School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)

Focused Question:
Does physical exercise improve the driving performance of older adults?

Prepared By:
Annie Guiliano and Danielle Palmer

Date Review Completed:

October 8, 2015

Clinical Scenario:
Driving is an instrumental activity of daily living (IADL) that is very important to older
people. Driving allows for older adults to live independently, making access to shopping,
leisure and social activities, and medical management possible. Staying behind the wheel is
important for the health and wellness of older adults because it keeps them involved with
meaningful activities. Finding alternative transportation can be inconvenient, causing older
adults to withdraw from engaging in activities that define who they are as occupational beings.

With the baby boomers aging, it is estimated that by 2020 more than 40 million individuals in
the United States, over the age of 65 will be driving (NHTSA, 2013). As drivers age there is
an increased risk that they will die in a motor vehicle accident. Fatalities are the highest in
accidents involving drivers over the age of 85 (NHTSA, 2013). Aging can result in a gradual
decline of sensory, cognitive, and physical functioning necessary for safe driving (Eby,
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Molnar, & Pellerito, 2005).

Identifying effective interventions to improve the driving performance in older adults is

important for road safety and promoting the quality of life for older adults. Flexibility,
coordination, and speed of movement have been associated with the driving performance of
older adults. The benefits of physical exercise on successful aging has been well studied. A
synthesis of literature indicates many potentially positive effects of participation in physical
activity on the aging process (Singh, 2004). The direct impact of physical exercise on the
driving performance of older adults has been less researched. The objective of this critically
appraised topic (CAT) is to summarize the body of evidence resulting from studies related to
the effects of physical exercise on the driving performance of older adults.

Summary of Key Findings:

Summary of Levels I, II and III:
One study found that an intervention using the Microsoft Xbox and Kinect system,
specifically the Electric Arts (EA) Active Sports 2 Package, could improve the driving
performance skills of older adults by increasing torso and neck rotation (DAmbrosio,
2013, Level I). Another study found that utilizing an intervention incorporating highspeed power training, which includes repetitions of explosive movements at high
speeds, has greater effects on the driving performance of older adults than an
intervention using slow-speed power training (Sayers & Gibson, 2012, Level I).
Cognition, an important factor for safe driving, can be improved in older adult drivers
by an intervention of combined aerobic and anaerobic exercise (Chattha, 2011, Level
I). Studies indicate that physical exercise can improve the reaction time of older adult
drivers (Marmeleira, Soares de Melo, Tlemcani, & Godinho, 2011, Level I;
Marmeleira, Godinho, & Fernandes, 2009, Level I). The findings of one study
indicate that ankle training with elastic bands can decrease the foot movement time
from the gas pedal to the brake pedal in older adult women drivers (Weber & Porter,
2010). Another study found that delivering a home exercise program targeting
flexibility, coordination, and speed of movement can maintain the driving
performance of older adults, as well as, decrease the risk for falls (Marottoli, Allore,
Araujo, Ianone, Acampora, Gottschalk, & Peduzzi, 2007, Level I). The final Level I
study found that a physical fitness program for older adult drivers incorporating
range-of-motion exercises, such as static-stretching, can improve shoulder flexibility,
trunk rotation, and improve scores on observed driving skills (Ostrow, Shaffron, &
McPherson, 2009, Level I).
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The first Level II study found that a driving fitness program designed for older adults,
consisting of engineering enhancements, driver education, and physical fitness, can
improve strength, endurance, agility, flexibility, hand reaction time, and driving
confidence (Caragata, Tuokko, & Damini, 2009, Level II). Another study found that
older adults that play tennis regularly have better reaction times during open road
driving than sedentary older adults and older adults that participate in running
(Marmeleira, Melo, Tlemcani, & Fernandes, 2013, Level II).

Summary of Level IV and V:

No Level IV and V studies were used for this CAT.

Contributions of Qualitative Studies:

No qualitative studies were used for this CAT.

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
Occupational therapists can be consultants at community centers, senior centers, and work out
centers, helping to design programs which include physical exercises that focus on improving
the driving performance of older adults.
A fitness program targeting specific driving skills can improve driving performance in older
adults. This information can be utilized when the therapist is educating and completing therapy
with their client (Caragata, Tuokko & Damini, 2009).
A home exercise program designed specifically to target factors related to driving can be used
with any adults who want to increase their driving performance (Marottoli, Allore, Araujo,
Iannone, Acampora, Gottschalk & Peduzzi, 2007).

Program development:
Exercise should be included in driving programs to improve the performance skills in older
adult drivers (Chattha, 2011).
Healthcare needs a non-pharmaceutical intervention for older drivers whom want to maintain
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their independence by staying behind the wheel (Chattha, 2011).

