review of literature physical education

Physical Activity and Health Through Physical Education

• First Online: 25 August 2024

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• Adrià Muntaner-Mas 2 , 3  

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Physical education (PE) is an academic subject that provides the opportunity for students to learn the knowledge and skills needed to establish and maintain physically active lifestyles throughout their lifetime. Unequivocally, PE play a crucial role in augmenting physical activity (PA) daily levels, which are linked to a myriad of health benefits. One of the aims of this chapter is to provide an overview of findings from systematic reviews and meta-analyses that have explored PE’s influence on youth health, highlighting its impact on physical fitness, academic performance, cognition, and obesity-related factors within the educational framework. Despite the necessity of additional research, PE via PA programs has revealed improvements in cardiorespiratory fitness, muscular strength, and academic outcomes and has shown a positive effect on obesity-related factors. The chapter emphasizes that PE offer unique opportunities for enhancing health in the school environment, which are not offered by other academic subjects. The chapter concludes by highlighting the necessity for ongoing research to better understand and advocate for PE’s importance in both public health and educational contexts.

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Muntaner-Mas, A. (2024). Physical Activity and Health Through Physical Education. In: García-Hermoso, A. (eds) Promotion of Physical Activity and Health in the School Setting. Springer, Cham. https://doi.org/10.1007/978-3-031-65595-1_7

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Committee on Physical Activity and Physical Education in the School Environment; Food and Nutrition Board; Institute of Medicine; Kohl HW III, Cook HD, editors. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington (DC): National Academies Press (US); 2013 Oct 30.

Educating the Student Body: Taking Physical Activity and Physical Education to School.

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4 Physical Activity, Fitness, and Physical Education: Effects on Academic Performance

Key messages.

• Evidence suggests that increasing physical activity and physical fitness may improve academic performance and that time in the school day dedicated to recess, physical education class, and physical activity in the classroom may also facilitate academic performance.
• Available evidence suggests that mathematics and reading are the academic topics that are most influenced by physical activity. These topics depend on efficient and effective executive function, which has been linked to physical activity and physical fitness.
• Executive function and brain health underlie academic performance. Basic cognitive functions related to attention and memory facilitate learning, and these functions are enhanced by physical activity and higher aerobic fitness.
• Single sessions of and long-term participation in physical activity improve cognitive performance and brain health. Children who participate in vigorous- or moderate-intensity physical activity benefit the most.
• Given the importance of time on task to learning, students should be provided with frequent physical activity breaks that are developmentally appropriate.
• Although presently understudied, physically active lessons offered in the classroom may increase time on task and attention to task in the classroom setting.

Although academic performance stems from a complex interaction between intellect and contextual variables, health is a vital moderating factor in a child's ability to learn. The idea that healthy children learn better is empirically supported and well accepted ( Basch, 2010 ), and multiple studies have confirmed that health benefits are associated with physical activity, including cardiovascular and muscular fitness, bone health, psychosocial outcomes, and cognitive and brain health ( Strong et al., 2005 ; see Chapter 3 ). The relationship of physical activity and physical fitness to cognitive and brain health and to academic performance is the subject of this chapter.

Given that the brain is responsible for both mental processes and physical actions of the human body, brain health is important across the life span. In adults, brain health, representing absence of disease and optimal structure and function, is measured in terms of quality of life and effective functioning in activities of daily living. In children, brain health can be measured in terms of successful development of attention, on-task behavior, memory, and academic performance in an educational setting. This chapter reviews the findings of recent research regarding the contribution of engagement in physical activity and the attainment of a health-enhancing level of physical fitness to cognitive and brain health in children. Correlational research examining the relationship among academic performance, physical fitness, and physical activity also is described. Because research in older adults has served as a model for understanding the effects of physical activity and fitness on the developing brain during childhood, the adult research is briefly discussed. The short- and long-term cognitive benefits of both a single session of and regular participation in physical activity are summarized.

Before outlining the health benefits of physical activity and fitness, it is important to note that many factors influence academic performance. Among these are socioeconomic status ( Sirin, 2005 ), parental involvement ( Fan and Chen, 2001 ), and a host of other demographic factors. A valuable predictor of student academic performance is a parent having clear expectations for the child's academic success. Attendance is another factor confirmed as having a significant impact on academic performance ( Stanca, 2006 ; Baxter et al., 2011 ). Because children must be present to learn the desired content, attendance should be measured in considering factors related to academic performance.

