Evaluation of two assessment tools in predicting driving ability of senior drivers

OBJECTIVE: To evaluate Motor Free Visual Perceptual Test (MVPT) and Clock Drawing Task (clock test) as quick assessment tools in predicting driving capability of senior drivers for an on-road driving test. DESIGN: Senior drivers (> or = 55 yrs) referred for evaluation and recommendation for license renewal were given the MVPT, clock test, and an on-road driving test. Receiving operating characteristic (ROC) analysis and stepwise multivariate logistic regression (SMLR) were used to develop a probability model to differentiate between capable and incapable senior drivers. RESULTS: Data for 232 seniors who had completed all written tests and the on-road driving test were analyzed. Of the 232 seniors, 131 (56%) were classified as capable and 101 (44%) as incapable drivers on the road test. Mean scores for capable and incapable drivers were MVPT 32.0 +/- 4.0 vs. 28.4 +/- 4.6 and mean clock test score 3.5 +/- 0.8 vs. 2.7 +/- 1.2, and mean processing time was 7.1 + 6.5 vs. 10.6 + 5.5. The means of the three measurements were significantly different between the two groups (P value <0.001). ROC curve analysis revealed an optimal cut point of > or = 32 for MVPT score with 60% sensitivity and 83% specificity. The optimal cut point for clock test scores is > or = 3 with 70% sensitivity and 65% specificity. The optimal cut point for processing times is < or = 6.27 secs with 60% sensitivity and 80% specificity. SMLR showed that the most significant predictor of seniors' driving capabilities are the MVPT test scores and clock test scores. CONCLUSION: MVPT and clock test tools are significant predictors of driving capability on an on-road driving test.     

On the road again after traumatic brain injury: driver safety and behaviour following on-road assessment and rehabilitation

Purpose: To examine pre- and post-injury self-reported driver behaviour and safety in individuals with traumatic brain injury (TBI) who returned to driving after occupational therapy driver assessment and on-road rehabilitation. Method: A self-report questionnaire, administered at an average of 4.5 years after completing an on-road driver assessment, documenting pre- and post-injury crash rates, near-crashes, frequency of driving, distances driven, driving conditions avoided and navigation skills, was completed by 106 participants, who had either passed the initial driver assessment (pass group n?=?74), or required driver rehabilitation, prior to subsequent assessments (rehabilitation group n?=?32). Results: No significant difference was found between pre- and post-injury crash rates. Compared to pre-injury, 36.8% of drivers reported limiting driving time, 40.6% drove more slowly, 41.5% reported greater difficulty with navigating and 20.0% reported more near-crashes. The rehabilitation group (with greater injury severity) was significantly more likely to drive less frequently, shorter distances, avoid: driving with passengers, busy traffic, night and freeway driving than the pass group. Conclusions: Many drivers with moderate/severe TBI who completed a driver assessment and rehabilitation program at least 3 months post-injury, reported modifying their driving behaviour, and did not report more crashes compared to pre-injury. On-road driver training and training in navigation may be important interventions in driver rehabilitation programs.

• Implications for Rehabilitation

• Driver assessment and on-road retraining are important aspects of rehabilitation following traumatic brain injury.

• Many drivers with moderate/severe TBI, reported modifying their driving behaviour to compensate for ongoing impairment and continued to drive safely in the longer term.

• Navigational difficulties were commonly experienced following TBI, suggesting that training in navigation may be an important aspect of driver rehabilitation.

     

Effectiveness of a visual attention retraining program on the driving performance of clients with stroke

OBJECTIVE: To compare the effectiveness of a visual attention retraining program using the Useful Field of View (UFOV) with a traditional visuoperception treatment program on the driving performance of clients with stroke. DESIGN: Randomized controlled trial. SETTING: Rehabilitation hospital located in Quebec, Canada. PARTICIPANTS: Ninety-seven individuals referred for driving evaluation after a stroke. INTERVENTIONS: Participants were randomized to receive 20 sessions of either UFOV training of visual processing speed, divided attention, and selective attention or traditional computerized visuoperception retraining. MAIN OUTCOME MEASURES: Subjects were evaluated with an on-road driving evaluation, visuoperception tests, and the Test of Everyday Attention. An occupational therapist unaware of group assignment conducted all evaluations. RESULTS: Eighty-four participants completed the outcome evaluation. There were no significant differences between groups on any of the outcome measures. There was, however, almost a 2-fold increase (52.4% vs 28.6%) in the rate of success on the on-road driving evaluation after UFOV training for subjects with right-sided lesions. CONCLUSIONS: Rehabilitation that targets visual attention skills was not significantly more beneficial than traditional perceptual training in improving the outcome of an on-road driving evaluation. However, results suggest a potential improvement for subjects with right-sided lesions, indicating that training must target specific skills.     

