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Rehabilitation for improving automobile driving after stroke

  1. Stacey George1,*,
  2. Maria Crotty2,
  3. Isabelle Gelinas3,
  4. Hannes Devos4

Editorial Group: Cochrane Stroke Group

Published Online: 25 FEB 2014

Assessed as up-to-date: 14 JAN 2014

DOI: 10.1002/14651858.CD008357.pub2


How to Cite

George S, Crotty M, Gelinas I, Devos H. Rehabilitation for improving automobile driving after stroke. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD008357. DOI: 10.1002/14651858.CD008357.pub2.

Author Information

  1. 1

    Flinders University, Department of Rehabilitation, Aged and Extended Care, Daw Park, South Australia, Australia

  2. 2

    Flinders University, Repatriation General Hospital, Department of Rehabilitation and Aged Care, Daw Park, South Australia, Australia

  3. 3

    McGill University, School of Physical and Occupational Therapy, Montreal, Quebec, Canada

  4. 4

    Georgia Regents University, Department of Physical Therapy, Augusta, GA, USA

*Stacey George, Department of Rehabilitation, Aged and Extended Care, Flinders University, Daws Road, Daw Park, South Australia, 5041, Australia. stacey.george@health.sa.gov.au.

Publication History

  1. Publication Status: New
  2. Published Online: 25 FEB 2014

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Characteristics of included studies [ordered by study ID]
Akinwuntan 2005

MethodsRCT


ParticipantsRehabilitation unit of the University Hospital Pellenberg, Belgium

83 participants: 42 intervention, 41 control

Inclusion criteria: within 3 months of first stroke, in possession of a valid driver's licence, actively driving before stroke

Exclusion criteria: ≥ 75 years old, history of epilepsy within previous 6 months, severe motor or sensory aphasia

Mean age (years): intervention 54 (SD 12), control 54 (SD 11)

81% male

Side of lesion: 44% left, 52% right, 4% bilateral

Stroke details: 77% ischaemic, 44% right hemiparesis

Mean time post stroke (days): intervention 53 (SD 6), control 54 (SD 6)


InterventionsExperimental intervention: driving simulator-based training in full-sized automatic gear transmission Ford Fiesta. Adaptive equipment such as spinner knob on steering wheel and left-foot accelerator were added as necessary. Training was graded for familiarisation, then advanced to an assortment of 5-km driving scenarios including regular traffic demands such as lane tracking, speed control, road sign recognition, anticipation hazard perception and overtaking. Each skill was initially trained on a scenario that simulated daily driving tasks and then later the same scenarios were presented with distracters to train divided attention

Control intervention: driving-related cognitive tasks. These included route finding on a paper or road map, recognition of road and traffic signs using cards, memory training with numbers and forming different patterns using tiles, utilising commercially available games including 'Rush Hour' and 'Tantrix'

Sessions were 60 minutes, 3 times a week for 5 weeks (15 hours total)


OutcomesOutcomes recorded at baseline, post intervention and at 6 months with some participants followed up at 5 years

Pre and post training

  • Primary outcome: on-road driving test (using Test Ride for Investigating Practical Fitness to Drive checklist), decision of fitness to drive ("fit to drive", "temporarily unfit to drive", "unfit to drive")
  • Secondary outcomes:
    • vision tests: monocular and binocular acuity, kinetic vision
    • cognitive tests: UFOV Test, components of the Stroke Driver Screening Assessment (dot cancellation, square matrix and road sign recognition test)


6-months follow-up

  • Primary outcome: outcome of official pre-driving assessment with the Belgian Road Safety Institute, decision of fitness to drive, and pass/fail classifications (pass - "fit to drive", fail - "temporarily unfit to drive", "unfit to drive")
  • Secondary outcomes: vision and cognitive tests mentioned above


Baseline and 5-year follow-up

  • Primary outcome: as for 6-month follow-up and driving status (actively driving or stopped driving)
  • Secondary outcomes: as for 6-month follow-up, Barthel Index, Hospital Anxiety and Depression Scale, number of kilometres driven per year, number of self reported traffic tickets and accidents