• PHYSICAL FITNESS AND PHYSICAL ACTIVITY: RELATION TO ACADEMIC PERFORMANCE

State-mandated academic achievement testing has had the unintended consequence of reducing opportunities for children to be physically active during the school day and beyond. In addition to a general shifting of time in school away from physical education to allow for more time on academic subjects, some children are withheld from physical education classes or recess to participate in remedial or enriched learning experiences designed to increase academic performance ( Pellegrini and Bohn, 2005 ; see Chapter 5 ). Yet little evidence supports the notion that more time allocated to subject matter will translate into better test scores. Indeed, 11 of 14 correlational studies of physical activity during the school day demonstrate a positive relationship to academic performance ( Rasberry et al., 2011 ). Overall, a rapidly growing body of work suggests that time spent engaged in physical activity is related not only to a healthier body but also to a healthier mind ( Hillman et al., 2008 ).

Children respond faster and with greater accuracy to a variety of cognitive tasks after participating in a session of physical activity ( Tomporowski, 2003 ; Budde et al., 2008 ; Hillman et al., 2009 ; Pesce et al., 2009 ; Ellemberg and St-Louis-Deschênes, 2010 ). A single bout of moderate-intensity physical activity has been found to increase neural and behavioral concomitants associated with the allocation of attention to a specific cognitive task ( Hillman et al., 2009 ; Pontifex et al., 2012 ). And when children who participated in 30 minutes of aerobic physical activity were compared with children who watched television for the same amount of time, the former children cognitively outperformed the latter ( Ellemberg and St-Louis-Desêhenes, 2010 ). Visual task switching data among 69 overweight and inactive children did not show differences between cognitive performance after treadmill walking and sitting ( Tomporowski et al., 2008b ).

When physical activity is used as a break from academic learning time, postengagement effects include better attention ( Grieco et al., 2009 ; Bartholomew and Jowers, 2011 ), increased on-task behaviors ( Mahar et al., 2006 ), and improved academic performance ( Donnelly and Lambourne, 2011 ). Comparisons between 1st-grade students housed in a classroom with stand-sit desks where the child could stand at his/her discretion and in classrooms containing traditional furniture showed that the former children were highly likely to stand, thus expending significantly more energy than those who were seated ( Benden et al., 2011 ). More important, teachers can offer physical activity breaks as part of a supplemental curriculum or simply as a way to reset student attention during a lesson ( Kibbe et al., 2011 ; see Chapter 6 ) and when provided with minimal training can efficaciously produce vigorous or moderate energy expenditure in students ( Stewart et al., 2004 ). Further, after-school physical activity programs have demonstrated the ability to improve cardiovascular endurance, and this increase in aerobic fitness has been shown to mediate improvements in academic performance ( Fredericks et al., 2006 ), as well as the allocation of neural resources underlying performance on a working memory task ( Kamijo et al., 2011 ).

Over the past three decades, several reviews and meta-analyses have described the relationship among physical fitness, physical activity, and cognition (broadly defined as all mental processes). The majority of these reviews have focused on the relationship between academic performance and physical fitness—a physiological trait commonly defined in terms of cardiorespiratory capacity (e.g., maximal oxygen consumption; see Chapter 3 ). More recently, reviews have attempted to describe the effects of an acute or single bout of physical activity, as a behavior, on academic performance. These reviews have focused on brain health in older adults ( Colcombe and Kramer, 2003 ), as well as the effects of acute physical activity on cognition in adults ( Tomporowski, 2003 ). Some have considered age as part of the analysis ( Etnier et al., 1997 , 2006 ). Reviews focusing on research conducted in children ( Sibley and Etnier, 2003 ) have examined the relationship among physical activity, participation in sports, and academic performance ( Trudeau and Shephard, 2008 , 2010 ; Singh et al., 2012 ); physical activity and mental and cognitive health ( Biddle and Asare, 2011 ); and physical activity, nutrition, and academic performance ( Burkhalter and Hillman, 2011 ). The findings of most of these reviews align with the conclusions presented in a meta-analytic review conducted by Fedewa and Ahn (2011) . The studies reviewed by Fedewa and Ahn include experimental/quasi-experimental as well as cross-sectional and correlational designs, with the experimental designs yielding the highest effect sizes. The strongest relationships were found between aerobic fitness and achievement in mathematics, followed by IQ and reading performance. The range of cognitive performance measures, participant characteristics, and types of research design all mediated the relationship among physical activity, fitness, and academic performance. With regard to physical activity interventions, which were carried out both within and beyond the school day, those involving small groups of peers (around 10 youth of a similar age) were associated with the greatest gains in academic performance.

