EDITORIAL
Shifting up a Gear: Considerations on Assessment and
Rehabilitation of Driving in People with Neurological
Conditions. An Extended Editorial
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1535
Driving is more than pedal pushing
Driving an automobile is embedded in the social and
economic lifestyle of the industrialized world. Safe
driving involves not only intact motor, visual and
cognitive skills, it also requires the precise and timely
interaction between all these skills in addition to the
numerous constraints the environment places on
driving. Time of day, weather, road type, vehicle size,
type of transmission and amount of other vehicles
on the road are some of the environmental factors that
affect driving performance. Despite the complexity of
driving, it becomes almost an automated process
when individuals gradually gain experience while
driving. This automaticity is, however, lost in most
individuals with neurological conditions, including
stroke, Alzheimer’s disease and Parkinson’s disease
(PD), enhancing the risk of accidents (Vaa, 2003).
Driving rehabilitation programmes may increase their
chances to regain driving and maximize their integra-
tion in the community. We present an overview of
the different rehabilitation concepts used to re-train
driving skills in people with neurological conditions
and the difficulties encountered during attempts to
implement the concepts in rehabilitation or driving
assessment centres. Additionally, most countries in
the industrialized world have established minimum
medical standards of fitness to drive. The standards
and the legislation related to the standards, however,
vary greatly across countries. We discuss the different
relevant legislations in Europe, North America and
Australasia, as well as identify the limitations of
fitness to drive assessments. We also provide recom-
mendations to streamline the licence re-certification
procedures in general and discuss the impact of
driving cessation on the persons with a neurological
condition. Finally, on the basis of all of the aforemen-
tioned, we present the research agenda for driving into
the next decennium.
Physiother. Res. Int. 17 (2012) 125–131 © 2012 John Wiley & Sons, Ltd.
Driving rehabilitation
Although driving cessation is acknowledged to
have enormous socio-economic consequences and
repercussions on quality of life, self-esteem and
mood (Marottoli et al., 1997), few studies have been
conducted to investigate whether persons with neuro-
logical conditions may benefit from driving re-training
programmes to regain their fitness to drive. Most
studies have focused on the driving rehabilitation
potential of people with acute neurological conditions.
These studies report mixed findings that is most
likely because of the methodological limitations
(small sample, absence of control or comparative
groups or inadequate outcome measures) or the
different rehabilitation strategies used in the studies.
Two of the rehabilitation strategies (remedial versus
contextual training) are briefly discussed later with a
focus on people with stroke.
Remedial training of driving skills
The re-training of underlying skill deficits takes a number
of forms including the following: paper and pencil tasks
(Sivak et al., 1984a, b; Klonoff et al., 2010) or comput-
erized methods such as the Dynavision (Dynavision
Performance Enterprises, Markham, ON, Canada)
(Klavora et al., 1995; Crotty and George, 2009), the
Useful Field of View visual attention analyzer (Visual
Resources Inc, Bowling Green, KY, USA) (Mazer et al.,
2003; Roenker et al., 2003; Belchior, 2007), video games
(Belchior, 2007) and computer programmes (Sivak
et al., 1984a, b). These tools target mainly the visual-motor,
perceptual and cognitive driving-related skills and assume
a transfer to functional performance in on-road driving.
The evidence on the effectiveness of these methods
to re-train driving ability remains limited and suggests
that training should be targeted at specific skill
deficits. In the existing trials, cohorts of persons with
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stroke were included with heterogeneous deficits, not
necessarily in the area targeted by the remedial training.
It is also conceivable that the driving task, which is
highly complex and requires the integration of many
skills, may be more amenable to more functional
approaches to re-training. Furthermore, a more
detailed understanding of the neurological recovery,
via plasticity and/or compensatory mechanisms,
behind remedial interventions is required.
Contextual training of driving skills
The ability to drive is initially learnt in a contextual
mode by practising to drive a vehicle in a structured
or unstructured programme. The contextual strategy
adheres to the same principles. A review of the litera-
ture in persons with acute neurological conditions
suggests that only contextual re-training of impaired
skills relevant for safe driving generalizes better to
improved driving performance on practical road tests
when compared with non-contextual training pro-
grammes (Jones et al., 1983; Kewman et al., 1985;
Cimolino and Balkovec, 1988; Klavora et al., 1995; Galski
et al., 1997; Mazer et al., 2001; Roenker et al., 2003;
Akinwuntan et al., 2005; Crotty and George, 2009).