NotesCombined data from Akinwuntan 2005; Akinwuntan 2010; Devos 2009; Devos 2010


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputerised number generation

Allocation concealment (selection bias)Low riskAllocation managed by an independent person

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere was a large amount of missing data due to the number of participants who withdrew (12% withdrew from the intervention group and 10% from the control group, 25% of participants were lost to follow-up, and 26.5% at the 5-year follow-up)

Intention-to-treat analysis determined that drop-out was random and balanced evenly across groups

Selective reporting (reporting bias)Low riskAll outcomes reported, including negative results

Other biasLow riskNo other outcomes were collected

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants not blinded to allocation

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors blinded to allocation

Crotty 2009

MethodsRCT


Participants4 rehabilitation centres in Adelaide, Australia

26 participants: 13 intervention, 13 control

Inclusion criteria: no visual field impairments, binocular vision of minimum 6/12, minimum 1 month post stroke, desire to return to driving, clearance from medical practitioner to perform driving assessment, holder of driver's licence and driving pre stroke

Exclusion criteria: visual field < 120 degrees; unable to provide informed consent; required the use of greater modifications than a spinner knob on the steering wheel, such as a left foot accelerator to complete on-road assessment

Mean age (years): 65.6 (SD 13.1)

92.31% male

Side of lesion: 27% left, 58% right, 15% other

Median time post stroke (days): 83.5 (range 29 to 816)


InterventionsExperimental intervention: training on the Dynavision device (developed to train visuomotor abilities) using a standardised programme of intervention of grading in complexity of tasks from self paced to apparatus paced, in which the time required to respond was reduced as skilled level increased

Control intervention: no intervention and wait-listed for 6 weeks

Sessions were 3 times a week for 6 weeks, each session approximately 40 minutes (total of 12 hours)


OutcomesOutcomes recorded at baseline and post intervention

  • Primary outcome: on-road driving test (pass that included lessons, or fail)
  • Secondary outcomes
    • vision tests: visual scanning
    • cognitive tests: response speed and driving self efficacy


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputerised number generation

Allocation concealment (selection bias)Low riskAllocation managed by an independent person

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were some missing data due to the number of participants who withdrew (12% withdrew from their allocated intervention, 16% of participants were lost to follow-up)

Intention-to-treat analysis performed

Selective reporting (reporting bias)Low risk All outcomes and negative results reported

Other biasUnclear riskParticipation bias as participants may have been reluctant to enter study, particularly those with more disability and poor driving skills as results were sent to licensing agency

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants not blinded to allocation

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors blinded to allocation

Mazer 2003

MethodsRCT


ParticipantsAcute care and rehabilitation centres in Montreal area, Quebec, Canada

97 participants: 47 intervention, 50 control

Inclusion criteria: hemispheric stroke occurring within previous 6 months, licensed to drive prior to stroke, having driven in 6 months prior to stroke, a desire to return to driving, willing to participate in either 20-session training programme, were available during daylight hours, and signed an informed consent form

Exclusion criteria: those criteria indicated by the Canadian Medical Association, visual homonymous hemianopia, primary visual impairment inadequately improved with corrective lenses, class IV cardiac status, seizure activity within the previous year, bilateral lesion, cerebellar or brainstem stroke, severe cognitive deficit (< 6 on Pfeiffer Short Portable Mental Status Questionnaire), severe perceptual, comprehension or motor deficit, as determined by treating medical team, or an inability to communicate in English or French

Mean age (years): 66.5 years (SD intervention 11.4, control 8.9)

73% male

Side of lesion: 48.5% left, 51.5% right

Mean time post stroke (days): intervention 91.2 (SD 51.8), control 66.7 (SD 28.2)


InterventionsExperimental Intervention: 20-session training programme with the UFOV tool including speed of processing, divided and selective attention tasks, which followed a standard training protocol designed according to participant's pre-test evaluation. The programme was graded by increasing speed of presentation of stimuli, eccentricity, colours of peripheral targets from distinct colours to white, which is difficult to see

