Symbol digit modalities test predicts decline of off-road driving ability in Japanese patients with multiple sclerosis

Published:August 26, 2022DOI:


      • Driving ability was evaluated using driving simulator and SDMT in MS patients (78/85).
      • MS patients are associated with cognitive decline even when motor disability is mild (85/85).
      • SDMT detects deteriorations of attention and information processing speed in MS (80/85).
      • This study revealed a relationship between driving abilities and SDMT scores (75/85).
      • Clinical evaluation using SDMT may help to make a decision on driving in MS (76/85).



      Multiple sclerosis (MS) is a chronic progressing neurological disease with exacerbations and remissions. Patients with MS can show a variety of neurological symptoms. Cognitive decline is noticed as one of them and is related with deterioration of daily life quality in a clinical practice. Driving a car is one of the common activities required in daily life and is also an important issue in MS patients.


      To clarify the relationship between cognitive function and driving ability in MS patients, the symbol digit modalities test (SDMT) and a driving simulator were evaluated. We enrolled 24 patients with MS (5 males, 19 females, 39.04 ± 8.27 years old) and age- and sex-matched 24 healthy controls (5 males, 19 females, 40.54 ± 9.78 years old) in this study. They underwent the SDMT and also used a driving simulator to measure a total of 12 response values related to driving ability. In order to evaluate the relationship between SDMT and driving ability, MS patients were divided into two groups according to the median SDMT score: group A (SDMT 51 or more) and group B (SDMT less than 51). The data were statistically analyzed among control group, MS group A, and MS group B using Jonkheere-Terpstra trend test and Bonferroni's multiple comparison test.


      The group with higher scores on the SDMT tended to have significantly higher driving performance. Multiple comparison analysis among three groups showed that the reaction values for speed of response behavior were significantly higher in MS group B than control group.


      This study revealed a relationship between driving abilities and SDMT scores. Clinical evaluation using the SDMT may help to detect cognitive decline and to make a decision on driving a car in patients with MS.


