Occupational Therapy In Health Care, 28(2):154–162, 2014  C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.901590


Driving Simulators for Occupational Therapy Screening, Assessment, and Intervention Sherrilene Classen1 & Johnell Brooks2 1

School of Occupational Therapy, Elborn College, Western University, London, Ontario, Canada, 2 Automotive Engineering, Clemson University International Center for Automotive Research, Greenville, South Carolina, USA

ABSTRACT. Simulation technology provides safe, objective, and repeatable performance measures pertaining to operational (e.g., avoiding a collision) or tactical (e.g., lane maintenance) driver behaviors. Many occupational therapy researchers and others are using driving simulators to test a variety of applications across diverse populations. A growing body of literature provides support for associations between simulated driving and actual on-road driving. One limitation of simulator technology is the occurrence of simulator sickness, but management strategies exist to curtail or mitigate its onset. Based on the literature review and a consensus process, five consensus statements are presented to support the use of driving simulation technology among occupational therapy practitioners. The evidence suggests that by using driving simulators occupational therapy practitioners may detect underlying impairments in driving performance, identify driving errors in at-risk drivers; differentiate between driving performance of impaired and healthy controls groups; show driving errors with absolute and relative validity compared to on-road studies; and mitigate the onset of simulator sickness. Much progress has been made among occupational therapy researchers and practitioners in the use of driving simulation technology; however, empirical support is needed to further justify the use of driving simulators in clinical practice settings as a valid, reliable, clinical useful, and cost effective tool for driving assessment and intervention. KEYWORDS.

Aged, automobile driving, elderly, medical conditions, safety

BACKGROUND Interactive driving simulators, used by trained professionals, are valuable for screening, assessment, or intervention purposes. Driving simulator technology provides a viable mode to assess the fitness to drive skills of at-risk drivers who may not be ready or competent to pursue an on-road assessment (Classen et al., 2013). Simulation technology provides safe, objective, and repeatable performance Address correspondence to: Sherrilene Classen, PhD, MPH, OTR/L, FAOTA, Professor and Chair: School of Occupational Therapy, Elborn College, Western University, 1201 Western Road, London, ON N6G 1H1, Canada (E-mail: [email protected]). (Received 14 January 2014; accepted 3 March 2014)


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measures pertaining to operational (e.g., avoiding a collision) or tactical (e.g., lane maintenance) driver behaviors. The simulator programmer/ or operator can control the driving environment (e.g., snow, rain, night driving), modify the degree of risk exposure for the client (e.g., no hazards, or events that may potentially lead to a crash), and expose the client to a variety of driving situations (e.g., residential, suburban, rural, or highway areas). Driving simulation is a representation of driving, but not real world driving itself and is therefore not a panacea for driving assessment or intervention. Much work remains to be completed to integrate driving simulation as a valid, reliable, evidence based and practice based tool for occupational therapy practitioners (both generalists and driving rehabilitation specialists). Nevertheless, the technology in driving simulators has evolved over the past decade to make driving simulator systems more appropriate and available for widespread use in clinical settings. Notably, driving simulators are evolving to be more capable, less expensive, and simpler to operate than in years past. Many occupational therapy researchers and other professionals are using driving simulators to test a variety of applications across diverse populations. Some examples include: Alzheimer’s (Frittelli et al., 2009; Rizzo et al., 2001), civilians with traumatic brain injury (TBI) (Gamache et al., 2011; Lew et al., 2005), combat veterans with mild TBI and post traumatic stress disorder (PTSD) (Classen et al., 2011b; Classen & Owens, 2010), epilepsy (Crizzle et al., 2012), hemianopia (Bowers et al., 2009), Parkinson’s disease (Devos et al., 2007; Ranchet et al., 2011), stroke (Akinwuntan et al., 2005; Lundqvist et al., 2000), and teens with Attention Deficit Hyperactivity Disorder and Autism Spectrum Disorder (Classen et al., 2013). Several research teams are examining older drivers (e.g. Freund & Colgrove, 2008; Freund et al., 2005a, 2005b; Harvey et al., 1995; Hoffman & McDowd, 2010; Lee et al., 2002; Lee et al., 2003; Ni et al., 2010; Szlyk et al., 2002). In addition, researchers are using simulators to examine the impact of roadway design among older and younger drivers (e.g., Shechtman et al., 2007), or the impact of new technologies on different driving populations (e.g., Lee & Lee, 2005; Lee et al., 2003; Martin & Elefteriadou, 2010). The following simulator studies specifically address occupational therapy practice and are grouped in areas of research topics. Validity of Driving Simulators to On-Road Studies In “Validation of driving simulators”, Shechtman (2011) provides a literature review of driving simulator validation studies, addresses possible reasons for controversy often seen in the literature, and suggests using health measurement terminology to better define simulator validity. She also offers ways to match the types of measurement validity terms with examples of existing diving simulator validation studies. In fact, Shechtman et al., (2009), examined if driver response validity (type and number of errors) was similar between on-road and in-simulator. The authors replicated real-world intersections using the STISIM M500W driving simulator (Systems Technology Inc, Hawthorne, California) and assessed the number and type of driving errors committed by 39 participants while negotiating a right and a left turn both on-the-road and in-the-simulator. They found no significant interactions between the type of vehicle (road vs. simulator) and the type of turn (right versus left) for any of the driving errors, indicating the same trends exist between driving errors made on-road and in-simulator and thus suggesting relative validity


