School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE
Name: Annie Guiliano and Danielle Palmer
Date: October 8, 2015
Focus Question: Does physical exercise improve the driving performance of older adults?
Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table: Articles
were in included if they: were Level I and II articles, written in English, published in peer reviewed journals, provided full article
publication and contained and answered all aspects of the (PICO) focus question.

Author/
Year

Study
Objectives

Level/Design/
Subjects

Intervention and
Outcome Measures

Results

Study
Limitations

Implications for OT

DAmbrosio
(2013)

The purpose of the

study was to
address what older
adults might be
able to do
proactively to
extend their safe
driving careers.

Level/ Design: Level I/

Randomized Control
Trial (RCT)

Intervention: The
intervention group
exercised using the
Microsoft Xbox and
Kinect system. The
exercises on the
Electronic Arts (EA)
Active Sports 2 package
were designed by an
expert specifically for
older adults. The

The intervention
group was faster to
enter the vehicle
compared to the
control group. Also
the intervention
group improved
their time getting
into the vehicle
from pretest to
posttest compared to

The Xbox and the

Kinect system with
the EA Active
Sports 2 program
may not have been
adequate to cause
changes in driving
behavior. The
participants could
have been doing the
exercises incorrectly

The clinical based and

community-based practice
of OT: The study indicates
that physical exercise,
conducted on a Kinect
system, can be a vital
component to improving
driving performance in
older adults. Occupational
therapy works with clients
with driving deficits.

Subjects: The
participants were
community dwelling
drivers whose ages
ranged from 60-74. All
participants were
recruited from eastern

Massachusetts. No
participants reported
any significant health
conditions that would
prohibit them from
participating in the
exercise program. The
gender of the
participants was not
addressed.

participants could choose

from 1 of 2 exercises that
each lasted for 15-20
minutes. They were to
perform the exercises
daily for 8-10 weeks. The
study did not say what
the control group did, but
it is assumed they did not
complete any exercises.
Outcome Measures:
-Montreal Cognitive
Assessment
-Geriatric Depression
Scale
-UFOV test and Trails
Tests (assessing physical
function, amount of
effort of getting in and
out of driving simulator,
torso rotational
flexibility, and reaction
time test)
At posttest: the
participants drove in the
instrumented AgeLab
Aware Car on a predetermined route. This
looked at degree of
rotation to look when
making turns and
changing lanes. The
participants were also

the control group.

The intervention
group was 3.6
seconds faster from
pre to post test.
While the control
group was only 1.88
seconds faster from
pre to post test.
(F(1,45)=4.399,
p=.042) There was a
significant
difference in
rotational degree of
the 2 first right hand
turns that were
completed in the
vehicle. The
intervention group
rotated further.
Control group:
M=52.766, SD
=16.638 and the
intervention group:
M=61.512,
SD=7.99;
F(1,39)=4.336,
p=.044). The
intervention group
reported that it was
easier to rotate their
torso to back up the
car. The Kinect was
also a good
predictor of how

or may not have

completed them
with enough
intensity to see
changes in their
fitness performance.
Also, the
intervention only
lasted 8-10 weeks,
which could have
been too short of a
time. More research
needs to be
conducted. The
study did not
address how many
males and females
were in the study,
which could skew
the results.

Physical exercise using a

Kinect system, can be
incorporated into therapy
to improve clients driving
performance.
Program development:
OTs can educate clients
on the use of a gaming
system (Kinetic System) in
order to get their physical
exercise, which in the long
run would improve their
driving performance.
Societal needs: There are
many elderly adults that
have decreased driving
performance and need
assistance.
Health care delivery and
health policy: This study
indicates that gaming
systems can be used and
implicated as a therapy
tool to improve driving
performance.
Education and training of
OT students: OT students
should have the knowledge
associated with what
factors are needed when
driving and how these

asked to reverse the

vehicle to look at the
degree of rotation when
looking behind them.

Marmeleira,
Melo,
Tlemcani, &
Fernandes
(2013)

The purpose of this

study was to
investigate the
association of
tennis playing and
running with the
psychomotor speed
of older drivers.
This study
investigates the
effects of tennis
playing and
running, which are
forms of physical
exercise, on driving
performance
demand. The study
concentrates on
healthy older
adults, identical to

Level/Design:
Level II/Cross-sectional
Subjects:
Participants were
recruited in recreational
and sports associations
in the region of Evora
(Portugal) by posted
flyers and public
meetings. General
inclusion criteria were:
age 55 years or older;
living independently in
the community; healthy
without serious
cardiovascular or
musculoskeletal
disease; possessing a
valid driving license;

