effect of classroom-based physical activity interventions
TRANSCRIPT
REVIEW Open Access
Effect of classroom-based physical activityinterventions on academic and physicalactivity outcomes: a systematic review andmeta-analysisAmanda Watson, Anna Timperio, Helen Brown, Keren Best and Kylie D. Hesketh*
Abstract
Background: Physical activity is associated with many physical and mental health benefits, however many childrendo not meet the national physical activity guidelines. While schools provide an ideal setting to promote children’sphysical activity, adding physical activity to the school day can be difficult given time constraints often imposedby competing key learning areas. Classroom-based physical activity may provide an opportunity to increaseschool-based physical activity while concurrently improving academic-related outcomes. The primary aim of thissystematic review and meta-analysis was to evaluate the impact of classroom-based physical activity interventionson academic-related outcomes. A secondary aim was to evaluate the impact of these lessons on physical activitylevels over the study duration.
Methods: A systematic search of electronic databases (PubMed, ERIC, SPORTDiscus, PsycINFO) was performed inJanuary 2016 and updated in January 2017. Studies that investigated the association between classroom-basedphysical activity interventions and academic-related outcomes in primary (elementary) school-aged children wereincluded. Meta-analyses were conducted in Review Manager, with effect sizes calculated separately for eachoutcome assessed.
Results: Thirty-nine articles met the inclusion criteria for the review, and 16 provided sufficient data and appropriatedesign for inclusion in the meta-analyses. Studies investigated a range of academic-related outcomes includingclassroom behaviour (e.g. on-task behaviour), cognitive functions (e.g. executive function), and academic achievement(e.g. standardised test scores). Results of the meta-analyses showed classroom-based physical activity had a positiveeffect on improving on-task and reducing off-task classroom behaviour (standardised mean difference = 0.60 (95% CI:0.20,1.00)), and led to improvements in academic achievement when a progress monitoring tool was used (standardisedmean difference = 1.03 (95% CI: 0.22,1.84)). However, no effect was found for cognitive functions (standardised meandifference = 0.33 (95% CI: -0.11,0.77)) or physical activity (standardised mean difference = 0.40 (95% CI: -1.15,0.95)).
Conclusions: Results suggest classroom-based physical activity may have a positive impact on academic-relatedoutcomes. However, it is not possible to draw definitive conclusions due to the level of heterogeneity inintervention components and academic-related outcomes assessed. Future studies should consider theintervention period when selecting academic-related outcome measures, and use an objective measure ofphysical activity to determine intervention fidelity and effects on overall physical activity levels.
Keywords: Classroom, Physical activity, Academic performance, Children, Schools, Intervention, Systematicreview, Meta-analysis
* Correspondence: [email protected] for Physical Activity and Nutrition (IPAN), School of Exercise andNutrition Science, Deakin University, Geelong, Australia
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 DOI 10.1186/s12966-017-0569-9
BackgroundMultiple physical and mental health benefits can beattained when children participate in the recommended60 min per day of moderate- to vigorous-intensity phys-ical activity [1, 2]. Despite these benefits, populationbased-studies have reported that over 50% of children inAustralia and internationally are not meeting recom-mendations [3–6]. Schools are considered ideal settingsfor the promotion of children’s physical activity. Thereare multiple opportunities for children to be physicallyactive over the course of the school week, includingduring break times, sport, Physical Education classand active travel to and from school. Studies haveshown interventions targeting these discrete periodsmay be effective in increasing children’s physical ac-tivity levels [7, 8], with the potential to contribute toup to 50% of the physical activity required to meetphysical activity guidelines [9]. However, with limitedtime available during these discrete periods, additionalopportunities may be required in order for childrento achieve the recommended levels of physical activ-ity. Classroom-based physical activity provides anotherway for children to be active at school. This involvesclassroom teachers incorporating physical activity intoclass time through either integrating physical activityinto lessons (physically active lessons), or addingshort bursts of physical activity, either with curricu-lum content (curriculum focused active breaks) orwithout (active breaks).There is increasing interest from researchers and
education professionals about the potential forclassroom-based physical activity to positively impactacademic-related outcomes, including classroom beha-viour, cognitive function and academic achievement.While some teachers express concern that classroom-based physical activity may have an adverse effect onon-task classroom behaviour [10], emerging evidencefrom systematic reviews and meta-analyses suggest thatoverall physical activity may have a small positive effecton on-task classroom behaviour [11–17]. There is lessevidence on classroom-based physical activity.Narrative reviews [18–20], one systematic review [21]
and two meta-analyses [22, 23] have explored the impactof classroom-based physical activity interventions onacademic-related outcomes. However, these were narrowin scope, included few studies, and combined findingsamong primary and secondary school students, whichmay be problematic due to the difference in educationsettings.A systematic review of 11 studies concluded that
physically active lessons may have a positive effect, orno effect on academic-related outcomes [21]. However,that study did not consider other forms of classroom-based physical activity (e.g. active breaks), combined
findings among primary and secondary school students,and did not include a meta-analysis [21].A meta-analysis of four intervention studies found that
classroom-based physical activity had a positive effect onacademic-related outcomes (M = 0.67; 95%CI:0.26,1.09)[23]. Similar results were reported in a meta-analysis of24 intervention studies investigating the associationbetween different types of physical activity (e.g., du-ring recess or lunch vs. active breaks vs. physically ac-tive lessons) and school engagement (behaviour athome and at school, and emotions, e.g. lesson enjoy-ment) [22]. In that meta-analysis, overall resultsshowed physical activity had a significant positive ef-fect on school engagement (d = 0.28;95%CI:0.12,0.46)[22]. When broken down into type of physical acti-vity, active breaks (n = 4 studies) appeared to be themost effective type of intervention for improvingschool engagement (d = 0.55; 95%CI:0.02,1.06), com-pared with recess or lunch time physical activity(n = 3 studies; d = 0.26; 95%CI:-0.19,0.73) and physic-ally active lessons (n = 5 studies; d = 0.22; 95%CI:-0.21,0.66) [22]. However, results from those meta-analyses are limited by the small number of includedstudies [22, 23], the narrow range of potentialacademic-related outcomes assessed, the combinationof findings among primary and secondary school stu-dents [22], and their recency [23].The current paper aims to expand on findings from
these reviews by conducting a systematic review andmeta-analyses of the evidence of effect of classroom-based physical activity interventions (active breaks,curriculum-focused active breaks and physically activelessons) on a broad range of academic-related out-comes (classroom behavior, cognitive function andacademic achievement), specifically among primaryschool-aged children. A secondary aim is to examinethe effect of these interventions on children’s physicalactivity levels.
MethodsDefinitionsWhile there are no set definitions for classroom-basedphysical activity, the following definitions are providedin order to maintain consistency and clarity throughoutthe remainder of this systematic review.Classroom-based physical activity: physical activity
carried out during regular class time, and can occur ei-ther inside or outside the classroom (e.g. hallway, play-ground), and is distinct from school recess/lunch breaktimes. Classroom-based physical activity can take threeforms:
� Active breaks: short bouts of physical activityperformed as a break from academic instruction [24].
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 2 of 24
� Curriculum-focussed active breaks: short bouts ofphysical activity that include curriculum content[25, 26].
� Physically active lessons: the integration of physicalactivity into lessons in key learning areas other thanphysical education (e.g. mathematics) [27, 28].
Academic-related outcomes: overarching term to en-compass factors associated with academic performanceat school. These can be grouped into three maincategories:
� Classroom behaviour: Observed behaviours that maypromote or interfere with learning in the classroom,including on-task behaviour [29] (e.g. concentratingon tasks assigned by the teacher), and off-task be-haviour (e.g. not concentrating on tasks assigned bythe teacher).
� Cognitive function: Mental process (e.g. executivefunction) that may influence academicperformance [29].
� Academic achievement: A child’s performance onschool-related tasks; often reported via classroomgrades, national standardised tests or progress moni-toring tools [29], as well as self-reported perceivedacademic competence [30].
Registration and protocolThis study followed the Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA)recommendations for systematic review reporting, andwas registered with the International ProspectiveRegister of Systematic Reviews (PROSPERO) (record#CRD42016027294).
Search strategyStudies were identified through a systematic search offour electronic databases (PubMed, ERIC, SPORTDiscusand PsycINFO), first conducted in January 2016, and up-dated in January 2017 by one author (AW). The searchstrategy consisted of four elements (see Table 1). Thesearch was limited to peer-reviewed articles published inEnglish in all available years. ‘Grey’ literature, includingthe reference lists from the websites of two organisations(“Active Academics” and “Active Living Research”) in-volved in children’s physical activity research were alsosearched.
Inclusion criteriaA predetermined set of inclusion criteria were used toselect papers for this systematic review. Each study hadto meet the following criteria:
1. Intervention study design;
2. Investigated associations between classroom-basedphysical activity and at least one academic-relatedoutcome. Interventions involving strategies inaddition to classroom-based physical activity wereexcluded (to enable the effects of classroom-basedphysical activity to be isolated);
3. Study population included primary school-aged chil-dren (5–12 years);
4. Presented original data;5. Did not focus specifically on special populations (e.g.
overweight children).
Study selectionThe search yielded 7729 citations from electronic data-base records, and 17 from ‘grey’ literature (Fig. 1). Afterremoving duplicates (n = 500), the titles and/or abstractsof 7246 unique publications were screened by one au-thor (AW). A total of 101 publications were identified aspotentially relevant according to the inclusion criteria.Full texts of 98 of these 101 articles were obtained andreviewed independently by two authors to determine eli-gibility (AW, KB). Two full texts were conference ab-stracts only, and one full-text was unable to be retrieveddespite extensive librarian-assisted enquiries and emailsdirectly to the contact author. Of the 98 full-text articles,a total of 59 were excluded as not meeting inclusion cri-teria. Disagreements between the two reviewers wereresolved through discussion with all authors. Referencelists of included articles were also examined, however noadditional studies were identified. Thirty-nine uniquecitations satisfied the eligibility criteria and wereincluded in this systematic review.