The efficacy of re-training impaired driving skills in
neurodegenerative conditions is not as well established
as it is for stroke survivors. However, preliminary
findings from ongoing studies involving individuals
with PD (Uc et al., 2011) show potential benefits from
contextual-based driving programmes.
Although an on-road training programme enables
contextual re-training of impaired driving skills (Jones
et al., 1983), it can also be very risky and lacking in
opportunity to offer pre-determined traffic situa-
tions needed to re-train specific skills such as
hazard detection and avoidance. A simulator-based
programme is the other context-based training
programme that is effective for re-training impaired
driving skills (Kewman et al., 1985; Cimolino and
Balkovec, 1988; Akinwuntan et al., 2005; Devos
et al., 2009). Experiencing poor and risky driving
behaviours in a safe environment is a valuable way to
improve driving knowledge, skills and abilities. The
immediate feedback provided through replaying
recorded performance also proves valuable to trainers
and researchers for deconstructing complex, dynamic
patterns, such as error-prone behaviours. Learning is
better enhanced when a therapist provides direct,
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H. Devos et al.
interactive feedback during or immediately after a
subject’s simulator-based driving experience (Stern et al.,
2004; Stern and Schold, 2006).
Implementation of contextual driving
rehabilitation in current practice
In practice, training of driving rehabilitation is often
carried out when candidate drivers are referred to a
driving school following the fitness to drive evaluation
or while clients are admitted to the rehabilitation
centre in anticipation of the fitness to drive assessment.
On the basis of our own experience, we describe some
of the difficulties that are encountered when offering
contextual driving rehabilitation programmes to
patients with neurological conditions.
The driving lessons at a driving school are offered by
certified driving instructors using real cars and real
driving situations. The vehicles used for the training
are adequately adapted to ensure driving safety.
Safety adaptations are additional mirrors and dual con-
trols to enable the driving instructor to intervene in
dangerous situations. The referral to driving schools
rarely accounts for candidate drivers with neurodegen-
erative conditions such as Alzheimer’s disease or PD.
Persons who have suffered an acute neurological
condition such as stroke, traumatic brain injury or
spinal cord injury are referred more frequently to
driving schools. Such drivers often need appropriate
vehicle modifications to compensate for their loss of
functioning. Frequently used car adaptations include
changing the manual gear system to automatic trans-
mission, a contralateral accelerator pedal for persons
with unilateral hemiplegia, a spinner knob with horn
and direction indicators mounted at the steering wheel
to enable one-handed driving, and hand controls to
operate the accelerator and brake for persons with
paraplegia and tetraplegia. The driving lessons are
usually provided by privately run driving instruction
businesses (Crotty and George, 2009) that often have
no medical background and expertise in training and
coaching of drivers with brain damage. Training of
driving ability is often restricted to 10 hours of driving
lessons with a focus on familiarization with car modifi-
cations. Yet, training driving ability in people with brain
damage requires a tailor-made, integrative approach that
only can be achieved if the instructor has insight in the
visual, motor and neuropsychological deficits that hinder
subjects to drive. For example, the training of candidate
Physiother. Res. Int. 17 (2012) 125–131 © 2012 John Wiley & Sons, Ltd.
H. Devos et al.
drivers with hemianopia and persons with (very) mild
visual inattention require two different rehabilitation
techniques. Persons with hemianopia have a visual field
deficit opposite to the brain lesion. Those drivers may
be taught to overcome this problem by teaching them
to actively move their eyes and head towards the blind
visual field. Additionally, extra mirrors or prisms may
be used to compensate for their visual field deficit.
Drivers with visual inattention need to be made aware
of their deficit by training them to see, perceive and react
to road situations at the affected side. Finally, on-road
training can be quite expensive with no guarantee of
obtaining a driver’s licence.
Clients admitted to rehabilitation centres may
receive tailor-made driving training by occupational
therapists or psychologists who are trained to identify
the functional deficits that hinder safe driving.
It is our experience that the dearth in literature on
evidence-based driving rehabilitation programmes,
the limited medical background of driving instructors
and the lack of financial resources of rehabilitation
centres (Crotty and George, 2009) currently impede
the implementation of contextual driving rehabilitation
programmes for people with neurological conditions.
While driving rehabilitation research requires increased
attention before evidence-based guidelines can be
derived, legislation issues with regard to fitness to drive
pose another set of challenges in the field of driving for
people with neurological conditions.
Legislation of fitness to drive
While mobility is a right, driving a car is rather a privilege
granted by governments to help individuals in their
pursuit of mobility, independence and freedom.
