Posts Tagged driving
After having a stroke, many survivors are eager to start driving again. Driving offers independence and the ability to go where you want to go on your own schedule, so it is no surprise that survivors want to get back behind the wheel rather than rely on someone else for their transportation needs.
Unfortunately, having a stroke can have lasting effects that make driving more difficult. A survivor might not be aware of all of the effects of their stroke and could misjudge their ability to drive safely. Driving against a doctor’s orders after a stroke is not only dangerous, it may even be illegal. Many stroke survivors successfully regain their ability to safely drive after a stroke, but it is important that they do not attempt to drive until they are cleared by their healthcare provider.
How Stroke Affects the Ability to Drive
Having a stroke can affect an individual’s ability to drive in numerous ways, whether it be because of physical challenges, cognitive changes, or other challenges.
After a stroke, it’s common to experience weakness or paralysis on one side of the body, depending on which side of the brain the stroke occurred. More than half of all stroke survivors also experience post-stroke pain. Minor physical challenges may be overcome with adaptive driving equipment, but severe challenges like paralysis or contracture can seriously affect an individual’s ability to drive.
Driving requires a combination of cognitive skills, including memory, concentration, problem solving, judgement, multitasking, and the ability to make quick decisions. A stroke can cause cognitive changes that limit the ability to do many of those things.
As many as two-thirds of stroke victims experience vision impairments as a result of a stroke. This can include vision loss, blurred vision, and visual processing problems. Stroke survivors with vision problems should not drive until their problems are resolved and they have been cleared by a doctor.
Fatigue is a common physical condition after a stroke that affects between 40 and 70 percent of stroke survivors. Fatigue can arrive without warning, so it is dangerous to drive when suffering from post-stroke fatigue.
Warning Signs of Unsafe Driving
Stroke survivors are not always aware of how their stroke has limited their ability to drive. If they are choosing to drive after their stroke against their doctor’s advice, it is important for them and their loved ones to look out for warning signs that they might not be ready to start driving. Here are some of the common warning signs to look out for:
- Driving faster or slower than the posted speed or the wrong speed for the current driving conditions
- Consistently asking for instruction and help from passengers
- Ignoring posted signs or signals
- Making slow or poor decisions
- Becoming easily frustrated or confused
- Getting lost in familiar areas
- Being in an accident or having close calls
- Drifting into other lanes
If you or your loved one is showing any of these warning signs, immediately stop yourself or them from driving until your or their driving is tested.
Driving Again After a Stroke
Before a stroke survivor begins driving again, they should speak with their doctor or therapist to discuss whether or not it would be safe for them to continue driving. Many states require mandatory reporting by a physician to the DMV if their patient has impairments that may affect their driving after a stroke. Even if their doctor clears them to drive, they still will likely need to be evaluated by the DMV before they regain their driving privileges.
Driver rehabilitation specialists are available to help stroke survivors evaluate their driving ability from behind the wheel. There are also driver’s training programs that provide a driving evaluation, classroom instruction, and suggestions for modifying a car to the individual driver’s needs. For instance, an occupational therapist can provide a comprehensive in-clinic evaluation of a client’s current skills and deficits relative to driving.
From there a client could be sent for an in-vehicle assessment for further evaluation by a certified driver rehabilitation specialist (CDRS). They can assess driving skills in a controlled and safe environment. An in-vehicle driving test is the most thorough way to gauge a driver’s abilities. Each assessment takes about 1 hour and involves driving with a trained evaluator or driving in a computer simulator.
The “behind-the-wheel” evaluation will include testing for changes in key performance areas such as attention, memory, vision, reaction time, and coordination. After this assessment the CDRS can determine if the client is safe to drive, can not drive at all, or may drive with additional recommendations.
Often times clients may require certain modifications to their car in order to drive safely. In addition, some clients may benefit from on-going classroom training and simulation training in order to meet safety standards. These are all services that a driver rehabilitation specialist can provide. To help find these resources, The Association for Driver Rehabilitation Specialists has a directory of certified driver rehabilitation specialists, driver rehabilitation specialists, and mobility equipment dealers and manufacturers.
Get Back Behind the Wheel
Many stroke survivors successfully drive after a stroke; however, not all are able to. While reclaiming independence is important, staying safe is the greatest concern. It is important for stroke survivors to listen to their doctors and wait until they are fully ready before attempting to drive again. With some hard work and patience, getting back behind the wheel is possible.
All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.
