’ Original Article
Journal of the International Society of
Physical and Rehabilitation Medicine
Knowledge, attitude, and practice of patients,
health care practitioners, and road-traffic safety
regulators on patients’ return to driving policy after
recovery from musculoskeletal disorders
Udoka Chris Arinze Okafor, PhD, (PT)a, Sunday Rufus Akinbo, PhD, (PT)a, Daniel Oluwafemi Odebiyi, PhD, (PT)a,
Saturday Nicholas Oghumu, PhD, (PT)a,b,*
Background: Returning to driving is a major concern for many individuals who had developed the driving skill before injury or
disease. This study evaluated the knowledge, attitude, and practice of patients, health care practitioners, and road-traffic safety
regulators on patients’ return to driving policy after recovery from musculoskeletal disorders (MSDs).
Methods: The study was a cross-sectional design. Participants were aged 18–80 years and comprised patients recovering from
MSDs, health care practitioners, and road-traffic safety regulators. Questionnaires were distributed to patients who were managed
for MSDs, health care practitioners involved in the management of MSDs, and road-traffic safety regulators. Questionnaires seeking
relevant information on knowledge, attitude, and practice of patients’ return to driving for each category of participants were
distributed in this wise: 320 questionnaires to patients, 355 to health care practitioners, and 300 to road-traffic safety regulators.
Descriptive statistics of frequency and percentages were used to summarize the data, while χ2 was used to analyze associations
among variables at P < 0.05.
Results: The health care practitioners’ knowledge of return to driving policy after MSDs was fair (125, 41.8%); however, with a good
practice score (259, 86.6%). Both the health care practitioners and road-traffic safety regulators had positive attitudes. The patients
exhibited poor knowledge (122, 60.7%), negative attitude (126, 62.4%), and poor practice (160, 79.6%) toward return to driving
regulation (P = 0.0001). One hundred seventy-four (58.2%) of the health care practitioner respondents reported determining
patients’ return to driving after MSDs, while 137 (68.2%) patient respondents recommended health care practitioners and road-traffic
safety regulators collaboration in patient’s return to driving.
Conclusions: Return to driving policy after recovery from MSDs is a collaborative effort hinged on health care practitioners’
evaluation and a driving retest by the road-traffic safety regulators. Health care practitioners and road-traffic safety regulators have
good to fair knowledge of patients return to driving policy, while patients have poor knowledge and negative attitudes to return to
driving.
Keywords: Musculoskeletal disorders, Return to driving, Driving policy, Health care professionals, Road-traffic safety regulators
musculoskeletal system comprising inflammatory, osteoarthrosis, and regional pain syndromes of tenosynovitis, epicondylitis, bursitis, carpal tunnel syndrome, myalgia, low back
pain, and sciatica that arises from one time or cumulative exposure to habitual hazards.[3] Body regions most affected are the low
back, the neck, shoulder, forearm, and hand, although
recently the lower extremity has received more attention.[1,2]
Musculoskeletal disorders have been described as the most
notorious and most common causes of severe long-term pain and
physical disability that affect hundreds of millions of people
across the world.[4,5] They are ranked first in prevalence as the
cause of chronic health problems, long-term disabilities, and
consultations with health care professionals and ranked second
for causing restricted activity days.[6]
Musculoskeletal disorders are reported to occur in certain
industries and occupations, with rates up to 4 times higher than
the average across industries.[2,4] Such MSDs, which emanate
from work-related events within industries and occupations, are
termed work-related musculoskeletal disorders (WMSDs).[4,7]
Work activities that are frequent and repetitive or activities with
awkward postures cause WMSDs, which may be painful during
work or at rest. Studies have shown associations between
work-related risk factors such as manual material handling,
Introduction
Musculoskeletal disorders (MSDs) are a wide range of inflammatory and degenerative conditions affecting muscles, tendons,
ligaments, joints, peripheral nerves, and supporting blood vessels
with consequent ache or pain, discomfort, and movement
limitation.[1,2] They include clinical signs and symptoms of the
a
Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine,
University of Lagos, Lagos, Nigeria and bDepartment of Physiotherapy, School of
Postgraduate Studies, University of Lagos, Lagos, Nigeria
*Corresponding author. Address: Department of Physiotherapy, School of Postgraduate
Studies, University of Lagos; Department of Physiotherapy, School of Basic Medical
Sciences, University of Benin. Tel.: +234 803 421 5928.
E-mail address: nickyyivieosa@gmail.com; saturday.oghumu@uniben.edu. (S. Nicholas).
