Determinants of Performance on Specific On-Road Skills in Multiple Sclerosis

In this prospective cross-sectional study, we investigated the cognitive, visual, and motor deficits underlying poor performance during on-road driving in 102 individuals with multiple sclerosis (MS). Thirteen specific skills categorized into hierarchic clusters of operational, tactical, visuo-integrative, and mixed driving were assessed during the on-road evaluation. Stepwise regression analysis identified the off-road skills that influenced overall performance on the on-road test and in each cluster. Study results showed that visuospatial function (p=0.002), inhibition (p=0.008), binocular acuity (p=0.04), vertical visual field (p=0.02), and stereopsis (p=0.03) together accounted for the highest variance in total on-road score (R2 =0.37). Attentional shift (p=0.0004), stereopsis (p=0.007), glare recovery (p=0.047), and use of assistive devices (p=0.03) best predicted the operational cluster (R2 =0.28). Visuospatial function p=0.002), inhibition (p=0.002), reasoning (p=0.003), binocular acuity (p=0.04), and stereopsis (p=0.005) best determined the tactical cluster (R2 =0.41). The visuo-integrative model (R2 =0.12) comprised binocular acuity (p=0.007) and stereopsis (p=0.045). Inhibition (p=0.0001) and binocular acuity (p=0.001) provided the best model of the mixed cluster (R2 =0.25). These results provide more insights into the specific impairments that influence different dimensions of on-road driving and may be used as a framework for targeted driving intervention programs in MS

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. '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.’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

Exploring the cognitive workload during a visual search task in Parkinson's Disease

International Congress of Parkinson's Disease and Movement Disorders , NICE, FRANCE, 22-/09/2019 - 26/09/2019Objective: To investigate cognitive workload during a visual search task in patients with Parkinson's disease (PD). Background: Visual search is one of the most important features of human activity. Visual search may be impaired in PD, which in turn may negatively affect daily life activities, such as driving. While previous studies explored visual exploration strategies during visual search tasks, no study investigated cognitive workload during visual search in PD. Cognitive workload refers to the total amount of mental effort being used to perform a task. Methods: Twenty patients with PD (age: 69 ± 8 yo; sex (Men/Women): 16/4) and 15 controls (age: 61 ± 11 yo; sex: 8/7) performed a visual search task on a driving simulator, that provides a context similar to visual search during real-life driving. They were instructed to search for a target road sign among distractor road signs. In half of the trials, the target was present (target-present trials). Response times as well as measures of cognitive workload for correct detections trials were investigated in the two groups. Cognitive workload was measured by the Index of Cognitive Activity (ICA), which was based on the number of times per second that an abrupt discontinuity in the pupil signal was detected. To investigate the cognitive workload over time for correct detection trials in the two groups, response time values were transformed to a continuous scale of percentage completion time, ranging from 0 (start of the trial) to 100% (button press) since response times were different between participants. Results: PD patients were significantly slower than controls to respond correctly to the visual search task, particularly for target-present trials. PD patients had increased values in cognitive workload throughout the entire duration of the task when compared to baseline (p < 0.05). By contrast, few significant differences were observed in controls (at 5% and 15%). Conclusions: These findings suggest that PD patients required increased and longer effort to correctly perform the visual search task compared with baseline cognitive workload. The use of ICA in patients with PD while performing a static visual search task provides new information into the effort (cognitive workload) required by patients on a moment-to-moment basis

Agreement Between Physician Rating and On-Road Decision for Drivers with Multiple Sclerosis

The recommendation of the referring physician is paramount in the decision making process of fitness to drive for individuals with multiple sclerosis (MS). This medical advice is carefully considered by fitness to drive officials when making a final decision. In this study, we sought to determine the reliability between physician recommendation and decision of the on-road assessor in 95 individuals with MS. The percentage agreement (po) and prevalence and bias adjusted kappa (PABAK) were used as measures of reliability. The on-road assessor found no concerns on the road in 87 (92%) of the individuals; 6 (6%) exhibited difficulties on the road that were of concern; and 2 (2%) were advised to discontinue driving based on the findings of the road test. The po between referring physician and on-road assessor was 83%. The PABAK showed a reliability coefficient of 0.76 (p \u3c 0.0001). No differences were found in po between neurologists (83%) and general practitioners (88%, Fisher’s Exact = 0.56). Binocular acuity correlated significantly with the on-road driving decision (Spearman = -0.30; p = 0.004). We conclude that, in this sample of drivers with MS, physicians were most of the time accurate in their appraisal of their patients’ driving capabilities

Comorbidities in Drivers with Parkinson Disease

Previous studies have shown that comorbidities have an impact on driving performance in older adults. No study has established the relationships between comorbidities and driving in persons with Parkinson disease (PD). The aims of this study were (1) to report the types of comorbidity in a group of 111 drivers with PD and (2) to identify whether the comorbidity associated with PD is a predictor of overall fitness-to-drive decisions, crashes, and validity duration of driving license. Results showed that 72 participants (64.9%) had only Parkinson disease, and 39 (35.1%) participants had one or more medical conditions in addition to PD. The most frequent comorbidities were visual disorders (26.4%), heart and blood disorders (16.2%), neurological disorders other than PD (11.8%), and locomotor disorders (11.8%). Contrarily to what we expected, we did not find any significant associations between comorbidities and overall fitness-to-drive decisions, car crashes, or validity duration of driving license. We conclude that in this sample of drivers with PD, comorbidity was not a significant predictor of overall fitness-to-drive decisions

