspensions or crashes and therefore the

results of this study may not be an accurate reflection of how many drivers in total of the original

group, had continued to drive in the longer term.

5.6 Limitations

The findings of this PhD program of research should be considered in the context of a

number of limitations. The program was conducted at a single site and the study sample included

patients receiving comprehensive multi-disciplinary, inpatient and outpatient rehabilitation

funded by no-fault accident compensation schemes. Site specific referral protocols may have

introduced bias in the sample and therefore results may not generalise to other TBI populations or

TBI rehabilitation contexts. The costs of driving assessments and on-road training were covered

by transport accident and work-cover insurance. Uptake of on-road training and reassessments


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may have differed in a TBI population, not eligible for funding of such assessments or

interventions. In future studies, it would be important to increase the sample size and include

multiple sites, to ensure a wider representation of the TBI population.

The on-road assessment was not a fully validated assessment. Attempts were made to

ensure that the on-road assessment was consistent for all individuals, by using the same standard

route, and for 90% of assessments the same driving instructor was used. Behaviour sampling

may have varied across the individuals, as traffic conditions (e.g., weather, road works or volume

and complexity of traffic conditions) and unexpected traffic events, such as actions of other road

users, could not be controlled. The assessment conditions for some participants may therefore

have been more complex than for others, which may have influenced the pass/fail outcomes. To

provide consistency in driver behaviours observed and recording methods, the OTDAs used a

documented set route, with standard instructions and a pre-specified checklist of behaviours to

observe. Despite these measures, some subjectivity in observations and decision making is

unavoidable. To strengthen the research design, we could have measured the inter-rater reliability

between the six OTDAs who completed the OT driver assessments.

One of the disadvantages of using standardized instructions for the on-road assessment, is

the lack of opportunity to assess the strategic aspects of driving such as way-finding or problem

solving when faced with road-works requiring a detour. This would be a limitation of the study,

as drivers were not able to be evaluated at this level, using this method of driver assessment.

There is a current review by VicRoads of the standardized on-road assessment and the

opportunity to collaborate in investigating options for assessing navigation during the on-road

assessment is available and discussed in the section Directions for the Future.


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Additionally, for drivers assessed after 2012 (n= 131), the on-road checklist was slightly

modified to include more detail of errors observed, to comply with the Driver Observation

Schedule (DOS) (Vlahodimitrakou et al., 2013). However the same driving behaviours were

assessed and this change would not be expected to have affected overall pass/fail outcomes,

driving lesson goals or license restrictions.

Although most of the on-road training was provided by the same experienced driving

instructor, the high relicensing rate may not have been achieved with a less experienced

instructor. When examining hypotheses related to resumption of driving after on-road training,

the absence of a comparison group who did not receive driver rehabilitation was a further

limitation. However, in the context of a real world clinical environment, it was not considered

practical or ethical to have a group that did not receive driver rehabilitation. It was also not

possible to locate and then compare a group of drivers with TBI who had returned to driving

without an OT driver assessment. Such a group would not be attending a rehabilitation centre and

very difficult to identify and recruit.

Another limitation of the PhD program, was the lack of information about the number and

characteristics of the individuals with TBI who only completed the off- road part of the driver

assessment and did not proceed to the on-road assessment. As almost all individuals proceeded to

on-road assessment, the numbers in this subgroup would have been extremely small. Unless the

safety of the driving instructor, patient and OTDA was considered to be at risk, standard practice

was to offer all individuals the opportunity to demonstrate real world driving, commencing in a

low demand traffic area.

As discussed in Chapter 4, a number of limitations were identified in Study 3. Firstly, the

findings about driver safety and behaviour were based on an un-validated questionnaire.


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Secondly, the questionnaire response rate of 52% may not have captured ‘at risk’ drivers or those

not wishing to disclose a poor post-assessment driving record. Although participants were

advised that questionnaire responses would not be disclosed to the DLA, there may have been a

fear that by participating in the study, their ongoing right to licensure may be compromised.

