1.1

Introduction

Return to driving following a traumatic brain injury (TBI) is a positive element in the process of readaptation. Driving is often associated with greater independence and better quality of life , and is a public health issue. The regulation and the organisation of driving capacity assessments vary depending on the country. Some countries such as the United Kingdom, Italy, Belgium and Canada have one or several dedicated centers specialised in such assessments. In Australia, some occupational therapists are recognised by the driving licence authorities. Despite this, the decision to return to driving appears to be most often taken by the person themselves, with or without the advice of family, without any medical advice and even against medical advice . This is well illustrated by Brooks et al. in a study carried out in England. They report that very few people with TBI refer themselves to the British mobility centre before returning to driving. This can be partially explained by the fact that professionals are often poorly informed themselves and thus cannot properly inform patients as well as the fact that it is completely up to the initiative of the persons concerned to consult competent authorities.

The frequency of return to driving following TBI (moderate to severe) varies in the literature between 32% and 52% .

Driving is a complex and dynamic activity. The most cited conceptual model of driving is that of Michon , which schematizes the activity in three interconnected levels. The strategic level requires decisions to be taken (such as the day, time, itinerary, filling up etc.) with no time constraints. The tactical level requires the capacity to plan, be flexible and to adapt within time constraints (such as adapting speed to the level of traffic, taking decisions such as changeing lanes etc.). And lastly, the operational level which includes all the perceptive and automatic skills necessary to drive the vehicle. This level requires a certain amount of practice as well as visuo-spatial skills, good reaction times and muscle strength, under permanent time constraints.

Compensatory strategies could easily be put into place at the tactical level, however, it is more difficult for the strategic and operational levels. People with TBI are likely to have deficits of the functions described in this model, thus justifying a driving capacity assessment. However, to the best of our knowledge, no validated consensus regarding the assessment of driving capacity currently exist. Practices, along with regulations, vary between countries. This article aims to review the current knowledge of the impact of TBI on driving activity.

1.2

Materials and methods

A literature review was carried out using Pubmed and the Cochrane Library using the following key words: “automobile driving (Mesh) AND Traumatic Brain Injury (Mesh not exp)” for the period January 2000 to December 2010.

Sixty-three abstracts were obtained, 34 of which were included because they included an assessment of cognitive sequelae following TBI and the impact on driving and/or the impact of TBI on driving capacity, in French or English. Among these 35 articles, five report of literature review including an “evidence-based literature review”, three are devoted to descriptions of assessment practices, four relate to road accident after TBI. All studies, who have all low level of evidence, using neuropsychological testing are summarized in Table 1 .

1.3

Impact of traumatic brain injury on road traffic accidents

Retrospective studies carried out on road traffic accidents following TBI are interesting and motivating to better assess the capacity to return to driving. Indeed, even if the studies have a low level of evidence, they tend to show an increased risk of accident following TBI.

Mosberg et al. evaluated 62 brain-injured subjets (36 post stroke, 15 post TBI, mean age 50 years) who underwent a global assessment and were considered capable of driving. Fifteen months later, the same subjects were asked to fill in a questionnaire regarding their driving capacity and behaviour. There was a non-significant increase in the number of accidents for the whole group. However, the TBI subjects had a significantly greater number of accidents than the stroke subjects. The subjects implicated were mostly young TBI patients with executive function impairments.

An Italian study by Petrapiana et al. evaluated 66 subjects at least 1 year (mean 5.51 years) post severe TBI (initial Glasgow score ≤ 8, average of 12.44 days of coma) with a mean driving experience of 10.27 years. Close relatives who knew the subjects well before the TBI were questioned regarding their driving style and personality prior to the TBI. Thirty-three of 66 subjects (47%) had returned to driving at least one year previously. Twenty-one of these had received medical advice and ten had had no specific assessment. Thirty-five of 66 (53%) had not taken up driving again. It is interesting to note that there was no significant difference in the number of accidents or offences between the two groups prior to the TBI. However, eleven of the 31 subjects who returned to driving had had at least one accident (35.5%), which is reported as being higher than in the general population.

The positive correlation between the number of years post TBI and the number of accidents or offences post TBI suggests that dangerous driving behaviour persists over time.

In Sweden, Lundqvist et al. studied 38 brain-injured patients, of which 24 had diffuse cerebral lesions (ten TBI and 14 sub-arachnoid haemorrhage [SAH]), and compared them to 49 control subjects. All the subjects had undergone a neuropsychological assessment and an on-road assessment 10 years previously and replyed to a semi-strucutred interview regarding their current driving practices. The rate of accidents was significantly higher in the patient group (nine patients, six of which had TBI or SAH; 28%) in comparison with the control group (five subjects; 10%).

