Return to drive after non-evolutive brain damage: French recommendations

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Return to drive after non-evolutive brain damage: French recommendations Anne-Claire D’apolito a,*, Jean-Luc Leguiet b, Michel Enjalbert c, Francis Lemoine d, Jean-Michel Mazaux e a

Hoˆpital R.-Poincare´, AP–HP, 104, boulevard Raymond-Poincare´, 92380 Garches, France CMRRF Kerpape, 56270 Ploemeur, France USSAP/ASCV/Centre Bouffart-Vercelli, 66290 Cerbe`re, France d Centre He´liot-Marin, 06223 Vallauris, France e Universite´ et centre hospitalier universitaire de Bordeaux, 33000 Bordeaux, France b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 20 April 2016 Accepted 15 April 2017

Return to drive after brain damage is a crucial question either for patients than health professionals. The Socie´te´ franc¸aise de medicine physique et de re´adaptation (SOFMER) and Come`te France association developed recommandations for patient’s identification, evaluation and accompaniment as part of their project to resume to drive. The place of rehabilitation process and patient’s focus has been also discussed. Aims: Using a literature review, the aim was to define clinical pathways to determine people who need a fitness to drive evaluation after a non-evolutive brain damage as well as the assessment process. Method: Following the method for Clinical practice guidelines, 1388 abstracts were identified, among which 379 were analysed and confronted with the working group’s experience. The draft propositions were submitted to a review group before being validated by the High French Health Autority. Result: No article enabled the development of recommendations above the ‘‘expert opinion’’. The detection of sensory (visual), sensitive, motor and/or cognitive sequelaes is needed before return to drive. It is not recommended to return to drive in case of unilateral spatial neglect. Different assessment strategies, function of sequeale’s gravity, are proposed after stroke or brain injury. In case of sequeale, the assessment process (clinical, cognitive, on road evaluation) has to be pluriprofessional. The results are the subject of a pluriprofessional synthesis, shared with the patient and, if possible, in the presence of a close. An accompaniment to maintain the best mobility of the person is needed, whatever the assessment result.

C 2017 Elsevier Masson SAS. All rights reserved.

Keywords: Automobile driving Recommendations Acquired brain damage Traumatic brain injury Stroke

1. Introduction Driving is considered an essential activity for autonomy as well as social and occupational participation. It is a complex activity required motor, sensory and cognitive functions, and thus it can become impaired following brain damage. Even though there is no absolute consensus in the literature, several studies have shown an increase in car accidents in persons with traumatic brain injury (TBI) [1–3]. This risk was evaluated as 2 to 3 times higher than in the general population by Formisano et al. [4]. Thus, raising issues on the impact of sensory, functional and cognitive sequelae on the Abbreviations: HAS, French National Authority for Health; NPABD, non-progressive acquired brain damage; TBI, traumatic brain injury; UFOV, useful field of view. * Corresponding author. E-mail address: [email protected] (A.-C. D’apolito).

driving abilities of persons with non-progressive acquired brain damage (NPABD), such as traumatic brain injury (TBI), cerebral anoxia, and encephalitis. Laws vary according to the different countries. In France the law of December 18, 2015 mentions the regulatory contraindications (epilepsy, homonymous hemianopsia) along with pathologies or symptoms requiring a fitness to drive medical certificate, however the evaluation modalities of this fitness to drive remain imprecise. For this reason, the SOFMER as well as other concerned interest groups and scientific societies decided to elaborate good practices guidelines in order to help healthcare professionals better inform and support their patients while abiding by the laws and regulations in place, and harmonizing the decisions of physicians able to deliver those fitness to drive certificates (In France, they are called certified physicians). The objective of this article is to present these guidelines.

http://dx.doi.org/10.1016/j.rehab.2017.04.001 C 2017 Elsevier Masson SAS. All rights reserved. 1877-0657/

Please cite this article in press as: D’apolito A-C, et al. Return to drive after non-evolutive brain damage: French recommendations. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.04.001

