INSTRUCTIONAL REVIEW: LOWER LIMB
“When can I return to driving?” A REVIEW OF THE CURRENT LITERATURE ON RETURNING TO DRIVING AFTER LOWER LIMB INJURY OR ARTHROPLASTY
K. MacLeod, A. Lingham, H. Chatha, J. Lewis, A. Parkes, S. Grange, P. J. Smitham From Institute of Orthopaedics, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
Clinicians are often asked by patients, “When can I drive again?” after lower limb injury or surgery. This question is difficult to answer in the absence of any guidelines. This review aims to collate the currently available evidence and discuss the factors that influence the decision to allow a patient to return to driving. Medline, Web of Science, Scopus, and EMBASE were searched using the following terms: ‘brake reaction time’, ‘brake response time’, ‘braking force’, ‘brake pedal force’, ‘resume driving’, ‘rate of application of force’, ‘driving after injury’, ‘joint replacement and driving’, and ‘fracture and driving’. Of the relevant literature identified, most studies used the brake reaction time and total brake time as the outcome measures. Varying recovery periods were proposed based on the type and severity of injury or surgery. Surveys of the Driver and Vehicle Licensing Agency, the Police, insurance companies in the United Kingdom and Orthopaedic Surgeons offered a variety of opinions. There is currently insufficient evidence for any authoritative body to determine fitness to drive. The lack of guidance could result in patients being withheld from driving for longer than is necessary, or returning to driving while still unsafe. Cite this article: Bone Joint J 2013;95-B:290–4.
K. MacLeod, MBChB, BSc(Hons), Foundation Year 1 P. J. Smitham, MBBS, MRCS, Academic Clinical Lecturer The Institute of Orthopaedics, Royal National Orthopaedic Hospital Stanmore, Brockley Hill, Stanmore HA7 4LP, UK. A. Lingham, BSc (Hons), Medical Student King’s College London, School of Medicine, Hodgkin Building, Guy’s Campus, London SE1 1UL, UK. H. Chatha, MBBS, MRCS, MSc, Orthopaedics Trainee University Hospital, Department of Orthopaedics, Aintree, Longmoor Lane, Liverpool L9 7AL, UK. J. Lewis, MBBS, MRCS, MSc, Arthroplasty Fellow Nottingham University Hospital, Department of Orthopaedics, Hucknall Road, Nottingham NG5 1PB, UK. A. Parkes, Chief Scientist The Transport Research Laboratory, Crowthorne House, Nine Mile Road, Wokingham, Berkshire RG40 3GA, UK. S. Grange, MBChB, PhD, FRCS (Tr&Orth), Orthopaedic Surgeon, Adjunct Associate Professor University of Alberta, Rehabilitation Robotics Sandbox, ECHA, Faculty of Rehabilitations, Canada Correspondence should be sent to Dr K. MacLeod; e-mail:
[email protected] ©2013 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B3. 29540 $2.00 Bone Joint J 2013;95-B:290–4.
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“When can I drive again?” is a challenging question. Doctors usually combine their knowledge, clinical experience and radiological information to advise when a patient can resume driving. This presents the clinician with a dilemma. Although it has been reported that the Medical Defence Union (MDU), London, United Kingdom, have no case of legal action against a doctor for advising a patient that they were safe to drive, they have defended doctors for advising a patient against driving.1 This might be a reflection of the social and economic consequences for the patient of not driving. The medico-legal understanding of when patients can return to driving is unclear, with the only reliable information being that drivers have the final responsibility. This creates a situation where patients are uncertain of when they can drive again, potentially leading to starting to drive too soon, or delaying driving for longer than is necessary. This review aims to collate the evidence available currently and discuss the factors that influence the decision to return to driving.
Materials and Methods Medline, Web of Science, Scopus, and EMBASE databases were searched. The following terms were used without date
restrictions, English-language only: brake reaction time (BRT), brake response time, braking force, brake pedal force (BPF), resume driving, rate of application of force, driving after injury, joint replacement and driving, and fracture and driving. From this search 20 papers were found; two were discounted as they used a healthy cohort as their study population. This left 14 clinical studies and four relevant surveys. A further seven studies were found from the references of those publications. The studies that concerned arthroplasty mostly measured the patients’ pre- and post-operative braking profiles. The studies that concern injury were mostly cohort studies, and compared patients with healthy individuals, controlled for age and gender, in order to establish at what point (usually time in weeks) after injury the patients achieved a similar braking profile to that of the healthy cohort.
