Original article| Volume 96, ISSUE 3, P440-446, March 2015

Predictors of On-Road Driver Performance Following Traumatic Brain Injury

Published:October 11, 2014DOI:



      To examine assessment outcomes and factors associated with passing an occupational therapy (OT) on-road driver assessment after traumatic brain injury (TBI).


      Retrospective analysis of outcomes of on-road driver assessment completed by persons with TBI over an 8-year period.


      Inpatient and outpatient rehabilitation hospital.


      A consecutive sample of individuals (N=207) with mild to severe TBI who completed an on-road driver assessment and were assessed at least 3 months postinjury.


      Not applicable.

      Main Outcome Measure

      Outcome of on-road driver assessment.


      Of the drivers with TBI, 66% (n=137) passed the initial on-road driver assessment (pass group), whereas 34% (n=70) required on-road driver rehabilitation and/or ≥1 on-road assessment (rehabilitation group). After driver rehabilitation, only 3 participants of the group did not resume driving. Participants who were men, had shorter posttraumatic amnesia (PTA) duration, had no physical and/or visual impairment, and had faster reaction times were significantly more likely to be in the pass group. In combination, these variables correctly classified 87.6% of the pass group and 71.2% of the rehabilitation group.


      PTA duration proved to be a better predictor of driver assessment outcome than Glasgow Coma Scale score. In combination with the presence of physical/visual impairment and slowed reaction times, PTA could assist clinicians to determine referral criteria for OT driver assessment. On-road driver rehabilitation followed by on-road reassessment were associated with a high probability of return to driving after TBI.


      List of abbreviations:

      AIC (Akaike information criterion), GCS (Glasgow Coma Scale), PTA (posttraumatic amnesia), TBI (traumatic brain injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Novack T.A.
        • Labbe D.
        • Grote M.
        • et al.
        Return to driving within 5 years of moderate-severe traumatic brain injury.
        Brain Inj. 2010; 24: 464-471
        • Rapport L.J.
        • Hanks R.A.
        • Bryer R.C.
        Barriers to driving and community integration after traumatic brain injury.
        J Head Trauma Rehabil. 2006; 21: 34-44
        • Kreutzer J.S.
        • Marwitz J.H.
        • Walker W.
        • et al.
        Moderating factors in return to work and job stability after traumatic brain injury.
        J Head Trauma Rehabil. 2003; 18: 128-138
        • Ponsford J.
        • Sloan S.
        • Snow P.
        Traumatic brain injury: rehabilitation for everyday adaptive living.
        2nd ed. Psychology Pr, East Sussex (UK)2012
        • Hopewell C.A.
        Driving assessment issues for practicing clinicians.
        J Head Trauma Rehabil. 2002; 17: 48-61
        • Tamietto M.
        • Torrini G.
        • Adenzato M.
        • Pietrapiana P.
        • Rago R.
        • Perino C.
        To drive or not to drive (after TBI)? A review of the literature and its implications for rehabilitation and future research.
        Neurorehabilitation. 2006; 21: 81-92
        • Marshall S.C.
        • Gilbert N.
        Saskatchewan physicians' attitudes and knowledge regarding assessment of medical fitness to drive.
        CMAJ. 1999; 160: 1701-1704
        • Ortoleva C.
        • Brugger C.
        • Van der Linden M.
        • Walder B.
        Prediction of driving capacity after traumatic brain injury: a systematic review.
        J Head Trauma Rehabil. 2012; 27: 302-313
        • Classen S.
        • Levy C.
        • McCarthy D.
        • Mann W.C.
        • Lanford D.
        • Waid-Ebbs J.K.
        Traumatic brain injury and driving assessment: an evidence-based literature review.
        Am J Occup Ther. 2009; 63: 580-591
        • Pietrapiana P.
        • Tamietto M.
        • Torrini G.
        • Mezzanato T.
        • Rago R.
        • Perino C.
        Role of premorbid factors in predicting safe return to driving after severe TBI.
        Brain Inj. 2005; 19: 197-211
        • Dimarco F.
        • Cantagallo A.
        Safe driving after traumatic brain injury.
        Eura Medicophys. 2001; 37: 215-225
        • Hawley C.A.
        Return to driving after head injury.
        J Neurol Neurosurg Psychiatry. 2001; 70: 761-766
        • Fisk G.D.
        • Schneider J.J.
        • Novack T.A.
        Driving following traumatic brain injury: prevalence, exposure, advice and evaluations.
        Brain Inj. 1998; 12: 683-695
        • Formisano R.
        • Bivona U.
        • Brunelli S.
        • Giustini M.
        • Taggi F.
        Driving competence after severe brain injury: a retrospective study.
        Eura Medicophys. 2001; 37: 257-266
        • Korteling J.E.
        • Kaptein N.A.
        Neuropsychological driving fitness tests for brain-damaged subjects.
        Arch Phys Med Rehabil. 1996; 77: 138-146
        • Brown A.W.
        • Malec J.F.
        • McClelland R.L.
        • Diehl N.N.
        • Englander J.
        • Cifu D.X.
        Clinical elements that predict outcome after traumatic brain injury: a prospective multicenter recursive partitioning (decision-tree) analysis.
        J Neurotrauma. 2005; 22: 1040-1051
        • Kosch Y.
        • Browne S.
        • King C.
        • Fitzgerald J.
        • Cameron I.
        Post-traumatic amnesia and its relationship to the functional outcome of people with severe traumatic brain injury.
        Brain Inj. 2010; 24: 479-485
        • van Zomeren A.H.
        • Brouwer W.H.
        • Rothengatter J.A.
        • Snoek J.W.
        Fitness to drive a car after recovery from severe head injury.
        Arch Phys Med Rehabil. 1988; 69: 90-96
        • Korner-Bitensky N.
        • Bitensky J.
        • Sofer S.
        • Man-Son-Hing M.
        • Gelinas I.
        Driving evaluation practices of clinicians working in the United States and Canada.
        Am J Occup Ther. 2006; 60: 428-434
        • Coleman R.D.
        • Rapport L.J.
        • Ergh T.C.
        • Hanks R.A.
        • Ricker J.H.
        • Millis S.R.
        Predictors of driving outcome after traumatic brain injury.
        Arch Phys Med Rehabil. 2002; 83: 1415-1422
        • Brouwer W.H.
        • Withaar F.K.
        Fitness to drive after traumatic brain injury.
        Neuropsychol. 1997; 7: 177-193
        • Lew H.L.
        • Poole J.H.
        • Lee E.H.
        • Jaffe D.L.
        • Huang H.C.
        • Brodd E.
        Predictive validity of driving-simulator assessments following traumatic brain injury: a preliminary study.
        Brain Inj. 2005; 19: 177-188
        • Cyr A.A.
        • Stinchcombe A.
        • Gagnon S.
        • et al.
        Driving difficulties of brain-injured drivers in reaction to high-crash-risk simulated road events: a question of impaired divided attention?.