Intervention:
There were 3 groups, a
tennis group, a runners
group, and a control
group. They completed a
battery of four on-theroad driving tests. There
was no intervention
administered. The
participants were
determined to fit the
criteria for each group, so
they already had the
intervention in place
and established. The
testing measures were
described in detailed as
well as the recruitment of
participants.

easy the participants

were able to see
their right blind
spots when
changing lanes. The
participants in the
intervention group
responded that
seeing their blind
spot was easier
compared to the
response of the
control group when
asked in the post
examination.
Tennis players had
faster RT than the
control group
(p=.04, Cohens
d=1.27,
95%CI=0.36, 2.13).
Tennis players also
had faster RT than
the control (p=.02,
Cohens d=1.29,
95%CI=0.39, 2.17)
In every category,
the tennis players
had a better score
than both the
runners group and
control group, and
in every category
the runners group
had a better score

factors can be improved

with physical exercise.
Refinement, revision, and
advancement of factual
knowledge or theory:
More research and studies
should be conducted on
gaming system use for
physical exercise, to
improve driving
performance.

The study had a

small sample size
and participants
were all men.
Evaluations were
conducted during
open-road driving,
but drivers were
aware of the
stimulus-response
correspondence.
This study was
comparing older
runners to older
tennis players.
Older tennis players
likely have been
playing the sport for
a long time. People
that have been

The clinical based and

community-based practice
of OT:
OTs should encourage
clients to continue to
participate in the sport of
tennis if that is an
established meaningful
activity. Having a tennis
playing routine helps
driving skills in older
adults.
Program development:
OTs can consult in city
planning to encourage the
building of tennis courts.
Societal needs:
The study found that

the population we
are investigating.

20/40 or greater
corrected vision;
normal cognitive status
on the Mini Mental
State Examination
(MMSE). Additional
specific inclusion
criteria were: drivers in
the control group had
not been engaged in
any exercise program
for the last two years;
runners and tennis
players had been
engaged in these sports
at least two times per
week for the last two
years. Only male
drivers were recruited
because there were very
few women meeting the
inclusion criteria for the
sport groups. Thirtysix male active drivers
(12 by group) of ages
55 to 76 years were
enrolled in the study.
Questionnaires were
administered to gather
information on
demographic variables,
sport practice, driving
history, and medical
conditions.

Outcome Measures:
Reaction time (RT),
measured from the onset
of the leading cars brake
lights to the initial release
of the accelerator by the
driver participant;
movement time, the
period from the initial
release of the accelerator
to the initial brake
application; and response
time, measured from the
onset of the leading cars
brake lights to the
participants initial brake
application
Six red LED were
positioned 10, 20, 30
degrees to the left (L)
and right (R).
Participants had to react
to lights and performance
was recorded in the form
of number of signal
misses and RTs in
milliseconds.
Participants were given a
2 choice task and
instructed to react to
either of the 2 stimuli by
different methods.
Performance was
evaluated by the RTs and
number of errors. RT to

than the control

group.

playing a sport like

tennis for a long
time are likely to be
good athletes.
Running is an
activity that many
people pick up later
in life. There are
runners in a broad
range of physical
conditions.
Comparing older
runners to older
tennis players may
not be a fair
comparison.

tennis players and runners

had better performance
skills related to driving
than sedentary older
adults. The findings
suggest that society should
prioritize the importance
of physical exercise in
aging individuals.
Health care delivery and
health policy:
Health care should focus
of preventing disease by
encouraging physical
activity rather than focus
of medical management
once disease is present.
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.
Refinement, revision, and
advancement of factual
knowledge or theory:
To fully understand the
impact of tennis on

braking to the car lights

ahead was recorded
during the secondary task
of mental-calculation
task.

Sayers &
Gibson
(2012)

The purpose of this

study was to
examine the effect
of high-speed
power training
(HSPT) on muscle
power and its
components in
older men and
women and how
changes in those
parameters with
training impacted
braking speed using
a driving simulator.

Level/Design:
Level I/RCT
Subjects:
Eligible participants
were between the ages
of 65-90 years,
ambulatory with or
without an assistive
device (cane or 3 post
walker only) and
community dwelling.
Exclusion criteria
consisted of history of
heart disease, severe
visual impairment,
presence of
neurological disease,
pulmonary disease
requiring the use of
oxygen, uncontrolled
hypertension, hip
fracture or lower
extremity joint
replacement in the past
6 months, and current
participation in
structured exercise.

