Section 21

Musculoskeletal disabilities

Immobilization refers to placement of any rigid material (e.g., plaster, rigid brace, external fixation) that blocks the movement of a given joint. Physicians should be aware that any immobilization (even temporary) may affect a patient’s ability to drive. Any immobilization of a lower limb will have an obvious effect on the driver’s operation of the pedals, especially in a vehicle with manual transmission. Similarly, upper-limb immobilization can detract from the operation of the hand controls, especially the steering wheel. Some provinces have enacted regulations stipulating that any immobilization of a limb is inherently incompatible with safe driving. The physician is therefore advised to be aware of the relevant regulations in their province and to take these regulations into consideration when making a decision about a patient’s fitness to drive.

Experimental studies have shown the following effects of immobilization:

• Brachial/antebrachial immobilization is incompatible with safe driving (Kalamaras et al., 2006).
• Although brachial immobilization may interfere with the ability to firmly grip the steering wheel, an occupational therapy assessment may show that the person is able to drive safely (Kalamaras et al., 2006).
• Immobilization of a finger does not preclude safe driving (Kalamaras et al., 2006).
• Cruropedal (thigh–leg) immobilization is incompatible with safe driving (Orr et al., 2010).
• Although some simulated driving studies appear to have shown no significant differences in brake reaction times (Tremblay et al., 2009), anyone whose right leg is immobilized below the knee should refrain from driving (Waton et al., 2011), particularly if weight bearing is prohibited.
• Immobilization of all or part of the left leg precludes driving a vehicle with manual transmission.

After removal of an immobilization device from a lower limb, resumption of driving may be delayed for some weeks if there is pain, incomplete weight-bearing ability, or residual stiffness (Egol et al., 2008).

Immobilization of any limb or joint is incompatible with driving a motorcycle or scooter.

Amputation and deformities of the upper limb — Although no serious study has been done on the subject, it appears at first glance that there are acceptable modifications for all types of amputations and deformities of the upper limb. In addition, in most people who have had an upper-limb amputation, the impairment affects one or several fingers, not the entire limb, so they will not necessarily need such adaptive devices (National Highway Traffic Safety Administration, 2009: p. 15).

An individual assessment is advised. Any person with upper-limb amputation whose ability to drive safely may be questioned should be directed to an accredited agency for assessment of driving ability. It is up to each person to demonstrate their ability to drive, according to the type of impairment and various adaptive devices available.

Because of these various adaptive devices, a rehabilitation period is also advised before the resumption of highway driving.

Amputation and deformities of the lower limb — According to various studies, 45%–87% of people with lower-limb amputations resume driving afterward (Boulias et al., 2006; Meikle et al., 2006; Engkasan et al., 2012). Factors that support resumption of driving are age 55 years or younger, male sex, and frequency of driving before the event. The importance of addressing the concerns of family and friends about the patient resuming driving has also been demonstrated (Engkasan et al., 2012).

Most cases of lower-limb amputation involve one or more toes and generally do not preclude driving (National Highway Traffic Safety Administration, 2009: p. 15). People with below-the-knee amputation of one or both legs are usually able to drive any class of motor vehicle safely, provided they have full strength and movement in their back, hips, and knee joints and a properly fitted prosthesis or prostheses. No modification is needed in the case of a left-side amputation if the person drives a vehicle with automatic transmission.

As with amputations or deformities of an upper limb, individual assessment is advised. Any person with lower-limb amputation whose ability to drive safely may be questioned should be directed to an accredited agency for assessment of driving ability. It is up to each person to demonstrate their ability to drive, according to the type of impairment and various adaptive devices available.

Two-foot driving (i.e., operating the accelerator pedal with the prosthesis and the brake pedal with the left foot) is not recommended (Meikle et al., 2006; National Highway Traffic Safety Administration, 2009: p. 15).

Degenerative or inflammatory arthritis can result in pain, as well as loss of muscle strength, range of motion, and function of the involved joints (National Highway Traffic Safety Administration, 2009: p. 18). People with arthritis may have difficulty turning their heads to perform safety checks because of pain and stiffness of the cervical and thoracolumbar spine. Inflammatory arthritis can result in persistent pain and reduced range of movement in multiple joints, including knees, ankles, hips, shoulders, elbows, wrists, and joints of the hands.

A patient should be restricted from driving if pain adversely affects the ability to drive safely or they lack range of movement or strength to execute the coordinated activities required. However, most difficulties of this type can be overcome by simple modifications to the vehicle or adjustment of driving technique. If there are concerns, the individual should be required to demonstrate their ability to a driver examiner.

Patients with painful conditions who are taking strong medicine for pain relief may also fail to drive safely (see Section 6.3.3, Opioids).

Cervical — Some degree of loss of movement of the head and neck may be permitted, but the driver should then be restricted to driving vehicles equipped with panoramic mirrors, which may alleviate the need for shoulder checks. Although no study has shown a link between wearing a neck brace and the risk of a crash, people wearing a brace, cervical collar, or halo vest should refrain from driving. The same restriction applies to anyone with severe neck pain or very limited range of motion (see also Section 21.2.3, Arthritis, other musculoskeletal pain, and ankylosis). This restriction should remain in place until the pain is no longer debilitating or until the limitation of movement has been mitigated by adaptive devices. Experimental studies will eventually help determine whether, once a person has gone beyond a certain degree of loss of cervical mobility, adaptive mirrors can provide better visibility and safer driving.

