Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2018;99:2378-88

SPECIAL COMMUNICATION

Interdisciplinary Approaches to Facilitate Return to

Driving and Return to Work in Mild Stroke: A Position
Paper
Suzanne Perea Burns, PhD, OTR,a Jaclyn K. Schwartz, PhD,b Shannon L. Scott, OTD,c
Hannes Devos, PhD,d Mark Kovic, OTD,e Ickpyo Hong, PhD,f
Abiodun Akinwuntan, PhD, MPH, MBAd
From the aWISSDOM Center, Medical University of South Carolina, Charleston, SC; bNicole Wertheim College of Nursing and Health Sciences,
Florida International University, Miami, FL; cOccupational Therapy Department, Ithaca College, Ithaca, NY; dDepartment of Physical Therapy
and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS; eCollege of Applied Health Sciences, Midwestern University,
Glendale, IL; and fDepartment of Occupational Therapy, University of Texas Medical Branch, Galveston, TX.

Abstract
Adults with mild stroke face substantial challenges resuming valued roles in the community. The term “mild” provides false representation of the
lived experience for many adults with mild stroke who may continue to experience persistent challenges and unmet needs. Rehabilitation
practitioners can identify and consequently intervene to facilitate improved independence, participation, and quality of life by facilitating function
and reducing the burden of lost abilities among adults with mild stroke. The Health and Wellness Task Force identified 2 important, and often
interdependent, goals that frequently arise among adults living with mild stroke that must be addressed to facilitate improved community
reintegration: (1) return to driving and (2) return to work. Adults with mild stroke may not be receiving adequate rehabilitative services to facilitate
community reintegration for several reasons but primarily because current practice models are not designed to meet such needs of this specific
population. Thus, the Health and Wellness Task Force convened to review current literature and practice trends to (1) identify opportunities based on
the evidence of assessment and interventions, for return to driving and return to work; and (2) identify gaps in the literature that must be addressed to
take advantage of the opportunities. Based on findings, the task force proposes a new interdisciplinary practice model for adults with mild stroke who
are too often discharged from the hospital to the community without needed services to enable successful return to driving and work.
Archives of Physical Medicine and Rehabilitation 2018;99:2378-88
ª 2018 by the American Congress of Rehabilitation Medicine

Statement of purpose Stroke Interdisciplinary Special Interest Group’s mission is to bring

Few resources support practitioners in addressing mild stroke. In
the absence of clear evidence of quality and evidence-based
interventions, health care professionals must use their best
judgment integrating lower levels of evidence and expert reasoning.
Therefore, the Health and Wellness Task Force within the American
Congress of Rehabilitation Medicine Stroke Interdisciplinary
Special Interest Group seeks to support current practice through
this position paper on improving community reintegration after
mild stroke. The American Congress of Rehabilitation Medicine
Disclosures: none.
together rehabilitation professionals to advance the field of stroke
rehabilitation. The purpose of this position paper is to describe
current opportunities and gaps that support persons with mild
stroke as they reintegrate to the community, with a focus on return
to driving and return to work. The task force also proposes a new
community rehabilitation practice model that may better support
the unique needs of adults with mild stroke.
Rationale for position paper
Each year, approximately 795,000 adults in the United States have
a stroke.1 Recent data suggest that about half of all strokes are
mild in nature.2 While disagreement remains on the criteria for

