RESNA 27th International Annual Confence
Methodology for Using a Simulator to Assess and Improve the Driving of Individuals after Brain Injury
The long-term goal of this research effort is to investigate the effectiveness of a high-quality interactive driving simulator to safely assess and improve the driving abilities and quality of life of individuals following stroke and traumatic brain injury. Returning these people to driving satisfies the rehabilitation goals of community re-entry and independence.
Brain injury, stroke, driving, assessment, training, simulator
Driving ability is an essential component of activities of daily living for many individuals and one of the determinants of level of independence. Driving requires a complex of skills and abilities, including mobility, vision, visual-motor coordination, and multiple levels of cognitive function. Neurologic impairments, including traumatic brain injury (TBI) and cerebrovascular accident (CVA) can significantly decrease an individual's cognitive and motor function and hamper one's driving ability (1). Disabled veterans, including those undergoing rehabilitation, are entitled by Public Law 93-538 to have the opportunity to pursue a return to driving.
In support of veterans' efforts to regain driving proficiency, the VA Palo Alto Health Care System (VAPAHCS) performs driving evaluations and training for patients with traumatic brain injury, stroke, and other disabling conditions. However, these in-car activities create potentially hazardous situations for veterans with impaired cognitive function and driving skills, their instructor, and other cars, pedestrians, and property. Although an on-the-road test is the gold standard to decide whether or not the individual could drive safely, it is essentially subjective and lacks a standardized scoring system. An objective and standardized method of assessment would be preferable. In this study, the efficacy of using a computer-based driving simulator to provide objective data on driving ability and driving-related cognitive function will be investigated, with the intent that this approach could be used by the rehabilitation team to assess the safety and appropriateness of individuals with brain injury to return to driving. The primary goal of this effort is to measure the effectiveness of a driving simulator in the assessment and training of veterans with a brain injury who are pursuing a return to driving. Improved driving ability will reduce the incidence of on-road accidents and injury in these veterans, as well as provide an increased level of independence for daily living, thus enhancing their quality of life (2).
Computer technology can play an important role in assessing, predicting, and improving the driving ability of individuals with brain injury. A driving simulator is an interactive computer-based system that presents the user with a realistic visual, aural, and biomechanical driving experience without motion or a car. It can produce driving performance profiles similar to actual driving (3). The current generation of high performance computer-based driving simulators has the potential to safely assess and improve the driving skills of individuals following a brain injury.
The research study will employ a computer-based driving simulator to assess and improve the driving ability of VA patients following TBI or stroke. A simulator can increase the number of patients who can be trained by providing a realistic driving experience in an indoor clinical setting. It can also be an important tool in evaluating and determining the physical and mental capabilities of all types of disabled patients. The advance of computer and display technology now make it possible to achieve a high level of driving realism in current simulators, which, in turn, should provide an accurate means of assessing driving skills (4). The data acquisition capability of the driving simulator will provide objective and quantitative information on the patient's assessment performance and improvement during training.
The subject population will consist of veterans and active duty military personnel who have suffered a TBI or CVA and who are pursuing a return to driving. (See inclusion/exclusion criteria below.) Their visual and motor functions will be assessed, and those who pass will have their driving performance evaluated first on the simulator and then on-road. Four groups will be created, each consisting of 10 CVA and 30 TBI subjects. The first group will consist of individuals who pass the on-road evaluation. They will establish baseline performance data. The second group will consist of patients who fail the on-road evaluation and are judged "untrainable" by the driving evaluator. Patients who fail the on-road evaluation and are judged "trainable" will be randomized into two additional groups. (Past experience indicates that approximately 75% of those who fail the on-road evaluation are judged trainable.) The group that passes the on-road evaluation will receive no training. The "untrainable" group will undergo simulator training. One of the "trainable" groups will receive simulator training while the other will receive on-road training. Finally, upon completion of training, subjects will have their driving performance re-evaluated both with the simulator and on-road. Outcome measures, including subjective scores from the on-road driving evaluation, objective data from the simulator, responses from the Driving Questionnaire (IRB approved), neuropsychological tests, and the SF-36 ® Health Survey, will be administered twice, once when they are enrolled and after they finish all assessment and training sessions. All subjects will have their driving record reviewed and their driving re-assessed after 6 months.
This project has just begun: the driving simulator has been delivered and the road courses are being created for the evaluation and training portions of the study. By the summer of 2004 the first round of subjects will have been tested. Data and results from the first six months of the project will be presented at the conference.
If the proposed driving simulation program proves effective and efficacious, the findings will be transferred into clinical rehabilitation practice by: a) submitting a paper to the Journal of Rehabilitation Research and Development, b) considering deployment of this system to other VA and non-VA driving programs through multi-center trials and technology transfer activities and c) evaluating the potential benefits of the simulator with other patient populations.
The Department of Veterans Affairs, Rehabilitation Research and Development Service, is funding this research (Project B3288R).
David L. Jaffe, MS
VA Palo Alto Health Care System
3801 Miranda Ave., MS-153
Palo Alto, CA 94304
650/493-5000 ext 6-4480
jaffe@roses.stanford.edu