
==== Front
Cureus
Cureus
2168-8184
Cureus
2168-8184
Cureus Palo Alto (CA)

10.7759/cureus.68800
Neurology
Physical Medicine & Rehabilitation
Association of Age and Neurological Severity at Intensive Care Unit Admission With Driving Resumption Within 30 Days of Stroke: A Single-Center Historical Cohort Study
Muacevic Alexander
Adler John R
Morimatsu Chinatsu 12
Sotokawa Tasuku 3
Kikuchi Akio 3
1 Department of Occupational Therapy, Suiseikai Kajikawa Hospital, Hiroshima, JPN
2 Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, JPN
3 Department of Occupational Therapy, Faculty of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, JPN
Tasuku Sotokawa tsotokawa@yachts.ac.jp
6 9 2024
9 2024
16 9 e688006 9 2024
Copyright © 2024, Morimatsu et al.
2024
Morimatsu et al.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article is available from https://www.cureus.com/articles/292405-association-of-age-and-neurological-severity-at-intensive-care-unit-admission-with-driving-resumption-within-30-days-of-stroke-a-single-center-historical-cohort-study
Objectives

Guidelines in several countries recommend against driving soon after a stroke; however, some patients resume driving within one month after onset. This study aimed to examine the relationship between neurological and social background factors at intensive care unit (ICU) admission and resumption of motor vehicle driving within 30 days of the first acute stroke/cerebral hemorrhage.

Materials and methods

Data were extracted from medical records of a single center linked to the National Cerebral and Cardiovascular Center Administration Office for Stroke Data Bank in Japan. The data included age, sex, Japan Coma Scale (JCS), National Institutes of Health Stroke Scale (NIHSS), employment status, family situation, and outcomes of driving resumption in patients with a valid driving license transported to the ICU within 24 hours of stroke onset. Time-to-event analysis was used to explore the associations between these factors and driving resumption, with data censored 30 days from onset.

Results

In total, 239 patients had complete medical records, of whom 66 resumed driving. A multivariate Cox proportional hazards analysis showed that fewer patients aged ≥65 years resumed driving than those aged <65 years (hazard ratio 0.46; 95% confidence interval: 0.25-0.84; p=0.009). Patients with NIHSS scores ≥5 and JCS scores ≥1 were also less likely to resume driving compared with those with scores <5 (0.22; 0.08-0.56; p=0.008) and 0 (0.13; 0.04-0.37; p<0.001), respectively.

Conclusions

Age, NIHSS score, and JCS score at ICU admission are independently associated with the likelihood of resuming driving within 30 days of stroke onset. These findings may aid with the provision of support and education to facilitate the efficient resumption of driving after an acute event.

cerebral hemorrhage
stroke
driving resumption assessment
driving resumption
driving ability
nihss-national institutes of health stroke scale
post-stroke rehabilitation
acute phase
acute cerebral infarction
car driving
==== Body
pmcIntroduction

Driving is a crucial mode of transportation for daily life. Resuming driving is associated with various subsequent health considerations for patients with stroke. Driving resumption in patients with stroke positively impacts social participation and health [1]. Conversely, discontinuing driving leads to negative outcomes, including depressive symptoms [2] and reduced social participation [3-5]. Additionally, research has shown a relationship between driving resumption and improved health-related quality of life, although this relationship is also influenced by other factors such as returning to work [6]. Furthermore, rehabilitation for driving resumption requires consideration of both road safety and patient health [7], because stroke-related symptoms may increase the risk of traffic accidents [8].