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2. Method Guidelines presented in this article stem from a work conducted according to the good practices recommendations designed by the French National Authority for Health [5]. A steering committee, representing the various organizations and scientific societies promoting the project, elaborated 5 questions to which the guidelines had to bring an answer, as well as defining exclusion criteria (regulatory contraindications to driving a vehicle, heavy or occupational vehicles, persons who did not have a driving license prior to their injury, progressive brain damage such a dementia and brain tumors). A working group (15 persons) analyzed the literature (according to the level of evidence and the usual criteria), and elaborated a guideline proposal was submitted to an independent reading group (61 members) before writing the guidelines, submitted to the French National Authority for Health and validated in January 2016 (Appendix 1). The analysis of the literature was conducted from keywords concerning, driving, pathologies and healthcare professionals involved (Appendix 2). The databases used for this analysis were Medline, Science direct, Ric, NORART, Narcis, OTSeeker, SpeechBite, PsycBite, National Health and Medical Research Council, ISOCPsicologia, PsyIndex, PEDRO, EMBASE, Reedoc, and the Cochrane Library as well as websites publishing recommendations and accident report on this topic.

In all, 1388 abstracts were identified, 379 analyzed and 221 retained (Fig. 1). A rationale containing all the literature references is available on the co-promotors website (Appendix 1). 3. Results Studies were analyzed and are presented here in answer to 5 questions elaborated by the steering committee. Overall, the level of evidence was quite low, and only the expert opinion level (level 5) was attributed to the 47 guidelines from this review of the literature (Appendix 3). 3.1. How to identify people whose pathology might impact their driving? (Appendix 3: R1–10) French law, through a decree passed on 08/31/2010 amended by the decree of 12/18/2015 lists certain pathologies, such as TBI, or stroke (including transient ischemic attack) that require an assessment by a certified physician before resuming any driving [6]. Regarding the other neurological pathologies (encephalitis, brain anoxia), the need for consulting with a certified physician depends on the pathology-related symptoms and it becomes necessary in case of permanent movement coordination disorders, muscle strength or muscle control impairments or the presence of cognitive or psychiatric disorders. It is stated that the certified

Definion of research criteria with the help of the HAS librarian

1388 abstracts

Abstracts (in English or French) menoning specifically the pathologies studied (TBI, stroke, meningoencephalis, brain anoxia)- Merging the choices of the 2 readers

YES

NO

379

1009

Data related to: -

French laws and regulaons Evaluaon process of driving capacies Accident incidence and rates YES

221

NO

158

Fig. 1. Flow chart.

Please cite this article in press as: D’apolito A-C, et al. Return to drive after non-evolutive brain damage: French recommendations. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.04.001

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physician can request an expert advice to help in reaching a decision. This is why each physician should contribute to identifying potential neurological sequelae and inform patients on the potential impact of these sequelae on their ability to drive. Changes in driving behaviors reported in clinical cases [7,8] results from study on accident frequency rate according to the NPABD (Table 1), and the existence of symptoms that are hard to detect in a medical consultation (anosognosia or unilateral spatial neglect) require a reflection on the modalities needed to discriminate the persons who should be evaluated [9]. 3.1.1. Traumatic brain injury (Appendix 3: R3–5) The recommended required criteria for a multidisciplinary evaluation of driving abilities (including medical, functional, cognitive evaluations as well as a hands-on driving evaluation) vary according to the different countries [10–12]. Canada recommends such an evaluation as long as there are sensorimotor and/or cognitive sequelae or an impact of pain and/or implemented treatments [13]. The Canadian Medical Association alerts physician to the fact that the initial severity of TBI is often insufficient to

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determine if the cognitive sequelae will be problematic. Any sign indicating post-traumatic amnesia collected during the medical interview should alert physicians to the possibility of cognitive disorders and require a comprehensive evaluation of driving abilities [10]. It is recommended that a multidisciplinary evaluation of driving abilities be systematically proposed in case of moderateto-severe TBI, when the patient expresses the wish to resume driving. The issue of mild TBI remains debated. Here again, practices vary from one country to the next. The duration of the contraindication to drive vary between 3 to 24 hours (in light of the presence or not of initial loss of consciousness) in New Zealand, 48 hours minimum for Canada, and even up to symptoms’ stabilization or resolution in the US [10,12,14]. Two studies reported the impact of mild TBI, one on the reaction time to emergency situations, the other on the driving abilities on a simulator, both showed significantly lower performances in the slight TBI group than in the control group, such as an increased in the braking distance by 7.5 km when going 60 km/h [15,16].