Intervention:
The HSPT and SSST
groups exercised 3 times
per week for 12 weeks
using computerinterfaced Keiser a420
pneumatic leg press and
seated knee extension
resistance training
equipment. For HSPT,
each training session
consisted of 3 sets of 1214 repetitions at 40% of
max. Participants
performed an explosive
movement at high speed
during the concentric
phase of each repetition,
paused for one-second,
and performed the
eccentric portion of the
contraction over 2-3
seconds. The SSPT
group also exercised 3
times per week for 12
weeks with each training
session consisting of 3
sets of 8-10 repetitions at

When significant
associations were
found, those
variables were used
as covariates in all
analysis of variance
(ANOVA) models.
To evaluate baseline
differences in
subject
characteristics a
one-way ANOVA or
chi-square was run.
To evaluate baseline
differences among
groups in leg press
muscle
performance, the
change scores in
peak power, peak
power velocity, and
peak power force
with training were
calculated at each
condition and a
univariate ANOVA
was run covarying
for the baseline

There may have

been
intervention/perfor
mance bias. The
time of day and
exact conditions of
the intervention
were not provided
so the results cannot
be replicated.

performance skills of older

drivers, studies using
tennis as a new
intervention with
participants who have not
played the games should
be conducted.
The clinical based and
community-based practice
of OT:
The findings of this study
should influence the type
of exercise chosen as an
intervention to improve the
driving performance in
older adults. The study
found that HSPT had a
greater effect on driving
performance than SSPT.
Program development:
When creating driving
rehabilitation programs for
older adults, OTs should
utilize this study to
incorporate HSPT.
Societal needs:
Older adult drivers have a
major impact on society so
useful intervention such
and HSPT are needed to
address current and future
implications.

114 individuals were

contacted to participate
in the study. The study
does not say how these
individuals were found
or how they were
contacted. 89 of those
individuals were
randomized into one of
three groups: highspeed power training
(HSPT n=30), slowspeed power training
(SSPT n=30), and
control (CON n=29).
17 participants dropped
out during the baseline
period before training
started. 8 participants
withdrew during the
intervention. Data from
72 participants, 22m
and 50f (HSPT n=25,
SSPT n=25, CON
n=22) was analyzed in
the study.

80% max. Repetition

number was higher in the
HSPT group to more
closely equate work
performed between
groups and to remain
consistent with resistance
training guidelines for
exercise using lower
external resistances. The
participants performed
each movement at a slow
velocity (2-3 seconds for
concentric phase of rep),
paused for one second,
and performed the
eccentric portion of the
contraction over 2-3
seconds. The control
group met three times a
week for 12 weeks for
warm-up and stretching
exercises, but performed
no resistance training.
HSPT and SSST
performed the same
warm-up and stretching
exercise as CON. The
study does not clearly
state where these
workout occurred, the
time of day, or if the
groups co-mingled.
Outcome Measures:

measure. To
evaluate differences
among groups in
braking speed from
baseline to post
training, the change
score was calculated
and a univariate
ANOVA was run
covarying for the
baseline measure.
To determine
differences between
groups in average
daily RPE and work
performed during
the 12 week
intervention,
independent
samples t-tests were
performed between
the HSPT and SSST.
Statistical
significance for all
test was accepted at
P < 0.05. Data are
reported as means
(95% CI). Post hoc
tests showed that
both peak power
and peak power
velocity HSPT was
greater than CON
across all external
resistance 40-90%

Health care delivery and

health policy:
Non-pharmaceutical
interventions are needed in
health care to improve the
driving skills of older
drivers.
Education and training of
OT students:
Driver rehabilitation
should be included in OT
education to address the
growing number of older
drivers on the road.
Knowledge on effective
exercises to use as
interventions is important
for students.
Refinement, revision, and
advancement of factual
knowledge or theory:
This study suggests that
not all forms of exercise
are created equal. This is
important when using
exercise to improve the
driving skills of older
adults.

(1)Leg press and knee

extension (one repetition
max), muscle power
across a range of external
resistances, and
corresponding velocity at
peak power and
force/torque at peak
power (2)Braking speed
using an automobile
driving simulator
measured by participant
slamming on the brakes
when stimulus change
from green to red,
computer recorded initial
reaction time and the
time from foot movement
from accelerator to brake
(3)Ratings of perceived
exertion using Borg scale
to rate exertion they felt
immediately following
each set of leg press and
knee extension

of max (p 0.02),
while SSST was
only greater than
CON from 70-90%
of max (p 0.04).
These findings
indicate the HSPT
exerted a broader
training effect than
SSPT when
comparing the
change in baseline
power and speed
across a range of
typically
encountered
external resistances.
Univariate ANOVA
demonstrated a
significant group
main effect for the
change in braking
speed with training
(p = 0.02). There
was a difference in
average daily RPE
between HSPT and
SSPT (p 0.001)
during both leg
press and knee
extension exercise.
These results
indicate that despite
being exposed to
similar workloads

during training,
HSPT perceived the
exercise to be easier.
Chattha
(2011)

The purpose of this

study was to
investigate the
effects of physical
activity on the
driving abilities of
sedentary older
adults.

