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EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

A Journal on Physical Medicine and Rehabilitation after Pathological Events


Official Journal of the Italian Society of Physical and Rehabilitation Medicine (SIMFER), European Society of Physical and Rehabilitation Medicine (ESPRM), European Union of Medical Specialists - Physical and Rehabilitation Medicine Section (UEMS-PRM), Mediterranean Forum of Physical and Rehabilitation Medicine (MFPRM), Hellenic Society of Physical and Rehabilitation Medicine (EEFIAP)
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  RETURN TO DRIVING AFTER TRAUMATIC BRAIN INJURY - Part I
Guest Editors: Bruno Gradenigo, Anna Mazzucchi


Europa Medicophysica 2001 December;37(4):257-66

language: English

Driving competence after severe brain injury. A retrospective study

Formisano R., Bivona U., Brunelli S., Giustini M. *, Taggi F. *

From the ­Santa ­Lucia Foun­dation, ­Rome
*­National Insti­tute of ­Public ­Health, ­Rome, ­Italy


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Back­ground. Eval­u­ating fit­ness to ­drive ­after cere­bral ­injury ­includes the pos­sible pres­ence of: sen­sory defi­cien­cies, ­motor dif­fi­cul­ties, cog­ni­tive impair­ments, per­son­ality or behav­ioral dis­tur­bances. ­Driving is in ­fact a com­plex inter­ac­tion of cog­ni­tive and per­cep­tual abil­ities (espe­cially ­related to ­visual ­input), ­motor ­skills and envi­ron­mental fac­tors. At the ­moment no cri­teria are avail­able to ­decide ­whether ­patients ­have suf­fi­ciently recov­ered ­from ­their ­injury to ­resume par­tic­i­pa­tion in ­traffic as ­drivers. ­Michon ­studied the cog­ni­tive con­trol of ­driving ­describing a con­cep­tual ­model ­with ­three-­level hier­archy:
— Oper­a­tional ­Level: ­involves the exe­cu­tion of the ­basic ­actions of ­driving, ­such as ­steering or ­braking. ­Time pres­sure may be ­high, espe­cially for maneu­vers ­aimed at ­avoiding ­acute ­danger;
— Tac­tical ­Level: con­cerns ­behavior and deci­sion in ­traffic; ­time pres­sure is inter­me­diate;
— Stra­tegic ­Level: ­involves deci­sions ­about ­choice of ­route, ­avoiding ­rush ­hour ­traffic or deci­sion not to ­drive at all in par­tic­ular envi­ron­mental con­di­tions; ­time pres­sure is low and plan­ning is an impor­tant fea­ture. Aim of the ­study was to eval­uate if the acci­dent ­rate of our pop­u­la­tion (11 out of 29 ­patients) was a wor­rying per­centage, in com­par­ison ­with ­normal sub­jects.
­Methods. Sev­eral ­methods of ­assigning ­scores to ­road ­tests ­have ­been pro­posed in the Lit­er­a­ture. Like­wise, the ­tests ­have ­also ­been eval­u­ated by a ­number of dif­ferent ­observers (occu­pa­tional ther­a­pists, ­driving instruc­tors). The use of ­driving sim­u­la­tors ­might ­prove a ­useful ­means of auto­mat­i­cally cal­cu­lating ­data ­related to ­driving per­for­mance. On the ­other ­hand, sim­u­la­tors ­should be ­fitted ­with suit­able ­means for ­increasing the per­cep­tion of move­ment, tac­tile and kin­es­thetic sen­sa­tions, ­visual ­field. ­Road ­tests ­using a ­closed and pro­tected cir­cuit ­might not ­have suf­fi­cient eco­log­ical ­validity, espe­cially ­with ­regard to the ­ability to ­drive in ­traffic. ­Road ­tests are gen­er­ally con­sid­ered the ­best, but ­their reli­ability, stan­dar­disa­tion and ­validity ­require fur­ther ­study.
­Results. Out of 90 ­patients ­admitted to the ­Santa ­Lucia Foun­da­tion 29 (32%) ­resumed ­driving; 11 of the 29 ­patients (38%) ­were ­involved in a ­road acci­dent, ­after ­resuming ­driving. The ­result was ­that the fore­seen ­cases was 4.7 and the ­observed 11. Our pre­lim­i­nary and ret­ro­spec­tive ­data ­show ­that a ­person who suf­fered ­from ­severe ­brain ­injury (GCS<8) and ­coma ­lasting ­longer ­than 48 ­hours has a ­higher ­risk of ­being ­involved in a ­traffic acci­dent. The sub­se­quent ­requests of our ­work ­group ­have ­recently ­been ­accepted by the ­Italian Par­lia­ment to ­foresee a ­review of the ­driving ­license ­after a ­coma ­lasting ­more ­than 48 ­hours. A stan­dard­ized pro­tocol ­able to eval­uate fit­ness to ­drive is there­fore ­even ­more ­urgent. In our pro­ject, the pro­tocol ­should be dif­fer­en­tiated in 4 ­phases:
— ­Phase I: Neu­ro­psy­cho­log­ical ­tests (pre-­driver eval­u­a­tion);
— ­Phase II: ­Driving sim­u­lator ­test (off-­road ­test);
— ­Phase III: ­Closed-­course ­test (­behind-the-­wheel ­test);
— ­Phase IV: ­Real ­traffic ­test (on-­road ­test).
Eval­u­a­tion ­would be ­improved by:
— devel­oping sim­u­la­tors ­that pro­vide ­detailed infor­ma­tion ­about ­both the ­nature and ­extent of spe­cific neu­ro­psy­cho­log­ical def­i­cits and per­for­mance on spe­cific ­driving ­tasks;
— estab­lishing the rela­tion­ship of ­these deter­mi­nants to sim­u­lator and ­behind-the-­wheel ­driving;
— ­using ­this infor­ma­tion as a ­basis for devel­oping effi­cient ­retraining pro­grams.

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