Table 1 Controlled studies regarding risk of traffic accident following stroke or traumatic brain injury (Source = PUBMED). Authors

Population

Judgment criteria

Results

Commentary

Cyr, 2009 Canada

17 patients with moderate to severe TBI who passed their driving ability assessment without need for adjustment Time since injury > 1 year Vs. 16 age-matched controls 50 stroke patients from PRM units time since injury > 6 months Vs. 105 controls

Number of crashes in the simulator in multiple task conditions

Higher rate of simulated crashes in TBI patients than in controls (P < 0.05)

No correlation with a higher rate of crashes in real-life driving conditions

Numbers of self-reported crashes and offences

Data non related to distance performance No information on resuming driving conditions

Haselkorn, 1998 USA

6896 hospitalized TBI patients compared to 4369 hospitalized orthopedic patients and to 2409 hospitalized persons for appendicitis

Number of crashes registered in a driving license database

Number of crashes higher in stroke patients (8%) than in controls (6%) Number of offences higher in stroke patients (8%) than in controls (5.7%) P = 0.113 No significantly enhanced rate of crashes in the year following the hospitalization RR (95% CI) = 0.8 (0.6–1)

Haselkorn, 1998 USA

1910 stroke patients vs. 3732 ageand gender-matched controls

Numbers of crashes 1 year before and 1 year after the stroke

RR = 0.8 (CI 95%: 0.6–1)

Lundqvist, 2008 Sweden

38 patients with acquired brain damage (24 TBI patients and 14 stroke patients) Vs. 49 controls (27 for TBI patients and 22 for stroke patients) 1583 TBI drivers involved in crashes Vs. 1583 controls matched on age, gender, car speed, and crashes in urban vs. rural areas)

Numbers of crashes registered at the insurance company/non registered crashes

40 TBI patients, including 31 mild with PTA < 5 min, 5 mild with PTA > 5min, 4 moderate with PTA 1–24 h mean time since injury = 7.13 years Vs. 40 controls CA on average in both groups 40 TBI drivers out of 47 TBI patients with driving ability assessment in PRM units within the last 5 years Mean time since injury: 2.14 years Vs. 22 controls free from neurological impairment and who were driving since at least 1 year

Numbers of crashes and offences

Number of registered crashes significantly higher in braindamaged patients (n = 9, 28%) than in controls (n = 5, 10%) (P = 0.041) 13.7% of TBI drivers involved in multiple crashes, (25.6% of crashes) TBI drivers are significantly more involved in multiple crashes than controls (P < 0.001) Mean rate crash/person higher in TBI patients (0,60) than in controls (0.33) (P < 0.05) Mean rate offence/person non significantly different in TBI patients (0.65) and in controls (0.50) (P = 0.226) Number of registered crashes non significantly higher in TBI patients than in controls (10 vs. 6, OR = 0.89) Number of non-registered crashes significantly higher in TBI patients than in controls (16 vs. 7, OR = 1.43) Number of situations at risk significantly higher in TBI patients than in controls (8 vs. 12, OR = 0.21)

Fisk, 2002 USA

Neyens, 2012 USA

Schneider, 2005 USA

Schultheis, 2002 USA

Number of multiple car crashes

Numbers of registered/ non registered crashes Number of situations at risk

Rough rates non provided No information on TBI severity, length of stay in hospital, resuming driving conditions, distance performed in the year, and existence of non-registered crashes No information on stroke severity and on conditions of returning to drive Number of non-related crashes to distance performance No information on TBI severity and decision process after assessment Number of crashes non related to distance performance Self-reported data Data dependent on the quality of police reports. Lack of information about conditions of returning to drive Self-administered questionnaire Small samples size CA on average

Lack of information about TBI severity and on decision process after assessment Number of crashes non related to distance performance selection biases

TBI: traumatic brain injury; PRM: physical and rehabilitation medicine; PTA: post-traumatic amnesia; CA: cognitive assessment.