Level/Design:
Level I/RCT
Subjects:
A multi-step protocol
was used to recruit
participants for the
intervention. Recruited
sedentary older adults
within the city of
Thunder Bay, Ontario
by television and
newspaper
advertisements, posters
and flyers. Letters
describing the study
and enrollment criteria
were distributed to
interested parties.
Announcements were
made in the Lakehead
University community
bulletin, which was
distributed to university
staff and students by
email and also
displayed on website.
131 individuals were
then screened, of which
70 satisfied enrollment
criteria. Then those

Intervention:
Intervention consists of
12 weeks of both aerobic
and anaerobic exercise.
Cardiovascular training
consisted of brisk
walking for 30 to 40
minutes, three days per
week. The muscular
component included
standard strength training
exercises for 1-3 sets of
10-15 reps of each
exercise for 3 days per
week. The flexibility
component involved
performing 4 reps of
standard total body, static
stretches for 3 days per
week.
Outcome Measures:
Stroop Colour-Word Test
Trail Making Test
Useful Field of View test
Driving Simulation Test
Cardiorespiratory Fitness
Endurance Level
Body Composition
Flexibility
Barriers Self-Efficacy

MANCOVAs were
conducted by
entering post-test
values as the
dependent variables
and pre-test values
as covariates.
Barriers to SelfEfficacy score
differed
significantly across
experimental and
control participants.
The study
demonstrates that
unsupervised fitness
intervention of
short-term duration
can produce
significant cognitive
changes in
sedentary older
adults, which are
particularly relevant
to safe driving.
Analysis showed
that visual attention
improved
significantly
compared to control
group.

One limitation of
the study was the
low participation
rate of 17.7%. The
sample size was
small, and overall
sample consisted of
participants over
three decades.
More precise age
differences might
have been washed
out due to the large
age range in the
study.

The clinical based and

community-based practice
of OT:
Exercise is an effective
intervention to improve the
driving skills in older
adults.
Program development:
Exercise should be
included in driving
programs to improve the
performance skills in older
adults.
Societal needs:
Society will be faced with
the consequences of the
declining driving
performance by older
adults. This study
indicates that exercise is a
great intervention to
address this problem.
Health care delivery and
health policy:
Healthcare needs a nonpharmaceutical
intervention for older
drivers whom want to

individuals that chose

to proceed had to obtain
medical clearance. 39
individuals were left.
Out of those 39, only
30 wished to continue
with the study. One
more dropped out
before beginning.
Groups were stratified
by age and gender.
There was an exercise
group and a wait-list
control group. Two
participants who were
randomized into the
exercise group asked to
be put into the control
so 13 participants were
in experimental and 16
participants were in the
control.
Inclusionary/Exclusion
ary Criteria: Aged 55 or
older, sedentary, have a
valid Ontario drivers
license, no serious
medical condition,
understand that after
initial
testing/enrollment in
the study they will be
randomly assigned to
one of the 12 week
sessions being

Experimental
groups mean score
on selective
attention improved
by 43.37 ms, while
the control groups
mean declined 43.19
ms after the 12 wks.
No significant
differences were
recorded in driving
scenarios.

maintain their
independence by staying
behind the wheel.
Education and training of
OT students:
Driving performance of
older adults is part of the
curriculum for many OT
students. Utilizing the
intervention of exercise is
an important implication
for this study.
Refinement, revision, and
advancement of factual
knowledge or theory:
Exercise is known to have
many benefits. The effect
of exercise on driving
skills of older adults have
not had substantial focus.
This study can contribute
to the knowledge base of
the many benefits of
exercise.

Marmeleira,
Soares de
Melo,
Tlemcani, &
Godinho
(2011)

The main aim of

this research was to
study the effects of
an exercise
program on the
speed of behavior
of older adults
during on-the-road
(not simulated)
driving.

conducted, willing to
fully participate, must
be able to transport
oneself to and from the
fitness center.
Level/Design:
Level I/RCT
Subjects:
Participants were
recruited from the local
community by posted
flyers and local radio
and newspaper
announcements. 26
participants fulfilled the
inclusion criteria, of
being age 55 or more,
living independently in
the community, being
healthy without serious
cardiovascular or
musculoskeletal
disease, and having a
valid driving license,
good visual acuity, and
normal cognition. The
age ranges were 55-76
years and 57-68 years
in the exercise group
(EG) and control group
(CG), with 9 and 8
women in the CG and
EG.