Thirdly, reliance on retrospective data collection and self-reported crash rates, near misses and

traffic infringements in a cognitively impaired population may compromise accuracy. Obtaining

DLA records and opinions of significant others may have provided corroborating data for some

measures (e.g., police reported crashes and traffic infringements). However, these methods

would have had their own limitations, such as the assumption that significant others know about

all crashes, near misses and traffic violations, and the fact that data pertaining to minor,

unreported crashes is not available from DLA records.

Additional questions could have been added to the questionnaire such as how many of

the respondents still had a restricted license, the type of restrictions, whether they had complied

with the restriction and whether the restriction had been reviewed. Although this information

would have been subject to the same possible inaccuracies described in the paragraph above, it

may have provided additional data about using restricted licensing in a TBI population.

Previous research has found both age and gender predicted avoidance of challenging

driving situations (Labbe et al., 2013). The gender and age of the respondents who did not report

any modifications to their driving behaviour was not examined and is a further limitation of

Study 3. In Study 2, lack of confidence was reported as a goal of on-road training in over half of

the participants who failed their initial on-road assessment. A significant limitation of the study

was the omission of a measure of anxiety and one for confidence. This has been recognized by

the author, and pre and post measures for anxiety and confidence have been included in the


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design of a new study investigating the effect on pass/fail rates of using a driving simulator to

provide training prior to on-road assessment.

The sample was drawn from a TBI group receiving rehabilitation, in a multi- disciplinary

rehabilitation setting who were referred on the basis of potential to drive. The assessment of

‘readiness to drive’ was made by the doctor and treating team.

5.7 Strengths and Unique Contributions

The main objective of this PhD program of research was to contribute to knowledge about

driver assessment and rehabilitation after TBI to inform clinical practice. The current OT driver

assessment and rehabilitation process described in this study, appears to be an acceptable and

successful methodology for enhancing return to driving after TBI. Study 2 is the first to describe

the outcomes of using on-road training as a functional, context- based intervention for driver

rehabilitation in a TBI population and the resources required to deliver the intervention. This is a

unique contribution of this PhD program to knowledge about providing an intervention for

drivers who failed the initial OT driver assessment. Most drivers, who failed the initial OT driver

assessment, successfully resumed driving after less than ten driving lessons to address a range of

goals and an average of two and a half OT on-road assessments. This finding can therefore be

used to estimate the likely cost of the intervention and is useful for treatment planners and

clinicians. The success of the intervention also offers hope to both clinicians and many drivers

with TBI that with appropriate driver rehabilitation, return to independent driving and the

associated quality of life benefits may eventually be achieved.

Based on self-report, an increase in crash rate was not found, following resumption of

driving. Therefore the current practice of delaying return to driving for a minimum of three

months post-injury, appears to be appropriate and sufficiently safe. The significant difference in


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timing of return to driving between the pass and rehabilitation groups highlights the need for

medical fitness of drive guidelines to provide some differentiation in timing of driving

resumption based on injury severity. Some international guidelines recommend a 6 month

abstinence from driving, however the results from the PhD program found that many drivers

safely resume driving as early as three months post injury.

Study 1 found that the model using PTA duration, gender, physical/visual impairment and

reaction times, classified 87.6% of cases who passed an initial driver assessment. Taken together,

the results indicated that patients with longer PTA duration, physical/visual impairment, and

slower reaction times, should be referred for OT driver assessment as they are more likely to fail.

Although fewer years of driving experience and older age were not predictive of driver

assessment outcome in this study, they should also be considered as reasons for referral for

practical assessment, based on over-representation of these groups in the road trauma statistics.

However, these variables alone are less reliable in predicting who will require driver

rehabilitation. Other factors, identified in Study 2, such as anxiety or lack of confidence and

relevant or recent driving experience, can influence driver assessment outcome and are also valid

reasons to refer for OT driver assessment. These factors could be used to improve in clinic

screening for doctors and health professionals to identify at risk patients who should be referred

for OT driver assessment following TBI.

