Section 8: Musculoskeletal Disabilities

1. Arthritis

2. Foot abnormalities

3. Limitation of cervical movement

4. Limitation of thoracic and lumbar spine

5. Loss of extremities

6. Muscle disorders

7. Orthopedic procedures/surgeries

  1. Amputation
  2. Anterior cruciate ligament (ACL) reconstruction
  3. Limb fractures and treatment involving splints and casts
  4. Rotator cuff repair—open or arthroscopic
  5. Shoulder reconstruction
  6. Total hip replacement
  7. Total knee arthroplasty (TKA)

The pain, decrease in motor strength, and compromised range of motion associated with musculoskeletal disabilities can affect an individual’s ability to drive safely. Physicians should encourage their patients with musculoskeletal disabilities to drive a vehicle with power steering and automatic transmission, if they do not already do so. Such vehicles require the least amount of motor ability for operation among all standard vehicles. If the physician is concerned that the patient’s musculoskeletal disabilities impair his/her driving performance, referral to a driver rehabilitation specialist for a driver evaluation (including on-road assessment) is also recommended. In addition to assessing the patient’s driving skills, the specialist can prescribe adaptive techniques and devices and train the patient in their use.

In some cases, rehabilitative therapies such as physical or occupational therapy and/or a consistent regimen of physical activity may help improve the patient’s ability to drive and overall level of physical fitness.

Whenever possible, the use of narcotics, barbiturates, and muscle relaxants should be avoided in those patients with musculoskeletal disabilities who wish to continue driving. See Section 5 for recommendations regarding specific classes of medications.


Section 8: Musculoskeletal Disabilities


Arthritis If symptoms of arthritis compromise the patient’s driving safety, referral to a physical or occupational therapist for rehabilitative therapy and/or to a driver rehabilitation specialist for driver evaluation (including on-road assessment) is recommended. The specialist may prescribe vehicle adaptive devices and train the patient in their use.

See below for specific recommendations regarding limitation of cervical movement and limitation of the thoracic or lumbar spine.

Foot abnormalities Foot abnormalities (eg, bunions, hammer toes, long toe nails, and calluses) that affect the patient’s dorsiflexion, plantar flexion and/or contact with vehicle foot pedals should be addressed and treated, if possible. The physician may also refer the patient to a driver rehabilitation specialist, who can prescribe vehicle adaptive devices and train the patient in their use.

Limitation of cervical movement Some loss of head and neck movement is acceptable if the patient has sufficient combined rotation and peripheral vision to accomplish driving tasks (eg, turning, crossing intersections, parking, backing up) safely. The physician should ask if the patient’s vehicle is equipped with right and left outside mirrors and encourage the patient to make use of them. The physician may also refer the patient to a physical or occupational therapist for rehabilitative therapy and/or to a driver rehabilitation specialist, who can prescribe wide-angle mirrors and train the patient in their use.

Limitation of thoracic or lumbar spine Patients with marked deformity, who wear braces or body casts, or who have painfully restricted motion in their thoracic or lumbar regions should be referred to a driver rehabilitation specialist. The specialist can prescribe vehicle adaptive devices such as raised seats and wide-angle mirrors and train the patient in their use. The specialist can also prescribe safety belt adaptations as needed to improve the patient’s safety and comfort, and ensure that the patient is seated at least ten inches from the vehicle air bags.

Patients with acute spinal fractures, including compression fractures, should not drive until the fracture has been stabilized and painful symptoms cease to interfere with control of the motor vehicle. (For paraplegia and quadriplegia, see Section 4.)

Loss of extremities For patients who have lost one or more extremities, referral to a driver rehabilitation specialist is highly recommended. These specialists can prescribe vehicle adaptive devices and/or adaptations to limb prostheses and train the patient in their use.

Note that the use of artificial limbs on vehicle foot pedals is unsafe because there is no sensory feedback (ie, pressure and proprioception). For these patients, specialized hand controls in place of pedals are required.

Driving should be restricted until the patient demonstrates safe driving ability with the use of adaptive devices.

