By Marcello Cherchi, MD PhD
Overview
From a neurological perspective, driving, “is highly complex, and requires the integration of many skills” (Devos, Akinwuntan et al. 2012), “combining perceptual, motoric, and executive functions” (Uwents, Jorissen et al. 2021). Since the vestibular system potentially interfaces with some or all of these functions, it is reasonable to inquire whether vestibular disorders can affect a person’s ability to drive.
This question is not straightforward. As far as decisions regarding driving restrictions are concerned, one editorial noted that, “The ‘vertiginous’ patient poses particular difficulties as there is a plethora of underlying causes and the clinical features vary widely” (McKiernan and Jonathan 2001).
Personal autonomy and public safety
On the one hand, if a clinician deems it unsafe for a patient to drive, then reporting this to the department of motor vehicles (which may result in license revocation) against a patient’s will constitutes a breach of confidentiality (McKiernan and Jonathan 2001), but on the other hand, since there is a clear public safety interest in keeping dangerous drivers off the road, the legal system accommodates this breach if the practitioner is acting in good faith.
But restriction from driving, whether self-imposed, or imposed by others, limits a person’s autonomy, and may affect some people more than others. One study noted that, “Dizzy patients, especially younger patients, women, and patients with Ménière’s disease, regularly experience limitations related to driving, and this often means they are unable to work” (van Leeuwen, Schermer et al. 2021).
Social and medico-legal issues introduce further complexity
Driving limitations are stigmatized. This topic can also be difficult to study in detail because of the confounding factors introduced by medico-legal issues (Gianoli and Soileau 2011).
How can one judge whether a vestibular disease impairs driving ability?
There is currently no universally accepted method for judging whether vestibular disease impairs driving ability. As we review below, the data pertaining to this question are mixed.
Data suggesting vestibular disease can impair driving ability
A study drawing on patient-reported data collected in the 2016 National Health Interview Survey (with 31,045 respondents) concluded that, “vestibular vertigo was associated with an over threefold increased odds of motor vehicle accidents (odds ratio, 3.5; 95% confidence interval, 1.7 – 7.3)” when “compared with individuals without vestibular vertigo” (Wei and Agrawal 2018). This study used criteria from Neuhauser and colleagues (Neuhauser, von Brevern et al. 2005) to define “vestibular vertigo” as, “(1) rotational vertigo, (2) positional vertigo, or (3) recurrent dizziness with nausea and either oscillopsia or imbalance.” A strength of this study is the large sample size. Drawbacks of this study include (1) the data are patient self-reported; and (2) the phrase “vestibular vertigo” is not a diagnosis, but refers to a constellation of clinical presentations.
Data suggesting that vestibular disease does not impair driving ability
Cohen and colleagues (Cohen, Wells et al. 2003) used the Driving Habits Questionnaire (Owsley, Stalvey et al. 1999) to study patients with several vestibular diagnoses (benign paroxysmal positional vertigo, “chronic vestibulopathy of unknown etiology,” Ménière’s disease, and patients who had just had surgery for a vestibular schwannoma or vestibular nerve section) versus normal controls. They found that “patient reports reduced driving skills, particular in situations when visual information is reduced, rapid head movements are used, and specific path integration or spatial navigation skills are needed,” “the self-reported crash rate and rate of citations for moving violations did not differ between the subject groups.” An obvious drawback of this study is that the data are patient self-reported.
A review of insurance claims data compared 4,509 patients with Ménière’s disease, 25,448 patients with vestibular neuritis, and 5,102,655 normal controls, concluded that, “There is no rationale for driving restrictions” (Huppert, Straube et al. 2019). A shortcoming of this study is that the “diagnoses” were reported from insurance data, with no way of verifying their accuracy.
A literature review concluded, “Driving ability was negatively affected by dizziness or a vestibular disorder in the majority of included studies with low risk of bias. This systematic review revealed a significant heterogeneity in studies reporting driving performance and contradictory results. We were, therefore, unable to identify a causal relationship between dizziness and driving ability” (Uwents, Jorissen et al. 2021).
Data suggesting that patients with vestibular disease may be more careful
Interestingly, some studies reported findings such as, “Patients reported slightly fewer incidents of being pulled over by the police… This finding probably reflects the caution with which most patients drive” (Cohen, Wells et al. 2003), and, “People with MD [Ménière’s disease] are at a lower risk of traffic accidents than individuals in the general population, which can be explained by selective driving” (Pyykko, Manchaiah et al. 2019). In other words, a person’s awareness of his or her own illness may in itself motivate the person to drive more carefully and lower the risk of driving mishaps.
What to conclude from conflicting data
Given that (1) “vestibular disease” is a heterogeneous group of disorders, (2) there is no universally accepted metric by which to judge whether vestibular disease impairs driving, and (3) different data suggest that patients with vestibular disease may be more, less, or equally safe in driving as people without vestibular disease, it is safe to say that there is no algorithm for arriving at a confident decision.
However, we believe it is fair to say that merely being diagnosed with a vestibular disorder should not automatically disqualify a person from driving. A study based on the results of anonymous questionnaires of patients with several vestibular disorders (bilateral vestibular hypofunction and benign paroxysmal positional vertigo comprised <10% of the sample, Ménière’s disease comprised 13%, labyrinthitis/vestibular neuritis comprised 13%, and “still undiagnosed” comprised 61%) concluded that, “The diagnosis of a vestibular disorder should not alone be grounds to suspend a patient’s driver’s license” (Sindwani, Parnes et al. 1999). Drawbacks of this study include that the data are patient self-reported, and that well over half of the patients (61%) were “still undiagnosed.”