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.01.032
Community reintegration after mild stroke
mild stroke, researchers often categorize scores of 6 or less on the
National Institutes of Health Stroke Scale as mild.3-5 Adults who
have had a mild stroke desire to return to meaningful roles in the
lived environment that may include return to work and return to
driving. These goals are often interdependent with those of living
at home and resuming social roles within the community.6
Returning to driving a vehicle facilitates everyday tasks such as
shopping for groceries and supplies, getting to and from work and
appointments, and attending social and community events.
Returning to work provides a means of earning an income and also
provides the identified social role of worker. Unfortunately, many
persons with mild stroke experience motor impairment, fatigue,
concentration difficulties, sensory changes, memory impairments,
emotional lability, stress, depression, anxiety, and uneasiness.7,8
As they return to high-demand tasks in real-world environments,
undetected impairments may emerge that can negatively influence
resumption of valued roles.9
Given the large number of adults with mild stroke and their
generally positive short-term outcomes, this population is
frequently discharged to the community with little to no rehabili-
tation.2,10,11 While 50% of strokes are classified as mild, Camicia
et al12 found that people with mild stroke make up only 13% of
patients with stroke in inpatient rehabilitation. Further, people with
mild stroke have relatively short length of stays (8.9d) compared
with those for people with moderate and severe strokes (13.9d and
22.2d, respectively).12 Rehabilitation can help adults with stroke
reach their goals through interventions that focus on task training,
coping strategies to support needs, strategies to overcome barriers,
impairment remediation, and promotion of health and well-being,
all to support what is often referred to as the ultimate goal of
rehabilitation: community reintegration.13-15 While research has
demonstrated that rehabilitation interventions can reduce the effect
of symptoms experienced by many adults with mild stroke, limited
research exists with a focus on this specific population.
Challenges emerging from a current health
care climate
Return to driving and return to work after stroke are essential
facets of community reintegration. Although return to driving and
return to work may be important and necessary for some persons
with mild stroke, the task force members recognize there are
alternatives to driving and that not everyone needs or wants to
work. Nonetheless, the concepts are important for many persons
with mild stroke. Unfortunately, the research indicates persons
with mild stroke do not typically receive rehabilitation to help
them transition back to their home and community.2,16 Such
services may be missing because of 1 or more of the 5 reasons
listed below:
1. For many years, researchers and practitioners believed that per-
sons with mild stroke did not experience deficits. Unfortunately,
the paradigm shift on mild stroke care requires time to infiltrate
large health care systems and the practitioners within them.
2. Many assessment tools used in stroke were developed for
persons with moderate to severe stroke. Therefore, current
List of abbreviations:
RCT randomized controlled trial
UFOV useful field of view
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2379
assessments may not be sensitive enough for persons with mild
stroke.17 Logically, health care systems and payers do not
provide rehabilitation services to persons who demonstrate “no
deficits” on an assessment.
3. Health care systems are currently situated to provide rehabili-
tation for persons with moderate and severe stroke.18 Given
that half of all strokes are mild in nature, addressing the needs
of all stroke survivors would presumably require doubling
rehabilitation resources.
4. Services to support persons with mild stroke may be frag-
mented across a variety of providers and health care systems.
Subsequently, referrals and follow-ups for needed services may
not be used in adults with stroke, resulting in persistent and
unmet needs in the community.19
5. Finally, whole systems of health care and reimbursement are
based on traditional models of rehabilitation for stroke.
Unfortunately, these systems focus on progressing persons with
stroke toward lower-cost facilities and may not support the
unique needs of persons with mild stroke.
While the barriers to changing practice are significant, the
anticipated outcomes outweigh the disadvantages. Specifically, 3
factors urge rehabilitation professionals to modify their practice to
adjust for this paradigm shift in mild stroke care in an expedi-
tious manner.
1. Driving is reported as one of the most frequently affected daily
occupations after mild stroke.20 Research suggests that 18% of
adults with mild stroke drive less frequently than before their
injury.21 Similarly, approximately 15% of persons with mild
stroke leave paid employment within the first 6 months because
of persistent stroke-related impairments, and many never
resume work after their injury.22 Health care professionals are
expected to support outcomes for return to the community; the
evidence suggests that this translates to increased services for
persons with mild stroke.23
2. Poor follow-up care for adults with mild stroke is a major
public health issue. Many mild stroke survivors resume driving
and work despite impairments to vision, cognition, and motor
functions.20,24 Approximately 25% to 35% of persons with
stroke or transient ischemic attack resume driving within 1
month of the event.25,26 In a driving simulator study,27 adults