Effect of Cognitive Demand on Functional Visual Field Performance in Senior Drivers with Glaucoma

A grant from the One-University Open Access Fund at the University of Kansas was used to defray the author's publication fees in this Open Access journal. The Open Access Fund, administered by librarians from the KU, KU Law, and KUMC libraries, is made possible by contributions from the offices of KU Provost, KU Vice Chancellor for Research & Graduate Studies, and KUMC Vice Chancellor for Research. For more information about the Open Access Fund, please see http://library.kumc.edu/authors-fund.xml.Purpose: To investigate the effect of cognitive demand on functional visual field performance in drivers with glaucoma. Method: This study included 20 drivers with open-angle glaucoma and 13 age- and sex-matched controls. Visual field performance was evaluated under different degrees of cognitive demand: a static visual field condition (C1), dynamic visual field condition (C2), and dynamic visual field condition with active driving (C3) using an interactive, desktop driving simulator. The number of correct responses (accuracy) and response times on the visual field task were compared between groups and between conditions using Kruskal–Wallis tests. General linear models were employed to compare cognitive workload, recorded in real-time through pupillometry, between groups and conditions. Results: Adding cognitive demand (C2 and C3) to the static visual field test (C1) adversely affected accuracy and response times, in both groups (p < 0.05). However, drivers with glaucoma performed worse than did control drivers when the static condition changed to a dynamic condition [C2 vs. C1 accuracy; glaucoma: median difference (Q1–Q3) 3 (2–6.50) vs. controls: 2 (0.50–2.50); p = 0.05] and to a dynamic condition with active driving [C3 vs. C1 accuracy; glaucoma: 2 (2–6) vs. controls: 1 (0.50–2); p = 0.02]. Overall, drivers with glaucoma exhibited greater cognitive workload than controls (p = 0.02). Conclusion: Cognitive demand disproportionately affects functional visual field performance in drivers with glaucoma. Our results may inform the development of a performance-based visual field test for drivers with glaucoma

Validation of Driving Simulation to Assess On-Road Performance in Huntington Disease

Driving simulators are increasingly used to assess the driving capabilities of persons with neurodegenerative conditions. However, few driving simulator evaluations have been validated against standardized on-road tests. The aim of this study was to investigate the concurrent validity of a comprehensive driving simulator evaluation in 29 persons with Huntington disease (HD). The Test Ride for Investigating Practical fitness to drive (TRIP) checklist was administered after a 15 km simulator drive and 20 km on-road drive. The total driving simulator TRIP score and each of its item scores were compared with the on-road TRIP scores using Spearman rho correlation statistics. We found significant correlations for 9 of the 12 items. Correlations ranged between 0.12 for the item gap distance at speed below 50 km/h and 0.72 for the total TRIP score, indicating variable strength of the associations. Items assessing operational skills correlated better with on-road driving performance than tactical or higher-order visual items. The results indicate that a fixed-base, single screen driving simulator is a valid tool to assess on-road driving capabilities in persons with HD

Five-year mortality and related prognostic factors after inpatient stroke rehabilitation : A European multi-centre study

Objective: To determine 5-year mortality and its association with baseline characteristics and functional status 6 months post-stroke for patients who received inpatient rehabilitation. Design: A prospective rehabilitation-based cohort study. Subjects: A total of 532 consecutive stroke patients from 4 European rehabilitation centres. Methods: Predictors were recorded on admission. Barthel Index was assessed at 6 months (BI6mths) and patients were followed for 5 years post-stroke. Survival probability was computed using Kaplan-Meier analysis and compared across 3 BI6mths-classes (0-60, 65-90, 95-100) (log-rank test). Significant independent predictors were determined using multivariate Cox regression analysis (hazard ratio (HR)). Results: Five-year cumulative risk of death was 29.12% (95% confidence interval (CI): 22.86-35.38). Age (HR = 1.06, 95% CI: 1.04-1.09), cognitive impairment (HR = 1.77, 95% CI: 1.21-2.57), diabetes mellitus (HR = 1.68, 95% CI: 1.16- 2.41) and atrial fibrillation (HR = 1.52, 95% CI: 1.08-2.14) were independent predictors of increased mortality. Hyperlipidaemia (HR = 0.66, 95% CI: 0.46-0.94), and higher BI6mths (HR = 0.98, 95% CI: 0.97-0.99) were independent predictors of decreased mortality. Five-year survival probability was 0.85 (95% CI: 0.80-0.89) for patients in BI6mthsclass: 95-100, 0.72 (95% CI: 0.63-0.79) in BI6mths-class: 65-90 and 0.50 (95% CI: 0.40-0.60) in BI6mths-class: 0-60 (p < 0.0001). Conclusion: Nearly one-third of rehabilitation patients died during the first 5 years following stroke. Functional status at 6 months was a powerful predictor of long-term mortality. Maximum functional independence at 6 months post-stroke should be promoted through medical interventions and rehabilitation. Future studies are recommended to evaluate the direct effect of rehabilitation on long-term survival