Impaired Right leg motor control post-stroke and its impact on return to driving in Australia:

A rehabilitation plan using motor control theory and motor learning approaches.

Case Study
HOPC:

Mr Hammond, 73-year-old male presented to ED with right-sided weakness. CTB

suggested a small acute ischaemic stroke in the left motor cortex, with MRI confirming a
middle cerebral artery stroke. He was treated at the base hospital then transferred to a
rehabilitation hospital. The doctor admitted him for estimated in-patient stay of two
weeks. Mr Hammond reported right leg weakness had significantly improved but
complained of on-going fatigue, and weakness in his right arm. He is left hand dominant.

SHx:

Mr Hammond is a retired insurance assessor, OH&S manager, and semi-professional

landscape photographer. He lives with his wife, a nurse, in their own home, accessed by
three stairs. His leisure activities include daily beach walks of several kilometres and
driving to remote locations in his 4WD to take photos.

PMHx:

HTN, T2DM, peripheral mononeuropathy in left foot, R) TKR 2022.

OE:

Mobility: Independent bed mobility + transfers. Mobilises independent nil aid >150m.
Stairs: x4 with assistance of x2 rails.

MMT:

- LL R=L 5/5 in all ROM

- UL L) 5/5 in all ROM,
- UL R) Unable to raise right arm to 90° forward flexion, limited to 50°and able to hold
for 30 seconds. Unable to externally rotate R UL, abduction 3-/5. Elbow
Flexion/Extension 3/5. Wrist Flex/Extension 3/5.

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 - Grip Strength: R=15kg L =55kg

Sensation: UL R=L NAD, LL R) NAD, L reduced sensation on plantar and dorsal surface of
foot (premorbid 2° peripheral neuropathy).

Co-ordination:

- R) UL Dysdiadochokinesia evident with fast finger tapping and rapid

pronation/supination of the forearm. Finger opposition slow and effortful
- L) UL NAD
- Step test: 17 R) Stance, 21 L) stance //note reduced accuracy in foot placement on R
LL, and a reliance on visual input for foot placement.

Proprioception: NAD R=L UL and LL

Tardieu: NAD

Vision: NAD// patient awaiting specialist optometrist review for return to drive

6MWT: 135 meters independent nil aid. Reduced arm swing in R UL. At 80 meters right
leg showed evidence of fatigue with reduced dorsiflexion and poor foot clearance in
swing phase of gait and weakness of right knee in stance // patient showed insight into
deficit commenting to therapist that right leg was “giving up” and showed reduced
ability to dual task as focus on correct gait increased.

TUG: 19 seconds (I) nil aid

MoCa: 30/30.

Impairment/Activity/Participation:

Mr Hammond has impaired right upper limb function, which potentially impacts steering
control and indicator operation, and reduced sensation and gross motor control of right
lower limb which worsens with fatigue and reduces dual tasking ability. This potentially
impacts the time dependent operational tasks of pedal control and braking in a complex
driving situations. He is currently unable to perform the activity of driving a car, and
operating a camera and computer, which limits his participation in his professional and
leisure activity of driving to remote locations to take photographs and then edit them.

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Physiotherapy rehabilitation goal:

Return to driving automatic transmission 4WD on dirt roads within four weeks to
participate in retirement business of semi-professional landscape photographer.

Plan:

MDT in-patient rehabilitation towards return to driving goal with OT focusing on upper
limb function/steering control/car modification and computer accessibility, and
physiotherapy targeting lower limb motor control with a focus on braking speed and
safe pedal use in co-ordination with UL, with follow up day rehabilitation program to co-
ordinate upper and lower limb function in simulated and real-world task specific
training.

