Review

Amika S Singh,1 Emi Saliasi,1 Vera van den Berg,1 Léonie Uijtdewilligen,2
Renate H M de Groot,3 Jelle Jolles,4 Lars B Andersen,5 Richard Bailey,6 Yu-Kai Chang,7
Adele Diamond,8 Ingegerd Ericsson,9 Jennifer L Etnier,10 Alicia L Fedewa,11
Charles H Hillman,12 Terry McMorris,13 Caterina Pesce,14 Uwe Pühse,15
Phillip D Tomporowski,16 Mai J M Chinapaw1
►► Additional material is
published online only. To view
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​
bjsports-​2017-​098136).

For numbered affiliations see
end of article.
Correspondence to
Amika S Singh, Department
of Public and Occupational
Health and the Amsterdam
Public Health research institute,
VU University Medical Center,
Amsterdam, The Netherlands;
a​ .​singh@​vumc.​nl
Received 20 June 2017
Revised 15 April 2018
Accepted 20 June 2018

© Author(s) (or their
employer(s)) 2018. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: Singh AS, Saliasi E,
van den Berg V, et al.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2017-098136

Abstract
Objective To summarise the current evidence on the
effects of physical activity (PA) interventions on cognitive
and academic performance in children, and formulate
research priorities and recommendations.
Design Systematic review (following PRISMA
guidelines) with a methodological quality assessment
and an international expert panel. We based the
evaluation of the consistency of the scientific evidence
on the findings reported in studies rated as of high
methodological quality.
Data sources PubMed, PsycINFO, Cochrane Central,
Web of Science, ERIC, and SPORTDiscus.
Eligibility criteria for selecting studies PAintervention studies in children with at least one
cognitive or academic performance assessment.
Results Eleven (19%) of 58 included intervention
studies received a high-quality rating for methodological
quality: four assessed effects of PA interventions on
cognitive performance, six assessed effects on academic
performance, and one on both. All high-quality studies
contrasted the effects of additional/adapted PA
activities with regular curriculum activities. For cognitive
performance 10 of 21 (48%) constructs analysed
showed statistically significant beneficial intervention
effects of PA, while for academic performance, 15 of
25 (60%) analyses found a significant beneficial effect
of PA. Across all five studies assessing PA effects on
mathematics, beneficial effects were reported in six
out of seven (86%) outcomes. Experts put forward 46
research questions. The most pressing research priority
cluster concerned the causality of the relationship
between PA and cognitive/academic performance.
The remaining clusters pertained to PA characteristics,
moderators and mechanisms governing the ’PA–
performance’ relationship and miscellaneous topics.
Conclusion There is currently inconclusive evidence for
the beneficial effects of PA interventions on cognitive
and overall academic performance in children. We
conclude that there is strong evidence for beneficial
effects of PA on maths performance. The expert panel
confirmed that more ’high-quality’ research is warranted.
By prioritising the most important research questions
and formulating recommendations we aim to guide
researchers in generating high-quality evidence. Our
recommendations focus on adequate control groups and

sample size, the use of valid and reliable measurement
instruments for physical activity and cognitive
performance, measurement of compliance and data
analysis.
PROSPERO registration number CRD42017082505.

Introduction

Cognitive skills are crucial for school readiness
and academic performance,1–3 and are supported
by a variety of brain regions, which continue to
mature throughout adolescence.4 This developmental window poses a great opportunity for experience-dependent plasticity,5 as the structural and
functional organisation of the brain can be positively influenced through enriched environmental
conditions6 like, for example, physical activity (PA).
As such, it is critical to advance our understanding
of opportunities that have the potential to positively influence brain development.
The physical and mental health benefits of PA are
widely acknowledged,7 8 but less is known about the
potential effects of PA on cognitive and academic
performance. A number of reviews and reports
on this topic have been published during the last
decade,9–19 mainly concluding that PA is positively
associated with cognition and with structural and
functional brain health and a neutral association
with academic performance for children.12 Not all
of these reviews were systematic, took into account
the methodological quality of the studies included,
and were exclusively looking at intervention studies.
Above all, most reviews summarised the existing
evidence at study level. So, if a study reported a
significant association of PA with one, but not all,
outcome measures, it was categorised as a ‘positive’
study. In addition, most reviews concluded that
many aspects of this relationship remain unclear
and that further research is needed to elucidate the
nature of the relationship.
Several hypotheses have been proposed to
explain posited PA-related effects on cognitive and
academic performance. Regular PA alters neurogenesis and angiogenesis and enhances central
nervous system metabolism.20 Furthermore, it

Singh AS, et al. Br J Sports Med 2018;0:1–10. doi:10.1136/bjsports-2017-098136

   1

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Effects of physical activity interventions on
cognitive and academic performance in children and
adolescents: a novel combination of a systematic
review and recommendations from an expert panel

Review

Methods

The current review was registered at PROSPERO
(CRD42017082505). We applied the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses)
reporting guidelines for this review.
This study followed a two-step procedure, with both steps
taking place in parallel: (1) a systematic literature review of
intervention studies investigating the effects of regular PA on
cognitive and/or academic performance in children and adolescents (0–18 years); (2) a Delphi study among scientific experts
on the topic of PA and cognitive/academic performance.

