Driving after stroke

Evidence Reviewed as of before: 16-01-2016

Author(s)*: Angela Kim, MSc OT; Annabel McDermott OT; Nicol Korner-Bitensky, PhD

Patient/Family Information

Introduction

Return to driving is a priority for many people following stroke. For some, the stroke has affected the abilities required for safe driving. The time required before it becomes safe to resume driving varies from one person to another. In some cases the abilities may be permanently affected, making it impossible to safely resume driving. Driving rules vary depending on the region and on the specific problems encountered following the stroke.

Patient/Family Information

Author: Nicol Korner-Bitensky, PhD

Will I be able to drive after my stroke?

People recover at different rates after a stroke. Some people will be back driving after a month, others may take longer. Studies suggest that about half of those who experience a stroke return to driving. When, and if, you return to driving depends on many factors. A health professional should speak to you about driving. If no one mentions driving, it is important that you or a family member ask a health professional, possibly your doctor or an occupational therapist, for information. It is important for your safety and the safety of others that your readiness for driving be assessed.

Is there rules or regulations about driving after stroke?

While rules vary in different provinces, states and countries, most have specific time delays before an individual is permitted to resume driving after a stroke. For example, the Canadian Medical Association has specific Guidelines regarding driving that say someone who has had a stroke should not be allowed to drive for at least one month.

There are also rules about driving if you experience specific problems related to your stroke. For example, people with an impairment called homonymous hemianopsia (blindness on one side of both eyes) that may occur after a stroke, are generally not permitted to drive.

When should I be assessed for driving?

Most of the recovery takes place within the first three months after the stroke, and continues at a slower pace for months, and possibly years following the stroke. While you might be very anxious to return to driving, it is important to be assessed at the right time, once your medical condition has stabilized. You may also need to learn some new skills or practice doing specific tasks differently after your stroke. For example, if your stroke paralyzed your right leg, you may need to learn to drive using your left leg. Also try not to take your assessment if you have just started taking a new medication. Some medications may affect your driving, especially when you first begin taking them.

What is the purpose of a driving assessment?

A detailed driving assessment should be performed by a health professional with expertise in driving assessment. The individual will be evaluating you to see if:

– specific problems you are experiencing from your stroke make driving dangerous;

– you need to work on specific skills and learn new ways of driving before you take an on-road driving test or resume driving;

– you are able to drive safely but you need certain adaptations to your car and training on how to use them;

– you are able to drive safely but with certain restrictions, for example, no night driving;

– you are able to drive safely without modifications or restrictions.

Who performs a driving assessment?

A detailed driving assessment should be performed by a health professional with expertise in driving assessment. This individual is termed a driver rehabilitation specialist or driving evaluator. Most often this person is an occupational therapist with special training in driving evaluation. You should verify that the person you see has specialized training in driving evaluation.

What does a driving assessment consist of?

You may undergo a quick evaluation by a doctor or other health professional, typically an occupational therapist. Based on the result of the quick evaluation they will either consider you ready to return to driving, or indicate that you need to have a detailed driving evaluation. A detailed driving assessment usually consists of two parts – a pre-road evaluation and an on-road evaluation.

Pre-road evaluation: The pre-road evaluation usually takes place in the driving evaluator’s office. She will typically ask you about your medical history and your driving history and habits. She may assess your arm and leg movements, strength and sensation. You will also need to have a visual assessment (there are specific rules about vision and driving) and you will usually need to bring a report from a visual specialist such as an ophthalmologist. The driving evaluator may decide to do a series of paper and pencil or computer tests to evaluate, amongst other things:

how you are dealing with visual information;
how quickly you respond to situations;
how your memory is functioning;
your judgment and awareness about specific driving situations.

On-road evaluation: The on-road assessment may be done on the same day as the pre-road evaluation, or on another day. Usually you will be asked to drive a car that is equipped with a passenger side brake for safety. There may be one or two people with you in the car. The person who sits in the front seat is usually a trained driving instructor who will give you directions on what route to take. This person is usually trained to work with people who have had a stroke. They understand about the stroke and how it can affect you and your driving. The driving evaluator will typically sit in the back seat and observe your driving while taking notes. The evaluation route may include driving on quiet and busy streets and may also include highway driving. You will be asked to perform specific driving maneuvers such as left turns. The evaluator will take notes on how you are doing – for example if you are keeping in your lane, driving at the correct speed, stopping at red lights and stop signs. You may also be asked to find a specific destination using road signs.