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. This is an
open access article distributed under the Creative Commons Attribution License 4.0
(CCBY), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Journal of the International Society of Physical and Rehabilitation Medicine (2024)
7:121–128
Received 18 May 2024; Accepted 30 August 2024
Published online 16 September 2024
http://dx.doi.org/10.1097/ph9.0000000000000044
121
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
rehabilitation, recovering from diagnosed MSDs from varied
causes with no cognitive impairment and attending the outpatient physiotherapy, surgery, and occupational therapy
departments of the National Orthopaedic Hospitals; health
care practitioners consisting of orthopedic surgeons and senior
registrars in orthopedics, physiotherapists, and occupational
therapists with a minimum of 2 years postqualifications and
road-traffic safety regulators who are senior field operators and
research officers of the federal road safety corps, not below the
rank of assistant route commander with at least 2 years of field
experience in the corps. Participants not meeting the inclusion
criteria were excluded from the study. Patients with amputation
and multiple or bilateral upper and lower extremity MSDs were
excluded from this study.
The research grants and experimentation ethics committees of
the College of Medicine of a University and 2 National
Orthopedic Hospitals gave approval for this study (NOH/DOTS/
2011, S/313/IV/745). Permission was obtained from the office of
the Corps Marshal and chief executive through the head of policy, research, and statistics of a federal road safety corps.
Informed consent was also obtained from each respondent before
their enrollment in the survey.
The Cochran formula for sample size determination was used
for the study: n = z2pq/d2.[23] Where n = minimum sample size for
statistically significant survey; z = the standard normal deviation,
usually set at 1.96, which corresponds to 95% CI; P = proportion of patients who returned to driving = 0.30 from a previous
study;[20] q = 1- P = 1–0.30 = 0.7 and d = degree of accuracy
(usually set at 0.05). Hence, the number of patients calculated
was n = 309.65≈310. For health care professionals and roadtraffic safety regulators, P was set as 0.5 since their proportion
was unknown, hence a value of n = 384 was obtained. Also, a
minimal sample size was estimated using nf = n/1 + n/N where
n = 310 and N = 560 for patient participants with resultant
nf = 200; n = 384 and N = 1302 for health care practitioner-parti
cipants with resultant nf = 296 and n = 310 with N = 721 for road
traffic participants with a minimum sample nf = 250.
The study utilized 3 independent questionnaires described as
“Return to Driving (RTD) Questionnaires,” which were specifically designed and adapted to collect data relating to each of the 3
survey categories. The RTD questionnaire was adapted from
Chen et al[20] on return to driving and developed for suitability for
assessing patients, health care professionals, and road-traffic
safety regulators models of return to driving with strong validity.
The initial drafts of the questionnaires for the 3 surveys were
variously improved upon and appropriately modified to suit the
current study objectives and the study sample by a seven-man
focus group. This focus group comprised physiotherapy academics, clinicians, and surgeons who are experts in questionnaire
design to produce the final draft of the instrument.
The Return to Driving Questionnaire-Patient Model (RTDPM) is a 43-items self- administered questionnaire. The RTD-PM
is divided into 4 sections A–D. Section A assessed the sociodemographic data of patient respondents. Section B assessed the
nature of musculoskeletal injury, section C assessed patients’
burden of stopped driving after musculoskeletal disorders, and
section D assessed patients return to driving after injury.
The Return to Driving Questionnaire-Practitioner Model
(RTD-PRM) is a 25-item questionnaire with 4 sections A to D.
Section A sought information on sociodemographic data of
practitioner respondents. Section B sought information on
heavy physical load, repetitive movement, psychological factors,
and musculoskeletal disorders.[5,7] Driving is a repetitive activity
usually performed by commercial and private vehicle owners.
Driving is a multisystem activity that requires a comprehensive
assessment of abilities.[8,9] It involves the act of operating a motor
vehicle or machine in motion. There are myriad of risk factors
associated with driving, including prolonged sitting, whole body
vibration, driving hours, the nature of the road surfaces, and
ergonomic mismatch, all of which have been reported to be
identifiable risk factors of MSDs.[10–12] The literature is replete
with diverse consequences of driving. About 1.3 million lives are
lost annually from road traffic crashes.[13,14] The crash death rate
is reported to be 3 times more in low-income countries than in
high-income countries while over 50 million people sustain var
ious degrees of injuries and disability from road crashes every
year according to World Health Organization.[14,15] Previous
studies have shown high prevalence rates of MSDs among pro
fessional drivers.[10,12,16] A high prevalence of musculoskeletal
pain in the lower and upper back regions was reported among
commercial drivers and motorcyclists in a Nigerian study, while
another study found a high annual prevalence of MSDs among
3-wheeled drivers.[10,17]
On the other hand, stopped driving is associated with
decreased work output, lost social activities, self-actualization,
and depressive symptoms.[18,19] Stopped driving is common
in situations where other forms of transports are easily accessible
or in the event of debilitating ill-health.[8,18] Due to the heavy
burden of cessation of driving, especially loss of social support
and self-actualization, there is the propensity for individuals
recovering from illness, including, MSDs to resort to driving even
when it is not safe. Thus, the decision on when a patient can
return to driving is a complex one that should not be made lightly
in view of patient and public safety implications and potential
legal issues that may arise following road crashes.[20]
Development of return to driving guidelines, model, or policy
is very important as there is often significant disparity and variation in practitioners’ expectations, recommendations, and
postoperative advice regarding return to driving.[21] Not much is
known about the extent to which patients and individuals return
to driving and the advice or evaluations they receive before
returning to driving following various health conditions. Studies
are sparse on the return to driving assessment following health
conditions, especially after MSDs. People who stopped driving
due to health or other reasons see the ability to drive again as a
crucial index of recovery.[8,22] Thus, returning to driving is a
major concern to many individuals who had developed the driv
ing skill before injury or disease. This study was designed to
determine the knowledge, attitude, and practice of patients,
health care practitioners and road-traffic regulators on patients’
return to driving policy after recovery from MSDs.