In some countries where driving laws were instituted that placed restrictions on driving for patients with vestibular disorders, there has been pushback from within the medical community. For instance, in 2014 a European-wide driving law was passed, and individual European Union member countries enacted their own (country-specific) legislation. In the years that followed there have been calls to loosen those restrictions for patients with vestibular disorders (Huppert, Straumann et al. 2018, Huppert and Brandt 2019).
So what should one do?
Unfortunately, at least in the United States there are not yet any widely accepted protocols or algorithms to guide practitioners through the issue of driving restrictions in patients with vestibular disorders. Absent such guidance, it is reasonable to draw on literature regarding driving impairment from other neurological diseases, recognizing that such extrapolation is imperfect and further studies may eventually prove them to be inadequate when applied to specific vestibular diseases.
A literature review regarding patients with “brain impairment” (not specifically vestibular disorders) concluded that, “Closed-course, off-road driving tests are recommended for examining vehicle operation skills and readiness for in-traffic evaluation only,” whereas, “a practical driving test in traffic, with standardized route and driving maneuvers, is recommended for determining driver competence” (Fox, Bowden et al. 1998).
Practically, if a patient with a vestibular disorder, or that patient’s family or employer, expresses concern about the patient’s driving ability, it is probably medically reasonable to seek a formal driving evaluation.
At the national level, the American Automobile Association maintains resources for locating driving evaluations at https://exchange.aaa.com/safety/senior-driver-safety-mobility/evaluate-your-driving-ability/ (accessed 2/15/23).
In the Chicagoland area, many of our patients use the list of resources maintained by various institutions such as (listed alphabetically, not ranked or graded or endorsed):
- NorthShore University HealthSystem at https://www.northshore.org/physical-medicine-rehabilitation/our-programs/driving/ (accessed 2/15/23)
- Rush University Medical Center at https://www.rush.edu/treatments/driving-rehabilitation (accessed 2/15/23)
- Shirley Ryan Ability Lab at https://www.sralab.org/lifecenter/resources/listing-drivers-rehabilitation-programs-chicago-area-and-beyond (accessed 2/15/23).
References
Cohen, H. S., J. Wells, K. T. Kimball and C. Owsley (2003). “Driving disability and dizziness.” J Safety Res 34(4): 361-369.
Devos, H., A. E. Akinwuntan, I. Gelinas, S. George, A. Nieuwboer and G. Verheyden (2012). “Shifting up a gear: considerations on assessment and rehabilitation of driving in people with neurological conditions. An extended editorial.” Physiother Res Int 17(3): 125-131.
Fox, G. K., S. C. Bowden and D. S. Smith (1998). “On-road assessment of driving competence after brain impairment: review of current practice and recommendations for a standardized examination.” Arch Phys Med Rehabil 79(10): 1288-1296.
Gianoli, G. J. and J. S. Soileau (2011). “Evaluation of dizziness in the litigating patient.” Otolaryngol Clin North Am 44(2): 335-346, viii.
Huppert, D. and T. Brandt (2019). “[Vertigo, a Driver’s Licence with and without Permission to Drive: Are the Current Guidelines Justified?].” Laryngorhinootologie 98(10): 674-684.
Huppert, D., A. Straube, L. Albers, R. von Kries and V. Obermeier (2019). “Risk of traffic accidents after onset of vestibular disease assessed with a surrogate marker.” J Neurol 266(Suppl 1): 3-8.
Huppert, D., D. Straumann, M. Magnusson, I. Pyykko and T. Brandt (2018). “Dizziness in Europe: from licensed fitness to drive to licence without fitness to drive.” J Neurol 265(Suppl 1): 9-17.
McKiernan, D. and D. Jonathan (2001). “Driving and vertigo.” Clin Otolaryngol Allied Sci 26(1): 1-2.
Neuhauser, H. K., M. von Brevern, A. Radtke, F. Lezius, M. Feldmann, T. Ziese and T. Lempert (2005). “Epidemiology of vestibular vertigo: a neurotologic survey of the general population.” Neurology 65(6): 898-904.
Owsley, C., B. Stalvey, J. Wells and M. E. Sloane (1999). “Older drivers and cataract: driving habits and crash risk.” J Gerontol A Biol Sci Med Sci 54(4): M203-211.
Pyykko, I., V. Manchaiah, J. Zou, H. Levo and E. Kentala (2019). “Driving Habits and Risk of Traffic Accidents among People with Meniere’s Disease in Finland.” J Int Adv Otol 15(2): 289-295.
Sindwani, R., L. S. Parnes, J. A. Goebel and S. P. Cass (1999). “Approach to the vestibular patient and driving: A patient perspective.” Otolaryngol Head Neck Surg 121(1): 13-17.
Uwents, M. H., C. Jorissen, A. Van Ombergen, B. Dobbels, R. van de Berg, S. Janssens de Varebeke, M. Lammers, V. Ross, O. Vanderveken, T. Brijs and V. Van Rompaey (2021). “Driving ability in patients with dizziness: a systematic review.” Eur Arch Otorhinolaryngol.
van Leeuwen, R. B., T. R. Schermer, C. Colijn and T. D. Bruintjes (2021). “Dizziness and Driving From a Patient Perspective.” Front Neurol 12: 693963.
Wei, E. X. and Y. Agrawal (2018). “Association Between Vestibular Vertigo and Motor Vehicle Accidents: Data From the 2016 National Health Interview Survey.” Ear Hear 39(6): 1232-1235.