The number of peer-reviewed publications on this topic is growing exponentially. Further evidence of the growth of this line of inquiry is its increased global presence. Positive relationships among physical activity, physical fitness, and academic performance have been found among students from the Netherlands ( Singh et al., 2012 ) and Taiwan ( Chih and Chen, 2011 ). Broadly speaking, however, many of these studies show small to moderate effects and suffer from poor research designs ( Biddle and Asare, 2011 ; Singh et al., 2012 ).

Basch (2010) conducted a comprehensive review of how children's health and health disparities influence academic performance and learning. The author's report draws on empirical evidence suggesting that education reform will be ineffective unless children's health is made a priority. Basch concludes that schools may be the only place where health inequities can be addressed and that, if children's basic health needs are not met, they will struggle to learn regardless of the effectiveness of the instructional materials used. More recently, Efrat (2011) conducted a review of physical activity, fitness, and academic performance to examine the achievement gap. He discovered that only seven studies had included socioeconomic status as a variable, despite its known relationship to education ( Sirin, 2005 ).

Physical Fitness as a Learning Outcome of Physical Education and Its Relation to Academic Performance

Achieving and maintaining a healthy level of aerobic fitness, as defined using criterion-referenced standards from the National Health and Nutrition Examination Survey (NHANES; Welk et al., 2011 ), is a desired learning outcome of physical education programming. Regular participation in physical activity also is a national learning standard for physical education, a standard intended to facilitate the establishment of habitual and meaningful engagement in physical activity ( NASPE, 2004 ). Yet although physical fitness and participation in physical activity are established as learning outcomes in all 50 states, there is little evidence to suggest that children actually achieve and maintain these standards (see Chapter 2 ).

Statewide and national datasets containing data on youth physical fitness and academic performance have increased access to student-level data on this subject ( Grissom, 2005 ; Cottrell et al., 2007 ; Carlson et al., 2008 ; Chomitz et al., 2008 ; Wittberg et al., 2010 ; Van Dusen et al., 2011 ). Early research in South Australia focused on quantifying the benefits of physical activity and physical education during the school day; the benefits noted included increased physical fitness, decreased body fat, and reduced risk for cardiovascular disease ( Dwyer et al., 1979 , 1983 ). Even today, Dwyer and colleagues are among the few scholars who regularly include in their research measures of physical activity intensity in the school environment, which is believed to be a key reason why they are able to report differentiated effects of different intensities. A longitudinal study in Trois-Rivières, Québec, Canada, tracked how the academic performance of children from grades 1 through 6 was related to student health, motor skills, and time spent in physical education. The researchers concluded that additional time dedicated to physical education did not inhibit academic performance ( Shephard et al., 1984 ; Shephard, 1986 ; Trudeau and Shephard, 2008 ).

Longitudinal follow-up investigating the long-term benefits of enhanced physical education experiences is encouraging but largely inconclusive. In a study examining the effects of daily physical education during elementary school on physical activity during adulthood, 720 men and women completed the Québec Health Survey ( Trudeau et al., 1999 ). Findings suggest that physical education was associated with physical activity in later life for females but not males ( Trudeau et al., 1999 ); most of the associations were significant but weak ( Trudeau et al., 2004 ). Adult body mass index (BMI) at age 34 was related to childhood BMI at ages 10-12 in females but not males ( Trudeau et al., 2001 ). Longitudinal studies such as those conducted in Sweden and Finland also suggest that physical education experiences may be related to adult engagement in physical activity ( Glenmark, 1994 ; Telama et al., 1997 ). From an academic performance perspective, longitudinal data on men who enlisted for military service imply that cardiovascular fitness at age 18 predicted cognitive performance in later life (Aberg et al., 2009), thereby supporting the idea of offering physical education and physical activity opportunities well into emerging adulthood through secondary and postsecondary education.

Castelli and colleagues (2007) investigated younger children (in 3rd and 5th grades) and the differential contributions of the various subcomponents of the Fitnessgram ® . Specifically, they examined the individual contributions of aerobic capacity, muscle strength, muscle flexibility, and body composition to performance in mathematics and reading on the Illinois Standardized Achievement Test among a sample of 259 children. Their findings corroborate those of the California Department of Education ( Grissom, 2005 ), indicating a general relationship between fitness and achievement test performance. When the individual components of the Fitnessgram were decomposed, the researchers determined that only aerobic capacity was related to test performance. Muscle strength and flexibility showed no relationship, while an inverse association of BMI with test performance was observed, such that higher BMI was associated with lower test performance. Although Baxter and colleagues (2011) confirmed the importance of attending school in relation to academic performance through the use of 4th-grade student recall, correlations with BMI were not significant.