However, governments are also entrusted with the
responsibility of providing to ensure public on-road
safety. Individuals’ driving privileges must therefore be
balanced against public interests, such as the protection
against drivers whose functional deficits may hamper
their ability to drive safely. The delicate balance between
the individuals’ privileges to drive a car and the society’s
duty to ensure safe roads is described in laws and
regulations on the determination of fitness to drive.
Legislation in Europe
The European Driving Licence Directive outlines the
minimum requirements of physical and mental fitness
Physiother. Res. Int. 17 (2012) 125–131 © 2012 John Wiley & Sons, Ltd.
Editorial
to drive (Directive, 2006/126/EC). The European
Directive takes a conservative approach to fitness to
drive in neurological conditions. Persons with neuro-
logical conditions are unfit to drive, unless a physician
decides that the medical condition does not hinder safe
driving. The opinion whether a person meets the
medical standards must be based on a medical assess-
ment of the condition, and where necessary, on a
practical test. Thus, the European Directive does not
necessitate an on-road evaluation to determine fitness
to drive. As a result, legislation criteria regarding fitness
to drive vary greatly across European countries in terms
of reporting and evaluation procedures (White and
O’Neill, 2000). While some countries merely rely on a
medical examination, others have initiated fitness to
drive assessment batteries that involve visual tests,
neuropsychological tests, on-road tests or a combination
of the aforementioned (White and O’Neill, 2000). These
fitness to drive assessments are undertaken by certified
physicians, neuropsychologists and physical or occupa-
tional therapists. Persons who show sufficient driving
skills may resume driving, while those who do not meet
the minimum medical criteria or who perform poorly
on the driving assessment are denied from driving and
need to return their driver’s licence. In some cases, the
European Directive considers graded licensure policies
that allow driving under certain conditions or restrictions
in time (e.g. not at night), speed (e.g. no highways) or
distance (e.g. only in close proximity of home address).
Legislation in North America
In the United States, most decisions regarding testing and
licencing drivers rest with the individual states and not
the Federal Government. With the exception of those
who drive commercial vehicles (large trucks or buses)
and those who must possess a valid commercial driver’s
licence and meet minimum national standards, all
policies and regulations concerning drivers with
neurological conditions are developed and implemented
at the state level. Accordingly, there may be 50 different
sets of regulations regarding medical certification
or approval, licence suspension or revocation, and
re-testing or re-training prior to re-licensure. Although
not mandatory in many states, most of the states have a
medical reporting form that a physician can complete
to either report an individual’s inability to continue to
drive safely or to indicate that a candidate is fit to
continue to drive safely.
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In Canada, driving licences are delivered by the
provincial or territorial authorities. Although there
are overall similarities, the specific regulations with
regards to the determination of fitness to drive for
individuals who have a medical condition vary according
to jurisdictions. Physicians from all provinces and
territories have a statutory duty to report people who
have a medical condition that could affect the ability to
safely operate a motor vehicle. However, this duty may
be mandatory or discretionary according to the jurisdic-
tion. A medical assessment is required in all provinces or
territories and constitutes an important element in the
licencing authorities’ decision to issue or renew a driver’s
licence for a person with a neurological condition. The
Canadian Medical Association has developed a guide to
assist medical practitioners in assessing a person’s fitness
to drive (Canadian Medical Association, 2006). The
guidelines remain, however, quite vague and provide
few recommendations for specific tools or cut-off scores
to use in determining safe driving. Although certain
provinces and territories have adopted specific tools for
assessing fitness to drive, most jurisdictions rely on the
clinical judgement of the professional for the selection
of the appropriate assessment methods. In certain
instances, the licencing authorities will request, in addi-
tion to the physician’s assessment, an on-road assessment
or expert opinions from medical (e.g. neurologist or
ophthalmologist) and rehabilitation specialists (usually
occupational therapists) before making a decision with
regards to issuing or renewing the driving licence. This
information will also be useful to the licencing authorities
to determine whether restrictions or conditions with
regards to time, distance or driving aids are necessary.
The restrictions or conditions vary between the various
licencing jurisdictions in the country.
Legislation in Australasia
Austroads have developed medical standards for licen-
cing and clinical management for driving, detailing the
minimum medical requirements for conditional and
unconditional licences (Austroads, 2012). Conditional
licences identify the need for medical treatments,
vehicle modifications, driving restrictions or a review
period for safe driving. Austroads differentiate between
a practical driving assessment, performed by an occu-
pational therapist and designed to assess the impact of
a neurological condition on driving skills that is
used to supplement the clinical assessment, and a test
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of competency conducted by driving authorities for
licencing purposes.