Data extractionPaper characteristics including country of study, studydesign, participant characteristics, intervention charac-teristics, academic-related outcome measures, physicalactivity measures, and results were extracted by one au-thor (AW). Interventions were then categorised as activebreak, curriculum focussed active break, or physicallyactive lesson intervention.
Methodological qualityTwo authors (AW, KB) independently assessed themethodological quality of the included studies using theEffective Public Health Practice Project (EPHPP) tool[31]. This six-component rating scale for interventionsassesses (1) selection bias; (2) study design; (3) con-founders; (4) blinding; (5) data collection methods; and(6) withdrawals and drop outs. Each component wasrated on a three-point scale as either strong, moderateor weak using the tool’s defined criteria. Based on theseratings, an overall methodological quality score wasgiven; either strong (no weak component ratings);
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 3 of 24
Table
1Articlesearch
term
sanddatabasessearched
Classroom
-based
Physicalactivity
Acade
mic-related
outcom
esStud
ypo
pulatio
nDatabasesearched
Classroom
[tiab]
ORbreak*[tiab]
OR
curricul*[tiab]
OR“activebreak”[tiab]
ORintegrat*[tiab]
ORlesson
*[tiab]
“Physicalactivity”[tiab]
OR“physically
active”[tiab]
ORexercis*[tiab]
OR
active[tiab]
ORactivity[tiab]
Educationalstatus[tiab]
ORed
ucationalm
easuremen
t[m
h:no
exp]
ORcogn
ition
[mh:no
exp]
ORAcade
mic[tiab]
OR“Grade
pointaverage”[tiab]
OR“Stand
ardisedtest
scores”[tiab]
OR“stand
ardizedtestscores”[tiab]
OR“test
scores”[tiab]
ORReading[tiab]
ORMath*[tiab]ORlearn
*[tiab]
ORgrade*[tiab]
ORliteracy[tiab]
ORnu
meracy[tiab]
ORacadem
ic[tiab]
ORattent*[tiab]
OR
Con
centratio
n[tiab]
ORbe
haviou
r[tiab]
ORbe
havior[tiab]
ORcogn
iti*[tiab]
OR“executivefunctio
n”[tiab]
OR“fluid
intellige
nce”[tiab]
ORachievem
ent[tiab]
ORlearning
[tiab]
Stud
ent[tiab]
ORStud
ent*[tiab]
ORchild[m
h]ORchild*[tiab]
ORclass*[tiab]
PubM
ed
classroo
mor
scho
olor
lesson
physicalactivity
orexercise
academ
icor
achievem
entor
cogn
itive
childrenor
child
orstud
entor
class
SPORTDiscus
ERIC
PsycINFO
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 4 of 24
moderate (one weak component rating); or weak (morethan one weak component rating), following the tool’saccompanying instructions. Where disagreementsexisted, deliberation occurred until a consensus wasreached.
Meta-analysesMeta-analyses were conducted where there were at leastthree studies investigating the same broad outcome, i.e.classroom behaviour, cognitive function, or academicachievement. Due to heterogeneity across study designs,for inclusion studies were required to have a separatecomparison group (i.e. RCT or quasi experimental withcontrol group). Studies that used a within subject orcross over study design were therefore excluded frommeta-analysis.To avoid duplication of studies under a single out-
come, where studies reported intervention effects onmultiple measures for an outcome (this happenedonly for cognitive functions) [32, 33] a decision wasmade to include outcomes relating to executive func-tions, over memory. Executive functions, inhibition inparticular, have been shown to be consistently related
to academic achievement [34] and therefore wereconsidered salient to teachers. Thus, where inhibitionand memory were reported, only inhibition was in-cluded in the meta-analysis; where executive functionsand short term memory were reported, only executivefunctions were included in the meta-analysis.Typically higher scores were reflective of betteracademic-related outcomes. Where lower scoresreflected better academic-related outcomes thesescores were reversed.As academic achievement tools varied widely in qual-
ity, only studies using national standardised tests orprogress monitoring tools were included in the meta-analyses. Further, intervention effects on mathematicswere used when studies reported multiple subject assess-ments, as math was the most commonly reportedoutcome. Of the 39 studies included in this systematicreview, 16 were included in meta-analyses. Reasons forexclusion were: insufficient data for calculating effectsizes and authors did not respond to email requests foradditional data (n = 6), using a within subject or cross-over study design (n = 9), not including a separate com-parison group (n = 2), insufficient studies investigating
Fig. 1 PRISMA Flow Diagram showing flow of studies through the review process
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 5 of 24
an outcome (n = 4), or only reporting results separatelyfor subgroups (e.g. BMI categories) (n = 2).
AnalysisMeta-analyses were conducted using Review Manager 5.3.The wide variation in interventions and academic-relatedoutcomes employed in the different studies warranted useof a random effects model. Effect sizes (standardised meandifference) were computed as the difference betweentreatment and control means.
ResultsOf the 39 studies identified, 19 examined the effect ofactive breaks [24, 26, 35–51], seven examinedcurriculum-focussed active breaks [25, 52–57], and thir-teen examined physically active lessons [27, 28, 32, 33,58–66] on academic-related outcomes. The majority ofstudies (n = 27) were published in or after 2014 [24, 26,32, 33, 36, 39–41, 43, 46–51, 57, 65, 66], and none be-fore 2006. Most (n = 18) were conducted in the USA[25, 36, 39, 40, 42, 44, 45, 51–55, 57–60, 64, 65], sevenin the Netherlands [32, 41, 49, 50, 61, 62, 66], four inAustralia [27, 28, 46, 47], three in Canada [24, 35, 43],two in Scotland [37, 38], and one each in South Africa[48], UK [63], Greece [56] Denmark [33], andSwitzerland [26]. Sample sizes ranged from 14 [60] toover 4500 participants [45], with sample sizes <300 inthe majority of studies (n = 28) [24–28, 33, 35, 39–41,43, 44, 46–51, 53, 55–57, 59–64]. Intervention periodsspanned from single lessons [49, 55, 59, 65] to 3 yearduration [58], with most lasting no longer than nineweeks (n = 23) [24–28, 33, 37–41, 43–46, 48, 50, 52,55–57, 59, 63]. Study information is presented in Table 2(active breaks), Table 3 (curriculum focused activebreaks) and Table 4 (physically active lessons).
Intervention contentThere was considerable variation across studies inintervention content. While most (12 out of 19) ac-tive break interventions featured basic aerobic move-ments that students could be performed in theirclassroom (e.g. jumping jacks), and required no set-upor equipment [24, 35–40, 42, 43, 45, 50, 51], otherswere performed outside the classroom (e.g. sportsfield) [26, 41, 46–48], and/or required additionalequipment (e.g. markers, skipping ropes, balls, exer-cise bands, dance videos, or specialised stacking cups)[41, 44, 46, 49]. One study utilised both cognitivelyengaging active breaks (i.e. physical activity combinedwith cognitive demand) and active breaks to exploreseparate and combined effects of physical activity andcognitive engagement on cognitive function [26]. Thetarget frequency, duration and physical activity inten-sity of the breaks varied, ranging from 4 min of
vigorous-intensity physical activity weekly [24, 43] to20 min of moderate intensity physical activity donetwice per day [49].There was more consistency in content across
curriculum-focussed active breaks, compared with theactive breaks without curriculum content. Allcurriculum-focussed active breaks featured physical ac-tivity integrated into a combination of key learningareas, including mathematics, language, science and/orsocial studies, and aimed to reinforce previously taughtlesson content [25, 52–57]. Further, most (5 out of 7)required daily participation in 10 to 20 min of physicalactivity [19, 52–54, 57]. When specified, participationwas required at a moderate-[56] or moderate-tovigorous-physical activity intensity [55], but intensitywas not specified in the majority (5 out of 7) of thesestudies [25, 52–54, 57].While curriculum-focussed active breaks aimed to
reinforce previously taught lesson content, physicallyactive lessons were used to teach new lesson content[27, 28, 32, 33, 58–62, 64–66]. These lessons predom-inately incorporated physical activity into mathematicsand/or language lessons, but some also incorporatedscience and/or social studies [27, 28, 32, 33, 58–62,64–66]. Lessons ranged in duration from 30 to60 min [27, 28, 32, 33, 60–64, 66] with most (8 outof 13) requiring participation three times per week[27, 28, 32, 33, 61, 62, 64, 66]. Other physically activelessons were described as single lessons as part ofpilot interventions [59, 63, 65], or stipulated physicalactivity time per week, rather than number of lessonsper week [58].
Intervention fidelityIntervention fidelity was reported in twelve studies.For the three active break interventions delivered byteachers, various measures of fidelity were used, how-ever, no study clearly reported compliance withimplementing active breaks daily or the number ofactive break sessions conducted. Active break inter-ventions delivered by research staff reported high fi-delity, showing most children achieved the requiredphysical activity intensity [39–41], or at least 50% ofeach intervention session was spent at the requiredintensity [46, 47].For physically active lesson interventions, teacher re-
ports showed they delivered lessons either as intended[27] or for at least 50% of the required minutes per week[58]. Similar to active break studies, when delivered byresearch staff, at least 60% of intervention lessons werespent at the required physical activity intensity [61, 62].No curriculum focussed active break study reportedfidelity.