“All great truths begin as blasphemies.”
— George Bernard Shaw
To understand the issues of driving with a homonymous hemianopsia, we have to better define the question. Too often the question is presented as, “Can an individual with homonymous hemianopsia drive safely?” This is the wrong question! The question today should be “Which homonymous hemianopsia patients are safe to drive?” Many research studies have found that even without the kind of clinical patient selection criterion, adaptive devices, therapy and driver’s training that a potential hemianopsia driver should undergo, a significant portion of hemianopsia patients in these studies demonstrated that they may have potential to drive safely.
If we look at the group of all hemianopsia patients, those who are safe to drive will be a very small group. This is owing to the great variability of associated problems of cognition, visual neglect, visual perception, alertness and ability to compensate. No clinician or researcher would ever argue that all hemianopsia patients are safe to drive.
Let us look instead at a limited group of hemianopsia patients for whom the higher order deficits have been screened to rule out cognitive deficits, visual neglect, and poor processing speed. In this group visual field expanders have been prescribed where indicated and the patients trained with these devices and given scanning training. Then these patients have been screened with a behind-the-wheel driving evaluation, we would see a much smaller group. But within that group, would emerge a patients that could have the potential to return to driving.
It is less about the visual field
Another question I see that demonstrates a failure for some to understand where the problem resides is “How much visual field is required to drive safely?” As clinicians that have worked for many decades with hemianopsia patients, we have learned that the visual field defect is only a small part of the driving safety issue. It is usually about the constellation of problems from the brain injury and each individual’s ability to compensate.
While the type and size of visual fields are factors, the higher order cognitive functions are far more important to safe driving than the size of the visual field. These higher cognitive and perceptual functions determine if the patient can safely compensate. The real question should be expanded to, “On a case-by-case basis does this patient with an acquired brain injury from stroke, tumor, trauma or other cause, have the higher-level cognitive skills, compensatory skills, optical devices, experience, stamina driving skills and discipline to drive with a reduced visual field?”
All hemianopsia are not created equal!
Let us look at two patients with identical measurable visual field, both presenting with left homonymous hemianopsias. The first has an isolated stroke in the right occipital lobe no deficits other than the visual field loss. This patient has no visual neglect and no deficits in saccadic eye movements that would impair compensatory scanning and searching into the area of loss. With training and appropriate devices, this patient may have potential to return to safe driving. The second patient has an identical appearing left homonymous hemianopsia but from a stroke in a different location, the right parietal lobe. Thus this patient also has severe left visual neglect, impairments in saccadic eye movements and thus will never return to driving. If we only look at the visual field results, these patients look identical, but they are totally different cases.
If a state law looks only at the visual field loss to determine if driving is possible, they would treat both patients the same, denying them both the option of a driver’s license. While the second patient should not drive, this can needlessly devastate the first patient’s life, robbing the patient of independence, ability to get to work, and to lead an otherwise normal life.
How do we predict safety?
The other question we must ask is, “What tests and evaluations best predict safe driving and what are the potential weaknesses that must be addressed in training?” Various neuropsychological tests can give us information on who may have potential to drive safely. More research to establish which tests give us the most effective data is needed. Additionally, behind-the-wheel research studies continue to expand our information on the unique driving behaviors of the hemianopsia driver.
Driving, however, is a complex function. Prior experience, stamina, motivation, and discipline combined with visual status and mental functioning all can shape the impact on safety. After all the testing and treatments are completed to help select those who show potential to drive, a behind-the-wheel driving evaluation with a driving rehabilitator experienced with acquired brain injury and hemianopsia is needed. Only during the behind-the-wheel examination and training can the full complexity of driving be evaluated and training performed to improve specific skills like lane position, use of optical devices and mirrors.
The most important question is, “Have we learned to treat each person as a unique individual, understanding that impairment, disability and handicap are not one in the same?”
Should state laws prevent all Hemianopsia driving?
Setting an arbitrary visual field width to discriminate against all hemianopsia patients is now seen by many current researchers as a needless burden on the portion of hemianopsia patients that have the ability to return to safe driving. Below is what a number of researchers have observed:
As Dr. Eli Peli, Senior Scientist from Harvard’s Schepens Eye Research Institute stated in Driving With Confidence, A Practical Guide to Driving with Low Vision:
“It is clear that not all people with hemianopia function at the same level and many probably could not drive safely. However, a fair percentage of these patients may compensate for their visual loss to such an extent that they can drive as safely as any driver.”
