Investigating feasibility and preliminary efficacy of a simulator-based driving intervention for people with acquired brain injury: A randomised controlled pilot study.

OBJECTIVE: To investigate the feasibility and preliminary efficacy of a driving simulator intervention on driving outcomes following acquired brain injury. DESIGN: Pilot randomised controlled trial. SETTING: Occupational therapy driver assessment and rehabilitation service. SUBJECTS: Individuals post-acquired brain injury aiming to return to driving. INTERVENTION: Eight sessions of simulated driver training over four weeks, in addition to usual care. Control: Usual care only. MAIN MEASURES: Feasibility outcomes: Participant recruitment and retention; data completeness; therapy attendance and fidelity; adverse events. Performance outcomes: on-road driving performance; Simulator Sickness Questionnaire; Brain Injury Driving Self-Awareness Measure and Driving Comfort Scale - Daytime, assessed at baseline and five weeks post-randomisation. RESULTS: Out of 523 individuals screened, 22 (4%) were recruited and randomised, with 20 completing their allocated group (n = 12 Simulator, n = 8 Usual Care). For those who completed training, session attendance was 100% with simulator sickness rated, on average, as mild. Six individuals (50%) in the Simulator group failed the on-road assessment, versus two (25%) in the Usual Care group (P = 0.373). On average, the Simulator group reported a positive change in confidence ratings (M = 5.77, SD = 13.96) compared to the Usual Care group, who reported a negative change (M = -6.97, SD = 8.47), P = 0.034. The Simulator group (M = 0.67, SD = 3.34) demonstrated no significant change in self-awareness relative to the Usual Care group (M = -0.83, SD = 1.83, P = 0.325). CONCLUSIONS: With adjustments to inclusion criteria and recruitment strategies, it may be feasible to deliver the intervention and conduct a larger trial. There is potential benefit of simulator training for improving driver confidence after acquired brain injury.

The development of a simulator-based intervention to rehabilitate driving skills in people with acquired brain injury.

PURPOSE: With little to guide researchers and clinicians on how best to develop driving simulator interventions for ABI survivors, we aimed to describe the development process of a driving simulator intervention for ABI survivors in a rehabilitation setting. METHOD: Intervention mapping methodology was used as a framework for the development of our driving simulator intervention. A qualitative synthesis of theoretical and empirical literature and stakeholder meetings enabled identification of factors affecting return to driving, selection of justifiable intervention goals, and identification of appropriate theoretically-informed techniques to facilitate change. These were used as a basis for design of intervention components and materials. A plan for delivery, implementation and evaluation was then developed. RESULTS: Determinants of driving ability, including knowledge and skills, self-efficacy, self-awareness of driving skills, awareness of risk and compensatory strategies were identified. These were applied to a range of tactical and operational driving behaviours to identify targets for change. Theoretically-informed strategies included direct instruction, repetition, graded difficulty, feedback and tailoring. An eight-session protocol, with a corresponding clinical manual, was developed for brain-injured patients who were referred for occupational therapy driving assessment. Protocols for recruitment, inclusion/exclusion criteria and facilitator training were developed, as well as a plan for evaluating feasibility, acceptability and effectiveness. CONCLUSIONS: Intervention mapping was a useful approach to systematically develop an intervention tailored to the rehabilitation hospital context to complement existing driver rehabilitation. The feasibility and effectiveness of the simulator programme developed in this study will be evaluated in future studies.IMPLICATIONS FOR REHABILITATIONWe were able to gather important information and provide recommendations to tailor a new driving simulator intervention for individuals with acquired brain injury within a rehabilitation service.The processes and methods described provide researchers and clinicians with a systematic process for the selection of driving simulator intervention components and delivery.This investigation can be used to educate rehabilitation clinicians and technicians to improve driver training and delivery to acquired brain injury survivors.

User experiences and perspectives of a driving simulator intervention for individuals with acquired brain injury: A qualitative study.

Driving a motor vehicle is a common rehabilitation goal following acquired brain injury (ABI). There is increasing interest in the use of driving simulators for driver rehabilitation post-ABI; however, there is still limited research demonstrating efficacy and acceptability. This study sought to examine the user experience of a driving simulator intervention for ABI survivors. Semi-structured interviews were conducted with 14 individuals, including 12 ABI survivors (42% male; Mean age = 53.92 years, SD age = 17.63) who completed the intervention, and 2 occupational therapist driver assessors who facilitated the intervention. Thematic analysis was adopted to analyse interview data. Findings suggest that individual differences (e.g., anxiety, previous experience) influenced participant response to training. The intervention allowed participants to practise various driving skills, re-familiarize themselves with the task of driving, and prepare for return to on-road driving within a safe environment. The intervention was perceived to be useful for enhancing driver self-awareness, autonomy, confidence and patience. Fidelity and simulator sickness were considered limitations of the simulator technology. Subjective accounts of the appropriateness of intervention components are also documented. Overall, the simulator intervention was reported to be a positive experience for participants. Themes emerging from this study can inform future driving simulator interventions for ABI survivors.