Several countries have rehabilitation guidelines for driving resumption, but differences exist in the timing across countries and medical conditions [9-11]. The Guidelines on Driving of Motor Vehicles by Persons with Stroke or Traumatic Brain Injury, published by the Japanese Association of Rehabilitation Medicine [12], do not specify a driving prohibition period after illness onset. Instead, they recommend submitting a medical certificate to the Public Safety Commission and following necessary procedures; however, whether to follow these procedures is up to the individual. In the United Kingdom, after a stroke or transient ischemic attack (TIA), patients are recommended to refrain from driving for one month or three months for multiple TIAs. In Australia, they are recommended to refrain from driving for four weeks after a stroke and two weeks after a TIA. In Ontario, Canada, patients with untreated cerebral aneurysms are prohibited from driving, while those with surgically treated aneurysms must wait three months. Overall, considering these guidelines, resumption of driving is not recommended for one month after stroke; however, some patients with acute stroke (30-40%) resume driving within this period [13-15]. Individuals who resume driving against medical guidelines reportedly do so because of social pressures, such as returning to work [14,16]. Additionally, some patients in acute-care hospitals lack medical records documenting their return to driving [17] and may not receive routine education on driving resumption [18].

Patients returning to work within one month of stroke onset are likely to consider driving if they have mild symptoms and were already independent in activities of daily living during hospitalization. In Japan, a study using the modified Rankin Scale (mRS) found that nearly half of patients with acute stroke at discharge from the hospital had mild symptoms [19]. Early driving resumption may be considered in these specific patient subpopulations; however, their neurological characteristics at onset are unknown, and few studies have been conducted on such patients.

We aimed to investigate the association between neurological characteristics and social background factors with motor vehicle driving resumption within 30 days after the onset of the first acute stroke (cerebral infarction or hemorrhage). The study's significance lies in the potential rationalization of patient education and motor vehicle driving assessments, if the characteristics of patients who are likely to resume driving early are known.

Materials and methods

Study design

This was a single-center, registry-based, historical cohort study.

Participants and setting

We enrolled patients who were admitted to our specialized stroke hospital registered in the Japan Stroke Data Bank (JSDB), between January 1, 2021, and January 1, 2023, for their first-ever cerebral infarction or hemorrhage. Patients with subarachnoid hemorrhage, TIA, recurrent stroke, or cerebral hemorrhage, those unwilling to participate, those without a driving license, those with unknown outcomes, and those who were driving before the illness but not seeking a medical certificate were excluded. Patients with subarachnoid hemorrhage were excluded due to immediate surgery needs and prolonged hospital stay hindering discharge within 30 days. The study was approved by the Ethical Review Committee of Suiseikai Kajikawa Hospital (approval number: 202303) and was conducted on an opt-out basis.

Outcome/event

The study outcome was defined as the resumption of driving within 30 days of onset. The observation start date was defined as the onset date, and the end date was defined as the number of days between the onset and issuance of the medical certificate for submission to the Public Safety Commission or between the onset and the decision by the doctor to allow or disallow driving. This definition was determined based on information from medical records and other sources. Each prefectural license center determined the outcome based on the medical certificate, containing information on the ability to drive, provided by the attending physicians, who were neurosurgeons and neurologists. The medical certificate was written by the attending physician based on the results of physical function tests, observation of daily life situations, neuropsychological tests, and driving simulator (DS) evaluations conducted by the occupational therapist and physiotherapist in charge. Driving assessments of the participants were conducted considering a low risk of recurrent stroke, dementia, alcohol or drug addiction, psychosis with symptoms of hallucination, illness-causing impaired consciousness or impaired movement due to seizures, blindness, or any other condition that would be considered a punishment under the Japanese Road Traffic Law, such as revocation, suspension, or refusal of driving license.

Measurements

Variables comprised baseline characteristics, including neurological features at the time of transport and other relevant information collected from the institutional database and medical records, including sex, diagnosis (first-ever cerebral infarction, first-ever cerebral hemorrhage), age, National Institutes of Health Stroke Scale (NIHSS) and Japan Coma Scale (JCS) on admission day, and the number of days from the onset of symptoms to the date of driving resumption (the date of issuance of medical certificate for submission to the Public Safety Commission or of the decision to allow or disallow driving).

NIHSS is a widely used tool for assessing neurological deficits in patients with stroke. NIHSS consists of 15 items, including assessments of the level of consciousness, speech, language, cognition, inattention, visual field abnormalities, motor strength, sensory impairment, and ataxia. Patients are rated on a scale of 0-2, 0-3, or 0-4 points for each item, resulting in a total score of 0-42 points. Higher scores indicate increased severity [20].