Validation of a driving simulator by measuring the visual attention skill of older adult drivers.

OBJECTIVE: The purpose of this study was to validate a laboratory-based driving simulator as an off-road screening tool for older adult drivers by measuring their visual attention skill, and to determine how the visual attention skill changes across time in a 45-minute simulated driving test. METHOD: One hundred and twenty-nine community-dwelling older drivers volunteered to take part in the study. A range of driving scenarios was devised and implemented in a simulator setting to assess the driving skills of the participants. Visual attention skill, an important contributing factor to motor vehicle crashes, was assessed by the participant's reaction times to a sequence of 14 visual stimuli during the primary task of sustained driving. Repeated measures of analysis of variance (ANOVA) were undertaken to determine the effects of age and gender on the visual attention skill. Trend analysis was performed to investigate how repeated exposures to the visual stimulus affected the reaction time. RESULTS: The visual attention skill of older drivers was found to decline with age (F(1,126)) = 42.52, p value = 0.002), whereas the effect of gender was not significant. Participants increased their speed of reaction times for the first half of the testing then slowed down during the second half. CONCLUSION: That visual attention skill declined with age was consistent with the literature, and validated the driving simulator as an effective screening tool for older adult drivers. With rapid advancements in computer technology, the driving simulator will likely play an important role in assisting occupational therapists with off-road assessment of older drivers.     

Characterizing on-road driving performance in individuals with traumatic brain injury who pass or fail an on-road driving assessment

Objective: To characterise on-road driving performance in individuals with traumatic brain injury who fail on-road driving assessment, compared with both those who pass assessment and healthy controls, and the injury and cognitive factors associated with driving performance.

Study design: Cross-sectional.

Methods: Forty eight participants with traumatic brain injury (Age M?=?40.50 SD?=?14.62, 77% male, post-traumatic amnesia days M?=?28.74 SD =27.68) and 48 healthy matched controls completed a standardised on-road driving assessment in addition to cognitive measures.

Results: Individuals with traumatic brain injury who passed on-road driving assessment performed no differently from controls while individuals with traumatic brain injury who failed the assessment demonstrated significantly worse driving performance relative to controls across a range of driving manoeuvres and error types including observation of on-road environment, speed control, gap selection, lane position, following distance and basic car control. Longer time post-injury and reduced visual perception were both significantly correlated with reduced driving skills.

Conclusions: This exploratory study indicated that drivers with traumatic brain injury who failed on-road assessment demonstrated a heterogeneous pattern of impaired driving manoeuvres, characterised by skill deficits across both operational (e.g., basic car control and lane position) and tactical domains (e.g., following distance, gap selection, and observation) of driving. These preliminary findings can be used for implementation of future driving assessments and rehabilitation programs.

• Implications for rehabilitation

• Clinicians should be aware that the majority of individuals with traumatic brain injury were deemed fit to resume driving following formal on-road assessment, despite having moderate to very severe traumatic brain injuries.

• Drivers with traumatic brain injury who failed an on-road assessment demonstrated a heterogeneous pattern of impaired skills including errors with observation, speed regulation, gap selection, and vehicle control and accordingly had difficulty executing a diverse range of common driving manoeuvres.

• Comprehensive, formal on-road assessments, incorporating a range of skills, and manoeuvres, are needed to evaluate readiness to return to driving following traumatic brain injury.

• Individually tailored driver rehabilitation programs need to address these heterogeneous skill deficits to best support individuals to make a successful return to driving post-traumatic brain injury.