Intervention:
The intervention was a
supervised exercise
program 3 days/week for
8 weeks. Sessions were
60 minutes. Exercise
incorporated physical
tasks that induced the
participants to respond to
challenging situations by
producing the desirable
motor responses,
activities strongly
depending on working
memory, and cooperative
games requiring a
dynamic group behavior.
It was a physical exercise
program in which
cognitively challenging
tasks are executed by the
older adults undertaking
physical activities such
as walking, stepping,
reaching, throwing, and
manipulating objects.
Outcome Measures:
RT, measured from the
onset of the leading cars

In the brake RT
task, significant
improvements were
found in the EG in
RT and response
time. In the
peripheral RT task,
significant
improvements were
found in the EG
group after 8 weeks.
In the choice RT
task, significant
improvements were
found in the EG in
RT. Intergroup
analysis indicated
significant
differences in the 8
week changes
between groups. In
the dual task
condition,
intergroup analysis
indicated significant
differences in the 8
week changes
between groups for
response time.

This study had a

relatively small
sample size of
drivers.
Investigators
involved in the
assessment were not
blinded to the
participants group
and because the
control group did
not receive
intervention. It was
not possible to
differentiate
between
contributions to the
obtained
improvements by
specific
characteristics of the
exercise program
and possible
training effects of
physical fitness.

The clinical based and

community-based practice
of OT:
This study contributes to
the intervention choice an
OT would use when
working with an older
adult improve their driving
performance.
Program development:
This study could be
referenced when creating a
driving program for older
adults.
Societal needs:
There are many older
drivers on the road with
many more to come. This
study is helpful in
determining effective
intervention strategies to
handle the impacts these
statistics will have on
society.
Health care delivery and
health policy:
Finding interventions to

Weber &

The purpose of this

Level/Design: Level I/

brake lights to the initial

release of the accelerator
by the driver participant;
movement time, the
period from the initial
release of the accelerator
to the initial brake
application; and response
time, measured from the
onset of the leading cars
brake lights to the
participants initial brake
application
Six red LED were
positioned 10, 20, 30
degrees to the L and R.
Participants had to react
to lights and performance
was recorded in the form
of number of signal
misses and RTs in
milliseconds. Participant
was given a 2 choice task
and instructed to react to
either of the 2 stimuli by
different methods.
Performance was
evaluated by the RTs and
number of errors. RT to
braking to the car lights
ahead was recorded
during the secondary task
of mental-calculation
task.
Intervention: The 50

help older drivers maintain

and improve their driving
performance is important
to healthcare delivery.
Education and training of
OT students:
OT students should be
aware of how to intervene
to assist older drivers
improve their driving
performance.
Refinement, revision, and
advancement of factual
knowledge or theory:
This study contributes to
the body of research that
supports the benefits of
exercise in successful
aging.

At baseline, there

All of the

The clinical based and

Porter
(2010)

study was to
determine the
effects of power
training on foot
movement time and
on ankle strength
and power in
mobility-impaired
older women.

RCT
Subjects: The study
included 50 mobilityimpaired women whose
ages ranged from 70-88
years old. Mobility
limitation was defined
as the inability to walk
1 mile at a moderate
pace. The exclusion
criteria were: unstable
acute or chronic
disease, involved in an
exercise program more
than once per week in
last six months, any
neurological or
musculoskeletal
impairment that would
affect their exercise
performance. The
women were recruited
from newspapers,
newsletters, posters,
television, and radio
shows. 192 women
responded but it was
reduced to 50 women
through exclusion
criteria.

women exercised twice a

week for 45 min for 12
weeks in their assigned
groups. The three groups
were those who exercised
with weights, exercised
with elastic bands, and
the placebo control
group. The exercise
groups were run by
kinesiology graduates
and a licensed
physiotherapist. The
groups participated in
warm up, and cool down
exercises and then their
designated types of
exercise (weights, elastic
bands). The control
group also participated in
warm up and cool down
exercises along with the
main exercise. The
control group completed
static neck stretches and
shoulder range of motion
exercises and received
information about proper
head and neck postures.
Outcome Measures:
-Lafayette Timer, Model
63017
-Biodex System 3 Pro
dynamometer

was no significant
differences in
reaction time
(P=0.15) and
movement time
(P=0.80) between
the groups. Results
and the P-value
were determined by
two-way repeatedmeasures ANOVA.
At the end of the
study, the results
showed there was a
significant decrease
in movement time in
the elastic bands
exercise group
(P=0.003 with the
significant level set
as (P=0.017)
whereas there were
not significant
changes in the
weights group
(P=0.03) and the
control group
(P=0.38). There
were no significant
changes in the
strength and power
of the groups.

participants in the
group were women
and were mobility
impaired, which
could affect the
generalization of the
results.

community-based practice
of OT: The study
concludes that, to increase
movement time and
decrease the risk of vehicle
accidents, ankle training
with elastic bands should
be used. This helps with
intervention planning and
goal planning with older
adults who want to
improve their movement
time.
Program development:
The OT can be the main
educator on how to
implement ankle training
with elastic bands to
improve driving
performance.
Societal needs: There are
many older adult women
drivers who have slow
movement time and
decreased ankle strength
which are vital
components of driving
safely.
Health care delivery and
health policy: The results
from the study should be
used to educate clients on

-Short Physical
Performance Battery Test

the effectiveness of elastic

bands to improve driving
performance.
Education and training of
OT students: OT students
need to be educated on the
use of elastic bands for
physical exercise for their
clients.
Refinement, revision, and
advancement of factual
knowledge or theory:
Further research needs to
be conducted on the types
of exercise programs that
can increase driving
performance. For this
study, elastic bands were
the most affective option.