JCS is a widely used method among healthcare professionals in Japan, including paramedics, for assessing the level of consciousness during the acute phase of stroke or head injury owing to its simplicity [21]. JCS scores range from 0 to 300 points and categorize consciousness levels as follows: 0 points for being fully awake and alert, 1-3 for being awake without any stimulus, 10-30 for being aroused but reverting to the previous state after stimulation cessation, and 100-300 for being unable to be aroused with any forceful mechanical stimulation. A JCS score of 1 denotes a state of nearly clear consciousness, where the patient maintains an open eye position, exhibits no disorientation, and is capable of following commands. Despite these signs of responsiveness, the patient still experiences a mild disturbance of consciousness.

Social background factors were recorded, including whether the participants had unpaid or paid work [14] and whether they lived with family members. Medical records of patients admitted to the hospital from outside their homes, such as those who suffered a stroke while being treated for another medical condition, were examined to determine whether they had a family member living with them prior to admission.

Statistical analysis

We performed comparative analyses for each variable to assess differences between patients who resumed driving within 30 days of onset and those who did not. Individuals aged ≥65 years were considered elderly according to the World Health Organization (WHO) definition. NIHSS score was analyzed and categorized into three categories, 0 (no symptoms), 1-4 (mild illness), and ≥5 (moderate or severe), based on a previous report [22]. JCS score was classified into two categories: JCS=0 and JCS≥1. Furthermore, we performed a comparative analysis after converting JCS to the Glasgow Coma Scale (GCS) [21].

Kaplan-Meier curves were used to assess the event rate of driving resumption based on different levels of each factor, and their differences were assessed through log-rank tests. The observation period lasted 30 days. The relevance of sex, age (≥65/<65 years), diagnosis (stroke/cerebral hemorrhage), NIHSS (0 points/1-4 points/≥5 points), JCS (JCS=0 or ≥1), presence of cohabiting family members (living alone/with others), employment status (employed/not employed), and number of employed individuals was assessed using adjusted/unadjusted Cox proportional hazards models. Statistical analyses were performed using R4.2.2 statistical software (R Foundation, Vienna, Austria), and the statistical significance level was set at 5%.

Results

Among the 1,289 patients admitted to the hospital during the study period, 239 were transported to the intensive care unit (ICU) within 24 hours of the onset of the first-ever stroke or cerebral hemorrhage (Figure 1).

Figure 1 Patient selection flowchart.

NIHSS: National Institutes of Health Stroke Scale; TIA: transient ischemic attack

Differences between the driving resumption group (n=66) and the non-resumption group (n=173) are presented in Table 1. There were no significant differences between the groups in terms of sex, but patients in the non-resumption group were significantly older (p<0.001). The frequency of cerebral infarction and cerebral hemorrhage was significantly different between the groups (p=0.036), and the JCS=0 and JCS≥1 categories showed significant differences in frequency (p<0.001). There were also significant differences in terms of family situation (living alone/living together; p=0.045) and employment status (p=0.003). When the JCS scores were converted to GCS, both subcategories (JCS=0 and JCS=1) were included in GCS=15, which is considered the mildest. Thus, all 66 patients in the driving resumption group were classified as GCS=15 (Table 1).

Table 1 Comparison of baseline characteristics between the resumed driving group and non-resumed driving group within 30 days from the onset of stroke.