Austroads stipulate different guidelines for varying
neurological conditions. Similar to New Zealand
(NZ Transport Agency, 2009), the standards state that
a person with stroke cannot drive for at least 4 weeks,
as fatigue and impairments in concentration are
common, even when there is no persisting neurological
condition. After this time-frame, visual and seizure
standards are considered and reviewed by a specialist,
commonly a rehabilitation physician and neurologist,
which is recommended for those with ongoing
neurological symptoms. Medical practitioners refer
for a practical driving assessment if information related
to functional ability to drive is required.
Following this period of non-driving, the process of
return to driving is handled differently between clinical
units, as the way in which the guidelines are interpreted
varies. In some instances, stroke survivors are required
to obtain a letter, certificate or some ‘evidence’ of
fitness to drive from a medical practitioner; and in
other instances, a verbal clearance is provided by the
treating medical practitioner. Confusion also exists as
to who should be offered an on-road assessment as in
some cases, health professionals advocate such assess-
ments for all people with stroke after the 1-month time
frame is reached. The guidelines do not support
on-road assessment for all people following stroke.
This results in disparities as some people are forced to
have on-road tests, and others are not. Furthermore,
variability in access and funding for on-road assess-
ment and re-training will result in further disparities
of returning to driving for people with stroke.
Limitations in legislation and
recommendations
It is clear that the differences in fitness to drive assess-
ments across the world do not add to the efficiency of
the procedure. About 50% of stroke drivers do not
receive any advice regarding driving re-licensing, and
nearly 90% do not receive any type of driving evalua-
tion (Fisk et al., 1997). Similar percentages can be
found for other neurological conditions, which raises
the question whether these standards should not be
subjected to rigorous investigation and perhaps
revision. The main limitations for this inefficient
re-licensing procedure include the following: 1) vague
legislation criteria; 2) limited knowledge of the
Physiother. Res. Int. 17 (2012) 125–131 © 2012 John Wiley & Sons, Ltd.
H. Devos et al.
legislation criteria; 3) risk of lawsuits; 4) deontological
issues; and 5) the limited implementation of clinical
screening batteries in the consultation routine.
The vague legislation criteria make it difficult to apply
the re-licensing procedure. The origins of the laws and
regulations on fitness to drive are often historic and have
rarely been put to empirical tests. In fact, the evidence
supporting their validity is rather sparse. As a result,
proper advice about driving resumption remains an issue
for physicians and health professionals throughout the
world (Fisk et al., 1997). The conflicting results in litera-
ture on the most accurate determinants of fitness to drive
(Devos et al., 2011) further complicate harmonization of
the driving re-licensing procedure and currently fail to
provide clear-cut guidelines. Hence, further research is
urgently needed to develop evidence-based standards
regarding the determination of fitness to drive, supported
by physicians, health care professionals, researchers and
policy makers. These guidelines should be based on the
functional abilities of candidate drivers rather than on
diagnostic categories.
In large surveys of physicians’ attitudes towards
driving, it is repeatedly noted that some physicians
demonstrate limited knowledge of the legislation
criteria for people with neurological conditions
(Adler and Rottunda, 2011). Physicians who are less
aware of the regulations overestimate the driving
performance of their clients. Those who are aware
of the regulations are more likely to initiate discus-
sions regarding driving cessation. It is strongly recom-
mended that outreach efforts to inform, educate and
sensitize physicians are initiated. Continuing medical
education activities that use a variety of instructional
methods and give repeated exposure to a topic have
been shown to be the most effective method for
knowledge retention and skills application. A continu-
ing medical education workshop on driving cessation
in people with dementia found physicians to have
improved knowledge, increased confidence and making
changes in practice behaviours towards driving (Meuser
et al., 2006).
Physicians may be at risk of lawsuits for reporting
unsafe drivers, resulting in a suggested violation of
the patient–doctor relationship, although it must be
noted that physicians are mostly exempted from
lawsuits for such good faith reports. Driving re-license
legislation across continents recommends physicians to
inform candidate drivers about their responsibility to
amend their driver’s licence to the legal criteria,
Physiother. Res. Int. 17 (2012) 125–131 © 2012 John Wiley & Sons, Ltd.
Editorial
especially when the client is discouraged to drive. We
recommend that this information is carefully noted in
the client’s file. Likewise, physicians may expose
themselves to risk of lawsuits should clients who appear
to be safe drivers, be involved in an accident.
