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Driving after brain injury

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

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There can be no question that vision is a vital component of driving ability (Johnson & Keltner, 1983), nor that problems with visual information processing are a frequent consequence of TBI. Cohen and Rein (1992) pointed out that most occupational therapy and cognitive rehabilitation services, including driving assessment and training, depend on visual information and processing. Defining visual perceptual processing as "...the entire process by which we receive visual information, integrate it, perform an action and adjust behavior accordingly," (p. 531), Cohen and Rein (1992) separated the physical and cognitive elements of visual processing, noting that the integrity of the optical system affects input to the brain, and that cognitive perception is a process that includes form constancy, visual closure, figure ground analysis, visual sequencing, spatial relationships, visual memory, visual auditory integration and visual motor integration.

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In a general study of 10,000 individuals, Johnson and Keltner (1983) found that (a) individuals over the age of 65 had a 13% visual field loss, compared to a three to three and a half percent visual field loss for individuals ranging in age from 16 to 60; (b) half of the individuals were unaware of their visual field loss; and (c) individuals with binocular field loss had twice the accident and conviction rate for moving violations as people with normal visual fields. Similarly, Gianutos, Ramsey, and Perlin (1988) found that many individuals with TBI were unaware of neurologically based partial losses of vision, and therefore might not report nor be able to compensate for such losses. They also found that more than half of the 55 individuals studied had visual field problems that might not be detected in a standard optometric examination.

Proposing a hierarchical model of visual perceptual skills that has implications for both diagnosis and treatment of visual problems associated with TBI, including driving evaluation and remediation, Warren (1992) concurred with Gianutos et al. that conventional visual acuity tests are inadequate and that specialized optometric screenings should be part of any evaluation of a person with a brain injury. Warren theorized that higher level visual skills (i.e., visual memory, visual cognition) depend on mid-level skills (i.e., visual attention, scanning, pattern recognition), which further depend on basic skills (i.e., oculomotor control, acuity, visual field). Disruption of lower level skills disrupts skills at the next level and, conversely, remediation of lower level skills may improve functioning at the higher levels. In people with TBI, the predominant visual loss is in the superior horizontal visual fields, which Warren directly associated with driving ability.

In summary, the research related to visual processes supports the need for specialized rehabilitation optometric examinations. These specialized examinations are particularly important, because many individuals with TBI are unaware that they have lost some of their vision.

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Driving after brain injury

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

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