Fitness to drive after trigger or carpal tunnel release surgery: perceptions of patients versus clinicians

INTRODUCTION Patients who have undergone limb surgery are often told not to drive after surgery based on arbitrary guidelines and experience. Although this decision transcends socioeconomic1234 and legal5,6 spheres, there is relative paucity in guidelines on driving after surgery, as opposed to driving after sedation or general anaesthesia. Most studies relating to driving after limb surgery examined the effect of lower extremity surgery or general anaesthesia/sedation.789101112 Studies on upper extremities usually focused on the effect of immobilisation on the ability to drive.1314151617 This survey study aimed to determine: (1) the perception of patients who returned to driving after trigger release or carpal tunnel release surgery performed under local anaesthesia without sedation; and (2) the perception of clinicians (hand surgeons, residents and therapists) regarding when patients could resume driving and the bases for their opinions. METHODS Following Institutional Review Board approval (reference no. 2016/00417), patients who were drivers (in personal or commercial capacity) and who were scheduled for unilateral carpal tunnel release or single-digit trigger release were identified and invited to participate in this study, which spanned a 6-month period. Exclusion criteria were patients who did not drive or had incomplete questionnaire. Surgical procedures were performed under local anaesthesia (without sedation), with no narcotics given perioperatively. Patients were discharged on the day of surgery and advised not to drive that day, as per current practice. They were followed up routinely based on individual clinician's schedule. A patient questionnaire Supplemental Digital Appendix 1 at https://links.lww.com/SGMJ/A94 was administered through telephone calls by a single research coordinator at postoperative week 1, 2 and 6 upon patients' consent. The questionnaire sought to evaluate patients' confidence level based on the Visual Analogue Scale (VAS) (1–100) and factors (pain, stiffness, dressings) that affect driving abilities (parking, gear transmission, cruising). Clinicians, comprising hand surgeons, hand surgery residents and hand therapists, were invited to complete an electronic questionnaire Supplemental Digital Appendix 2 at https://links.lww.com/SGMJ/A93. The questionnaire examined clinicians' perception regarding when patients could return to driving following surgery. They were asked to rank the factors that could influence driving ability, including patient factors (hand dominance, pain, dressings, range of motion, wound); vehicle parameters (size, transmission type, private vs. commercial), and to provide their views on whether objective measures should be used to determine fitness to drive. Means were calculated for descriptive statistics, while nonparametric analysis was performed with chi-square test (www.socscistatistics.com). A P value < 0.05 was considered statistically significant. RESULTS A total of 19 patients (three females and 16 males) completed the survey. The mean age of the patients was 60.4 ± 8.6 years. Fourteen patients underwent trigger release and five underwent carpal tunnel release. Surgery was performed on the left hand in seven (36.8%) patients and the right hand in 12 (63.2%) patients. All the patients were right-hand dominant, and the vehicles driven were all right-hand drive, with left hand for gear change. Sixteen (84.2%) patients drove private cars, while three (15.8%) drove commercial trucks. None of the patients surveyed received workplace compensation. Sixteen (84.2%) patients drove vehicles with automatic transmission, and three (15.8%) with manual transmission (all commercial trucks). All patients resumed driving in postoperative week 1, and the mean self-reported confidence level increased from 77.5 ± 19.4 at week 1 to 91.1 ± 13.6 and 97.9 ± 9.1 at weeks 2 and 6, respectively. There were no statistically significant differences in postsurgery driving confidence levels between patients with trigger release and those with carpal tunnel release. However, patients who underwent surgery in the left hand cited lower confidence levels in postoperative weeks 1 and 2, compared to those who underwent surgery in the right hand Table 1. There were six responses indicating challenges in parking (n = 3), gear shift (n = 2) and driving (n = 1) in the first week, and this became progressively better Table 1. Digital stiffness was the primary cause cited for these inconveniences. There were no postoperative complications or road traffic accidents.Table 1: Results of patient questionnaire.Seventy-three clinicians (17 post-fellowship hand surgeons, 20 residents and 36 hand therapists) completed the survey. Most recommended resuming driving 11 days or later following surgery Figure 1, with a greater proportion suggesting that patients who underwent trigger release could return to driving earlier than those who underwent carpal tunnel release (P = 0.042). Respondents who felt that patients were able to drive on the same day following trigger release (n = 4) or carpal tunnel release (n = 1) highlighted that it was possible if the patient did not have pain. Clinicians ranked pain, wound condition and range of motion as the key factors influencing their opinions Table 2. They also recognised the difference between private and commercial vehicles as the factor that could affect patients' motivation to drive.Figure 1: Chart shows that surgeons generally recommended earlier resumption of driving, compared to residents and therapists.Table 2: Factors ranked by clinicians to be important in determining fitness to drive.Of the 73 clinicians, 43 indicated that objective measures should be considered when advising their patients on when they could resume driving after an elective hand surgery Table 2. Therapists were more likely than attending surgeons and residents to use objective measures to assess fitness to drive (P < 0.01). Therapists and residents tended to measure two or more parameters such as pain score (VAS), active range of motion (AROM), distance between the pulp and the crease (DPC), and grip strength. There were two therapists who indicated in the free-text response that driving simulator should be used for high-fidelity evaluation. DISCUSSION The key finding from this study was the dichotomy between patients' and clinicians' perception of fitness to drive postsurgery. Patients returned to driving sooner than clinicians believed they could. Our results reflect previous observations, ranging from immediately after surgery18 to 9 days following surgery.19 Patients who reported challenges with driving in this study were mainly commercial truckers who drove vehicles with manual transmission. Despite the inconveniences, they were able to resume their vocation. Stiffness was cited as a common factor affecting their ability. It is likely that the decision to resume driving is influenced by patients' motivation to recover their earning capacity, and not merely due to medical advice.20 The range of opinions among surgeons, residents and therapists suggests different risk tolerance and experience among clinicians, and the challenge of reconciling these differences. Objective parameters such as range of motion, grip strength and pain score are commonly noted but may not provide adequate granularity in the overall assessment of driving abilities. Full-size driving simulators, as suggested, are inaccessible in a hospital setting and not feasible for routine use. These findings highlight the need for objective measures tailored to driving. Potential tools such as the Disabilities of the Arm, Shoulder and Hand21 or the Patient-Reported Outcome Measurement Information System22 scores could potentially be coupled with realistic gaming simulators (Thrustmaster TMX Force Feedback System)23 for more comprehensive and representative evaluation, analogous to the Jebsen Hand Function Test.24 However, initiatives at objective evaluation should dovetail national policies, which vary across jurisdictions. In the United States of America, the Driver Fitness Medical Guidelines by the National Highway Traffic Safety Administration and the American Association of Motor Vehicle Administrators25 recommend healthcare professionals to refer patients for further assessment if there were any doubts about safe driving. In contrast, the Irish Road Safety Authority guidelines26 and the Driver and Vehicle Licensing Agency guidelines27 from the United Kingdom delegate the mandate to the attending healthcare professional. One of the limitations of this study is its methodological weakness due to the small patient sample size and unequal representations between clinical groups. Also, the study was conducted in Singapore, a country with a highly urbanised traffic system, and thus, the results may not apply to cross-country and rural traffic conditions. In conclusion, there is great heterogeneity in the recommendations on driving following surgery of the hand among patients, clinicians and regulatory bodies. This calls for clinicians and patients to exercise discretion when adopting practical objective measures and when formulating safe recommendations. Acknowledgement We would like to thank Dr. Ruth Tan Si En, Ms Pang Liying, Ms Jewel Ze Yi and Ms Jasmine Yong for their help in disseminating the questionnaires. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.