On the Road Again: Return to Driving after Traumatic Brain Injury

Returning to driving following a traumatic brain injury (TBI) is often a key rehabilitation goal, as the ability to drive enables return to independence and many previous life roles. The ‘gold standard’ assessment of driving after TBI is considered to be the on-road assessment, usually conducted by a specialised occupational therapy driver assessor (OTDA). However there have been few studies investigating the patient characteristics and pre-injury and injury related factors associated with passing or failing the on-road OT driver assessment after TBI. In addition, little is known about the processes and goals of driver rehabilitation provided to those who fail the initial on-road assessment. There has also been limited research into the post-assessment driving behaviour and safety of individuals returning to driving after driver rehabilitation.
    Accordingly, the main aims of the PhD program of research were to a) examine which patient characteristics and pre-injury and injury-related factors were associated with the outcome of initial on-road driver assessment, b) describe the range of goals, processes, timing and outcomes, including the use of restricted licensing and resources, associated with providing on-road training to those who failed an initial OT driver assessment and c) examine and compare the characteristics and self-reported pre- and post-injury driver safety and patterns of driving behaviour of those drivers who returned to driving after one on-road assessment with those who received on-road training and subsequent reassessments.
   In Study 1, the results of all on-road driver assessments completed by patients with a TBI (n = 207), in a rehabilitation setting, over an 8-year period were reviewed retrospectively. Two outcome groups were identified: a ‘pass’ group who resumed driving after passing the initial on-road assessment and a ‘rehabilitation’ group who failed and required on-road training in the form of driving lessons.
   Key-findings; Post traumatic amnesia (PTA) duration proved to be more strongly associated with driver assessment outcome than Glasgow coma scale (GCS) score. Participants, who were male, had shorter PTA duration, faster reaction time and no physical or visual impairment and were at least 3 months post-injury were more likely to pass the initial on-road assessment. These variables correctly classified 87.6% of the pass group and 71.2% of the rehabilitation group. On-road training, followed by subsequent on-road re-assessments were associated with a high probability of return to driving after TBI.
   Recommendations; Factors to consider when determining whether to refer for a practical driver assessment include; ensuring that the client is at least 3 months post-injury, evidence of moderate to severe TBI measured by PTA, slowed choice reaction times and presence of physical or visual impairment that may impact on driver capacity. On–road training is an important driver rehabilitation intervention and should be offered to drivers with TBI who fail the initial on-road assessment.
   From a sample of 340 participants, Study 2 examined the goals, outcomes, timing, use of restricted licenses and number of on-road training lessons and OT driver reassessments provided to the 94 participants who failed the initial on-road assessment.
   Key-findings; The use of goal directed driving lessons to facilitate compensation for cognitive, physical or visual impairment, improve confidence or enhance previously learned driving skills and restricted licensing were found to be associated with return to driving following moderate/severe TBI. An average of seven driving lessons (range 1 – 35) and 2.5 OT driver reassessments (range 1-6), were provided to participants, resulting in 93% (n=87) of cases resuming driving and 7 (7%) failing to meet licensing standards. An open license was recommended for 42 (45%) cases and 45 (48%) resumed driving with a restricted license. The mean time for referral for driving assessment varied significantly between the pass (7.62 months) and rehabilitation groups (13.31 months).
   Recommendation; Investment in on-road training lessons addressing individual goals, followed by reassessment and use of restricted licenses, can achieve successful return to driving following TBI. Although delaying driving by at least 3 months appears to be appropriate, a much longer time frame is often required, particularly with severe TBI.
    Finally, Study 3 examined self-report responses of 106 participants regarding post-injury changes in driving behaviour and number of pre- and post-injury crashes.
   Key findings: No significant differences were found in pre- and post-injury crash rates or in crash rates between the pass (n= 74) and rehabilitation (n= 32) groups. Many drivers reported changes to their driving behaviour: Compared to pre-injury, 36.8% of drivers reported limiting driving time, 40.6% drove more slowly and 41.5% reported greater difficulty with navigating. The rehabilitation group (with greater injury severity) was significantly more likely to drive less frequently, shorter distances and avoid driving with passengers, in busy traffic, at night and on freeways than the pass group.
   Recommendation: As most of the study participants resumed driving and were safe to do so in the longer term, the importance of offering driver assessment and rehabilitation following moderate to severe TBI has been emphasized.
   This PhD program of research, has also highlighted the complexity of the decision-making process required by rehabilitation clinicians in determining fitness to drive after TBI. Factors that were found to contribute to this situation included the wide variation in optimum timing for resuming driving and the range of variables that may impact on the outcome of the on-road assessment, such as injury severity, physical/visual issues, driver confidence, ability to compensate for cognitive issues and driver experience. The findings and recommendations of this PhD program may contribute to development of improved referral criteria and guidelines for resuming driving after TBI.