Driving behavior in simulator and on-road assessments in brain injury and stroke: a scoping review

Driving requires the coordination of complex cognitive and motor abilities that are often impaired after brain injury or stroke. This scoping review aimed to synthesize the driving behaviors observed in individuals with brain injury through simulator-based and on-road driving assessments using Michon’s hierarchical framework. Following the PRISMA extension for Scoping reviews, we systematically searched five databases in July 2024. The eligible studies included adults with brain injuries assessed using either simulators or on-road evaluations. Driving behaviors were categorized as operational, tactical, or strategic. Thirty-eight studies met the inclusion criteria. Individuals with brain injury who failed the driving assessments (i.e. simulator or on-road) exhibited more frequent tactical-level errors, including lane deviations, and inadequate visual scanning than those with brain injury who passed. Simulator assessments are often used in studies comparing individuals with brain injury with healthy controls, whereas on-road assessments are more commonly used in studies assessing pass/fail outcomes. Tactical-level errors, such as those involving decision-making and maneuvering in response to traffic, were consistently observed in individuals with brain injury. Assessment tools should prioritize the evaluation of operational and tactical abilities while expanding their capacity to capture strategic-level performance, which remains underassessed.