     

Visual testing for readiness to drive after stroke: a multicenter study

OBJECTIVE: The purpose of this study was to determine the ability of a visual-perception assessment tool, the Motor-Free Visual Perception Test, to predict on-road driving outcome in subjects with stroke. DESIGN: This was a retrospective study of 269 individuals with stroke who completed visual-perception testing and an on-road driving evaluation. Driving evaluators from six evaluation sites in Canada and the United States participated. Visual-perception was assessed using the Motor-Free Visual Perception Test. Scores range from 0 to 36, with a higher score indicating better visual perception. A structured on-road driving evaluation was performed to determine fitness to drive. Based on driving behaviors, a pass or fail outcome was determined by the examiner. RESULTS: The results indicated that, using a score on the Motor-Free Visual Perception Test of < or =30 to indicate poor visual-perception and >30 to indicate good visual perception, the positive predictive value of the Motor-Free Visual Perception Test in identifying those who would fail the on-road test was 60.9% (n = 67/110). The corresponding negative predictive value was 64.2% (n = 102/159). Univariate logistic regression analyses revealed that older age, low Motor-Free Visual Perception Test scores and a right hemisphere lesion contributed significantly to identifying those who failed the on-road test. CONCLUSIONS: The predictive validity of the Motor-Free Visual Perception Test is not sufficiently high to warrant its use as the sole screening tool in identifying those who are unfit to undergo an on-road evaluation.     

Identifying safe versus unsafe drivers following brain impairment: the Coorabel Programme.

The Coorabel Driver Assessment and Training Programme commenced in January 1988, with the aim of providing assessments of the ability of people with a disability to resume or commence driving. This programme incorporates assessments by a medical practitioner, a neuropsychologist, an occupational therapist and a driving instructor, conducted both off and on the road. The first 129 consecutive referrals were reviewed. Non-brain-impaired clients demonstrated a lower failure rate relative to brain-impaired clients. Diagnosis was not found to have predictive value within the brain-impaired clients, and there was no statistical difference in failure rates between left and right hemispheric strokes. Whilst only six cases failed the medical assessment, in 47 cases the medical practitioner was unable to make a final decision regarding driver competence. Neuropsychological and on-road assessments resulted in definitive decisions for 39 of these 47 cases. Twenty cases passed the medical assessment but subsequently failed the neuropsychological or on-road assessment. Only three cases passed at neuropsychological assessment subsequently failed on-road testing. It is suggested that multidisciplinary assessment of driver competence, inclusive of on-road testing, is essential, as medical guidelines alone are insufficient to predict driver fitness.     

Development of the Adelaide driving self-efficacy scale

OBJECTIVE: To describe the development of the Adelaide Driving Self-Efficacy Scale (ADSES) and to report on its reliability and validity. METHODS: A set of 12 driving behaviours, developed through literature review, clinical experience and expert review, were rated for self-efficacy using a Likert scale. Internal consistency was investigated using a Cronbach's alpha coefficient and construct validity by comparing ADSES scores of stroke and non-stroke drivers. Criterion-related validity was examined by comparing ADSES scores with the result on a standardized on-road assessment. SETTING: A rehabilitation hospital in Adelaide, South Australia. PARTICIPANTS: Staff from the hospital and stroke patients from the rehabilitation unit. Data from a non-stroke sample (n -/ 79) and stroke patients (n -/ 81) were used to test internal consistency and construct validity. A separate group of 45 people recommended for a driving assessment, of whom 34 were stroke patients, were used to test criterion validity. RESULTS: Cronbach's alpha coefficient was 0.98, indicating high internal consistency. The non-stroke and stroke groups showed significant differences in ADSES scores (t(158)-/ 5.5, P B < 0.05), demonstrating construct validity. Differences in ADSES scores for those participants who passed or failed the on-road assessment were significant for both the entire driving assessment group (t(43)-/ 3.2, P B < 0.05) and the stroke subgroup (t(43)-/ 3.2, P B < 0.05), indicating criterion validity. CONCLUSION: The ADSES has demonstrated internal consistency and construct validity with the stroke and non-stroke population. The scale demonstrated criterion validity in its relationship with outcome of an on-road driving assessment. It appears to be a reliable and valid measure of driving self-efficacy.     

Driving evaluation practices of clinicians working in the United States and Canada.

OBJECTIVE: To determine off-road and on-road driving evaluation practices of clinicians in the United States and Canada who assess individuals with disabilities for fitness to drive. PARTICIPANTS: Participants were 114 clinician attendees at the 2003 annual Association of Driver Educators for the Disabled with driving assessment experience ranging from 1 month to 25 years. MEASURES: Information was elicited regarding the clinician, clientele, referral practices, and off-road and on-road driving evaluation practices and retraining practices using a self-administered questionnaire. RESULTS: Participants were largely occupational therapists (68%) who worked in 42 different states and provinces. The most prevalent clientele were persons with traumatic brain injury (97%) and stroke (96%). Testing times greater than 60 min were common for both the off-road (61%) and on-road (49%) evaluations. Commonly performed off-road assessments included the Brake Reaction Timer; Trail Making Test, Parts A and B; and the Motor Free Visual Perception Test, used by 73%, 72%, and 66%, respectively; comprehensive computer-based driving evaluation was rare. Sixty-one percent indicated that all clients underwent on-road evaluation regardless of the off-road results. Finally, 78% used a standard driving route, whereas 24% used a scoring system to evaluate on-road driving. CONCLUSION: Driving assessment in Canada and the United States is multidimensional and time-intensive. Although the domains being assessed are similar across clincians, specific off-road and on-road assessment practices vary greatly. The majority use nonstandardized on-road assessments.     

Clinical Determinants of Fitness to Drive in Persons With Multiple Sclerosis: Systematic Review

ObjectiveTo critically appraise the evidence for the clinical determinants of fitness to drive in adults with multiple sclerosis (MS).Data SourcesThe research librarian and lead author searched 7 databases for driving simulator and on-road studies for adults with MS published in the English language from 1991 to 2018.Study SelectionThree reviewers independently screened titles, abstracts, and full-texts for studies with: cohort, case-control, or cross-sectional designs; participants, 18 years or older, with relapsing or progressive MS; visual, cognitive, or motor clinical assessments as predictors; and driving performance through simulator or fitness to drive through on-road assessment as outcomes.Data ExtractionUsing the 2017 American Academy of Neurology guidelines, reviewers independently classified each study from class I to class IV, or highest to lowest amount of rigor. For each clinical assessment, reviewers independently rated the level of confidence for predicting driving performance or fitness to drive from level A, highly probable; B, probable; C, possible; to level U, insufficient conclusions.Data SynthesisThrough qualitative synthesis, 2 class III and 4 class IV driving simulator studies employed 24 clinical assessments with level C (n=4) or level U (n=20) confidence for predicting driving performance. Six class II and 3 class IV on-road studies employed 35 clinical assessments with level B (n=9), level C (n=22), or level U (n=4) confidence for predicting fitness to drive.ConclusionsThis systematic review identified mostly insufficient conclusions for predicting driving performance in driving simulator studies, and possible conclusions for predicting fitness to drive in on-road studies. The best available evidence suggests that the Stroke Driver Screening Assessment and Useful Field of View test probably predict fitness to drive in adults with MS (level B). Class I studies that compare predictors of fitness to drive with large prospective samples of adults with and without MS are necessary for highly probable conclusions.     

Intérêt du simulateur de conduite pour la reprise de la conduite automobile en situation de handicap

AIMS: To evaluate the value of our driving simulator in deciding whether or not to allow patients with physical and/or cognitive deficits to resuming driving and to analyze whether or not the medical expert's final decision is based more on the results of the driving simulator than those of the neuropsychological examination. METHODS: One hundred and twenty-three patients were evaluated with the driving simulator. Thirty-five of those with cognitive deficits also underwent a neuropsychological examination prior to the medical expert's decision on driving aptitude. In cases of uncertainty or disagreement, a driving assessment in real conditions was performed by a driving instructor. RESULTS: In cases of physical handicap, the medical expert's decision concurred with that of the occupational therapist. For brain-injured patients, there was a significant correlation between the neuropsychologist's opinion and that of the occupational therapist (kappa=0.33; P=0.01). However, the sensibility and specificity were only 55 and 80%, respectively. The correlation between an occupational therapy decision based on the driving simulator and that of the medical expert was very significant (kappa=0.81; P<0.0001) and the sensibility and specificity were 84 and 100%, respectively. In contrast, these values were lower (63 and 71%, respectively) for the correlation between the neuropsychologist's opinion and that of the medical expert. CONCLUSION: Our driving simulator enables the danger-free evaluation of driving aptitude. The results mirror an in situ assessment and are more sensitive than neuropsychological examination. In fact, the neuropsychologist's opinion often is more negative or uncertain with respect to the patient's real driving aptitude. When taking a decision on a patient's driving aptitude, the medical expert is more inclined to trust the results of the driving simulator.     

Changes in health status for persons with wrist or hand impairments receiving occupational therapy or physical therapy.