An occupational therapist can replicate and design a home exercise program specifically for
older adults with driving deficits (Marottoli, Allore, Araujo, Iannone, Acampora, Gottschalk &
Peduzzi, 2007).

Societal Needs:
Society will be faced with the consequences of the declining driving performance of older
adults. Exercise is an effective intervention to address this problem (Chattha, 2011).
There are many elderly adults that have decreased driving performance in need of assistance
(DAmbrosio, 2013).

Healthcare delivery and policy:

Healthcare should focus on preventing disease by encouraging physical activity rather than
focusing on medical management once disease is present (Marmeleira, Melo, Tlemcani, &
Fernandes, 2013).
Non-pharmaceutical interventions are needed in healthcare to improve the driving skills of
older drivers (Sayers & Gibson, 2012).

Education and training of OT students:

OT students should understand the importance of physical exercise and successful aging. An
emerging practice for OT is driving rehabilitation. Exercise can be utilized as a preventive
intervention (Marmeleira, Melo, Tlemcani, & Fernandes, 2013).
OT students should have knowledge regarding the performance skills needed when driving
and how these skills can be improved with physical exercise (DAmbrosio, 2013).

Refinement, revision, and advancement of factual knowledge or theory:

Not all forms of exercise are created equal. This is important when using exercise to improve
the driving skills of older adults. More research needs to be conducted to identify specific
exercises that can improve driving performance (Sayers & Gibson, 2012).
Exercise is known to have many benefits. However, the effects of exercise on driving skills of
older adults have not had substantial research focus. More research needs to be completed on
the benefits of exercise on driving performance (Chattha, 2011).

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Review Process:
A search was completed to discover the population, intervention, and outcomes for the PICO
question.
The focus question was created using the PICO format.
Focus question was reviewed by course instructor.
Exclusion and inclusion criteria were created and documented.
A compiled list of research databases were identified.
A comprehensive literature search was conducted to locate articles that fit the criteria of the
PICO question.
Every article and database utilized was documented.
Each articles methodology was assessed using the McMaster form.
An evidence table was created with all of the 10 articles analyzed.
The evidence table was reviewed by a peer and by course instructor.
The evidence table was used to create the critically appraised topic.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:
Inclusion criteria included studies that were Level I and II articles, written in English,
published in peer reviewed journals, provided full text article publication, and answered all
aspects of the (PICO) focus question.

Exclusion Criteria:
Exclusion criteria included studies that were Level III, IV, or V. Systematic reviews were
excluded from the study, as well as, any studies that were not written in English, were not full
text publications, or were published before 1990.

Search Strategies:
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Categories

Key Search Terms

Patient/Client Population

Adults, elderly, older adults, old aged, older drivers

Intervention

Physical exercise, exercise, fitness program

Outcomes

Driving performance, driving

Databases and Sites Searched

Cinahl, OT Search, TRID, google scholar, and hand searching through articles

Quality Control/Peer Review Process:

The focus question was reviewed by the course instructor.
Each of the 10 articles methodology was reviewed using the McMaster form.
The focus question, articles, evidence table, and CAT were reviewed by a peer and by the
course instructor.
All feedback and comments were taken into consideration and the final CAT was completed.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence

Study Design/Methodology of Selected Articles

Number of Articles
Selected

Systematic reviews, meta-analysis, randomized

controlled trials

II

Two groups, nonrandomized studies (e.g., cohort,

case-control)

III

One group, nonrandomized (e.g., before and after,

pretest, and posttest)

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IV

Descriptive studies that include analysis of outcomes

(single subject design, case series)

Case reports and expert opinion, which include

narrative literature reviews and consensus statements

Qualitative Studies

Other

TOTAL:

10

Limitations of the Studies Appraised:

Levels I, II, and III
The participants learned and completed the exercises through the Kinetic gaming
system. The participants had to choose from two different exercise routines and selfreport whether the exercises were completed. Without supervision, the exercises may
not have been executed correctly or to full potential (DAmbrosio, 2013, Level I).

The study did not address the male to female ratio of the study, which may have
impacted the interpretation of results (DAmbrosio, 2013, Level I).

The study had a small sample size and all of the participants were men (Marmeleira,
Melo, Tlemcani & Fernandes, 2013, Level II).

The study compared older runners to older tennis players. This may not have been a
fair comparison since different physical aspects are involved in each sport
(Marmeleira, Melo, Tlemcani & Fernandes, 2013, Level II).

The time of day and the exact conditions of the intervention were not provided so the
intervention cannot be replicated (Sayers & Gibson, 2012, Level I).

The sample size was small and the overall sample consisted of participants with ages
ranging over 3 decades. The difference of driving skills between precise age ranges
may have been washed out due to the large age range in the study (Chattha, 2011,
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Level I).