Results Table I lists the literature survey.2-19 Most clinical studies used the BRT and total braking time as the outcome measures, but a few measured the BPF. The BRT varied between 0.5 to 1.5 seconds with varying recovery periods proposed based on the type and severity of injury or surgery, as well as the BRTs of the controls. THE BONE & JOINT JOURNAL
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Table I. Summary of the literature Authors
Sample (n)
Indication*
Method
Safe to drive
Dalury et al4 Egol et al 5 Egol et al6
TKR Ankle fracture Complex lower trauma
Brake reaction time Reaction time Reaction time
4 weeks 9 weeks 6 weeks
Ganz et al7 Gotlin et al8 Hau et al 9 Holt et al10 Kane et al11
29 31 22 right leg 35 left leg 90 12 30 28 25
THR ACL repair Knee arthroscopy First metatarsal osteotomy Ankle fracture
Reaction time Reaction time Reaction time, clinical test Reaction time Reaction time
Liebensteiner et al 12 MacDonald and Owen13 Marques et al14 Marques et al15 Nguyen et al16 Nunn et al17
62 25 24 21 72 -
TKR THR Left TKR Right TKR ACL repair Below-knee cast
Brake reaction time Reaction time, brake force Brake reaction time Brake reaction time Reaction time, clinical test Driving ability
Orr et al18 Pierson et al19 Spalding et al2
35 31 20 control 40 patients 48
Immobilisation TKR TKR
Total brake time Reaction time Reaction time, brake force
4 to 6 weeks 4 to 6 weeks 1 week 6 weeks 4 weeks post-operative; 2 weeks plaster Maximum 2-week wait 8 weeks 10 days 30 days Left: 2 weeks. Right: 6 weeks Left: safe in automatic cars. Right: unsafe Right leg: unsafe 6 weeks Left: no effect. Right: 8 weeks
Different casts: Walking Cast; Aircast Walker
Reaction time, brake force
Tremblay et al3
Increases brake reaction time and total braking time
* TKR, total knee replacement; THR, total hip replacement; ACL, anterior cruciate ligament
In studies examining BPF, 100 N of force was used as a cutoff for reaction time by Spalding et al2 and 200 N was used by Tremblay et al.3 Tremblay et al3 looked at both maximum BPF and BRT in healthy people wearing casts and immobilising devices on their legs but concluded that although these devices impact on BPF and BRT, driving might not necessarily be impaired. While most injury studies used broadly the same design, and controlled for factors such as age and gender between the groups, some measured pre- and post-operative braking profiles. The studies concerning arthroplasty, including those by Spalding et al2 and Dalury, Tucker and Kelley,4 compared pre- and post-operative braking profiles in order to establish the time in weeks to recover pre-operative braking ability. Spalding et al2 concluded that the braking profile recovered after eight weeks following total knee replacement compared with four weeks as described by Dalury et al.4 The use of driving simulators and whether or not a driving scenario was used when measuring the braking profile varied, as well as the time at which the braking profile was measured post-operatively. These variations could account for different results between studies exploring the same injury. MacDonald and Owen13 were the first to measure reaction times in patients with total hip replacement (THR), and concluded that most patients can resume driving after eight weeks. But a similar study published more recently by Ganz et al7 concluded that four to six weeks are sufficient to achieve normal reaction time after THR. Egol et al5 measured total braking time in patients who underwent surgery for an ankle fracture and concluded that they could return to driving nine weeks post-operatively. Another VOL. 95-B, No. 3, MARCH 2013
study from the same institution proposed that after six weeks of weight-bearing the braking functions in patients with complex lower limb trauma is improved. Furthermore, nine weeks post-fracture it had returned to normal.6 Kane et al,11 however, concluded that BRT returns to normal four weeks after a surgically treated ankle fracture, and two weeks after a conservatively treated fracture. Our survey reveals that the recovery of BRT depends on the injury or operation. The BRT returns to normal six weeks after a first metatarsal osteotomy.10 Despite these minor variations it was generally agreed that returning to driving should be determined on a case-by-case basis, with many factors taken into account, including the nature of the injury or surgery, the anaesthetic, the use of analgesics, any neurological impairment, the confidence of the patient and if applicable the state of healing of the fracture.