Please cite this article in press as: D’apolito A-C, et al. Return to drive after non-evolutive brain damage: French recommendations. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.04.001

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This is why the working group recommended that any person presenting with mild TBI waits 24 hours before driving again, and this person should consult a physician if symptoms persist. 3.1.2. Strone and Transient ischemic attack (Appendix 3: R6–8) In the French law, TIA is a cause for temporary driving interruption (without any precise duration) and medical validation by a certified physician is required before resuming driving. In the literature, durations of driving cessation after TIA vary from 15 days to 3 months [10,11,13,14]. In light of the risk of recurrence, but also the socio-professional impact, the working group proposed a 15-day delay before getting the advice of the certified physician in order to resume driving. After stroke, time before resuming driving varies from 1 month (New Zealand) to 6 months (Belgium) [14,17]. The type of evaluation necessary to resume driving is also quite heterogeneous: a systematic comprehensive evaluation in Belgium, when there is the slightest doubt about a person’s ability in New Zealand, a systematic evaluation in case of moderate to severe sequelae even with mild impairment in the US [10,12,14,17]. For stroke with or without minor impairments, the working group recommended a 15-day driving cessation associated to a systematic screening consultation to identify potential sequelae. For moderate to severe stroke (defined by the need for rehabilitation care after the initial hospitalization), recommendations are a one-month driving cessation and systematic multidisciplinary evaluation of driving abilities. 3.1.3. Other pathologies (Appendix 3: R11–12) No specific study was found in the literature. Only guidelines form New Zealand and Canada bring up these pathologies and consider them like TBI. 3.2. How to evaluate the driving abilities in the identified population? 3.2.1. Which functions should be evaluated? (Appendix 3: R13–16) There is a consensus in the literature on functions to evaluate, in general in reference to the model published by Michon, describing the driving activity as a cognitive process based on 3 hierarchical levels (strategic, tactical and operational) and analyzes all functions needed to drive safely [18–21]. Thus, the literature underlines the relevance of evaluating:  visual functions, especially visual acuity and the peripheral binocular visual field since at least 90% of the information required to drive comes from visual functions [12–14,22,23]; the Goldman perimetry-type measure is recommended to assess the peripheral binocular visual field;  sensorimotor functions and their impact on functional abilities [11,13,22,23];  cognitive functions: simple and complex reaction times, attention, executive functions, self-awareness of disorders, visuospatial construction abilities, memory [10–13,22,23];  language (expression/oral and written comprehension for road signage) [23,24]. Regarding attentional functions, Heikkila¨ et al. showed a correlation between driving ability and sustained attention in 20 stroke patients [25]. Schanke et al. reported that visuospatial attention was a discriminating element in determining the aptitude to drive in a population of 55 persons with brain lesions [26]. This study underlined the issue of unilateral spatial neglect, which in the literature is very often considered as a reason for being unfit to drive [17,27,28,24,29]. If some authors accept to put patients with neglect in a driving situation, Akinwuntan et al.