Systematic review
Literature search and eligibility

Randomised and non-randomised intervention studies that
investigated the effects of PA on cognitive/academic performance in children were identified from a systematic search of the
literature using six electronic bibliographic databases (PubMed,
PsycINFO, Cochrane Central, Web of Science, ERIC, and
SPORTDiscus), until September 2017. Search terms were related
to (1) physical activity (eg, physical activity, exercise, physical
fitness, and sport); (2) cognitive and academic performance (eg,
academic achievement, cognitive performance, academic performance, and school learning); (3) age (eg, infant, child, adolescent, and 0–18 years old); (4) intervention studies with various
study designs (eg, randomised controlled trials (RCTs), cluster
randomised trials). These terms were used as the major topic and
free text words in the title, and were adapted to each specific
database. Information on the search strategy is included as an
appendix to this manuscript (see online supplementary appendix
1). Studies were considered eligible if they met the following
criteria: (1) they were PA-related intervention studies; (2) they
had at least one cognitive or academic performance assessment;
(3) the population sample consisted of apparently healthy children or adolescents. We included only full-text articles published
2

in English-language peer-reviewed journals. For purposes of
generalizability, studies that focused on a clinical sample (eg,
overweight/obese children, Attention-Deficit Hyperactivity
Disorder (ADHD)) were excluded.

Data extraction

One researcher (ES, VB, or AS) selected studies of potential relevance based on titles, abstracts and inclusion criteria. Reasons
for studies to be excluded in this phase were mainly that it was a
clinical sample, a cross-sectional study design or it assessed acute
effects of PA. The researchers in the expert panels were asked
to cross-check the retrieved studies to ensure that no important
studies were missing. Thereafter, two reviewers independently
checked whether the full text studies met the inclusion criteria
and extracted data (either ES and VB or AS and LU, RdG, JJ,
MC, or VB). A total of 58 intervention studies fulfilled the inclusion criteria.

Methodological quality assessment and synthesis of scientific
evidence

The methodological quality of the included studies was rated
using an adapted version of the ‘Quality assessment tool for quantitative studies’,27 that assesses study quality based on predefined
criteria. After relevant studies were identified, four authors
(either ES and VB or AS and MC) independently assessed the
methodological quality in seven dimensions— that is, selection
bias, study design, adjustment for potential confounders (eg, age,
gender, social economic status, and baseline academic/cognitive
performance), data collection methods, blinding, withdrawals,
and dropouts. Discrepancies between authors were discussed
and resolved by consensus. In case of disagreement, a third
reviewer who was not involved in the scoring was consulted (AS,
MC or VB) .
The assessment tool used for the methodological assessment
of the intervention studies defines high-quality studies as having
at least two strong and no weak dimensions, moderate-quality
studies as having less than two strong dimensions, but no more
than one weak dimension, and low-quality studies as having
more than one weak dimension.28
In accordance with a previous systematic review by our
group,9 the level of scientific evidence was rated based on the
following criteria:
►► Strong evidence, provided by a minimum of two highquality
(ie, strong rating) studies with generally consistent findings
►► Moderate evidence, provided by a minimum of one high
-quality study and one or more ‘lower quality’ (ie, moderate
or weak rating) studies with generally consistent findings
►► Inconclusive evidence, when only one study was available or
when findings were not consistent in two or more studies.
Findings were considered to be consistent when at least 75%
of the studies reported statistically significant results in the same
direction. When two or more studies of high methodological
quality were identified, the studies of moderate or weak quality
were not considered in the evaluation of the consistency of the
scientific evidence. Evidence synthesis took place at the level of
construct for cognitive performance (eg, attention inhibition)
and outcome for academic performance (eg, mathematics).