State-mandated implementation of the coordinated school health model requires all schools in Texas to conduct annual fitness testing using the Fitnessgram among students in grades 3-12. In a special issue of Research Quarterly for Exercise and Sport (2010), multiple articles describe the current state of physical fitness among children in Texas; confirm the associations among school performance levels, academic achievement, and physical fitness ( Welk et al., 2010 ; Zhu et al., 2010 ); and demonstrate the ability of qualified physical education teachers to administer physical fitness tests ( Zhu et al., 2010 ). Also using data from Texas schools, Van Dusen and colleagues (2011) found that cardiovascular fitness had the strongest association with academic performance, particularly in mathematics over reading. Unlike previous research, which demonstrated a steady decline in fitness by developmental stage ( Duncan et al., 2007 ), this study found that cardiovascular fitness did decrease but not significantly ( Van Dusen et al., 2011 ). Aerobic fitness, then, may be important to academic performance, as there may be a dose-response relationship ( Van Dusen et al., 2011 ).

Using a large sample of students in grades 4-8, Chomitz and colleagues (2008) found that the likelihood of passing both mathematics and English achievement tests increased with the number of fitness tests passed during physical education class, and the odds of passing the mathematics achievement tests were inversely related to higher body weight. Similar to the findings of Castelli and colleagues (2007) , socioeconomic status and demographic factors explained little of the relationship between aerobic fitness and academic performance; however, socioeconomic status may be an explanatory variable for students of low fitness ( London and Castrechini, 2011 ).

In sum, numerous cross-sectional and correlational studies demonstrate small-to-moderate positive or null associations between physical fitness ( Grissom, 2005 ; Cottrell et al., 2007 ; Edwards et al., 2009; Eveland-Sayers et al., 2009 ; Cooper et al., 2010 ; Welk et al., 2010 ; Wittberg et al., 2010 ; Zhu et al., 2010 ; Van Dusen et al., 2011 ), particularly aerobic fitness, and academic performance ( Castelli et al, 2007 ; Chomitz et al., 2008 ; Roberts et al., 2010 ; Welk et al., 2010 ; Chih and Chen, 2011 ; London and Castrechini, 2011 ; Van Dusen et al., 2011 ). Moreover, the findings may support a dose-response association, suggesting that the more components of physical fitness (e.g., cardiovascular endurance, strength, muscle endurance) considered acceptable for the specific age and gender that are present, the greater the likelihood of successful academic performance. From a public health and policy standpoint, the conclusions these findings support are limited by few causal inferences, a lack of data confirmation, and inadequate reliability because the data were often collected by nonresearchers or through self-report methods. It may also be noted that this research includes no known longitudinal studies and few randomized controlled trials (examples are included later in this chapter in the discussion of the developing brain).

Physical Activity, Physical Education, and Academic Performance

In contrast with the correlational data presented above for physical fitness, more information is needed on the direct effects of participation in physical activity programming and physical education classes on academic performance.

In a meta-analysis, Sibley and Etnier (2003) found a positive relationship between physical activity and cognition in school-age youth (aged 4-18), suggesting that physical activity, as well as physical fitness, may be related to cognitive outcomes during development. Participation in physical activity was related to cognitive performance in eight measurement categories (perceptual skills, IQ, achievement, verbal tests, mathematics tests, memory, developmental level/academic readiness, and “other”), with results indicating a beneficial relationship of physical activity to all cognitive outcomes except memory ( Sibley and Etnier, 2003 ). Since that meta-analysis, however, several papers have reported robust relationships between aerobic fitness and different aspects of memory in children (e.g., Chaddock et al., 2010a , 2011 ; Kamijo et al., 2011 ; Monti et al., 2012 ). Regardless, the comprehensive review of Sibley and Etnier (2003) was important because it helped bring attention to an emerging literature suggesting that physical activity may benefit cognitive development even as it also demonstrated the need for further study to better understand the multifaceted relationship between physical activity and cognitive and brain health.