In Automobile Driving Performance of Brain-Injured with Visual Field Defects , T Schulte, H Strasburger, E Muller-Oehring, E Kasten and B Sabel 1999, American Journal of Physical Medicine & Rehabilitation, researchers performed a driving simulator-based study of six hemianopsia patients and a similar size group of normally sighted. They summarized:
“Contrary to our expectations, the findings showed no reliable difference in the performance of visually impaired and the normally sighted subjects on a driving simulator. …Thus on a practical level our results indicate that the suspension of driving privileges for persons having visual field impairments may be unwarranted on the basis of visual field loss alone.”
In a study by Racette & Casson (1999), Visual field loss and driving performance: a retrospective study Abstracts of the Eighth International Conference Vision in Vehicles, they studied 13 homonymous hemianopsia patients and 7 homonymous quadranopsia patients. They determined those who were unsafe, those who need additional assessment, and those who were safe. Only 23% of the hemianopsia patients were found unsafe and none of the quadranopsia patients were deemed unsafe.
“Clearly, the evidence provided by these reports indicate that homonymous visual field defect and homonymous hemianopia by itself can not be an absolute and inevitable contra-indication for practical fitness to drive.”
A 2009 study, On-road driving performance by persons with hemianopia and quadrantanopia, Investigative Ophthalmology Vis Sci 50 (2) 2009, J. Wood, G. McGwin, J. Elgin, M. Vaphiades, R. Braswell, D. DeCarlo, L Kline, G Meek, K Searcy and C. Owsley studied 22 hemianopsia and 8 quadranopsia patients and a normal control group driving over a 14.1 mile course of city and interstate driving. Two back seat evaluators, who were masked to the status of the patient, evaluated the drivers. They found 100% of normal drivers were safe to drive and 73% of hemianopsia and 88% of quadranopsia patients were safe to drive.
The study concluded that:
“Some drivers with hemianopia or quadrantanopia are fit to drive compared with age-matched control drivers. Results call into question the fairness of governmental policies that categorically deny licensure to persons with hemianopia or quadrantanopia without the opportunity for on-road evaluation.”
Continued research is crucial to define all of the parameters of hemianoptic driving. Information from these studies helps us define the best candidate, the areas of weakness and will guide driving rehabilitation specialists in training these patients.
A study by Bower et al, from The Schepens Eye Research Institute, Harvard Medical School, Boston, Massachusetts, Driving with Hemianopia, I: Detection Performance in a Driving Simulator, published November 2009 in Investigative Ophthalmology and Visual Science, tested twelve hemianopsia patients without visual neglect or cognitive loss and twelve matched normals on a simulator test over a two hour period. The hemianopsia patients were tested without visual field expanding systems and they demonstrated significantly more difficulty in detection of suddenly appearing pedestrians on their impaired side inside the simulator.
There was great variability in pedestrian detection among the small group of 12 hemianopsia patients with older driver’s demonstrating lower rates. The authors of this study warned that simulator studies may not match results in real world driving and they further suggested that this also means we must look at each driving candidate individually. They stated:
“In determining fitness to drive for people with HH, the results underscore the importance of individualized assessments including evaluations of blind-side hazard detection.”
The same scientists now plan to do similar tests with patients using visual field expanders. Our years of work would support that the visual field expanders and training can help fill in detection of pedestrians in many patients, but more research is needed.
How could states regulate hemianopsia licensing?
It is clear from the research that we cannot make generalizations about the driving safety of all hemianoptic drivers. Thus simply removing visual field requirements could lead to hemianopsia drivers being licensed who have other cognitive or perceptual problems at make them unsafe.
States that still contain absolute prohibitions against driving with homonymous hemianopsias should consider removing these, and replacing them with a process to judge each patient individually based on current science. The process should include mandatory evaluation with a low vision specialist experienced in hemianopsia for evaluation and treatment followed by additional therapy/training as needed including occupational therapy if indicated. Then a behind-the-wheel driving evaluation and training as appropriate to each case with a certified driving rehabilitation specialist should be completed.
Then, the doctor with the report of the driving rehabilitation specialist would file a special application with the state. The states medical advisory committee would review each case individually. If the application is approved, the patient would have to demonstrate adequate driving skills on an extended state behind-the-wheel test by the state driver’s license bureau. Restrictions on type of driving and time of day could be considered in each case cases.