Regardless of the legal issues, fitness to drive evalua-
tions remain a deontological burden for physicians
knowing that if they are unwilling to sign the re-license
form, candidate drivers may ‘shop around’ until they
find another physician who is willing to sign the certif-
icate for re-licensing. Additionally, physicians may be
apprehensive to deny persons from driving because
they know that driving is associated with mobility,
freedom, independence and quality of life (Marottoli
et al., 1997). If possible, the use of other modes of
transport (public transport and proxy) should be dis-
cussed with the clients before their impairments affect
driving. In addition, current transportation systems
need to be assessed to determine whether they are
effectively meeting the full transportation needs of
people with neurological conditions.
In general, if physicians feel that they are not
confident to grant the licence certificate, if they cannot
decide in total immunity or if they are faced with
deontological issues, it is recommended to refer these
candidate drivers to the driving rehabilitation specia-
lists for a detailed administration of driving-related
functions. This referral should be based on science-
based clinical screening batteries with high predictive
accuracy rather than on clinical judgement alone
(Devos et al., 2011). Clinical screenings have been
found to be more accurate in predicting fitness to drive
than the physician’s appraisal, patient’s self-appraisal
or the appraisal of their caregiver (Heikkila et al.,
1998). Unfortunately, these tools have rarely been
validated in new patient groups and therefore have only
seen limited application in clinical practice.
Viewpoint of the persons in the
driver’s seat
Qualitative interviews have been undertaken to
demonstrate the need for more information regarding
driving resumption and driving rehabilitation in
persons with stroke (Patomella et al., 2009, White et al.,
2012). Most individuals reported receiving no formal
advice and therefore continued driving without medical
clearance (Fisk et al., 1997; White et al., 2012). For those
who received advice, reported inconsistencies and lack of
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clear information, the advice not to drive often came
unexpected and did not reflect their self-appraisal of
driving ability (Patomella et al., 2009; White et al.,
2012). Individuals who ceased driving experienced a state
of occupational deprivation because of the disruption in
the ability to participate in activities that brought
meaning to life (White et al., 2012). The decision to
cease driving, whether self-imposed or obligated by care-
givers, physicians or insurances may lead to depression
(Legh-Smith et al., 1986; White et al., 2012), even several
years after driving cessation (Devos et al., 2010).
Driving lessons are offered to only few individuals
and often are at the instigation of their physician
(White et al., 2012). The driving lessons are often
associated with frustration because of the personal
expenses and the significant perceived delay when
waiting for driving lessons (White et al., 2012).
Driving research: shifting up a gear
In summary, research on driving rehabilitation in people
with neurological disorders is still in its infancy. The few
studies that have been published so far suffer from
methodological issues, which complicate making recom-
mendations based on current evidence. Yet, the results
suggest that contextual driving rehabilitation via on-road
training or simulator-based driving training may be
superior to the training of the underlying cognitive
deficit. The identification of the most beneficial driving
rehabilitation concept via adequately powered, multicen-
tre randomized controlled trials is a priority on the
research agenda for the next decennium. The superiority
of contextual training should be explored in terms of
on-road success rates and time and cost-effectiveness
before implementing in clinical practice. Further steps
that should be considered involve the determination of
the optimal treatment programme in terms of content,
duration, frequency and intensity of therapy. In people
with acute neurological conditions, future studies need
to investigate which time after the event would yield the
most beneficial results. Financial resources should be
made available to educate driving instructors at driving
schools about the specificity of driving rehabilitation in
persons with neurological conditions and to enable the
purchase of driving simulators at rehabilitation centres
if the encouraging results of driving simulator rehabilita-
tion can be confirmed.
In terms of fitness to drive assessments, we urgently
plead for an international, multidisciplinary task force
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that proposes a multidimensional approach of tackling
the difficulties identified previously. Physicians and
allied health professionals should be sensitized about
providing adequate information regarding driving
resumption and rehabilitation. Information and support
are the minimum requirements when persons are faced
with such a big impact on their quality of life.
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Hannes Devos1
Abiodun E. Akinwuntan2
Isabelle Gélinas3
Stacey George4
Alice Nieuwboer1
Geert Verheyden1
1
Department of Rehabilitation Sciences, Katholieke
Universiteit Leuven – University of Leuven, Belgium
2
Department of Physical Therapy, Georgia Health
Sciences University, Augusta, GA USA
3
Department of Physical and Occupational Therapy,
McGill University, Montréal, Canada
4
Department of Aged Care and Rehabilitation, Repa-
triation General Hospital, Adelaide, Australia
131
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