Royal Liverpool University Hospital, Department of Rheumatology, Liverpool, UK and 1Cork University Hospital, Department of Rheumatology, Cork, Ireland
Correspondence to: S. Busteed. E-mail: sandra_busteed{at}hotmail.com
SIR, The ability to drive has become an integral part of modern life. This is particularly true in areas where public transport is less developed [1]. The proportion of UK households with access to a car has grown from 14% in 1951 to 72% in 1999 and over a quarter of all households has access to more than one car [2]. Patients with rheumatoid arthritis (RA) face particular difficulties with driving, depending on their degree of functional impairment. However, these difficulties are not specifically addressed in functional assessments such as the Health Assessment Questionnaire. We decided to conduct a questionnaire-based observational study of patients with RA to determine the type of problems they encountered while driving.
Thirty patients with RA agreed to take part in the survey. All were in possession of a current driver's licence; 53% (16/30) were male. Respondents were asked about the type of car they drove and whether their car had power steering or automatic transmission. Any adaptations made to the vehicle were documented such as the addition of rear view mirrors or seat belt attachments. Participants were asked whether they experienced pain or fatigue while driving and were also questioned about specific problems encountered, for example on entering or alighting the vehicle, engaging the clutch, changing gears or reversing. Finally, respondents were asked to record whether a doctor had ever asked them about driving or if they had ever been referred to either an occupational therapist or specialist centre for advice on driving. A Health Assessment Questionnaire (HAQ) was completed in each case and a drug history was also recorded.
The average age of the participants was 51 yr and the average duration of RA was 9 yr. Twenty-seven patients were on at least one disease-modifying drug (including biologics) and 29 were using either non-steroidal anti-inflammatory drugs or prednisolone. The average HAQ score was 0.66 with a range of 02.25 and over a third had a disability index greater than 1 (11/30). Twenty-three patients had power steering and only one had automatic transmission. Only eight respondents said they had made adaptations to their vehicles to assist their driving. Four patients had fitted a lumbar cushion or wedge support. Nine replied that they experienced a lot of pain while driving and 13 complained of fatigue. Twenty responded that they had specific problems with driving. Fourteen had difficulties with entering and leaving the car, 10 reported problems with reversing while eight had difficulties with looking left and right at a junction. Using the gear stick (7/30), engaging the clutch (7/30) and starting the ignition (6/30) were also cited as problematic. Three patients had difficulties in engaging the brakes. Eight respondents were unable to drive because of their arthritis at least once a month. One patient, who worked as a taxi driver, reported difficulties with both reversing and junctions, but had not made adaptations to his vehicle apart from a steering wheel cover to aid grip. Only 11 patients carried a mobile phone in the car. All patients responded that a doctor had never enquired specifically about problems with driving. Interestingly, half of the 20 patients who reported difficulties had a disability index less than 1 on a HAQ.
This survey highlights a number of points. People with RA often encounter practical difficulties with driving, in particular getting in and out of the car and reversing. These difficulties can occur in patients who otherwise have little by way of functional limitation. Despite the reported difficulties with junctions and reversing, no respondent had fitted their vehicle with an additional side or rear view mirror, although these are cheap and easily bought in a car accessory shop. A US study of elderly drivers with arthritis suggested that the most important factors in management were the provision of power steering and automatic transmission [3]. In our group, only one patient had automatic transmission; however, this is likely to be related to the expense and availability of these vehicles. It has previously been found that patients with RA have difficulties in all areas of function but especially with upper limb function, for example reaching the seat belt [1]. Many of these problems could be overcome with a few simple adaptations such as an enlarged key handle or supplementary mirrors [4, 5]. It has also been reported that while half of patients with RA continue to drive, only a quarter will directly ask for advice on driving [6]. Even allowing for the fact that more men than women hold a car driving licence (82% of men compared with 60% of women, 19982000, National Statistics), there was a higher than expected percentage of men in this surveythis may be due to the fact that women with RA are less likely to drive than their male counterparts and warrants further study.
There appears to be a lack of awareness of these difficulties in the medical profession. Rheumatologists in particular should be more vigilant to potential problems in drivers with RA and if necessary refer to an occupational therapist or a mobility centre. There are a number of mobility centres throughout the UK and Ireland that provide services including advice on vehicle choice and driving tuition, as well as fitting of car adaptations in some centres.
In summary, difficulty with driving is common in patients with RA, even in patients with little functional impairment. Simple and inexpensive adaptations may be all that is required to improve a patient's safety and comfort behind the wheel.
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