        J Clin Exp Neuropsychol. 2009; 31: 472-482
        • Duquette J.
        • McKinley P.
        • Mazer B.
        • et al.
        Impact of partial administration of the cognitive behavioral driver's inventory on concurrent validity for people with brain injury.
        Am J Occup Ther. 2010; 64: 279-287
        • Bliokas V.V.
        • Taylor J.E.
        • Leung J.
        • Deane F.P.
        Neuropsychological assessment of fitness to drive following acquired cognitive impairment.
        Brain Inj. 2011; 25: 471-487
        • Di Stefano M.
        • Macdonald W.
        Australian occupational therapy driver assessors' opinions on improving on-road driver assessment procedures.
        Am J Occup Ther. 2010; 64: 325-335
        • Fox G.K.
        • Bowden S.C.
        • Smith D.S.
        On-road assessment of driving competence after brain impairment: review of current practice and recommendations for a standardized examination.
        Arch Phys Med Rehabil. 1998; 79: 1288-1296
        • Di Stefano M.
        • Macdonald W.
        On-the-road evaluation of driving performance.
        in: Pellerito J. Driver rehabilitation and community mobility: principles and practice. Elsevier Mosby, St Louis2006: 255-274
        • Di Stefano M.
        • McDonald W.
        Advanced strategies for on-road driver rehabiliation and training.
        in: Pellerito J. Driver rehabilitation and community mobility: principles and practice. Elsevier Mosby, St Louis2006: 297-308
        • Jones R.
        • Giddens H.
        • Croft D.
        Assessment and training of brain-damaged drivers.
        Am J Occup Ther. 1983; 37: 754-760
        • Shute R.H.
        • Woodhouse J.M.
        Visual fitness to drive after stroke or head injury.
        Ophthalmic Physiol Opt. 1990; 10: 327-332
        • Bush B.A.
        Validation of a model for evaluating outcome after traumatic brain injury.
        Arch Phys Med Rehabil. 2003; 84: 1803-1807
        • D’apolito A.C.
        • Massonneau A.
        • Paillat C.
        • Azouvi P.
        Impact of brain injury on driving skills.
        Ann Phys Rehabil Med. 2013; 56: 63-80
        • Austroads
        Assessing fitness to drive for commercial and private vehcile drivers.
        4th ed. Austroads, Sydney2012
        • Marosszeky N.
        • Ryan L.
        • Shores E.
        • Batchelor J.
        • Marosszeky J.
        The PTA protocol: guidelines for using the Westmead Post-Traumatic Amnesia (PTA) Scale.
        Wild & Wooley, Sydney (Australia)1997
        • Roads Corporation (Vic)
        Competency standards for occupational therapy driver assessors.
        OT-Australia Victoria, Melbourne1998
      1. POLA criteria. VicRoads, Melbourne1999
        • Johnson J.B.
        • Omland K.S.
        Model selection in ecology and evolution.
        Trends Ecol Evol. 2004; 19: 101-108
        • Labbe D.R.
        • Vance D.E.
        • Wadley V.
        • Novack T.A.
        Predictors of driving avoidance and exposure following traumatic brain injury.
        J Head Trauma Rehabil. 2014; 29: 185-192
        • Sommer M.
        • Heidinger C.
        • Arendasy M.
        • Schauer S.
        • Schmitz-Gielsdorf J.
        • Hausler J.
        Cognitive and personality determinants of post-injury driving fitness.
        Arch Clin Neuropsychol. 2010; 25: 99-117
        • Priddy D.A.
        • Johnson P.
        • Lam C.S.
        Driving after a severe head injury.
        Brain Inj. 1990; 4: 267-272
        • Schulte T.
        • Strasburger H.
        • Muller-Oehring E.M.
        • Kasten E.
        • Sabel B.A.
        Automobile driving performance of brain-injured patients with visual field defects.
        Am J Phys Med Rehabil. 1999; 78: 136-142
      2. Transport Accident Commission. Transport Accident Comission safety statistics. 2010. Available at: Accessed January 2014.

        • Schultheis M.T.
        • Matheis R.J.
        • Nead R.
        • DeLuca J.
        Driving behaviors following brain injury: self-report and motor vehicle records.
        J Head Trauma Rehabil. 2002; 17: 38-47
        • Schanke A.K.
        • Rike P.O.
        • Molmen A.
        • Osten P.E.
        Driving behaviour after brain injury: a follow-up of accident rate and driving patterns 6-9 years post-injury.
        J Rehabil Med. 2008; 40: 733-736
        • Galski T.
        • Ehle H.T.
        • McDonald M.
        • Mackevich J.
        Evaluating fitness to drive after cerebral injury: basic issues and recommendations for medical and legal communities.
        J Head Trauma Rehabil. 2000; 15: 895-908
        • Bivona U.
        • D'Ippolito M.
        • Giustini M.
        • et al.
        Return to driving after severe traumatic brain injury: increased risk of traffic accidents and personal responsibility.
        J Head Trauma Rehabil. 2012; 27: 210-215
        • Rapport L.J.
        • Bryer R.C.
        • Hanks R.A.
        Driving and community integration after traumatic brain injury.
        Arch Phys Med Rehabil. 2008; 89: 922-930