Muscle disorders If the physician is concerned that the patient’s symptoms compromise his/her driving safety, referral to a driver rehabilitation specialist for driver evaluation (including on-road assessment) is recommended. If needed, the specialist may prescribe vehicle adaptive devices and train the patient in their use.

Orthopedic procedures/surgeries Physicians should counsel patients who undergo surgery—both inpatient and outpatient—not to drive themselves home. In addition to deficits in range of motion, motor strength, proprioception, and reaction time from the surgical procedure itself, the patient’s driving skills may be affected by anesthesia, analgesics, and pain.

In helping the patient make decisions about temporary driving restrictions, it is useful for the physician to ask whether the patient’s car has power steering and automatic transmission, and whether the patient normally uses one or two feet in operating the foot pedals. As patients resume driving, they should be advised to assess their comfort level in familiar, traffic-free areas before driving in heavy traffic.

Amputation
See the recommendations for loss of extremities.
Anterior cruciate ligament
The patient should not drive for four weeks following right ACL reconstruction. If the patient drives a vehicle with manual transmission, he/she should not drive for four weeks following right or left ACL reconstruction.38

Limb fractures and treatment involving splints and casts
No restrictions if the fracture or splint/cast do not interfere with driving tasks. If the fracture or splint/cast interfere with driving tasks, the patient may resume driving after the fracture heals or the splint/cast is removed, upon demonstration of the necessary strength and range of motion.

Physicians should counsel patients to wear their safety belts properly (over the shoulder, rather than under the arm) whenever they are in a vehicle as a driver or passenger. The patient should sit in the vehicle seat that best accomodates this need.

Rotator cuff repair—open or arthroscopic
The patient should not drive for four to six weeks following rotator cuff repair. If the patient’s vehicle does not have power steering, the waiting period may be much longer.

Physicians should counsel patients to wear their safety belts properly (over the shoulder, rather than under the arm) whenever they are in a vehicle as a driver or passenger. The patient should sit in the vehicle seat that best accomodates this need.

Shoulder reconstruction
The patient should not drive for four to six weeks following shoulder reconstruction. If the patient’s vehicle does not have power steering, the waiting period may be longer. Physicians should counsel patients to wear their safety belts properly (over the shoulder, rather than under the arm) whenever they are in a vehicle as a driver or passenger. The patient should sit in the vehicle seat that best accomodates this need.

Total hip replacement
The patient should not drive for at least four weeks following right total hip replacement. If the patient drives a vehicle with manual transmission, he/she should not drive for at least four weeks following right or left total hip replacement. Physicians should counsel patients to take special care when transferring into vehicles and positioning themselves in bucket seats and/or low vehicles, either of which may result in hip flexion greater than 90 degrees. Physicians should also advise patients that reaction time may not return to baseline until eight weeks after the surgery, and that they should exercise extra caution while driving during this time.39

Total knee arthroplasty (TKA)
The patient should not drive for three to four weeks following right TKA. If the patient drives a vehicle with manual transmission, he/she should not drive for three to four weeks following right or left TKA.40 The physician should also counsel patients that reaction time may not return to baseline until eight weeks after the surgery, and that they should exercise extra caution while driving during this time.41


38 Gotlin RS, Sherman AL, Sierra N, Kelly MA, Pappas Z, Scott WN. Measurement of brake response time after right anterior cruciate ligament reconstruction. Archives of Physical Medicine and Rehabilitation. 2000;81(2):201-204.

39 MacDonald W, Owen JW. The effect of total hip replacement on driving reactions. Journal of Bone and Joint Surgery. 70B(2):202-205, 1988.

40 Pierson JL, Ramsey J, Clayton RT, Stippich KT. TKA improves drivers’ brake reaction time. The American Academy of Orthopaedic Surgeons: Academy News. February 7, 1999.

41 Spalding TJ, Kiss J, Kyberd P, Turner-Smith A, Simpson AH. Driver reaction times after total knee replacement. Journal of Bone and Joint Surgery. British Volume. 1994;76(5):754-756.


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