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Driving after brain injury

Journal of Rehabilitation, April-June, 1995 by Barbara S. Handler, Jeanne Boland Patterson

Driving an automobile is a deeply cherished part of American culture and acquiring a driver s license is a rite of passage into adulthood that signifies the onset of privileges and independence. However the capacity of survivors of brain injury to drive, with all its implications for independent function and self-esteem, must be carefully and thoughtfully balanced against concerns for each survivor's safety and the right of the public to be protected from unreasonable danger (van Zomeren, Brouwer, & Minderhoud, 1987).

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It has been estimated that one to two million individuals sustain a brain injury each year in the United States and 70,000 to 90,000 of these individuals require rehabilitation and follow-up services that may last 5-10 years (Sells, 1993). The costs associated with the long-term care of an individual who sustains a severe TBI range from $4.1 to $9 million. Because of the increased survival rate for individuals with severe TBI, estimated to be four-fold between 1968 and 1988 (Hickey, 1993; McMahon & Growick, 1988), it is logical to assume that more individuals with some degree of cognitive impairment are both currently operating motor vehicles (Hopewell, 1988) and being assessed in various rehabilitation facilities for their capacity to drive safely. Great strides have been made in adapting vehicles for drivers with physical limitations (e.g., amputation, paralysis), so that those who have the motivation and the funds to equip their vehicles with necessary adaptive aids can be trained to drive safely. However different obstacles to safe driving arise for individuals whose disabilities cause seizures or affect their cognitive functions (e.g., slowed thinking, poor judgement, lack of insight, impulsivity, outbursts of anger, inability to sustain concentration, difficulty with divided attention, and inability to self-monitor) (Michon, 1979). This article provides an overview of models, research, and issues related to driving to assist rehabilitation professionals in evaluating the components of driving evaluation and training programs.

Predictors of Fitness to Drive

The complexity of issues involved with driving after brain injury has led to the development of two theoretical frameworks related to driving. Most research on driving after brain injury has been based on Michon's (1979) model, which posits a three-level hierarchy of task performance in car driving. The highest level of Michon's model involves strategical decisions such as time of day, planned route, and whether to drive or use alternative transportation. Decisions at this level affect all other driving-related behaviors. The second level is tactical, which involves decisions made while operating the vehicle (e.g., adapting speed to road and traffic conditions, deciding to pass or not). Appearing to have some overlap with the tactical, the third level is operational and includes the physical manipulation of the controls, use of visual-motor skills, and overall coordination.

In contrast to Michon's model, Galski, Bruno, and Ehle (1992) suggested a "Cybernetic Model of Driving," based on a computer analogy. This model was developed to identify and test elements of driving ability and to diagnose the cause of driving problems through neuropsychological tests, behavioral observations, simulator evaluations, and behind-the-wheel testing. The authors consider the complex of driving behaviors "an expert system" that requires the use of existing learning and permits integration of new learning on a continuous basis. The model includes two programs: (a) a general driving program "that initiates and directs all driving-related activities" (Galski, et al., 1992, p. 326) and (b) a specific driving program for each "trip" behind the wheel.

Most of the literature on driving after brain injury focuses on studies of various neuropsychological and performance tests as predictors of a survivor's capacity to pass the state driving examination and to drive safely (e.g., reaction time, severity of injury [generally judged by length of post-traumatic amnesia], performance in driving simulators, performance on a range of psychologic tests, and behind-the-wheel evaluations by a driving instructor or rehabilitation professional) (van Zomeren et al., 1987). In addition, most of the studies include some elements of pre-driving psychological tests, some type of visual screening, and a graduated system of behind-the-wheel experiences, starting in an environment that presents minimal distraction find stress (usually a parking lot) and gradually increasing to whatever level of on-the-road driving the evaluator and/or the treatment team of the facility judged reasonably safe.

Despite the nearly universal use of Michon's (1979) model, however, it is difficult to compare these studies. There are some common factors, especially standardized neuropsychological tests, but in many cases, there is a diversity in terminology, especially in terms of ocular functions, scanning, attention, and the various frontal lobe functions most often grouped under the umbrella "executive functions" (Mayer & Schwartz, 1993). Even the designation of the disability is confusing, because some studies refer to people with "brain damage," and do not distinguish between those with cerebro-vascular accidents (CVA), traumatic injuries, and other neurologic disorders. Also some studies refer to "head injury" rather than "brain injury." Despite the lack of a common linguistic framework, the results of the major studies conducted between 1986 and 1993 are as follows:

Health Care Industry

Driving after brain injury

Journal of Rehabilitation, April-June, 1995 by Barbara S. Handler, Jeanne Boland Patterson

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