The regular engagement in physical activity achieved during physical education programming can also be related to academic performance, especially when the class is taught by a physical education teacher. The Sports, Play, and Active Recreation for Kids (SPARK) study examined the effects of a 2-year health-related physical education program on academic performance in children ( Sallis et al., 1999 ). In an experimental design, seven elementary schools were randomly assigned to one of three conditions: (1) a specialist condition in which certified physical education teachers delivered the SPARK curriculum, (2) a trained-teacher condition in which classroom teachers implemented the curriculum, and (3) a control condition in which classroom teachers implemented the local physical education curriculum. No significant differences by condition were found for mathematics testing; however, reading scores were significantly higher in the specialist condition relative to the control condition ( Sallis et al., 1999 ), while language scores were significantly lower in the specialist condition than in the other two conditions. The authors conclude that spending time in physical education with a specialist did not have a negative effect on academic performance. Shortcomings of this research include the amount of data loss from pre- to posttest, the use of results of 2nd-grade testing that exceeded the national average in performance as baseline data, and the use of norm-referenced rather than criterion-based testing.

In seminal research conducted by Gabbard and Barton (1979) , six different conditions of physical activity (no activity; 20, 30, 40, and 50 minutes; and posttest no activity) were completed by 106 2nd graders during physical education. Each physical activity session was followed by 5 minutes of rest and the completion of 36 math problems. The authors found a potential threshold effect whereby only the 50-minute condition improved mathematical performance, with no differences by gender.

A longitudinal study of the kindergarten class of 1998–1999, using data from the Early Childhood Longitudinal Study, investigated the association between enrollment in physical education and academic achievement ( Carlson et al., 2008 ). Higher amounts of physical education were correlated with better academic performance in mathematics among females, but this finding did not hold true for males.

Ahamed and colleagues (2007) found in a cluster randomized trial that, after 16 months of a classroom-based physical activity intervention, there was no significant difference between the treatment and control groups in performance on the standardized Cognitive Abilities Test, Third Edition (CAT-3). Others have found, however, that coordinative exercise ( Budde et al., 2008 ) or bouts of vigorous physical activity during free time ( Coe et al., 2006 ) contribute to higher levels of academic performance. Specifically, Coe and colleagues examined the association of enrollment in physical education and self-reported vigorous- or moderate-intensity physical activity outside school with performance in core academic courses and on the Terra Nova Standardized Achievement Test among more than 200 6th-grade students. Their findings indicate that academic performance was unaffected by enrollment in physical education classes, which were found to average only 19 minutes of vigorous- or moderate-intensity physical activity. When time spent engaged in vigorous- or moderate-intensity physical activity outside of school was considered, however, a significant positive relation to academic performance emerged, with more time engaged in vigorous- or moderate-intensity physical activity being related to better grades but not test scores ( Coe et al., 2006 ).

Studies of participation in sports and academic achievement have found positive associations ( Mechanic and Hansell, 1987 ; Dexter, 1999 ; Crosnoe, 2002 ; Eitle and Eitle, 2002 ; Stephens and Schaben, 2002 ; Eitle, 2005 ; Miller et al., 2005 ; Fox et al., 2010 ; Ruiz et al., 2010 ); higher grade point averages (GPAs) in season than out of season ( Silliker and Quirk, 1997 ); a negative association between cheerleading and science performance ( Hanson and Kraus, 1998 ); and weak and negative associations between the amount of time spent participating in sports and performance in English-language class among 13-, 14-, and 16-year-old students ( Daley and Ryan, 2000 ). Other studies, however, have found no association between participation in sports and academic performance ( Fisher et al., 1996 ). The findings of these studies need to be interpreted with caution as many of their designs failed to account for the level of participation by individuals in the sport (e.g., amount of playing time, type and intensity of physical activity engagement by sport). Further, it is unclear whether policies required students to have higher GPAs to be eligible for participation. Offering sports opportunities is well justified regardless of the cognitive benefits, however, given that adolescents may be less likely to engage in risky behaviors when involved in sports or other extracurricular activities ( Page et al., 1998 ; Elder et al., 2000 ; Taliaferro et al., 2010 ), that participation in sports increases physical fitness, and that affiliation with sports enhances school connectedness.

Although a consensus on the relationship of physical activity to academic achievement has not been reached, the vast majority of available evidence suggests the relationship is either positive or neutral. The meta-analytic review by Fedewa and Ahn (2011) suggests that interventions entailing aerobic physical activity have the greatest impact on academic performance; however, all types of physical activity, except those involving flexibility alone, contribute to enhanced academic performance, as do interventions that use small groups (about 10 students) rather than individuals or large groups. Regardless of the strength of the findings, the literature indicates that time spent engaged in physical activity is beneficial to children because it has not been found to detract from academic performance, and in fact can improve overall health and function ( Sallis et al., 1999 ; Hillman et al., 2008 ; Tomporowski et al., 2008a ; Trudeau and Shephard, 2008 ; Rasberry et al., 2011 ).