Methods
The study was a cross-sectional, multicenter, descriptive survey
that involved a developed questionnaire as the survey tool. The
patients and health care professionals of 3 National Orthopaedic
Hospitals were recruited for this survey. Also, road-traffic safety
regulators resident in the 3 cities of National Orthopaedic
Hospitals were recruited. Inclusion criteria were participants
aged 18 to 80 years and comprised, patients in their last week of
122
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
practitioners predicting factors to return to driving, section C
assessed the effect of strong medications on driving, and section D
assessed the return to driving (retest) model.
The Return to Driving Questionnaire-Regulator Model (RTDRM) is a 26-item self-administered questionnaire developed primarily for this study. It also has 4 sections. section A assessed the
sociodemographic data of regulator respondents, section B
assessed predictors of crash risks, section C assessed crash risk
following return to driving, while section D assessed return to
driving (retest) Model.
Four questions that tested knowledge were utilized to determine scoring of level of knowledge of return to driving.
Participants only completed sections that are of concern to them.
Each question carried 1 mark, thus the highest possible score was
4, while the lowest was 0. A score between 0 and 1 = poor,
2–3 = fair, and a score of 4 = good. Three questions that tested
attitude were utilized to determine the scoring of attitude toward
return to driving. Each question carried 1 mark, thus the highest
possible score was 3, while the lowest was 0. A score between 0
and 1 was considered negative while a score of 2–3 was considered positive. Four questions that tested practice were utilized
to determine the level of practice of return to driving. Each
question carried 1 mark, thus the highest possible score was 4,
while the lowest was 0. A score between 0 and 1 = poor,
2–3 = fair while a score of 4 = good.
The questionnaire was distributed to patients, health care
practitioners, and road-traffic safety regulators and collected the
following day. Three hundred twenty questionnaires were distributed to patients only, 355 questionnaires were distributed to
health care practitioners, while 300 copies were distributed to
road traffic regulators.
Data were analyzed using the Statistical Package for Social
Sciences (SPSS) software (Version 17; SPSS, Chicago, IL).
Descriptive statistics of frequency and percentages were used to
summarize data. χ2 analysis was used to determine associations
among variables. Level of significance was set at P < 0.05.
www.jisprm.org
Table 1
Sociodemographic Characteristics of Patient Respondents.
Variables
Age (y)
21–30
31–40
41–50
51–60
61–70
71–80
Gender
Male
Female
Marital status
Married
Single
Widowed
Separated
Divorced
Education
Tertiary
Secondary
Primary and below
Occupation
Unemployed
Professional
Skilled
Unskilled
Retired
Frequency (n) percentage (%)
26 (12.9)
61 (30.4)
53 (26.4)
26 (12.9)
27 (13.4)
8 (4.0)
134 (66.7)
67 (33.3)
137 (68.2)
53 (26.3)
9 (4.5)
1 (0.5)
1 (0.5)
152 (75.6)
39 (19.4)
10 (5.0)
13 (6.5)
37 (18.4)
62 (30.8)
42 (20.9)
13 (6.5)
respondents’ ranks ranged between assistant route commander
and deputy corps marshal (Table 3).
The cause of injury among 123 patients (61.1%) was road
traffic crashes. Eighty-six (70.0%) sustained motor vehicle crashes, while 30 (24.2%) were involved in motorcycle crashes
Table 2
Sociodemographic characteristics of practitioner respondents.