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of the simulator as compared to the on-road gold standard criterion (Di Stefano & Macdonald, 2012). Drivers made more errors during left-turn than right-turn, on-road and in the simulator. They also found no significant differences between the road and the simulator for driving errors pertaining to lane maintenance, adjustment to stimuli, and visual scanning, indicating absolute validity for these types of errors. As such, this Shechtman et al. study represents the growing body of literature that is examining the validity of simulated driving in respect to actual on-road driving. Validity and Reproducibility of Driving Simulators Using Clinical Battery of Tests ´ Bedard et al. (2010) examined the validity and reproducibility of simulator-based driving evaluations in three experimental studies: Two addressing the validity of simulators to clinical tests and one examining the reproducibility of data obtained from a driving simulator. In Study 1, they examined correlations among Trail Making Test Part A and B, demerit points for simulated drives, and simulator-recorded errors. Correlations ranged from .44 (p = .103) to .83 (p = .001), suggesting, with one exception, moderate to good correlations. In Study 2, they examined correlations among Trail Making Test Part A, Useful Field of ViewTM (UFOV), and demerit points for simulated drives; correlations ranged from .50 to .82 (all ps < .001), again suggesting moderate to good correlations. The correlation between demerit points for on-road and simulated drives was .74 (p = .035). They also examined reproducibility of simulator assessments using the playback function; intra class correlation coefficients ranged from .73 to .87 (all ps < .001). Using a DriveSafety CDS-250 (Salt Lake City, Utah) simulator (Crizzle et al., 2012) determined, from a battery of clinical tests, which clinical tests were correlated with driving errors in people with epilepsy. The sample consisted of 16 drivers with epilepsy (mean age 44.3 ± 12.0; 63% women) who completed cognitive, visual and motor tests, as well as a 35-minute drive on the simulator. Significant correlations emerged between: visual acuity with visual scanning (r = .69, p < .01) and adjustment to stimuli (r = .60, p < .05); contrast sensitivity with lane maintenance (r = −.54, p > .05), vehicle position (r = −.61, p < .05) and total number of errors (r = −.72, p < .01); and UFOV subtest 2 scores with visual scanning (r = .57, p < .05) and vehicle position (r = .63, p < .05). These findings suggest that visual and visual–cognitive tests are associated with driving errors in a simulated driving environment. Despite the literature supporting that the driving simulation may be a valid and reproducible modality when compared to on-road studies, driving simulation is not without limitations. One of the major limitations is that simulator adaptation syndrome, or simulator sickness, (Kennedy et al., 1993) may occur with some individuals. Simulator Sickness In an evidence-based literature review Classen et al. (2011a) published the findings of examining simulator adaptation syndrome, a.k.a. simulator sickness (SS) (Kennedy et al., 1993). They used the American Academy of Neurology’s classification criteria and extracted data from 10 studies, assigned each study a class