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Possible mechanisms of the client's impairments

Driving is a dynamic task requiring interactions between visual, cognitive, perceptual, and
motor systems (Akinwuntan et. al., 2012) in a hazardous environment using expensive
equipment (Debeljak et. al., 2019). Safe driving requires the ability to steer, maintain and
control speed, and react to unpredictable events by braking, with impaired braking time
being predictive of crash-risk (Lodha et. al., 2019). Reaction time is essential for safe driving
and is defined as “the time from the perception of a signal until the execution of a particular
action” (Debeljak et. al., 2019, p. 1). The cognitive component of braking requires perceiving
and processing visual and sensory input and planning the speed and force modulation of
pedal depression, the motor component involves releasing the accelerator, moving the foot
to the brake, and applying the appropriate force (Lodha et. al., 2021).

Speed control involves tibialis anterior and plantar flexors working in synergy to control
forces exerted on the accelerator (Fujita et. al., 2021). Sudden braking increases tibialis
anterior activity to rapidly dorsiflex the foot off the pedal with the leg in slight external
rotation, while triceps surae decreases plantarflexion (Fujita et. al., 2021) During pedal
switching, toes move left, the hip internally rotates and adducts, rectus femoris flexes the
hip to facilitate transitioning to the brake pedal, and soleus and gastrocnemius activate at
high velocity to depress the brake (Fujita et. al., 2021). Motor impairments that hinder
lower limb (LL) function post stroke include declines in strength and motor control, which
can manifest as difficulty generating force with the paretic limb and inability to produce
precise and steady motor output (Akinwuntan et. al., 2012).

Impaired LL control causes pedal errors (Fujita et. al., 2021). Mr Hammond has impaired
right LL control, evidenced by poor step-test score and decreased dorsiflexion in swing
phase of gait exacerbated by fatigue. Tibialis anterior fatigue diminishes ability to produce
precise, steady motor output required for sustained pedal control (Lodha, 2019) and causes
accidental accelerator depression or catching the underside of the brake pedal during
transitions (Fujita et. al., 2021). Sustained attention when driving is focused externally to the
road environment (Shimonaga et. al., 2021) so foot movement needs to happen without
visual feedback on foot position. Whilst Mr Hammond has good cognition and directed
sustained attention, which is congruent with research supporting the role of the (intact)
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right hemisphere in sustaining attention necessary for driving (Shimonaga et. al., 2021).
When challenged with sudden braking, the potential inability to rapidly divide attention
between the road and ankle movement may result in slower reactions (Lodha et. al., 2021).
Rapid braking could be considered a higher order motor behaviour requiring integration of
sensory outputs to accurately assess the surrounding environment and produce the correct
motor output (Chen et. al., 2018).

This requires a computational model which co-ordinations motor planning, prediction, and
state estimation (Flash & Sejnowski, 2001) to select the correct kinematic model to ensure
co-ordinated foot movement with the correct velocity, based on the predicted sensory
outcome of the motor command, which depends on the environment or road surface
(gravel/bitumen/wet/dry), with rapid monitoring of sensorimotor input to determine if the
action is achieving the desired outcome (e.g., timely and safe stopping). From a hierarchical
motor control perspective, information from visual signals (what is happening on the road
ahead, speedometer, position of the vehicle in space) is co-ordinated with task context
(wet/dry/dirt road) requiring high level cognitive control with co-ordinated input from
proprioceptive and sensory information about foot position relative to pedals (Merel et. al.,
2019).

Constraints impacting outcomes relate to the individual, the environment, and the task
(Newell, 1986). Individual constraints could include structural components of muscle
strength and endurance and sensation, and functional constraints such as cognitive ability,
dual tasking, impulse control, and fatigue. Environment constraints could pertain to car
type, road conditions, weather or traffic, and task constraints could include driving on the
correct side of the road, and obeying road signs and speed limits. According to motor
schema theory (Wulf, 2012), the task of driving could be conceived to be a movement
pattern based on a generalised motor program based on learned and remembered motor
response based on the sensory consequences of previous motor commands i.e., previous
experience with braking in various conditions would inform motor skill of pedal control.

Rehabilitation for return to driving goals.