1n (%), mean (standard deviation); 2Pearson's chi-squared test; 3Wilcoxon rank-sum test

NIHSS: National Institutes of Health Stroke Scale; JCS: Japan Coma Scale; GCS: Glasgow Coma Scale

Characteristic	Overall, N=2391	Fit to drive, N=661	Unfit to drive, N=1731	P-value	
Sex	 	 	 	0.82	
Male	174 (73%)	49 (74%)	125 (72%)	 	
Female	65 (27%)	17 (26%)	48 (28%)	 	
Age (years)	65 (12)	61 (12)	66 (11)	<0.0013	
Diagnosis	 	 	 	0.0362	
Brain hemorrhage	67 (28%)	12 (18%)	55 (32%)	 	
Brain infarction	172 (72%)	54 (82%)	118 (68%)	 	
Total NIHSS	6 (7)	2 (3)	8 (7)	<0.0013	
JCS	 	 	 	<0.0012	
0	153 (64%)	62 (94%)	91 (53%)	 	
≥1	86 (36%)	4 (6.1%)	82 (47%)	 	
GCS	 	 	 	<0.0012	
≤14	49 (21%)	0 (0%)	49 (28%)	 	
15	190 (79%)	66 (100%)	124 (72%)	 	
Family situation	 	 	 	0.0452	
Living alone	45 (19%)	7 (11%)	38 (22%)	 	
Living together	194 (81%)	59 (89%)	135 (78%)	 	
Employment	 	 	 	0.0032	
Employed	149 (62%)	51 (77%)	98 (57%)	 	
Not employed	90 (38%)	15 (23%)	75 (43%)	 	

Cumulative driving resumption rates within 30 days were compared using the Kaplan-Meier method (Figure 2). The results showed a significantly higher driving resumption rate in participants aged <65 years than in those aged ≥65 years (p=0.013). Additionally, the NIHSS≥5 category had significantly higher rates of driving resumption than the 0 and 1-4 categories (p<0.0001). The driving resumption rates were significantly higher in patients diagnosed with ischemic stroke than in those diagnosed with cerebral hemorrhage (p=0.003). Additionally, the resumption rate was higher in the JCS=0 category than in the JCS≥1 category (p<0.0001), in patients living with family than in those living alone (p=0.033), and in those with employed work compared to those not employed (p=0.0001). No significant differences were found regarding sex (p=0.9).

Figure 2 Kaplan-Meier curves and log-rank tests for cumulative driving resumption rates across multiple group factors.

The Kaplan-Meier curves allow for the comparison of cumulative driving resumption rates according to (a) sex, (b) age category (≥65 or <65 years), (c) diagnosis (brain hemorrhage or brain infarction), (d) score of NIHSS (0, 1-4, ≥5), (e) score of JCS (0, >1), (f) family situation (living together or living alone), and (g) employment (employed or not employed).

JCS: Japan Coma Scale; NIHSS: National Institutes of Health Stroke Scale

Univariate Cox proportional hazards analysis revealed that patients with cerebral hemorrhage had a hazard ratio (HR) of 0.40 (95% confidence interval (CI): 0.21-0.75, p=0.002; Table 2). Patients aged ≥65 years had an HR of 0.53 (95% CI: 0.32-0.89, p=0.013). Those with a JCS score ≥1 had an HR of 0.08 (95% CI: 0.03-0.22, p<0.001), and those living alone had an HR of 0.44 (95% CI: 0.20-0.95, p=0.021). All these factors were significantly associated with a lower rate of driving resumption. In contrast, the HR for paid employment was 1.92 (95% CI: 1.08-3.41, p=0.019) and was significantly associated with a higher rate.

Table 2 Univariate and multivariate Cox proportional hazards model for resuming car driving within 30 days from stroke onset.

1HR: hazard ratio

CI: confidence interval; NIHSS: National Institutes of Health Stroke Scale; JCS: Japan Coma Scale