Single Bouts of Physical Activity

Beyond formal physical education, evidence suggests that multi-component approaches are a viable means of providing physical activity opportunities for children across the school curriculum (see also Chapter 6 ). Although health-related fitness lessons taught by certified physical education teachers result in greater student fitness gains relative to such lessons taught by other teachers ( Sallis et al., 1999 ), non-physical education teachers are capable of providing opportunities to be physically active within the classroom ( Kibbe et al., 2011 ). Single sessions or bouts of physical activity have independent merit, offering immediate benefits that can enhance the learning experience. Studies have found that single bouts of physical activity result in improved attention ( Hillman et al., 2003 , 2009 ; Pontifex et al., 2012 ), better working memory ( Pontifex et al., 2009 ), and increased academic learning time and reduced off-task behaviors ( Mahar et al., 2006 ; Bartholomew and Jowers, 2011 ). Yet single bouts of physical activity have differential effects, as very vigorous exercise has been associated with cognitive fatigue and even cognitive decline in adults ( Tomporowski, 2003 ). As seen in Figure 4-1 , high levels of effort, arousal, or activation can influence perception, decision making, response preparation, and actual response. For discussion of the underlying constructs and differential effects of single bouts of physical activity on cognitive performance, see Tomporowski (2003) .

Information processing: Diagram of a simplified version of Sanders's (1983) cognitive-energetic model of human information processing (adapted from Jones and Hardy, 1989). SOURCE: Tomporowski, 2003. Reprinted with permission.

For children, classrooms are busy places where they must distinguish relevant information from distractions that emerge from many different sources occurring simultaneously. A student must listen to the teacher, adhere to classroom procedures, focus on a specific task, hold and retain information, and make connections between novel information and previous experiences. Hillman and colleagues (2009) demonstrated that a single bout of moderate-intensity walking (60 percent of maximum heart rate) resulted in significant improvements in performance on a task requiring attentional inhibition (e.g., the ability to focus on a single task). These findings were accompanied by changes in neuroelectric measures underlying the allocation of attention (see Figure 4-2 ) and significant improvements on the reading subtest of the Wide Range Achievement Test. No such effects were observed following a similar duration of quiet rest. These findings were later replicated and extended to demonstrate benefits for both mathematics and reading performance in healthy children and those diagnosed with attention deficit hyperactivity disorder ( Pontifex et al., 2013 ). Further replications of these findings demonstrated that a single bout of moderate-intensity exercise using a treadmill improved performance on a task of attention and inhibition, but similar benefits were not derived from moderate-intensity exercise that involved exergaming ( O'Leary et al., 2011 ). It was also found that such benefits were derived following cessation of, but not during, the bout of exercise ( Drollette et al., 2012 ). The applications of such empirical findings within the school setting remain unclear.

Effects of a single session of exercise in preadolescent children. SOURCE: Hillman et al., 2009. Reprinted with permission.

A randomized controlled trial entitled Physical Activity Across the Curriculum (PAAC) used cluster randomization among 24 schools to examine the effects of physically active classroom lessons on BMI and academic achievement ( Donnelly et al., 2009 ). The academically oriented physical activities were intended to be of vigorous or moderate intensity (3–6 metabolic equivalents [METs]) and to last approximately 10 minutes and were specifically designed to supplement content in mathematics, language arts, geography, history, spelling, science, and health. The study followed 665 boys and 677 girls for 3 years as they rose from 2nd or 3rd to 4th or 5th grades. Changes in academic achievement, fitness, and blood screening were considered secondary outcomes. During a 3-year period, students who engaged in physically active lessons, on average, improved their academic achievement by 6 percent, while the control groups exhibited a 1 percent decrease. In students who experienced at least 75 minutes of PAAC lessons per week, BMI remained stable (see Figure 4-3 ).

Change in academic scores from baseline after physically active classroom lessons in elementary schools in northeast Kansas (2003–2006). NOTE: All differences between the Physical Activity Across the Curriculum (PAAC) group ( N = 117) and control (more...)