Caragata,
Tuokko &
Damini
(2009)

The purpose of the

study was to
determine if
maintaining a
drivers license
could motivate
older adults to
participate in a
fitness program.
The study also
analyzes how
improving the older
adults fitness

Level/Design:
Cohort/ Level 2
Subjects: A fitness
program called Fit to
Drive was advertised
at the local senior
center. Posters in the
senior center were used
to advertise the fitness
program. There were
also coupons given out
for the classes. All

Intervention: The
intervention consisted of
3 main components:
engineering
enhancements, driver
education and physical
fitness. A certified
fitness instructor
developed the fitness
program. The fitness
program focused on the
movements required for
driving: neck and torso

The results showed

that the men had
significant
improvement in
endurance while the
women had
improvement in
strength, endurance,
agility, flexibility,
and hand reaction
time. Of the
participants, half of
them said they felt

This was a pilot

study and had an
inadequate sample
size and inadequate
ability to find
definitive answers.
Participants were
self-selected and
might have been
more motivated in
the fitness class.
The study also
relied on self-

The clinical based and

community-based practice
of OT: The study showed
that a fitness program
geared at aspects related to
driving can improve
driving performance in
older adults. This
information can be utilized
when the therapist is
educating and completing
therapy with their client.

could, in return,
improve their
driving
performance.

participants who were

enrolled in this fitness
class were asked to
participate in the study.
Anyone that did not
drive at least once a
week were not allowed
in the sample. A control
group of 5 people was
used. They did not
participate in the fitness
program and were
found through an
advertisement in the
senior centers
newsletter. The
intervention group ages
ranged from 62-87 and
the control group ages
ranged from 71-76.
There was a total of 19
participants in the
intervention group.

flexibility, hand and

lower body strength,
balance, endurance, and
reaction time. Visual
tracking exercises were
also included. Some of
the exercises used
driving-related props and
movements needed for
driving. They were
offered twice per week
for 6 weeks for an hour
long.
Outcome Measures:
-Short Physical
Performance Battery Test
-Jamar dynamometer
-Head mounted Laser
Light(neck flexibility)
-Foot-tap test
-Hand Reaction Test
-Short Form 36
questionnaire
-Driving Habits
Questionnaire
At follow up, the
participants were asked
to perceive their changes
in their health and
driving. They were asked
how their level of fitness,
driving confidence, and
overall health and driving

their driving skills

had improved. Also,
40% of the
participants said
they had an increase
in confidence when
driving. While the
control group had
improvements in
endurance and foot
reaction time, no
one reported
improvements in
their driving
performance.
For the analysis of
the data, a SPSS
version 15 was used
and was restricted to
chi-square for
nominal and ordinal
variables and t test
for continuous
variables

reports for some of

the results. There
needs to be further
research conducted.
Randomized control
studies should be
used. There was a
short amount of
time when the study
was conducted. The
women in the
intervention group
were significantly
younger than the
men which could
skew the results
from the study.

Program development:
OTs should educate their
clients on the importance
of physical fitness for
improving driving
performance.

Also, there was not

a mandatory amount
of classes the
participants had to
attend. The study
stated that a
majority (75.9%) of
the participants
completed 10 or
more of the 12
classes.

Education and training of

OT students: OT students
should be educated on the
importance of physical
exercise for improving
driving performance.

Societal needs: There are

many older adults who
have driving deficits.
Health care delivery and
health policy: Exercise
programs specifically
designed for older adults
with driving issues should
be available for the elderly.

Refinement, revision, and

advancement of factual
knowledge or theory:
Randomized control
studies should be used to
improve the results of the
study.

was compared to 3
months ago. They were
also asked what areas of
fitness improved and
which did not, through
the class.

Marmelieira
, Godinho,
& Fernandes
(2009)

The purpose of this

study was to
investigate the
effects of
participation in an
exercise program
on several abilities
associated with
driving
performance in
older adults.