Differentiation between contributions to the obtained improvement by specific

characteristics of the exercise program and the possible training effects of physical
fitness was impossible to determine (Marmeleira, Soares de Melo, Tlemcani &
Godinho, 2011, Level I).

The researchers of the study were not blinded to the participants group which may
have led to bias (Marmeleira, Soares de Melo, Tlemcani & Godinho, 2011, Level I).

All of the participants in the study were women. There were no men in the study
(Weber & Porter, 2010, Level I).

All of the women in the group had some degree of mobility impairment which
prohibits generalization of results (Weber & Porter, 2010, Level I).

It was a pilot study and had an inadequate sample size and the participants were selfselected (Caragata, Tuokko, & Damini, 2009, Level II).

The women in the study were significantly younger than the men in the group which
could alter the results (Caragata, Tuokko, & Damini, 2009, Level II).

All of the participants were recruited from a small town in Portugal (Marmeleira,
Godinho & Fernandes, 2009, Level I).

There was a lack in detail provided about the intervention. The exercise routine
needed a more thorough explanation in order to be replicated (Marmeleira, Godinho
& Fernandes, 2009, Level I).

There were two different physical therapist who were conducting the exercise
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program. This could lead to inconsistency in the administration of the exercises or

techniques (Marottolo, Allore, Araujo, Iannone, Acampora, Gottschalk & Peduzzi,
2007. Level I).

The participants had to self-report whether the exercises were completed. Participants
may have exaggerated this information (Ostrow, Shaffron, & McPherson, 1992, Level
I).

All of the participants were recruited from Morgantown, West Virginia, which is a
form of selection bias (Ostrow, Shaffron, & McPherson, 1992, Level I).

Levels IV and V
No level IV and V articles used in this CAT.

Other
No other articles were used for this CAT.

Articles Selected for Appraisal:

Caragata, G., Tuokko, H., & Damini, A. (2009). Fit to drive: a pilot study to improve the
physical fitness of older drivers. Activities, Adaptation & Aging, 33(4), 240-255.
doi:10.1080/01924780903349080.

Chattha, H. K. (2011). The influence of physical activity on driving performance and cognitive
functioning in older adults: A randomized controlled trial (Unpublished doctoral
dissertation). Lakehead University, Ontario, Canada.

DAmbrosio, L. (2013). Keeping fit and fit to drive: an experimental intervention to explore
the impact of physical exercise on older adults driving. New England University
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Transportation Center, 1-3.

Marottoli, R. A., Allore, H., Araujo, K. L. B., Iannone, L. P., Acampora, D., Gottschalk, M.,
Peduzzi, P. (2007). A Randomized Trial of a Physical Conditioning Program to
Enhance the Driving Performance of Older Persons. Journal of General Internal
Medicine, 22(5), 590597. doi:10.1007/s11606-007-0134-3

Marmeleira, J., Godinho, M., & Fernandes, O. (2009). The effects of an exercise program on
several abilities associated with driving performance in older adults. Accident Analysis
and Prevention, 41, 90-97.

Marmeleira, J., Soares de Melo, F., Tlemcani, M., & Godinho, M. (2011). Exercise can
improve speed of behavior in older drivers. Journal of Aging and Physical Activity, 19,
46-61.

Marmeleira, J., Melo, F., Tlemcani, M., & Fernandes, J. (2013). Tennis playing is related to
psychomotor speed in older drivers. Perceptual & Motor Skills, 2(117), 457-469.

Ostrow, A. C., Shaffron, P., & McPherson, K. (1992). The effects of a joint range-of-motion
physical fitness training program on the automobile driving skills of older adults.
Journal of Safety Research, 23(4), 207-219. doi:10.1016/0022-4375(92)90003-R

Sayers, S. P., & Gibson, K. (2012). Effects of high-speed power training on muscle
performance and braking speed in older adults. Journal of Aging Research, 2012,
426278. doi: 10.1155/2012/426278

Webber, S., & Porter, M. (2010). Effects of ankle power training on movement time in
mobility-impaired older women. Medicine & Science In Sports & Exercise, 42(7),
1233-1240. doi:10.1249/MSS.0b013e3181cdd4e9
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Other References:
Eby, D. W., Molnar, L. J., & Pellerito, J. M. (2005). Driving cessation and alternative
community mobility. In J. M. Pellerito (Ed.), Driver rehabilitation and community
mobility: Principles and practice (pp. 425-454). Philadelphia: Mosby Medical Books.
National Highway Traffic Safety Administration, National Center for Statistics and Analysis.
(2013). Traffic safety facts: 2011 data-Older population (Publication N. DOT HS 811
745). Retrieved from http://www-nrd.nhtsa.dot.gov/Pubs/811745.pdf
Singh, M. A. (2004). Exercise and aging. Clinics in Geriatric Medicine, 20, 201-221.
doi:10.1016/j.cger.2004.03.003

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