showed that they all drove on one side of the road only and lack the adequate visual perception in complex situations [27]. 3.2.2. Which evaluation tools should be used? 3.2.2.1. Clinical and functional evaluation tools (Appendix 3: R17). Some autonomy in daily life scales were studied as predictive factors for resuming driving, such as the Barthel index for Stroke of the Functional Independence Measure for TBI, without being able to demonstrate evidence of their relevance in these populations [7,25,30,31]. 3.2.2.2. Cognitive evaluation tool (Appendix 3: R18–19). Several tools are brought up in the literature as being useful for a quick evaluation of all cognitive functions required to drive. The Montre´al Cognitive Assessment is considered as the most valid tool and can be easily administered in clinical practice to screen for cognitive disorders, which would justify an additional evaluation [32,33]. Yet, it is the Stroke Drivers’ Screening Assessment, specific to the driving itself, which remains the most studied in stroke patients. Results are interesting, in particular to evaluate the relevance of a real-life driving evaluation after mild stroke, however, to date, no version is validated in the French language [17,18,27,34–36]. Batteries of tests (30–60 minutes) were developed by different authors [37,38]. Several studies highlighted the predictive values of certain tests, according to the pathology, without being able to identify a threshold value, or permitting to avoid performing a ‘‘real-life’’ on road driving evaluation to determine driving abilities after NPABD. One can refer to the meta-analysis by Devos et al. that identified 5 cognitive tests significantly correlated with driving abilities post-stroke: the copy of cube test, Road Sign Recognition, Compass, Stroke Drivers’ Screening Assessment and TMT-B [39]. Akinwuntan et al. showed that the negligence subtest of the TAP is one of the 3 best tests for predicting capacities during an on-road driving test in different studies [26,40] as well as on a simulator [41] for a stroke  TBI population. No predictive value was found for persons with TBI [7]. UFOV study’s results are in favor of a predictive value for on-road driving evaluation for moderate to severe TBI [42]. Other tests, such as the Motor-free Visual Perception Test, Benton VRT, some sub-tests of the WAIS were predictive on driving abilities in 1 or 2 studies [26,37,38,43]. 3.2.2.3. Driving abilities evaluation tools (Appendix 3: R20–26). To date, on-road driving evaluation is the gold standard. It is recommended in New Zealand, Australia and the US [11,12,14,22]. It was further validated by a Belgian team, using as a comparison the results from the Stroke Drivers’ Screening Assessment and the conclusions from both assessors [35]. It is recommended that this evaluation be performed in diverse environments in order to be confronted to several different driving situation. Several evaluation grids, such as the Test Ride Investigate Practical fitness to drive, were proposed but no threshold value was identified [27,28,34]. This is why no evaluation scale could be recommended. Only observation criteria were proposed [12,36]. Regarding the evaluation on a driving simulator, very few studies are available. They are most often conducted on a low sample of patients, with different tools and scenarios. The review of literature by Lew et al. identified 7 studies comparing driving simulator and on-road driving in person with brain injuries [44]. Among them, five concerned TBI, and found a moderate to high concordance between driving performances on a simulator and on-road evaluation. In their review of the literature Classen et al. identified only one Grade-2 study on 11 persons with moderate to severe TBI and 16 controls. If authors showed that persons with TBI exhibited lower performances compared to controls, and fond a significant correlation with their driving

Please cite this article in press as: D’apolito A-C, et al. Return to drive after non-evolutive brain damage: French recommendations. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.04.001

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performances on the long term (evaluated by their closed ones after at least a 3-hour observation period of their driving performance), the authors also concluded that data obtained from the simulator were not redundant with on-road driving results. Classen et al. concluded that this unique study brought insufficient evidence to establish the ecologic validity of simulators in this population [45]. This is why the working group did not recommend to use exclusively the driving simulator to evaluate driving abilities in persons with brain injuries. 3.2.3. Which professional competencies are required? (Appendix 3: R27–28) There is consensus stating that these evaluations must be a multidisciplinary one [46]. The role of the physician in the clinical evaluation is recommended in Australia and Canada [10,11,13]. The functional evaluation is most often done by occupational therapists or Certified Driving Rehabilitation Specialists (CDRS), a specialty non-existent in France [13,16,19,30]. The cognitive evaluation is mainly performed by neuropsychologists [8,25,26,24,34,40]. The main argument promoting the presence of a teaching instructor is that the latter is responsible from the instructions and ensuring the safety of the driving vehicle with dual control while the occupational therapist notes the person’s driving abilities [36,46]. Akinwuntan et al. showed that an evaluator who does not have to ensure the safety of the driving vehicle performs a better observation of the person’s driving abilities [28]. 3.2.4. Which synthesis of all these evaluations should be performed? (Appendix 3: R29–33) The complex process of the final decision is rarely described in the literature. Taking into account elements giving information on a person’s driving history (driving experience, number of km/year, history of driving citations/accidents, and the duration of the driving cessation) is recommended in the US and underlined by several authors [23]. In the Australian recommendations, the decision takes into account all the elements of the evaluation, based on the correlations between the clinic and the abilities observed during the on-road evaluation [11]. Results of the cognitive evaluation can help understand the difficulties observed during that same evaluation [41]. Several authors consider that the need for a physical intervention of the driving instructor on the wheel and/or the pedals to ensure the safety of the vehicle or other persons on the road, or to prevent dangerous behaviors are negative elements for resuming driving [47,48]. The American Medical Association recommends that physicians take a decision only at the end of the comprehensive evaluation [12]. Several authors highlight the importance of a multidisciplinary synthesis before making the final decision [17,26,27,35,49,50]. 3.3. What is the place of the rehabilitation process after driving abilities’ evaluation? (Appendix 3: R34–35) Different rehabilitation processes are brought up in the literature. In the US on-road rehabilitation training can be proposed, as long as its objectives were correctly determined and readjusted if necessary, without any time line recommendation. However, the absence of visible improvement after 3 or 4 consecutive training sessions should lead to interrupting this rehabilitation process [23]. Results from the meta-analysis by Devos et al. are encouraging since the success rate on the on-road evaluation for stroke patients who benefited from on-road rehabilitation training was significantly better than subjects who received classic cognitive rehabilitation training. [39]. However, this rehabilitation training would seem to be specifically useful for persons without anosognosia, and for whom the initial on-road evaluation was declared ‘‘borderline’’ [18,46].