with mild stroke committed over twice as many driving errors
(eg, center-line crossings, speed exceedances) as control
drivers in a simulated drive of city traffic. Another study found
that persons with mild stroke demonstrated deficits in rapid
judgment, automatic reactions, and mental flexibility in
complex traffic situations, such as turning left across oncoming
traffic and following a bus.27,28 In a nation of over 200 million
drivers and over 300 million passengers, road users depend on
mild stroke survivors’ ability to return to driving (or alternative
forms of transportation) safely.29 In terms of return to work,
lost earnings was the highest cost contributor to the nearly
$33.9 billion cost of stroke in the United States.30 Disability
payments constitute 86% of Social Security benefits, and stroke
is the leading cause of disability in the United States.31 As a
nation of drivers and taxpayers, it is within the best interest of
all citizens to improve community reintegration for persons
with mild stroke.
3. Finally, the Patient Protection and Affordable Care Act is
shifting the focus from quantity to quality of care. Specifically,
the Affordable Care Act supports the use of quality measures
2380
Fig 1 Practice model of community rehabilitation for adults with mild stroke.
focused on functional status and patient satisfaction.32 While
the U.S. health care system may change, health care will likely
continue to focus on quality. Individuals with mild stroke
expect to recover and resume “prestroke life” after hospitali-
zation.33 The prevailing literature is clear and suggests that
current systems leave persons with mild stroke with poor
functional status, reduced participation, and diminished quality
of life.
Community rehabilitation practice model
for mild stroke
Community reintegration after mild stroke is complex and
multifactorial34; therefore, coordinated, interdisciplinary services
to support improved functional long-term outcomes are needed.
Coordinated models of care such as those that use a case man-
agement or resource facilitator approach improve return-to-work
outcomes.35,36 Based on current systems of care, we know that
it is possible to provide services to persons with stroke.18 How-
ever, it is necessary to alter current practice models to support the
specific needs of persons with mild stroke. Therefore, members of
the task force posit that helping persons with stroke, family
members, practitioners, and the community understand the
persistent disability associated with mild stroke is a first step in
advocating for change to current practice.
Figure 1 depicts a proposed alternative practice model for
community rehabilitation for persons with mild stroke as they
move from the hospital to the community. The model is designed
to illustrate how a person reacts to a mild stroke and is treated with
early rehabilitation to support recovery, transitions, adaptation,
and community reintegration. Interdisciplinary community reha-
bilitation is delivered in the context of the community, as longer
inpatient stays are negatively associated with improved functional
outcomes.12 Holistic care is delivered by a collaborative inter-
disciplinary team, which is associated with a more successful
recovery in the community.37 Although each person with mild
S.P. Burns et al
stroke has specific needs, members of the task force recommend
key stakeholders in community rehabilitation, including case
managers, social workers, occupational therapists, physical ther-
apists, speech-language pathologists, nurses, primary care physi-
cians, neurologists, neuropsychologists, neuro-optometrists/
ophthalmologists, driving rehabilitation specialists, vocational
rehabilitation specialists, pharmacists, recreational therapists,
music therapists, community health workers, volunteers, peer
support, and family members/care partners. Many team members
have complementary roles. It is up to each facility to assemble a
team to best meet the needs of persons with mild stroke.
Stroke recovery can extend well into the chronic phase of
stroke.38-40 While providing interdisciplinary services within the
first year of recovery supports improved outcomes, services should
be available for persons with mild stroke if they experience
additional long-term challenges or decline. Community rehabili-
tation should integrate interventions at the various levels described
in the Social Ecological Model41 including individual, interper-
sonal, organizational, community, and public policy to support
meaningful outcomes and community reintegration in this unique
population. Additionally, the members of the task force recognize
the importance of integrating the virtual context for addressing the
needs of persons with mild stroke in the community. Increasing
the quality and quantity of care for persons with mild stroke will
require a pragmatic approach. Incorporating the electronic health
interventions that maximize impact while limiting costs will be
paramount in the future of intervention delivery. In fact, low-cost
technologies are both feasible and desirable interventions among
persons with stroke.42 Technology interventions can improve the
skills of persons with stroke and their care teams, or they may be
tools that better support everyday life tasks. For example, it is now
possible to order shared ride services with smartphone technology
or use apps to support residual cognitive impairments.43,44 Addi-
tionally, telerehabilitation is an emerging practice area that has
substantial implications for delivering rehabilitation in the com-
munity. Integrating these concepts may enhance community
reintegration outcomes by leveraging naturalistically emerging
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Community reintegration after mild stroke 2381