An unexpected finding of the study, was the need to consider on-road training for patients

with visual issues after TBI. Despite receiving a formal eyesight clearance to drive, 16% of

participants required on-road training to address visual issues, indicating that impairments

affecting eyesight should be considered as a valid reason to refer for on-road training prior to

resuming driving.


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The other important finding is that 72% of drivers in Study 3 passed the initial on-road

assessment and resumed driving without requiring driver rehabilitation. In addition, 81 % of this

group had PTA duration of less than 28 days and supports previous research that drivers with

PTA duration less than 28 days generally resume driving with few issues (Brouwer & Withaar,

1997) . The study has identified a group of drivers with TBI who may not require OT driver

assessment. The characteristics of this group would include those with shorter PTA duration, no

physical/visual issues, average reaction times and relevant pre-injury driving experience, no other

relevant co-morbidity issues and at least three months post-injury.

Another unique contribution of the PhD program was the description of prevalence of

restricted licenses in a TBI population and how they can be used to ‘grade’ return to driving by

offering the opportunity to have the license restriction reviewed and eventually removed or

modified. This is the first study to describe how restricted licensing can be used to support

resumption of driving for patients who have been assessed as unsuitable for an open license.

Combined with on-road training it provides an opportunity to learn and practice compensatory

strategies and could support the introduction of restricted licensing in countries where it is not

commonly used.

The prevalence of navigation difficulties in a TBI population has not previously been

examined, but was found to be a significant ongoing problem, with 41.5 % of drivers reporting

difficulty in planning and remembering routes. This finding implies that both assessment and

treatment of poor navigation skills should be addressed as part of the driver rehabilitation

process. Study 3 has highlighted that better assessment methods for route finding difficulties are

required as part of the OT driver assessment. For selected patients, this may include training to

use adaptive equipment, such as GPS systems, if appropriate.


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In summary, a number of questions have been identified that clinicians need to address

when determining fitness to drive following TBI (Hopewell, 2002). These have included: 1)

which patients to refer for driver assessment and how this will occur, 2) the process for license

disqualification, 3) the goals of driver rehabilitation and who takes responsibility for the driving

program. Based on the finding described above, the PhD program has shed some light on these

three questions as follows:

1) A number of factors were found to be important to consider when determining who to

refer for driving assessment after TBI. Study 1 found that PTA duration was a better

predictor of on-road assessment outcome than GCS score. Although 81% of individuals

with PTA duration of less than 28 days passed the initial assessment, PTA duration

cannot be used alone to determine who will pass or fail a driving assessment and

therefore, who should be referred for assessment. In addition to injury severity, referral

criteria should also ensure that any physical or visual issues, slower reaction times,

reduced confidence and lack of relevant or recent driving experience are considered. All

participants had received medical and eyesight clearances, based on the Austroads

medical guidelines for driving (Austroads, 2012) and completed a neuropsychological

assessment. The decision about when to refer to the driving program was made by the

treating team based on this information.

2) Very few participants in this study were disqualified from driving, however the second

study has described the process leading to license disqualification. A unique aspect of

this study is that none of the drivers were disqualified on the basis of one on-road

assessment. All individuals were offered on-road training followed by subsequent


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reassessments. The decision to recommend license disqualification was made when no

further benefit was gained from driving lessons and the driver was still assessed as not

safe to resume driving. This recommendation was provided by the OTDA in a written

report to the DLA.

3) Study 2 provided a detailed description of the goals of rehabilitation and the

responsibilities of the OTDA in making recommendations to the DLA. The types and

prevalence of goals of driver rehabilitation and the resources required to deliver the

intervention have not previously been reported in a TBI population and are unique aspects

of the study. This knowledge could assist rehabilitation clinicians and funders in planning

appropriate interventions for resuming driving after TBI.

Whilst other studies have found that many drivers with TBI, modify their patterns of driving,

this is the first study to compare the post-assessment driving behaviour of those who passed their

initial assessment and those who received on-road training. Although conclusions cannot be

drawn about an association between on-road training and improvement in awareness of driving

capacity, it was interesting to find that the drivers with greater injury severity, who received

driving lessons, were more likely to modify their patterns of driving compared to pre-injury,

suggesting that they may have developed some degree of self- awareness of driving capacity.

