Rehabilitation for improving automobile driving after stroke
Abstract
Background
Interventions to improve driving ability after stroke, incl
uding driving simulation and retraining visual skills, hav
e limited evaluation
of their effectiveness to guide policy and practice.
Objectives
To determine whether any intervention, with the specific aim o
f maximising driving skills, improves the driving performa
nce of people
after stroke.
Search methods
WesearchedtheCochrane Stroke GroupTrialsregister(August 2
013), theCochrane Central Registerof ControlledTrials(
The Cochrane
Library
2012, Issue 3), MEDLINE (1950 to October 2013), EMBASE (1980 to Octo
ber 2013), and six additional databases. To
identify further published, unpublished and ongoing trial
s, we handsearched relevant journals and conference proceeding
s, searched
trials and research registers, checked reference lists and conta
cted key researchers in the area.
Selection criteria
Randomised controlled trials (RCTs), quasi-randomised trials
and cluster studies of rehabilitation interventions, with t
he specific aim
of maximising driving skills or with an outcome of assessing d
riving skills in adults after stroke. The primary outcome of i
nterest was
the performance in an on-road assessment after training. Secon
dary outcomes included assessments of vision, cognition and dr
iving
behaviour.
Data collection and analysis
Two review authors independently selected trials based on pr
e-defined inclusion criteria, extracted the data and assessed ri
sk of bias. A
third review author moderated disagreements as required. T
he review authors contacted all investigators to obtain missi
ng information.
Main results
We included four trials involving 245 participants in the revi
ew. Study sample sizes were generally small, and interventi
ons, controls
and outcome measures varied, and thus it was inappropriate to
pool studies. Included studies were at a low risk of bias for th
e majority
of domains, with a high/unclear risk of bias identified in the a
reas of: performance (participants not blinded to allocation), a
nd attrition
(incomplete outcome data due to withdrawal) bias. Interventio
n approaches included the contextual approach of driving simula
tion
and underlying skill development approach, including the ret
raining of speed of visual processing and visual motor skills
. The studies
were conducted with people who were relatively young and the ti
ming after stroke was varied. Primary outcome: there was no cle
ar
evidence of improved on-road scores immediately after trainin
g in any of the four studies, or at six months (mean difference 15
points
on the Test Ride for Investigating Practical Fitness to Drive -
Belgian version, 95% confidence intervals (CI) 4.56 to 34.56, P v
alue =
0.15, one study, 83 participants). Secondary outcomes: road sig
n recognition was better in people who underwent training comp
ared
with control (mean difference 1.69 points on the Road Sign Recogn
ition Task of the Stroke Driver Screening Assessment, 95% CI 0
.51
to 2.87, P value = 0.007, one study, 73 participants). Significan
t findings were in favour of a simulator-based driving rehabil
itation
programme (based on one study with 73 participants) but these r
esults should be interpreted with caution as they were based o
n a single
study. Adverse effects were not reported. There was insufficie
nt evidence to draw conclusions on the effects on vision, other me
asures
of cognition, motor and functional activities, and driving beh
aviour with the intervention.
Authors’ conclusions
There was insufficient evidence to reach conclusions about the use
of rehabilitation to improve on-road driving skills after st
roke.
We found limited evidence that the use of a driving simulator m
ay be beneficial in improving visuocognitive abilities, such as
road
sign recognition that are related to driving. Moreover, we we
re unable to find any RCTs that evaluated on-road driving lesso
ns as an
intervention. At present, it is unclear which impairments tha
t influence driving ability after stroke are amenable to rehab
ilitation, and
whether the contextual or remedial approaches, or a combinatio
n of both, are more efficacious.
Description
Publisher version made available in accordance with the publisher's policy. This item is under embargo for a period of 12 months from the date of publication, in accordance with the publisher's policy.
'This review is published as a Cochrane Review in the
Cochrane Database of Systematic Reviews 2014, Issue 2.
Cochrane Reviews are regularly updated as new evidence
emerges and in response to comments and criticisms, and
the Cochrane Database of Systematic Reviews should be
consulted for the most recent version of the Review.’