ecological supports. To facilitate successful community reinte-

$50 per 100 copies

gration, alternative techniques such as resource facilitation,35
telerehabilitation,45,46 and reimbursement of both protracted
rehabilitation services and services provided within the commu-
nity47 may offer new opportunities for optimizing successful

$200y
$200y
reintegration to the community after mild stroke.

Cost

* Effect size was calculated as the absolute difference of the mean score of the test of the fail group and the mean score on the test of the pass group divided by the pooled variance.
Cutoff Score
Practice changes
8.551
Evaluation
51

2551
90

Changing models of practice is a slow process. Therefore, clinicians

across the continuum of care can begin to make small changes to
Training
Minimal
Minimal
Minimal

better enable persons with mild stroke to reintegrate into the com-
munity through return-to-driving and return-to-work services. Given
the complicated nature of returning to the community, a compre-
hensive evaluation integrating a team approach is necessary.
Boards and cards
Boards and cards
Paper and pencil

Neuropsychological evaluation
Standard care should require that all adults with mild stroke
Equipment

participate in interdisciplinary evaluation during or shortly after

discharge from acute care. Neuropsychological evaluations using
standardized clinical assessments may support rehabilitation
teams in establishing baseline cognition that can then be useful in
understanding one’s level of cognitive function.48 Practitioners
Administration

should evaluate multidimensional processes that can affect one’s

Time (min)

ability to return to driving and work including standardized as-

sessments of vision, perception, motor, cognition, and subjective
5e10

functioning.9,49,50 Additionally, a previous systematic review and

3
5

meta-analysis51 found 3 assessments to be highly predictive of

failing a road test after stroke: Road Sign Recognition Test,27,52
Compass Test,52,53 and the Trail Making TestePart B.54,55 Refer
1.22 (1.01e1.44)51
51

1.06 (.74e1.39)51
.81 (.48e1.15)

to table 1 for specific assessment examples.

Effect Size*
Examples of assessments that predict failing a road test after stroke

Ecologically valid evaluation

While standardized screening tests and neuropsychological as-
Subtests of the Stroke Drivers Screening Assessment (1 payment of $200).

sessments are useful as a first-level evaluation to identify the need

for further services, these tools often fall short in establishing
direct associations with real-world performance because of their
limited ecological validity.57 For example, even adults with mild
Test-retest reliability rZ.6756
Test-retest reliability rZ.7356

stroke who demonstrate no impairments with screening tests and

neuropsychological assessments may encounter substantial diffi-
culty with driving in real-world scenarios. Therefore,
performance-based testing reflecting concepts of ecological val-
idity is recommended.58 Through use of ecologically valid as-
sessments, practitioners are able to evaluate not only the
Reliability
55

functional cognitive abilities, but also the visual, sensory-

rZ.67

perceptual, and physical abilities of adults with mild stroke to

understand the impact that subtle impairments may have on
community reintegration outcomes.22 Examples of standardized
ecologically valid assessments that have been tested in adults with
Road Sign Recognition Test

mild stroke that may be particularly useful in the context of the

Trail Making TestePart B

community include the Executive Function Performance Test,59

the Complex Task Performance Assessment,60 and the Multiple
Errands Test Home Version.61
Compass Test

