DRIVING AFTER CONCUSSION

Driving is one of the most complex cognitive and physical tasks performed daily by adults and older adolescents. Safe driving requires a high degree of concentration, executive processing, visual-spatial skills/fine motor skills, reaction time, information processing, and memory. Transient impairments due to acute or persistent concussion symptoms in any of these domains may make patients with postconcussive symptoms unsafe on the road, putting themselves and others on the road at risk.1-3 Despite high-quality guidance related to safely returning to physical and cognitive activities, such as sport, school, work, and military duty, evidence to support driving competency following concussion is weak or nonexistent. As driving is related to autonomy and may be required for income, healthcare, and family responsibilities, without clear guidance, concussion healthcare professionals may be reticent to transiently restrain this activity.

POSTCONCUSSION CARE

An important element of concussion recovery in patients of all ages is the resumption of social, cognitive, and physical activities in a safe manner that facilitates continued recovery. The current consensus among concussion experts and clinicians is that concussion is best managed by prescribing an initial 24 to 48 hours of rest, followed by a gradual stepwise return to cognitive and physical activities.4-6 While resumption of noncontact aerobic exercise can improve the recovery trajectory, returning to activities that put the patient at risk for another concussion (eg, full-contact sport practices, sport game play, unpredictable environments) requires medical clearance.

WHEN IS IT SAFE TO RESUME DRIVING WHILE RECOVERING FROM CONCUSSION?

Without a strong evidence base, current clinical guideline recommendations related to returning to driving are subjective and based on weak evidence:

Advise to avoid driving during the first 24-48 hours after a concussion. Advise patients to begin driving when they are feeling improved, can concentrate sufficiently to feel safe behind the wheel, and when the act of driving does not provoke significant concussion symptoms. Level of Evidence: C (Consensus, usual practice, opinion or weaker-level evidence).4

A clear guide or standardized objective assessment to determine when it is safe for adolescents and adults to resume driving following a concussion is not available. Medical clearance for driving is often overlooked or avoided during the postconcussion medical examination and often absent from patient education handouts related to concussion recovery.7,8 Without transparent expectations, drivers and those with whom they share the road may be at risk due to premature driving postconcussion and/or may be hesitant to report a concussion.9 Others may have unnecessary prolonged avoidance from driving despite the fact that they are physically capable of driving and would benefit psychosocially from the resumption of this activity of daily living.

CRITICAL RESEARCH PRIORITIES TO HELP DEVELOP CLINICAL GUIDELINES

Evidence-based clinical guidelines and expert consensus statements standardize the diagnosis and management to improve outcomes for those with concussion. Guideline recommendations are informed by peer-reviewed publications and enable an evidence-based approach for treating and managing concussion.3,5 The paucity of studies assessing driving recommendations postconcussion results in a serious gap in evidence-based concussion management. Studies need to evaluate driving competency postconcussion to determine whether there is an association between (1) self-reported symptom burden and (2) objective physiological (ie balance, visual tracking, orthostatic vitals) and cognitive deficits (eg, processing speed, memory, reaction time). Studies should also specifically address safe driving following concussion in older adolescents to ensure that safe recommendations can be made to the pediatric population.

In most high-income countries, motor vehicle injuries are the leading cause of death and serious injury in teens and young adults. As clinicians and scientists committed to evidence-based concussion management, we believe that developing objective assessments and biomarkers (including physiological) to identify transient impairments and the resolution of these impairments to help guide safe driving recommendations following a concussion is an important research priority. Strong evidence in this domain will provide clinicians treating concussion with an evidence-based framework that includes clear expectations and time points to gradually guide their patients safely back to the road.

REFERENCES