“Doctor, when can I drive?” – Can we compensate an immobilization of the right wrist while driving a car: A pilot study

Falk Hilsmann; Felix Lakomek; Max Prost; Dominique Schoeps; Ahmed Al Asadi; Erik Schiffner; David Latz

doi:10.1371/journal.pone.0341628

Peer Review History

Original SubmissionJuly 18, 2025
28 Aug 2025 Decision Letter - Priti Chaudhary, Editor PONE-D-25-35823-->-->"Doctor, when can I drive?" – Can we compensate an immobilization of the right wrist while driving a car?-->-->PLOS ONE?> Dear Dr. Hilsmann, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ACADEMIC EDITOR: Please submit your revised manuscript by Oct 12 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Priti Chaudhary, M.S. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. In the online submission form, you indicated that [The data cannot be made publicly available due to the data size of the raw data and the stepwise processing. The data, including the raw data, are available on request from the corresponding author for researchers who meet the criteria for access to confidential data. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. 4. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: I Don't Know Reviewer #3: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** Reviewer #1: The introduction well structured with clear aim. Combining the aim with statistics related to road accidents would have been a plus The methods please add a brief description of the motion capturing system used The limitation and conclusion are an add to the paper Reviewer #2: Thank you for giving me the opportunity to review this valuable work. The topic is clinically meaningful, and the manuscript provides new insights into compensatory kinematics. Overall, the work is good and promising, but several sections need clearer reporting, correction of inconsistencies, and tempering of conclusions before publication can be considered. In the abstract, please include the number of participants, mean age, and sex distribution in the results section. The study objective sentence is too long and difficult to follow. Sample size justification is missing, please provide a sample size calculation or state that the study is exploratory. Randomization procedure unclear, Describe how conditions were randomized. Limitations include the lack of adjustment for multiple comparisons, a small sample size, and concerns about simulator generalizability. Additionally, potential learning effects should be considered. Reviewer #3: Overall Assessment The manuscript addresses an interesting and clinically relevant question concerning the impact of wrist immobilization on driving ability. This is a pertinent topic in orthopedic and trauma care, as patients frequently inquire about their fitness to drive following immobilization or surgery. The use of a driving simulator combined with motion capture analysis is a clear strength and adds objectivity to the study. The paper is well-structured, the methodology is described in detail, and the results are generally clear. However, several methodological, analytical, and reporting issues require clarification and revision before the work can be considered for publication. Strengths 1. Novelty and Relevance: The study focuses on an underexplored area—upper extremity immobilization and compensatory strategies during driving. 2. Methodological Rigor: Use of motion capture and a standardized driving simulator protocol provides objective kinematic data. 3. Clinical Importance: Results may aid physicians in counseling patients regarding return to driving after wrist immobilization. 4. Clear Structure: The manuscript follows a logical format with clear separation of Introduction, Methods, Results, and Discussion. Major Concerns 1. Sample Size and Power o Only 20 participants were included, all of them healthy volunteers without actual injury or pain. While the study demonstrates biomechanical compensation, the small and homogeneous sample raises questions about generalizability. o A power analysis to justify the sample size is not provided. 2. External Validity o The study used healthy young adults (mean age ~28 years) without pain or disability. This limits applicability to real patients who often have pain, swelling, decreased grip strength, or comorbidities. o This limitation is acknowledged but not sufficiently emphasized in the Discussion. A stronger statement is needed about how this affects clinical translation. 3. Simulator Limitations o Only three driving scenarios were tested (shifting, left turn, right turn), which may not represent the complexity of real-life driving (e.g., emergency braking, rapid steering corrections, highway driving). o Automatic transmission was used in some parts, potentially underestimating the role of the immobilized wrist. 4. Statistical Analysis o The choice of linear mixed models is appropriate, but details of the model specification are sparse. o It is not clear if adjustments for multiple comparisons were performed, given the large number of joint angles and outcomes analyzed. This raises the risk of type I errors. o Effect sizes and confidence intervals are not presented, which would strengthen the interpretation. 5. Clinical Implications o The conclusion that “safe driving with the right immobilized wrist is possible” may be overstated given the limited scenarios and lack of patient population. o A more cautious interpretation is needed, highlighting that these findings apply only to healthy individuals in controlled conditions. Minor Concerns 1. Abstract o The abstract is generally well written but should explicitly state that only healthy volunteers were studied. o Reporting of key statistical values (p-values, confidence intervals) would strengthen clarity. 