Please contact us if you have any questions:
The Low Vision Centers of Indiana
Richard L. Windsor, O.D., F.A.A.O., D.P.N.A.P.
Craig Allen Ford, O.D., F.A.A.O.
Laura K. Windsor, O.D., F.A.A.O.
Indianapolis (317) 844-0919
Fort Wayne (260) 432-0575
Hartford City (765) 348-2020
From Hemianopsia.net, The Low Vision Centers of Indiana. Used with permission. www.hemianopsia.net.
Written By Drusilla Moorhouse
Don’t you dare put that spoon in my mouth.
1. Epilepsy is a brain disorder that causes seizures, which are basically like electric storms in your brain.
Epilepsy, also known as a seizure disorder, is a disorder of the brain that causes recurrent, unprovoked seizures. Those seizures are caused by surges of electrical activity in the brain, often compared to an electric storm.
In most cases, the cause of epilepsy is unknown. “Our challenge now is to understand the genetic architecture underlying each individual epilepsy,” Dr. Ley Sander, medical director at the Epilepsy Society in the U.K. and professor of neurology at University College London, told BuzzFeed. “We are also trying to understand why some people will respond well to a certain drug while others won’t.”
2. Not everyone with epilepsy has convulsive, jerking seizures.
In fact, most people with epilepsy experience “partial” (or focal) seizures. These affect one area of the brain and can result in an aura, physiological reactions, or motor and sensory changes. They can cause a person to stare blankly and/or smack their lips, pluck at their clothing, wander around, or perform other bizarre (but involuntary) actions.
The dramatic convulsions that most people associate with epilepsy are a result of a seizure affecting both sides of the brain at once. These “generalized” seizures can also cause “staring spells,” brief body jerking, and “drop attacks” (suddenly falling to the ground).
3. When someone’s having a convulsive seizure, keep them safe, supported, and on their side.
When a person is having a convulsive seizure (or you know/they have indicated they are about to), gently roll them on one side (to allow any fluids to drain out of their mouth and keep their airway open), support their head, remove any dangerous objects nearby (including their glasses), and time the seizure.
If a seizure lasts longer than five minutes, call 911.
“Seizures usually end within a few minutes and keeping a person safe from injury during a seizure and paying attention to the seizure duration are the best first aid,” Dr. John Stern, director of the Epilepsy Clinical Program at UCLA, tells BuzzFeed. “If a seizure is longer than five minutes, then the risks may be greater and emergency care may become more important. If a person is not known to already have epilepsy or has a complicated medical condition, then emergency care may be needed sooner.”
For other types of seizures, it is important to remain with the person, gently guide them from danger (but avoid restraining them), and call 911 if the seizure lasts longer than five minutes.
4. NEVER force something into the mouth of someone having a seizure.
It’s physically impossible to swallow your tongue, and a “bite block” (wooden spoon, wallet, etc.) could cause serious injury.
A person having a convulsive seizure may briefly stop breathing and have a blue skin color, but Stern explains that “this is mostly due to the diaphragm becoming stiff along with the other muscles for breathing.”
This is normal and brief, and the person will start breathing normally again as soon as their muscles relax. Do not attempt mouth-to-mouth or CPR during a convulsive seizure. Positioning the person on their side with their mouth pointed downward is the best way to keep their airway open.
5. Please remain with the person after they have a seizure to calm and reassure them.
They will be very confused and disoriented (after my first seizure I believed I had been in a plane crash!), and usually surrounded by frightened faces. It is extremely helpful if you are direct and candid and explain what just happened, who and where you are, and try to give them as much privacy as possible.
And if a person has urinated (which can happen with some seizures), cover that up to help limit any embarrassment, suggests Sander. Because after reassuring us and making sure we’re safe, the best thing you can do is help us restore our dignity.
6. Seizures are scary!
Seizures are truly terrifying, whether you’re the person experiencing an aura or someone witnessing a grand mal seizure with convulsions. During a seizure, you lose consciousness, your muscles violently contract (I once broke a bed frame during a seizure), and your skin often turns blue from lack of oxygen.
Although we aren’t awake for the convulsions (and don’t remember them afterward), the aura preceding them (which is actually a seizure itself) is frightening for a host of other reasons: We could just be enjoying a hilarious kitten video at home or out running errands when suddenly we’re overcome by one or more of these unnerving sensations: a feeling of dread, déjà vu, blurry or tunnel vision, a strange sensation in our bellies, and/or the inability to speak.