Characterizing on-road driving performance in individuals with traumatic brain injury who pass or fail an on-road driving assessment.

OBJECTIVE: To characterise on-road driving performance in individuals with traumatic brain injury who fail on-road driving assessment, compared with both those who pass assessment and healthy controls, and the injury and cognitive factors associated with driving performance. STUDY DESIGN: Cross-sectional. METHODS: Forty eight participants with traumatic brain injury (Age M = 40.50 SD = 14.62, 77% male, post-traumatic amnesia days M = 28.74 SD =27.68) and 48 healthy matched controls completed a standardised on-road driving assessment in addition to cognitive measures. RESULTS: Individuals with traumatic brain injury who passed on-road driving assessment performed no differently from controls while individuals with traumatic brain injury who failed the assessment demonstrated significantly worse driving performance relative to controls across a range of driving manoeuvres and error types including observation of on-road environment, speed control, gap selection, lane position, following distance and basic car control. Longer time post-injury and reduced visual perception were both significantly correlated with reduced driving skills. CONCLUSIONS: This exploratory study indicated that drivers with traumatic brain injury who failed on-road assessment demonstrated a heterogeneous pattern of impaired driving manoeuvres, characterised by skill deficits across both operational (e.g., basic car control and lane position) and tactical domains (e.g., following distance, gap selection, and observation) of driving. These preliminary findings can be used for implementation of future driving assessments and rehabilitation programs. Implications for rehabilitation Clinicians should be aware that the majority of individuals with traumatic brain injury were deemed fit to resume driving following formal on-road assessment, despite having moderate to very severe traumatic brain injuries. Drivers with traumatic brain injury who failed an on-road assessment demonstrated a heterogeneous pattern of impaired skills including errors with observation, speed regulation, gap selection, and vehicle control and accordingly had difficulty executing a diverse range of common driving manoeuvres. Comprehensive, formal on-road assessments, incorporating a range of skills, and manoeuvres, are needed to evaluate readiness to return to driving following traumatic brain injury. Individually tailored driver rehabilitation programs need to address these heterogeneous skill deficits to best support individuals to make a successful return to driving post-traumatic brain injury.

Using Naturalistic Methods to Examine Real-World Driving Behavior in Individuals With TBI Upon Return to Driving: A Pilot Study.

OBJECTIVES: To characterize the real-world driving habits of individuals with traumatic brain injury (TBI) using naturalistic methods and to demonstrate the feasibility of such methods in exploring return to driving after TBI. METHODS: After passing an on-road driving assessment, 8 participants with TBI and 23 matched controls had an in-vehicle device installed to record information regarding their driving patterns (distance, duration, and start/end times) for 90 days. RESULTS: The overall number of trips, distance and duration or percentage of trips during peak hour, above 15 km from home or on freeways/highways did not differ between groups. However, the TBI group drove significantly less at night, and more during the daytime, than controls. Exploratory analyses using geographic information system (GIS) also demonstrated significant within-group heterogeneity for the TBI group in terms of location of travel. CONCLUSIONS: The TBI and control groups were largely comparable in terms of driving exposure, except for when they drove, which may indicate small group differences in driving self-regulatory practices. However, the GIS evidence suggests driving patterns within the TBI group were heterogeneous. These findings provide evidence for the feasibility of employing noninvasive in-car recording devices to explore real-world driving behavior post-TBI.

Interventions for resuming driving after traumatic brain injury.

PURPOSE: To describe the goals, processes, resources and outcomes of on-road training lessons provided to drivers with traumatic brain injury (TBI) who failed an initial occupational therapy (OT) driver assessment. METHOD: Descriptive cohort study using file audit design of 340 drivers with mild to severe TBI. Measures included; number and goals of on-road training lessons and reassessments, time from injury to independent driving, license restrictions, years licensed, physical/visual impairments and injury severity. RESULTS: Initial OT driver assessment was passed by 72% (n = 246) cases. Of the 28% (n = 94) who failed, 93% (n = 87) resumed driving following on-road training; 42 (45%) with an open licence, 45 (48%) with restricted licence and seven (7%) failed to meet licencing standards. Individuals required, on average, 7.0 driving lessons (14 driving instructor hours), and 2.5 on-road reassessments, (9.8 OT and 3.8 driving instructor hours). Lesson goals were recommended to develop compensatory strategies for cognitive impairments (64%), improve previously learned driving skills (57%), improve confidence (53%), and address physical (26%) or visual impairment (16%). CONCLUSIONS: 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. Implications for Rehabilitation Driver rehabilitation specialists should offer on-road driver training to individuals with moderate to severe TBI who fail an initial driver assessment. Goal directed driving lessons can train individuals with moderate to severe TBI to compensate for cognitive, physical, visual, and psychological barriers to driving, enabling them to pass a reassessment and return to driving. Restricted licences may enable some drivers with TBI to meet their driving needs and achieve safe return to driving.