Ecologically valid performance-based assessments specifically

Assessment

designed for return to driving are also available. Driving simula-

Table 1

tors offer an important complementary role in screening for fitness

to drive, especially after mild stroke. Driving simulators have the
y

unique capability of reproducing complex, unexpected, and

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2382
potentially hazardous events in a real-life, yet safe setting.53 A
limitation of driving simulators is the feasibility of implementing
the technology into a range of practice settings often because of
financial or environmental constraints. Many driving rehabilitation
centers have fixed-based stationery simulators; however, it may be
difficult for adults with stroke, especially those who live in rural or
remote areas, to find someone to transport them to such centers.
An alternative to stationary simulators is the concept of simulators
that are housed in mobile systems such as trailers and transported
to any location. While simulators in mobile systems have the
advantage of bringing driving simulation technology to the rural
or remote dwellers, a major challenge is the additional cost of an
adequate mobile system. Although the task force members did not
find any literature on the efficacy of assessments conducted using
simulators housed in a mobile system, some form of contextual
assessment of driving will provide more useful and meaningful
information than no assessment at all. As such, this task force
recommends that where accessibility to a fixed-base stationery
simulator is a problem, simulators housed in mobile systems
should be used if available. New devices, such as mobile driving
simulators, may transcend barriers such as cost and accessibility.
Advancement in driving simulator technology and the increasing
user friendliness of the simulator software will increase the op-
portunity to provide contextual training.62 The criterion standard
for fitness to drive remains an on-road test.37 Subtle deficits that
remain undetected by neuropsychological assessments lacking
direct associations with real-world performance may emerge when
adults with mild stroke are evaluated in highly demanding,
interactive environments.
Practitioners can also evaluate one’s abilities to return to work.
An occupational therapist can perform a job analysis to identify
job-related duties and requirements through use of multiple
methods that include an interview, a review of formal job de-
scriptions, obtaining information from the U.S. Department of
Labor’s Occupational Information Network, or through adminis-
tration of assessments such as the Worker Role Interview62 and the
Work Environment Impact Scale.63 Ecologically valid assess-
ments can then be administered to screen for and detect functional
impairments that may interfere with the ability of the adult with
mild stroke to perform the physical, cognitive, psychological, and
social demands of the job. A key positive predictor of return to
work is a match between a person’s abilities and the demands of
the job.64 Nonstandardized assessments can be performed through
observation of simulated or real-world work task performance in
simulated or real-world work environments.
Intervention
Facilitating community reintegration in persons with mild stroke
is a long and complex process. Each person with stroke has unique
needs, and it is necessary that interventions for return to driving
and return to work remain client-centered. While there is sub-
stantial information on interventions for persons with stroke, there
is limited information tailored to persons with mild stroke.
Therefore, this task force describes interventions that have been
tested in the general stroke population but have relevance to adults
with mild stroke. Fortunately, interdisciplinary rehabilitation
professionals can implement interventions targeted at the person’s
body function and structure, activity and participation, and envi-
ronmental factors across the continuum of care to support the
community reintegration.65 Although this task force recognizes
the complexities associated with return-to-driving and
S.P. Burns et al
return-to-work interventions, the task force aims to briefly
describe select evidence-based interventions organized within the
International Classification of Functioning, Disability and Health
framework.66 For additional information about interventions and
resources for persons with mild stroke, refer to the Information/
Education Pages developed by members of the task force (H
Devos, AE. Akinwutan, I Hong, et al, unpublished data, 2018; S
Scott, M Kovic, J Schwartz, et al, unpublished data, 2018).
Body functions
After mild stroke, individuals often experience deficits in their
motor, visual, and cognitive functions that negatively affect their
ability to engage in meaningful and valued roles in the context of
the community.7,8 Rehabilitation professionals can engage in skill
and impairment remediation to help persons with stroke achieve
their long-term community reintegration goals.
Motor functions
Persons with mild stroke demonstrate small but significant im-
pairments to motor function.8 Motor skills in persons with mild
stroke are often not the primary cause of community reintegration
limitation; however, every person with stroke is different and some
may wish to return to tasks associated with high motor demands.46
Unfortunately, there is little research specific to persons with mild
stroke. Research from persons with stroke encompassing all levels
of severity suggests that task-oriented training, biofeedback, and
physical fitness training improves motor skills.13
Sensory functions
Persons with stroke often experience various sensory impairments
including those affecting the visual system.67 Vision and visual
processing are also targeted for remediation by rehabilitation
professions. Unfortunately, limited research describes the preva-
lence, impact, or interventions for vision related to community