 	Univariable	Multivariable	
Variable	N	HR1	95% CI1	P-value	HR1	95% CI1	P-value	
Sex	239	 	 	>0.9	 	 	0.4　	
Male	 	1.0	Reference	 	1.0	Reference	 	
Female	 	0.98	0.56, 1.70	 	0.76	0.43, 1.36	 	
Diagnosis	239	 	 	0.002	 	 	0.3	
Brain hemorrhage	 	1.0	Reference	 	1.0	Reference	 	
Brain infarction	 	2.49	1.33, 4.67	 	1.39	0.69, 2.78	 	
Age	239	 	 	0.013	 	 	0.009	
≤65 years	 	1.0	Reference	 	1.0	Reference	 	
>65 years	 	0.53	0.32, 0.89	 	0.46	0.25, 0.84	 	
NIHSS	239	 	 	<0.001	 	 	0.008	
0	 	1.0	Reference	 	1.0	Reference	 	
1-4	 	0.77	0.40, 1.49	 	0.45	0.22, 0.92	 	
>5	 	0.13	0.05, 0.32	 	0.22	0.08, 0.56	 	
JCS	239	 	 	<0.001	 	 	<0.001	
0	 	1.0	Reference	 	1.0	Reference	 	
≥1	 	0.08	0.03, 0.22	 	0.13	0.04, 0.37	 	
Family situation	239	 	 	0.021	 	 	0.12	
Living alone	 	1.0	Reference	 	1.0	Reference	 	
Living together	 	2.30	1.05, 5.03	 	1.82	0.81, 4.11	 	
Employment	239	 	 	0.019	 	 	0.5	
Employed	 	1.0	Reference	 	1.0	Reference	 	
Not employed	 	0.52	0.29, 0.93	 	0.80	0.40, 1.61	 	

Multivariate Cox proportional hazards analysis revealed an HR of 0.46 (95% CI: 0.25-0.84, p=0.009) for individuals aged ≥65 years, 0.22 (95% CI: 0.08-0.56, p=0.008) for those with an NIHSS score ≥5, and 0.13 (95% CI: 0.04-0.37, p<0.001) for those with a JCS≥1, all associated with a lower rate of driving resumption.

Discussion

We aimed to investigate whether specific neurological and social background factors at the time of stroke onset were linked to the occurrence of driving resumption events within 30 days of onset in patients hospitalized due to a first-ever ischemic stroke or hemorrhagic stroke. The results showed that younger age (<65 years), mild NIHSS score (<5 points) at transport, and JCS of 0 (clear consciousness) at transport were associated with early driving resumption.

It was easier for younger participants aged <65 years to resume driving compared to those aged ≥65 years. Older patients generally report slower recovery after stroke than younger patients [23,24]. In addition, driving behavior has been reported to decline with age in terms of perceptual, motor, and cognitive functions [25]. For instance, the operation of the steering wheel may become awkward, acceleration and braking may slow down, and individuals may miss people, signs, and signals owing to decreased visual acuity and narrowing of the visual field. Additionally, decreased attentional function may render individuals unable to pay attention to their surroundings. In addition, younger patients showed a higher ability to adapt to neuropsychological tests [26] and DS and were considered to benefit more from driving rehabilitation [27]. Therefore, age-related factors affecting post-stroke recovery, as well as driving-related functions and abilities, may have influenced the resumption of driving within 30 days after stroke.

Lower NIHSS scores at the time of transport, indicating milder neurological damage, were associated with a quicker resumption of driving. Previous studies have shown that the NIHSS score is a reliable predictor of return to work [28], functional outcomes [29], and discharge destinations [30] in patients with stroke. Specifically, if the NIHSS score is <5 points, approximately 80% of patients are predicted to be dischargeable [31,32]. Therefore, patients expected to be discharged home are likely to consider resuming driving when they return to the community.

Patients with a JCS score of 0 found it easier to resume driving than those with a JCS score ≥1. Shigematsu et al. [33] reported that 64% of patients with stroke and a JCS score of 0 at onset did not have any symptoms or significant disability and were able to perform normal activities without assistance 30 days after onset. While GCS is widely used internationally for assessing disturbances in consciousness, the JCS demonstrates greater sensitivity in detecting near-normal states [34]. These findings suggest that even with a JCS score of 1, instrumental activities of daily living (IADLs) such as driving may be impaired. Furthermore, a GCS score of 15, indicating the mildest impairment, includes a mixture of JCS scores of 1 and 0, which may complicate accurate predictions. Therefore, it is important to use the JCS as an index for determining when to resume driving in the acute post-stroke period. A low JCS score at the time of transport is expected to be beneficial for the ability to resume driving within 30 days.