Control Intervention: 20-session training programme using same touch screen as intervention group using commercially available software programs commonly used by occupational therapists to retrain perceptual and cognitive skills in neurologically impaired adults including Tetris, Mastermind, Othello and Jigsaw Puzzle chosen as did not include aspects of speed of visual processing. The therapist graded the level of complexity in each programme as participants' performance improved

In addition, all participants, regardless of allocation, received 4 sessions of physical retraining on a simulator, which provided training on steering, acceleration, braking and use of adaptive equipment

Both groups received 2 to 4 treatment sessions per week, with duration ranging from 30 to 60 minutes depending on individuals' needs and abilities

The mean number of treatment sessions did not differ significantly between groups, with intervention mean 17.5 (SD 5.3), control mean 18.1 (SD 5.0), P value = 0.53. The duration of sessions differed significantly between groups, with intervention mean 34.1 minutes (SD 6.7) and control mean 43.8 minutes (SD 8.0), P value < 0.0001


OutcomesOutcomes recorded at baseline and post intervention

Primary outcome: on-road driving test (pass, or fail including lessons)

Secondary outcomes: cognitive tests: UFOV, complex reaction timer, Motor-Free Visual Perception Test, Single and Dot Cancellation Tests, Money Road Map Test of Direction Sense, Trail Making Tests Parts A and B, Bells test, Charron test, and Test of Everyday Attention


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated sequence of random numbers. Participants stratified in groups of 6 according to side of lesion and severity of visual processing deficit (mild, moderate or severe) as determined by UFOV test

Allocation concealment (selection bias)Low riskAllocation managed by an independent person

Incomplete outcome data (attrition bias)
All outcomes
High riskThere was a large amount of missing data due to the number of participants who withdrew (17% from intervention group and 12% in the control group, 13% of participants were lost to follow-up). Stated intention-to-treat analysis performed. However, this included only randomised participants who completed the on-road test (84.5%). Secondary analyses were performed by excluding participants who did not comply with the training programme

Selective reporting (reporting bias)Unclear riskAll outcomes and negative results reported

Other biasLow riskNo other outcomes were recorded

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants not blinded to allocation

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors blinded to allocation. On-road evaluation performed prior UFOV test to prevent evaluators from observing participants performance, which may have been an indication of the intervention the participant received. Despite this, the outcome evaluator correctly identified the treatment received 79% of the time. However, this did not result in any difference in rate of passing in either groups

Mazer 2005

MethodsRCT


ParticipantsRehabilitation hospital in Laval, Quebec, 2 driving evaluation centres and a private driving evaluation clinic in Montreal area, Quebec, Canada

39 participants: 20 intervention, 19 control

Inclusion criteria (for stroke participants): people with a diagnosis of stroke who did not pass the driving tests at a recognised driving evaluation service. Had licence to drive and were driving prior to the stroke and desire to return to driving

Exclusion criteria: medical condition precluding driving (e.g. hemianopia, seizures), received their driving evaluation more than 2 years post diagnosis, unable to communicate in English or French, inadequate communication of basic verbal instructions or judged as dangerous by the therapist in the on-road evaluation

Mean (SD) age (years): intervention 68 (14), control 69 (9)

69% male

Side of lesion: 31% left, 56.5% right
Other CVA: 12.5%

Mean time post stroke (years): intervention 1.4 (SD 1), control 1.7 (SD 1)


InterventionsExperimental Intervention: driving simulator. Simulator was a car frame with 3 large screens providing a large field of view. Participants were progressed through 4 increasingly complex scenarios. Level 1, participants were familiarised with the simulator and controls; level 2 involved a simulated road circuit without traffic; level 3 focused on performing different driving manoeuvres and level 4 involved a variety of traffic conditions (e.g. rain, wind, reduced visibility, pedestrians). Instant feedback was provided by the simulator when errors were made