In Italy, a study by Formisano et al. confirmed this tendencywith a study of 90 subjects with severe brain injury which 80% of TBI. Only 29 subjects (32%) had returned to driving. An interview of their relatives revealed that 38% of the subjects who had returned to driving (11/29) had had at least one road traffic accident. Forty-five percent had had more than one accident and one subject, who had a prevalence of behavioural problems in proportion to his cognitive impairment according to a neuropsychological assessment, had had nine accidents. The risk of accident in this population is 2.3 times higher than in the general population.

Similarly, a study by Schanke et al. showed a significantly higher number of accidents per kilometre driven for TBI patients (28 subjects, on average 9.1 years post accident) compared with values in the general population in Norway, despite a specific assessment prior to returning to driving. This was not the case for the stroke population (65 subjects) of their study. The authors suggested that the long follow up in comparision with other studies, the difficulty in detecting impairments of executive function in their assessment and the possible existence of a premorbid “accident-type behaviour” could explain the high level of accidents in the TBI subjects.

The results of Schulheis et al. are more encouraging for multidisciplinary assessments, although the follow up was shorter. Forty-seven TBI subjects who had returned to driving since an average 2.14 years following a multidisciplinary assessment which included a neuropsychological assessment as well as an on-road assessment, were compared to 22 control subjects. The results showed similar numbers of offences and accidents declared to the insurance companies (around ¼) between the two groups. The only difference, which was not significant, was for accidents which were not declared to the insurance company, around 40% in the TBI group and 31.8% in the control group.

1.4

Traumatic brain injury and recovery of automobile driving: which predictive factors?

Clinical factors which could predict return to driving were investigated.

The impact of the initial severity of the TBI, most often assessed using the Glasgow Coma Scale (GCS), the duration of the inital coma and less frequently the duration of post-traumatic amnesia have been studied several times but without a consensus of results . Coleman et al. did not reveal any impact of the initial TBI severity, in a study of 71 subjects with moderate to severe TBI which occurred on average 4.3 years previously.

While studies of Pétrapiana et al. and Haway show a negative correlation between severity of TBI, in particular the duration of coma, and return to driving.

The TBI population is often described as young with risk behaviour prior to the accident.

The results regarding the impact of these factors as predictive or not on the resumption of driving diverge. Pietrapiana et al. studied a group of 66 severe TBI subjects at least 1 year post accident. According to the authors, the factors which predict safe driving following TBI are a low number of previous accidents or offences, a low-risk personality index (which includes indolence, impulsiveness, calmness, irritability, sociability, agressivity and a tendency to inattention) and a low-risk driving style (evaluating attention, tendency to inattention, competitiveness, adherence to the highway code and audacity). This was, however, not confirmed in a study by Coleman et al. in which only the history of accidents and offences were taken into account.

The young age at the time of the TBI has been found to be a negative predictive factor for return to driving . This factor is associated with the role of driving experience as a positive factor regarding the capacity to return to driving after TBI.

1.5

How should driving capacity following traumatic brain injury be evaluated?

1.6

Discussion

This review of literature highlights the many difficulties surrounding the issue of assessing the impact of cognitive impairment on the on-road capacity after TBI.

It is interesting to notice that the studies concern only TC moderated in severe. The impact of a light TC on the capacities of driving, if only in the short term, are never mentioned. Such studies would better define the criteria of the populations TC whose driving skills shoud be assessed.

Some disturb deserve special attention.

Firstly, the unilateral neglect. If Brouwer and al considers it as being able to be estimated in situation of driving, implying that this one can be compensated in situation of driving, what asks the question of the possibilities of compensation of a “unconscious” disorder. Can we end that the absence of appearance of this unilateral neglect in situation of driving (on a duration varying from 45 till 120 minutes) means no “over risk” in situation of driving? Many elements of answers are still lacking, in particular as regards the tests to be used and their value threshold, which remain to define.