In our study population, the number of male participants was higher than that of female participants; however, no significant effect of sex on driving resumption rates was observed. In Japan, while the proportion of women holding driving licenses has increased in recent years, men still constitute a greater number of driving license holders [35]. This observation is consistent with findings by Ouellet et al. [17] who also reported a higher proportion of men. Therefore, our study population reflects the current situation in Japan and is supported by previous research. Moreover, there is a lack of literature reporting a direct effect of sex differences on driving resumption rates. Perrier et al. [36] reported that being female might indirectly reduce driving resumption rates one year after stroke through mediating factors such as fatigue, strength, and motor activity. As our study focuses on driving resumption within 30 days of stroke onset, the influence of sex on driving resumption may not be as pronounced as observed in studies examining driving resumption one year post-stroke. Additionally, individuals who consider resuming driving within 30 days are likely to have milder stroke symptoms, potentially reducing their susceptibility to sex-related effects. Furthermore, although sex may influence social background factors, our study found no association between sex and driving resumption rates, even after adjusting for factors such as family situation and employment. Considering these factors, it is likely that the impact of sex on driving resumption within 30 days post-stroke is minimal or negligible.

Furthermore, this lack of association was found in the results of this study also for social background factors such as living arrangements or employment status. While such factors may not significantly affect diagnosis, or evaluation and training by occupational therapists and others, social background may contribute to make patients feel compelled to resume driving within one month of the onset of illness despite guidelines prohibiting it, as previously reported [16]. We found no significant association between social background and driving resumption within 30 days at the population level. However, at the individual level, some patients resumed driving out of necessity despite being prohibited from doing so by their doctors or license centers. It is possible that such cases may have been relatively rare in the study population and, therefore, may not have reached significance during the analysis.

This study has some limitations. First, it is based on a single-center database, which may limit its generalizability. Second, we excluded patients with unknown outcomes and for whom time information was unknown. Reportedly, some patients in acute-care hospitals lack documented medical records related to driving [17]. In this study, some patients expressed a desire to resume driving, but their outcome and time information were unknown. Including these patients in the analysis could have led to different results. Third, some patients who were mildly ill but were transferred to a different hospital due to a diagnosis of another disease or condition during their hospitalization were not evaluated. Additionally, the families of some patients strongly opposed the resumption of driving. It is possible that unexamined background factors beyond those considered in this study may be relevant to the resumption of driving. Fourth, in this study, neuropsychological tests and other assessment items typically used during driving evaluations were not selected as factors. This decision was based on the potential for significant variation in the timing of driving evaluations depending on the severity of the condition. For instance, mild cases might be evaluated within 30 days, while severe cases might be evaluated after more than 30 days. This could be an unmeasured factor. Additionally, selecting assessments used to determine directly the resumption of driving could compromise the independence between the outcomes and the factors. Fifth, the resumption of driving not a little depend on the patient's willingness and permission from the attending physician. Finally, we did not adequately assess the validity of resuming driving, such as car accident after resuming driving. However, to the best of our knowledge, this study is the first to identify factors during ICU admission that are associated with the resumption of driving within 30 days. A significant strength of this research is the use of data from the JSDB, a representative dataset for stroke in Japan.

Conclusions

We conducted a time-to-event analysis to examine the association between neurological and social background factors at the time of transport and the resumption of driving within 30 days of onset in patients with a first acute ischemic stroke or cerebral hemorrhage. The findings indicated that patients who were older than 65 years and had an NIHSS score higher than 5 and a JCS score higher than 1 exhibited a lower rate of driving resumption. These findings indicate that the information gathered at ICU admission can help identify individuals who may be able to resume driving within 30 days. This can aid with the provision of support and education to facilitate the efficient resumption of driving after an acute event.

The data that support the findings of this study are not publicly available due to ethical restrictions. The data contain sensitive information that could compromise the privacy of research participants. We want to thank all the participants in this study and the staff members from the Suiseikai Kajikawa Hospital for their cooperation. We are also grateful to the members of our research team for their helpful advice in drafting this manuscript.