5.8 Directions for the Future

This study has highlighted a number of areas to consider for future research. It has been

difficult to compare the small number of studies investigating driving after TBI due to the

different outcome measures used, lack of consistent injury severity measures and methodologies

that have been employed. It is recommended that future research should report whether the


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participants who had resumed driving had received a formal driver assessment. If so, referral

criteria for driving assessment programs should be included. When reporting pass/fail outcomes,

future studies should specify whether driver rehabilitation was offered or whether results are

based on an initial driver assessment. Furthermore, injury severity, using PTA duration should be

reported, when describing TBI samples.

Changes in self-awareness of perception of driving performance, from pre- to post- driver

rehabilitation, were not measured in this PhD program. The impact of on-road training on self-

awareness of driving warrants further investigation and is now the focus of a current study by our

research group using the recently developed BIDSAM - a measure of self-awareness following

TBI (Gooden et al., 2016).

Learner drivers with a TBI were excluded from the current study. The incidence of

childhood and adolescent TBI is very high (Feigin et al., 2013) and therefore identifying the

pertinent assessment and training issues for this TBI group is also an important topic that requires

further research. The driving program at Epworth rehabilitation has assisted many novice drivers

with TBI to obtain a driver’s license. The data from these driving programs has not been

evaluated and is a future area of research as the knowledge may contribute to this under-

researched but very important area of TBI rehabilitation.

The complex issue of timing for resuming driving has been highlighted by the results of

this PhD program and the challenge this presents for clinicians in determining readiness to

resume driving after TBI. The variability in the guidelines between countries contributes to this

situation and is an area requiring further research. In particular, a closer examination of the

association between timing of resuming driving, injury severity, crash involvement and driving

frequency may help to improve medical guidelines in this area.


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In Study 2, the mean age of the women with TBI who required on-road training was

significantly higher than those who passed their initial on-road assessment. This result indicates

that this group may benefit from driver assessment and then require assistance to resume driving.

A more comprehensive review of on-road assessment outcomes for older drivers with TBI to

explore this area in detail is warranted, as it may reflect a need to develop better clinical

guidelines for this group of older drivers.

Additional data is being collected by the driver rehabilitation program at Epworth

Rehabilitation. Future studies will combine this new data with the data from the three studies to

form a larger sample to extract and analyse more detailed information about timing of resuming

independent driving and association with a range of variables (eg. injury severity, physical and

visual impairment). A larger sample of older drivers with TBI may also be obtained enabling a

more comprehensive review of the outcomes of assessments, use of restricted licensing and on-

road training provided to the older driver cohort.

Most drivers in this study eventually resumed driving and those with less severe injury

were less likely to report modifying their driving patterns. A more detailed examination of near

misses, crash involvement and driving patterns using a larger sample of drivers with a very

severe TBI would be recommended, as Study 2 may not have provided an accurate picture of this

group.

In Australia, no specific training is available for driving instructors to learn how to work

with medically impaired clients and OTDAs in driver assessment and rehabilitation. It is

recommended that resources be provided to develop the skills of driving instructors in this

specialised area. In addition, procedures for OTDAs to document goals of driving lessons should

be developed, to ensure that appropriate and consistent driving instructor guidance, feedback,


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lesson content and processes are provided to clients. These are areas of future work and it is

planned that they will be the focus of a collaborative project with the university that conducts

training for OTDAs in Victoria and the DLA, VicRoads.

Many advances are being made to improve driver safety for the general population with

the use of assistive technology. Some of these technologies have the potential to support safe

driving amongst individuals with TBI and are becoming standard features on new vehicles (Lane

& Benoit, 2011). Some examples of these new technologies include; lane departure warning

systems, which assist with lane maintenance by monitoring the vehicle's position within the road

lane markings and initiating an auditory warning if the driver is drifting out of the lane, as well

as adaptive speed control. This maintains the speed that is set by the driver, but also regulates the

speed, to ensure that a set distance is maintained from the car in front. Other technologies include

blind-zone assist technology to help a driver when changing lanes and pre-collision brake assist,

which can detect a potential frontal impact and assist the driver by applying full braking force in

an emergency-braking situation. Reversing cameras and rear, front and side sensors can also

assist the driver when parking or when reversing out of a parking space (Lane & Benoit, 2011).