2. Introduction o While background references are provided, the review of existing literature could be more concise. Some citations appear repetitive. o Clarify how this study advances beyond earlier work on elbow immobilization and driving. 3. Methods o More information about randomization (order of immobilized vs. non-immobilized trials) is needed. o Describe the wrist immobilization device more clearly—was thumb immobilization included? How standardized was the splint? o Provide explicit exclusion criteria (e.g., musculoskeletal disorders, neurological conditions). 4. Results o Tables are informative but could be simplified; some parameters (e.g., minimum/maximum values) may not add substantial value. o Figures would benefit from clearer legends and consistent labeling (NI = no immobilization; WO = with immobilization). 5. Discussion o The discussion is comprehensive but occasionally repetitive. o Greater emphasis on the limitations (young healthy participants, lack of pain, limited scenarios) is necessary. o Some references are dated; ensure that the most recent literature (past 5 years) is adequately included. 6. Language and Style o Overall, the manuscript is well written. Minor grammatical edits and simplification of long sentences would improve readability. Suggestions for Improvement • Include a power analysis or at least a rationale for the sample size. • Report effect sizes and confidence intervals along with p-values. • Clarify whether correction for multiple comparisons was applied. • Strengthen the limitations section, particularly regarding generalizability to real patients. • Revise the conclusion to be more cautious, stressing that results cannot be directly generalized to injured or post-operative populations. • Improve clarity of tables and figures, and ensure consistent terminology. Conclusion and Recommendation This is a well-designed pilot study that provides valuable biomechanical insights into compensatory mechanisms during driving with wrist immobilization. However, methodological clarifications, more cautious interpretation, and improvements in reporting are needed. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No Reviewer #3: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: reportPLOS.docx https://doi.org/10.1371/journal.pone.0341628.r001
Revision 1
24 Oct 2025 Author Response Dear academic editor and reviewers, Thank you for reviewing our manuscript and for your valuable, constructive suggestions for improvement. Academic Editor We address your comments below: 1) We have revised the manuscript regarding the style requirements. If further adjustments are necessary, we will be happy to make them upon specific notification. 2) We would like to make the data underlying our study available to other researchers as supplementary information. 3) The ORCID ID of the corresponding author, Felix Lakomek, is: 0009-0000-1074-0246. 4) This point does not apply to our manuscript and was therefore not considered. Reviewer #1: We have added a description of the motion capturing system (Xsens). Reviewer #2: As requested, we simplified the sentence about the study's objective in the abstract and expanded the information in the results section. We also addressed the sample size and, as you suggested, explained that this is an exploratory study. We described the procedure for randomizing in more detail and added your points about the study's limitations. Reviewer #3: First, we would like to address your most important concerns: 1. Sample size and power We decided to include healthy volunteers to achieve the best possible comparability in basic research. This excluded influencing factors such as reduced responsiveness, chronic mobility restrictions, and visual impairment. Furthermore, we selected volunteers who were pain-free, as it is difficult to assess the extent to which pain affects each individual volunteer. A power analysis was not performed prior to the study because it’s an exploratory study and no comparable studies were available. Therefore, we based the sample size on the basic research studies conducted by our research group (Latz, D; Schiffner, E; Schneppendahl, J, et al.: Doctor, when can I drive? -Range of functional ankle motion during driving. Foot and ankle surgery: official journal of the European Society of Foot and Ankle Surgeons. 10.1016/j.fas.2019.12.006; Latz, D; Schiffner, E; Schneppendahl, J, et al.: Doctor, when can I drive? - the range of elbow motion while driving a car. J Shoulder Elbow Surg. 28: 1139-1145. 10.1016/j.jse.2018.11.053; Latz, D; Schiffner, E; Schneppendahl, J, et al.: Doctor, when can I drive? - Range of motion of the knee while driving a car. The Knee. 26: 33-39.10.1016/j.knee.2018.11.005; Latz, D; Pfau, S; Koukos, C, et al.: Doctor, when can I drive. Obere Extremität. 12: 234-241. 10.1007/s11678-017-0426-0). 2. External Validity You are right about the limited applicability to real patients. Therefore, we have adjusted the limitations and conclusion sections. 3. Limitations of the Simulator The volunteers completed a scenario that required shifting gears and making left and right turns. These are typical maneuvers required when driving a car. Further investigation of the maneuvers you mentioned, such as rapid steering corrections, is of clinical relevance. However, the aim of this study was not to make a statement about reaction time and the lower extremities. During cornering, only an automatic transmission was initially used in basic research. When to shift gears while cornering is an individual decision of the driver, which would lead to poor comparability. As you noted, this can lead to the role of the immobilized right wrist being underestimated. In the conclusion, we explicitly refer to the critical combination of shifting gears and simultaneous steering. 