Disclosures

Author Contributions

Human subjects: Consent was obtained or waived by all participants in this study. Ethical Review Committee of Suiseikai Kajikawa Hospital issued approval 202303. This retrospective study was approved on August 14, 2023. The study employed an opt-out approach, which was deemed ethically appropriate by the IRB given the retrospective nature of the data collection and minimal risk to participants. Notices were provided (https://www.suiseikai.jp/other/%E8%87%A8%E5%BA%8A%E7%A0%94%E7%A9%B6.html) to inform participants of their right to opt-out. All data were anonymized, ensuring the protection of participants' privacy. This study was conducted in accordance with the Declaration of Helsinki and other relevant international ethical guidelines.

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Concept and design:  Tasuku Sotokawa, Chinatsu Morimatsu, Akio Kikuchi

Acquisition, analysis, or interpretation of data:  Tasuku Sotokawa, Chinatsu Morimatsu, Akio Kikuchi

Drafting of the manuscript:  Tasuku Sotokawa, Chinatsu Morimatsu

Critical review of the manuscript for important intellectual content:  Tasuku Sotokawa, Chinatsu Morimatsu, Akio Kikuchi

Supervision:  Tasuku Sotokawa, Akio Kikuchi
==== Refs
References

1 Who’s in the driver’s seat? Impact on social participation and psychosocial wellbeing in adults aged 50 and over Transp Res F Traffic Psychol Behav Donoghue OA McGarrigle CA Kenny RA 522 531 64 2019
2 Driving after a stroke J R Soc Med Legh-Smith J Wade DT Hewer RL 200 203 79 1986 3701764
3 Barriers to driving and community integration after traumatic brain injury J Head Trauma Rehabil Rapport LJ Hanks RA Bryer RC 34 44 21 2006 16456390
4 Driving and community integration after traumatic brain injury Arch Phys Med Rehabil Rapport LJ Bryer RC Hanks RA 922 930 89 2008 18452742
5 Long-term predictors of social and leisure activity 10 years after stroke PLoS One Norlander A Carlstedt E Jönsson AC Lexell EM Ståhl A Lindgren A Iwarsson S 0 11 2016
6 Change in quality of life in relation to returning to work after acquired brain injury: a population-based register study Brain Inj Matérne M Strandberg T Lundqvist LO 1731 1739 32 2018 30296173
7 Occupational therapy in driving and community mobility 1 2024 2019 https://wfot.org/resources/occupational-therapy-in-driving-and-community-mobility
8 The risk of motor vehicle crashes and traffic citations post stroke: a structured review Top Stroke Rehabil Perrier MJ Korner-Bitensky N Petzold A Mayo N 191 196 17 2010 20797963
9 Assessing fitness to drive: A guide for medical professionals 1 2024 2024 https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals
10 Assessing fitness to drive 1 2024 2022 https://austroads.com.au/
11 Stroke, driving and the health care professional rules and guidelines 1 2024 2007 https://integratedrehab.org/wp-content/uploads/2019/11/Stroke-Driving-and-the-Health-Care-Professional-Rules-and-Guidelines.pdf
12 Clinical guidance for management of driving after stroke and traumatic brain injury Clinical guidance for management of driving after stroke and traumatic brain injury Tokyo, Japan Shinkoh Igaku Shuppan Co. Ltd 2021 https://shinkoh-igaku.jp/mokuroku/data/799.html
13 Returning to driving after stroke: a systematic review of adherence to guidelines and legislation Br J Occup Ther Frith J Hubbard IJ James CL Warren-Forward H 349 355 78 2015
14 Driving in stroke survivors aged 18-65 years: the Psychosocial Outcomes In StrokE (POISE) cohort study Int J Stroke Yu S Muhunthan J Lindley R 799 806 11 2016 27016514
15 Driving after a transient ischaemic attack or minor stroke Emerg Med J McCarron MO Loftus AM McCarron P 358 359 25 2008 18499820
