RESEARCH REPORT PLATFORM PRESENTATION

EFFECT OF SIMULATOR TRAINING ON DRIVING AFTER STROKE: A RANDOMIZED CONTROLLED TRIAL. Akinwuntan A¹, De Weerdt W², Feys H², Pauwels J², Baten G³, Arno P³, Kiekens C⁴; ¹Medical College of Georgia, Augusta GA, USA. ²Katholieke Universiteit Leuven, Belgium. ³CARA, Belgian Road Safety Institute, Brussels, Belgium. ⁴University Hospital Pellenberg, Belgium

PURPOSE: The neurological deficits experienced after stroke affect the ability to perform most activities of daily living including driving, an activity that many stroke survivors (>50%) wish to continue. Different methods have been employed to train persons with stroke to resume driving without convincing evidence of benefits from such training programs. The authors investigated the effect of the most promising method (use of driving simulators) on driving training after stroke. RELEVANCE: An effective and safe training method of driving after stroke will not only ensure more safe post-stroke drivers but improve the quality of rehabilitation and further enhance the quality of life after stroke. PARTICIPANTS: Eighty-three persons with first-ever stroke and in the subacute phase. METHODS: Subjects performed a 5-week 15-hour training program in which they were randomly allocated to either an experimental (simulator-based driving training) or control (driving-related cognitive tasks) group. Performance in off-road evaluations and an on-road test were used to assess the driving ability of subjects pre- and post-training. Outcome of an official pre-driving assessment administered 6 to 9 months post stroke was also considered. ANALYSIS: The differences between the experimental and control groups at pre-training, post-training and follow-up assessments as well as improvements from pre- to post-training were tested using unpaired t-tests or Wilcoxon rank sum tests. Within-group improvements in each group at post-training were compared using paired t tests or Wilcoxon signed rank tests. The decisions of driving fitness (in three classes) based on the on-road test during each assessment period were compared between groups using chi-square statistics. Improvements in the tasks evaluated in the simulator immediately after 15 hours of training were investigated using Wilcoxon signed rank tests. Logistic regression analyses were performed to identify subgroups of subjects that benefited most from the training programs. RESULTS: Both groups significantly improved in a visual and many neuropsychological evaluations and in the on-road test after training. There were no significant differences between both groups in improvements from pre- to post-training except in the “road sign recognition test” in which the experimental subjects improved more. Significant improvements in a three-class decision of driving fitness (“fit to drive,” “temporarily unfit to drive,” and “unfit to drive”) were found in favor of the experimental group post-training. Significantly more experimental subjects (73%) than control subjects (42%) passed the follow-up official pre-driving assessment and were legally allowed to resume driving. Academic qualification and overall disability together determined subjects that benefited most from the simulator-based driving training. CONCLUSIONS: Simulator-based driving training improved driving ability better than driving-related cognitive tasks, especially for well educated and less disabled persons with stroke. However, the findings of the study may have been modified as a result of the number of dropouts and the possibility of some neurologic recovery unrelated to training. IMPLICATIONS: The outcome at follow-up demonstrates the long-term effect of simulator-based driving training and suggests the usefulness of implementing such training program in the active rehabilitation phase after stroke. However, patients with severe post-stroke deficits should be allowed more time to physically recover before inclusion in such training programs. KEYWORDS: Cerebrovascular accident; Motor vehicles, Driving simulators. FUNDING ACKNOWLEDGEMENTS: Supported by Stichting Van Goethem Brichant and Interfaculty Office for Development Cooperation of the Katholieke Universiteit Leuven, Belgium. CONTACT: aakinwuntan@mcg.edu

ETHICS COMMITTEE: Study protocols were approved by the Medical Ethics Committee of the University Hospitals Leuven, Belgium.