The anosognosia is considered as having an important influence on the capacities of resumption of the conduct driving after a TBI . However, no author specifies the modalities of evaluation of this one. It would be certainly useful to define a scale, which would include, in particular, elements relative to the critique of on road situation(s). The use of embarked cameras, allowing to visualize at the same time the field before and defers, as well as the face of the driver could become tools of completely interesting awareness. If all the elements of this review of the literature demonstrates the interest and the importance of a global evaluation of the capacities of driving after TBI moderated in severe, their modalities must be specified. As far as the definition of a “security” driving, is for our sense, not stemming from a “binary” system, because it is a question of correlating numerous elements supplied by the clinical examination, and on road situation, with the estimated cognitive functions. However, multicenter studies, based on harmonized evaluations would allow to improve our knowledge. It would require the definition on one hand, of one neuropsychologic protocol of evaluation in terms of tests and used standards. If the interest of the UFOV and the TMT A-B is recognized, the tests of evaluation of the other functions (offices), such as the attention with the “Test of Attention Performance” for example, remain to define. On the other hand, a harmonization of the evaluations on road, what is complex to realize, because these cannot be reproduced as before, according to the environment of every center, conditions of circulation (traffic), meteorological… However, the definition of situations of driving to be estimated (as for example the insertion in freeway, traffic circles, the turned left, maneuver), and of criteria of security driving (such as the preservation of trajectories, the adaptation of the speed, the anticipation) with common modalitiesof quotation, would allow to limit the disparities of results. As suggested by the results of Mosberg et al. and Lundqvist et al. studies , make sure of the validity of these evaluations would be desirable. Yet, the factors of validity are not clearly formulated. We can reasonably think that the absence of on-risk of accident (declared and undeclared) for this population estimated TBI, with regard to the general population, would be the best answer. This subject remains to discuss, and its complex implementation. But the results of such studies would favor certainly the evolution of the regulations as for the capacity in the driving after TBI. If the evaluation of the capacities of driving after TBI gives rise to a binary answer (possibility of resumption of a security driving or not), it is also the opportunity to propose a reeducation, centered on the persistent cognitive difficulties. As such, it is surprising to find no study, in this review of the literature, stating the interest, or not, the training in driving activity (on simulator or on road). It would be certainly useful for the TBI persons that such studies can be realized.

1.7

Conclusion

Driving is an important activity which provides autonomy for the person concerned and is often associated with a better quality of life and better socioprofessional integration following TBI.

However, it is also a potentially dangerous activity for the person as well as for other road users and thus requires particular consideration.

Although the increased risk of accident following moderate to severe TBI is well recognised, there are no specific regulations or recommendations which harmonise assessment practices in this population to ensure safe return to driving. Much research is still required in this area.

However, it seems necessary that a comprehensive evaluation is conducted before a decision on the resumption of the driving is given. This should include a physical examination, a neuropsychologic evaluation, in particular attentional abilities, executive, visuo-spatial functions, processing speed of the information, in particular visual, and on road situations, in the presence of a healthcare professional (occupational therapist mostly). This evaluation must not overlook the pre- and post-traumatic behavioral, as well as the degree of anosognosia of the TBI person, and can be renewed because it was shown that driving skills could evolve until at least 5 years after a severe TBI.

The multidisciplinary teams within physical medicine and rehabilitation departments play an important role in the assessment and provision of information and advice for the person concerned and his/her family.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

2.1

Introduction

La reprise de la conduite automobile pour les personnes victimes d’un traumatisme crânien (TC) est un élément favorisant leur processus de réadaptation. Souvent associée à une meilleure autonomie et une meilleure qualité de vie , elle représente également une préoccupation de santé publique. La réglementation et l’organisation de l’évaluation des capacités de conduite automobile varient selon les pays. Certains, comme le Royaume-Uni, l’Italie, la Belgique, le Canada, possèdent une ou plusieurs structures dédiées à ces évaluations. En Australie, certains ergothérapeutes sont agréés par l’autorité responsable des permis de conduire. Malgré cela, la décision pour reprendre cette activité semble le plus souvent prise par la personne elle-même avec ou sans le conseil de ces proches, sans aucun avis médical, voire même contre avis médical . Cela est très bien illustré par Brooks et al. qui rapportent que très peu de sujets inclus dans leur étude au Royaume-Uni, se sont référés au centre de mobilité anglais avant d’envisager une reprise de la conduite automobile. Le manque d’information des professionnels , associé au fait que la présentation auprès des autorités ou structures compétentes soit laissée à l’initiative de chacun, peuvent en partie expliquer ce constat.

Le taux de reprise de la conduite automobile après un TC (d’intensité modérée à sévère) varie dans la littérature de 32 % à 52 % .

