Rehabilitation for improving automobile driving after stroke

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identify further published, unpublished and ongoing trial\ud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