Fortunately, my own auras last long enough that I’m able to text people to alert them about what’s happening (I have aphasia so I can’t actually tell them) but that also means that I have longer to experience the terrifying knowledge that my brain is about to fuck me up big time.
7. Epilepsy is actually not unlike The Wizard of Oz.
Picture yourself fleeing an evil witch who wants to take your little dog Toto when suddenly a tornado strikes and you’re tossed around in a twister. Then you wake up and don’t know where you are (it’s definitely not Kansas) or why the fuck you’re surrounded by diminutive townspeople singing your praises in an absurdly bright, colorful, and unfamiliar place.
8. Seizure “hangovers” are the absolute worst.
Imagine the worst hangover of your life, combined with food poisoning, a migraine, sore muscles, and memory loss. Like Dorothy in Oz, you don’t just have a seizure and automatically return to normal.
“A seizure consists of a wave of abnormal electrical activity spreading through different parts of the brain,” explains Dr. Jacqueline French, a neurologist and the chief scientific officer for the Epilepsy Foundation. “Once the ‘wave’ of electricity goes past, the brain that it affected becomes exhausted, and often is unable to function.” That fog and confusion can last anywhere from a few minutes to a few days.
9. Seizures aren’t just triggered by flashing lights.
In fact, less than 2% of people with epilepsy have photosensitive epilepsy, says Sanders. They’re more commonly triggered by stress or being overtired.
Other common triggers include specific times of day or night (for instance, I’ve had most of my seizures just before sunset); sleep deprivation; stress; illness; flashing bright lights or patterns; caffeine, alcohol, or drug use; menstrual cycles or other hormonal changes; poor diet; and certain medications.
“Epilepsy affects everyone differently,” emphasizes Sander. “Although there can be similarities, people tend to have different triggers for their seizures, while some have none. Recognizing those triggers and trying to avoid them is an important part of self-management.”
10. Having a seizure isn’t the same as having epilepsy.
11. Medications can control seizures in most people with epilepsy.
Anti-epileptic drugs (AEDs), aka anticonvulsants, taken daily can control seizures “by reducing the excessive electrical activity in the brain that causes the seizures,” explains Sander. “The exact mechanism of AEDs is not well understood, but it is likely that different AEDs work in slightly different ways. The aim of optimal therapy is to get maximum seizure control with minimum side effects.”
According to the Epilepsy Foundation, medication controls seizures in about 7 out of 10 people with epilepsy.
12. Even though there are risks associated with taking anti-seizure medication during pregnancy, for many it would be riskier to stop treatment.
“Although there is no anti-seizure medication that is proven safe during pregnancy, the risks for several are low and are believed to be reasonable in the context of the risks of seizures during pregnancy if treatment is stopped,” says Stern. “Pregnancy is overall safer when the seizures are best controlled, and this should be considered in the planning.”
Faye Waddams, who has documented her experience in the award-winning blog Epilepsy, Pregnancy, Motherhood and Me, tells BuzzFeed, “My neurologist advised me that although there is a risk with any anti-epileptic drug, my epilepsy was so uncontrolled that the risks of not taking it and having a seizure, causing harm to myself and the baby, was greater than any risk from the medication.”
And although Waddams (pictured above with her son, Noah) unfortunately did have seizures during her pregnancy despite the medication and was hospitalized several times, she is happy to report that she has “a healthy, happy, perfect baby boy who turns 1 this week.” (Waddams also ran a half marathon “nine months to the day” after giving birth to Noah!)
13. People with epilepsy can lead very active lives.
Eric Wheeler (shown above) is a marathoner and triathlete who — like many other athletes — also happens to have epilepsy. According to Stern, “A healthy lifestyle is important for everyone and it should not be avoided because of epilepsy. Moreover, some people with epilepsy find their seizures are better controlled when they are active. Exercise and recreation can help reduce stress, improve mood, and help brain health, which can benefit seizure control.”
Of course, seizures should be well-controlled — through medication, healthy habits (like avoiding known triggers), and sometimes even brain surgery — before a person with epilepsy participates in sports like triathlons.
As Stern emphasizes, “the activities need to be safe ones with regard to the person’s seizure risk.”
14. Driving is…complicated.
State laws require that most people with epilepsy be seizure-free for six months to a year before they can drive again.