La conduite est une activité complexe et dynamique. Le modèle conceptuel le plus souvent cité est celui de Michon , qui schématise l’activité de conduite en trois niveaux interconnectés. Le niveau stratégique, comporte les décisions à prendre en rapport avec la conduite (tels que le jour, l’heure, l’itinéraire, faire le plein…), et n’implique pas de contrainte temporelle. Le niveau tactique qui implique des capacités de planification, de flexibilité et d’adaptation sous contrainte de temps (tels que l’adaptation de la vitesse au trafic, les prises de décision pour les changements de voies…). Et enfin, le niveau opérationnel, qui concerne toutes les compétences perceptives et automatiques nécessaires à l’utilisation du véhicule. Ce niveau dépend à la fois d’une certaine pratique, mais également de capacités visuospatiales, des temps de réaction, de la force musculaire, alors qu’il existe une contrainte temporelle permanente.

On peut concevoir sans difficultés la mise en place de stratégies de compensation pour le niveau tactique, mais cela semble plus difficile pour les niveaux stratégique et opérationnel. Or, les traumatisés crâniens sont susceptibles de présenter des déficits cognitifs des fonctions décrites dans ce modèle, ce qui justifie qu’une évaluation des capacités de conduite automobile soit réalisée pour cette population. Cependant, il n’existe à ce jour, à notre connaissance, aucun consensus validé pour leur réalisation. Les pratiques, tout comme la réglementation, varient d’un pays à l’autre. Cet article vise à faire le point sur les connaissances actuelles de l’impact d’un TC sur l’activité de conduite automobile.

2.2

Matériel et méthode

Il s’agit d’une revue de la littérature réalisée sur Pubmed et Cochrane Library sur la période janvier 2000 à décembre 2010, en utilisant les mots clés suivants: « automobile driving (Mesh) AND Traumatic Brain Injury (Mesh not exp) ».

Soixante-trois abstracts ont été obtenus, 35 articles ont été retenus dès lors qu’ils abordaient l’évaluation des séquelles cognitives du TC et leur retentissement sur la conduite et/ou le retentissement d’un TC sur les capacités de conduite automobile en langue anglaise ou française. Parmi ces 35 articles, cinq font état de revue de la littérature dont un evidence-based literature review , trois sont consacrés à des descriptions de pratiques d’évaluation, quatre concernent l’accidentologie routière après TC. L’ensemble des études, toutes de faible niveau de preuve, utilisant des évaluations neuropsychologiques sont synthétisées dans le Tableau 1 .

Tableau 1

Synthèse des études utilisant des évaluations neuropsychologiques.