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 6 of 24
Table
2Stud
iesinvestigatingtheeffect
ofactivebreaks
onph
ysicalactivity
andacadem
ic-related
outcom
esPape
r/coun
try
Stud
yde
sign
Samplesize
Age
Interven
tion
Duration
Delivery
Physical
activity
measure
Acade
mic
outcom
emeasure
Stud
yqu
ality
Results
Maet
al.,2014
[34]
Cana
da
With
insubject
Stud
ents:
n=44
Scho
ols:
n=2
Classes:
n=2
Years2
&4
FUNtervals=20s
VPAseparatedby
10srestrepe
ated
8tim
esDose:alternating
days
3weeks
Research
staff
Non
eOff-task
behaviou
r:direct
observation
Strong
Off-task
behaviou
rSign
ificantly
less
followingFU
Ntervals,
comparedwith
noactivity
cond
ition
-Year
4children:off-task
passive(ES=0.31);off-task
motor
(ES=0.48)
-Year
2children:off-task
passive(ES=0.74);off-task
verbal(ES=0.45)off-task
motor
(ES=1.076)
How
ieet
al.,2015
[31]
USA
With
insubject
n=96
Age
9to
12years
Years4
&5
BrainBITES(Better
IdeasThroug
hExercise)=5,10
and20
min
MVP
Aactivebreaks
Dose:1cond
ition
delivered
twice
perweek
4weeks
Research
staff
Interven
tion
fidelity:d
irect
observation
Executivefunctio
n:trailm
akingtest&
digitrecalltests
Mathe
matics:1-min
mathfluen
cytest
Mod
erate
Executivefunctio
n:no
differencebe
tweengrou
psMathe
matics:sign
ificant
improvem
entafter10-m
in(ES=0.24)and20-m
in(ES=0.27)activebreak,
comparedwith
sede
ntary
cond
ition
How
ieet
al.,2014
[30]
USA
On-task
behaviou
r:direct
observation
Mod
erate
On-task
behaviou
r:largest
improvem
entafter10
min
activebreak(d
=0.50)
Janssenet
al.,2014
[32]
Netherland
sWith
insubject
n=123
Age
10to
11years
Year
5
15min
active
breaks
ofvarying
PAintensities
(MPA
,VP
A,p
assive
break,
nobreak)
Dose:un
clear
4weeks
Research
staff
PAintensity
durin
gactive
breaks:
Accelerom
eter
Selectiveattention:
Testof
Everyday
Atten
tionfor
children
(TEA
-chtest)
Mod
erate
Selectiveattention:im
proved
mostafterMPA
cond
ition
(B=−0.59,95%
CI:−0.70,-0.49),
comparedwith
VPA(B
=−0.29,
95%
CI:−0.39,-0.19),p
assive
break(B
=0.27,95%
CI:−0.35,-
0.18)andno
breakcond
ition
s
Maet
al.,2015
[21]
Cana
daWith
insubject
n=88
Age
9to
11years
Years3to
5
FUNtervals=20s
VPAseparatedby
10srest,rep
eated
8tim
esDose:on
ce/w
eek
3weeks
Research
staff
Non
eSelectiveattention:
d2Testof
Atten
tion
Mod
erate
Selectiveattention:sign
ificant
improvem
entfollowing
FUNtervals,comparedwith
noactivity
cond
ition
Barnardet
al.,
2014
[39]
SouthAfrica
Quasi-
expe
rimen
tal
with
preand
posttesting
Stud
ents:
n=149
Scho
ols:
n=2
Classes:
n=6
Scho
olA
meanage:
7.33
years
Scho
olB
meanage:
7.47
years
2interven
tion
prog
rams:
*integ
rated-30
min
integrated
academ
icskillsandmotor
skill
prog
ram
*inten
sive
prog
ram
-30
min
physical
activity
prog
ram
Dose:3tim
es/w
eek
8weeks
Unclear
Non
eLiteracy:ESSIR
eading
andSpellingtests
Num
eracy:VA
SSI
MathSkillsTest
Mod
erate
Reading:
fortheintegrated
(26%
)andintensive(30%
)prog
ramstestscores
improved
butno
tsign
ificant.
Spelling:
fortheintegrated
(32%
)andintensive(47%
)prog
ramstestscores
improved
butno
tsign
ificant.
Num
eracy:fortheintegrated
(30%
)andintensive(21%
)prog
ramstestscores
improved
butno
tsign
ificant.
Hillet
al.,
2011
[29]
Cross
over
n=552
Age
8to
12years
10to
15min
MPA
activebreak.
2weeks
Not
repo
rted
Non
eAtten
tionand
executivefunctio
n:Mod
erate
Atten
tionandexecutive
functio
n:im
proved
onlyfor
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 7 of 24
Table
2Stud
iesinvestigatingtheeffect
ofactivebreaks
onph
ysicalactivity
andacadem
ic-related
outcom
es(Con
tinued)
Scotland
Years4to
7Dose:on
ce/day
foron
eweek,no
interven
tionin
the
second
week
pacedserialadd
ition
,size
orde
ring,
listening
\span,
digitspan
backwards
&visual
coding
thosereceivingthe
interven
tionin
week2(m
ean
difference=3.85,95%
CI=
0.26,7.44)
Schm
idt
etal.,2016
[26]
With
insubject
n=98
Year
510
min
activebreak
involvingrunn
ing
atdifferent
speeds
Dose:5different
days
over
3weeks
3weeks
Not
repo
rted
Non
eAtten
tion:d2
Test
ofAtten
tion
Mod
erate
Atten
tion:no
sign
ificant
improvem
ent
Aham
edet
al.,2007
[35]
Cana
da
Cluster
RCT
Stud
ents:
n=288
Scho
ols:
n=10
Age
9to
11years
Years4
and5
ActionScho
ols!
BC=15
min
MVP
Aactivebreak.
Dose:on
ce/day
16mon
ths
Teache
rHabitu
alPA
:Mod
ified
Physical
Activity
Questionn
aire
forChildren
(PAQ-C)
Mathe
matics,
Readingand
Lang
uage
:Canadian
Achievemen
tTest
Weak
Mathe
matics,Readingand
Lang
uage
(totalscore)
Alth
ough
controlschoo
lhad
sign
ificantlyhigh
erscores
atbaseline,no
sign
ificant
differencebe
tween
interven
tion(m
ean=1672
(9.6)andcontrolg
roup
s(m
ean=1688.6(16.6)
atfollow
up Physicalactivity:increaseby
47min/w
eekininterventio
nscho
ols(139
±62
vs92
±45,p
<0.001)
Carlson
etal.,
2015
[27]
USA
Quasi-
expe
rimen
tal
(nopre-testing)
Stud
ents:
n=1322
Teache
rs>:
n=397
Scho
ols:
n=24
Meanage:
8.8years
Years1to
6
10min
MVP
Aactive
break
Dose:Atleaston
ce/
day
8mon
ths
Teache
rScho
oldayPA
:Accelerom
eter
Classroom
behaviou
r:Teache
rrepo
rtWeak
Classroom
behaviou
r:Teache
rswho
repo
rted
implem
entin
gactivebreaks
repo
rted
fewer
stud
entswho
lacked
effortor
gave
upeasily
(β=−0.17,95%
CI:−.033,
−0.01),weremorelikelyto
agreethat
stud
entswork
improves
following
participationin
activebreaks
(OR=1.88;95%
CI:1.04,3.37),
andshow
edatren
dtowards
agreem
entthat
stud
ents
stay
ontask
moreafter
activebreaks
(OR=1.88;
95%
CI:0.98,3.61;p=0.056),
comparedwith
non-im
plem
enters
Physicalactivity:stude
nts
ofteache
rswho
repo
rted
ever
holdingactivebreak
had3.14
moreminutes
perdayof
MVP
Aandwere
75%
morelikelyto
have
met
the30
min
perdaygu
ideline
forMVP
Adu
ringscho
ol(OR:1.75;95%
CI:1.22,2.51)
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 8 of 24
Table
2Stud
iesinvestigatingtheeffect
ofactivebreaks
onph
ysicalactivity
andacadem
ic-related
outcom
es(Con
tinued)
Hillet
al.,
2010
[28]
Scotland
Cross
over
n=1224
Age
8to
12years
Years4to
7
10to
15min
MPA
activebreak.
Dose:on
ce/day
for
oneweek,no
interven
tion
inthesecond
week
2weeks
Not
repo
rted
Non
eAtten
tionand
executivefunctio
n:pacedserialadd
ition
,size
orde
ring,
listening
span,d
igitspan
backwards
&visual
coding
Weak
Atten
tionandexecutive
functio
n:im
proved
only
forthosereceivingthe
interven
tionon
week2
oftheinterven
tion(con
trol
grou
pmean=58.20(18.03)
vs.interventiongrou
pmean=60.19(19.38)
Katzet
al.,
2010
[33]
USA
RCT
n=1214
Years2to
4Activity
Burstsin
the
Classroom
=MVP
Aactivebreaks
totaling
30minspe
rday.
Dose:Leng
thand
numbe
rof
sessions/
daycouldvary
8mon
ths
Teache
rNon
eClassroom
behaviou
r:Workandsocialskills
compo
nent
ofInde
pend
ence
Scho
olDistrict(ISD)prog
ress
repo
rtcard
Mathe
maticsandEnglish:
Year
4:Missouri
Acade
mic
Perfo
rmance
Test
(MAP)
Years2–4:ISD
prog
ress
repo
rt
Weak
Classroom
behaviou
r:no
differencebe
tweengrou
psAcade
micachievem
ent:no
differencebe
tweengrou
psforMAPtestresults
(Year4
only),bu
tagreaterprop
ortio
nof
controlg
roup
stud
ents
(Years2to
4)show
edim
provem
entin
math
(28.6%
vs.20.8%
)and
reading(21.1%
vs.16.1%
)as
measuredviaISDrepo
rt,
comparedwith
interven
tion
grou
p
Lisahu
nter
etal.,2014
[38]
Australia
Quasi-
expe
rimen
tal
with
control
grou
p
Stud
ents:
n=107
Teache
rs:
n=6
Scho
ols:
n=1
Classes:
n=4
Age
approx.
10years
Year
5
ActiveKids,A
ctive
Minds
(AKA
M)=
additio
nal
30minsof
MPA
activebreak.
