Occupational therapy driving assessment outcomes, life space, and on-road driving rehabilitation post acquired brain injury

The effectiveness of rehabilitation following acquired brain injury (ABI) may be measured in terms of community participation and integration (Levack, Kayes, & Fadyl, 2010). Return to driving is an avenue through which integration and participation goals such as independent living, social engagement and return to work can be achieved (Norlander et al., 2016) and psychological morbidity such as loneliness, depression and diminished life satisfaction can be reduced (Griffen, Rapport, Coleman Bryer, & Scott, 2009). This project will explore the life space experience of people referred for occupational therapy driver assessment (OTDA) following ABI in ways not previously explored. The research project has three aims. Firstly, to investigate life space after acquiring a brain injury prior to and following comprehensive OTDA so as to explore whether this process may enhance, restrict, or have no impact on community access and community participation. Secondly, to investigate the efficacy of on-road driving rehabilitation following ABI not only in achieving medical fitness to drive but in maintaining that status at follow-up. Finally, the research aims to explore potential relationships between driving status, driving rehabilitation and psychosocial aspects of adjusting to life following ABI in terms of self awareness, driving self efficacy and depression. Knowledge gained will provide understanding as to how the process of OTDA, irrespective of outcome, may impact upon life space following ABI. Following consent process, demographic data will be collected at point of recruitment and all participants will complete a life space travel diary over a two-week period to record the frequency, destination and purpose of travel outside the home to quantify and define the geographical space of activities undertaken and the Life Space Assessment tool. A semi-structured interview will be conducted at the conclusion of the data collection period for every third participant with a member of the research team either face-to-face or over the phone to capture qualitative aspects of life space. Interviews will be audio-recorded with consent and transcribed for analysis to elaborate, enhance, clarify and contextualise qualitative factors influencing community access from the participant perspective. All participants will then receive a baseline comprehensive OTDA with the outcome of that assessment determining their pathway. Occupational Therapy driving assessments (OTDA) in Australia are undertaken by occupational therapists with advanced training and post-graduate qualifications in the field (Fields, Unsworth & Harreveld, 2018). OTDA consist of two main components: an off-road evaluation and an on-road driving assessment. The off-road review provides opportunity for the therapist to understand the participant’s current functioning across a range of domains identified as underpinning safe and effective driving. These include consideration to the individual’s past driving experience and anticipated future driving goals, medical status, visual, physical and cognitive function and behavioural aspects (Fields et al., 2018). If indicated, the evaluation progresses to the implementation of an on-road assessment where functional analysis of the individual’s capacity to operate a vehicle, negotiate the driving environment and interact with other road users can occur. The session is completed on an open road route, in a dual control vehicle with the participant driving the vehicle, the driving instructor positioned in the front passenger seat with access to dual controls and the occupational therapist positioned in the rear passenger seat. It is the driving instructor’s role to provide directions to the participant and to ensure safe passage of the vehicle. The occupational therapist observes and records the person’s driving performance across a diverse range of road and traffic conditions (Unsworth, 2007; Mallon & Wood, 2004; 2018 Fields et al., 2018). Current evidence supports this comprehensive off- and on-road driving assessment process as the “gold standard” in evaluating medical fitness to drive (Paillat, Massonneau, Azouvi, & D’Apolito, 2015). In the first pathway, the participants who are deemed fit to resume driving or not medically fit to resume driving, will be asked to repeat the life space measure at 6 month follow-up and will then exit the study. In the second pathway, participants who are recommended to receive on-road driving rehabilitation will enter into an embedded randomised controlled trial that has had previous feasibility testing (Bassingthwaighte, Griffin, Fleming, & Gustafsson, 2019) and will be randomly assigned to an intervention or wait-list control group to receive the on-road driving rehabilitation. For the intervention group, an individualised on-road driving remediation program devised by the driver trained occupational therapist and delivered by a qualified driving instructor experienced in working with people with medical conditions in a dual control car over a period of 4 to 8 weeks, at a frequency of 1-2 lessons/week for a duration of 50 minutes/session. The duration of the driving remediation program is determined by the occupational therapist conducting the initial OTDA and is related to the number and significance of driving skills/performance requiring address based upon clinical reasoning. Following each driving lesson, the participant and driving instructor will independently complete a brief questionnaire concerning driving conditions encountered and perceived driving performance. The post-intervention OTDA will be completed within 2 weeks of completing the on-road driving remediation intervention. The wait-list control group will receive no driving related remediation for a period of 6 weeks. This group will then complete a second OTDA prior to receiving on-road remediation program. All participants will complete a post intervention OTDA and a 6 month follow up OTDA and repeat measurement of life space.