reintegration after mild stroke. Of note, there are no studies
linking visual processing remediation to mild stroke and fitness to
drive. Although large-scale randomized controlled trials (RCTs) to
support the findings of current research are warranted, the results
suggest that visual field deficits should not automatically prevent
drivers with mild stroke from driving.49
Cognitive functions
Cognitive impairments are well documented and one of the most
debilitating deficits after mild stroke.21,57,59 Although the mem-
bers of the task force are not aware of any intervention studies that
have specifically targeted remedial training of cognitive skills
after mild stroke related to resumption of driving or work, pre-
liminary conclusions can be deduced from the few RCTs on
training on the useful field of view (UFOV) system after
stroke.68,69 The UFOV program targets training of driving-related
cognitive functions that are relevant for safe driving after stroke,
including speed of processing, divided attention, and selective
attention.68 Although persons with stroke seem to benefit from
training, no superior effect of the UFOV program could be found
on cognitive function or on-road driving in those studies.68,69
Activity and participation
Impairments to body functions often limit the ability of persons
with mild stroke to complete tasks and become involved in life
situations. Interventions targeting education and skills training can
directly improve the ability of people with mild stroke to reinte-
grate into the community.
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Community reintegration after mild stroke
Education
The research suggests that adults with stroke find it beneficial to
learn about community reintegrationerelated resources and
services in the early stages poststroke.34 Therefore, the interdis-
ciplinary team should support persons with stroke by educating
them about their strengths and limitations, available resources, and
most likely path to reintegration as early as acute care and
continue through the stages of care.
In terms of driving, best evidence suggests that adults with mild
stroke should refrain from this activity during the acute phase of
stroke.27 After this driving ban, a medical clearance for driving
resumption may be issued if adults with stroke (1) show no
substantial cognitive, visual, or motor deficits; (2) are not at
significant risk of sudden recurrence; (3) have been treated for the
underlying cause of the stroke; and (4) are not at risk of epileptic
fits.27 The physician usually has the final responsibility to determine
the fitness to drive, but may consult with other relevant members of
the team, including occupational therapists, psychologists, physical
therapists, and social workers. Members of the interdisciplinary
team can educate persons with stroke on the risks of early driving
resumption, support problem-solving issues regarding trans-
portation, and facilitate conversations between family members.
In terms of return to work, adults with mild stroke should be
educated on relevant laws, regulations, programs, and resources
that support workers’ rights and return to work including the
Family Medical Leave Act 1993, Americans with Disabilities Act
1990, and the Social Security Act. An important resource for
information is the Social Security Administration’s annual Red
Book designed to provide educators, rehabilitation professionals,
and counselors with a working knowledge of the Social Security
Administration’s policies and work incentive programs.70 Also,
adults with stroke should be made aware that rehabilitation ser-
vices such as occupational therapy and/or state vocational
rehabilitation are available and can facilitate successful
reintegration into the workforce.34
Remedial training
Persons with mild stroke looking to return to driving can engage in
repeated training of driving tasks. Training can occur in simulators
or on the road. One RCT comparing the effects of simulator-based
driving intervention with paper-and-pencil cognitive interventions
found that 73% of participants who trained using a simulator passed
the driving evaluation compared with a 42% pass rate in the
cognitive interventioneonly group.71 One study examined the
benefit of training stroke survivors on the road.72 The study involved
34 first-ever stroke survivors and 20 healthy controls who all per-
formed a comprehensive driving evaluation that included a driving
test. The persons with stroke were retrained on-road for 6 hours
(nZ8) or for 12 hours (nZ7). Thirteen of the 15 stroke survivors
passed a second driving test that was administered after training and
at about 3 months after the first evaluation. The research suggests
that direct skills training either through a simulator or on the road
training can improve driving skills. Although encouraging, more
research is warranted to evaluate the effect of different intervention
strategies to improve on-road driving, driving-related cognitive
skills, and community reintegration after mild stroke.
A systematic review by Donker-Cools et al73 explored effec-
tive return-to-work interventions for those after acquired brain
injury that included studies involving adults with varied stroke
severity from mild to severe. The results of this review revealed
that effective return-to-work treatment strategies incorporate a
combination of interventions directed at the worksite, coaching
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2383
and education, and skills training. More specifically, work-related
skills training and training that addresses coping and emotional
regulation were found to be important.
Environmental factors
Another option to improve community reintegration among per-
sons with mild stroke includes environmental modifications.
Features in the car, workplace, and community can be modified to
improve the ability of the person with mild stroke to navigate the