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In case of a negative multidisciplinary evaluation, the working group recommended to inform the person that a specific training in a driving center could be looked at, without guaranteeing its effectiveness. If the person decides to go ahead with this training, it is recommended that the total duration not exceed 10 hours and that it could be interrupted in the absence of improvements after a few sessions. Rehabilitation training on a simulator is seldom used, even though several professionals find it useful [29,51]. The randomized-controlled study by Akinwuntan et al., on a population of 83 stroke patients, highlighted the significant positive impact of rehabilitation on a driving simulator at 6 months [17]. However, this improvement is no longer significant in the study by Devos, with a 5-year follow-up [34]. The review of the literature by Lew et al. does not bring proof of the effectiveness of this type of rehabilitation training post TBI, but it does however underline the relevance of the simulator regarding the patients’ awareness of their condition, rehabilitation of attentional and visual exploration functions [44]. The Cochrane review stated that there was no sufficient evidence to conclude to the relevance of rehabilitation to improve the driving abilities of stroke patients [52]. 3.4. What type of support should be implemented for these evaluated populations? (Appendix 3: R36–37) 3.4.1. When the evaluation deems that the person is fit to drive Only scarce data are available in the literature. Only the American Medical Association recommends a specific support for persons whose evaluation stated that their driving abilities were compatible with resuming driving [12]. This support includes choosing the necessary adaptations and their modalities as well as delivering information on the available financial aids. 3.4.2. When the evaluation deemss that a person cannot resume driving American et Canadian guidelines insist that the evaluation process should not be limited to the evaluation of driving abilities, but also include a support program when the results of the evaluation are negative and the person cannot resume driving [10,12]. Authors all agree on this point and recommend a practical support, in relations with the occupational therapists, to help them use alternatives to driving a car. The randomized study by Logan et al., showed a significant improvement of the number of days spent outside the home for the 86 persons with TBI supported by trained occupational therapists [53]. The implementation of psychological support is also brought up by several authors and a study by Liddle showed that this type of support was expected from patients with TBI [21,29,49,54]. 3.5. What is the role of the person throughout this process? (Appendix 2: R38–47) Patients, just like their closed ones and healthcare professionals, report the lack of information available on the consequences of brain injury on driving abilities (regulations, sequelae and their potential impact, evaluation process, support) [54,55]. This probably contributes to explaining the high rate (up to 80%) of persons able to resume driving without any prior evaluation [20,31]. Thus, in Australia just like in the US, it is recommended to deliver written recommendations and guidelines, summing up all the elements involved in the resuming driving process [22,23]. When patients are evaluated, qualitative studies bring up the difficult life experience of these persons especially on an emotional level (irritation, anger, anxiety, confusion) [49,56–58]. If the relevance of the evaluation process is validated in case of a positive