Level/Design:
Level I/RCT
Subjects:
Participants were
recruited in the region
of Evora, Portugal by
posted flyers and local
radio/newspaper
announcements.
Questionnaires were
administered to gather
information on
demographic variables,
physical activity
practice, driving habits,
functional impairments,
and medical conditions.
The inclusion criteria
for participants were:
aged 60+; live
independently in the
community; healthy
without serious
cardiovascular or
musculoskeletal

Intervention:
The exercise group
participated in a
supervised exercise
program 3 days a week
for 12 weeks. Each
session lasted
approximately 60
minutes. The exercise
intervention was planned
to stress not only
physiological systems but
also perceptive and
cognitive mechanisms.
Training volume was
characterized as steps per
session. All participants
used pedometers.

Outcome Measures:
Single-task condition was
measured by simple
reaction time and choice
reaction time (driving
simulator

The results showed

that a specific
exercise program is
capable of
enhancing some
important abilities
for driving
performance (and
safety) in older
adults. After 12
weeks of
intervention,
significantly
positive effects
occurred in
behavioral speed (in
single and dual-task
conditions), visual
attention, and lower
limb mobility. The
results are important
and can be
referenced when
choosing an
intervention for an
older driver with a

The major limitation

of this study was the
lack of detail
provided about the
intervention. The
exercise routine
needed a more
thorough
explanation in order
to be replicated.
This study had
selection bias. All
participants were
recruited from a
small town in
Portugal.

The clinical based and

community-based practice
of OT:
This study contributes to
selecting an evidencebased intervention when
working with older adult
drivers.
Program development:
When developing a
program to improve the
driving performance of
older adults, this study can
be reference to justify the
inclusion of an exercise
program.
Societal needs:
Society will be impacted
by the growing number of
seniors on the road.
Developing an effective
intervention will address
the toll on society.

disease; possess a valid

driving license; 20/40
or greater corrected
binocular vision
measured with a
Snellen Chart; normal
cognitive status on the
MMSE; and no
engagement in any
exercise program for at
least 1 year.
There was a control
group and an exercise
group. Both groups
had 16 participants and
similar age, sex,
education, visual acuity,
MMSE scores, time
with drivers license,
and weekly distance
driven.

(DS)/established by
computing the mean and
standard deviation (SD)
separately for each group
and dropping any trial
exceeding the mean by 3
or + DSs). Dual-task
condition was measured
identically as above, then
a secondary task was
added. Useful field of
view measured speed of
visual processing,
divided attention, and
selective attention/data
was collected in time. To
measure time-to-contact,
drivers saw video of
oncoming vehicle and
had to press and button
when vehicle reached a
pre-established location.
To measure foot tap test,
drivers had to tap
alternating sides of a 2
inch barrier with R foot
10 times. Timed up and
go test, which consists of
standing up, walking 3
m, turning around,
walking back to chair,
and sitting, was utilized.
Functional reach test
(forward reach), trail
making test (using a

goal of improving
driving
performance.

Health care delivery and

health policy:
Non-pharmaceutical
medical interventions are
needed to improve the
driving performance in
older adults.
Education and training of
OT students:
Effective interventions to
treat older adults are
important aspects for OT
students considering they
will be working with older
adult drivers in their future
practice.
Refinement, revision, and
advancement of factual
knowledge or theory:
There has not been a
substantial amount of
research on of exercise as
an intervention for the
driving performance of
older adults. This study
contributes to the support
of using exercise as an
intervention.

Marottoli,
Allore,
Araujo,
Iannone,
Acampora,
Gottschalk
& Peduzzi
(2007)

The purpose of the

study was to
analyze if a
physical
conditioning
program that
targeted extremity
flexibility,
coordination, and
speed of movement
could improve
driving
performance in
older drivers.

Level/Design: Level I/
RCT
Subjects: There were
178 drivers, all over 70
years of age. They had
to have visual acuity of
20/40 or better and had
to have a score of 24 or
better on the Mini
Mental State
Examination. The
participants were
recruited from clinics
and community
sources.

pencil to sequentially
connect a mix of integers
and letters that are
distributed across a page
in an alternating and
ascending order), and the
Stroop color-word test
were all utilized.
Intervention: The
intervention group
received a weekly visit
for 12 weeks by a
physical therapist who
administered a graduated
exercise program that
addressed physical
abilities needed for
driving. There were 2
physical therapists who
were specifically trained
to administer the exercise
program. The therapist
gradually increased the
intensity of the exercise
program throughout the
12 weeks. The therapist
taught the exercises to
the participants and the
participants were
instructed to perform the
exercises once a day for
15 min. The control
group received monthly
in home education
modules that addressed

The article stated

that a clinically
meaningful
difference in the
outcome was
defined as a change
in 2 points. The
intervention group
scored 2.43 points
higher than the
control group from
the pre and post
driving test.
(p=0.03).
Participants in the
intervention group
had 37% lower
number of critical
errors than the
control group
(p=0.08). The
driving evaluators
rating was
comparable between
the intervention
group and the
control group

One limitation of
the study was that
there were a low
number of females
and few
demographic
differences in the
participants. Also,
the clinical
relevance of the
study was unknown.
Yes, there was a
2.43 point
difference between
the treatment group
and the control
group but what does
that imply? There
were 2 different
physical therapists
who were giving the
exercise program.

