RETURN TO DRIVING AFTER TRAUMATIC BRAIN INJURY - Part I
Guest Editors: Bruno Gradenigo, Anna Mazzucchi Free

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

Copyright © 2009 EDIZIONI MINERVA MEDICA

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

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.