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        • Benedict R.H.B.
        • Zivadinov R.
        Risk factors for and management of cognitive dysfunction in multiple sclerosis.
        Nat. Rev. Neurol. 2011; 7: 332-342
        • Benedict R.H.B.
        • Deluca J.
        • Phillips G.
        • Larocca N.
        • Hudson L.D.
        • Rudick R.
        Validity of the symbol digit modalities test as a cognition performance outcome measure for multiple sclerosis.
        Mult. Scler. 2017; 23: 721-733
        • Chiaravalloti N.D.
        • Deluca J.
        Cognitive impairment in multiple sclerosis.
        Lancet Neurol. 2008; 7: 1139-1151
        • Classen S.
        • Bewernitz M.
        • Shechtman O.
        Driving simulator sickness: an evidence-based review of the literature.
        Am. J. Occup. Ther. 2011; 65: 179-188
        • Devos H.
        • Vandenberghe W.
        • Tant M.
        • Akinwuntan A.E.
        • Weerdt W.D.
        • Nieuwboer A.
        • Uc E.Y.
        Driving and off-road impairments underlying failure on road testing in Parkinson's disease.
        Mov. Disord. 2013; 28: 1949-1956
        • Grace J.
        • Amick M.M.
        • D'abreu A.
        • Festa E.K.
        • Heindel W.C.
        • Ott B.R.
        Neuropsychological deficits associated with driving performance in Parkinson's and Alzheimer's disease.
        J. Int. Neuropsychol. Soc. 2005; 11: 766-775
        • Harand C.
        • Mondou A.
        • Chevanne D.
        • Bocca M.L.
        • Defer G.
        Evidence of attentional impairments using virtual driving simulation in multiple sclerosis.
        Mult. Scler. Relat. Disord. 2018; 25: 251-257
        • Jacobs M.
        • Hart E.P.
        • Roos R.A.C.
        Driving with a neurodegenerative disorder: an overview of the current literature.
        J. Neurol. 2017; 264: 1678-1696
        • Kotterba S.
        • Orth M.
        • Eren E.
        • Fangerau T.
        • Sindern E.
        Assessment of driving performance in patients with relapsing-remitting multiple sclerosis by a driving simulator.
        Eur. Neurol. 2003; 50: 160-164
        • Kurtzke J.F.
        Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
        Neurology. 1983; 33: 1444-1452
        • Lings S.
        Driving accident frequency increased in patients with multiple sclerosis.
        Acta Neurol. Scand. 2002; 105: 169-173
        • Lopez-Gongora M.
        • Querol L.
        • Escartin A.
        A one-year follow-up study of the symbol digit modalities test (SDMT) and the paced auditory serial addition test (PASAT) in relapsing-remitting multiple sclerosis: an appraisal of comparative longitudinal sensitivity.
        BMC Neurol. 2015; 15
        • Marcotte T.D.
        • Rosenthal T.J.
        • Roberts E.
        • Lampinen S.
        • Scott J.C.
        • Allen R.W.
        • Corey-Bloom J.
        The contribution of cognition and spasticity to driving performance in multiple sclerosis.
        Arch. Phys. Med. Rehabil. 2008; 89: 1753-1758
        • Mckay K.A.
        • Bedri S.K.
        • Manouchehrinia A.
        • Stawiarz L.
        • Olsson T.
        • Hillert J.
        • Fink K.
        Reduction in cognitive processing speed surrounding multiple sclerosis relapse.
        Ann. Neurol. 2022; 91: 417-423
        • Michon J.A.
        • Evans L.
        • Schwing R.C.
        A critical view of driver behavior models: what do we know, what should we do?.
        Human Behavior and Traffic Safety. Plenum Press, New York1985
        • Morrow S.A.
        • Classen S.
        • Monahan M.
        • Danter T.
        • Taylor R.
        • Krasniuk S.
        • Rosehart H.
        • He W.
        On-road assessment of fitness-to-drive in persons with MS with cognitive impairment: a prospective study.
        Mult. Scler. 2018; 2018: 1499-1506
        • Nakagawa Y.
        • Park K.
        • Ueda H.
        • Ono H.
        • Miyake H.
        Being watched over by a conversation robot may enhance safety in simulated driving.
        J. Saf. Res. 2019; 71: 207-218
        • Niino M.
        • Mifune N.
        • Kohriyama T.
        • Mori M.
        • Ohashi T.
        • Kawachi I.
        • Shimizu Y.
        • Fukaura H.
        • Nakashima I.
        • Kusunoki S.
        • Miyamoto K.
        • Yoshida K.
        • Kanda T.
        • Nomura K.
        • Yamamura T.
        • Yoshii F.
        • Kira J.
        • Nakane S.
        • Yokoyama K.
        • Matsui M.
        • Miyazaki Y.
        • Kikuchi S.
        Apathy/depression, but not subjective fatigue, is related with cognitive dysfunction in patients with multiple sclerosis.
        BMC Neurol. 2014; 14
        • Okuma R.
        • Watanabe S.
        • Tatewaki M.
        • Iwai K.
        • Abo M.
        Relationship between the evaluation of driving simulators and the judgment of resumption of driving for brain injured persons: examination of standard value for judging the possibility of restarting operation.
        JOTR. 2020; 39: 202-209
        • Ooba H.
        • Inoue T.
        • Hirano M.
        • Takehara I.
        • Watanabe S.
        • Hitosugi M.
        Management of rehabilitation for resumption of post-stroke taxi driving.
        JCTS. 2017; 16: 46-54
        • Parmenter B.A.
        • Weinstock-Guttman B.
        • Garg N.
        • Munschauer F.
        • Benedict R.H.B.
        Screening for cognitive impairment in multiple sclerosis using the symbol digit modalities test.
        Mult. Scler. 2007; 13: 52-57
        • Polman C.H.
        • Reingold S.C.
        • Banwell B.
        • Clanet M.
        • Cohen J.A.
        • Filippi M.
        • Fujihara K.
        • Havrdova E.
        • Hutchinson M.
        • Kappos L.
        • Lublin F.D.
        • Montalban X.
        • O’Connor P.
        • Sandberg-Wollheim M.
        • Thompson A.J.
        • Waubant E.
        • Weinshenker B.
        • Wolinsky J.S.
        Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria.
        Ann. Neurol. 2011; 69: 292-302
        • Rao S.M.
        • Leo G.J.
        • Bernardin L.
        • Unverzagt F.
        Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction.
        Neurology. 1991; 41: 685-691
        • Rao S.M.
        • Leo G.J.
        • Ellington L.
        • Nauertz T.
        • Bernardin L.
        • Unverzagt F.
        Cognitive dysfunction in multiple sclerosis. II. Impact on employment and social functioning.
        Neurology. 1991; 41: 692-696
        • Rocca M.A.
        • Amato M.P.
        • Stefano N.D.
        • Enzinger C.
        • Geurts J.J.
        • Penner I.K.
        • Rovira A.
        • Sumowski J.F.
        • Valsasina P.
        • Filippi M.
        Clinical and imaging assessment of cognitive dysfunction in multiple sclerosis.
        Lancet Neurol. 2015; 14: 302-317
        • Ryan K.A.
        • Rapport L.J.
        • Harper K.T.
        • Fuerst D.
        • Bieliauskas L.
        • Khan O.
        • Lisak R.
        Fitness to drive in multiple sclerosis: awareness of deficit moderates risk.
        J. Clin. Exp. Neuropsychol. 2009; 31: 126-139
        • Schultheis M.T.
        • Garay E.
        • Deluca J.
        The influence of cognitive impairment on driving performance in multiple sclerosis.
        Neurology. 2001; 56: 1089-1094
        • Stein A.C.
        • Dubinsky R.M.
        Driving simulator performance in patients with possible and probable Alzheimer's disease.
        Ann. Adv. Automot. Med. 2011; 55: 325-334
        • Takehara I.
        • Hitosugi M.
        • Watanabe S.
        • Hayashi Y.
        • Yonemoto K.
        • Abo M.
        A reference value of higher brain function for resumption of driving in patients with brain injury.
        Jpn. J. Rehabil. Med. 2016; 53: 247-252