I am really nervous about the driving evaluation

It is normal to be nervous during the evaluation. Try to do your best and focus on driving. Listen carefully to what the instructor is telling you to do and try to do each task as best as you can.

Since my stroke I have difficulty speaking or understanding people when they speak – how will I be able to follow the driving instructor’s directions?

If you have a problem understanding spoken directions because of your stroke, the instructor can show you cards with pictures on them to explain what he wants you to do. Make sure that you take the time to understand what you need to do. For example, he may show you a card that has a car turning left that he uses to let you know he wants you to turn left.

How long does a driving assessment take to complete and what do I need to do to prepare for the assessment?

A complete driving assessment usually takes about 2 hours (about 1 hour for the pre-road assessment and 1 hour on the road). This can vary depending on you and your driving evaluator.

It is important to ask about the details before you start the assessment including:

How many appointments will it take to complete the assessment?
What do I need to bring with me when I come for my appointment? For example, if you wear glasses make sure to bring them.
What, if any, medical reports do I need to bring?

Will I have to pay for the assessment?

Depending on where you live and other circumstances related to the health care system in your area, you might have to pay for the assessment. The cost for assessment can range from $300 to $700, depending on the province that you live in. There is the cost of the driving evaluator’s time and also of the driving instructor’s time and the rental of the car you will use for the evaluation. Some driving evaluators will let you use your own car.

Is there any therapy to help me prepare to return to driving?

There are very few studies that have looked at the effects of retraining driving abilities after stroke. One study found that people who had a specific problem after the stroke – visual perception problems – benefited from a specialized computer training program when practiced for 6 weeks.

What are the possible outcomes of the driving evaluation?

The test might show that the specific problems caused by the stroke make driving dangerous and that it is unlikely that you will benefit from practice or retraining. The evaluator will then recommend that you do not continue driving.

The test might show that you have specific problems that you need to work on or new ways of driving that you must learn before you resume driving. The evaluator may suggest that you take some lessons with a specialized driving instructor. This instructor is usually someone who works with people who have had a stroke.

You may need certain adaptations (for example, a special mirror) to your car and training on how to use the adaptations. If all goes well with the training you will be able to resume driving.

The test may show that you drive safely in certain situations (light traffic). The evaluator may then recommend that you have certain restrictions placed on your driver’s license. These “restricted licenses” are available in some, but not all, places. You will need to check for the specific rules where you live.

The test may show that you drive safely. The recommendation from the evaluator will be that you are licensed to drive with no restrictions.

What happens if I’m no longer allowed to drive?

Individuals with a stroke sometimes have to stop driving because of the paralysis or other problems related to the stroke. Many people find this very hard to accept. It is understandable if you feel angry or depressed about having to stop driving. It will be very important that you find help from family and friends so that you can continue your typical outings. Some communities have special transportation for those who have had a stroke. Find out about what is available in your community or ask a family member or friend to help you get information. It is important that you find ways of getting around your community – Research shows that those who stop driving after a stroke do less socializing, and are more likely to become depressed. You have probably driven people around for many years – now it is your turn to let them return the favour.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Driving is considered one of the most important activities of daily living and is highly associated with maintaining quality of life post-stroke. Individuals who have had a stroke may experience difficulties that affect their ability to drive such as physical impairments, poor visual scanning, attention, information processing speed and psychomotor skills, which can also be impaired with aging (Crotty et al., 2003). It is therefore important to screen our stroke population who is often at-risk drivers. Driving cessation post-stroke often leads to social isolation and studies have shown higher rates of depression, comorbidities and lower functional independence than individuals who resume driving post-stroke (Devos et al., 2010). Post-stroke assessment of safety to drive is necessary for many patients, with figures showing that only 30% of stroke survivors are able to resume driving following stroke (Finestone et al., 2007). Because of the significant impacts of driving cessation, a growing importance has been developing on interventions to help individuals resume driving following an acute medical condition or prolong the ability to drive in the elderly.