Dose:on
ce/day
2term
s/approx.
20weeks
Specially
employed
PEteache
r
Habitu
alandscho
oldayPA
:Ped
ometer
(Yam
axCW700)
Scho
oldayPA
ofat
leastMPA
:Accelerom
eter
(ActiGraph
)
Cog
nitivefunctio
n:Cog
nitiveAssessm
ent
System
Academicachievem
ent:
totalscorefor8
classroom
subjects
Classroom
behaviou
r:scho
olbe
haviou
rrecords
Weak
Nodifferencebe
tweengrou
psforanyof
theacadem
icou
tcom
esassessed
Physicalactivity:d
aily
step
sde
clined
from
pre-
(con
trol
=13,772;
interven
tion=12,447)to
post-
(con
trol
=12,046;
interven
tion=9702)forbo
thinterven
tionandcontrolg
roup
s
Whit-Glover
etal.,2011
[ 36]
USA
RCT
Stud
ents
n=4599
Scho
ols:n=8
Years3to
5InstantRecess
=10
min
MPA
active
break.
Dose:on
ce/day
8weeks
Teache
rPA
durin
gInstant
Recess
lesson
:Direct
observation
Classroom
behaviou
r:direct
observation
Weak
Classroom
behaviou
r:11%
increase
intim
espen
ton
-taskin
interven
tion,
comparedwith
controlg
roup
Physicalactivity:M
PAincreasedby
16%
andLPA
increasedby
51%
Wilson
etal.,
2015
[37]
Australia
With
insubject
Stud
ents:
n=58
boys
Scho
ols:
n=1
Classes:
n=4
Meanage:
11.2years
Years5&6
10min
MVP
Aactive
breakou
tsidethe
classroo
mDose:on
ce/day,3
times/w
eek
4weeks
Teache
rPA
intensity
durin
gactivebreaks:
accelerometer
Sustaine
dattention:
5-min
Psycho
motor
VigilanceTask
On-task
behaviou
r:direct
observation
Weak
Sustaine
dattention:no
differenceinterven
tiongrou
ppreactivebreak:mean=477
(285)v
s.po
stactivebreak:
mean=479(200)
Off-task
behaviou
r:no
difference:interven
tiongrou
ppreactivebreak:mean=13.6
(10.0)
vs.p
ostactivebreak:
mean=14.8%
(11.6)
Uhrich&
Swarm.,2007
[35]
Quasi-
expe
rimen
tal
Stud
ents:
n=41
Scho
ols
Age
10to
11years
Year
5
20min
ofsport
stacking
:using
both
hand
sto
stacka
6weeks
Research
staff
Non
eDecod
ingand
compreh
ension
skills:
Gates
MacGinitie
Weak
Decod
ingskills:no
difference
betw
eengrou
ps(F1,41
=0.03,
p>0.05)
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 9 of 24
Table
2Stud
iesinvestigatingtheeffect
ofactivebreaks
onph
ysicalactivity
andacadem
ic-related
outcom
es(Con
tinued)
USA
with
control
grou
pn=1
Classes
n=2
grou
pof
12specialized
cups
inpred
etermined
combinatio
nsDose:3tim
es/w
eek
ReadingTestFourth
Edition
(GMRT-4)
Decod
ingand
Com
preh
ension
skill
subtests
Com
preh
ension
skills:
Improvem
entin
interven
tion
grou
p,comparedwith
control
(F1,41
=4.54,p
<0.05)
Altenb
urget
al.,
2016
[49]
Netherland
s
RCT
Stud
ents
n=62
Scho
ols
n=5
*con
venien
cesample
Age
d10
to13
years
20min
MPA
active
breaks
comprising
vide
o-baseddance
activities
Dose:on
cepe
rday&
twicepe
rday
1day
Supe
rvised
byresearch
staff
PAintensity
durin
gactivebreaks:heart
rate
mon
itor
Selectiveattention:
SkySearch
subtest
oftheTestof
Everyday
Atten
tion
forchildren(TEA
-ch
test)
Weak
Selectiveattention:test
scores
better
after2
bouts(β
=−0.26
(95%
CI:-0.52,-
0.004),com
paredwith
one
bout
(β=0.06
(95%
CI:−0.23,0.36)
and
controlcon
ditio
n.Note:ane
gativebe
taindicatedabe
tter
attention
score
VandenBerg
etal.,2016
[50]
Netherland
s
With
insubject
Stud
ents:
n=195
Scho
ols:
n=3
Classes:n
=8
Age
10to
13years
Year
5&6
12min
MPA
active
breaks
=3cond
ition
s(aerob
ic,coo
rdinative
&streng
th-based
PA)
Dose:on
ceoff
3days
Children
followed
pre-
recorded
vide
oof
active
breaksessions,
supe
rvised
byresearch
staff
PAintensity
durin
gactivebreaks:heart
rate
mon
itor
Inform
ation
processing
speed:
Letter
Digit
SubstitutionTest
Selectiveattention:
d2Testof
Atten
tion
Weak
Inform
ationprocessing
speed:
nochange
[F(1174)
=0.71,
p=0.040
Selectiveattention:
nochange
[F(1172)
=0.91,
p=0.34
Meadet
al.,2016
[51]
USA
Quasi-
expe
rimen
tal
with
preand
posttesting
Stud
ents:
n=81
Scho
ols:
n=1
Classes:n
=3
Year
6Age
11to
12years
3cond
ition
s-
implem
enteddu
ring
80min
mathclass
(2×5-min
active
breaks,sittingon
stability
balls
&tradition
alseated
lesson
)Dose:everyday
Unclear
Teache
rNon
eReading,
Mathe
matics
andScience:Minne
sota
Com
preh
ensive
Assessm
ents
Reading,
Mathe
matics
andLang
uage
:Measuresof
Acade
micProg
ress
Weak
Reading,
Mathe
maticsand
Science:no
differencebe
tweenactive
break(pretest:527.3(29.8)
vs.p
osttest(620.9(34.2)
and
seated
lesson
cond
ition
s(pretest:543.9(13.1)
vs.
posttest643.1(12.4)
Reading,
Mathe
maticsand
Lang
uage
:nodifference
betw
eenactive
break(pretest:219.7(14.0)
vs.
posttest(226.8(15.1)
and
seated
lesson
cond
ition
s(pretest:221.2(16.0)
vs.
posttest226.0(15.1)
Abb
reviations
PA:p
hysicala
ctivity
LPA:light
intensity
physical
activ
ityMPA
:mod
erateph
ysical
activ
ityintensity
MVP
A:m
oderateto
vigo
rous
physical
activ
ityintensity
VPA:vigorou
sintensity
physical
activ
ityRC
T:rand
omised
controlledtrial
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 10 of 24
Table
3Stud
iesinvestigatingtheeffect
ofcurriculum
focussed
activebreaks
onacadem
icandph
ysicalactivity
outcom
es
Pape
r/coun
try
Stud
yde
sign
Sample
size
Age
Interven
tion
Duration
Delivery
Physicalactivity
measure
Acade
micou
tcom
emeasure
Stud
yqu
ality
Results
Vazou
etal.,
2012
[44]
Greece
With
in-sub
ject
n=147
Years4to
610
minsMPA
active
breakincorporating
lang
uage
arts,m
ath
andsocialstud
ies
Dose:un
clear
2weeks
Senior
prim
ary
educationstud
ent
teache
rs
Non
eAcade
micmotivation:
IntrinsicMotivation
Inventory
Mod
erate
Acade
micmotivation:
Perceivedacadem
iccompe
tenceincreasedin
interven
tioncomparedwith
control.(F=4.87,p
<0.05)
Goh
etal.,
2016
[57]
USA
With
in-sub
ject
Stud
ents:
n=210
Classes:
n=9
Scho
ols:
n=1
Age
d8to
12years
Year
3to
5
Take
10!=
10min
activebreaks
incorporating
lang
uage
arts,m
ath,
science,socialstud
ies
andge
neralh
ealth
Dose:de
term
ined
byteache
r
8weeks
Teache
rNon
eOn-task
behaviou
r:direct
observation
Mod
erate
On-task
behavior:
sign
ificant
increase
inpe
rcen
ton
-taskbe
havior
from
pre-TA
KE10!(82.3±4.5)
topo
stTA
KE10!
(89.5±2.7)
Erwin
etal.,
2013
[41]
USA
Quasi-
expe
rimen
tal
Stud
ents:
n=29
Scho
ols:
n=1
Classes:
n=2
Meanage:
8.87
years
Year
3
20+minutes
active
breakincorporating
mathandreading
Dose:daily
20weeks
Teache
rInterven
tion
effectsof
PAon
academ
icou
tcom
es:
Pedo
meter
(Walk4Life,
LS2500)
ReadingandMathe
matics:
curriculum
based
measures(CBM
),teache
rrepo
rted
grades
&standardised
testscores
(T-PRO
,STA
Rand
Discovery
Education
Assessm
ent)
Mod
erate
Mathe
matics:high
erscores
ininterven
tioncomparedwith
controlg
roup
attim
e3
(Mdiff=10.87,p=0.003),
butno
ttim
e1(M
diff=2.75,
p=0.39)or
2(M
diff=2.16,p
=0.49)
Reading:
high
erscores
ininterven
tion
grou
pat
time1(M
diff=
79.46,p<0.01),tim
e2
(Mdiff=87.41,p<0.01),
time3(M
diff=92.46,
p<0.01)
Standardised
testscores:
Tren
dtowards
improvem
ent
Bailey&
DiPerna
.,2015
[40]
USA
Multip
lebaseline
design
Stud
ents:
Meanof
16Year
1and
14Year
2stud
ents
/classroom
Scho
ols:
n=1
Classes:
n=6
Years1&2
Energisers=approx.