16 Driving resumption and its predictors after stroke Conn Med Lee N Tracy J Bohannon RW Ahlquist M 387 391 67 2003 https://pubmed.ncbi.nlm.nih.gov/14502860/ 14502860
17 Portrait of driving practice following a mild stroke: a secondary analysis of a chart audit Top Stroke Rehabil Ouellet MA Rochette A Miéville C Poissant L 181 189 27 2020 31702449
18 Shifting gears: an inpatient medical record audit and post-discharge survey of return-to-driving following stroke/transient ischaemic attack Aust Occup Ther J Frith J Warren-Forward H Hubbard I James C 264 272 64 2017 28211060
19 Twenty-year change in severity and outcome of ischemic and hemorrhagic strokes JAMA Neurol Toyoda K Yoshimura S Nakai M 61 69 79 2022 34870689
20 Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group J Neurosci Nurs Spilker J Kongable G Barch C 384 392 29 1997 9479660
21 Development and validation of a novel method for converting the Japan Coma Scale to Glasgow Coma Scale J Epidemiol Nakajima M Okada Y Sonoo T Goto T 531 535 33 2023 35851565
22 Semantic analysis of NIH Stroke Scale using machine learning techniques Yu J Kim D Park H Jeju, South Korea IEEE 2019
23 Does age influence early recovery from ischemic stroke? A study from the Hessian Stroke Data Bank J Neurol Kugler C Altenhöner T Lochner P Ferbert A 676 681 250 2003 12796828
24 Effects of age on long-term functional recovery in patients with stroke Medicina (Kaunas) Yoo JW Hong BY Jo L Kim JS Park JG Shin BK Lim SH 56 2020
25 The association of physical activity, cognitive processes and automobile driving ability in older adults: a review of the literature Geriatr Nurs Miller SM Taylor-Piliae RE Insel KC 313 320 37 2016 27260109
26 Neuropsychological practice effects x age: a brief note Percept Mot Skills Horton AM Jr 257 258 75 1992 1528677
27 Slower adaptation to driving simulator and simulator sickness in older adults Aging Clin Exp Res Kawano N Iwamoto K Ebe K 285 289 24 2012 https://pubmed.ncbi.nlm.nih.gov/23114558/ 23114558
28 Determinants of return to work after a stroke: a systematic review and meta-analysis Arch Phys Med Rehabil Orange C Lanhers C Coll G 359 368 105 2024 37797913
29 Stroke scale score and early prediction of outcome after stroke J Coll Physicians Surg Pak Ahmed R Zuberi BF Afsar S 267 269 14 2004 https://pubmed.ncbi.nlm.nih.gov/15225452/ 15225452
30 Predicting outcome after stroke: the role of basic activities of daily living predicting outcome after stroke Eur J Phys Rehabil Med Gialanella B Santoro R Ferlucci C 629 637 49 2013 https://pubmed.ncbi.nlm.nih.gov/22641250/ 22641250
31 Utility of the NIH Stroke Scale as a predictor of hospital disposition Stroke Schlegel D Kolb SJ Luciano JM Tovar JM Cucchiara BL Liebeskind DS Kasner SE 134 137 34 2003 12511764
32 Predictors of resource use after acute hospitalization: the Northern Manhattan Stroke Study Neurology Rundek T Mast H Hartmann A 1180 1187 55 2000 11071497
33 The eye response test alone is sufficient to predict stroke outcome--reintroduction of Japan Coma Scale: a cohort study BMJ Open Shigematsu K Nakano H Watanabe Y 0 3 2013
34 Use of the Glasgow Coma Scale and the Jouvet Coma Scale to evaluate the level of consciousness [Article in Portuguese] Rev Esc Enferm USP Muniz EC Thomaz MC Kubota MY Cianci L de Sousa RM 287 303 31 1997 9411580
35 The 2019 white paper on traffic safety 1 2024 2019 https://www8.cao.go.jp/koutu/taisaku/r01kou_haku/english/pdf/wp2019.pdf
36 Patient factors associated with return to driving poststroke: findings from a multicenter cohort study Arch Phys Med Rehabil Perrier MJ Korner-Bitensky N Mayo NE 868 873 91 2010 20510976