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of I-IV, with “I” indicating the highest level of evidence, made recommendations (A-C, with A being the strongest level of recommendation), and grouped primary studies into categories of specific aspects of SS using the Occupational Therapy Framework: Domain and Process (e.g., client factors, performance patterns, environmental factors, and person-environment factors) (American Occupational Therapy Association, 2008). They found that client factors (i.e., clients >70 yrs. [Level B], women [Level B]) and context/environment factors (e.g., refresh rates, scenario design and duration, simulator configuration, and calibration; Level B) probably increase the rates of SS, whereas activity demands (vection, speed of driving, and postural instability [Level C] possibly contribute to SS. Using this knowledge on simulator sickness, Classen and Owens (2010) examined the differences in simulator sickness in combat veterans (CV) with mild TBI and PTSD. In this retrospective simulator study, the occurrence of simulator sickness was analyzed for combat veterans compared to healthy controls. Susceptibility to simulator sickness occurred in combat veterans at two time periods (after the acclimation scenario and after the main drive) and increased as driving exposure progressed. Overall, these findings suggest that combat veterans may have pre-existing conditions that make them more susceptible to simulator sickness; and that they are affected over the cause of the simulated drive more severely, as compared to healthy controls. It is important for occupational therapy practitioners to understand that some clients may be prone to simulator sickness. The population described in the preceding paragraph is an example where additional considerations are needed, such as before testing those with a head injury and/or PTSD. Moreover, proper adaptation to a driving simulator, a strategy that reduces or eliminates the onset of simulator sickness, combined with appropriate choice of scenarios (e.g., straight drives in simple landscapes) are critical for the driving comfort of any client who uses a simulator. Adaptation thus must be a carefully considered to ensure success for both the client, the assessment or intervention processes and characteristics of the simulator (Goodenough et al., 2012; Yuen et al., 2012). Brooks et al. (2010) provide strategies for the set-up of the room where the simulator is housed, as well as a survey tool to use with clients, both of which were used successfully, in reducing the onset of simulator sickness, in their research laboratory. Strong evidence suggests that some drivers will be negatively affected by simulator sickness especially in complex environments with stops and turns (Classen et al., 2011a). Research demonstrates that well designed simulators, coupled with adaptation training, can reduce the occurrence of simulator sickness (Brooks et al., 2010; Goodenough et al., 2012). However, more needs to be done in simulator sickness research to enable driving in complex environments, as such assessments are critical for fitness to drive evaluations or for planning successful interventions. In the absence of well-designed trials to mitigate simulator sickness in complex driving environments, users of this modality will continue to experience limitations in the use of driving simulators. Consensus Statements and Process After a thorough review of the literature (including many articles not mentioned here), two invited members of the expert panel (two co-authors of this


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publication) provided the expert panel committee members with an overview of current evidence. This evidence, necessary for background information prior to the formulation of consensus statements, pertained to the use of interactive driving simulators for assessments and interventions. After the meeting, these two members met through conference calls and presented joint consensus statements that were sent to all expert members for their further recommendations and approval. The five consensus statements that were presented received a vote of agreement from the group members. Note that the procedure for reaching consensus is described in this journal in the contribution by Dickerson et al. Although this topic needs further research (e.g., about pre-existing conditions that may contribute to simulator sickness) and application to practice, there was clear agreement that those who choose to use driving simulation must do so with clear objectives, seek appropriate training, and be prepared for dealing with simulator adaptation issues or simulator sickness. The statements in this area that achieved consensus as Agreed were:

• Due to driving simulator adaptation, unfamiliarity and anxiety with technology, and a lack of standardization and validation of outcome metrics, driving simulators should not be the sole determinant of fitness to drive for older adults. • Occupational therapists using driving simulation need to seek and obtain the appropriate education and training to use this tool effectively, appropriately, and with the knowledge to minimize simulator sickness. • Carefully designed and tested driving simulation activities may offer controlled and repeatable driving conditions for intervention that are unavailable or limited in open-roadway conditions, allowing clients/patients to practice the abilities and skills that will be required for driving during the rehabilitation process, and understanding that the evidence to support this claim is still emerging. • Simulators may be valuable as part of a more comprehensive assessment. • Driving simulators can be used as a tool to determine impaired visual, cognitive, and motor abilities underlying the task of driving when used by an occupational therapist knowledgeable and skilled in its use. Future Needs Future research is needed to identify the most appropriate and effective uses of driving simulation technology in clinical settings and to understand pre-existing conditions that may make participants more susceptible to simulator sickness. Researchers also need to further understand the benefits of the testing environment, validity, consistency, and repeatability offered by driving simulators. In addition, simulators provide significant opportunities to address the assessment or intervention needs of occupational therapy practitioners in relation to determining fitness to drive among older adults. Identifying the needs of occupational therapy practitioners (e.g., training requirements, assessment tools, use of scenarios, identifying outcome measures, applicability of information to real world driving, etc.) and clients (applicability of testing or interventions to real world driving) represent an opportunity to guide researchers and developers’ efforts to further enhance simulator technology for optimal use among medically-at-risk clients.

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The expert panel agreed that well designed simulators and simulator protocols have the potential to provide a safe and effective means for studying, assessing, and training drivers to positively affect their fitness to drive skills or behaviors (Allen & Classen, 2010). New and innovative driving simulator applications continue to be developed as evidenced by the papers cited in this review. The application of driving simulation is becoming more appealing to a wide range of researchers in various disciplines and is encouraging new innovative assessment and training applications. However, efficacy and effectiveness studies are needed to illustrate translation of the research to the clinical practice area. Likewise feasibility, clinical utility, and cost-effectiveness studies are necessary to examine the use of driving simulators in occupational therapy practice. As for the studies mentioned in this review, larger sample sizes and replication in on-road conditions are needed to increase the generalizability of the claims, and to show ecological validity. Findings must also be confirmed in randomized controlled trials that are at the least matched for age and gender. However, evidence exists today suggesting that through the use of driving simulators, occupational therapy practitioners may: (1) detect underlying impairments in driving performance; (2) identify driving errors (e.g., maintaining lane, yielding, speeding, accepting safe gaps) in at-risk drivers; (3) differentiate between driving performance of impaired and healthy control groups; (4) show driving errors with absolute and relative validity compared to on-road studies; and (5) mitigate the onset of simulator sickness CONCLUSION Occupational therapy practitioners must be active in determining the appropriate use of driving simulators in their clinical practices. A recent study examining physicians and older adults’ attitudes toward using driving simulators in clinical settings demonstrated that both parties were positive to the use of this technology. The physicians are willing to refer patients to a driving simulator program for assessment and intervention purposes, while the older adults felt the simulator could be an appropriate tool for practicing driving, learning new skills, and having one’s driving assessed after a significant medical event (Crisler et al., 2012). However, the older adults were neutral in regards to whether a simulator could be used to replace a behind the wheel assessment. To ensure the successful use of driving simulators in clinical practice, occupational therapists must therefore make informed choices when selecting their evaluation equipment and tools. In using simulator technology, the user must be competent and confident in being properly trained, assessing and intervening with clients that are medically at risk, identifying outcome measures and interpreting results. Moreover, the user must also be skilled in making decisions about driver fitness, applying the results to real world driving, and communicating the outcomes to physicians, clients, families, and other stakeholders. In the last decade occupational therapy researchers and practitioners have advanced in the use of driving simulation technology. However, much empirical support is needed to further justify the use of driving simulators in


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clinical practice settings as a valid, reliable, clinical useful, and cost effective tool for driving assessment and intervention. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

ABOUT THE AUTHORS Sherrilene Classen, PhD, MPH, OTR/L, FAOTA, Professor and Chair: School of Occupational Therapy, Western University, Elborn College, 1201 Western Road, London, Ontario, Canada N6G 1H1. E-mail: [email protected] Johnell Brooks, PhD, Associate Professor: Automotive Engineering, Clemson University International Center for Automotive Research, 4 Research Drive, Greenville, SC 29607, USA. E-mail: [email protected]

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Driving simulators for occupational therapy screening, assessment, and intervention.

Simulation technology provides safe, objective, and repeatable performance measures pertaining to operational (e.g., avoiding a collision) or tactical...
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