Control intervention: no intervention provided

Sessions were 60 minutes, twice a week for 8 weeks (16 hours total)


OutcomesOutcomes recorded at baseline and post intervention (or after 8 weeks for the control group)

Primary outcome: DriveAble Testing Ltd Driver Evaluation - standardised driving evaluation involving a screen test and on-road evaluation (pass or fail)

Secondary outcomes: cognitive tests - UFOV test, Cognitive Behavioural Drivers Inventory, Motor Free Vision perception Test, Bells test, Functional Independent Measure


NotesNote that this study also recruited 6 people with traumatic brain injury. However, we were able to separate data for participants with stroke ; this review reports on the stroke data only


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated sequence of random numbers. Participants stratified according to diagnosis and severity of impairment (recommended driving lessons or fail)

Allocation concealment (selection bias)Low riskAllocation managed by an independent person

Incomplete outcome data (attrition bias)
All outcomes
High risk7 participants, 13% (5 control, 2 simulator) did not complete the outcome evaluation and were therefore considered to have dropped out from the study
Analysis was completed based on the actual number of participants contributing data and it is unclear whether intention-to-treat analyses were conducted 1 participant who did not complete the intervention was removed from the analysis

Selective reporting (reporting bias)Low riskAll outcomes and negative results reported

Other biasUnclear riskParticipation bias as participants may have been reluctant to enter study, particularly those with more disability and poor driving skills as results were sent to licensing agency

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants not blinded to allocation

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors blinded to allocation. Outcome evaluator correctly identified the participants' group allocation 64% of the time

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Hitosugi 2011Study design: not an RCT

Inoue 2006Study design: not an RCT

Jacobs 2012Participants with stroke and brain injury

Katz 1990Study design: not an RCT

Klavora 1995Study design: not an RCT

Kotterba 2005Study design: not an RCT

Lings 1991Study design: not an RCT

Mazer 2001Study design: not an RCT

Monning 2002Study design: not an RCT

Schultheis 2007Study design: not an RCT

Söderström 2006Study design: not an RCT

 
Comparison 1. Comparison of outcomes: on-road score 6 months/road sign recognition

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 On-road score 6 months183Mean Difference (IV, Random, 95% CI)15.0 [-4.56, 34.56]

 2 Road sign recognition173Mean Difference (IV, Fixed, 95% CI)1.69 [0.51, 2.87]

 
Table 1. Outcome measures used for included trials

Author and yearOn-road assessmentVisual functionCognitive functionDriving behaviourOther

Akinwuntan 2005Test-ride for Investigating Practical Fitness to Drive checklistMonocular and binocular acuity

Kinetic vision
Useful Field of View test

Components of Stroke Driver Screening Assessment

(dot cancellation, square matrix

and road sign recognition test)
5 years:

driving status

kilometres driven

self reported traffic tickets and accidents
6 months:

official pre-driving assessment with licensing agency

5 years Barthel index

Hospital Anxiety and Depression Scale

Crotty 2009Standardised on-roadVisual scanningResponse speedDriving self-efficacy-

Mazer 2003On-road assessmentSingle and dot cancellationUseful Field of View test

Complex Reaction Timer

Motor-free Visual Perception Test

Money Road Map Test of Direction Sense

Trail Making Tests Part A and B

Bells test

Charron test

Test of Everyday Attention
--

Mazer 2005DriveAble Testing Ltd Driver Evaluation-Useful Field of View test

Cognitive Behavioural Drivers Inventory

Motor Free Vision Perception test Bells test
-Functional Independent Measure

 
Table 2. Number screened, number still in trial and driving intervention at end of trial

Author and yearScreenedRandomisedAllocation interventionCompleted trial/analysed at final follow-upCompleted intervention

Akinwuntan 2005126834273 post training

52 at 6 months

61 at 5 years
37

Crotty 20093726132410

Mazer 2003Not reported97478439 completed 75% of intervention

considered compliant

Mazer 2005Not reported46223920