Results
Variables
Patient respondents returned a total of 201 completed filled
questionnaires out of 320 questionnaires yielding a response rate
of 62.8%. Patient respondents’ age ranged from 21 to 80 (45.08
+1 3.23) years. The most affected age range was 31–40 years
(30.3%). One hundred thirty-four (66.7%) were males, whereas
137 (68.2%) were married (Table 1). A total of 299 validly
completed questionnaires out of 355 questionnaires were
returned by health care practitioners with a response rate of
84.2%. The health care practitioners comprised orthopedic surgeons and senior registrars in orthopedics and trauma medicine
(96, 32.1%), physiotherapists (193, 64.5%), and occupational
therapists (10, 3.3%). Practitioners with practice experience
between 2 and 5 years (123, 41.1%) and 6–10 years (80, 26.8%)
made up the largest number in this category. Orthopedic/
Specialist Hospitals (130, 43.5%) and Teaching Hospitals (118,
39.5%) were the most common work settings among these
respondents (Table 2). The road traffic safety regulator respondents yielded a response rate of 84.0% with 252 filled and
returned questionnaires out of 300 questionnaires distributed to
them. Among the road-traffic safety regulator respondents, 152
(60.3%) had 6–9 years of experience in the corps, whereas the
Gender
Male
Female
Total
Professional group
Physiotherapist
Orthopedic surgeon/senior registrar
Occupational therapist
Total
Years of experience
2–5
6–10
11–15
16 and above
Total
Work settings
Orthopaedic/specialist hospital
Teaching hospital
Federal Medical Centre
General hospital
Others
Total
123
Frequency (n) percentage (%)
214 (71.6)
85 (28.4)
299 (100.0)
193 (64.5)
96 (32.2)
10 (3.3)
299 (100.0)
123 (41.1)
80 (26.8)
46 (15.4)
50 (16.7)
299 (100.0)
130 (43.5)
118 (39.5)
34 (11.2)
14 (4.7)
3 (1.1)
299 (100.0)
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
Table 3
Sociodemographic characteristics of regulator respondents.
Variables
Gender
Male
Female
Total
Years in FRSC
2–5
6–9
> 0
Total
Rank
ARC
RC
SRC
CRC
ACC
DCC
CC
DCM
Total
Table 5
Knowledge, attitude, and practice scores of all respondents.
Frequency (n) percentage
(%)
Variables
Knowledge
Good
Fair
Poor
Total
Attitude
Positive
Negative
Total
Practice
Good
Fair
Poor
Total
189 (75.0)
63 (25.0)
252 (100.0)
92 (36.5)
152 (60.3)
8 (3.2)
252 (100.0)
53 (21.0)
29 (11.5)
31 (12.3)
37 (14.7)
42 (16.7)
20 (7.9)
3 (1.2)
1 (0.4)
252 (100.0)
Regulators
[n (%)]
32 (15.9)
47 (23.4)
122 (60.7)
201 (100.0)
125 (41.8)
86 (28.8)
88 (29.4)
299 (100.0)
86 (34.1)
135 (53.6)
31 (12.3)
252 (100.0)
—
—
—
—
—
—
143.26 0.0001*
75 (37.6)
126 (62.4)
201 (100.0)
280 (93.6)
19 (6.4)
299 (100.0)
187 (74.2)
65 (25.8)
252 (100.0)
—
—
—
—
190.36 0.0001*
21 (10.4)
20 (10.0)
160 (79.6)
201 (100.0)
259 (86.6)
20 (6.7)
20 (6.7)
299 (100.0)
103 (40.9)
10 (4.0)
139 (55.1)
252 (100.0)
—
—
—
—
—
310.30 0.0001*
χ2
P
part 130 (64.7%) (Table 4). The knowledge scores on return to
driving policy and regulation after musculoskeletal disorders
showed that health care practitioners had a fair knowledge (125,
41.8%), the practitioners and regulators had a positive attitude,
whereas a good practice score was shown by the practitioners
(259, 86.6%). The patients exhibited poor knowledge (122,
60.7%), negative attitude (126, 62.4%), and poor practice (160,
79.6%) toward a return to driving regulation (P = 0.0001)
(Table 5).
One hundred seventy-four (58.2%) of the practitioner
respondents stated that they determined when their patients
returned to driving after injury. Two hundred thirty-five (78.6%)
advised patients to resume driving following clinical evidence that
injury/surgery had resolved, while 54 (18.1%) allowed their
patients to resume when they expressed readiness. Only 10
(3.3%) approved their patients’ return at the point of hospital
discharge. On their opinions on who should decide on patients’
return to driving after MSDs, injury, or surgery, 137 (68.2%)
among patient respondents recommended the decision should be
a collaboration between health care practitioners and the roadtraffic safety regulators (Fig. 1), whereas 199 (66.6%) practitioner respondents recommended a collaboration among health
care practitioners, particularly the orthopedic surgeons, physiotherapists, and occupational therapists in deciding return to
driving after MSDs, injury, or surgery (Fig. 1).
Two hundred sixty-five (88.6%) of the practitioner respondents claimed to be aware of the existence of return to driving
policy or retest model in other countries, even though 280
(93.6%) were unaware of the existence of such policy or model
(Fig. 2). Ninety-eight (32.8%) recommended a model where the
health care practitioner alone should certify a patient suitable to
return while 149 (49.8%) preferred that the health care practitioner’s certification should be followed by a driving retest which
is to be carried out by the road traffic safety regulators (Fig. 2). On
strict return policy, 117 (39.1%) supported a driving retest model
for all musculoskeletal injuries while 166 (55.5%) supported a
model where driving retest should apply only to patients who had
been out of driving for at least 6 months because of MSDs, injury,
or surgery (Fig. 2).