The ability of drivers with TBI to take advantage of this technology is not known.

Despite the safety features that this technology offers, a driver must still have the sensory, motor

and cognitive abilities to drive safely. There have been concerns about the effect of driver

distraction when using some types of assistive technology (Young, Regan, & Hammer, 2007).

Whilst adaptive equipment shows great promise for facilitating driving tasks after TBI, further

research may be required to confirm this premise. In particular a major area of research that

warrants investigation is the use of GPS to assist drivers with TBI with navigation. A review of

the design of the standardized on-road assessment routes used in Victoria Australia is currently


215

being conducted by VicRoads. Our driving program is participating in this trial but to my

knowledge, route finding and navigation have not been considered as possible standard

requirements of on-road assessment but may be a necessary part of the assessment for drivers

with cognitive impairment.

Finally, in addition to the assistive technology that is now available, driverless or

autonomous cars are being developed and tested. This may result in a significant change to our

driving patterns in the future. This would obviously greatly enhance the independence and

community participation not only for individuals with a TBI but all drivers with a disability. The

introduction of this technology will raise a new set of human factor issues regarding capacity to

operate and use these vehicles. As this technology is not likely to be available for many years,

and transition issues related to operating within a mixed fleet will be challenging, there is still a

need to address the areas of research that have been identified, to improve road safety and

rehabilitation interventions after TBI.

5.9 Personal Reflections

I commenced this PhD program with a wealth of clinical experience, but virtually no

research experience. I also had very little knowledge of the literature and past research in the area

of driver rehabilitation. I was concerned that the outcomes of the driving program had never

been examined and was particularly interested to know about longer term outcomes of the

patients I had assessed as safe to return to driving. Had they continued to drive and had they

remained safe? Anecdotally, it seemed that most patients appeared to continue driving safely but

I felt that it was important to establish whether this was in fact true. In addition to longer term

safety, I had also questioned whether everyone with TBI required a driver assessment. I had

observed that a specific group of patients with shorter PTA duration and who were experienced


216

drivers nearly always passed the on-road assessment. These questions were therefore the basis for

Study 1 and Study 3. As a clinician, I was aware that I did not have the knowledge or experience

to answer these questions and realized that I would need supervision. I enrolled in an honours

program with the expectation that I would complete the study in one year. It became clear that the

time frame was unrealistic and was then encouraged to commence a PhD program.

As a result of the findings of these two studies and in particular the success rates of

providing on-road training to the patients who failed, I became aware of the lack of studies,

describing this important intervention for resuming driving after TBI. This gap in the literature

demonstrated the need for a study that could describe how these interventions (goal directed on-

road training and restricted licensing) could be used in a TBI population. I was also interested to

know how frequently restricted licenses had been recommended in this group.

With the benefit of hindsight and the vast amount of knowledge I have gained during the

PhD program, there are a number of aspects of the study design that I would approach differently.

In particular, I would have improved the design of the questionnaire by asking more specific

questions about status of and compliance with license restrictions. I would also have used more

formal measures of confidence and anxiety and tried to examine the changes in awareness of

impairment from pre too post-training. There may have been more in –depth analyses that could

have been undertaken of the data, particularly with regard to older drivers with TBI. I have

recognized the importance of continuing to collect data on driver assessment and rehabilitation

outcomes and with an increased sample size may be able to contribute further research into the

areas of both older drivers and learner drivers with TBI.

Based on the results of Study 1, I have also been able to influence the referral procedures

at the centre. Doctors and clinicians are now informally using the results of this study as referral


217

criteria to screen for whether to refer for an OT driver assessment. It will be important to collect

data on the longer term safety and driving patterns of this group who do not complete the driving

program.