community.74 Examples of vehicle modifications may include
automatic gear transmission, spinner knobs mounted to the
steering wheel, and left-foot accelerator pedals. Additionally, ad-
vances in automotive technology offer promising options for
people with mild stroke. For instance, the National Highway
Safety Administration ruled that by 2018, new cars weighing less
than 10,000lb will require rear visibility technology. Other tech-
nologies are emerging in highly automated vehicles and include
features that have the potential to support function and safety such
as automatically engaging brakes and vehicles that can self-steer
back into the lane if the vehicle veers off course.75,76 Although
technological advances offer exciting options for adults with mild
stroke, a dearth of evidence remains on driving with assistive
technologies among adults with mild stroke. Studies examining
the access, needs, and barriers to alternative forms of trans-
portation found that public transportation, commercial trans-
portation services, and support from family and friends are
inadequate in replacing the transportation needs of individuals
with stroke who have retired from driving.77 If driving is not a
possibility for persons with mild stroke, the rehabilitation team
can support the identification and attainment of alternate forms of
transportation.
Environmental modifications to promote success in the work-
place can include a variety of strategies such as creating quiet
spaces, reducing clutter, modifying lighting, or providing support
personnel.78 Additionally, use of everyday technology such as
memory aids, timers, voice recorders, and calendars have the
potential for enhancing work and other daily activities for in-
dividuals with stroke.79 Not only can physical environments
support persons with mild stroke, but social-political environ-
ments can as well. Ideally, employers should be involved in the
return-to-work process early and often. Research suggests that
work cultures that are supportive, flexible, and open to possible
accommodations are a positive predictor of return to work.80,81 It
is important that rehabilitation professionals evaluate the viability
of return to prior employment both initially and throughout the
recovery process,73 and support consistent communication be-
tween the adults with stroke and their employer.82 It is important
to engage the employer in the rehabilitation process,82 as reha-
bilitation work preparedness programs that are coordinated with
the worksite have improved return-to-work outcomes.47,83 A
qualitative study by Coole et al80 found that employers may have
limited knowledge as to the effects of stroke and are receptive to
education, support, and health care provider collaboration.
Occupational therapists can be key service providers who can
collaborate with employers on work activity and environmental
adaptations and work transition programs.84
Call to action
Current evidence supports a call to action in the areas of research,
policy, and practice.
2384
Fig 2 Framework for driving assessment and intervention after mild stroke.
Research
Significant research is needed around all facets of mild stroke. For
instance, specific mechanisms for how mild stroke affects function
is unclear. Medical research is needed to better understand how
mild stroke affects the brain so that more targeted interventions
can be developed. In terms of rehabilitation, practitioners need
assessments sensitive to the unique deficits experienced by per-
sons with mild stroke. Intervention research is also needed to
identify effective approaches to facilitate return to driving
and work.
Policy
Although some assessments and interventions have shown prom-
ise in persons with mild stroke, these approaches are difficult to
implement because of policy barriers within health care systems,
licensure boards, and payers. Advocacy is needed at all levels for
reimbursement of rehabilitation services that address driving and
work and that are protracted beyond usual care. The American
Medical Association has a Current Procedural Terminology code
for community/work reintegration (97537) which includes shop-
ping, transportation, money management, avocational activities
and/or work environment/modification analysis, work task anal-
ysis, use of assistive technology device/adaptive equipment.85
This specific code can be used for addressing both return to
work and driving in some persons with mild stroke. At the facility
level, managers will have to staff the rehabilitation department at
levels that support meeting the needs of all people with stroke.
Specifically related to return to driving, legislation is needed to
support on-road safety. Although several states in the United States
have developed vision requirements for driving,86 state and/or
federal legal criteria specific to driving resumption after stroke are
lacking. Clinical guidelines have been published by U.S. profes-
sional organizations such as the American Heart Association and the
National Highway Traffic Safety Association, but there is no
S.P. Burns et al
evidence-based endorsement for those clinical guidelines.87,88 The
United States should develop clear evidence-based practice guide-
lines and governmental policies for the return to driving after stroke
to ensure the safety of drivers with stroke and other road users (ie,
drivers, pedestrians, cyclists). A schematic framework for driving
evaluation and intervention after mild stroke based on best evidence
and practice is shown in figure 2. Additionally, the Health and
Wellness Task Force members refer readers to the Information/
Education Page on return to driving after mild stroke developed by
this task force to support clinical education (H. Devos, AE. Akin-
wutan, I Hong, et al, unpublished data, 2018).
Practice
While the developed community rehabilitation model is ideal, the
task force recognizes several limitations in a current health care
system that may negatively affect feasibility for application.