“The driving restrictions vary among the states, but six months is a common period of restriction after a seizure,” says Stern. “This time period is somewhat arbitrary, but it relates to the fact that the likelihood of a seizure decreases as time passes after a seizure. Most of the risk is in the first year and much of it is in the first six months. The six-month period is intended to reduce the risk of injury at the time when the risk of a seizure is highest.”
The Epilepsy Foundation of America has a helpful database of state driving laws pertaining to epilepsy.
15. Epilepsy is probably more common than you think.
According to the World Health Organization, “Approximately 50 million people worldwide have epilepsy, making it one of the most common neurological diseases globally.”
Many epilepsy advocacy organizations cite a startling statistic: One in 26 people will develop epilepsy in their lifetime. That number, based on a life expectancy of 80 years, “seems inaccurate because people do not talk about epilepsy even when they have it. In actuality, epilepsy is more common than Parkinson’s disease, multiple sclerosis, ALS, and cerebral palsy combined,” asserts French, the Epilepsy Foundation’s chief scientific officer.
16. And we’re in good company with lots of famous people.
Celebrities with epilepsy include Prince (who referenced his childhood epilepsy in the song “The Sacrifice of Victor”), the Beastie Boys’ Adam Horovitz, Danny Glover, Lil Wayne, Neil Young, NFL twins Tiki and Ronde Barber, and Harriet Tubman.
17. People with epilepsy are strong and resilient as hell.
It’s easy to get caught up in the things that people with epilepsy lose: our dignity, our independence (especially when our driving privileges are revoked), and, for many, our ability to participate in certain activities ranging from scuba diving to bathing (because of the risk of drowning).
That’s why we appreciate every moment we have without a seizure, finding an anticonvulsant that is effective without debilitating side effects, and victories like being seizure-free for six months and longer.
We’re fighting like hell to not only manage this disease but also dispel the stigma associated with epilepsy. We are people to admire, not fear, and the best thing you can do for us is to learn more about this disease and first aid guidelines. Don’t be afraid to ask us questions — we want to talk about it!
Monday, December 5, 2016
The longer the seizure, the greater the chance of a “crash.” Seizures lasted an average of 75 seconds among patients who crashed and 30 seconds among those who didn’t crash.
The study was to be presented Sunday at the annual meeting of the American Epilepsy Society, in Houston.
“Our goal is to identify if certain types of seizures — coming from a specific part of the brain or causing a particular brain wave pattern — are more likely to lead to a crash. That information could then be used by doctors to objectively determine who can safely drive and who should not,” said study author Dr. Hal Blumenfeld, director of the Yale Clinical Neuroscience Imaging Center, in New Haven, Conn.
Blumenthal, who is also a professor of neurology, neuroscience and neurosurgery at Yale, added that it isn’t clear why people who have longer seizures are more likely to crash.
“It’s going to take a lot more data to come up with a reliable way of predicting which people with epilepsy should drive and which should not,” Blumenfeld said in a news release from the epilepsy society.
“We want to unearth more detail, to learn if there are people with epilepsy who are driving who shouldn’t be, as well those who aren’t driving who can safely drive,” he said.
SUNDAY, Dec. 4, 2016 (HealthDay News) — People with epilepsy who experienced longer seizures during a simulated driving test may face an increased risk for crashes while on the road, a new study suggests.
SOURCE: American Epilepsy Society, news release, Dec. 4, 2016
HOUSTON — Researchers are making headway in determining which patients with epilepsy should be allowed to drive.
A new analysis suggests that factors such as seizure duration and impaired consciousness influence later driving performance.
“Our goal is to figure out if there are clues” that will “inform doctors and patients” about whether it’s safe to drive, said epilepsy specialist and lead study author, Hal Blumenfeld, MD, PhD, professor of neurology, neuroscience and neurosurgery, Yale School of Medicine, New Haven, Connecticut.
All too often, he said, patients with epilepsy who can safely drive are “lumped together” with all patients with epilepsy and discouraged from getting behind the wheel.
The researchers’ findings were presented here at the American Epilepsy Society (AES) 2016 Annual Meeting.
For this analysis, patients with epilepsy underwent video/electroencephalographic monitoring that analyzed ictal and interictal driving data captured prospectively from a driving simulator. The simulator had a steering wheel, gas pedal, and brake attached to a laptop computer.
Participants were asked to drive as long as they could and, if possible, to continue to drive if they had a seizure. The test was conducted in an inpatient unit with medical care available if needed. Patients drove from 1 to 10 hours, most for an average of 3 to 4 hours.