Please cite this article in press as: D’apolito A-C, et al. Return to drive after non-evolutive brain damage: French recommendations. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.04.001

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evaluation [49,59], a negative evaluation triggers feelings such as sadness, anger, or even the fact of being unfairly treated or unhappy [49,54,56]. A correlation with depression was brought up by Legh-Smith, but was not found when the authors adjusted for age and the Barthel index [34,60]. Finally, family members do not feel they are getting enough support, faced with the aggressiveness and the anger of the person with brain injury [54]. In Canada, it is recommended that the evaluation feedback takes place with a family member, using empathy and ensuring that a written report of all the discussions related to this topic are noted on the patient’s medical chart [10]. As such, it is recommended to deliver orally and in writing to patients the elements related to regulations, medical issues (consequence of the brain injury on the driving abilities and its potential evolution; the evaluation and rehabilitation process) or social (technical aids available to maintain mobility). It will be important specifically focus on how these elements will be delivered, in order to adapt them to the patient’s needs and expectations but also to the clinical context. 4. Discussion Faced with the very low numbers of randomized controlled studies and the low level of evidence from most studies available, the guidelines and recommendations from this work are only at the expert opinion level. As such they are designed to guide physicians. It is necessary to develop further studies with a good methodological quality in this area, especially in France, since the different rules and regulations most often do not allow to transpose the results from foreign studies to the French context. Regarding evaluation tools, and despite of its relevance, the Stroke Drivers’ Screening Assessment could not be recommended since no validated French version is available. The validation of this tool in French, and the study of its relevance in a French population would be essential to improve clinical prediction and reduce the number of comprehensive driving ability evaluations for persons with minor brain injuries. The debate on the place of the driving simulator or on-road evaluation in determining driving abilities according to NPABD is very interesting. If the on-road evaluation remains the Gold standard today, conducting studies to compare the predictive values of these methods on driving performances, especially in terms of accident rates, remain essential. The publication of these recommendations on resuming driving after NPABD should contribute to informing healthcare professionals and patients, especially in case of TIA, while harmonizing evaluation practices. One might wonder if there are enough personnel and means in France to perform these multidisciplinary evaluations within a reasonable time frame. The costs of the evaluations and their related reimbursement need to be assessed. Finally, the psychological impact of the evaluation process and even more so the decision to stop driving (on the short or long term) is acknowledged in the literature. It would certainly be important to continue the care management efforts in this field, which implies not only healthcare professionals but also political decisions in terms of maintaining the mobility of persons who do not have the necessary capacities to ensure their safety and the safety of other on the road. 5. Conclusion The study of the literature confirmed the complexity of the issue of resuming driving after non-progressive acquired brain damage. This review of the literature enabled to elaborate guidelines to promote the dissemination of information regarding the French laws and the duties of each person (healthcare

professionals and citizens). It also helped to harmonize professional practices all over France. The low number of studies but especially their low level of scientific evidence underlines the need for conducting new research projects, on accident incidence as well as evaluation tools. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements Authors would like to thank the following:  associations and scientific societies, as well as members who represented them within the steering committee, who are;  l’association Come`te France,  le Colle`ge National Professionnel – Fe´de´ration Franc¸aise de Me´decine Physique et de Re´adaptation,  l’Institut Franc¸ais des Sciences et Technologies des Transports, de l’Ame´nagement et des Re´seaux,  la Socie´te´ Franc¸aise de me´decine Physique et de re´adaptation;  all healthcare professionals and patients associations’ representatives who contributed to the design of the HAS recommendations (see Appendix 1);  as well as Dr Laurence and Mrs. Andre´-Vert for their support all along this project.

Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.rehab.2017.04. 001.

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Please cite this article in press as: D’apolito A-C, et al. Return to drive after non-evolutive brain damage: French recommendations. Ann Phys Rehabil Med (2017), http://dx.doi.org/10.1016/j.rehab.2017.04.001