10to
20min
active
breakincorporating
core
curriculum
Dose:tw
icedaily
5,7or
9weeks
Teache
rScho
oldayPA
:New
-Lifestyles
Accelerom
eter
(NL-800):
Interven
tionacceptability:
stud
ent
andteache
rqu
estio
nnaire
Weak
Interven
tionacceptability:M
ost
teache
rsstrong
lyagreed
(11%
)or
agreed
(89%
)that
Energisers
didno
tadverselyaffect
learning
.Mostteache
rsstrong
lyagreed
(11%
)or
agreed
(67%
)that
stud
entswerebe
tter
ableto
payattentionfollowingEnergisers
76%
ofstud
entsrepo
rted
beingableto
paybe
tter
attentionin
classfollowing
Energisers
Physicalactivity:intervention
sign
ificantlyincreasedscho
olbasedstep
s(ES=0.71
to1.26)
Fedewa
etal.,
2015
[42]
USA
RCT
Stud
ents:>
n=460
Scho
ols:
n=4
Years3to
55min
activebreaks
incorporatingcore
curriculum
,totaling
20minsPA
perday
Dose:daily
1year
Teache
rTo
explainvariance
influid
intellige
nce
andacadem
icachievem
entscores:
pedo
meter
(Walk4Life)
Fluidintellige
nce:
Standard
Prog
ressive
Matrices
ReadingandMathe
matics:
Measuresof
Acade
mic
Prog
ress
Weak
Mathe
matics:im
provem
entin
interven
tion,
comparedwith
controlg
roup
:t(33)
=2.17,
p=0.04
Reading:
improvem
entin
interven
tion,
compared
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 11 of 24
Table
3Stud
iesinvestigatingtheeffect
ofcurriculum
focussed
activebreaks
onacadem
icandph
ysicalactivity
outcom
es(Con
tinued)
with
controlg
roup
t(32)
=1.69,p
=0.10
Fluidintellige
nce:no
differencebe
tweengrou
pst(3
6)=0.23,p
=0.82
Grieco
etal.,
2009
[43]
USA
With
insubject
Stud
ents:
n=97
Scho
ols:
n=1
Classes:
n=9
Age
8to
10years
TexasI-C
AN=on
e10–15min
MVPA
activebreakincorporating
math,
lang
uage
arts,
science,socialstud
ies
andhe
alth
Dose:on
eofflesson
1-day
Teache
rTo
compare
PAam
ongBM
Igroup
s:pe
dometer
(Omron
HJ105)
On-task
behaviou
r:direct
observation
Weak
On-task
behaviou
r:slight
increase
afterinterven
tionlesson
comparedwith
control,
althou
ghno
tsign
ificant
(F1,94
=2.19,p>0.10)
Mah
aret
al.,
2006
[22]
USA
Cluster
RCT
with
multip
lebaseline
design
Stud
ents:
n=243
Scho
ols:
n=1
Classes:
n=15
Kind
ergarten
toYear
4Energisers=approx.10
minsactivebreak
incorporatingcore
curriculum
Dose:daily
4or
8weeks
Teache
rScho
oldayPA
:Pedo
meter
(Yam
axSW
-200)
On-task
behaviou
r:direct
observation(assessedin
2Year
2,and2Year
4classes)
Weak
On-task
behaviou
r:Im
provem
entin
interven
tion,
comparedwith
controlg
roup
(ES=0.60).Greatestim
provem
ent
inon
-taskbe
havior
forstud
ents
mostoff-task(ES=2.20).
Physicalactivity:intervention
grou
ptook
morein
scho
olstep
s,comparedwith
control
grou
p(ES=0.49)
Abb
reviations:
MVP
A:m
oderateto
vigo
rous
physical
activ
ityintensity
MPA
:mod
erateph
ysical
activ
ityintensity
PA:p
hysicala
ctivity
RCT:rand
omised
controlledtrial
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 12 of 24
Table
4Stud
iesinvestigatingtheeffect
ofph
ysicallyactivelesson
son
academ
icandph
ysicalactivity
outcom
es
Pape
r/coun
try
Stud
yde
sign
Sample
size
Age
Interven
tion
Duration
Delivery
PAmeasure
Acade
micou
tcom
emeasure
Stud
yqu
ality
Results
DeGreeff
etal.,2016
[32]
Netherland
s
RCT
Stud
ents:
n=499
Scho
ols:
n=12
Years2&3
Meanage:
8.1±0.7years
Fit&Acade
mically
proficient
atscho
ol=30
min
physicallyactive
(MVPA)mathand
lang
uage
lesson
sDose:3xpe
rweek
22weeks
peryear
scho
ol,w
ith1-year
and
2-year
follow
up
1styear
-interven
tion
teache
rs2n
dyear
–teache
r
Non
eExecutivefunctio
n:Inhibitio
n:Golde
nStroop
test
Working
mem
ory:
Digitspan
backward
&Visualspan
backward
Strong
Inhibitio
n:no
differencebe
tween
interven
tionM
=19.6(8.1)and
controlg
roup
M=19.9(9.5)
Digitspan
backward:no
difference
betw
eeninterven
tionM
=6.0
(2..2)andcontrolg
roup
M=6.2(1.9)
Visualspan
backward:
nodifferencebe
tweeninterven
tion
M=6.6(1.7)andcontrolg
roup
M=6.8(1.6)
Rileyet
al.,
2014
[24]
Australia
Cluster
RCT-
pilotstud
yStud
ents:
n=54
Classes:
n=2
Scho
ols:
n=1
Age
10to
12years
Years5&6
EncouragingActivity
toStim
ulateYo
ung
(EASY)Minds
=PA
integrated
into
existin
gmath
lesson
s,60
mins
per
lesson
Dose:3xpe
rweek
6weeks
Research
staff
Activelesson
and
scho
oldayPA
:Accelerom
eter
(GT3X)
On-task
behaviou
r:direct
observation
Strong
On-task
behaviou
r:Greater
durin
ginterven
tionlesson
s,comparedwith
control(19.9%
meandifference)
Physicalactivity:9.7%
increase
inMVPAacross
mathtim
eslot,
and8.7%
increase
across
scho
olday
Rileyet
al.,
2015
[23]
Australia
Cluster
RCT
Stud
ents:
n=240
Scho
ols:
n=8
Age
10to
12years
Years5&6
EASY
Minds
=PA
integrated
into
existin
gmathprog
ram,60mins
perlesson
Dose:3xpe
rweek
6weeks
Teache
rActivelesson
and
scho
oldayPA
:Accelerom
eter
(Walk4Life,LS,
2500)
Ontask
behavior:
direct
observation
Mathe
matics:
Prog
ressive
Achievemen
tTest
Strong
On-task
behaviou
r:13.8%
increase
ininterven
tion
comparedwith
controlg
roup
Mathe
matics:no
difference
betw
eengrou
psPh
ysicalactivity:2.6%
increase
inMVPAdu
ringmath
timeslot,and1.7%
increase
across
scho
olday
Don
nelly
etal.,2009
[45]
USA
Cluster
RCT
(pre-and
post-test)
Stud
ents:
n=1527
Scho
ols:
n=24
Years2&3
PhysicalActivity
Across
theCurriculum
(PAAC)
=MVPAintegrated
into
lang
uage
,math,
science
andsocialstud
ieslesson
sDose:90
min
perweek,
delivered
interm
itten
tlythroug
hout
scho
olday.
App
rox.10
minspe
rsession.
3years
Teache
rScho
olday,weekend
dayandweekday
PA:
ActiGraph
accelerometer
Academicachievem
ent:
subsam
ple(n=454)
WIAT-II-Astandardised
test(m
ath,reading,
spelling)
Strong
Acade
micachievem
ent:
improvem
entin
reading,
math
andspellingscores
from
baseline
to3yearsin
interven
tion,
comparedwith
controlschoo
lsPh
ysicalactivity:g
reater
scho
oldayPA
(12%
),weekend
dayPA
(17%
)andweekday
PA(8%)in
interven
tioncompared,
with
controlg
roup
Beck
etal.,
2016
[33]
Denmark
Cluster
RCT
Stud
ents:
n=165
Scho
ols:
n=3
Classes:
n=9
Year
1Group
A=grossmotor
movem
entsintegrated
into
60min
mathlesson
s,(e.g.skipp
ing,
craw
ling,
throwingwhilesolving
mathprob
lems)
Group
B=finemotor
movem
entsintegrated
into
60min
mathlesson
s(e.g.m
anipulatingLEGO
6weeks
Teache
rPh
ysicalactivity
intensity
durin
glesson
s:Com
bine
dhe
art
rate
(Polar
Team
2System
)and
accelerometer
(Minim
axXS4)-
Subsam
ple(n
=49)
Mathe
matics:
standardized
test
(nam
eno
tspecified
)
Mod
erate
Mathe
matics:change
sin
mean
mathpe
rform
ance
weregreater
forthegrossmotor
grou
p,comparedwith
finemotor
grou
pfro
mbaselineto
interven
tionen
d(1.87±0.71).How
ever
thisaffect
was
noteviden
tfro
mbaseline
to8weekfollow
up.