The variables researchers considered included car velocity, steering wheel movement, application of the brake pedal, and crash occurrence during the ictal and postictal periods, as well as during subclinical epileptiform discharges.
In a poster presented at the meeting, investigators reported an analysis of a total of 20 clinical seizures in 16 patients. Seven of these seizures resulted in crashes.
The analysis determined that the longer the seizure, the more likely the person was to have an accident. “The average for people who crash is 80 seconds and the average for the ones who don’t have driving impairment is 23 seconds, so on average, the seizures are longer” in those who crash, said Dr Blumenfeld.
No Time Limit
But the analysis doesn’t provide a time limit for seizures. “So far, this shows that seizures lasting longer are more dangerous; but we don’t have a cutoff yet,” said Dr Blumenfeld. “That’s one thing that could be helpful.”
He stressed that these are averages and that other factors, such as severe motor impairment and loss of consciousness, contribute to safety.
The current study also showed that when patients lose consciousness during seizures, they are significantly more likely to crash (P < .05). “That stands to reason based on common sense, but no one had really tested that before,” said Dr Blumenfeld.
He and his colleagues plan to do additional research, looking at other things that might affect safety, for example, from what part of the brain seizures originate.
“There may be factors that we can put together in a model and come up with a real decision tree,” he said. “We aren’t there yet, but that’s the goal.”
Rules and regulations surrounding driving with epilepsy vary significantly around the world. In India, for example, having a single seizure means you can’t drive for life.
In the United States, states variously require 2 years, 6 months, or 3 months of seizure freedom, while others, including Connecticut, don’t have a set limit but leave the driving decision to the discretion of the clinician.
“So it goes to show that we really don’t know what the limit should be,” said Dr Blumenfeld. “We are working basically out of common sense and little bits of information available from retrospective studies and questionnaires.”
He thinks there should be uniform global regulations concerning epilepsy and driving because under the current climate, “it’s very confusing for physicians, for patients and for the general public.”
“When there are accidents, everyone blames everyone else because nobody has agreement on what the guidelines or consensus should be.”
Robert Fisher, MD, PhD, professor of neurology and neurological sciences, and director, Comprehensive Epilepsy Center, Stanford University, California, wants patients with epilepsy to be treated justly when it comes to driving.
“We don’t want people with epilepsy to crash a car, but we don’t want them to be unfairly discriminated against either.”
Dr Fisher has published articles on driving and epilepsy and has been a defense witness in cases involving patients with epilepsy who have been in a motor vehicle accident.
He pointed out that in the United States, the accident rate for women with epilepsy is lower than for men without epilepsy, especially among drivers 18 to 25 years old.
“That doesn’t mean that epilepsy is not a risk factor; it just means that it really ought to be individualized,” he said.
While patients with uncontrolled seizures shouldn’t drive, those whose seizures have been controlled for a specific length of time “have a risk that’s lower than we are willing to accept for a number of conditions,” said Dr Fisher.
Driving is “one of the most discussed” topics in the epilepsy clinic and can contribute to significant stress in the doctor–patient relationship, he noted.
American Epilepsy Society (AES) 2016 Annual Meeting. Poster 2.276. Presented December 4, 2016.
[THESIS] Returning to driving post-stroke: Identifying key factors for best practice decision making over the recovery trajectory -Full text PDF
The purpose of this thesis is to examine the process of returning to driving post-stroke in order to contribute to best practice decision making. A decision tree is suggested to build patient-centred procedures for returning to driving along the post-stroke recovery trajectory.
Part one reviews literature on the return to driving process post-stroke and identifies gaps in knowledge. The stroke recovery trajectory’s three main phases of recovery (acute, rehabilitation and community care) are outlined and act as a framework for the thesis structure. Part two of the thesis describes five separate but related studies carried out to address the research gaps identified.
The first study is a qualitative study that examines attitudes and perceptions of stroke survivors from one to 16 weeks post-stroke. Independence was found to be the primary motivator in stroke survivors’ decisions about fitness to drive. However, during the acute phase stroke survivors were focused on their physical recovery, not returning to driving. Study participants had little knowledge of return to driving procedures or legislation, despite information being available. Gender differences were apparent in factors affecting the return to driving decision making.
