Driving: A lifestyle choice

Reasons for driving

Driving has become a major part of our lives and tends to both reflect and govern our lifestyles.

We adapt our social lives through driving and the ability to drive has broadened our horizons. For many the ability to drive is a fundamental part of their occupation, and therefore an important component of their financial, as well as emotional wellbeing. It provides self-esteem or self identity (what car do you drive?) and can both facilitate and actually be a pleasurable activity or hobby.

 

Losing the ability to drive can bring about low self esteem, social isolation or even financial hardship.

Given the social importance of driving, and how much we take it for granted, it is perhaps necessary to remind ourselves of what a complex and interactive activity it is.
Driving requires reasonable physical integrity (although current developments in driving aids and adaptations may compensate) but it is perhaps following neurological or brain injury that more catastrophic problems can arise. Damage to the senses, particularly vision, can simply be the tip of the iceberg when we consider associated disorders of balance, awareness, attention and planning, to say nothing of temper control. Judgement and thought are often thought to be important components of driving but how do we define these concepts? Such factors are common sequelae of brain injury and other neurological disorders. Unlike visual impairment or physical handicap they are not immediately or obviously apparent, but their impact on driving can be extreme.

Driving is possibly the most complicated skill acquired by humans and while it may seem that like riding a bicycle, once mastered, it is never forgotten, this ignores the fact that driving is an ongoing skill with the brain computing millions of functions in a constantly changing environment.

Illness or Neurological impairment of driving ability

Various illnesses, such as traumatic brain injury, acquired brain injury, epilepsy, multiple sclerosis or motor neurone disease, together with the medications required for their management, can bring about fatigue, attentional problems and reduced stamina, in tandem with various cognitive, sensory, physical, communicational and behavioural anomalies and all their complex interactions.

As noted by Hawley (2005) there are a number of features related to driving common in differing types of brain injury:

  • Gaps in concentration. You may be easily distracted, get muddled when there is a lot going Reduced ability to read the road or work out what is happening in complex situations. For example you may not notice a stop sign.
  • Reduced ability to reach the right decision in time, or to correctly gauge such things as speed and distance. Some people can't foresee the consequences of actions or situations.
  • Slow reactions.
  • Reduced ability to control temper.

As will be seen, these disabilities will not be immediately obvious and therefore professionals working with neurological injury must be alert to the possibility of "invisible" problems that may impair driving skills and be in a position to provide suitable assessment.

Assessment of driving skills

Generally speaking, the best way to assess a complex cognitive sensorimotor skill is to observe its performance, but clearly the potentially dangerous "invisible" impairments could be hazardous in the real world. Ecological validity or real life assessment must be balanced with risk assessment. A comprehensive neurological, cognitive, physical, functional and behavioural assessment should inform any professional when assisting in rehabilitation and offering guidance regarding a return to driving following neurological injury or impairment. However given the importance generally attached to driving in our society a return to driving may be considered as an important goal, if consistent with road safety.

An informed assessment may lead on to more realistic practise, such as in off road situations or simulators. An important part of this process must be an awareness of generalisation of skills acqusition, such as when driving different vehicles, or different types of vehicles such as bicycles. Of course an apparently faultless drive in low density traffic in a well known area may not be replicated safely in high density, novel traffic situations. Perhaps more importantly we should be aware that skilled driving is not just monitoring our own actions but also those of often unpredictable others.

Remediation of driving skills

It should not be beyond the skills of a resourceful rehabilitation specialist to assist those wishing to regain driving skills through, for example, appropriate adaptations.

Cognitive rehabilitation and the development of suitable strategies, possibly developed through the combined efforts of an Occupational Therapist and Neuropsychologist, could well play a part. This could lead on to formal driving lessons which could give further feedback to the rehabilitation process. The fact that driving is such a complex skill raises the question as to whether successful remediation of driving skills would have a generalising effect to other cognitive skills apart from driving? There also remains the interesting question of the presumably differing demands of learning to drive following brain or neurological injury (for the first time) and relearning driving skills previously acquired.

Naturally all enthusiastic rehabilitation professionals should be aware of DVLA guidelines (www.dft.gov.uk/dvla/medical.aspx) , but given the significance of driving in our society we should be able to assess and safely rehabilitate driving skills, particularly where an inability to drive could force either premature retirement from employment or reduced social networks and associated low self esteem. It is widely recognised that maintaining social networks reduces the risk of depression and enhances well being.

As Classen et al (2009) suggest in their Traumatic Brain Injury and Driving Assessment: An Evidenced Based Literature Review, to assist clinicians in making decisions regarding testing the driving performance of people with brain injury or other neurological problems they recommend a formidable battery of neuropsychological tests, off-road tests, self-report, other report, post injury disability status and comprehensive driving evaluation. Given the damage that can be caused by driving skill failure, this seems entirely reasonable and professionally appropriate.

References

Classen, S et al. ( 2009) Traumatic Brain Injury and Driving assessment: An Evidenced-Based Literature Review, AJOT, Vol 63, pp 580-591

Hawley, C A (2005) Return to driving after severe brain injury: a British perspective http://go.warwick.ac.uk/wrap

Declan McNichol

Bill Young

Angela Gordon

Birgit Rathje-Vale

Helen Smart