Expert panel
Structured communication (Delphi) method

The leading authors (AS, ES, VB, MC) independently recommended a multidisciplinary group of international experts on the
topic of PA and cognitive/academic performance in children from
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has been suggested that regular PA increases the availability of
certain growth factors, such as brain-derived neurotrophic factor
(BDNF), insulin-like growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF). All these systems and factors are
involved with the maintenance and plasticity of the structure and
function of the brain,20 21 and thus with learning and memory.
The cognitive and academic training of children is, in large
part, a task entrusted to the educational system. Within the
school context, the academic performance of pupils is typically
rated through the assessment of their knowledge and scholastic
aptitude in various subjects, the most prominent of which are
mathematics and literacy.22 To enhance academic performance,
instructional time for core academic subjects is prolonged and
protected, often at the expense of time spent in physical education
(PE) and other areas of the curriculum. PE has been attributed a
lower status than academic subjects23 and is perceived by some
to interfere with academic performance.24 25 There is, however,
no evidence indicating that increased time spent in PA in the
school setting has an adverse effect on academic performance.26
To foster progression in this research field we: (1) systematically summarised current experimental evidence on the effects
of PA interventions on cognitive and academic performance in
children, considering the methodological quality of the studies;
(2) conducted a Delphi study among acknowledged researchers
in this field to identify gaps in knowledge, compile a list of future
research priorities, and generate recommendations for future
research.

Review

Procedure

The opinions of the experts on the topic of the relationship
between PA and cognitive/academic performance in children
were systematically gathered through a modified Delphi technique, similar to the procedure of Gillis and colleagues.29 In the
first round, we asked the experts in panel A to provide a minimum
of five alternatives in response to the following question: “In
your opinion, what are the most important theoretical and methodological questions that need to be addressed in order to elucidate the relationship between physical activity and cognitive and
academic performance in children and adolescents?”. Each expert
in panel A received a link to a digital survey via email and was
asked to provide five research questions. Two authors (ES, AS)
collected and summarised the suggestions of panel A. Reoccurring or similar research questions were combined into one. In the
second round, experts from both panels (A and B) received a link
to a digital questionnaire containing the summarised responses
from round 1 and were asked to rate them on importance for
generating new scientific evidence on a 5-point Likert scale
(5=very important, 4=important, 3=moderately important,
2=of little importance and 1=unimportant). The cumulative

score for each item was calculated. Next, the issues were organised into clusters, according to the overarching topics they
addressed. This information was presented to the experts in the
final round, wherein they received the clustered research questions and were asked whether they agreed with the proposed
clusters. Experts were blinded to the individual answers of other
experts in the panels.

Results
Systematic review

From the 8103 identified references from the six electronic databases, 58 studies30–87 met the inclusion criteria (figure 1).

General study characteristics

The general description of the studies, their methodological
characteristics, rating and main results are summarised in the
online supplementary table 1.
Of the identified intervention studies, 20 were conducted in
the USA and 23 in Europe (Italy (n=6), Sweden (n=4), Netherlands (n=3), Denmark (n=2), Germany (n=2), Norway (n=2),
UK (n=2), Spain (n=1), and Switzerland (n=1)). The other
studies were conducted in Australia (n=6), India (n=3), Taiwan
(n=2), Canada (n=1), South Africa (n=1), Iran (n=1) and New
Zealand (n=1).
The number of participants included in the intervention
studies ranged from 1651 to 195531, and participants’ ages at

Figure 1 Flow of literature selection.
Singh AS, et al. Br J Sports Med 2018;0:1–10. doi:10.1136/bjsports-2017-098136

3

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different regions of the world. This initial sample of experts was
asked to recommend additional experts. Experts were assigned
to two separate panels (panel A: senior position; panel B: junior
or mid career position or previously affiliated with research
groups of experts in panel A).

Review

Measurements of cognitive and academic performance

Eleven studies reported on unstandardised school grades on
subjects like mathematics and language as measure of academic
performance. The other 19 studies that reported effects on
academic performance assessed effects on national curriculum
levels, standardised school grades (eg, grade point average), or
standardised performance tests (eg, Wechsler Individual Achievement Test, Canadian Achievement Test). A small number of
studies assessed academic performance on other subjects, such as
drawing or English as a foreign language. Most studies reporting
intervention effects on cognitive performance, assessed domains
of executive functions (in particular inhibition, working memory,
updating, attention, task switching, and planning), speed of
information processing, fluid and crystallised intelligence.

Methodological quality

Eleven studies were rated as of high methodological
quality,30 36 38 41 42 50 51 54 65 70 83 29 studies as of moderate, and
17 as of weak methodological quality (see online supplementary table 1). McClelland et al31 reported on three substudies,
resulting in categorisation of one study as moderate/weak, which
reflects the differences in quality among the three substudies.
For the evidence synthesis, only studies of high methodological quality were taken into account.
4