A systematic review by Unsworth & Baker (2014) identified the types of interventions used by Occupational Therapists (OTs) to improve on-road fitness-to-drive and the effectiveness of these interventions. The review included participants with a range of conditions (TBI, older drivers, stroke, ABI, physical and intellectual disability, SCI, and younger drivers with information processing deficits) and included 16 studies*, two of which are included in this StrokEngine module. The most commonly-used interventions were bottom-up in nature (computer-based driving simulator training, off-road skill-specific training, off-road education programmes), whereas just one intervention used a top-down approach (car adaptations/modifications). There were inconsistencies in frequency, duration and total number of sessions among studies of each intervention type. The secondary aim of the systematic review was to determine effectiveness of driving interventions: 2 of the 4 types of interventions (computer-based driving simulator training, off-road skill-specific training) showed moderate (level 1b) evidence supporting effectiveness for regaining on-road fitness-to-drive.

* Five RCTs, four pre-post tests, two case studies, two case control design, two cohort studies, and one cross-sectional design study.

Petzold et al. (2010) conducted a cross-sectional Canada-wide telephone survey of 480 Occupational Therapists (OTs) working in stroke rehabilitation to examine clinicians’ management of driving-related issues. Participants were recruited from both inpatient and community-based settings over an 18-month period. The survey used a clinical vignette to gather information from clinicians regarding their use of driving-related assessments and interventions. The frequency of use of driving-specific assessments was as low as 11% across the continuum of care with off-road driving screening the most common type of assessment. Non-driving-specific assessments (e.g. MVPT, Cognistat) were used by 59% of inpatient rehabilitation clinicians and 37% of community-based clinicians. In terms of interventions, less than 6% of respondents reported using general interventions in driving rehabilitation and only 3% of respondents used driving-specific intervention. No clinicians reported using computer game/virtual reality interventions in driving rehabilitation. Potential explanations for the lack of attention to driving-related issues post-stroke include the need for best practice standards in driving rehabilitation, clinicians’ need to prioritize post-stroke rehabilitation goals, as well as clinicians’ self-perceived lack of competence regarding driving retraining.

This module reviews evidence regarding interventions used in driving rehabilitation post-stroke and their effectiveness in regaining safe driving skills.

Results Table

View results table

Outcomes

Acute phase

No studies have reviewed driving training among patients in acute phase

Subacute phase - Simulator-based driving training

Cognitive perceptual driving skills

Not effective

One high quality RCT (Akinwuntan, et al., 2005) examined the effects of simulator-based driving training on cognitive-perceptual driving skills in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive simulator-based driving training or driving-related cognitive training, in addition to conventional rehabilitation. There were no significant between-group differences in cognitive-perceptual driving skills (evaluated using the Stroke Driver Screening Assessment dot cancellation, square matrix test direction and compass and road sign recognition subtests) at 5 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that simulator-based driving training is not more effective than driving-related cognitive training for improving cognitive perceptual driving skills in patients with subacute stroke.

On-road driving performance

Not effective

One high quality RCT (Akinwuntan, et al., 2005) and one fair quality follow-up study (Devos et al., 2010) examined the effects of simulator-based driving training on on-road driving performance in patients with subacute stroke.

The high quality RCT (Akinwuntan, et al., 2005) randomized patients with subacute stroke to receive simulator-based driving training or driving-related cognitive training, in additional to conventional rehabilitation. Driving performance was evaluated by an on-road driving evaluation that resulted in (i) a 3-class decision (fit to drive, temporarily unfit to drive, unfit to drive) and (ii) a pass/fail decision. There were no significant between-group differences in any measure of on-road driving performance at 5 weeks (post-treatment, when participants were 11-14 weeks post-stroke). However, there was a significant between-group difference in on-road driving performance at follow-up (when participants were 6-9 months post-stroke) in favour of simulator-based driving training compared to driving-related cognitive training.

The fair quality follow-up study (Devos et al., 2010) conducted a 5-year follow-up to the study by Akinwuntan et al. (2005). Participants from the original study, now with chronic stroke, were assessed for fitness-to-drive (pass/fail) based on medical, visual, neuropsychological and on-road tests. No significant between-group differences in fitness-to-drive were found at 5 years follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that simulator-based driving training is not more effective than driving-related cognitive training for improving immediate (11-14 weeks post-stroke) or long-term (5 years post-stroke) on-road driving performance among patients with stroke.
NOTE: However, simulator-based driving training was more effective than driving-related cognitive training at 6-9 months post-stroke.

Visual attention skills

Not effective

Visual attention skills – Useful Field of View (UFOV), Speed of processing, Divided attention, Selective attention

Two high quality RCTs (Akinwuntan et al., 2010; Akinwuntan, et al., 2005) examined the effect of simulator-based driving training on visual attention skills in patients with subacute stroke.

The first high quality RCT (Akinwuntan et al., 2010) randomized patients with subacute stroke to receive simulator-based driving training or non-computerized cognitive training, in addition to conventional rehabilitation. There were no significant between-group differences in visual attention skills (speed of processing, divided attention and selective attention measured by the Useful Field of View) at 5 weeks (post-treatment) or 3 months (follow-up).

The second high quality RCT (Akinwuntan, et al., 2005) randomized patients with subacute stroke to receive simulator-based driving training or driving-related cognitive training, in addition to conventional rehabilitation. There were no significant between-group differences in visual attention skills (measured using the Useful Field of View) at 5 weeks (post-treatment).

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that simulator-based driving training is not more effective than non-computerized cognitive training for improving visual attention skills in patients with subacute stroke.

Subacute phase - Useful Field of View (UFOV) training

Attention

Not effective

One high quality RCT (Mazer et al., 2003) examined the effects of Useful Field of View (UFOV) driving training on attention in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There was no significant between-group difference in attention (measured by the Test of Everyday Attention (TEA) after 20 sessions (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that UFOV driving training is not more effective than traditional computerized visual-perception training for improving attention in patients with subacute stroke.

On-road driving performance

Not effective

One high quality RCT (Mazer et al., 2003) examined the effects of Useful Field of View (UFOV) driving training on on-road driving performance in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There were no significant between-group differences in on-road driving skills (measured using a pass/fail functional driving evaluation) after 20 sessions (post-treatment).

Visual attentions skills

Not effective

Visual attention skills – Useful Field of View (UFOV) Speed of processing, Divided attention, Selective attention

One high quality RCT (Mazer et al., 2003) examined the effects of driving training using the Useful Field of View (UFOV) on visual attention skills in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There was no significant between-group difference in visual attention skills (measured using the UFOV total score and visual processing speed, divided attention and selective attention subscores) after 20 sessions (post-treatment).

Conclusion: There is moderate evidence (level 2b) from one high quality RCT that UFOV driving training is not more effective than traditional computerized visual-perception training for improving visual attentions skills in patients with subacute stroke.

Visual-perceptual skills

Not effective

One high quality RCT (Mazer et al., 2003) examined the effects of Useful Field of View (UFOV) driving training on visual-perceptual skills in patients with subacute stroke. This high quality RCT) randomized patients with subacute stroke to receive UFOV driving training or traditional computerized visual-perception training. There were no significant between-group differences in visual perceptual skills (evaluated using the Complex Reaction Timer, Motor-Free Visual Perception Test, Single and Double Letter Cancellation Tests, Money Road Map Test of Direction Sense, Trail Making Test Parts A and B, Bells test and Charron Test) after 20 sessions (post-treatment).

Chronic phase - Dynavision training

Dynavision Parameters

Insufficient evidence

One non-randomized study (Klavora et al., 1995) examined the effects of Dynavision driving training on Dynavision assessment parameters in patients with chronic stroke. This pre-post study assigned patients with chronic stroke who had failed a Behind-the-Wheel (BTW) assessment to receive Dynavision training. At 6-weeks (post-treatment) 6 of 10 participants showed a significant improvement in Dynavision driving parameters of endurance and speed. Results remained significant at 3-month follow-up.

Conclusion: There is insufficient evidence (level 5) regarding the effect of Dynavision driving training on Dynavision assessment parameters among patients with chronic stroke. However, one non-randomized study reported a significant improvement in Dynavision assessment performance.

On-road Driving Performance

Insufficient evidence

One non-randomized study (Klavora et al., 1995) examined the effects of Dynavision driving on on-road driving performance in patients with chronic stroke. This pre-post study assigned patients with chronic stroke who had failed a Behind-the-Wheel (BTW) assessment to receive Dynavision driving training. There was a significant improvement in BTW performance (measured using a subjective on-road evaluation of driving skills) among 6 of 10 participants* at 6 weeks (post-treatment). Results remained significant at 3-month follow-up.
* Participants were deemed “safe to resume driving and/or to receive on-road driving lessons”.

Conclusion: There is insufficient evidence (level 5) regarding the effect of Dynavision driving training on on-road driving performance among patients with chronic stroke. However, one non-randomized study reported significant improvement in on-road driving performance following Dynavision training.

Pre-driving skills

Insufficient evidence

One non-randomized study (Klavora et al., 1995) examined the effects of Dynavision driving training on pre-driving skills (visual processing skills, visual reaction and movement time and anticipation time) in patients with chronic stroke. This pre-post study assigned patients with chronic stroke who had failed a Behind-the-Wheel (BTW) assessment to receive Dynavision driving training. There was a significant improvement in most pre-driving skills (measured by the Simple and Choice Response Timers – response time, visual reaction time and movement time) at 6 weeks (post-treatment). Results remained significant at 3-month follow-up. There were no significant improvements in other measures of pre-driving skills (Choice Response Timer – Choice Visual Reaction Time, Bassin Anticipation Timer – anticipation time) at either time point.

Conclusion: There is insufficient evidence (level 5) regarding the effect of Dynavision driving training on pre-driving skills among patients with chronic stroke. However, one non-randomized study reported significant improvements in pre-driving skills following Dynavision training.

Chronic phase - Visual Restorative Function Training

Driving safety

Insufficient evidence

One pre-post study (Bergsma et al., 2011) examined the effects of visual Restorative Function Training (vRFT) on driving safety in patients with chronic stroke. This pre-post study assigned patients with chronic stroke and homonymous Visual Field Defect (VFD) to receive vRFT intervention using custom-built computer software. After 15 sessions (post-treatment) participants showed a significant improvement in average speed (measured using the STISIM driving simulator), but there was no significant change in other STISIM simulator measures of driving safety (number of collisions, number of pedestrians hit, number of times speed was exceeded, percentage of total distance driving out of lane).

Conclusion: There is insufficient evidence (level 5) regarding the effect of visual Restorative Function Training on driving safety in patients with chronic stroke. One non-randomized study reported improvements in driving speed following visual Restorative Function Training, but no significant change in other measures of driving safety.

Oculomotor behaviour

Insufficient evidence

One pre-post study (Bergsma et al., 2011) examined the effects of visual Restorative Function Training (vRFT) on oculomotor behaviour (eye movements/saccades) in patients with chronic stroke. This pre-post study assigned patients with chronic stroke and homonymous Visual Field Defect (VFD) to receive vRFT intervention using custom-built computer software. Two of nine patients showed significant increase in saccades in the direction of the visual field defect after 15 sessions (post-treatment).

Conclusion: There is insufficient evidence (level 5) regarding the effect of visual Restorative Function Training on oculomotor behaviour in patients with chronic stroke. One non-randomized study reported improvements in 2 of 9 patients following visual Restorative Function Training.

Visual field defect border shift

Insufficient evidence

One pre-post study (Bergsma et al., 2011) examined the effects of visual Restorative Function Training (vRFT) on Visual Field Defect (VFD) border shift in patients with chronic stroke. This pre-post study assigned patients with chronic stroke and homonymous Visual Field Defect (VFD) to receive vRFT intervention using a custom-built computer software program. Two of nine patients showed significant improvement after 15 sessions (post-treatment) with VFD border shift of ≥ 5 degrees towards the affected visual field, and four patients showed average shifts of 2-5 degrees towards the affected visual field at post-treatment.

Conclusion: There is insufficient evidence (level 5) regarding the effect of visual Restorative Function Training on visual field defect border shift in patients with chronic stroke. One non-randomized study reported improvements in 6 of 9 patients following visual Restorative Function Training.

Phase of stroke not specified - Dynavision training

Driving Self-Efficacy

Not effective

One high quality RCT (Crotty et al., 2009) examined the effects of Dynavision driving training on driving self-efficacy in patients with stage of stroke not specific to one period. This high quality RCT randomized patients to receive driving training using the Dynavision or no intervention. There were no significant between-group differences in driving self-efficacy (measured by the Adelaide Driving Self-Efficacy Scale) at 6 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that Dynavision training is not more effective than no intervention for improving driving self-efficacy in patients with stage of stroke not specific to one period.

