Original Research| Volume 56, ISSUE 3, P568-572, May 2017

Download started.


Diabetic Driving Studies—Part 1: Brake Response Time in Diabetic Drivers With Lower Extremity Neuropathy


      Although the effect of lower extremity pathology and surgical intervention on automobile driving function has been a topic of contemporary interest, we are unaware of any analysis of the effect of lower extremity diabetic sensorimotor neuropathy on driving performance. The objective of the present case-control investigation was to assess the mean brake response time in diabetic drivers with lower extremity neuropathy compared with that of a control group and a brake response safety threshold. The driving performances of participants were evaluated using a computerized driving simulator with specific measurement of the mean brake response time and frequency of abnormally delayed brake responses. We analyzed a control group of 25 active drivers with neither diabetes nor lower extremity neuropathy and an experimental group of 25 active drivers with type 2 diabetes and lower extremity neuropathy. The experimental group demonstrated a 37.89% slower mean brake response time (0.757 ± 0.180 versus 0.549 ± 0.076 second; p < .001), with abnormally delayed responses occurring at a greater frequency (57.5% versus 3.5%; p < .001). Independent of a comparative statistical analysis, the observed mean brake response time in the experimental group was slower than the reported safety brake response threshold of 0.70 second. The results of the present investigation provide original data with respect to abnormally delayed brake responses in diabetic patients with lower extremity neuropathy and might raise the potential for impaired driving function in this population.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Marecek G.S.
        • Schafer M.F.
        Driving after orthopedic surgery.
        J Am Acad Orthop Surg. 2013; 21: 696-706
        • Goodwin D.
        • Baecher N.
        • Pitta M.
        • Letzelter J.
        • Marcel J.
        • Argintar E.
        Driving after orthopedic surgery.
        Orthopedics. 2013; 36: 469-474
        • Holt G.
        • Kay M.
        • McGrory R.
        • Kumar C.S.
        Emergency brake response time after first metatarsal osteotomy.
        J Bone Joint Surg Am. 2008; 90: 1660-1664
        • Egol K.A.
        • Sheikhazadeh A.
        • Koval K.J.
        Braking function after complex lower extremity trauma.
        J Trauma. 2008; 65: 1435-1438
        • Egol K.A.
        • Sheikhazadeh A.
        • Mogatederi S.
        • Barnett A.
        • Koval A.J.
        Lower-extremity function for driving an automobile after operative treatment of ankle fracture.
        J Bone Joint Surg Am. 2003; 85: 1185-1189
        • Liebensteiner M.C.
        • Kern M.
        • Haid C.
        • Kobel C.
        • Niederseer D.
        • Krismer M.
        Brake response time before and after total knee arthroplasty: a prospective cohort study.
        BMC Musculoskelet Disord. 2010; 11: 267
        • Gotlin R.S.
        • Sherman A.L.
        • Sierra N.
        • Kelly M.
        • Scott W.N.
        Measurement of brake response time after right anterior cruciate ligament reconstruction.
        Arthroscopy. 2000; 16: 151-155
        • MacDonald W.
        • Owen J.W.
        The effect of total hip replacement on driving reactions.
        J Bone Joint Surg Br. 2008; 70: 202-205
        • Liebensteiner M.C.
        • Birkfellner F.
        • Thaler M.
        • Haid C.
        • Bach C.
        • Krismer M.
        Driving reaction time before and after primary fusion of the lumbar spine.
        Spine (Phila Pa 1976). 2010; 35: 330-335
        • Talusan P.G.
        • Miller C.P.
        • Save A.V.
        • Reach Jr., J.S.
        Driving reaction times in patients with foot and ankle pathology before and after image-guided injection: pain relief without improved function.
        Foot Ankle Spec. 2015; 8: 107-111
        • Jeng C.L.
        • Lin J.S.
        • Amoyal K.
        • Campbell J.
        • Myerson M.S.
        Driving brake reaction time following right ankle arthrodesis.
        Foot Ankle Int. 2011; 32: 896-899
        • Tremblay M.A.
        • Corriveau H.
        • Boissy P.
        • Smeesters C.
        • Hamel M.
        • Murray J.C.
        • Cabana F.
        Effects of orthopaedic immobilization of the right lower limb on driving performance: an experimental study during simulated driving by healthy volunteers.
        J Bone Joint Surg Am. 2009; 91: 2860-2866
        • Waton A.
        • Kakwani R.
        • Cooke N.J.
        • Litchfield D.
        • Kok D.
        • Middleton H.
        • Irwin L.
        Immobilisation of the knee and ankle and its impact on drivers’ braking times: a driving simulator study.
        J Bone Joint Surg Br. 2001; 93: 928-931
        • Murray J.C.
        • Tremblay M.A.
        • Corriveau H.
        • Hamel M.
        • Cabana F.
        Effects of right lower limb orthopedic immobilization on braking function: an on-the-road experimental study with healthy volunteers.
        J Foot Ankle Surg. 2015; 54: 554-558
        • Von Arx O.A.
        • Langdown A.J.
        • Brooks R.A.
        • Woods D.A.
        Driving whilst plastered: is it safe, is it legal? A survey of advice to patients given by orthopaedic surgeons, insurance companies and the police.
        Injury. 2004; 35: 883-887
        • Tesfaye S.
        • Boulton A.J.
        • Kickenson A.H.
        Mechanisms and management of diabetic painful distal symmetrical polyneuropathy.
        Diabetes Care. 2013; 36: 2456-2465
        • Boulton A.J.
        Lowering the risk of neuropathy, foot ulcers and amputations.
        Diabet Med. 1998; 15: S57-S59
        • Adler A.
        Risk factors for diabetic neuropathy and foot ulceration.
        Curr Diabetes Rep. 2001; 1: 202-207
        • Wukich D.K.
        • McMillen R.L.
        • Lowery N.J.
        • Frykberg R.G.
        Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes.
        Diabetes Care. 2011; 34: 2211-2213
        • Andersen H.
        Motor dysfunction in diabetes.
        Diabetes Metab Res Rev. 2012; 28: 89-92
        • Andreassen C.S.
        • Jakobsen J.
        • Ringgaard S.
        • Ejskjaer N.
        • Anderson H.
        Accelerated atrophy of lower leg and foot muscles—a follow-up study of long-term diabetic polyneuropathy using magnetic resonance imaging (MRI).
        Diabetologia. 2009; 52: 1182-1191
        • Andersen H.
        • Nielsen S.
        • Mogensen C.E.
        • Jakobsen J.
        Muscle strength in type 2 diabetes.
        Diabetes. 2004; 53: 1543-1548
        • Bonnet C.
        • Carello C.
        • Turvey M.T.
        Diabetes and postural stability: review and hypothesis.
        J Mot Behav. 2009; 41: 172-190
        • Gutierrez E.M.
        • Helber M.D.
        • Dealva D.
        • Ashton-Miller J.A.
        • Richardson J.K.
        Mild diabetic neuropathy affects ankle motor function.
        Clin Biomech (Bristol, Avon). 2001; 16: 522-528
        • Ites K.I.
        • Andersen E.J.
        • Cahill M.L.
        • Kearney J.A.
        • Post E.C.
        • Gilchrist L.S.
        Balance interventions for diabetic peripheral neuropathy: a systematic review.
        J Geriatr Phys Ther. 2011; 34: 109-116
        • van Deursen R.W.
        • Simoneau G.G.
        Foot and ankle sensory neuropathy, proprioception, and postural stability.
        J Orthop Sports Phys Ther. 1999; 29: 718-726
        • Simoneau G.G.
        • Derr J.A.
        • Ulbrecht J.S.
        • Becker M.B.
        • Cavanagh P.R.
        Diabetic sensory neuropathy effect on ankle joint movement perception.
        Arch Phys Med Rehabil. 1996; 77: 453-460
        • Katoulis E.C.
        • Ebdon-Parry M.
        • Hollis S.
        • Harrison A.J.
        • Vileikyte L.
        • Kulkarni J.
        • Boulton A.J.
        Postural instability in diabetic neuropathic patients at risk of foot ulceration.
        Diabet Med. 1997; 14: 296-300
        • M M.
        • Sembian U.
        • Babitha
        • N E.
        • K M.
        Study of auditory, visual reaction time and glycemic control (HBA1C) in chronic type II diabetes mellitus.
        J Clin Diagn Res. 2014; 8: BC11-BC13
        • Sanchez-Marin F.J.
        • Padilla-Medina J.A.
        Simple reaction times and performance in the detection of visual stimuli of patients with diabetes.
        Comput Biol Med. 2010; 40: 591-596
        • Mohan M.
        • Thombre D.P.
        • Das A.K.
        • Subramanian N.
        • Chandrasekar S.
        Reaction time in clinical diabetes mellitus.
        Indian J Physiol Pharmacol. 1984; 28: 311-314
        • Engkasan J.P.