Driving is an important rehabilitation goal post-stroke (Devos et. al., 2021, Rapoport et. al.,
2019) that improves quality of life by fostering independence, social engagement, and
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opportunities for participation in employment and leisure (Debeljak et. al., 2019). Multiple
factors need to be considered for safe driving in all conditions, including perception,
judgement of spatial relationships, planning, memory, self-control, motor function, reaction
times, attention, and fatigue (Debeljak et. al., 2019). Physiotherapists must consider patients
ability to perform motor skills e.g., pedal operation, the ability to apply these skills in rule-
based situations e.g., reducing speed at an intersection, and ability to apply knowledge e.g.,
risks of driving on a wet dirt road (Akinwuntan, 2012). Patients also need to demonstrate
insight into non-motor stroke impairments such as fatigue and attention in relation to
environmental factors such as traffic, weather, and time of day, and be able to make safe
decisions about when abilities may be impaired (Austroads, 2022).

Retraining patients to appropriately respond to driving hazards involves targeting motor

adaptations to update the existing skill of driving to adapt to physical changes post stroke
(Caligiore et. al., 2019), with consideration given to sensorimotor feedback and the role of
cognition in skill application (George et. al., 2014.) Evidence is limited as to which
interventions and assessments are most salient in addressing post-stroke driving ability
(Devos. Et al., 2021, George et. al., 2014). In NSW, fitness to drive is determined by GPs in
co-operation with specialist OTs and state government licensing officials, with assessors
considering driving tasks, individual impairments, and the driver’s ability to function with
and compensate for these impairments (Austroads, 2022). A minimum four-week driving
restriction exists post-stroke, with medical clearance needed to resume driving (Stroke
Foundation, n.d.). If deficits persist past four weeks, driver-trained OT assessment may be
required (Frith et. al., 2021). Clearance may be contingent on car modifications (e.g.,
steering aid, power brakes) or licencing category (e.g., distance or time restricted
categories). Return-to-drive rehabilitation plans must consider screening, assessment,
intervention (Devos et. al., 2021), and time constraints. MDT rehabilitation should include
detailed OT cognitive screening and assessments of motor and visual abilities, and
interventions to improve driving skills which may include contextual training in a simulator
or on the road (Devos et. al., 2021). Driving simulators may seem to be a judicious
intervention to expose patients to complex and challenging situations without the
consequences of a real-world crash, however limited evidence exists as to the relationship
between performance on simulators and real driving situations, and limitations include
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simulation sickness (which predominantly affects older people) and lack of access to
technology (Rapoport et. al., 2019).

Mr Hammond scored well on memory, executive functioning, attention, and visuospatial

awareness in his MocA (Wood et. al.,2021), and previously worked in a field assessing risk
and seeing the consequences of road accidents so driving is a realistic rehabilitation goal as
his main impairments are fatigue and lower limb function and he shows good insight into
impairments and is likely to make safe strategic decisions. Interventions targeting
movement training to restore the motor skill of timely pedal operation and education about
the impacts of attention and fatigue are necessary achieve his goal of returning to dirt road
driving in four weeks.

A systematic review in Australia showed less than 50% of stroke survivors received return to
drive education, and 30% resumed driving against recommendations (Frith et. al., 2021), so
rehabilitation needs to include comprehensive driver education. Rehabilitation principles of
use it or lose it, use it, and improve it, specificity, repetition, intensity, and salience are
relevant for driving rehabilitation (George et. al., 2014). As access to driving simulators may
not be possible, and in-patient rehabilitation takes place during the restricted driving period,
specificity and salience may be facilitated through motor priming motor cortex with specific
motor imagery and action observation to influence the corticospinal excitability to specific
muscles (Stoykov & Madhavan., 2015).

Rehabilitation plan
Physiotherapy rehabilitation intervention will target deficits in braking to prevent collision
and road injury (Lodha et. al., 2021) and will be structured around 10 guiding principles for
movement training in neurorehabilitation: actual and predicted bodily state, feedback,
error-based learning, reward-based learning, practice and variability, biomechanics, physical
capacity, attention, and belief/self-efficacy, (McLoughlin., 2020). Consideration needs to be
given to ensuring that the goal of driving is addressed in the acute phase of stroke recovery
as it may be more likely to be more effective (McNamara (2016).