It is important to note that cognitive tasks completed before, during, and after physical activity show varying effects, but the effects were always positive compared with sedentary behavior. In a study carried out by Drollette and colleagues (2012) , 36 preadolescent children completed two cognitive tasks—a flanker task to assess attention and inhibition and a spatial nback task to assess working memory—before, during, and after seated rest and treadmill walking conditions. The children sat or walked on different days for an average of 19 minutes. The results suggest that the physical activity enhanced cognitive performance for the attention task but not for the task requiring working memory. Accordingly, although more research is needed, the authors suggest that the acute effects of exercise may be selective to certain cognitive processes (i.e., attentional inhibition) while unrelated to others (e.g., working memory). Indeed, data collected using a task-switching paradigm (i.e., a task designed to assess multitasking and requiring the scheduling of attention to multiple aspects of the environment) among 69 overweight and inactive children did not show differences in cognitive performance following acute bouts of treadmill walking or sitting ( Tomporowski et al., 2008b ). Thus, findings to date indicate a robust relationship of acute exercise to transient improvements in attention but appear inconsistent for other aspects of cognition.

Academic Learning Time and On- and Off-Task Behaviors

Excessive time on task, inattention to task, off-task behavior, and delinquency are important considerations in the learning environment given the importance of academic learning time to academic performance. These behaviors are observable and of concern to teachers as they detract from the learning environment. Systematic observation by trained observers may yield important insight regarding the effects of short physical activity breaks on these behaviors. Indeed, systematic observations of student behavior have been used as an alternative means of measuring academic performance ( Mahar et al., 2006 ; Grieco et al., 2009 ).

After the development of classroom-based physical activities, called Energizers, teachers were trained in how to implement such activities in their lessons at least twice per week ( Mahar et al., 2006 ). Measurements of baseline physical activity and on-task behaviors were collected in two 3rd-grade and two 4th-grade classes, using pedometers and direct observation. The intervention included 243 students, while 108 served as controls by not engaging in the activities. A subgroup of 62 3rd and 4th graders was observed for on-task behavior in the classroom following the physical activity. Children who participated in Energizers took more steps during the school day than those who did not; they also increased their on-task behaviors by more than 20 percent over baseline measures.

A systematic review of a similar in-class, academically oriented, physical activity plan—Take 10!—was conducted to identify the effects of its implementation after it had been in use for 10 years ( Kibbe et al., 2011 ). The findings suggest that children who experienced Take 10! in the classroom engaged in moderate to vigorous physical activity (6.16 to 6.42 METs) and had lower BMIs than those who did not. Further, children in the Take 10! classrooms had better fluid intelligence ( Reed et al., 2010 ) and higher academic achievement scores ( Donnelly et al., 2009 ).

Some have expressed concern that introducing physical activity into the classroom setting may be distracting to students. Yet in one study it was sedentary students who demonstrated a decrease in time on task, while active students returned to the same level of on-task behavior after an active learning task ( Grieco et al., 2009 ). Among the 97 3rd-grade students in this study, a small but nonsignificant increase in on-task behaviors was seen immediately following these active lessons. Additionally, these improvements were not mediated by BMI.

In sum, although presently understudied, physically active lessons may increase time on task and attention to task in the classroom setting. Given the complexity of the typical classroom, the strategy of including content-specific lessons that incorporate physical activity may be justified.

It is recommended that every child have 20 minutes of recess each day and that this time be outdoors whenever possible, in a safe activity ( NASPE, 2006 ). Consistent engagement in recess can help students refine social skills, learn social mediation skills surrounding fair play, obtain additional minutes of vigorous- or moderate-intensity physical activity that contribute toward the recommend 60 minutes or more per day, and have an opportunity to express their imagination through free play ( Pellegrini and Bohn, 2005 ; see also Chapter 6 ). When children participate in recess before lunch, additional benefits accrue, such as less food waste, increased incidence of appropriate behavior in the cafeteria during lunch, and greater student readiness to learn upon returning to the classroom after lunch ( Getlinger et al., 1996 ; Wechsler et al., 2001 ).

To examine the effects of engagement in physical activity during recess on classroom behavior, Barros and colleagues (2009) examined data from the Early Childhood Longitudinal Study on 10,000 8- to 9-year-old children. Teachers provided the number of minutes of recess as well as a ranking of classroom behavior (ranging from “misbehaves frequently” to “behaves exceptionally well”). Results indicate that children who had at least 15 minutes of recess were more likely to exhibit appropriate behavior in the classroom ( Barros et al., 2009 ). In another study, 43 4th-grade students were randomly assigned to 1 or no days of recess to examine the effects on classroom behavior ( Jarrett et al., 1998 ). The researchers concluded that on-task behavior was better among the children who had recess. A moderate effect size (= 0.51) was observed. In a series of studies examining kindergartners' attention to task following a 20-minute recess, increased time on task was observed during learning centers and story reading ( Pellegrini et al., 1995 ). Despite these positive findings centered on improved attention, it is important to note that few of these studies actually measured the intensity of the physical activity during recess.

