After a stroke, a person usually has a long road of rehabilitation ahead of them before they can get back to their “normal life”. One of the first things they want to know is when they can get behind the wheel again. As therapists, this is not usually the first question that comes to our minds. We are too busy breaking down their current disability into all its various impairments, so we can make appropriate goals and piece things together in order to help them become more independent with moving around and with basic needs of daily life. However, to the patient…driving is often something that will make or break how they perceive the quality of their life after recovery from a stroke.
After a CVA, there are several abilities that should be intact in order to be cleared to return to driving. Here, we discuss the skills needed to return to driving post-stroke, and some considerations you may want to think about, as a clinician.
Return to driving after a stroke is a topic you may continuously educate your client about. Keep in mind, that all along the rehab journey, you may use the impairments observed in your patient as opportunities to educate them about the return to driving process. You don’t want to avoid the subject or wait until the very end of their stay to talk about it. For example, if they are unable to feel their right lower leg, you could say… “Mr. Smith, remember since we normally use our right foot to operate the pedals in the car, this could be one of the challenges to overcome before you’re able to get back on the road. We will continue to monitor it here and facilitate recovery, but if you still have this impairment by the time you think you’re ready to drive… we may need a driver rehab specialist to look into what modifications are available to ensure everyone’s safety.” (Rinse and repeat for any other impairment.) OK – let’s dive in!
Stroke Impairments that will affect driving ability:
This may seem like an obvious barrier to on-road driving, but we must ensure that our patients have adequate cognitive skills after stroke recovery to handle the predictable and unpredictable conditions that pop up during a road trip.
Attention/Concentration: There are so many distractions for any driver on the road… When you mix in a variety of impairments that come along with stroke, it’s a whole new ball game! If your patient has impairments in attention, they are most likely not going to be successful with any part of driving a vehicle. Sustained attention is needed to keep our eyes on the road, keep our foot on the gas pedal at a certain pressure, wait for the light to turn green, etc. If your patient has impairments in sustained attention, they will most likely not be able to focus on those basic pieces of driving just listed. They will be easily distracted and will not be able to effectively complete the task. Selective attention while driving may come into play when driving through a heavy rainstorm or hale storm. Being able to tune out the visual and auditory stimuli of those severe weather conditions and being able to maintain focus on operating the vehicle is essential! A combination of alternating and divided attention happens throughout the process of driving. At times, the driver will need to use divided attention and “pay attention” to many different things all at once (i.e. – oncoming traffic, operating the turn signals or wipers, listening to the radio or GPS, etc.) and at other times one will need to use alternating attention (i.e. – looking both ways before turning left, where your full attention needs to be placed on looking left, then looking right). As you can see, without intact attention… driving will be almost impossible!
Memory: Do you remember how to drive? Do you remember where you turned? Will you remember to take your keys out of the car? So many things to remember! One main thing to consider when talking about memory and return to driving after stroke, is if the person can remember the modifications or different safely recommendations that you or other clinicians may be making after their stroke. They may be able to remember the “normal” way of doing things, however after a stroke there are usually many modifications to daily life that are being recommended.
Decision making/Problem Solving/Judgement: Being able to make appropriate decisions and problem solve through unforeseen situations while driving is crucial! The light turns yellow… you must determine if you have enough time to go through or if you should stop. The car in front of you is going too slowly… you must decide if it is safe to pass them. You have a quarter tank of gas left… you must decide the best time to stop for gas. The car in front of you stops short… you must decide if swerving to the shoulder is the right move. The list goes on!
Strength & Range of Motion: Stroke often leaves people with asymmetrical strength, sometimes limited range of motion, and even atypical tone (either hyper or hypo). If their right leg has been affected, their ability to push on the gas and brake pedals and move between them will be impaired. Steering the wheel with one hand is certainly possible, but there are many things to consider regarding training and modification in order to make this safe. And a consideration for anyone getting behind the wheel (post-stroke or otherwise) is their ability to adequately turn their head to look in their blind spot.
Sensation & Proprioception: Imagine that feeling you get when you sit on your foot too long and it completely “falls asleep”. Now imagine you immediately hop in the driver’s seat and attempt to accelerate up to a stop sign then slow down and come to a stop… without the ability to feel your foot or where it may be located. It would be challenging to say the least… and that is just the tip of the ice burg of what a person may be experiencing after stroke.