As an experienced OTDA, the PhD program has also highlighted areas of OT driver

assessment and rehabilitation practice that need to be improved. For example the need for

training for driving instructors working in this area, improved documentation of goals of on-road

training and how this information is provided to the driving instructors and how their feedback is

obtained and documented. Finally the need for improved methods of assessing strategic aspects

of driving such as route planning and navigation while driving is required. Having completed the

PhD program, I now feel that I have the confidence and skills to tackle these projects and further

research in this area.

Throughout the PhD journey I have developed a much greater understanding of the

different practices in assessing fitness to drive internationally and I have also gained an

appreciation of the key researchers in this area and had opportunities to present my work.

Although combining work and study has been a difficult journey, the benefits in terms of the

knowledge and skills I have gained have been immeasurable.

5.10 Conclusion

The study has achieved the aims and main objective, which was to extend current

knowledge about resumption of driving after TBI to support clinical decision-making and

optimize the driver assessment and rehabilitation process for individuals with TBI. This body of

information has contributed to identifying the factors that may influence return to driving

following TBI. Unique contributions include an improved understanding of timing of resuming


218

driving after TBI and how injury severity measured by PTA, combined with presence of physical

and/or visual impairment and slow reaction times may be used to improve fitness to drive

guidelines to differentiate which drivers should be referred for OT driver assessment. The

challenges and driving behaviour for those returning to driving and the issues most commonly

addressed in driver rehabilitation have been presented. An important finding of the PhD program

has been the success of providing on-road training to individuals who failed the initial on-road

assessment. Taking a graded approach, including comprehensive OT driver assessment, on-road

training, on-road reassessments and restricted licensing, can achieve a successful and safe return

to driving for many individuals with TBI. Most drivers, deemed suitable for referral to driver

rehabilitation successfully resumed driving after less than ten driving lessons and an average of

two and a half on-road assessments to address a range of goals. Importantly, an increase in self-

reported crash rate was not found following resumption of driving. After returning to driving,

many drivers were also found to have modified their patterns of driving to avoid more

challenging driving situations which may have contributed to the lack of self-reported crashes.

The PhD program was also the first to describe the prevalence and use of restricted

licensing in a TBI population and may contribute to adoption by other countries of this

intervention as a method of grading a return to driving. Most importantly, the program has

highlighted the importance of offering driver assessment and rehabilitation to all drivers with TBI

who have the potential to resume driving.

Based on these findings, the current fitness to drive guidelines could be improved to assist

doctors and clinicians determine timing of resuming driving and factors to consider when

screening for the need for practical OT assessment of driving. As the ability to return to driving is

associated with life satisfaction and positively influences community integration and employment


219

participation, it is important that all individuals with a TBI are provided with appropriate advice,

and the opportunity to access driver assessment and rehabilitation.

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APPENDICES

Appendices

Appendix A; Questionnaire for Current Drivers

Questionnaire for Return to Driving

This information will be gathered for research purposes only and will remain confidential

as outlined in the attached information.

Please place a tick in the box next to the response or write your answer in the space

provided. If you make a mistake, just cross it out and tick the correct box.

1. How old were you when you got your driver’s licence? _________

2. Have you continued to drive since your driving assessment at Epworth?

No Please answer the questions on the yellow sheet of paper.

Yes Please continue to answer the questions below.

These Questions are for Current Drivers

The questions in the left column are about your driving behaviour in the 5 years before your

injury and the questions in the right column are about your driving since your injury.

In the 5 years before your injury:

Since your injury:

1a. How often did you drive?

Nearly every day

One to three days each week

A few times each month

Once a month or less Don’t know Learner or Unlicensed

1b.How often do you usually drive?

Nearly every day

One to three days each week

A few times each month

Once a month or less

Don’t know

2aHow important was driving to your

lifestyle?

Not important

Important

Very important

Essential

2b. How important is driving to your lifestyle?

Not important

Important

Very important

Essential

References

254

3a. Did you mainly drive:

within 5 km from home


anywhere

3b. Do you mainly drive:



anywhere

In the 5 years before your injury:

Since your injury:

4a. At the time of your injury what was your

employment status?