Recommendations Four studies surveyed opinions amongst clinicians, insurance companies and the police (Table II).1,20-22 The advice given to patients varied, but it was agreed that the patient held the ultimate responsibility, although insurance companies and the police were reluctant to comment. All the surveys concluded further guidance was needed but none proposed specific advice. In the United Kingdom, the Driver and Vehicle Licensing Agency (DVLA) regulates driving standards and has extensive guidance to both the public and medical professionals on many common medical conditions but the online resource for the public states “If you have broken a limb you do not need to tell the DVLA about it”.23 Information provided to doctors states that patients do not need to
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Table II. A summary of advice and criteria found in the literature Authors
Population
Questions asked
Surveyed (n)
Response rate
Advice given
Haverkamp et al20
Dutch orthopaedic surgeons
1) Is advice given?; 2) Criteria used; 3) Legal context; 4) Response to scenarios
150
50%
Von Arx et al21
United Kingdom orthopaedic surgeons, insurance companies, police forces
Different scenarios given: different wrist fracture with different treatment; fractured ankle with below knee walking plaster; clavicle fracture, broad arm sling
126 surgeons, 27 insurance companies, 6 regional police constabularies
53% of surgeons, 0.04% of insurers, national police statement issued
Chen et al22
United States orthopaedic surgeons, patients
Recommendations on 41 return to driving following specific injury. Decision-making and attitudes towards liability
-
Rees and Sharp1
United Kingdom orthopaedic surgeons, insurance companies, Thames Police Constabulary
Scenarios given: 100 different fractures, treatments and stages of recovery. Asked ‘Is this patient fit to drive?’
66%
1/3 did not give advice; 78.4% used full weight-bearing as a criterion. Guidelines must be developed Varying agreement. 90% not fit in right below-knee cast. Follow doctors’ advice. Drivers must take responsibility. All agreed need for guidance Conservative ankle fracture (7 to 8 weeks); operative treatment for ankle fracture (12 weeks). Most held patient responsible. 35% of patients returned to driving while still taking pain medication; 36% did not consult doctor before External fixation: cannot drive. Nail or plate: can drive if pain-free and weightbearing. Insurance providers and police did not respond
inform the DVLA unless the disability and impaired driving will last longer than three months. The DVLA then states that licence holders should establish with their doctors when it is safe to drive again and also suggests that they should contact their insurance companies. Finally it states that it is the responsibility of the driver to be in control of the vehicle at all times, and should be able to demonstrate this to police if necessary.23 Little advice has been forthcoming from police forces, but according to a survey conducted by Von Arx et al21 the police strongly recommend that clinicians remain uninvolved and refer patients to the DVLA. Insurers and the DVLA, on the other hand, suggest that patients seek advice from their doctors.23 Insurance companies provide as little guidance as the DVLA and are inconsistent. For this review we contacted two motor vehicle insurance companies, by telephone, to establish what advice they gave to motorists returning to driving after lower limb injury or arthroplasty. One insurer, Swiftcover (Cobham, United Kingdom), suggests that ‘motor insurers need to know about any medical conditions likely to affect safe driving’. In contrast, Aviva (Norwich, United Kingdom) stated ‘Our understanding is that if the DVLA are happy for you to drive, then there is no need to inform your insurance company’. Previously the Association of British Insurers have advised that patients should check with their doctor to determine fitness to drive.24 In an earlier publication Giddins and Hammerton25 concluded
that insurance companies raised no objections once a treating physician allowed a person to drive; this was confirmed elsewhere.1 It is evident that there are several inconsistencies within insurance companies. Each body appears to pass the responsibility of guidance to the other two bodies, while maintaining that the patient carries the final responsibility. As a result of the DVLA passing on responsibility to clinicians, patients anticipate specific guidance. Nuñez and Giddins24 observed that the British Medical Association (BMA) advises against clinicians stating that a patient is fit to drive but instead highlight health risks that may impede driving.24 Insurers expect doctors to state when a patient can drive but in contrast, the police strongly recommend that doctors do not involve themselves.21 A doctor must be able to assess whether the patients’ limb can comfortably apply sufficient force required to brake for an adequate period of time and whether the reaction time and rate of application of force have returned to normal. This task is generally based on other criteria such as weight-bearing. In a survey of Dutch orthopaedic surgeons, 78.4% used weight-bearing as the main determinant.20 In most countries, the patient carries the final responsibility in determining their ability to drive safely22 but the importance of guidance given by various bodies differs. In the Netherlands, clinicians are primarily responsible in authorising patients to drive.22 The United States has no specific guidelines, similar to the United Kingdom. It has been reported that the THE BONE & JOINT JOURNAL
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American Occupational Therapy Association is the only organisation to consider the problem directly, and offers written and practical guidance as to when a patient can drive.22 In Canada, physicians have the legal responsibility to advise patients regarding driving.26 However, there are still no specific guidelines for clinicians defining when a patient may return to driving after lower limb injury or surgery.
Discussion The debate about what and who determines a patient’s fitness to drive is not a new issue. Most of the papers referenced by this review concerned the BRT and the total braking time. Some studies2,9 only measured the minimum force as a threshold to record the BRT time, but this time may be different if patients are required to apply the maximum Brake Pedal Force (BPF) as a result of pain or apprehension of causing pain. It is important to measure the BPF and BRT together, because during the early rehabilitation period, patients may achieve a normal BRT but still not reach the normal threshold of the BPF. MacDonald and Owen13 postulated that the main limiting factor is determined by the ability to move the foot between the pedals, not the BPF. The study acknowledges that a simple braking test, measuring BPF, might be helpful in providing an indication of the rate of post-operative recovery. Gotlin et al8 pointed out that other factors may prevent patients from driving safely, despite concluding that patients can achieve a BRT near to the control subjects at four to six weeks after anterior cruciate ligament reconstruction. During the trial, neither study cohort (male or female) matched the controls for range of movement until the tenth post-operative week,8 suggesting that although the BRT may have recovered, limited movement or pain could still prevent a patient from driving. The DVLA recommends that before returning to driving there are several issues that should be taken into account, including age, type of injury or surgery, recovery from anaesthesia, pain and co-morbidities.23 Any of these could affect the BRT, total braking time or BPF necessary to achieve an emergency stop. Where do clinicians stand legally?. The need for guidance is demonstrated by Chen et al,22 who found that 68% of trauma surgeons were uneasy about telling patients they could drive again, and 44% expressed concern about potential litigation. While a physician might be able to determine when a limb can withstand the demands of driving, the ability to resume driving might not be so readily determined. There is a potential risk of physicians being exposed to medico-legal claims, should the patients be involved in an accident where pre-existing injury is a contributing factor. In the United Kingdom it has been reported that no such challenges have been made.1 Another medicolegal aspect is the physician’s duty to report an unsafe driver to the DVLA, if the patient them self is unwilling to do so, when they present a risk to the wider public. With no strict guidance for temporary disabilities physicians again face a dilemma. A study by Nunn et al17 stated that VOL. 95-B, No. 3, MARCH 2013
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insurance companies need to be informed by patients if they are driving with a fracture. This contradicts the earlier findings of Rees and Sharp1 that insurance companies generally allow patients to drive when a doctor gives consent. The Association of Chief Police Officers of the United Kingdom points out that ‘Rule 79 of the Highway Code states that it is the driver’s responsibility to make sure they are fit to drive’,26 warning of potential liability if a doctor gave advice,21 as does the BMA24 and the MDU.1 Guidelines. Although most studies call for guidelines, none suggest what they should be. A study of Dutch orthopaedic surgeons found that 79% believed that guidelines should be developed.21 In the United States Chen et al22 proposed a return-to-driving-policy at one trauma centre. The policy states that clinicians no longer ‘clear’ patients for driving but only advise them when they might be ready for assessment with the Department of Motor Vehicles. As an alternative, clinicians can also refer patients to return-to-driving programmes run in the area. However, there are economic considerations about driving assessments. The centre cannot be justified in offering this service to patients who have a short-term disability and will return to their previous driving standard, and instead it is reserved for those suffering a permanent disability that affects the way they drive. The authors pointed out that the American Occupational Therapy Association is the only organisation that offers Driving and Mobility Specialty Certification. Mobility Centres in the United Kingdom offer testing for disabled patients returning to driving but this primarily caters to long-term disability or older patients.26 The formal assessment of driving may be the best solution but this may not be financially and logistically viable. Where to go next?. The ability to perform an emergency stop is used as the benchmark because it is a safety procedure. When the braking ability matches that of the controls. the patient is considered fit to drive, as defined by Hau et al.9 However, the BRT is not the only factor in returning to drive.7 The BPF required during an emergency stop needs to be identified. Another way of addressing a return-to-drive policy is to create a test that could be performed in the outpatient setting. This would enable a clear policy to be devised according to a patient’s specific abilities. In studies following arthroscopy9 and anterior cruciate ligament reconstruction16 a clinical test was included to simulate the action of foot transfer during an emergency stop by measuring the number of steps a patient could perform across a box in ten seconds. Currently there is not enough evidence for any authoritative body to determine fitness to drive after lower limb injury or surgery as a result of the many variables that apply. In consequence some patients could be prevented from driving for longer than is necessary, whilst other might return too soon. The DVLA in the United Kingdom currently does not specify any guidelines for temporary disability and the Highway code27 states the responsibility rests with the driver.
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No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primarily edited by G. Scott and first-proof edited by J. Scott.
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