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 13 of 24
Table
4Stud
iesinvestigatingtheeffect
ofph
ysicallyactivelesson
son
academ
icandph
ysicalactivity
outcom
es(Con
tinued)
bricks
whilesolving
mathprob
lems)
Dose:3xpe
rweek
McCrady
Spitzer
etal.,2015
[47]
USA
Quasi-
expe
rimen
tal
Stud
ents:
n=14
Scho
ols:
n=1
Classes:
N=1
Age
6to
7years
Year
1
30–40min
mathand
lang
uage
lesson
using
ActiveClassroom
Equipm
ent
Dose:daily
9mon
ths
Teache
rScho
oldayPA
:Accelerom
eter
Acade
micachievem
ent:
Dynam
icIndicatorsof
BasicEarly
Literacy
Skills(DIBELS)-oral
readingfluen
cy,w
hole
words
read,correct
letter
soun
d
Mod
erate
Correct
letter
soun
d:children
ininterven
tiongrou
pshow
edgreaterim
provem
ent
(Mdiff=45
±34)compared
with
childrenin
thecontrol
grou
p(M
diff=15
±22)
Who
lewords
read:childrenin
interven
tiongrou
pshow
edgreaterim
provem
ent
(Mdiff=20
±14)compared
with
childrenin
thecontrol
grou
p(M
diff=7±9)
Oralreading
fluen
cy:n
odifferencebe
tween
interven
tion(M
diff=27
±27)
andcontrolg
roup
s(M
diff=19
±16)
Physicalactivity:46%
increase
ondays
used
activeclassroo
meq
uipm
ent,comparedwith
days
intradition
alclassroo
m
Mullend
er-
Wijnsm
aet
al.,2015a
[49]
Netherland
s
With
insubject
Stud
ents:
n=86
Scho
ols:
n=4
Meanage:
8.2years
Years2&3
Fit&Acade
mically
proficient
atscho
ol=30
min
physically
active(M
VPA)math
andlang
uage
lesson
sDose:3xpe
rweek
22weeks
Interven
tion
teache
rsNon
eOn-task
behaviou
r:direct
observation
Mod
erate
On-task
behaviou
r:high
erpo
stinterven
tion,
compared
with
postcontrollessons
(ES=0.41)
Graha
met
al.,2014
[46]
USA
Non
-rand
omised
controlled
trial
Stud
ents:
n=21
Scho
ols:
n=1
Classes:
n=1
Age
7–8years
Year
2JumpIn!=
PAintegrated
into
math
lesson
Dose:on
e-offlesson
1day
Teache
rand
researcher
Non
eMathe
matics:
postsession
know
ledg
equ
estio
nnaire
Weak
Mathe
matics:no
difference
betw
eeninterven
tion
(M=4.08)andcontrol
grou
ps(M
=4.25)
Mullend
er-
Wijnsm
aet
al.,2015b
[48]
Netherland
s
Quasi-
expe
rimen
tal
with
control
grou
p
Stud
ents:
n=228
Scho
ols:
n=6
Meanage:
8.1years
Years2&3
Fit&Acade
mically
proficient
atscho
ol=30
min
physically
active(M
VPA)math
andlang
uage
lesson
sDose:3xpe
rweek
21weeks
Interven
tion
teache
rsNon
eMathe
matics:
speedtest
arith
metic
Reading:
1-min
test
Weak
Mathe
matics:
-Year
3:interven
tiongrou
phadhigh
erscores,com
pared
with
controlg
roup
(F[1,99]
=11.72,p<0.05).
-Year
2:interven
tiongrou
phadlower
scores
compared
with
controlg
roup
(F[1109]
=12.40,p<0.05)
Reading:
-Year
3:interven
tiongrou
phadhigh
erscores,com
pared
with
controlg
roup
(F[1,98]
=6.97,p
<0.05).
-Year
2no
differencebe
tween
grou
ps(F[1109]
=0.72,p
=0.40)
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 14 of 24
Table
4Stud
iesinvestigatingtheeffect
ofph
ysicallyactivelesson
son
academ
icandph
ysicalactivity
outcom
es(Con
tinued)
Norris
etal.,2015
[50]
UK
Quasi-
expe
rimen
tal
Stud
ents:
n=85
Scho
ols:
n=2
Classes:
n=4
Age
9to
10years
Year
5
Lond
onOlympic
them
evirtualfield
trip
=30
mins
completingprom
pted
activities
(e.g.run
ning
100m
sprin
ton
thespot)
Dose:on
eofflesson
May
and
June
but
interven
tion
ranfor1-day
ineach
class
Teache
rActivelesson
PA:
Accelerom
eter
Lesson
conten
trecall:
10item
conten
trecallqu
iz
Weak
Con
tent
recallqu
iz:no
differencebe
tweengrou
psPh
ysicalactivity:increasein
interven
tiongrou
p
Reed
etal.,
2010
[51]
USA
Cluster
RCT;
pre-andpo
st-
test
Stud
ents:
n=155
Scho
ols:
n=1
Classes:
n=6
Age
9to
11years
Year
3
30minsPA
integrated
into
lang
uage
andmath
andsocialstud
ieslesson
s.Dose:3xpe
rweek
3mon
ths
Teache
rDIGI-WALKER
pedo
meter
SW200-
used
ininterventiongroup
torecord
steps
duringlesson
only
Fluidintellige
nce:
Standard
Prog
ressive
Matrices
Acade
micachievem
ent:
Palm
etto
Achievemen
tChalleng
eTests(Eng
lish,
math,
scienceandsocial
stud
ies
Weak
Fluidintellige
nce:high
erscores
ininterven
tion,
comparedwith
controlgroup
(M=36.66,p=0.45)
Socialstud
ies:high
erscores
ininterven
tion,
comparedwith
controlg
roup
(t=p=0.004)
Mathe
matics:no
difference
betw
eengrou
ps(t=1.107,p=0.09)
English:
nodifferencebe
tween
grou
ps(t=0.71,p
=0.0478)
Science:no
differencebe
tween
grou
ps(t=1.490,p=0.140)
Grieco
etal.,2016
[65]
USA
Mixed
factorial
design
Stud
ents:
n=320
Scho
oldistricts:
n=1
Classes:
n=20
Age
7to
12years
SpellingRelay=10–
15min
PAintegrated
into
spellinglesson
sde
livered
atdifferent
PAintensities
(seatedtradition
allesson
,seated
game,LM
PAgame
&MVPAgame)
1xlesson
per
cond
ition
Research
staff
Physicalactivity
intensity
durin
glesson
s:accelerometer
On-task
behavior:
direct
observation
Weak
On-task
behaviou
r:sign
ificant
increase
intim
eon
task
from
pre-
topo
st-LM
PAgame
(ES=0.43)andMVPA
game(ES=1.22)
Mullend
er-
Wijnsm
aet
al.,2016
[66]
Netherland
s
RCT
Stud
ents:
n=499
Scho
ols:
n=12
Years2&3
Meanage:
8.1±0.7years
Fit&Acade
mically
proficient
atscho
ol=30
min
physically
active(M
VPA)mathand
lang
uage
lesson
sDose:3xpe
rweek
22weeks
peryear
scho
ol,w
ith1-year
and
2-year
follow
up
1styear
-interven
tion
teache
rs2n
dyear
–teache
r
Non
eReading:
1min
test
Spelling:
spelling
scores
retrievedfro
machild
academ
icmon
itorin
gsystem
Mathe
matics:speedtest
arith
meticandge
neral
mathscores
retrieved
from
achild
academ
icmon
itorin
gsystem
Weak
Mathe
matics:interven
tion
grou
pshow
edgreater
improvem
entin
math
speedtest(ES=0.51)and
gene
ralm
athscores
(ES=0.42),
comparedwith
controlg
roup
Spelling:
interven
tiongrou
pshow
edgreaterim
provem
ent
inspellingscores
(ES=0.45),
comparedwith
controlg
roup
.Reading:
nodifferencebe
tween
grou
ps(t=0.00;p
=1.00)
Abb
reviations:
MVP
A:m
oderateto
vigo
rous
physical
activ
ityintensity
MPA
:mod
erateph
ysical
activ
ityintensity
PA:p
hysicala
ctivity
RCT:rand
omised
controlledtrial
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 15 of 24
Methodological qualityOf the 39 identified studies, most (36 out of 39) receiveda moderate [24, 26, 33, 38–41, 48, 53, 55–57, 60, 62], orweak quality rating score [25, 27, 28, 35–37, 42, 44–47,49–52, 54, 59, 61, 63–66]. Three received a strong qual-ity rating score [32, 43, 58]. Low to moderate qualityscore ratings were mostly attributable to not reportingor controlling for relevant demographic confounders,not reporting blinding of participants and researchers,and not reporting participant attrition. Further, for manystudies, authors did not report the rate of participant orschool participation. See Appendix A for further detailon quality assessment of included studies.
Academic-related outcomes: Classroom behaviourStudies assessed the effect of participation in these pro-grams on academic-related outcomes both immediatelyfollowing participation in a session (acute) and after alonger exposure (chronic; e.g. pre- and post- interven-tion periods spanning up to 8 months). Regardless oftype of classroom-based physical activity, the majority ofstudies (10 out of 12) showed participation in these pro-grams had an acute effect on improving on-task class-room behaviour [25, 27, 28, 39, 52, 57, 62, 65] andreducing off-task behaviour [36, 43] However, evidencein the few studies with longer term follow-up (2 out of 2studies) suggest that this improvement may dissipateover time, with no difference between groups whenchronic intervention effects on reported behaviour inci-dents were assessed [42, 47]. Due to few studies investi-gating chronic effects of classroom-based physicalactivity on on-task and off task classroom behaviour(<5) it was not possible to separate acute and chronic ef-fects in the meta-analysis. Results from the 4 includedstudies show classroom-based physical activity had apositive effect on improving on-task behaviour and redu-cing off-task behaviour (standardised mean differ-ence = 0.60 (95% CI: 0.20,1.00)) (see Fig. 2).
Academic-related outcomes: Cognitive functionStudies also assessed acute and chronic effects ofclassroom-based physical activity on a range of cognitivefunctions [24, 32, 37, 38, 40, 41, 46, 47, 49, 50, 54, 64].