Evidence synthesis
Of the 11 high-quality studies, four reported outcomes on
cognitive performance,36 50 54 65 six on academic performance,30 38 41 42 51 83 and one on both.70 We present the outcomes
of the 11 high-quality studies in the online supplementary table
2.
Ten out of 21 (48%) analyses in five high-quality studies
examining the effect of PA on cognitive performance found a
significant beneficial intervention effect, resulting in inconclusive evidence. For intervention effects of PA on academic
performance, 15 out of 25 (60%) analysed constructs in six highquality studies found a significant beneficial effect, also leading
to inconclusive evidence. Stratifying the evidence synthesis at the
level of outcome for academic performance we conclude that
there is strong evidence for beneficial effects of PA on maths
performance (beneficial effects on 86% of the outcomes), but
inconclusive evidence for language performance (beneficial
effect on 27% of the outcomes).
None of the studies reported significant adverse effects of PA
on cognitive and academic performance.
The studies are now briefly described based on the extent
to which the findings were supportive of beneficial effects of
exercise. Donnelly and colleagues42 found improved academic
performance on all reported outcome measures (ie, the
composite scores of reading, spelling and mathematics), when
comparing children who received daily bouts of moderate to
vigorous PA during academic lessons for 3 years (up to 90 min/
week) with children who followed the regular curriculum. Other
studies found selective effects of PA interventions on specific
measures of cognitive and academic performance. For example,
Ericsson70 found higher grades in literacy and mathematics in
children who participated in a 45 min PE session each school day
and an optional modified motor training of 60 min per week for
3 years, than in children following the regular PE curriculum at
1 and 2 year follow-up. Intervention effects on literacy were not
sustained into the third year. The intervention also showed small
significant beneficial effects on attentional performance and
impulse control after 1 and 2 years, which were not sustained
into the third year. After 9 years, children in the intervention
group had significantly higher qualification scores for upper
school.
Participation in an exergaming-based intervention (2×15 min,
three times a week) in a study by Gao et al38 resulted in higher
maths grades in fourth-grade children compared with a group
receiving unstructured recess, but no significant differences in
reading scores. Kirk et al51 found that preschoolers who participated in twice-daily 15 min physically active academic lessons
during 6 months performed significantly better on picture
naming and alliteration tasks than the group who participated
in regular academic lessons. In contrast, preschoolers in the
control and intervention groups showed similar performance on
the rhyming task. Telford et al41 compared 2 years of specialist-taught PE with non-specialist taught PE and found a significant intervention effect of 10.9 points in numeracy but not
in reading or writing in 8- to 11-year-old children.
Hillman and colleagues50 reported more improvement from
pre-test to post-test in some aspects of cognitive performance
and measures of brain function in children aged 8 to 9 years
who followed the FITKids intervention versus a control group.
In particular, enhanced performance accuracy and increased P3
amplitude were observed in tasks requiring higher amounts of
attention, inhibition and cognitive flexibility. Tasks requiring less
executive control were unaffected by the FITKids intervention.
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baseline ranged from 351 to 16 years.56 88 The majority of the
studies included in the current review assessed the effects of PA
in children aged 6–12 years. Seven studies reported children aged
5 years or younger,44 51 52 64 77 79 80 and 13 studies included youths
(ie, older than 12 years) in their studies.37 39 43 56 61 63 65 68 74 75 82 84 85
Most intervention studies had a strong experimental design,
with 27 studies using an RCT design or cluster RCT design,
and 21 studies using a controlled trial (CT) design. Five studies
used a quasi-experimental design, four a pre-post-test, and one
a cohort analytic design. Two studies, reporting on the effects of
three substudies each, applied different designs per substudy.31 61
The shortest intervention duration was 1 week,54 62 79 and the
longest spanned a period of 9 years.35 The lowest PA dose delivered was 10 min per week.80 The FITKids intervention delivered
the highest dose of PA (ie, 350 min per week in exercise sessions,
made up of 70 min for 5 days a week33 49 50 57). The majority
of the intervention studies implemented PA sessions of at least
30 min (n=41). Seventeen interventions assessed the effects of
PA sessions with a shorter duration, varying from 5 to 30 consecutive minutes. Most interventions delivered PA in one session
per day, except for seven studies in which either two sessions per
day were delivered,51 77 78 83 85 87 or PA was spread throughout the
day aiming to reach at least 10 000 steps.40 Many studies applied
interventions that were delivered 5 days a week (n=28). The
lowest frequency was 143 44 and the highest frequency was 6 days
per week.36 65 Most studies (n=34) assessed the effects of PA
consisting primarily of aerobic exercise. Five studies contrasted
the effects of yoga to aerobic exercise,36 39 56 75 82 and nine studies
implemented more cognitively engaging PA, consisting of either
coordinative exercise,58 71 72 86 skill-based training,69 motor
skills training,35 gesturing physical exercise,52 perceptual motor
training,64 and motor-enriched learning activities.73 Six studies
assessed the effects of motor demanding or cognitively engaging
activities.31 43 44 53 54 70 Three of these studies implemented PA
games specifically tailored to challenge core executive functions
in a gross-motor fashion.43 44 54 The majority of studies implemented separate PA sessions, whereas 14 studies delivered physically active academic lessons.42 48 51 62 66 77–80 83 85 87