OBJECTIVE: The purpose of this study was to describe changes of health status as perceived by clients with hand or wrist impairments who received rehabilitation in acute, orthopedic outpatient facilities from occupational therapy or physical therapy personnel. METHOD: One thousand three hundred ninety-nine adults with wrist (n = 692) or hand (n = 707) impairments who were treated between July 1996 and June 1997 were selected from the Focus On Therapeutic Outcomes, Inc. (FOTO) national rehabilitation database. Each client completed a health status questionnaire on intake and discharge. Data consisted of number of outpatient visits, duration of treatment episode, and health status scores for six functional scales. Measures of intensity, global health status, global utilization, and client satisfaction were calculated. Outcomes were evaluated across occupational therapists and physical therapists. RESULTS: Clients perceived improvement (p < .05) in their health status over the course of therapy. Number of visits and measures of health status and client satisfaction were similar across type of therapist. Episode duration was longer (p < .05) and intensity was less (p < .05) for clients seen by occupational therapists. CONCLUSION: Clients receiving rehabilitation in acute orthopedic outpatient centers perceived improvement in their functional abilities and health and well-being (global health status and individual functional scales) over the time during which treatment was provided. Results confirm the responsiveness of the outcomes instrument to clinical change in the clients' perception of their health status over the course of therapy and support the use of health status as a measure of clinical outcome.     

Outcomes of an occupational therapy school-based consultation service for students with fine motor difficulties

PURPOSE: This paper reports on a study that was conducted to address the perceived occupational performance changes among school-aged children who received occupational therapy services for fine motor difficulties. It also addressed teacher awareness and the degree of implementation of occupational therapy recommendations by teachers. METHODS: The study sample included 91 school-aged children referred for occupational therapy services for fine motor difficulties. The children were assessed, before and after intervention. Outcome measures used were the Canadian Occupational Performance Measure (COPM) and the Teacher Awareness Scale (TAS). RESULTS: Significant change scores in both scales of the COPM were (Performance = 1.50, p < 0.001; Satisfaction = 1.92, p < 0.001). Regression analyses showed that lower teacher ratings of the students'performance and satisfaction of performance on the initial COPM resulted in significantly greater COPM change scores in the students'performance and satisfaction of performance at reassessment. The greater the degree of implementation of occupational therapy strategies by the teacher, the greater the COPM performance and satisfaction change scores. The greater the degree of teacher awareness of students'special needs resulted in greater COPM performance change scores. PRACTICE IMPLICATIONS: Teachers may benefit from more education regarding fine motor difficulties in children and how the implementation of occupational therapy strategies are helpful to improve children's fine motor difficulties.     

Predicting fitness-to-drive following stroke using the Occupational Therapy – Driver Off Road Assessment Battery

Introduction: It is difficult to determine if, or when, individuals with stroke are ready to undergo on-road fitness-to-drive assessment. The Occupational Therapy – Driver Off Road Assessment Battery was developed to determine client suitability to resume driving. The predictive validity of the Battery needs to be verified for people with stroke.

Aim: Examine the predictive validity of the Occupational Therapy – Driver Off Road Assessment Battery for on-road performance among people with stroke.

Method: Off-road data were collected from 148 people post stroke on the Battery and the outcome of their on-road assessment was recorded as: fit-to-drive or not fit-to-drive.

Results: The majority of participants (76%) were able to resume driving. A classification and regression tree (CART) analysis using four subtests (three cognitive and one physical) from the Battery demonstrated an area under the curve (AUC) of 0.8311. Using a threshold of 0.5, the model correctly predicted 98/112 fit-to-drive (87.5%) and 26/36 people not fit-to-drive (72.2%).

Conclusion: The three cognitive subtests from the Occupational Therapy – Driver Off Road Assessment Battery and potentially one of the physical tests have good predictive validity for client fitness-to-drive. These tests can be used to screen client suitability for proceeding to an on-road test following stroke.

• Implications for Rehabilitation:

• Following stroke, drivers should be counseled (including consideration of local legislation) concerning return to driving.

• The Occupational Therapy – Driver Off Road Assessment Battery can be used in the clinic to screen people for suitability to undertake on road assessment.

• Scores on four of the Occupational Therapy – Driver Off Road Assessment Battery subtests are predictive of resumption of driving following stroke.