Self-Awareness and Self-Ratings of On-Road Driving Performance After Traumatic Brain Injury.

OBJECTIVE: To examine self-rated, clinician-rated, and self-awareness of on-road driving performance in individuals with traumatic brain injury (TBI) deemed fit and unfit to resume driving and healthy controls, and to explore their associations with demographic, injury, cognitive, and mood variables. METHODS: Participants included 37 individuals with moderate to severe TBI, and 49 healthy age, sex, and education-matched controls from Australia and Canada. Participants completed an on-road assessment, the Brain Injury Driving Self-Awareness Measure (BIDSAM), and a comprehensive neuropsychological assessment. RESULTS: Awareness scores on the BIDSAM were significantly different between groups, F(2, 83) = 28.44 (P < .001; η = 0.41), with post hoc tests indicating TBI participants who failed the on-road assessment had worse scores compared with those who passed and controls. Poor self-awareness was significantly correlated with reduced psychomotor speed (rs = -0.37; P < .01) and attentional switching (rs = 0.28; P < .01). Worse self-ratings of driving were associated with depression (rs = 0.42; P < .01) and anxiety (rs = 0.38; P < .01). CONCLUSIONS: Individuals with TBI who failed an on-road assessment significantly overestimated their driving ability. Impaired cognitive function was associated with reduced self-awareness of driving. These findings suggest impaired awareness of driving may need to be addressed as part of driver rehabilitation programs.

The development and initial validation of a new tool to measure self-awareness of driving ability after brain injury.

AIM: The aim of this study was to develop and provide initial validation data for a self-awareness of on-road driving ability measure for individuals with brain injury. METHOD: Thirty-nine individuals with Traumatic Brain Injury completed an on-road driving assessment, the Self-Regulation Skills Interview (SRSI) and the newly developed Brain Injury Driving Self-Awareness Measure (BIDSAM). RESULTS: BIDSAM self, clinician and discrepancy scales demonstrated high levels of internal consistency (α = 0.83-0.92). Criterion-related validity was established by demonstrating significantly higher correlations between clinician ratings and on-road performances, rs  = 0.82, P < 0.01, compared to self-ratings, rs  = 0.45, P < 0.05. Discrepancy scores were significantly correlated with the SRSI emergent, rs  = 0.52, P < 0.01, and anticipatory awareness scores, rs  = 0.37, P < 0.05, indicative of convergent validity. CONCLUSIONS: These results provide initial support for the BIDSAM as a reliable and valid measure of self-awareness of on-road driving ability following TBI.

Predictors of on-road driver performance following traumatic brain injury.

OBJECTIVE: To examine assessment outcomes and factors associated with passing an occupational therapy (OT) on-road driver assessment after traumatic brain injury (TBI). DESIGN: Retrospective analysis of outcomes of on-road driver assessment completed by persons with TBI over an 8-year period. SETTING: Inpatient and outpatient rehabilitation hospital. PARTICIPANTS: A consecutive sample of individuals (N=207) with mild to severe TBI who completed an on-road driver assessment and were assessed at least 3 months postinjury. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Outcome of on-road driver assessment. RESULTS: Of the drivers with TBI, 66% (n=137) passed the initial on-road driver assessment (pass group), whereas 34% (n=70) required on-road driver rehabilitation and/or ≥1 on-road assessment (rehabilitation group). After driver rehabilitation, only 3 participants of the group did not resume driving. Participants who were men, had shorter posttraumatic amnesia (PTA) duration, had no physical and/or visual impairment, and had faster reaction times were significantly more likely to be in the pass group. In combination, these variables correctly classified 87.6% of the pass group and 71.2% of the rehabilitation group. CONCLUSIONS: PTA duration proved to be a better predictor of driver assessment outcome than Glasgow Coma Scale score. In combination with the presence of physical/visual impairment and slowed reaction times, PTA could assist clinicians to determine referral criteria for OT driver assessment. On-road driver rehabilitation followed by on-road reassessment were associated with a high probability of return to driving after TBI.