Review

Expert panel
Expert demographics

The initial sample of experts suggested by the leading authors
of this manuscript, provided names of 33 other experts. Experts
were assigned to two separate panels: 16 researchers with a
senior position were assigned to panel A; the 17 researchers who
were assigned to panel B held a junior or mid career position or
had been previously affiliated with research groups of experts
in panel A. Of the experts invited to join panel A, 12 agreed to
participate, three declined and one expert did not respond to
the email and reminder. For panel B, 11 researchers accepted the
Singh AS, et al. Br J Sports Med 2018;0:1–10. doi:10.1136/bjsports-2017-098136

invitation, one declined, and five did not respond. See the online
supplementary appendix 2 for the experts participating in panels
A and B.
The 23 experts participating in our panels were affiliated with
educational organisations located in Asia, Australia, Europe and
North America (figure 2), and were in different stages of their
academic careers, ranging from the last stages of their PhD to
full professors. Experts in panel A had an average of 23 years of
research experience, of which 17 years were dedicated to investigating the association between PA and cognitive and academic
performance in children. Experts in panel B had an average of
9 years of research experience with 7 years on PA and cognitive
and/or academic performance in children.

Expert panel results

Twelve experts (panel A) completed the first round;
11 experts nominated five research questions each and one
expert nominated four, resulting in a total of 59 questions. After
removing duplicating research questions, for the second round,
we put forward 46 questions to panels A and B to be rated. All
the experts agreed with the final formulation and clustering of
the research questions (see online supplementary table 3).
The highest rated research question (111 out of 115 points)
highlighted the need to establish the causality of the relationship between PA and cognitive and academic performance. This
research question was grouped in cluster 1 ‘Causality’ (total
number of research questions in this cluster n=8). The remaining
research questions were grouped into four clusters, addressing
the following overarching topics: PA characteristics (n=18),
moderators (n=8), and mechanisms (n=7). Seven research questions did not fit into one of the above mentioned clusters, therefore we formed a ‘miscellaneous’ cluster. Two questions fitted
two clusters, and were included in both.

Discussion

We summarised the current evidence on the effects of PA
interventions on cognitive and academic performance in children by conducting a systematic literature review including a
methodological quality assessment. Hereafter, we discuss the
review's main findings in light of the recommendations of our
expert panel.
Six high-quality studies included in our systematic review
examined the effect of PA on cognitive performance constructs:
48% of the analyses showed a significant beneficial effect of
PA, resulting in inconclusive evidence for beneficial PA effects
on cognitive performance. Fifteen out of 25 (60%) analysed
academic performance outcomes in seven high-quality PA intervention studies were significant, also leading to inconclusive
evidence at a summary level.
When stratifying at the level of outcome for academic performance, we found strong evidence for beneficial effects of PA on
maths performance. There is inconclusive evidence for beneficial
effects of PA on tests assessing indicators related to language.
It is important to keep in mind that many studies compared
various types and doses of physical activity against one another
and did not include true no-PA control conditions. This resulted
in a large variation in intervention contents, as well as contrasts
between intervention and control groups. As such, our conclusion refers to the effects of additional PA or adaptations of the
PA curriculum such as structured recess, frequency/intensity/
specialist taught PE, active academic lessons on cognitive or
academic performance, but not on the effects of PA per se.
5

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Schmidt et al54 found that in 10- to 12-year-old children the group
that participated in a cognitively- and physically-demanding exercise intervention (team games) showed more improvement from
pre-test to post-test on cognitive flexibility (ie, being able to shift
from one task to another) than the group receiving an aerobic
intervention with low cognitive demands or the group receiving
standard PE with low physical and low cognitive demands.
Performance on the other two executive function subcomponents (ie, updating and inhibition) were similar between groups.
Subramanian et al65 reported beneficial effects of structured PA
versus unstructured physical and creative sedentary activities in
12- to 17-year-olds on tasks measuring attention, concentration,
non-verbal fluency, and mental flexibility. Both groups received
a comparable dose (ie, 120 min, 6 days per week) during the
6 month intervention period and showed improved performance
compared with baseline, with significantly better scores of the
group receiving structured PA on all constructs measured.
Three high-quality studies found no significant intervention
effects on any of the assessed outcome measures. Ahamed et
al30 found no significant intervention effect on academic performance in 9- to 11-year-old children. This intervention included
15 min additional classroom-based PA 5 days a week for 16
months. Chaya and colleagues36 compared daily yoga with
structured PA (stretching and aerobic exercise) and found no
significant differences on any of the cognitive performance tests
between groups. Resaland et al83 found no significant intervention effect on mathematics, reading or English in 10-year-old
children. Analyses of the subgroup who performed worse at
baseline for numeracy showed significant beneficial effects of
the intervention. The 7-month intervention consisted of physically active lessons, active breaks between lessons, and active
homework.
Five high-quality studies examined the effects on
academic performance measures indicators related to mathematics.38 41 42 70 83 Across all five studies, beneficial effects
were reported in six out of seven (86%) outcomes. Six highquality studies that examined effects on academic performance,
measured indicators related to language (eg, literacy/reading/
rhyming).38 41 42 51 70 83 Three of these studies reported significant
beneficial effects in eight out of all 15 (53%) outcomes assessed.
All high-quality studies assessed the effects of an adapted
curriculum (eg, increased frequency or duration of the PE
session, adapted content of PE lessons, structured recess) or
active academic lessons compared with regular curriculum
activities (eg, regular academic and PE lessons, unstructured
recess). Most of the high-quality studies used control groups
that followed regular PE lessons. Hillman et al50 used a wait-list
group, Gao et al38 and Subramaniam et al65 compared structured
versus unstructured recess, and Kirk et al51 compared physically
activity lessons in pre-schoolers to lessons without an activity
component.