Thoracic — People with a marked deformity or painful restriction of motion in the thoracic vertebrae are not able to drive large commercial transport or passenger-carrying vehicles safely.

Their ability to drive non-commercial vehicles can best be determined by a driver examiner. Patients wearing braces or body casts must be evaluated according to their ability to move without pain, to operate the controls, and to observe approaching vehicles.

Lumbar — Applicants for a licence to drive a passenger-carrying or heavy commercial vehicle should be free of lumbar pain that limits movement, attention, or judgment. Less stringent standards may be applied to drivers of non-commercial vehicles. However, this group may need to be restricted to driving vehicles with power-assisted brakes.

Paraplegia and quadriplegia — On the basis of a favourable recommendation from a medical specialist in physical medicine and rehabilitation, patients with new paraplegia or quadriplegia may obtain a learner’s permit. With the permit, these patients may then take driving lessons in an adapted vehicle fitted with specially modified controls. However, in one study, people with lumbar radiculopathy had slower reaction times than a control group. This was especially true after a selective nerve block (Al-khayer et al., 2008).

To date, all experimental studies involving patients who have undergone orthopedic surgery have been conducted on driving simulators and therefore have tested only for emergency braking reaction times. Consequently, little attention has been paid to other possible related factors, such as pain, limited mobility, reduced strength, and the effects of analgesics, age, and comorbidities.

As for many other conditions, it must be underscored that the driver is responsible for driving safely. The following paragraphs list timelines for safely resuming driving after orthopedic surgery, as reported by some studies. These timelines are provided for information only. Physicians should advise their patients about other related factors that could affect safe driving, in addition to the direct effects of their surgery.

Arthroplasties — Current literature covers only some aspects of hip and knee replacements. At the time of writing, no articles could be found mentioning driving a car after arthroplasty of the shoulder, elbow, wrist, fingers, ankle, or toes.

According to experimental studies, the following timelines have been reported for safe resumption of driving, in the absence of other limiting factors such as pain, limited mobility, reduced strength, and the effects of analgesics, age, and comorbidities:

• For right hip arthroplasty, 6 weeks (Ganz et al., 2003) to 8 weeks (MacDonald and Owen, 1988; Abbas and Waheed, 2011).

• For left hip arthroplasty, 2 weeks (Ganz et al., 2003), or longer if the person is driving a small car, in which the knees will be higher than the hips.

  Although 81% (105/130) of the participants in one study (Abbas and Waheed, 2011) were able to resume driving between 6 and 8 weeks, and an additional 17% (22) were able to resume driving in 12 weeks, 2% (3) still lacked the confidence to drive at 12 weeks or more.

• For right knee arthroplasty, 2 weeks (Liebensteiner et al., 2010), 4 weeks (Marques et al., 2008; Dalury et al., 2011), 6 weeks (Pierson et al., 2003), or 8 weeks (Spalding et al., 1994).
• For left knee arthroplasty, 10 days (for vehicles with automatic transmission) (Marques et al., 2008), 2 weeks (Liebensteiner et al., 2010), 4 weeks (Dalury et al., 2011), or 6 weeks (Spalding et al., 1994; Pierson et al., 2003).

Given this high variability, a clinical assessment is essential before safe driving can be resumed. In particular, the physician must confirm that, in an emergency, the driver will be able to apply the brakes without pain.

Anterior cruciate ligament (ACL) — Six weeks after reconstructive surgery of the right ACL, patients’ brake reaction times were comparable to those of matched controls (Gotlin et al., 2000; Nguyen et al., 2000). As with hip arthroplasty, patients may drive 2 weeks after reconstructive surgery of the left knee if they have no problem with the clutch, in the case of manual transmission.

Right knee arthroscopy — Although a recent survey showed that patients resumed driving between day 1 and week 3 after knee arthroscopy (Lewis et al., 2011), experimental studies of emergency brake reaction times (Hau et al., 2000) have shown that safe driving is not possible any earlier than the start of week 2.

Fixation of displaced ankle fracture — In patients who underwent fixation of a displaced right ankle fracture, normal braking function returned after 9 weeks (Egol et al., 2003).

First metatarsal osteotomy (hallux valgus) — At week 6 following osteotomy of the first metatarsus to correct hallux valgus, emergency brake reaction times were comparable to those of a healthy population (Holt et al., 2008).

Spinal surgery — Although it has been reported that patients who underwent lumbar fusion surgery were able to drive upon discharge from hospital (Liebensteiner et al., 2010), the data are too limited to make that recommendation.

In all of the above situations, even after the prescribed timeline has elapsed, other limiting factors, such as pain, consumption of analgesics, absence of full weight-bearing capacity, failure to comply with postoperative instructions, or comorbidities, may still impede safe driving. Therefore, evaluation of these factors and discussion with the patient’s surgeon are recommended before advising the patient that it is safe to resume driving.