Not working

Working full time

Working part time

Student

Volunteer

4b. What is your employment status now?

Not working

Working full time

Working part time

Student

Volunteer

5a. Did you avoid busy traffic situations?

Yes No

5b. Do you avoid busy traffic situations now?

Yes No

6a. Did you avoid taking passengers or limit

the number of passengers?

Yes No

6b. Do you now avoid taking passengers or

limit the number of passengers?

Yes No

7a. Did you avoid driving at night?

Yes No

7b. Do you now avoid driving at night?

Yes No

8a. Did you avoid driving on freeways?

Yes No

8b. Do you avoid driving on freeways now?

Yes No

9a. In the 5 years before your injury, did you

have any accidents (minor and major) when

you were driving?

None 1-2 3-4 5 or more

9b. Since your injury, have you had any

accidents (minor and major) when you were

driving?


10a. Did you have any speeding fines?

10b. Have you had any speeding fines?

References

255



11a. Was your licence ever suspended or

cancelled?

Yes No

11b. Has your licence been suspended or

cancelled since your injury?

Yes No

Compared to before your injury:

12a. Do you limit the amount of time you

drive for?

Yes No

12b. If Yes, why?

13a. Do you avoid unknown places?

Yes No

13b. If Yes, why?

14a. . Do you drive more slowly?

Yes No

14b. If Yes, why?

15. Do you feel you have had more ‘near

misses’ or ‘close calls’?

Yes No

After returning to driving, some people report that they get lost more often and have

difficulty remembering and planning routes.

Compared to before your injury:

More The Same Less Never

16. Do you have more difficulty

planning or remembering routes?

17. Do you use a street directory?

18. Do you use a GPS?

19 Some of the common problems that people report after a brain injury are listed below.

Do you think any of these problems affect your driving?

References

256

Anxiety

Difficulty concentrating

Tiredness or fatigue

More easily distracted

Poor memory

Slowness in thinking

Anger

Lack of confidence

None of the above

Other: ___________________________________________________________

20. Compared to before your injury how would you rate the standard of your driving now?

Better

About the same

Not as good. If not, why do you think this is?

__________________________________________________________________

21. Did you find the driving assessment procedure at Epworth helpful in returning to

driving?

Not helpful Helpful Very helpful

22. Have you any other comments you would like to make?

23. Would you be willing to participate in

any further similar research?

Yes No

Thank you for completing the survey. Your participation will be very valuable and will help

us to improve the assessment and rehabilitation offered for people returning to driving

after a brain injury.

Please post it back to us, with the signed consent form, in the reply paid envelope.

References

257

Appendix B; Questionnaire for Non-Drivers

Questionnaire for Return to Driving

This section is for people who are not currently driving

B1. Below are some of the reasons people don’t drive after a brain injury.

Please tick all responses that apply to you.

No access to a car (Unable to afford a car)

Medical reasons (vision, epilepsy, medication, physical problems, another medical

condition)

Licence suspension/cancellation

Lack of confidence

Family or friends advised you to stop driving

Involved in a crash or almost involved in a crash

Someone else was available to drive you

You do not feel you are a safe driver

You use other forms of transport and don’t need to drive

Difficulty planning and remembering how to get to places

Poor concentration

Tiredness or fatigue

Other ________________________________________________

_________________________________________________________________

_________________________________________________________________

References

258

B2 How important is driving to your lifestyle?

Not important

Important

Very important

Essential

B3. Did you find the driving assessment

procedure at Epworth helpful?

Yes No

B3a If Yes, please describe what was helpful:

B3b Is there anything you would change?

B4 Have you any other comments you would like to make about returning to driving?

B5. Would you be willing to participate in

any further similar research?

Yes No

Thank you for completing the survey. Your participation will be very valuable and will help

us to improve the assessment and rehabilitation offered for people returning to driving

after a brain injury.

Please post it back to us, with the signed consent form, in the reply paid envelope.