The clinical based and

community-based practice
of OT: A home exercise
program was designed
specifically to target
factors related to driving.
This home exercise
program can be used with
any adults who wanted to
increase their driving
performance.
Program development:
The OT can replicate and
design a home exercise
program specifically for
older adults with driving
deficits.
Societal needs: There are
many older adults who
have driving deficits.
Health care delivery and
health policy: Home
exercise programs
specifically used to

safety issues about fall

prevention, home safety,
vehicle care, given by
trained research
assistants. The
intervention group also
received these modules.

Ostrow,
Shaffron, &
McPherson
(1992)

This study is the

first experimental
investigation of the
effects of a physical
fitness training
program on the
automobile driving
performance of
older adults.

Level Design: Level I/

RCT
Subjects:
There were 32
participants in the
study. The ages ranged
from 60-85 years old
and the participants
were recruited from the
Morgantown, West
Virginia area. They
were recruited through

Outcome Measures:
On-road driving
performance (rated in 3
different ways)
1.) 36- item scale
assessing the
participants driving
maneuvers and traffic
situations
2.) Evaluators overall
rating
3.) Critical errors that
were committed by the
participant
Intervention:
The experimental group
participated in an 8 week
range-of-motion exercise
training program which
focused on static-type
stretching exercises of
the upper body. The
exercises were adapted to
meet the requirements of
the designated driving
skills. The experimental
group completed their

(p=.29) The
intervention group
maintained their
driving performance
while the control
group declined.
There was also
fewer falls in the
intervention group
compared to the
control group (this
analysis was not
statistically
significant). The
SAS version 8.1
was used for all
statistical analysis
and the value of
0.05 was used to test
significance.

The results showed

that the
experimental group
had improvements
in shoulder
flexibility, trunk
rotation, and
improvement in
their scores on the
observing driving
skill measure.
ANOVA was the
analysis method

increase driving
performance for the
elderly can be
implemented to increase
overall community safety.
Education and training of
OT students: OT students
should be educated in how
to create and implement
home exercise programs
for their clients.
Refinement, revision, and
advancement of factual
knowledge or theory:
Further research still needs
to be conducted on home
exercise programs that
increase driving
performance.
A limitation of the
study was that the
participants were all
recruited from the
Morgantown, West
Virginia area and no
were else, which
could lead to biases.
The participants had
to self-report if they
completed the
exercises.

The clinical based and

community-based practice
of OT: The study
concluded that physical
exercise can improve
driving performance in the
areas of shoulder
flexibility, trunk rotation,
and the skill of
observation.
Program development:
The OT can replicate and

announcements on the
radio, television, and
the newspapers. They
were also recruited
through Rotary,
Kiwanis clubs and the
American Association
of Retired Persons.

exercises at home and

were asked to keep a log
where they recorded
daily about the
completion of their
exercises and the
frequency and extent of
driving. Every week,
each driver would meet
with a clinician who
added new elements to
the exercise program,
reviewed all of the
previously learned skills,
and monitored the
drivers compliance with
the program. The control
group did not receive any
exercises. The
experimental group and
the control group were
given two sets of tests on
three different occasions.
Outcome Measures:
Range of motion tests:
-goniometer
-metric tape measure
Automobile Driving OnRoad Performance Test
(performed by 2 trained
examiners)

used for this study

and F-ratio values
were also used. The
experimental group
shoulder flexibility
F(2,60) =3.23,
p<0.05; trunk
rotation to the right
F(2,60) = 3.31,
p<0.05; trunk
rotation to the left
approached
statistical significant
with p<0.06. The
control group
decreased in trunk
rotation and only
had a slight increase
in shoulder
flexibility. The
experimental
groups skill for
observation
improved F(2,59)
=3.62 and p<0.05.
The observation
skill declined for the
control group.
Handling position
skill, surprisingly,
improved for the
control group
F(2,59) = 3.55,
p<0.05.

direct the exercise training

program that focus on
skills needed for driving.
Societal needs: There are
many older adults that
have driving performance
deficits.
Health care delivery and
health policy: Exercise
programs that focus
directly on increasing
driving performance
should be available to the
elderly.
Education and training of
OT students: OT students
need to understand the
concepts of shoulder
flexibility, trunk rotation
and the skill of
observation.
Refinement, revision, and
advancement of factual
knowledge or theory:
Further research still needs
to be conducted on rangeof-motion training
programs that differ in
length, frequency and
duration.