The intervention will be delivered in the following format:

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 - 0-2 weeks: in-patient rehabilitation: including physiotherapy (PT), occupational
therapy (OT), social work and rehabilitation physician. Divided into A and B Day
therapy plans to maintain interest.
- 2 weeks- 3 months: out-patient rehabilitation: 6 hours per week MDT intervention
- 3 months- 12 months: 1:1 sessions targeting stroke prevention.

The following plan addresses the in-patient rehabilitation plan targeting return-to-drive
goals and addresses the physiotherapy component of the MDT rehabilitation plan.

Considerations in the delivery of the intervention include education on the process of return
to drive including printing out information for patients from Stroke Foundation website
(Stroke Foundation n.d), and education on the impact of fatigue on muscle function and
dangers of dual tasking such as talking on the phone or holding an intense conversation.

In-patient therapy 2 x 1-hour daily sessions including :

Motor imagery, mental practice of driving in specific situations, and action observation:
observe recording of previous sessions, as observing an action and action execution shares
the same functional execution in the brain and motor imagery enhances corticospinal
excitability of specific muscles involved in motor tasks (Stoykov & Madhavan., 2015).

10 minutes of movement-based priming, resting as needed, as any repetitive or continuous

movement can enhance the effect of the accompanying therapy and facilitate the activation
of long-term potentiation or long-term depression neuroplasticity mechanisms (Stoykov &
Madhavan., 2015).

A day: 3x 1 min each - sit-to-stands/ boxing.

B day: 5 min each - upper limb ergometer/cycling, resting as required

Leg strengthening: power, endurance, and control: weakness of the lower limb and loss of
ability to develop ankle torques impairs braking action, and driving rehabilitation must
target tibialis anterior, plantar flexors quadriceps and hip adductors, with consideration of
both strength and motor control (Fujita et. al., 2021) to ensure rapid movement of the foot
between pedals and endurance of long-duration force modulation on the accelerator.

A
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 - Heel raises on edge of foam/non-compliant surface as many reps as possible
(AMRAP) – use affected UL to hold on to parallel bar to enable loading of UL
- Heel raises on reformer, double/single leg – eccentric dorsiflexion fast up, controlled
down (AMRAP)
- Leg press on reformer double/single leg – increase load as soon as comfortable able
to perform 3x10.
- TheraBand dorsiflexion/plantarflexion

- Adductor squeeze with Pilates ball - seated

- Squats – add weights, increase load as soon as comfortable able to perform 3x10.
- High knee marching (AMRAP in 4x 60 secs)
- Seated Toe taps (AMRAP in 4x 60 secs)

Co-ordination + dual tasking to train reaction time.

- Seated Toe taps holding pulleys level + dual tasking activity “stop” cue.
- Seated rapid toe taps between two targets/cups/dumbbells (eyes closed as foot
movement must occur with no visual input) (AMRAP in 2x 60 secs)

- Step tap (no vision/eyes front – need sensory target to provide knowledge of results
– either audible or able to be felt + dual tasking activity
- Simulation of foot movement between pedals required for rapid braking e.g.,
pressing the pedals on a Sara Stedy/practicing in a real car to ensure specificity and
salience – use “stop” prompt – can use video/gamification if available to simulate
driving.

Proprioception and balance training

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A

- step downs to target whilst standing on a non-complaint surface, use affected UL to

hold on to parallel bar to enable loading of UL.
- multidirectional stepping

- Foam: feet together eyes open/closed, single leg stance

- Balance board

Physiotherapy and OT must communicate to ensure upper limb and lower limb components
of driving are both addressed, where possible activities should incorporate upper and lower
limb as well as cognitive/dual tasking aspects of training – e.g., getting Mr Hammond to use
a stopwatch or rep counter in affected hand to time/count activity. The aim of acute
physiotherapy is restoration of function improve motor control and reaction time in the
right foot to enable participation in leisure through returning to drive.

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References

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