Review

Although we found no evidence for beneficial effects on
cognitive performance or overall academic performance, we
found strong evidence for beneficial effects of PA on maths
performance. This finding is in line with Fedewa’s and Ahn’s89
meta-analysis, in which they conclude that the largest effectiveness of PA was found for maths performance. Interestingly, all
four studies38 41 42 70 that reported beneficial effects on maths
performance assessed intervention programmes with a minimal
frequency of three sessions per week and a minimal programme
duration of two school years.
This inconsistency in our findings is echoed by the call of our
expert panel for more well-designed studies that provide insight
into the causality, mechanisms and moderators of this effect, as
well as the PA characteristics that optimally benefit cognitive/
academic performance. More insight into the causal relationship and the effects of different parameters of PA (eg, duration,
frequency, sort of PA, timing of PA) could be established by highquality RCTs with multiple PA intervention arms as well as a
non-active control group.
To establish the effect of combining academic content and
PA, there should be at least three groups: (a) the intervention
group that combines PA with academic content; (b) the non-active control group that only receives the same academic content
as the intervention group, but without PA; (c) the active control
group that only receives the PA component. Up to now, many
studies with a programme combining academic content with PA
compared the intervention group to a regular curriculum control
group with a different academic content, which does not allow
us to draw clear conclusions on the added value of combining
PA with academic content as the academic content also differs
between groups. The aforementioned design would allow us
6

to test (1) for causality because of random assignment and the
manipulation of the independent variables and (2) for main
effects and interactions simultaneously.
Cognitive/academic performance can theoretically improve
through biological or psychosocial pathways,20 and an interplay between the two is possible and probable. Evidence to
support these proposed mechanisms is sparse. Our expert panel
highlighted the need to understand PA effects not only at the
behavioural level, but also at the cellular, functional and morphological level. A small number of studies examined functional
brain correlates that may underlie the effects of PA on cognitive
performance.49 50 57 58 The study conclusions suggested that their
findings provided evidence for a more efficient use of neural
resources underlying executive functions after participation in
PA interventions, reflected in enhanced neural activity in regions
supporting attention and working memory functions.49 50 57 58
Expanding on these findings, Chaddock and colleagues57 stated
that a PA intervention may result in a more adult-like recruitment of prefrontal brain regions, which is important for many
aspects of executive functions. As confirmed by our expert
panel, more research is needed to understand the mechanisms
underlying the potential effects of PA on cognitive performance.
Specific suggestions related to elucidating PA-related effects on
BDNF and other cellular and molecular mechanisms, exploring
the potential mediating role of psychological mediators and
advancing our understanding of the potential roles of social
belonging and support in improving cognitive and academic
performance.
Our expert panel also emphasised the need to distinguish
between the different qualitative and quantitative characteristics of PA, and the differential effects that these characteristics
Singh AS, et al. Br J Sports Med 2018;0:1–10. doi:10.1136/bjsports-2017-098136

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Figure 2 Delphi panel: geographical location of the experts.