     

The effectiveness of cardiopulmonary resuscitation instruction: animation versus dispatcher through a cellular phone

INTRODUCTION: We developed a cardiopulmonary resuscitation (CPR) instruction programme using motion capture animation integrated into cellular phones. We compared the effectiveness of animation-assisted CPR instruction with dispatcher-assisted instruction in participants with no previous CPR training. METHODS: This study was a single blind cluster randomized trial. Participants were allocated to either animation-assisted CPR (AA-CPR; 8 clusters, 44 participants) group or dispatcher-assisted CPR (DA-CPR; 8 clusters, 41 participants). The overall performance and time of each step of CPR cycle were recorded on a checklist by 3 assessors. The objective performances were evaluated using the Resusci Anne SkillReporter Manikin. Differences between the groups were compared using an independent t-test adjusted for the effect of clustering. RESULTS: The AA-CPR group had a significantly better checklist score (p<0.001) and time to completion of 1 CPR cycle (p<0.001) than the DA-CPR group. In an objective assessment of psychomotor skill, the AA-CPR group demonstrated more accurate hand positioning (68.8+/-3.6%, p=0.033) and compression rate (72.4+/-3.7%, p=0.015) than DA-CPR group. However, the accuracy of compression depth (p=0.400), ventilation volume (p=0.977) and flow rate (p=0.627) were below 30% in both groups. CONCLUSION: Audiovisual animated CPR instruction through a cellular phone resulted in better scores in checklist assessment and time interval compliance in participants without CPR skill compared to those who received CPR instructions from a dispatcher; however, the accuracy of important psychomotor skill measures was unsatisfactory in both groups.     

Rehabilitation of chronic stroke patients: changes in functional performance

Forty stroke patients who were at least one year post-onset completed a one-month intensive rehabilitation program. The month before the program served as a control period. During the program, patients received individual sessions in occupational and physical therapy four days a week, and they participated in group activities on the fifth day. Therapy emphasized instruction in motor planning, balance and weight shift, and the use of adaptive equipment; these motor abilities were then practiced within real life situations. The patients demonstrated significant improvement in the outcome measures of weight shift, balance, and ADL scores after the one-month rehabilitation program (weight shift: F = 16.1, p = .0001; balance: F = 6.26, p = .0007; ADL: F = 13.8, p = .0001). They retained these new skills during a three-month follow-up period.     

Retraining Visual Processing Skills To Improve Driving Ability After Stroke

Crotty M, George S. Retraining visual processing skills to improve driving ability after stroke.

Objective

To evaluate the effectiveness of retraining using the Dynavision on driving performance of people with stroke.

Design

Randomized controlled trial.

Setting

Outpatient rehabilitation clinic in Australia.

Participants

People with stroke (N=26) referred for driving assessment.

Interventions

Eligible participants were randomized to either receive retraining with the Dynavision apparatus for 18 sessions or to receive no intervention and go onto a waitlist.

Main Outcome Measures

The primary outcome was an assessment of on-road ability. Secondary outcomes included measures of response speed, visual scanning, and self-efficacy. All assessments were conducted by assessors blinded to group assignment.

Results

No significant difference (P=.223) was found between the intervention and control groups in results of on-road assessment in terms of pass or fail; the primary outcome measure; or the results on the secondary outcome measures of response speed, visual scanning, and self-efficacy.

Conclusions

In this small trial, training underlying skills (such as executing a continuous wide scan, combining motor and visual processing into a motor response) using the Dynavision apparatus did not improve the outcomes of an on-road assessment for people after strokes. Larger trials are needed to evaluate devices that claim to retrain underlying skills related to driving.     

A web-based tutorial to enhance student learning of activity analysis

BACKGROUND: This paper describes the impact on learning of a web-based tutorial for the application of activity analysis, with occupational therapy students, at McGill University, Montreal, Quebec. This tutorial offers unique, interactive instructional strategies allowing for self-directed higher cognitive and reflective learning, which has not been possible, to date, in current web-based technology. SCOPE: Through repeated practice, students collaboratively (in dyads) apply concepts of activity analysis, and receive immediate feedback by comparing their answers to a standard. METHODS AND RESULTS: Comparisons of performance outcomes on summative exams before and after implementation of the tutorial are made, suggesting a decrease in variance scores indicating fewer students are falling below the class average. These results are attributed to opportunities to practice activity analysis and to receive immediate feedback. PRACTICE IMPLICATIONS: Web-based instruction can impact student learning if the instructional strategies ensure coherence with all other instructional components, match the learning outcomes, facilitate self-directed and collaborative learning, and allow for practice and feedback.