Therefore, this position paper is a call to action in which the
members of the task force hope researchers and interdisciplinary
practitioners will continue work in mild stroke and support future
local and national policy directions. The literature provides
guidance for recommendations, some, that can be implemented
immediately into practice and others that will require collabora-
tive interdisciplinary program planning within individual health
care systems and settings. Best practice, as currently supported by
the literature includes awareness by all members of the interdis-
ciplinary team that adults with mild stroke may experience stroke-
related impairments that can negatively affect resumption of prior
life roles but that might not be initially evident.
The Health and Wellness Task Force developed a list of action
items for interdisciplinary practitioners working with this popu-
lation across the continuum of care.
 Early conversations and education from all health care pro-
viders about the potential impact that mild stroke may have on
driving and work performance.
www.archives-pmr.org
Community reintegration after mild stroke
Fig 3 Framework for return-to-work assessment and intervention after mild stroke.
 Education by health care providers on laws, regulations, ser-
vices, and programs that protect rights and support return to
driving and return to work.
 Refer adults with mild stroke for follow-up evaluations after
discharge from acute care that address a range of deficits
important for return to work and return to driving.
 Refer adults with mild stroke who may be at risk of (based on
results of recommended postdischarge follow-up and assessments)
or are experiencing impaired work performance, to occupational
therapy for services specific to evaluation of work activities, the
work environment, and interventions that include employer
collaboration. Incorporating interdisciplinary teams is also rec-
ommended to meet the specific needs of each individual (fig 3).
 Refer adults with mild stroke who desire to return to driving, to
driving rehabilitation specialists who may comprise a range of
interdisciplinary practitioners (see fig 2). Physicians will make
Table 2 Action item goals and metrics
Action Item Goals
1. Improve community understanding of implications of mild
stroke for community reintegration
2. Facilitate opportunities for advocacy to support long-term
needs in the community among adults with mild stroke
3. Identify specific barriers and supports to implementing our
community rehabilitation practice model for addressing
community reintegration goals
www.archives-pmr.org
2385
final decisions about return to driving, but maintaining commu-
nication and collaboration between the physician and interdis-
ciplinary teams may improve decision-making processes.
 Early and sustained efforts, when possible, to involve employers in
the return-to-work process. At a minimum, this can be accom-
plished through facilitation of self-advocacy in persons with mild
stroke and/or provision of written information and resources.
 Collaboration and/or referral to state Vocational Rehabilitation
Services if returning to prior employment is not feasible.
 Establishment of interdisciplinary task forces to develop and
implement health care system/setting specific alternative
models of care and standard pathways that address driving and
work beyond traditional rehabilitation services.
Additionally, the Health and Wellness Task Force has devel-
oped a set of action item and goal metrics to continue working
Action Item Metrics
1. The Health and Wellness Task Force will develop a series of
Information/Education Pages on topics pertinent to per-
sons with mild stroke to support persons with stroke,
family, practitioner, and community understanding of mild
stroke in the community
2. The Health and Wellness Task Force will develop advocacy
resources and distribute to persons with stroke, family, and
practitioners
3. TheHealth and Wellness Task Forcewill survey practitioners,
persons with mild stroke, and family members/care partners
of persons with mild stroke to examine barriers and sup-
ports to addressing community reintegration and publish/
present findings
2386
toward implementation of the community rehabilitation model to
better meet the needs of persons with mild stroke in the com-
munity (table 2). The task force plans to address these goals within
the next 3 years.
Conclusions
Supporting persons with mild stroke in the community by
addressing return to driving and return to work will result in better
outcomes for persons with mild stroke, better quality of health
care, and improved public health. Although the processes
described in this paper may not be feasible for implementation in
the current health care climate, the primary aim of this paper was
to describe current evidence on return to work and return to
driving in adults with mild stroke. In doing so, members of the
task force realized the inherent need to propose a practice model
that would support outcomes in the context of the community by
integrating interdisciplinary community rehabilitation and
leveraging components of the Social Ecological Model and
emerging technologies. The work of the Health and Wellness Task
Force provides rationale for addressing community goals among
this complex population. Future research initiatives are necessary
among various stakeholders to support the needs of adults with
mild stroke living in the community.
Keywords
Automobile driving; Community integration; Delivery of health
care; Rehabilitation; Return to work; Stroke
Corresponding author
Suzanne Perea Burns, PhD, OTR, 99 Jonathan Lucas St, MSC160,
Charleston, SC 29425. E-mail address: sburns3@twu.edu.
Acknowledgments
The authors present this paper on behalf of the Health and Well-
ness Task Force. The task force also thanks Mrs. Amanda Frias for
her contributions to the development of this paper.
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