Review

Strengths and limitations

This study employed a structured Delphi technique to map the
research priorities set and ranked by international experts. An
important strength of this method is the anonymity of responses
throughout the rounds. Experts were not influenced by one
another in generating or rating the responses, and, in fact,
were not known to each other until after data collection was
completed. These steps were taken to assure greater objectivity
and generalisability in rating the research questions. In addition,
experts on our panel represented research institutions in various
countries and continents and offered experience from different
scientific fields.
A major strength of our review is that we only included intervention studies, which enables us to draw conclusions on the
effects of PA interventions on cognitive and academic performance. Another strength is the combination of the systematic
literature search with a methodological quality assessment:
both served as the basis for the evidence synthesis at the level
of outcome measures. Previous reviews based their conclusions
on study level findings (ie, if a study reported beneficial effects
of an intervention on one but not all outcome measures, the
study was rated as ‘positive’). We believe that our choice of
assessing evidence on the level of outcomes provides a more
Singh AS, et al. Br J Sports Med 2018;0:1–10. doi:10.1136/bjsports-2017-098136

detailed picture of potential PA effects on cognitive/academic
performance.
Two researchers independently rated the methodological
quality, and, when necessary, the authors of the included studies
were approached to provide additional information to ensure an
optimal level of accuracy. While this is a strength of the study, the
methodological quality scores of studies included here and in a
previous study by Norris and colleagues92 showed discrepancies
in the outcome quality assessment, suggesting a degree of subjectivity. This subjectivity is partly due to the interpretation of the
categories, but also to the fact that weighing and interpretation
of certain methodological aspects are highly dependent on the
specific research question. We have not recorded the percentage
agreement between the raters in the different phases (ie, selection of the studies, quality assessment), but all disagreements
were resolved by discussion between both raters or if necessary
by a third author. Another potential limitation is publication
bias: positive findings are more likely to be published, resulting
in an overestimation of the beneficial effect of PA on cognitive/
academic performance.

Recommendations

Less than a quarter of the 58 studies included in our review were
rated as of high methodological quality. Based on our analyses,
discussions and reflections, we formulated the following recommendations for future research.
a. An important aspect in PA interventions is the control group.
Many studies in our review compared a specific PA intervention versus regular PE lessons or more PA versus less PA,
often leading to little contrast in duration or frequency of PA
between groups. When designing future studies, the contrast
in PA between intervention and control groups needs careful
consideration, specifically in the recruitment of schools (eg,
striving for maximal contrast in PA but minimal differences
with respect to background variables).
b. Most studies report on the ‘increased opportunities’ they
offered children for being more physically active (eg, increase in the number of PE lessons per week). Few studies assessed the actual PA levels (eg, by accelerometry) or
programme compliance (eg, attendance). Therefore, the
exact dose of PA that children received is unknown, or it
is unclear whether they compensated the increased PA in
school with less PA after school. We recommend that future
studies monitor actual PA levels and consider compliance in
their analyses in addition to the standard intention-to-treat
analysis.
c. Adequate sample sizes are needed to be able to pick up relevant changes in cognitive and academic performance, but
also to reduce the likelihood of baseline differences between
different conditions.
d. More effort should be directed towards the application of
valid and reliable measures of cognitive performance using
standardised and practical assessment tools, thereby creating
better opportunities to compare  findings across PA interventions more directly.
e. Many studies only mention whether the intervention effect
was significant or not without providing information on effect sizes, confidence intervals or an exact P-value. To be able
to judge not only the significance but also the practical relevance of the intervention effects, we recommend to always
report both effect sizes and confidence intervals to enhance
the value of the results presented in a single study and enable
inclusion in future meta-analytic reviews.
7

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may have on various aspects of cognitive and academic functioning. For instance, the effect of different types of PA on cognitive performance needs further investigation. One high-quality
study54 suggested larger effects of coordinative or perceptual–
motor forms of exercise on cognitive performance, particularly
on executive functions, than aerobic exercise. Differential effects
between exercise types may stem from various reasons.90 Variability of practice that is central to coordination and perceptual–motor exercise training, for example, may be an interface
between motor and cognitive development promotion.91
Further research is needed to establish whether more cognitively
engaging forms of exercise have larger effects on cognitive and
academic performance.
Our understanding of the relationship between PA and cognitive and academic performance can also be further improved by
exploring possible mediators and moderators (eg, baseline PA and
cognitive performance). The evidence regarding possible mediators, including proposed biological or psychosocial mediators,
is scarce. Only one study conducted by Pesce et al43 conducted a
mediation analysis and found that ball skills mediated the effect
an intervention programme during physical education on inhibition, a core executive function.
Regarding moderators, it is likely that some children may benefit
more from additional PA such as children with low PA levels or
overweight children. For example, Subramaniam et al65 found
larger benefits in non-athletes and Crova et al69 found PA to be
more beneficial to overweight children in the intervention group.
The expert panel also indicated the need to examine the potential effects of limiting or interrupting sedentary behaviour on
cognitive and academic performance. Most examined PA interventions require a high level of commitment from school staff to
be implemented. Interrupting and limiting sedentary time with
standing desks or short activity bouts may be more feasible in the
school setting and, therefore, a promising form of intervention.
Summarising the expert opinion, we conclude that more
well-designed studies are needed to: (1) assess the effects of PA on
cognitive and academic performance; (2) specify PA characteristics that affect cognitive of academic performance; (3) understand
underlying mechanisms and moderators of this effect.