The second study examines the psychometric property of practice effect on the Useful Field of View (UFOV, Ball & Owsley, 1993) a pre-driving screening assessment. UFOV scores have been found to be associated with on-road driving assessment scores (George & Crotty, 2010) and used in medical recommendations. Study participants were all stroke survivors with a control group performing the UFOV at three months and assessment group at one, two and three months post-stroke. Findings suggest there was no practice effect in relation to a single three month post-stroke time point. Timing of reassessment was also examined.
The third study examined self-perceived driving confidence measured by the Adelaide Driving Self Efficacy Scale (ADSES, George et al., 2007; George & Crotty, 2010) and driving habits. Results indicated there was a significant statistical association between low self-perceived driving confidence and lower kilometres driven per week, reduce driving scope, driving closer to home and avoiding challenging driving situations.
The fourth study explored self-perceived driving confidence of post-stroke drivers and their non-stroke, aged-matched driving peers measured by the ADSES. No difference was found, suggesting once stroke survivors have returned to driving they have the same levels of selfperceived driving confidence and potential driving scope as their non-stroke driving peers.
The final study focused on decisions to relinquish a driver’s licence among the older Australian general population and used a novel Discrete Choice Experiment (DCE) methodological approach. A general population was used to establish a norm with which future research on specific chronic conditions such as stroke could make comparison. Recommendation of General Practitioners’ (GPs), participants’ local doctors was found to be the primary influencing factor in the decision of older Australians to relinquish their driver’s licence. Advice from family and friends, age and crash risk in the next year were also influencing factors. The costs and availability of public transport options were not influencing factors.
The last chapter of this thesis is the Discussion section which identifies the common themes emerging along with limitations and recommendations for future research directions.
[ARTICLE] A randomized clinical trial to determine effectiveness of driving simulator retraining on the driving performance of clients with neurological impairment
Introduction Following a neurological event, returning to driving is an important activity contributing to improved participation within the community. The purpose of this study was to examine the effectiveness of driving simulator retraining on driving in clients with neurological impairment and to examine factors associated with treatment effectiveness.
Method Individuals with non-degenerative brain injury were randomized to either a simulator training or control group. The simulator group received individualized training (16 sessions) using a driving simulator. The control group did not receive intervention. A blind evaluator assessed participants on the DriveAble On-Road Driving Evaluation.
Results There was no significant difference between groups in the proportion of individuals who passed the driving evaluation (Chi2 = 0.65; p = 0.42; CI = −0.41 to +0.17). However, participants with moderate impairment who received simulator training were more likely to pass the driving test compared with those in the control group (86% versus 17%; Chi2 = 6.2; p = 0.03; CI = −1.00 to −0.30). There were no differences in pass rate according to diagnosis, gender, or for those with severe impairments.
Conclusion Results provide clinicians with preliminary information on the potential clinical usefulness of driving simulator training. While the findings do not support simulator retraining for the group as a whole, they suggest that clients with moderate impairment have the potential to benefit.
In technically advanced societies, driving has become an integral part of daily living for all aspects of adult life. For people with disabilities, whose mobility has become severely curtailed, driving represents the ultimate freedom; the means by which to attain their highest level of independence and autonomy over their lives.
On the other hand, medical and health professionals have a responsibility towards society as a whole as well as towards the person with a disability to ensure that the best advice is given regarding safe control of an automobile. Weighing up the issues involved is often a difficult task for medical and health professionals. It calls for sensitivity and diplomacy and an understanding of the disability and its progression. As well as medical and functional information, knowledge of the person’s level of insight and the likelihood of their displaying responsible behavior, as a direct result of their disability, or originating from their actual personality traits will have a bearing on the final recommendations regarding the advisability of driving. Despite extensive research, no firm conclusions have been drawn on which specific cognitive deficits may constitute a barrier to driving. However, literature shows a consensus of the need for assessment to be carried out on several levels, including medical, psychological, functional and, if deemed safe to do so, an on road drive. The difficulty of separating individual skills as predictors of actual performance is recognized by Evans (1) who nonetheless comments that “perhaps a distinction should be made between perceptual-motor skills and total performance”.
In comparison to the attention given to assessing brain injured drivers, little emphasis has been found in the literature regarding the driving safety of those with physical disabilities, but without brain injuries. Those studies which do focus on physical disability demonstrate that, given the correct vehicle adaptations, driving safety is not compromised (2-5).
This chapter aims to provide an introduction to the issues involved in driver assessment for a wide range of disability types. It outlines several models of driving skill theory, examines the steps to be followed when assessing driving skill and discusses aspects of behavior and environment which impinge on the person’s ability to drive safely.
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