Results showed active breaks had an acute positive effecton selective attention (3 out of 4 studies) [24, 41, 49].No acute effect was reported for sustained attention[46], information processing [50] or focussed attention,processing speed and accuracy [26], and no chronic ef-fect was reported for planning, attention, simultaneousor successive cognitive processes [47] or executive func-tion [32]. Acute intervention effects on executive func-tion were inconsistent, with no difference betweengroups reported in one study [40], while another re-ported improvements in executive function but only forthose receiving the intervention in the second week ofdelivery [37, 38]. Results were also inconsistent forchronic intervention effects on fluid intelligence, withone study reporting a significant improvement after3 months [64], while another reported no difference be-tween groups after 1-year [54]. Due to few studiesreporting chronic effects of participation (<5) results foracute and chronic studies were combined in the meta-analysis (5 studies). Results from the meta-analysis indi-cate classroom-based physical activity had no effect oncognitive function (standardised mean difference = 0.33(95% CI: -0.11,0.77) (see Fig. 3).
Academic-related outcomes: Academic achievementStudies assessed intervention effects on academicachievement using a range of academic assessmenttools, including standardised tests, progress monitor-ing tools, grades and content recall quizzes. Reportedeffects on academic achievement varied by interven-tion duration and the type of assessment tool used.Interventions of shorter duration tended to show im-provement in academic achievement if a progressmonitoring tool was used, but not if a national stan-dardised test was used. Seven out of 8 studies using aprogress monitoring tool reported significant improve-ment in academic achievement following interventionperiods ranging from 4 weeks to 1-year [40, 44, 53,54, 60, 61, 66]. In contrast, most (4 out of 7) studiesindicated no difference between groups followingintervention periods less than 1-year when nationalstandardised tests were used as the outcome measure[27, 42, 64, 66]. However, standardised test scores
Fig. 2 Forrest plot of the effect of classroom-based physical activity on classroom behaviour
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 16 of 24
significantly improved following a 1-year [51] and 3-year physically active lesson intervention [58]. Theseresults were confirmed in the meta-analysis. Whenprogress monitoring tools were used (4 studies) asthe outcome measure, academic-related outcomesgenerally showed improvement (standardised meandifference = 1.03 (95% CI: -0.22,1.84)). However, whenmeasured using a national standardised test (6 stud-ies), academic-related outcomes generally showed noimprovement (standardised mean difference = −1.13(95% CI: -0.72,0.46)) (see Fig. 4).In addition to standardised tests and progress moni-
toring tools, a small number of studies (not includedin the meta-analysis) measured academic achievementvia grades, content recall quizzes and self-reportedacademic competence. Results were inconsistent. Onestudy reported no difference between groups forgrades across eight subjects (total score) following a20-week active break program [47], Another reporteda greater proportion of students in the control group
showed improvement in grades for math and reading,compared with an active break intervention group[42]. Other studies assessed academic achievement viacontent recall quizzes and perceptions of academiccompetence, with no difference between groups inmath and social studies scores following participationin single lessons lasting between 10 and 30 min [59, 63].Another study reported self-reported perceptions ofacademic competence improved during physically activelessons [56].
Dose response relationshipFour studies aimed to explore the optimal dose ofactive break (i.e. amount of physical activity requiredto confer academic benefits) required to provide max-imum effects on academic-related outcomes, by ma-nipulating intensity [41], duration [39, 40], andfrequency [49] of active break sessions. Howie andcolleagues [39, 40] compared 5-, 10- and 20-min ac-tive breaks with a 10-min no break condition. Results
Fig. 3 Forrest plot of the effect of classroom-based physical activity on cognitive function
Fig. 4 Forrest plot of the effect of classroom-based physical activity on academic achievement
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 17 of 24
showed on-task classroom behaviour significantly im-proved after the 10-min active break condition [39]and math scores were highest after the 10-min(ES = 0.24) and 20-min (ES = 0.27) active break con-ditions [40]. Janssen et al. [41] compared selective at-tention scores across 15 min of each of the followingfour conditions: no break (continued with schoolwork), passive break (teacher read story), moderate-intensity active break (jogging, passing, dribbling), andvigorous-intensity active break (running, jumping,skipping) [41]. Results showed that selective attentionscores improved most after the moderate-intensity ac-tive break [41]. Altenburg and colleagues [49] com-pared acute effects of different frequencies (one perday vs. twice per day) of 20 min moderate-intensityactive breaks. Results showed significantly better se-lective attention scores for children who received thetwice per day frequency [49].
Physical activity outcomesEleven studies examined the effect of classroom-basedphysical activity interventions on children’s physical ac-tivity levels using a range of measures, including ques-tionnaire [35], direct observation [45], pedometer [25,47, 52], and accelerometer [27, 28, 36, 47, 58, 60, 63].Across most (10 out of 11) classroom-based physicalactivity interventions, small increases in physical activitywere reported [25, 27, 28, 35, 36, 45, 52, 58, 60, 63].Across studies there was a 2% to 16% increase in moder-ate- to vigorous- intensity physical activity during inter-vention lessons, [27, 28, 45, 60, 63], and 2% to 12%increase in school day moderate- to vigorous- intensityphysical activity [27, 28, 58]. However, as shown in Fig. 5results from 3 studies included in meta-analysis indicateclassroom-based physical activity did not affect physicalactivity (standardised mean difference = 0.40 (95% CI:-0.15,0.95).
DiscussionA systematic search of the literature found 39 studiesassessing the effect of classroom-based physical activityon academic-related outcomes, including classroom be-haviour, cognitive function and academic achievement.In the majority of studies, academic-related outcomesimproved following participation in classroom-basedphysical activity programs. These findings are gener-ally consistent with earlier reviews finding that overallphysical activity level was either positively associated,or was not associated with academic-related outcomes[14, 15, 17]. In addition, the interventions included inthe current review generally resulted in more physicalactivity.The finding that classroom-based physical activity
improves on-task or reduces off-task classroom
behaviour immediately following participation inintervention sessions is consistent with previous re-views of school-based physical activity. For example,systematic reviews of the effect of physical activityduring the school break time on academic-relatedoutcomes showed positive associations between par-ticipation in physical activity before class (e.g. duringrecess/snack time) and on-task classroom behaviourin subsequent lessons [17, 29]. Therefore, breaking uplesson time with physical activity offers a promisingstrategy to improve on-task behaviour. Further, phys-ically active lessons may provide a strategy to engagestudents in lesson content, which may lead to im-proved on-task classroom behaviour. However, thisassumption is purely speculative and further researchis needed to confirm this. One study reported a non-significant increase in on-task classroom behaviourafter intervention sessions, compared with control[55]. A possible reason for this finding may be thatthe sample size in that study (n = 97) may not havebeen large enough to detect a significant improve-ment. Few studies (n = 3) reported that classroom-based physical activity had no effect on classroombehaviour. The majority of these studies (2 out of 3)reported that, while behaviour incidents and off-taskbehaviour increased in both the intervention and con-trol groups, the increase was greater in the controlgroup, compared with the intervention group [46, 47].These findings may encourage teachers to considerimplementing classroom-based physical activity pro-grams by alleviating concerns about reducing on-taskbehaviour due to the disruption to the classroom rou-tine [10].While classroom-based physical activity showed rela-
tively consistent positive associations with classroom be-haviour, effects on cognitive function were inconsistent.A possible explanation for this finding may relate tothe variability in the quality of measures used. Overallresults showed studies that reported improvements incognitive function used measures with moderate tohigh levels of reliability and validity [67, 68]. In con-trast, studies reporting no improvement in cognitivefunction mainly used measures with lower levels ofreliability and validity [69–71]. It may be importantfor future studies to use tests of cognitive functionwith established validity and reliability.A further possible explanation for inconsistent ef-
fects on cognitive function may relate to the level ofcognitive engagement inherent in each type ofclassroom-based physical activity. It has been sug-gested that cognitively engaging physical activity (i.e.physical activity combined with cognitive demands)may enhance cognitive function to a greater degreethan non-cognitively engaging physical activity (e.g.
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 18 of 24
repetitive exercise) [72]. As curriculum-focused activebreaks and physically active lessons can be consideredcognitively engaging physical activity, it could behypothesised that these types of classroom-basedphysical activity would lead to greater improvementsin cognitive function, compared with active breaksthat involve no cognitive content. While the majorityof physically active lesson and curriculum focussedactive break interventions (2 out of 3 studies) andonly half of active break interventions (5 out of 10studies) led to improvements in cognitive function,there were too few cognitively engaging interventionsincluded in the review to draw a definitive conclu-sion. The one study that compared cognitively en-gaging and non-cognitively engaging active breaks,showed an impact on cognitive outcomes for the cog-nitively engaging breaks group only, lending supportto this hypothesis [26]. Although not explicitly stated,many studies which do not purport to involve cogni-tively engaging physical activity involve some activitieswhich are likely to confer cognitive engagement e.g.hopping sequences to music [37, 38], and coordina-tive exercises [50]. Some of these report positive andsome null findings, yet it is difficult to ascertain theproportion of physical activity children were exposedto that was cognitively engaging. Future studies areencouraged to separate the effects of cognitively en-gaging and non-cognitively engaging physical activityon cognitive functions.In addition to the cognitive test used, results may
be dependent on the type of cognitive functionassessed. For example, classroom-based physical activ-ity appeared to have a particularly beneficial effect onselective attention [24, 41, 49], compared with othercomponents of cognitive function, including sustainedattention [46], fluid intelligence [54, 64], informationprocessing speed [50], and executive function [32, 37,38, 40]. However, a recent systematic review con-cluded that there is insufficient evidence to concludewhat specific cognitive functions are most affected byphysical activity [73]. Exercise-induced arousal mayprovide a further explanation for inconsistency infindings. This theory suggests that the heightened
level of arousal during physical activity facilitates cog-nitive function and that this effect may be moderatedby physical activity intensity [74]. However, while themajority of included studies reported a target physicalactivity intensity, few measured physical activity inten-sity during interventions precluding conclusions re-garding the role of physical activity intensity oncognitive function. Thus, the favourable effect ofphysical activity on selective attention indicated inthis review requires further research for confirmation.Nonetheless, should improvements in selective atten-tion occur, such as the ability to ignore distractionsthis may be of particular interest to teachers and mayprovide motivation to incorporate physical activityinto their classroom routine.In addition to classroom behaviour and cognitive
function, classroom-based physical activity may alsohave a positive effect on academic achievement.However, effects on academic achievement may bedependent on intervention duration and the type ofassessment tool used to measure academic achieve-ment. In the current review it appeared that inter-ventions of shorter duration were more likely toshow an improvement in academic achievement if aprogress monitoring tool was used, rather than anational standardised test. This may be becausecurriculum-based measures are sensitive to smallchanges in academic achievement, and can be admin-istered frequently (e.g. weekly) [75, 76], while stan-dardised tests are usually designed to be administeredless frequently (e.g. yearly), and are not sensitive toshort-term progress. Therefore, progress monitoringtools may be a more suitable choice to determineintervention effects on academic achievement in theshort-term. This finding has important implicationsfor future research, indicating it may be important toconsider intervention duration when selecting themeasure of academic achievement. Therefore, futureintervention studies may consider using a progressmonitoring tool for intervention periods less than 1-year, and standardised tests for intervention periodslonger than 1-year if academic achievement is theoutcome of interest.