On-road Driving Performance

Not effective

One high quality RCT (Crotty et al., 2009) examined the effects of Dynavision driving on-road driving performance in patients with stage of stroke not specific to one period. This high quality RCT randomized patients to receive Dynavision driving training or no intervention. There were no significant between-group differences in on-road driving performance (measured using a standardized pass/fail on-road driving test) at 6 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that Dynavision training is not more effective than no intervention for improving on-road driving performance in patients with stage of stroke not specific to one period.

References

Akinwuntan, A.E., De Weerdt, W., Feys, H., Pauwels, J., Baten, G., Arno, P., & Kiekens, C. (2005). Effect of simulator training on driving after stroke: A randomized controlled trial. Neurology, 65(6), 843-850. http://www.ncbi.nlm.nih.gov/pubmed/16186521

Akinwuntan A.E., Devos H., Verheyden, G., Baten, G., Kiekens, C., Feys, H. & De Weerdt, W. (2010). Retraining moderately impaired stroke survivors in driving-related visual attention skills. Topics in Stroke Rehabilitation, 17(5), 328-36. http://www.ncbi.nlm.nih.gov/pubmed/21131257

Bergsma, D. P., Leenders, M. J. A., Verster, J. C., van der Wildt, G. J., & van den Berg, A. V. (2011). Oculomotor behavior of hemianopic chronic stroke patients in a driving simulator is modulated by vision training. Restorative Neurology and Neuroscience, 29(5), 347-359. http://www.ncbi.nlm.nih.gov/pubmed/21811023

Crotty M. & George S. (2009). Retraining visual processing skills to improve driving ability after stroke. Archives of Physical Medicine & Rehabilitation, 90(12), 2096-102. http://www.ncbi.nlm.nih.gov/pubmed/19969174

Devos, H., Akinwuntan, A. E., Nieuwboer, A., Ringoot, I., Van Berghen, K., Tant, M., … & De Weerdt, W. (2010). Effect of simulator training on fitness-to-drive after stroke: A 5-year follow-up of a randomized controlled trial. Neurorehabilitation and Neural Repair, 24(9), 843-850. http://www.ncbi.nlm.nih.gov/pubmed/20656965

Finestone, H. M., Guo, M., O’Hara, P., Greene-Finestone, L., Marshall, S. C., Hunt, L., … & Jessup, A. (2010). Driving and reintegration into the community in patients after stroke. PM&R, 2(6), 497-503. http://www.ncbi.nlm.nih.gov/pubmed/20630436

Klavora, P., Gaskovski, P., Martin, K., Forsyth, R. D., Heslegrave, R. J., Young, M., & Quinn, R. P. (1995). The effects of Dynavision rehabilitation on behind-the-wheel driving ability and selected psychomotor abilities of persons after stroke. American Journal of Occupational Therapy, 49(6), 534-542. http://www.ncbi.nlm.nih.gov/pubmed/7645666

Mazer, B.L., Sofer, S., Korner-Bitensky, N., Gelinas, I., Hanley, J., & Wood-Dauphinee, S. (2003). Effectiveness of a visual attention retraining program on the driving performance of clients with stroke. Archives of Physical Medicine and Rehabilitation, 84(4), 541-50. http://www.ncbi.nlm.nih.gov/pubmed/12690593

Marshall, S. C., Molnar, F., Man-Son-Hing, M., Blair, R., Brosseau, L., Finestone, H. M., … & Wilson, K. G. (2007). Predictors of driving ability following stroke: A systematic review. Topics in stroke rehabilitation, 14(1), 98-114. http://www.ncbi.nlm.nih.gov/pubmed/17311796

Petzold, A., Korner-Bitensky, N., Rochette, A., Teasell, R., Marshall, S., & Perrier, M. J. (2010). Driving poststroke: Problem identification, assessment use, and interventions offered by Canadian occupational therapists. Topics in stroke rehabilitation, 17(5), 371-379. http://www.ncbi.nlm.nih.gov/pubmed/21131262

Unsworth, C. A., & Baker, A. (2014). Driver rehabilitation: A systematic review of the types and effectiveness of interventions used by occupational therapists to improve on-road fitness-to-drive. Accident Analysis & Prevention, 71, 106-114. http://www.ncbi.nlm.nih.gov/pubmed/24906164