Two hundred forty-three (81.3%) practitioner respondents
claimed to be familiar with traffic laws, while 291 (97.3%) agreed
(Table 4). Among those involved in road traffic crashes, 89
(67.4%) were passengers, whereas 43 (32.6%) drove at the time
of their crash. One hundred forty-two (70.6%) sustained bone
injury/fractures while the lower limb was the most affected body
Table 4
Causes, types, and distribution of musculoskeletal disorders/
injury.
Causes of musculoskeletal injury
Road traffic crashes
Domestic injuries
Industrial accident
Others
Total
Type of auto crash
Motor vehicle
Motorcycle
Tricycle
Total
Nature of injury
Bone injury/fracture
Spinal cord injury
Head injury
Soft tissue/disk injury
Degenerative/OA
Total
Body part involved
Lower limb
Upper limb
Back/spine
Head
Others
Total
Practitioners
[n (%)]
*Statistical significance.
ACC indicates Assistant Corps Commander; ARC, Assistant Route Commander; CC, Corps
Commander; CRC, Chief Route Commander; DCC, Deputy Corps Commander; DCM, Deputy Corps
Marshal; DRC, Deputy Route Commander; FRSC, Federal Road Safety Corps; RC, Route Commander;
SRC, Superintendent Route Commander.
Variables
Patients
[n (%)]
n (%)
123 (61.1)
60 (29.9)
16 (8.0)
2 (1.0)
201 (100.0)
86 (70.0)
30 (24.3)
7 (5.7)
123 (100.0)
142 (70.6)
4 (2.0)
6 (3.1)
25 (12.4)
24 (11.9)
201 (100.0)
130 (64.7)
52 (25.8)
9 (4.5)
1 (0.5)
9 (4.5)
201 (100.0)
124
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
Figure 3. Evaluation of patients by health care practitioners before return to
driving.
Figure 1. Patient and practitioners’ opinions on deciding to return to driving.
that improved traffic regulation will enhance road safety (Fig. 3).
Only 14 (4.7%) practitioner respondents admitted knowledge of
any driving law offering legal immunity to a health care practitioner who reports medically unfit drivers. One hundred seventysix (69.8%) practitioner respondents reported the nonexistence
of any traffic law requiring the health care practitioner to stop or
report impaired drivers (Fig. 3). Although 102 (40.5%) reported
knowledge of a traffic law requiring the health care practitioner
to certify patients fit before return, they did not provide information on the health conditions covered by such law (Fig. 3).
Two hundred thirty-eight (94.4%) practitioner respondents’
suggested that health care practitioners should evaluate their
patients’ ability to return to driving after musculoskeletal
conditions (Fig. 3) while 233 (92.5%) agreed that an indigenous
return policy and retest model will improve driving safety and
lead to significant improvement in road safety.
Although 169 (84.1%) patient respondents claimed they were
willing to seek health care practitioner’s approval before return,
48 (70.6%) of those who had returned to driving stated that they
did return on their own without consulting a health care practitioner. Only 28 (41.2%) of the returned patient respondents had
approval from their health care practitioner before their return to
driving (Table 6). Only 6 (3%) patient respondents had driving
Table 6
Attitude and coping strategies of patient respondents toward
return to driving.
Variables
Figure 2. Awareness and recommendation of a driving return/retest Model.
Unaware of any retest model Practitioner certification only certification should
be followed by driving retest driving retest for all MSDs driving retest for MSDs
after 6 months of stopped driving.
www.jisprm.org
Willing to seek health care practitioner’s approval
Yes
No
Indifferent
Health practitioner approved my return to driving
Yes
No
Total
I just felt like and resumed driving on my own
Yes
No
Indifferent
Total
Practitioner gave me drug dose advice
Yes
No
I will drive even with explanation of the side effect
Yes
No
Coping strategies as a result of stopped driving
I had to hire a driver
I depended on public transportation
I depended on support from family members
I coped through other means (unspecified)
125
n (%)
169 (84.1)
22 (10.9)
10 (5.0)
28 (41.2)
40 (58.8)
68 (100.0)
48 (70.6)
15 (22.1)
5 (7.3)
68 (100.0)
26 (12.9)
175 (87.1)
31 (15.4)
170 (84.6)
41 (20.4)
53 (26.4)
81 (40.3)
26 (12.9)
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
especially in the driving process where they are actively engaged.
Again, the lower limb, by its weight bearing and mobility functions may be more exposed to fracture from trauma.
In this study, inability to drive again resulted in respondents to
depend on public transportation; family members or friends or
had to stay at home all the time. These adopted coping strategies
could result in a major financial burden, given that they may
provide for the social supports sought, a finding similar to that
reported by respondents in the study by Chen et al.[20] Also, this
study found that the patient respondents who were professional
drivers lost their jobs because of their inability to drive again
following their musculoskeletal condition. Thus, in situations
where unemployment rates are on steady rise, job loss because of
stopped driving following musculoskeletal injury will increase the
economic burden of such citizens and worsen their perceived
socioeconomic challenges.