Fig. 5 Forrest plot of the effect of classroom-based physical activity on physical activity
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 19 of 24
Other studies investigated the impact of differentdoses of classroom-based physical activity on academic-related outcomes. However, results are based on few(n = 4) heterogeneous studies which considered a lim-ited range of potential physical activity doses. Thus, fur-ther research is needed to be able to draw conclusionsregarding the minimal dose of active break required toimpact academic-related outcomes.Several studies aimed to explore the effect of
classroom-based physical activity on children’s phys-ical activity levels [25, 27, 28, 35, 36, 45, 47, 52, 58,60, 63]. Results from the meta-analysis showedclassroom-based physical activity did not affect phys-ical activity levels. However, as only three of the 11identified studies could be included in the meta-analysis these results should be interpreted with cau-tion, and further research is warranted. Findings fromthe systematic review consistently revealed small in-creases in physical activity in children participating inthe intervention, compared with students in the com-parison group. These findings are in line with resultsfrom another review reporting positive associationsbetween classroom-based physical activity interven-tions and children’s physical activity levels [21]. Whilepromising, it is possible compensation for this activityoccurs outside of school. However, with limited infor-mation available, it is difficult to make strong conclu-sions on this. Further, it can be difficult to implementphysical activity interventions in schools, often due toa lack of time associated with competing curriculumdemands [77]. However, classroom-based physical ac-tivity is unique from other forms of school-basedphysical activity (e.g. Physical Education class andschool sport) in that it does not compete for instruc-tional time (physically active lessons and curriculum-focussed active breaks) or requires only minimal timecommitment (active breaks). Thus, classroom-basedphysical activity may be a potentially appealing optionfor schools as it offers a time-efficient strategy to pro-mote physical activity.
LimitationsThe considerable variation between studies in studydesigns, intervention content and outcome assessmenttools make it difficult to draw definitive conclusions,as evidenced by the small proportion of studies thatcould be included in meta-analyses. For studies thatassessed intervention effects on physical activity, themajority compared physical activity levels during theclassroom-based physical activity session, with a trad-itional seated lesson [27, 28, 45, 47], or assessedintervention effects on school day physical activitylevels only [25, 27, 28, 36, 52, 60]. Therefore, it is un-clear if the increase in physical activity during these
sessions is compensated for by a reduction in physicalactivity at other times of the day. However, as inter-vention effects on improving on-task, reducing off-task classroom behaviour and cognitive functionappear to be primarily acute, this may not be a prob-lem for these outcomes. In addition, few studies usedan objective measure of physical activity intensity [27,28, 35, 36, 47, 58, 60, 63]. Thus, future studies usingobjective measures of physical activity are required todetermine intervention effects on overall moderate-to- vigorous-intensity physical activity, and to deter-mine intervention fidelity (i.e. if the required physicalactivity intensity is met) within the sessions. Lastly,given that the majority of included studies reportedsignificant improvements in academic-related out-comes, it is possible publication bias may haveimpacted the lack of published null associations.
ConclusionClassroom-based physical activity interventions mayprovide a practical, low-cost, and effective strategy to in-crease academic-related outcomes, particularly acutepositive effects on improving on-task and reducing off-task classroom behaviour and selective attention.Classroom-based physical activity could also have thepotential to increase children’s physical activity levels,however further research is needed to confirm this.Findings from this systematic review should be inter-preted with caution given the high number of includedstudies of low methodological quality, suggesting there isroom for improvement in classroom-based physical ac-tivity intervention study designs and reporting. This re-view has identified a number of areas for furtherresearch in order to increase understanding of the effectof classroom-based physical activity on academic andphysical activity outcomes. These include the need forfuture studies to use objective measures of physical ac-tivity, and to consider intervention duration when select-ing a measure of academic achievement. In addition,future studies should explore the effect of classroom-based physical activity interventions on specific cognitiveoutcomes, as well as the impact of different types ofphysical activity (aerobic versus anaerobic versus resis-tance training and cognitively engaging vs. non-cognitivelyengaging physical activity) on academic-related outcomes.Further, it is not clear if improvements in academic-related outcomes are a result of the physical activity or aresult of the break from academic instruction, thereforefuture research is encouraged to add an attention controlgroup. Lastly, it is recommended future studies use a stan-dardized measure of cognitive function with establishedreliability and validity to be able to make comparisonsacross studies.
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 20 of 24
Appendix
Table 5 Quality assessment of included studies
Paper Selection bias Study design Confounders Blinding Data collectionmethods
Withdrawals& dropouts
Overall
Goh et al., 2016 moderate moderate strong moderate moderate weak MODERATE
Beck et al., 2016 moderate strong strong moderate weak strong MODERATE
De Greeff et al., 2016 moderate strong strong moderate strong moderate STRONG
Altenburg et al., 2016 weak strong strong moderate strong weak WEAK
Mead et al., 2016 weak strong weak moderate weak weak WEAK
Mullender Wijnsma et al., 2016 moderate strong weak weak strong strong WEAK
Van den berg et al., 2016 weak strong strong moderate moderate weak WEAK
Grieco et al., 2016 moderate strong weak strong moderate weak WEAK
Carlson et al., 2015 moderate weak weak weak strong strong WEAK
Ma et al., 2015 moderate moderate strong moderate strong weak MODERATE
Ma et al., 2014 moderate moderate strong moderate moderate strong STRONG
Howie et al., 2014 moderate moderate strong moderate strong weak MODERATE
Howie et al., 2015 moderate moderate strong moderate strong weak MODERATE
Janssen et al., 2014 weak moderate strong moderate strong weak MODERATE
Wilson et al., 2015 moderate moderate strong moderate weak weak WEAK
Hill et al., 2011 moderate moderate strong strong weak strong MODERATE
Hill et al., 2010 moderate moderate strong strong weak weak WEAK
Ahamed et al., 2007 moderate strong strong moderate weak weak WEAK
Whitt-Glover et al., 2011 moderate strong weak moderate weak strong WEAK
Uhrich & Swarm., 2007 moderate strong weak moderate strong weak WEAK
Katz et al., 2010 moderate strong weak moderate weak weak WEAK
Lisahunter et al., 2014 weak strong weak moderate strong weak WEAK
Bernard et al., 2014 moderate strong weak moderate strong strong MODERATE
Fedewa et al., 2015 weak strong weak moderate strong strong WEAK
Erwin et al., 2013 moderate strong weak moderate strong strong MODERATE
Grieco et al., 2009 moderate moderate strong moderate moderate weak MODERATE
Mahar et al., 2006 moderate strong weak moderate moderate weak WEAK
Bailey & DiPerna., 2015 moderate moderate strong moderate weak weak WEAK
Vazou et al., 2012 moderate moderate strong moderate strong weak MODERATE
McCrady-Spitzer et al., 2015 weak moderate strong moderate strong strong MODERATE
Norris et al., 2015 moderate strong strong moderate weak weak WEAK
Mullender Wijnsma et al., 2015a moderate moderate strong moderate moderate weak MODERATE
Mullender Wijnsma et al., 2015b moderate strong weak moderate moderate weak WEAK
Graham et al., 2014 weak strong and moderate weak moderate weak weak WEAK
Riley et al., 2014 moderate strong weak weak weak strong WEAK
Riley et al., 2015 moderate strong strong weak weak strong WEAK
Donnelly et al., 2009 moderate strong strong moderate strong strong STRONG
Reed et al., 2010 weak strong weak moderate strong weak WEAK
Schmidt et al., 2016 moderate strong strong moderate strong weak MODERATE
Overall ratingStrong = no weak ratingsModerate = 1 weak ratingWeak = 2 or more weak ratings
Watson et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:114 Page 21 of 24
AcknowledgementsAW is a recipient of a Postgraduate Scholarship from Deakin University.AT is supported by a National Heart Foundation of Australia FutureLeader Fellowship (Award 100046). KDH is supported by an AustralianResearch Council Future Fellowship (FT130100637) & Honorary NationalHeart Foundation of Australia Future Leader Fellowship (100370).
FundingN/A.
Availability of data and materialsN/A.
Authors’ contributionsAW conducted the database searches, screened titles, abstracts and full textsfor eligibility criteria, performed methodological quality assessments anddata extraction, and drafted the initial manuscript. KB reviewed full textsfor eligibility criteria, and performed methodological quality assessments.KDH, HB, and AT contributed to interpretation of the data, and madecontributions to multiple revisions of the manuscript. All authors readand approved the final manuscript.
Authors’ information (optional)AW is an experienced primary school teacher, and holds a Master of PublicHealth from the University of Adelaide.
Ethics approval and consent to participateN/A.
Consent for publicationN/A.
Competing interestsThe authors declare they do not have any competing interests.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Received: 29 September 2016 Accepted: 14 August 2017
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