Balance & Coordination: You may have great strength and flexibility. You may be able to feel every inch of every limb. But when you try to move your foot from the gas pedal to the brake pedal… you over or undershoot every time. When you try to make a smooth turn with the steering wheel, the movements are choppy and not uniform. You can imagine how this would impact safe driving!
Reaction Time: Along with being able to place your foot directly on the brake pedal when needed, a driver needs to complete this maneuver quickly at times. There’s a certain amount of anticipation that occurs with braking, however we cannot always predict if someone will stop suddenly in front of us, or if a car pulls out to turn without looking, or if a pedestrian or animal wanders out into the road. All of these circumstances require a driver to react quickly! After stroke, processing of sensory information and assessment of the environment may be a bit slower… and therefore production of the needed motor response with also be delayed. Adequate reaction time is needed to ensure safety of everyone involved… and seconds count!
Visual Acuity: Many people drive and wear glasses. Requiring correction of vision does not eliminate anyone as a driver, however after stroke we would want to make sure that vision is still adequate to see everything necessary to drive safely. Street signs, GPS, pedestrians, lines on the road, other cars, and anything else in the environment… we all have to be able to see what we are doing and what is ahead of us and around us. Visual acuity requirements to drive vary by state, so make sure to know what your state requires in order to assist your patients to assess baseline and get an idea of where they stand.
Visual Fields (Peripheral vision): Depending on where the stroke occurs, it could bring with it some other visual difficulties, such as field cuts. There are already certain areas considered to be “blind spots” in driving… however is a person’s visual fields are not all intact this will leave them with a larger “blind spot” they may have to compensate for. When we drive, most of our visual attention is forward, on the road ahead. But it is important to be able to rely on peripheral vision to alert us of danger and see things coming in order to act appropriately.
Oculomotor function: As mentioned above, most of the time we are looking straight ahead while we drive. However throughout the time a driver is behind the wheel, they are required to quickly move eyes from one target to another (saccades), stay focused on a street sign while the car is in motion (smooth pursuit), or stay focused on any number of things in the environment while the car is moving and/or their head is moving (VOR). If a patient has any kind of oculomotor dysfunction after stroke, they will not last very long in the driver seat without becoming dizzy or nauseous.
What’s the next step to getting behind the wheel?
Provide Preliminary results:
As you can see, there are many roadblocks a person can have to getting back to driving after stroke. Many times, clinicians will defer to the physician when patients ask if they can start driving again. And this is mostly due to simply not knowing how to answer the question. But, if you break it down by impairment, you really can provide the patient with a lot of useful information! Become familiar with what rehab driving school will be assessing and start to work on the areas that your patient struggles with. Many of the things looked at are the impairments listed above. Then talk to your patient about where they may fall short. Be open and honest about what you are seeing and encourage them to follow up with a rehab driving school to determine if there are any modifications related to their specific impairments that would be appropriate.
Refer to Driver Rehab:
Rehab driving school is where you will find the experts… the Driver Rehab Specialists. A Driver Rehab Specialist is a professional who plans, develops, coordinates, and implements driving services for individuals with disabilities. This could be a member of the allied health community or a driving instructor who has taken courses related to the field or obtained a credential in driving rehab. A great resource to find an OT Driver Rehab Specialist has been put together by the AOTA. Information about where to find driving school and Driver Rehab Specialists (including general information about the credential) can be found on the Association for Driver Rehabilitation Specialists website. Read this insightful article for more information, if you are interested in becoming a Driver Rehab Specialist.
When it comes to getting our patients back to living their best lives, we can always take a step toward their goals… driving included! Start with what you know. Evaluate their abilities post-stroke, and educate them about what is generally needed for driving. Then drill down to where they may struggle most and refer them on to the experts for a more comprehensive assessment and recommendation.
For more great ways to help your patients meet their goals after stroke, check out our course ‘Inpatient Stroke Rehab: 14 Strategies to get your Patient Home.’ This powerful and practical 7- credit course will supercharge your practice with those post-stroke, and help you get the most desired outcomes possible!