        • Ehsan F.M.
        • Chung T.Y.
        Ability to return to driving after major lower limb amputation.
        J Rehabil Med. 2012; 44: 19-23
        • Boulias C.
        • Meikle B.
        • Pauley T.
        • Devlin M.
        Return to driving after lower-extremity amputation.
        Arch Phys Med Rehabil. 2006; 87: 1183-1188
        • Meikle B.
        • Devlin M.
        • Pauley T.
        Driving pedal reaction times after right transtibial amputations.
        Arch Phys Med Rehabil. 2006; 87: 390-394
        • American Diabetes Association
        Diabetes and driving.
        Diabetes Care. 2012; 35: S81-S86
        • Inkster B.
        • Frier B.M.
        Diabetes and driving.
        Diabetes Obes Metab. 2013; 15: 775-783
        • Cox D.J.
        • Singh H.
        • Lorber D.
        Diabetes and driving safety: science, ethics, legality and practice.
        Am J Med Sci. 2013; 345: 263-265
        • Kilpatrick E.S.
        • Rigby A.S.
        • Warren R.E.
        • Atkin S.L.
        Implications of new European Union driving regulations on patients with type 1 diabetes who participated in the Diabetes Control and Complications trial.
        Diabet Med. 2013; 30: 616-619
        • Sohn S.Y.
        • Stepleman R.
        Meta-analysis on total braking time.
        Ergonomics. 1998; 41: 1129-1140
        • Green M.
        How long does it take to stop? Methodological analysis of driver perception-brake times.
        Transport Hum Factors. 2000; 2: 195-216
        • Feldman E.L.
        • Stevens M.J.
        • Thomas P.K.
        • Brown M.B.
        • Canal N.
        • Greene D.A.
        A practical two-step quantitative clinical and electrophysiological assessment for diagnosis and staging of diabetic neuropathy.
        Diabetes Care. 1994; 17: 1281-1289
        • Suder N.C.
        • Wukich D.K.
        Prevalence of diabetic neuropathy in patients undergoing foot and ankle surgery.
        Foot Ankle Spec. 2012; 5: 97-101
        • National Transportation Safety Board
        Special Investigation Report: The Use of Forward Collision Avoidance Systems to Prevent and Mitigate Rear-End Crashes.
        (NTSB/SIR-15/01; PB2015–PB104098; Notation 8638) National Transportation Safety Board, Washington, DC2015
        • Dugan E.
        • Barton K.N.
        • Coyle C.
        • Lee C.M.
        US policies to enhance older driver safety: a systematic review of the literature.
        J Aging Soc Policy. 2013; 25: 335-352
        • Levasseur M.
        • Audet T.
        • Gelinas I.
        • Bédard M.
        • Langlais M.È.
        • Therrien F.H.
        • Renaud J.
        • Coallier J.C.
        • D’Amours M.
        Awareness tool for safe and responsible driving (OSCAR): a potential educational intervention for increasing interest, openness and knowledge about the abilities required and compensatory strategies among older drivers.
        Traffic Inj Prev. 2015; 16: 578-586
        • Stephens B.W.
        • McCarthy D.P.
        • Marsiske M.
        • Shechtman O.
        • Classen S.
        • Justiss M.
        • Mann W.C.
        International older driver consensus conference on assessment, remediation and counseling for transportation alternatives: summary and recommendations.
        Phys Occup Ther Geriatr. 2005; 23: 103-121
        • Brouwer W.B.
        • Ponds R.W.
        Driving competence in older persons.
        Disabil Rehabil. 1994; 16: 149-161
        • Molnar L.J.
        • Eby D.W.
        The relationship between self-regulation and driving-related abilities in older drivers: an exploratory study.
        Traffic Inj Prev. 2008; 9: 314-319
        • Devlin A.
        • McGillivray J.A.
        Self-regulation of older drivers with cognitive impairment: a systematic review.
        Australas J Ageing. 2014; 33: 74-80

      Linked Article

      • Letter to the Editor
        The Journal of Foot and Ankle SurgeryVol. 59Issue 2
        • Preview
          We have read the article entitled “Diabetic Driving Studies—Part 1: Brake Response Time in Diabetic Drivers With Lower Extremity Neuropathy” (JFAS 56:568–572, 2017) published in the May/June issue of your Journal with outmost interest because it has presented the data from a valuable and important study in an attempt to find an answer to a substantial question.
        • Full-Text
        • PDF