References

259

Appendix C; Participant Information and Consent Form

Guidelines for Return to Driving after Brain Injury Project:

Pam Ross, Occupational Therapist is currently investigating the outcomes of patients who completed an

occupational therapy driving assessment at Epworth Rehabilitation following a brain injury. Safe return to

driving is an important aspect of rehabilitation and currently there is a lack of information about which

factors indicate the need for a driving assessment and whether people notice any changes in their driving

behaviour after brain injury.

You have been contacted because you had a driving assessment at Epworth Rehabilitation and were

cleared to return to driving. We are asking you to complete the attached questionnaire about your

experience of driving since your injury. We are also seeking your permission to retrieve the results of

neuropsychological assessments conducted whilst you were a patient at Epworth in order to understand

how these results relate to your driving assessment.

Participation

Participation is voluntary. If you are happy to participate in the study, we ask you to complete the attached

consent form and questionnaire and return them in the pre paid and addressed envelope. It should take

only about 15 minutes of your time. If you do not wish to participate we ask you to send back the consent

form stating this. If you do not reply, a research staff member may contact you by telephone in 3 weeks,

and you will have the option to respond to the questions via telephone or decline to participate.

If you decide to participate in this study, you are free to withdraw at any time even after you have signed

the consent form. This will not prejudice your future care at any of the institutions with which the

investigators are associated.

Confidentiality

We want to assure you that the information we collect about you will be kept completely confidential. No

findings that could identify you will be published. Only the researchers will have

access to identifiable information about you. Paper copies of the questionnaire, will be kept in a locked

cabinet and stored for at least seven years as prescribed by hospital regulations. Unless required by law,

we will not give anyone any personal information without your permission. You have the right to request

access to the information that we have about you on file at any time.

In particular, we will not be forwarding any of your responses to VicRoads as we are not legally

obliged to do so, however, please note that you have a legal responsibility to notify VicRoads

yourself, if you have or develop a medical condition that may affect your ability to drive safely.

Risks and Benefits

We know of no risks to you in participating in the study. You will also receive no direct benefit from this

study, although your experiences will help improve rehabilitation procedures in return to driving after

brain injury.

References

260

Contact Information

If you agree to participate you may withdraw at any time. If you have any queries or would like to discuss

this with someone, please don’t hesitate to contact Pam Ross, Occupational Therapist at Epworth

Rehabilitation on 9426 8745 or Professor John Olver on 9426 8769

If you have any concerns about your driving and would like independent advice please contact your GP,

Epworth Rehabilitation or VicRoads.

Should you have any complaint concerning the manner in which this research is conducted, please do not

hesitate to contact the Human Research Ethics Committee at Epworth Hospital at the following address:

The Co-ordinator, Human Research Ethics Committee

Epworth Foundation

Level 5 Leigh Place

89 Bridge Road

RICHMOND VIC 3121

Phone: 9426 8806 Fax: 9426 6764

Email: [email protected]

References

261

Development of Guidelines for Return to Driving after Traumatic Brain Injury

CONSENT FORM

I, ……………………………………………………………………………………….. (print name) of ………………………………………………………………………………………. (address) have read the explanation of the above research and understand that my responses will be confidential. I agree to take part in the research project on development of guidelines for return to driving after traumatic brain injury described in the attached explanation, which is being conducted by Pamela Ross from Epworth Rehabilitation . I also give consent to retrieval of results from neuropsychological assessments conducted whilst I was a patient at Epworth. I have been given a copy of the Participant Information and Consent Form.

Signed ............................................................................................Date .............................

Signature of witness: ……………………………………………..……Date: ………………….

Name and address of witness (please print):

……………………………………………………….

………………………………………………………………………………………………………….

OR I do not wish to participate in the study

Signed ............................................................................................Date ........................

Please post this form back to us, with the questionnaire, in the reply paid envelope.

Thank you

Documents

On the Road Again: Return to Driving after Traumatic Brain Injury · 2017-02-07 · On the Road Again: Return to Driving after Traumatic Brain Injury Pamela Ross BAppSc OT (Hons),