The study findings showed that health care practitioners had a
fair knowledge and good practice of return to driving policy and
regulations guiding their patients. The road-traffic safety regulators had a positive attitude toward policy and regulation of
return to driving. The finding of this study that drivers had poor
knowledge, negative attitude, and poor practice toward return to
driving policy and regulation contrasts with the report of Gopaul
et al[32] that drivers are aware of traffic laws and regulations and
have improved attitude and practice toward traffic laws and
regulation. Similarly, the finding of poor knowledge, negative
attitudes, and poor practice toward road policy and regulations
by drivers after MSDs is consistent with the findings of
Olakulehin et al[33] among pedestrians. Thus, it behoves health
care practitioners to educate their patients after MSDs on road
traffic policy and regulations to sustain their improvement.
Educating patients on ergonomic advice, posture, and use of
recommended safety measures may be of help in returning to
driving. Atubi[31] asserted that drivers’s education and training
are common approaches to improving road safety with the aim to
change risky behavior in driving.
The finding of this study on respondents’ view on who should
decide patients’ return to driving is that the majority of the
practitioner respondents recommended collaboration among
health care practitioners, particularly orthopedic surgeons, physiotherapists, and occupational therapists. Similarly, majority of
the patient respondents recommended collaboration among
health care practitioners and the road traffic safety regulators,
nevertheless this finding is in contrast with the reports of Chen
et al[20] that recommended collaboration among members of the
health care profession alone in deciding return to driving following MSDs. Return to driving policy and retest models exist for
different health conditions, including MSDs in many developed
countries.[34,35] In the United Kingdom, the drivers medical sec
tion within the driver and vehicle licensing agency deals with all
aspects of driver licensing when there are medical conditions that
impact, or potentially impact, on safe control of a vehicle.[35]
Summarily, patients recovering from MSDs suffer an inabil
ity/delay to return to driving, which makes them reliant on social
support services. Patients’ poor knowledge and negative attitudes
toward return to driving policy is a call to road-traffic safety
regulators and health care professionals for re-education on
driving policy and regulations while recovering from MSDs.
Of significant interest in this study is the finding that two fifth
of the patient respondents reported employing the coping strategy
of depending on supports of family members for not returning to
evaluation recommended by their health care practitioners, while
only 2 (1%) applied for a special driver’s license before returning
to driving. Just 1 respondent (0.5%) reported that he had his
vehicle modified before he could drive again (Table 6).
Discussion
The study showed the highest predisposition to MSDs within the
age group of 31–40 years. This range represents a peak functional
age group for most individuals where they are often exposed to
various levels of danger and job hazards, which are often work
related. The age group of 15–44 years was also reported in a
previous study by Hoffman et al[24] as being the mostly affected
age group by musculoskeletal injuries. Ike and Adam[25] reported
most driving age in their studied population to be in the range of
30–49 years. Respondents with MSDs in this present study were
higher among males than females at a ratio of 2:1. This
observation may be because, in developing countries, men are
often more involved in routine daily activities, including driving,
which may expose them to various musculoskeletal injuries more
than the female gender. Ike and Adam[25] found that mass transit
driving in a city was male dominated. Similar gender trends have
also been previously reported for road traffic crashes in different
countries. Peden and colleagues reported 2.7:1 in Pakistan;
Ghaffara and colleagues reported 22.4:6.9, whereas a Saudi
Arabian survey reported a male-to-female ratio of 9:1.[26–28]
However, this extremely high ratio of male drivers relative to
the female gender in these previous studies may be connected to
the fact that females are often largely restricted from driving in
some countries which somewhat make them less exposed to road
traffic trauma and musculoskeletal injuries.
The finding that the patient respondents (drivers) sustained
their injuries through road traffic crashes of motor vehicle and
motorcycle crashes, respectively, implied that road traffic
crashes make up the highest individual causes of musculoskeletal injury. This result corroborates the findings of a
previous study that found a high prevalence of road traffic
crashes.[29] Also, Awoniyi et al[30] found a tendency for future
increases in road traffic crashes in their country. High incidence
of motorcycle crashes was attributed to the astronomical increase
in the use of motorcycles as a means of commercial transporta
tion because of worsening economic situation,[17,29] which is
consistent with finding of this present study. In this present study,
the road-traffic safety regulators observed that many respondents
drove with musculoskeletal injuries and physical impairments.
