Impact of COVID-19 on motor vehicle injuries and fatalities in older adults in Ontario, Canada.

BACKGROUND: Older adults constitute the group most vulnerable to COVID-19 mortality. As a result, in North America and elsewhere, older adults have been strongly advised to shelter in place. Older adults also represent the fastest growing segment of licensed drivers. OBJECTIVE: We examined the change in injuries and fatalities sustained by younger and older drivers and pedestrians during the first month of the COVID-19 pandemic. We hypothesized that adults ages 80 years and over would have a proportionally larger reduction than the other drivers and pedestrians. METHODS: Using a cohort design, we compared the proportion of drivers and pedestrians involved in injuries and fatalities attributable to individuals aged 80 years and over, as recorded in the Ministry of Transportation of Ontario (Canada) database, between the 30 days prior to shelter-in-place related to the COVID-19 pandemic and the subsequent 30 days. By way of comparison, we conducted a similar comparison for younger age cohorts (16-24 years, 25-34 years, 35-54 years, 55-64 years, and 65-79 years). RESULTS: Drivers aged 80 years and over represented 21 per 1000 injuries and fatalities in the 30 days prior to March 17, 2020 (95 % CI: 15-29), and 8 per 1000 injuries and fatalities in the 30 days beginning on that date (95 % CI: 2-20), a 64.7 % reduction (exp (ß) post 0.353, 95 % CI 0.105-0.892). Drivers in the 35-54 year age range underwent a significant but smaller reduction of 22.9 %; no significant changes were seen for drivers in other age groups, or for pedestrians of any age. CONCLUSIONS AND RELEVANCE: The physical distancing measures that aimed to reduce the spread of COVID-19 resulted in a marked reduction in driver injuries and fatalities in the oldest old, illustrating the impact of physical distancing recommendations in this population. The excess mortality burden faced by the oldest adults during the COVID-19 pandemic, by direct exposure to the virus, may be indirectly mitigated by the reduction in road-related deaths in this cohort.

Influence of Multiple Sclerosis on Spatiotemporal Gait Parameters: A Systematic Review and Meta-Regression.

OBJECTIVE: To quantify the effect of multiple sclerosis (MS) on spatiotemporal gait characteristics accounting for disability severity and fall classification. DATA SOURCES: MEDLINE (1946-August 2018), Allied and Complementary Medicine Database (1985-2018 August), and PsycINFO (1806-August 2018) were searched for terms on MS and gait. STUDY SELECTION: Dual independent screening was conducted to identify observational, cross-sectional studies that compared adults with MS grouped according to Expanded Disability Status Scale (EDSS) level or fall history, reported on spatiotemporal gait characteristics, and were published in English. The search retrieved 5891 results, of which 12 studies satisfied the inclusion criteria. DATA EXTRACTION: Two authors worked independently to extract and verify data on publication details, study methodology, participant characteristics, gait outcomes, conclusions, and limitations. Risk of bias was assessed using the QualSyst critical appraisal tool. A random-effects meta-regression and meta-analysis were conducted on pooled data. DATA SYNTHESIS: All studies received quality ratings of very good to excellent and collectively examined 1513 individuals with MS. With every 1-point increase in EDSS, significant changes (P<.05) were observed in gait speed (-0.12 m/s; 95% confidence interval (CI), 0.08-0.15), step length (-0.04 m; 95% CI, 0.03-0.05), step time (+0.04 seconds; 95% CI, 0.02-0.06), step time variability (+0.009 seconds; 95% CI, 0.003-0.016), stride time (+0.08 seconds; 95% CI, 0.03-0.12), cadence (-4.4 steps per minute; 95% CI, 2.3-6.4), stance phase duration (+0.8% gait cycle; 95% CI, 0.1-1.5), and double support time (+3.5% gait cycle; 95% CI, 1.5-5.4). Recent fallers exhibited an 18% (95% CI, 13%-23%) reduction in gait speed compared with nonfallers (P<.001). CONCLUSIONS: This review provides the most accurate reference values to-date that can be used to assess the effectiveness of MS gait training programs and therapeutic techniques for individuals who differ on disability severity and fall classification. Some gait adaptations could be part of adopting a more cautious gait strategy and should be factored into the design of future interventions.

A Systematic Review of the Risk of Motor Vehicle Collision in Patients With Syncope.

BACKGROUND: Drivers at risk of sudden incapacitation from syncope pose a potential threat to themselves and to society. The purpose of this systematic review is to synthesize the risk of motor vehicle collisions (MVCs) for patients with a history of syncope. METHODS: We systematically searched Medline (1946-2019) as well as Cinahl, Embase, Psychinfo, and the Transportation Research Information Documentation (1806-2017) for articles on MVCs and drivers with vasovagal syncope (VVS), arrhythmic syncope, or syncope not yet diagnosed (NYD). Quality ratings were assigned by team consensus. RESULTS: Eleven studies of moderate quality were included (n = 42,972). Compared with the general populations of Canada, the United States, and the United Kingdom (0.49%-2.29% per driver-year), the prospective MVC risk was lower for VVS (0.0%-0.31% per driver-year; 3 studies; n = 782) and higher for arrhythmic syncope (1.9%-3.4% per driver-year; 2 studies; n = 730). The results were more variable for syncope NYD (0.0%-6.9% per driver-year prospectively; 6 studies; n = 41,460). Patients with syncope NYD had an almost 2-fold increased MVC risk in the largest study, although the smaller studies showed contradictory findings. CONCLUSIONS: VVS patients appear to be at very low risk for MVCs, supporting current guidelines which do not recommend driving suspension for these patients in most cases. Although the data for other forms of syncope are too limited for definitive conclusions and must be improved, arrhythmic syncope appears to be associated with nontrivial risk.

Impact of medical fitness to drive policies in preventing property damage, injury, and death from motor vehicle collisions in Ontario, Canada.

INTRODUCTION: Drivers with medical conditions and functional impairments are at increased collision risk. A challenge lies in identifying the point at which such risk becomes unacceptable to society and requires mitigating measures. This study models the road safety impact of medical fitness-to-drive policy in Ontario. METHOD: Using data from 2005 to 2014, we estimated the losses to road safety incurred during the time medically-at-risk drivers were under review, as well as the savings to road safety accrued as a result of licensing decisions made after the review process. RESULTS: While under review, drivers with medical conditions had an age- and sex-standardized collision rate no different from the general driver population, suggesting no road safety losses occurred (RR = 1.02; 95% CI: 0.93-1.12). Licensing decisions were estimated to have subsequently prevented 1,211 (95% CI: 780-1,730) collisions, indicating net road safety savings resulting from medical fitness to drive policies. However, more collisions occurred than were prevented for drivers with musculoskeletal disorders, sleep apnea, and diabetes. We theorize on these findings and discuss its multiple implications. CONCLUSIONS: Minimizing the impact of medical conditions on collision occurrence requires robust policies that balance fairness and safety. It is dependent on efforts by academic researchers (who study fitness to drive); policymakers (who set driver medical standards); licensing authorities (who make licensing decisions under such standards); and clinicians (who counsel patients on their driving risk and liaise with licensing authorities). Practical Applications: Further efforts are needed to improve understanding of the effects of medical conditions on collision risk, especially for the identified conditions and combinations of conditions. Results reinforce the value of optimizing the processes by which information is solicited from physicians in order to better assess the functional impact of drivers' medical conditions on driving and to take suitable licensing action.

A systematic review of the risk of motor vehicle collision after stroke or transient ischemic attack.

BACKGROUND: Returning to driving after stroke is one of the key goals in stroke rehabilitation, and fitness to drive guidelines must be informed by evidence pertaining to risk of motor vehicle collision (MVC) in this population. OBJECTIVES: The purpose of the present study was to determine whether stroke and/or transient ischemic attack (TIA) are associated with an increased MVC risk. METHODS: We searched MEDLINE, CINAHL, EMBASE, PsycINFO, and TRID through December 2016. Pairs of reviewers came to consensus on inclusion, based on an iterative review of abstracts and full-text manuscripts, on data extraction, and on the quality of evidence. RESULTS: Reviewers identified 5,605 citations, and 12 articles met inclusion criteria. Only one of three case-control studies showed an association between stroke and MVC (OR 1.9, 95% CI 1.0-3.9). Of five cohort reports, only one study, limited to self-report, found an increased risk of MVC associated with stroke or TIA (RR 2.71, 95% CI 1.11-6.61). Two of four cross-sectional studies using computerized driving simulators identified a more than two-fold risk of MVCs among participants with stroke compared with controls. The difference in one of the studies was restricted to those with middle cerebral artery stroke. CONCLUSIONS: The evidence does not support a robust increase in risk of MVCs. While stroke clearly prevents some patients from driving at all and impairs driving performance in others, individualized assessment and clinical judgment must continue to be used in assessing and advising those stroke patients who return to driving about their MVC risk.

Substance use and internalizing symptoms among high school students and access to health care services: results from a population-based study.

OBJECTIVES: To examine co-occurring mental health problems among a population-based sample of high school students in Ontario, Canada, to understand their prevalence, associated risk factors, and relationship with mental health service access and utilization. METHODS: The data were derived from the 2013 Ontario Student Drug Use and Health Survey, a biennial survey of students attending publicly funded Ontario schools, from a subsample of students who completed both the internalizing and substance use portions of the survey (n = 2945). Rates of co-occurring problems were calculated for the previous 12 months. Service use for students with co-occurring problems was also calculated for the past 12 months. Odds ratios were estimated using binary logistic regression models correcting for the survey design. RESULTS: In an adjusted model, youth with internalizing symptoms were 2.40 times more likely and youth with substance use problems were 2.24 times more likely to have accessed mental health services during the past 12 months than youth without these problems. Youth with co-occurring internalizing and substance use problems were 6.74 times more likely (95% CI 4.66-9.76, p < 0.001) to have accessed mental health services during the past year compared with youth without co-occurring problems, but only 52.8% of youth with co-occurring problems (95% CI 45.6-59.9%) used mental health services. CONCLUSIONS: The findings suggest that just over half of Ontario students in grades 9 through 12 who have co-occurring internalizing and substance use problems are utilizing mental health services. Further research should examine the factors related to service use in this population in order to better inform policy and program development.

Risk of Motor Vehicle Collision or Driving Impairment After Traumatic Brain Injury: A Collaborative International Systematic Review and Meta-Analysis.

OBJECTIVE: To synthesize knowledge of the risk of motor vehicle collision (MVC) following a traumatic brain injury (TBI) and the associated risk of driving impairment, as measured by on-road tests, computerized simulators, and self-reported or state-recorded driving records. METHODS: Our international team searched 7 databases for studies published between 1990 and 2015 of people with TBI, controls, and data concerning either MVC or driving impairment. The included articles examined the risk of MVC among people with TBI; we excluded studies that examined the risk of having a TBI associated with being involved in an MVC. RESULTS: From 13 578 search results, we included 8 studies involving 1663 participants with TBI and 4796 controls. We found no significant difference in the risk of MVC (odds ratio = 1.24, 95% confidence interval = 0.80-1.91, P = .34). When we restricted the analysis to self-report, the risk of MVC was higher for those without a TBI (odds ratio = 1.63, 95% confidence interval = 1.21-2.22, P = .002). In contrast, participants with TBI consistently performed worse during on-road assessments and had more problems with vehicular control. CONCLUSION: Limitations of reviewed studies included small sample sizes, failure to specify TBI severity or time postinjury, and absence of objective measures of risk. Findings concerning the relationship between TBIs from non-MVC causes and crash risk are, therefore, inconclusive and do not provide evidence for major changes to existing clinical guidelines for driving with TBI.

An International Approach to Enhancing a National Guideline on Driving and Dementia.

PURPOSE OF REVIEW: The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement. METHODS: An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus. RECENT FINDINGS: The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript. The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.

Update on the Risk of Motor Vehicle Collision or Driving Impairment with Dementia: A Collaborative International Systematic Review and Meta-Analysis.

Guidelines that physicians use to assess fitness to drive for dementia are limited in their currency, applicability, and rigor of development. Therefore, we performed a systematic review to determine the risk of motor vehicle collisions (MVCs) or driving impairment caused by dementia, in order to update international guidelines on driving with dementia. Seven literature databases (MEDLINE, CINAHL, Embase, etc.) were searched for all research studies published after 2004 containing participants with mild, moderate, or severe dementia. From the retrieved 12,860 search results, we included nine studies in this analysis, involving 378 participants with dementia and 416 healthy controls. Two studies reported on self-/informant-reported MVC risk, one revealing a four-fold increase in MVCs per 1,000 miles driven per week in 3 years prior, and the other showing no statistically significant increase over the same time span. We found medium to large effects of dementia on driving abilities in six of the seven recent studies that examined driving impairment. We also found that persons with dementia were much more likely to fail a road test than healthy controls (RR: 10.77, 95% CI: 3.00-38.62, z = 3.65, p < 0.001), with no significant heterogeneity (χ2 = 1.50, p = 0.68, I2 = 0%) in a pooled analysis of four studies. Although the limited data regarding MVCs are equivocal, even mild stages of dementia place patients at a substantially higher risk of failing a performance-based road test and of demonstrating impaired driving abilities on the road.

Development of a video-based technique for ambulatory monitoring of foot placement with an instrumented rollator.

OBJECTIVE: To develop a video-based system, mounted on a rollator to quantify the step width values of rollator users in the community. SUBJECTS: A total of 5 able-bodied young adults, age range 24-28 years. METHODS: A digital video camera system was mounted on the rollator frame to capture the position of the participant's feet during overground walking. A method of estimating step width from the video data was developed and evaluated against the output from a concurrently recording Vicon MX motion capture system. RESULTS: Mean step widths of the rollator and motion capture systems were 14.40 cm (standard deviation (SD) 4.64) and 14.37 cm (SD 4.34), respectively, revealing a strong level of agreement; intra-class correlation coefficient 0.999 (95% confidence interval (95% CI) 0.987-1.000; and root-mean-square difference 0.70 cm. CONCLUSION: The video-based system mounted on a rollator to collect foot placement data enabled accurate measurement of step width during rollator use. The ability to record foot placement measurements outside the laboratory setting, characterizing foot placement patterns occurring in the community, will enable research into how these assistive devices influence mobility during everyday use.

Combining ambulatory and laboratory assessment of rollator use for balance and mobility in neurologic rehabilitation in-patients.

PURPOSE: Despite the common use of rollators (four-wheeled walkers), understanding their effects on gait and balance is limited to laboratory testing rather than everyday use. This study evaluated the utility of an ambulatory assessment approach to examine balance and mobility in everyday conditions compared to a laboratory assessment. METHODS: Standing and walking with a rollator was assessed in three neurological rehabilitation in-patients under two conditions: (1) in laboratory (i.e. forceplate, GaitRite), and (2) while performing a natural walking course within and outside of the institution. An instrumented rollator (iWalker) was used to measure variables related to the balance control (e.g. upper limb kinetics), destabilizing events (e.g. stumbling), and environmental context. RESULTS: Two of three patients demonstrated greater reliance on the rollator for standing balance (2.3-5.9 times higher vertical loading, 72-206% increase in COP excursion) and 29-42% faster gait during the walking course compared to the laboratory. Importantly, destabilizing events (collisions, stumbling) were recorded during the walking course. Such events were not observed in the laboratory. CONCLUSION: This study illustrated a greater reliance on the rollator during challenges in everyday use compared to laboratory assessment and provided evidence of specific circumstances associated with destabilizing events that may precipitate falls in non-laboratory settings. Implications for Rehabilitation The value of combining laboratory and ambulatory assessment approaches to provide a more comprehensive profile of the risks and benefits of rollator use to prevent falling was studied. Patients demonstrated greater reliance on rollator assistive devices for standing balance and exhibited higher gait speeds during ambulatory assessment, compared to standard laboratory protocols. Repeated instances of events that may precipitate falls (e.g. collisions, stumbling, and unloading behaviors) were observed only during the ambulatory assessment. Individual challenges to balance can be used to identify specific training targets, assess suitability for assistive devices, and recommend rehabilitation goals.

Foot placement patterns of female rollator users with multiple sclerosis in the community.

PURPOSE: The objective of this study was to investigate the relationship between medio-lateral foot placement characteristics and environmental context when individuals with Multiple Sclerosis (MS) walk with a rollator (four-wheeled walker). METHOD: Ten women diagnosed with MS, who used rollators regularly, participated in this study. First, a rollator-based technique of calculating step width (SW) was validated in this patient population by comparing the output of an instrumented rollator (iWalker) to a laboratory-based Vicon Motion Capture System. Secondly, the iWalker-based technique was used to calculate the participants' SW and SW variability as they used the iWalker in four common outdoor community environments. RESULTS: There was a strong level of agreement between the iWalker and Vicon SW calculations, with an intra-class correlation coefficient of 0.993 and a root-mean-square difference of 0.71 cm. Furthermore, SW variability (P = 0.002), but not SW (P = 0.288), was influenced by the walking environment (i.e. between the in-lab vs. up-ramp and up-ramp vs. down-ramp conditions). CONCLUSIONS: Foot placement variability appears to be influenced by the walking environment of MS patients. Therefore, an enhanced understanding of walker-user interactions in relation to the environment must be established in order to improve mobility.