Review
Based on 11 high-quality intervention studies, we found inconclusive evidence of a beneficial effect of PA interventions
on cognitive and overall academic performance in children.
However, based on academic outcomes related to mathematics,
we found strong evidence for beneficial effects of PA.
There is a need for more high-quality intervention studies to
establish a potential causal relationship between PA and cognitive and academic performance. Many aspects of this possible
relationship remain unclear: research priorities based on expert
opinion highlight the need for future research into the causality
of the ‘PA-cognitive performance’ relationship, including experimental studies on PA characteristics (eg, what type, duration,
and intensity is most effective), studies on relevant moderators (eg, age, gender, socioeconomic status) and the underlying
mechanisms.
By prioritising the most important research questions and
formulating recommendations, we hope to guide researchers in
generating high-quality evidence to further elucidate the relationship between PA and cognitive/academic performance.

11

Department of Educational, School, and Counseling Psychology, University of
Kentucky, Lexington, Kentucky, USA
12
Department of Psychology, Department of Physical Therapy, Movement, &
Rehabilitation Sciences, Northeastern University, Boston, Massachusetts, USA
13
Department of Sport and Exercise Science, Institute for Sport, University of
Chichester, Chichester, UK
14
Department of Movement, Human and Health Sciences, Italian University Sport and
Movement “Foro Italico”, Rome, Italy
15
Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
16
Department of Kinesiology, University of Georgia, Athens, Georgia, USA
Correction notice This article has been corrected since it was published Online
First. The affiliation of YKC has been corrected.
Acknowledgements We are grateful to all our experts in Panel A and B for their
valuable insights.

What is already known?

Contributors ASS, ES and MJMC: Involved in all stages of the manuscript
preparation, conception of the study, execution of the study, critical revisions of
the first draft and integration of all comments of the co-authors into several drafts
before submission. ASS, ES and VvdB: Literature search and review; data extraction,
data analysis, preparation of the first draft. VvdB and LU: Involved in data analysis
and critical comments on several drafts of the manuscript. JJ and RHMdG: Involved
in data analyses, giving feedback on study conception and critical comments on
several versions of the manuscript. The remainder of the authors: Provided and
rated all research priorities as part of the expert panel which is a major part of the
manuscript as well as critical comments on several drafts of the manuscript until its
final form.

►► Many aspects of the potential relationship between PA and

Funding The current research is part of the SMART MOVES! project, supported by a
grant from NWO (grant number: SPO-12-14).

►► Most reviews summarised the existing evidence at study

Competing interests None declared.

cognitive/academic performance in children remain unclear.
level, not taking into account the number of outcomes
analysed, thereby leading to a potential overestimation of the
suggested relationship between PA and cognitive/academic
performance.

What are the new findings?

Patient consent Not required.
Ethics approval As part of the SMART MOVES! project, the current study was
approved by the Medical and Ethical Committee of the VU University medical center
in Amsterdam, The Netherlands.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement This is a review based on existing data, no original
experimental data are presented.

►► There is inconclusive evidence for a beneficial effect of PA

interventions on cognitive and overall academic performance
in children. There is strong evidence for beneficial effects of
PA on maths performance.
►► Research priorities based on expert opinion highlight the
need for high-quality research into the causality of the ‘PAcognitive performance’ relationship, including experimental
studies on PA characteristics, relevant moderators, and
underlying mechanisms.
►► Expert opinion-based recommendations for future research
are formulated with regard to study design, adequate
control groups and sample size, measurement of cognitive
performance andcompliance, and data analysis.
Author affiliations
1
Department of Public and Occupational Health and the Amsterdam Public Health
Research Institute, VU University Medical Center, Amsterdam, The Netherlands
2
Saw Swee Hock School of Public Health, National University of Singapore, Singapore
3
Welten Institute - Research Centre for Learning, Teaching and Technology, Open
University of the Netherlands, Heerlen, The Netherlands
4
Centre for Brain & Learning, Faculty of Psychology and Education, LEARN! Institute,
Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
5
Department of Teacher Education and Sport, Western Norway University of Applied
Sciences, Sogndal, Norway
6
International Council of Sport Science and Physical Education, Berlin, Germany
7
Department of Physical Education, National Taiwan Normal University, Taipei,
Taiwan, Republic of China
8
Program in Developmental Cognitive Neuroscience, Department of Psychiatry,
University of British Columbia, Vancouver, Canada
9
Department of Sport Sciences, Faculty of Learning and Society, Malmö University,
Malmö, Sweden
10
Department of Kinesiology, University of North Carolina at Greensboro,
Greensboro, North Carolina, USA
8

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