Navigating a Misty Road: Novel Ways to Study the Impact of Cognition on Driving Performance in Multiple Sclerosis

Background/Objectives: The ability to drive is closely linked to participation in daily activities and quality of life in people living with neurological disorders. Cognitive deficits in people with multiple sclerosis (pwMS) are known to hinder this ability, yet concrete fitness-to-drive criteria remain elusive and assessment guidelines lack uniformity. A plethora of cognitive tests have provided associations with various aspects of driving performance and on-road behavior; however, several studies reveal limitations and inconsistencies in most tests' sensitivity and predictive effect. Novel and resurfaced modalities for cognitive assessment, in the form of advanced imaging techniques and electrophysiological studies, may offer improved sensitivity in driving-related abilities in earlier and milder stages. Their application in addition to evaluations in driving simulators may aid future research and enhance the quality of evidence to inform decision-making. Methods: We searched for the relevant literature in the PubMed database and synthesized the available findings for the applications of currently clinically used cognitive tests, markers derived from functional magnetic resonance imaging (fMRI) and diffuse tensor imaging (DTI), as well as event-related potentials (ERP). Results: Advanced imaging modalities and ERP studies may better capture neurobiological changes that lead to driving impairment in pwMS, and they may also be applied to detect cognitive alterations earlier and with greater precision, helping to predict driving difficulties in this population. Conclusions: Novel tools and driving simulator settings could improve our understanding of the relation between cognition and driving in pwMS, enhance protocol homogeneity in driving studies, and aid in the formation of guidelines. The evidence in this review supports an increase in their application in future studies.