This finding connotes that the drivers in this study are at risk of
developing chronic MSDs, given that they continue to drive
despite developing musculoskeletal injuries and physical impair
ment. Atibu suggested that in difference to improving driving
skills during training, high-order skills that include risk assess
ment, hazard perception, situational awareness, and the devel
opment of a responsible attitude reduces the risk of having cra
shes while driving.[31]
On the pattern of injury sustained and body parts affected,
bone injury, particularly fractures of the lower limbs ranked
highest. This finding agrees with Chen et al[20] who in a similar
study reported that the lower limbs were mostly affected. This
finding may be explained by the fact that the lower limbs comprise long bones, which maintain the body’s skeletal and postural
framework and as such may be more prone to external injuries,
126
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
driving after MSDs. This finding is quite interesting as psychological reason for lack of family support has been reported as one
of the barriers to interfere with workers’ recovery from injury.[36]
The expression of patients in this study is understandable given
the association of psychological constructs of fear of pain, catastrophizing, distress, job demands, long driving hours, lone
driving among others with MSDs and its recovery, as well as
being potential risks for road transport.[36,37]
Finally, the authors state to the best of their knowledge, that
the 3 specialist hospitals where this study was conducted were not
equipped with driving assessment and training equipment, hence,
may limit the implementation of the recommendation of this
study during in-patient hospital services in these hospital and the
studied population.
www.jisprm.org
Data availability statement
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
Declaration of generative AI and AI-assisted
technologies in the writing process
No AI tools/services were used during the preparation of this
work.
References
[1] Fahmy VF, Momen MAMT, Mostafa NS, et al. Prevalence, risk factors and
quality of life impact of work-related musculoskeletal disorders among
school teachers in Cairo, Egypt. BMC Public Health 2022;22:2257.
[2] Punnett L, Wegman DH. Work-related musculoskeletal disorders: the
epidemiologic evidence and the debate. J Electromyogr Kinesiol 2004;14:
13–23.
[3] Oakman J, Clune S, Stuckey R. Work-related Musculoskeletal Disorders
in Australia, 2019. Safe Work Australia; 2019.
[4] Oakman J, Weale V, Kinsman N, et al. Workplace physical and psychosocial hazards: a systematic review of evidence informed hazard
identification tools. Appl Ergon 2022;100:103614.
[5] Qureshi A, Manivannan K, Khanzode V, et al. Musculoskeletal disorders
and ergonomic risk factors in foundry workers’. IJHFE 2019;6:1–17.
[6] Sebbag E, Felten R, Sagez F, et al. The world-wide burden of musculoskeletal diseases: a systematic analysis of the World Health
Organization Burden of Diseases Database. Ann Rheum Dis 2019;78:
844–8.
[7] Okafor UAC, Oghumu SN, Abaraogu UO, et al. Musculoskeletal disorders and ergonomic risk exposure assessment in manual material
handlers in Lagos, Nigeria. Annals Biomed Sci 2020;19:96–104.
[8] Meyer J, Pattison N, Apps C, et al. Driving resumption after critical illness:A survey and framework analysis of patient experience and process.
J Intensive Care Soc 2023;24:9–15.
[9] Khan MQ, Lee S. A comprehensive survey of driving monitoring and
assistance systems. Sensors (Basel) 2019;19:2574.
[10] Yirdaw G, Adane B. Self-reported work-related musculoskeletal problems
and associated risk factors among three-wheel car drivers in Ethiopia: a
cross-sectional community-based study. J Pain Res 2024;17:61–71.
[11] Pickard O, Burton P, Yamada H, et al. Musculoskeletal disorders associated with occupational driving: a systematic review spanning 20062021. Int J Environ Res Public Health 2022;19:6837.
[12] Ilah SK, Ahmad IT. An evaluation of occupational hazards among tricycle drivers in Tarauni local government area, Kano State, Nigeria.
Sustainable Urban Mobility 2019;5(2b):258–65.
[13] Ahmed SK, Mohammed MG, Abdulqadir SO, et al. Road traffic accidental injuries and deaths: a neglected global health issue. Health Sci Rep
2023;6:e1240.
[14] World Health Organization (WHO). Global Status Report on Road
Safety 2018. The World Health Organization (WHO); 2018.
[15] Sheth A, Pagdhune A, Viramgami A. Prevalence of work-related musculoskeletal disorders (WRMSDs) and its association with modifiable
risk factors in metropolitan bus transit drivers: a cross-sectional comparison. J Family Med Prim Care 2023;12:1673–8.
[16] Joseph L, Standen M, Paungmali A, et al. Prevalence of musculoskeletal
pain among professional drivers: a systematic review. J Occup Health
2020;62:e12150.
[17] Akinbo SR, Odebiyi DO, Osasan AA. Characteristics of back pain among
commercial drivers and motorcyclists in Lagos, Nigeria. West Afr J Med
2008;27:87–91.
[18] Choi NG, DiNitto DM. Depressive symptoms among older adults who
do not drive: association with mobility resources and perceived transportation barriers. Gerontologist 2016;56:432–43.
[19] Marottoli RA, de Leon CFM, Glass TA, et al. Consequences of driving
cessation: decreased out-of-home activity levels. J Gerontol B Psychol Sci
Soc Sci 2000;55:S334–40.
[20] Chen V, Chacko AT, Costello FV, et al. Driving after musculoskeletal
injury. Addressing patient and surgeon concerns in an urban orthopaedic
practice. J Bone Joint Surg Am 2008;90:2791–7.
Conclusions
This study found that the preferred model to deciding return to
driving policy and regulation after recovery from MSDs is a
collaborative effort hinged on health care practitioners’ evaluation and a driving retest by the road-traffic safety regulators.
While health care professionals and road-traffic safety regulators
have good to fair knowledge on patients return to driving policy
and regulations, patients have poor knowledge and negative
attitudes to return to driving. The study recommends a retest
driving and safe driving evaluation in cases of musculoskeletal
conditions that have kept an individual out of driving before
returning to driving.
CRediT author statement
U.A.C.O.: designing the study, conducting the research, providing essential construct, analyzing the data, writing this paper, and
responsible for the final content for this research; S.R.A.: contribution to this research included designing the study, providing
essential construct, analyzing the data, writing this paper, and
responsible for the final content for this research; D.O.O.:
designing the study, providing essential construct, analyzing the
data, writing this paper, and responsible for the final content for
this research, S.N.O.: contribution to this research included
designing the study, analyzing the data, providing essential construct, writing this paper, and responsible for the final content for
this research.
Declaration of competing interest
The authors declare no conflict of interest.
Funding
This study received no external funding.
Ethics statement
Ethical approval was obtained from the research grant and
experimentation ethics committees of the College of Medicine of
the University of Lagos, Nigeria and two National orthopaedic
hospitals. All participants provided written informed consent.
127
Okafor et al. Journal of the International Society of Physical and Rehabilitation Medicine (2024)
[30] Awoniyi O, Hart A, Argote-Aramendiz K, et al. Trend analysis on road
traffic collision occurrence in Nigeria. Disaster Med Public Health Prep
2022;16:1517–23.
[31] Atubi AO. Traffic safety and the driver in Nigeria—a qualitative study.
Hmlyn J Human Cul Stud 2022;3:7–14.
[32] Gopaul CD, Singh-Gopaul A, Sutherland JM, et al. Knowledge, attitude
and practice among drivers in Trinidad, West Indies. J Trans Technol
2016;06:405–19.
[33] Olakulehin OA, Olowookere SA, Abiodun AA, et al. Knowledge, attitude, practices of road traffic regulations among pedestrians in a
University Community in Southwestern Nigeria. European Inter J Sci &
Technol 2019;8:41–56.
[34] Bonnie MD. Medical Conditions and Driving: A Review of the Scientific
Literature (1960 - 2000). 2005. Accessed 26 April 2024. https://www.
nhtsa.gov/sites/nhtsa.gov/files/medical20cond2080920690-8-04_medi
cal20cond2080920690-8-04.pdf
[35] Driver and vehicle licensing agency. Assessing fitness to drive – a guide for
medical professionals. 2024. Accessed 26 April 2024. https://assets.pub
lishing.service.gov.uk/media/65cf7243e1bdec001a322268/assessing-fit
ness-to-drive-february-2024.pdf
[36] Kumar R, Sharma R, Kumar V, et al. Relation of work stressors and
work-related MSDs among Indian heavy vehicle drivers. Indian J Occup
Environ Med 2021;25:198–203.
[37] Amoadu M, Ansah EW, Sarfo JO. Psychosocial work conditions and
traffic safety among minibus and long-bus drivers. J Occup Health 2024;
66:uiad019.
[21] Clayton M, Verow P. Advice given to patients about return to work and
driving following surgery. Occup Med (Lond) 2007;57:488–91.
[22] Platz T. ed. Clinical Pathways in Stroke Rehabilitation: Evidence-based
Clinical Practice Recommendations. Springer; 2021.
[23] Israel DG. Determining sample size. University of Florida Extension
Services Fact Sheet PEOD-6. http://edis.ifas.ufl.edu. Agricultural
Education and Communication Department, Florida Cooperative
Extension Service, Institute of Food and Agricultural Sciences, University
of Florida.; 1992.
[24] Hofman K, Primack A, Keusch G, et al. Addressing the growing burden of
trauma and injury in low- and middle-income countries. Am J Public
Health 2005;95:13–7.
[25] Ike I, Adam V. Socio-demographic and driving characteristics associated
with visual standards for driving among mass transit drivers in Abuja,
Nigeria. J Nigerian Optom Assoc 2022;24:42–53
[26] Peden M, Scurfield R, Sleet D, et al. World Report on Road Traffic
Injury Prevention. World Health Organization and World Bank;
2005.
[27] Ghaffar A, Hyder AA, Masud TI. The burden of road traffic injuries in
developing countries: the 1st national injury survey of Pakistan. Public
Health 2004;118:211–7.
[28] Khalaf AI, Moutaery FA. Implications of road accidents in Saudi Arabia.
Pan Arab J Neurosurg 2001;2:7–8.
[29] Ohakwe J, Iwueze IS, Chikezie DC. Analysis of road traffic accidents in
Nigeria: a case study of Obinze/Nekede/Iheagwa Road in Imo State,
South-eastern, Nigeria. Asian J Appl Sci 2011;4:166–75.
128