Étude	Objectif	Type d’étude population	Tests utilisés	Résultats
Predictors of driving outcome after traumatic brain injury Coleman et al. (2002)	Étudier les facteurs prédictifs des capacités de conduite après TC	Rétrospective et suivi prospectif de cohorte 71 TC/71 proches du patient	WAIS III letter-number sequencing WAIS III matrix reasoning test Colored Trails	Pas de différence significative entre ceux qui ont repris et ceux qui n’ont pas repris la conduite
The use of the color trails test in the assessment of driver competence: preliminary report of a culture-fair Elkin-Frankston et al. (2007)	Évaluer l’efficacité relative du TMT et du CTT comme instrument de dépistage dans l’identification des conducteurs à risque nécessitant une évaluation sur route	29 participants (dont 8 AVC et 1 TC) évalués sur route (60 minutes)	MMSE TMT A et B CTT	Les sujets ayant réussi l’évaluation sur route ont significativement de meilleurs scores au MMSE ainsi qu’au TMT et au CTT. Il existe une corrélation significative entre le CTT et le TMT Le CTT peut dont être une alternative intéressante pour les sujets analphabètes
Useful Field of View after TBI Fisk et al. (2002) a	Étudier la possibilité que les TC aient de moins bons résultats à l’UFOV que les sujets témoins	Expérimentation avec 2 groupes, sans aveugle 23 TC modérés à sévères/18 sujets témoins	UFOV et bilan neuropsychologique comprenant également une mesure d’intelligence (WAIS-R ou SILS ou SIT-R), CVLT, Digit span subtest de la Wais-R, grooved Pegboard Test, TMT A et B	Retrouve une augmentation significative des scores de l’UFOV pour les TC Les scores d’attention divisée et sélective sont significativement plus élevés Ralentissement non significative au subtest de vitesse de traitement Corrélation significative entre les résultats au TMT-B et l’UFOV Conclue qu’il est possible que les TC ayant un UFOV pathologique est un risque accru d’accident, à confirmer par d’autres études
Driving with cognitive deficits: neurorehabilitation and legal measures are needed for driving again after severe traumatic brain injury. Leon-Carrion (2005) a	Déterminer si les déficits cognitifs posttraumatiques empêchent une reprise de la conduite sécuritaire après TC sévère	Étude rétrospective 17 TC sévères 2 groupes : ceux ayant la conduite contre avis médical au début de leur réadaptation/ceux n’ayant pas repris la conduite	BNS tachistiscopic attention examination Hooper VOT, Benton VRT, Rey-Osterrieth complex figure, visual form discrimination test Tower of Hanoi-sevilla, WCST, STROOP BNS simple attention test, BNS examination of vigilance Grooved Pegboard test Tests for motor function of the Luria/Christensen Test Battery Nechapi	Les résultats aux tests neuropsychologiques sont en lien avec les accidents et les capacités de conduite
Factors influencing driving 10 years after brain injury Lundqvist et al. (2008)	Évaluer si la conduite 10 ans après une atteinte cérébrale est en lien avec les résultats des tests neuropsychologiques et les performances de conduite 10 ans avant et si les accidents sont corrélés à ces résultats	Étude rétrospective cas–témoin 38 patients (dont 24 TC et 22 AVC)/49 sujets témoins contactés par téléphone 10 ans après une évaluation des capacités de conduite comprenant une évaluation sur route et un BNP	TMT A et B Complex Reaction Time Test Focused attention test Simultaneous Capacity test	Les patients qui conduisent toujours 10 ans après avaient des résultats significativement meilleurs au BNP Pas de conclusion possible à partir des résultats des évaluations sur route 14 patients ont eu un accident sur cette période. Mais pas de différence significative sur les résultats au BNP et à l’évaluation sur route avec ceux n’ayant pas eu d’accident
UFOV performance and driving ability following TBI Novack et al. (2006)	Étudier la corrélation entre UFOV et capacités de conduite automobile (évaluées sur route)	60 TC modérés à sévères	UFOV TMT	Un score élevé au subtest 2 de l’UFOV est un facteur prédictif significatif d’échec à l’évaluation sur route
Role of premorbid factors in predicting safe return to driving after severe TBI Pietrapiana et al. (2005) a	Prédire la capacité de reprise d’une conduite sécuritaire après un TC	Étude rétrospective 66 TC sévère/66 proches	Visual Search Test WAIS-R symbol-Digit Subtest	Pas de résultats prédictifs d’une conduite sécuritaire
Validation of stroke drivers screening assessment for people with traumatic brain injury Radfort et al. (2004)	Évaluer l’intérêt du SDSA, seul ou avec d’autres tests cognitifs pour prédire les capacités de conduite des TC	Étude rétrospective 44 TC Évaluation neuropsychologique + mise en situation sur route	SDSA comprend : Dot cancellation Square Matrices Road sign recognition PASAT STROOP Test of Motor Impersistence Adult Memory and Information Processing Battery	Une analyse discriminante de l’équation originale du SDSA est prédictive dans 87 % des cas
Driving and community integration after TBI Rapport et al. (2008)	Évaluer les barrières à la reprise de la conduite automobile après TC	Étude de cohorte (transversale) 261 TC (modérés à sévères pour la majorité)	Score composite à partir des tests suivants : Symbol-Digit modalities test, judgement of line orientation-Short form, WAIS-III : séquences de lettre – nombres, STROOP test, CVLT-II, TMTa et B, Digit vigilance test	Plus le score composite est mauvais, plus les patients ont un risque d’accident
Comprehensive driving assessment: neuropsychological testing and on-road evaluation of brain-injured patients. Schanke et al. (2000)	Étudier la corrélation entre le degré de déficience neuropsychologique et le taux d’échec aux évaluations sur route	Étude de cohorte 55 patients dont 43 AVC et 5 TC	Visual field deficit Visual attention Auditory attention Digit span (Wais) REACT Grooved pegboard test Serial digit modalities test TMT A et B Picture completion (Wais) Block design (Wais) Copy a cross STROOP Awarness index	Les éléments significativement discriminants pour la reprise de la conduit sont les résultats aux tests d’attention visuelle, REACT, STROPP et TMT, les troubles visuospatiaux et visuo-constructifs (Picture completion, block design et copy a cross), et l’anosognosie
Utility of the UFOV test with mild traumatic brain injury Schneider et al. (2005) a	Étudier la prédictibilité de l’UFOV dans les accidents de la route après TC léger ?	Étude rétrospective cas–témoin 40 étudiants ayant rapporté un TC léger/40 sujets témoins Déclaration du nombre d’accidents et d’infractions	TMT A et B Waiss III Processing speed index SMDT UFOV	Pas de différence significative aux résultats de l’UFOV entre TC légers et sujets témoins Idem pour les autres tests neuropsychologiques Pas d’augmentation du nombre d’infractions chez les TC légers, mais nombre d’accidents significativement supérieur dans le groupe TC léger

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