Driving After Brain Injury

 A Traumatic Brain Injury (TBI) is an injury to the brain that is caused by a trauma to the head.

Numerous possible causes include road traffic accidents,assaults,falls and accidents at home or at work.

Often the effects of a traumatic brain injury can be very wide ranging and  they may depend on the location,type and severity of jnjury.

Acquired Brain Injury (ABI) on the other hand is an injury that is caused to the brain since birth.

Possible causes may include a fall, stroke, encephalitis, haemorrhage, hypoxic/anoxic brain injury, infection and medical accidents.

INCIDENCE: Males are 1.6 times more likely to be admitted for a head injury, however women are at increasing risk and are catching up to the males.

In fact the number of females being admitted to hospitals in the UK with non-superficial head injuries has risen by 24% since 2005-6. (1)

According to Headway, there were 348,934 admissions to hospital with acquired brain injury in 2013-2014.

This equates to 566 admissions per 100,000 of the population and translates to around 956 acquired brain injury admissions per day to UK hospitals or 1 every 90 seconds.                                                    

Furthermore, head injuries have increased 6%, strokes have increased 9% and all acquired brain injuries have increased by 10% since 2005-2006.

Indeed total stroke admissions in the UK in 2013-2014 were 130,551 which equates to 1 admission every 4 minutes. (1)

How do we determine when it is Safe to Return to Driving?

Cullen and colleagues examined 3 common measures as predictors of return to driving after traumatic brain injury.

They utilised the Glasgow Coma Score (GCS) within 24 hours of injury as well as the Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation admission. (2)                            

They asked 72 participants with traumatic brain injury to complete a questionnaire that assessed return to driving post-traumatic brain injury, as measured by reinstatement of the driver's license.

Those participants who did not return to driving for non-medical reasons or who had not driven pre-injury and did not obtain a driver's license post-injury were excluded from analysis.

Consequently the final sample size was reduced to 59 participants.

Scores on GCS, FIM and DRS, leveraged from an existing database, and were compared between participants who had and those who had not returned to driving post-injury.

Multiple logistic regression analysis was performed to determine the relationship of each predictor variable to return to driving.

RESULTS:

The authors found that only the Functional Independence Measure score at rehabilitation admission was significantly associated with return to driving (p?<?0.01).

FIM score had a sensitivity of 72% and specificity of 73% with respect to return to driving.                                                                                      

Their study results support the use of FIM at rehabilitation admission as a predictor of return to driving.

Furthermore they suggested that future studies should be directed at identifying other measures to be used in combination with FIM to accurately predict return to driving post-traumatic brain injury.

These authors also found that scores on two neuropsychological assessments were significantly better in participants who had returned to driving than in those who had not: Trail-making A (p < 0.01) and Trail-making B (p < 0.01).(3)

Interestingly, an Australian cross sectional electronic survey of emergency departments was carried out to obtain further information about fitness to drive after mild traumatic brain injury.(4)

104 medical, nursing and allied health professionals completed the survey.

The majority who completed the survey were medical staff (n=46, 51%) followed by allied health staff (n=23, 25%).

Over 1/3 of respondents’ emergency departments (n=34, 36%) recommended a period of “no driving”after mild traumatic brain injury.                                                                                                      

Furthermore, this recommendation was usually provided by medical staff (n=25, 80%)

There was no consensus with respect to the time to return to driving after mild traumatic brain injury.

Opinion however strongly suggested that a review of fitness-to drive management guidelines was  required for mild traumatic brain injury patients ( n=78,88%).

In another study these authors sort to determine the fitness-to-drive status of patients with mild traumatic brain injury at 24h and two weeks post injury.(5)

They recruited 2 groups of participants with one being a control group with orthopaedic injuries (n=60) and the other being mild traumatic brain injury patients (n=60).

They used a Mini mental state examination, occupational therapy-drive home maze test (OT-DHMT),Road Law Road Craft Test, University of Queensland-Hazard Perception Test, and demographic/interview form collected at 24h and at two weeks.

They found that at the 24h assessment, only the OT-DHMT showed a difference in scores between the two groups, with mild traumatic brain injury participants being significantly slower to complete the test (p=0.01).

At the two week follow-up, only 26 of the 60 mild traumatic brain injury patients had returned to driving. Injury severity combined with scores from the 24h assessment predicted 31% of the variance in time taken to return to driving.

Delayed return to driving was reported due to: "not feeling 100% right" (n=14, 23%), headaches and pain (n=12, 20%), and dizziness (n=5, 8%).

Fleming and colleagues wished to determine the rates, timing, correlates, and predictors of return to driving in the first 6 months after discharge from hospital following acquired brain injury (6).

They surveyed 212 participants with acquired brain injury and 121 family members at discharge and 3 and 6 months later.

The participants with acquired brain injury were grouped according to driving status (not driving, returned within 3 months, returned within 6 months).

The groups were then compared on demographics, severity, injury, functioning quality of life, psychosocial integration, depression, and carer well-being.

The authors found that by 6 months post-discharge 62.3% had resumed driving.

Between group differences existed on measures of injury severity, and psychosocial integration at 6 months, and carer depression and strain at discharge and 6 months.

Furthermore if and when someone returned to driving could be predicted by length of hospital stay,and level of community integration, and pain at discharge.

CONCLUSION: More research and additional methodologies are required for us to be able to identify when a patient is fit to safely resume driving after an acquired brain injury.

References:

(1) Headway the Brain Injury Association. https:www.headway.org.uk/home.aspx

(2) Cullen N, Krakowski A, Taggart C. Functional independence at rehabilitation admission as a predictor of return to driving after traumatic brain injury. Brain Inj.2014; 28 (2):189-95. doi:10.3109/02699052.2013.862738

(3) Cullen N, Krakowski A, Taggart C. Early neuropsychological tests as correlates of return to driving after traumatic brain injury. Brain Inj.2014:28 (1):38-43. doi: 10.3109/02699052.2013.849005

(4) Baker A, Unsworth CA, Lannin NA. What information in Australian emergency departments about fitness-to-drive after mild traumatic brain injury: a national survey. Aust Occup Ther J. 2015 Feb: 62 (1):50-5: doi:10.1111/1440-1630.12172.Epub 2014 Dec 11.

(5) Baker A. Unsworth CA, Lannin NA Fitness to drive after mild traumatic brain injury: mapping the time trajectory of recovery in the acute stages post injury. Accid Anal Prev.2015 Jun;79:50-5.doi:10.1016/aap.2015.03.014.Epub 2015 Mar 19

(6) Fleming J, Liddle J, Nalder E, Weir N, Cornwell P. Return to driving in the first 6 months of community integration after acquired brain injury. NeuroRehabilitation 2014; 34(1):157-66. doi: 10.3233/NRE-131012.