• William M Jackson, Nicholas Davis, Stephen A Sands, Robert A Whittington, and Lena S Sun.
• Departments of *Anesthesiology†Psychiatry‡Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY.
• J Neurosurg Anesthesiol. 2016 Oct 1; 28 (4): 373-380.

Research QuestionIs there an association between regular exercise, defined as a structured program of increased physical activity at least 1 month in duration, and improvements in measures of executive functions compared with children who engage in their normal daily activities?ContextThe association between increased physical activity and changes in performance on tasks of executive functions have not been well elucidated in children. Executive functioning is important to intellectual development and academic success in children, and inexpensive, nonpharmacological methods for the treatment of executive dysfunction represent an attractive interventional target.ObjectiveTo estimate the effect of a structured regular exercise program on neuropsychological domains of executive function in children ages 7 to 12.Data SourcesWe performed a systematic review of English and non-English articles using Cochrane Library, EBSCO CINAHL, Ovid MEDLINE, PSYCInfo, Pubmed, and Web of Science, including all years allowed by each individual search engine. The search string used was "(exercise OR phys*) AND (cognit* OR executive) AND (child* OR preadolesc*)." The authors of the studies selected for review were contacted for any unpublished data.Study Eligibility CriteriaRandomized controlled trials, which enrolled children between the ages of 7 and 12, with randomization to either normal activity or a structured physical activity intervention consisting of scheduled aerobic exercise, at least once per week, for a period of at least 1 month. Eligible studies must have included a neuropsychological battery of tests that measured at least 1 executive function both before and after the intervention was completed.Study AppraisalTwo independent reviewers examined the screened studies in detail for potential inclusion. The results of the individual examinations were compared; if any discrepancies were present, a third party analyzed the study to determine if it should be included in the meta-analysis.ResultsA total of 18 studies were identified by abstract as candidates for inclusion. From these 18 studies, 8 were independently selected by 2 authors for inclusion in the final analysis; there were no selection discrepancies between authors with regard to the studies to be included. In all, 770 subjects were included, 339 in the control group and 431 in the intervention group. All 8 studies contained a measure of inhibitory control; no other domain of executive function was measured frequently enough to perform meta-analysis, so only measures of inhibitory control were pooled and analyzed. A Cohen d effect size was calculated for each measure using the method of Morris for controlled pre-post control measurement studies. The studies were then combined in a random effects model using Comprehensive Meta Analysis software (Biostat, Englewood, NJ) for Windows (Microsoft, Redmond, WA). All studies showed a positive effect of regular exercise with improvements in measures of inhibitory control, but none were statistically significant for this measure. When pooled, the model revealed a combined Cohen d effect size of 0.2 (95% confidence interval, 0.03-0.37; P=0.021), indicating a small improvement of inhibitory control with long-term physical activity. Heterogeneity was very low (I=0).LimitationsMany studies used different neuropsychological tests to assess inhibitory control, which may have introduced unforeseen confounders. Other domains of executive functions were not measured frequently enough to perform meta-analysis. Despite attempts to gather unpublished data, positive results were observed in all of the included studies, raising the possibility of publication bias.Conclusions And ImplicationsIncreased regular physical activity is associated with a small and measurable, improvement in neuropsychological tests of executive functions, specifically inhibitory control. Executive functions play an important role in complex behavior, and may contribute to academic and career achievement as well as success in social interaction. This finding provides support for the important interaction between exercise and cognitive functioning.

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