4. Statistical Analysis No adjustment for multiple comparisons was performed. This is now mentioned under limitations. The 95% confidence intervals for difference were added as requested. Reporting effect sizes is very useful from a statistical perspective, as you already mentioned. Since our analysis was conducted with SPSS, and SPSS does not allow the calculation of effect sizes for the models used, the effect size could not be calculated. 5. Clinical Implications The conclusion has been adjusted to include a more cautious interpretation of our results under controlled conditions in healthy individuals. We now address your minor concerns: 1. Summary The summary now explicitly states that only healthy volunteers were included. Furthermore, the 95% confidence intervals for difference have been added. 2. Introduction This study differs from previous work on wrist immobilization by combining a driving simulator with a motion capture system. A comparable study on the elbow joint has already been published by our research group (Schiffner E, Lakomek F, Hilsmann F, Schoeps D, Prost M, Beyersdorf C, Windolf J, Latz D. Doctor, when can I drive? - compensation capability while driving with restricted elbow - a biomechanical analysis. JSES Int. 2024 Nov 1;9(2):542-548. doi: 10.1016/j.jseint.2024.09.028. PMID: 40182246; PMCID: PMC11962544). This was clarified again in the introduction. 3. Methods The order of the respective rides with the right wrist immobilized and the right wrist not immobilized was randomized using a random generator. The ride without immobilization was coded as 0, and the ride with the right wrist immobilized was coded as 1. The order was randomized individually for each volunteer. The right wrist was immobilized using a palmar hard cast splint without thumb inclusion. The following exclusion criteria were chosen musculoskeletal disorders, neurological disorders, active drug use, and lack of driving experience. 4. Results In our opinion, the tables have already been reduced to a minimum; further simplification would, in our opinion, result in a loss of information. For example, in Table 1, the parameter "minimum" was omitted for speed. The legends and labels of the tables and figures have been adjusted. 5. Discussion A stronger emphasis on the limitations has been made as requested. A recent literature review was conducted to compile this discussion, and we believe the literature is comprehensive regarding the topic being discussed. 6. Language and Style Changes have been made to improve readability. We hope that the implementation of your constructive criticism has led to a further improvement in the quality of the manuscript. Thank you very much. With kind regards, Falk Hilsmann Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0341628.r002
11 Dec 2025 Decision Letter - Priti Chaudhary, Editor PONE-D-25-35823R1-->-->"Doctor, when can I drive?" – Can we compensate an immobilization of the right wrist while driving a car?-->-->PLOS One?> Dear Dr. Hilsmann, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 25 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Priti Chaudhary, M.S. Academic Editor PLOS One Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: After revisions done by authors,The manuscript may be accepted as Pilot study; as the small sample size, the exclusive inclusion of healthy volunteers without pain or injury, and the limited range of simulated driving tasks reduces the generalizability to real patients. To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0341628.r003
Revision 2
4 Jan 2026 Author Response Dear Sir or Madam, Thank you for reviewing our revised manuscript. We are pleased to submit a revised version of our manuscript in accordance with your points of criticism, to meet the required publication criteria. We will now briefly address the points of criticism you raised: Journal requirements: As mentioned in our previous letter, there was no specific recommendation regarding the citation of particular, previously published works. Therefore, no review for relevance and citability was conducted. Furthermore, the bibliography was reviewed again for completeness and accuracy. No irregularities were found; in particular, no retracted works are cited. Additional comments from the editors: The manuscript has been revised as requested, including an adjustment of the title and other necessary changes. We now hope that the manuscript will be accepted as a pilot study. Thank you in advance. Sincerely, Falk Hilsmann Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0341628.r004
11 Jan 2026 Decision Letter - Priti Chaudhary, Editor "Doctor, when can I drive?" – Can we compensate an immobilization of the right wrist while driving a car: A pilot study PONE-D-25-35823R2 Dear Dr. Falk Hilsmann, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Priti Chaudhary, M.S. Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0341628.r005
Formally Accepted
Acceptance Letter - Priti Chaudhary, Editor PONE-D-25-35823R2 PLOS One Dear Dr. Hilsmann, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Priti Chaudhary Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0341628.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .