11 - Musculoskeletal Conditions

11.1About musculoskeletal conditions

This chapter is concerned with diseases or injuries that have a persistent impact on the musculoskeletal system.  Musculoskeletal refers to the system of muscles, tendons, ligaments, bones, joints, cartilage and other connective tissues.  The musculoskeletal system is responsible for body movement and stability. Examples of chronic musculoskeletal conditions that may have a persistent impact on driving are:

  • diseases of the joints, e.g. rheumatoid arthritis and osteoarthritis
  • disabilities of the spine, e.g. degenerative disc disease or permanent injuries
  • deformity, e.g. scoliosis, and
  • loss of limb.

Some musculoskeletal conditions, or procedures to treat the conditions, may result in temporary impairment of the functions necessary for driving, including fractures, temporary braces and casts, hip and knee replacements, and various orthopedic surgeries. These are considered transient impairments and authorities do not assess drivers with transient impairments.

11.2Prevalence

Statistics on the prevalence and incidence of musculoskeletal conditions in general are difficult to obtain because of the broadness of the category and the diversity of conditions within the category.  Research suggests that musculoskeletal conditions are a leading cause of pain and physical disability.  In Canada, the Ontario Health Survey (1994) found that musculoskeletal conditions are responsible for 54% of all long-term disability, 40% of all chronic conditions, and 24% of all restricted activity days. A study in the United States found that the leading causes of disability included back or spine problems, stiffness or deformity of limbs and arthritis.

Arthritis is an umbrella term referring to a group of more than 100 medical conditions. Two of the most common forms of arthritis are osteoarthritis (OA) and rheumatoid arthritis (RA).  It is estimated that 9.6% of males and 18.0% of females 60 years of age and older worldwide have symptomatic OA.

RA also has a worldwide distribution with an estimated prevalence of 1 to 2%. Both the incidence and prevalence of RA increase with age and both are two to three times greater in women than in men.

11.3Musculoskeletal conditions and adverse driving outcomes

Few studies have specifically examined the relationship between musculoskeletal conditions and impaired driving performance. As well, it is difficult to draw specific conclusions from this research because of differences in study design, outcome measures and the conditions studied, as well as limited measurement of the degree of impairment of the subjects.

Nonetheless, one broad conclusion that can be drawn is that many musculoskeletal conditions do appear to affect driving performance, often to a significant degree.  In those studies that examined crash outcomes, the majority report elevated risk for crashes for those with musculoskeletal impairments.  Two studies in particular (one a meta-analysis) identified that drivers with a musculoskeletal condition had crash rates that were 70% higher than those without musculoskeletal conditions.

Another important consideration for drivers with musculoskeletal conditions who are treated with non-steroidal anti-inflammatory drugs (NSAIDS) and/or narcotics is the effect of these drugs on driving performance. The effect of the use of NSAIDS and narcotics is discussed in Chapter 15, Psychotropic Drugs.

11.4Effect on functional ability to drive

Condition Type of driving impairment and assessment approach* Primary functional ability affected Assessment tools

Loss of limb

Diseases of the joints

Disabilities of the spine

Deformity

Persistent impairment: Functional assessment Motor

Medical assessments

Functional assessment

(*See Part 1 for a discussion of the use of functional assessments for driver licensing decisions.)

Drivers operating motor vehicles of any class must be able to carry out many complex muscular movements swiftly, accurately and repeatedly in order to control a vehicle properly. Truck and bus drivers must also have good muscular strength and functional range of motion in both their arms and legs in order to handle these heavier vehicles.

Musculoskeletal conditions may cause a persistent impairment of motor functions necessary for driving.  The specific impact on functional ability varies by condition and type of impairment.  Functional abilities that may be affected include:

  • muscular strength
  • range of motion
  • flexion and extension of upper and lower extremities
  • joint mobility, and
  • trunk and neck mobility

Osteoarthritis has a considerable effect on functional ability, with the extent of the disability associated with the location and severity of the disease.  For example, the risk for disability (defined as needing help walking or climbing stairs) attributable to OA of the knee is as great as that attributable to cardiovascular disease, and is greater than that due to any other medical condition in the aged population.

Functional disability is the major consequence of rheumatoid arthritis.  Drivers with RA often experience a substantial loss of mobility due to pain and joint destruction.  In the few studies that have examined the relationship between RA and driving performance, 25% - 50% of individuals with RA reported difficulties with aspects of the driving task such as steering, cornering, reversing, head turns and shoulder checks.

11.5Compensation

Drivers with musculoskeletal conditions may be able to compensate for functional impairment through strategies and/or vehicle modifications.

Strategies

For loss of limb, a driver may compensate through the use of a prosthetic device when driving.  Other strategies that do not require vehicle modifications may also be used to compensate, for example, rotating the upper body in order to check side view mirrors if the driver’s neck lacks sufficient mobility.  The effectiveness of individual strategies may be determined through a road test.

Vehicle modifications

Drivers with musculoskeletal conditions may be able to compensate for a functional impairment by driving a vehicle that has been modified to address their impairment. Compensatory vehicle modifications can include modifications to driving controls (e.g. hand controlled throttle and brake) or the use of additional mirrors.

An occupational therapist, driver rehabilitation specialist, driver examiner or medical professional may recommend specific compensatory vehicle modifications based on an individual functional assessment.  They are familiar with the full range of possible vehicle modifications and what is appropriate for the type of musculoskeletal condition. Listed below are examples of some possible vehicle modifications.

Musculoskeletal condition Possible vehicle modifications
Some degree of loss of movement of the head and neck

Left and right outside mirrors

Rear view cameras

Missing lower limb

Hand controls

Left foot accelerator

Amputation or deformity of either arm

Power assisted steering

Mechanical devices to permit all hand controls to be operated by the normal hand

There is little empirical research that considers the relationship between vehicle modifications and adverse driving outcomes. The effectiveness of individual vehicle modifications may be determined through a road test.

11.6Guidelines for assessment

11.6.1 Loss of upper or lower extremities - All drivers

National Standard

All drivers eligible for a licence if

  • a road test indicates ability to compensate for any loss of functional ability required for driving, and
  • the conditions for maintaining a licence are met
BC Guidelines
  • RoadSafetyBC will typically request an ICBC road test, unless there has been no significant change in the individual’s condition or functional ability since a previous functional assessment
  • If further assessment is required, RoadSafetyBC may request:
    • additional information regarding the individual’s medical condition, and/or an assessment from an occupational therapist or driver rehabilitation  specialist
  • Non-commercial drivers with: a left leg amputation, no Restriction 28 on the driving record, no other concerns noted from reporting doctor, and no information to indicate that a road test re-exam is required will have a R 28 added to their licence by RoadSafetyBC
Conditions for maintaining licence No conditions are required
Restrictions

RoadSafetyBC will restrict individuals’ licences so that they are only allowed to drive vehicles that have the permitted modifications and devices required to compensate for their functional impairment. This may include one or more of the following restrictions:

  • R 25 Fitted prosthesis/leg brace required
  • R 26 Specified vehicle modifications required
  • R 28 Restricted to automatic transmission
Reassessment
  • If the loss of limb is not the result of a medical condition that is progressive, RoadSafetyBC will not re-assess, other than routine commercial or age-related re-assessment
  • If the loss of limb is the result of a medical condition that is progressive, the re-assessment guidelines for that medical condition apply
Information from health care providers
  • Results of a road test in a vehicle with the permitted modifications or devices required
  • Health professional’s opinion as to whether the driver has insight into the impact their loss of limb may have on driving
Rationale The impact of a loss of limb on fitness to drive is variable and must be determined by an individual functional assessment

11.6.2 Chronic musculoskeletal condition

Chronic musculoskeletal conditions include diseases of the joints, disabilities of the spine and deformity.

National Standard

All drivers eligible for a licence if

  • the driver retains sufficient movement and strength to perform the functions necessary for driving
  • pain associated with the condition, or the drugs used to treat the condition, do not adversely affect ability to drive safely
  • where required, a road test or other functional assessment indicates ability to compensate for any loss of functional ability required for driving, and
  • the conditions for maintaining a licence are met
BC Guidelines
  • If further information regarding an individual’s medical condition is required, RoadSafetyBC may request
    • a Driver’s Medical Examination Report, or
    • additional information from the treating physician
  • If the treating physician indicates loss of range of motion, and/or weakness
    • RoadSafetyBC will typically request an ICBC road test, unless there has been no significant change in the individual’s condition or functional ability since a previous functional assessment.
  • If an ICBC driver examiner recommends further assessment, RoadSafetyBC may request
  • additional information regarding the individual’s medical condition, and/or an assessment from an occupational therapist or driver rehabilitation  specialist
Conditions for maintaining licence No conditions are required
Restrictions

RoadSafetyBC will restrict individuals’ licences so that they are only allowed to drive vehicles that have the permitted modifications and devices required to compensate for their functional impairment. This may include one or more of the following restrictions

  • R25 Fitted prosthesis/leg brace required
  • R26 Specified vehicle modifications required
  • R28  Restricted to automatic transmission
Reassessment RoadSafetyBC will not re-assess, other than routine commercial or age-related re-assessment, unless re-assessment is recommended by the treating physician
Information from health care providers
  • Opinion of treating physician on whether the driver has a loss of range of motion or strength that may affect functional ability to drive
  • Opinion of treating physician on whether pain or drugs may adversely affect functional ability to drive
  • Where required, the results of a functional assessment
  • Opinion of treating physicians as to whether the driver has insight into the impact their condition may have on driving
  • History of compliance with prescribed treatment regime
  • If known or applicable, whether the driver is compliant with any current conditions of licence related to their condition
Rationale The impact of a chronic musculoskeletal condition on fitness to drive is variable and must be determined by an individual functional assessment