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Rivista di Medicina Fisica e Riabilitativa dopo Eventi Patologici
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RETURN TO DRIVING AFTER TRAUMATIC BRAIN INJURY - Part I
Guest Editors: Bruno Gradenigo, Anna Mazzucchi
Europa Medicophysica 2001 Dicembre;37(4):257-66
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
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.