From a slightly different perspective, survey data from 547 Virginia elementary school principals suggest that time dedicated to student participation in physical education, art, and music did not negatively influence academic performance ( Wilkins et al., 2003 ). Thus, the strategy of reducing time spent in physical education to increase academic performance may not have the desired effect. The evidence on in-school physical activity supports the provision of physical activity breaks during the school day as a way to increase fluid intelligence, time on task, and attention. However, it remains unclear what portion of these effects can be attributed to a break from academic time and what portion is a direct result of the specific demands/characteristics of the physical activity.

• THE DEVELOPING bRAIN, PHYSICAL ACTIVITY, AND BRAIN HEALTH

The study of brain health has grown beyond simply measuring behavioral outcomes such as task performance and reaction time (e.g., cognitive processing speed). New technology has emerged that has allowed scientists to understand the impact of lifestyle factors on the brain from the body systems level down to the molecular level. A greater understanding of the cognitive components that subserve academic performance and may be amenable to intervention has thereby been gained. Research conducted in both laboratory and field settings has helped define this line of inquiry and identify some preliminary underlying mechanisms.

The Evidence Base on the Relationship of Physical Activity to Brain Health and Cognition in Older Adults

Despite the current focus on the relationship of physical activity to cognitive development, the evidence base is larger on the association of physical activity with brain health and cognition during aging. Much can be learned about how physical activity affects childhood cognition and scholastic achievement through this work. Despite earlier investigations into the relationship of physical activity to cognitive aging (see Etnier et al., 1997 , for a review), the field was shaped by the findings of Kramer and colleagues (1999) , who examined the effects of aerobic fitness training on older adults using a randomized controlled design. Specifically, 124 older adults aged 60 and 75 were randomly assigned to a 6-month intervention of either walking (i.e., aerobic training) or flexibility (i.e., nonaerobic) training. The walking group but not the flexibility group showed improved cognitive performance, measured as a shorter response time to the presented stimulus. Results from a series of tasks that tapped different aspects of cognitive control indicated that engagement in physical activity is a beneficial means of combating cognitive aging ( Kramer et al., 1999 ).

Cognitive control, or executive control, is involved in the selection, scheduling, and coordination of computational processes underlying perception, memory, and goal-directed action. These processes allow for the optimization of behavioral interactions within the environment through flexible modulation of the ability to control attention ( MacDonald et al., 2000 ; Botvinick et al., 2001 ). Core cognitive processes that make up cognitive control or executive control include inhibition, working memory, and cognitive flexibility ( Diamond, 2006 ), processes mediated by networks that involve the prefrontal cortex. Inhibition (or inhibitory control) refers to the ability to override a strong internal or external pull so as to act appropriately within the demands imposed by the environment ( Davidson et al., 2006 ). For example, one exerts inhibitory control when one stops speaking when the teacher begins lecturing. Working memory refers to the ability to represent information mentally, manipulate stored information, and act on the information ( Davidson et al., 2006 ). In solving a difficult mathematical problem, for example, one must often remember the remainder. Finally, cognitive flexibility refers to the ability to switch perspectives, focus attention, and adapt behavior quickly and flexibly for the purposes of goal-directed action ( Blair et al., 2005 ; Davidson et al., 2006 ; Diamond, 2006 ). For example, one must shift attention from the teacher who is teaching a lesson to one's notes to write down information for later study.

Based on their earlier findings on changes in cognitive control induced by aerobic training, Colcombe and Kramer (2003) conducted a meta-analysis to examine the relationship between aerobic training and cognition in older adults aged 55-80 using data from 18 randomized controlled exercise interventions. Their findings suggest that aerobic training is associated with general cognitive benefits that are selectively and disproportionately greater for tasks or task components requiring greater amounts of cognitive control. A second and more recent meta-analysis ( Smith et al., 2010 ) corroborates the findings of Colcombe and Kramer, indicating that aerobic exercise is related to attention, processing speed, memory, and cognitive control; however, it should be noted that smaller effect sizes were observed, likely a result of the studies included in the respective meta-analyses. In older adults, then, aerobic training selectively improves cognition.

Hillman and colleagues (2006) examined the relationship between physical activity and inhibition (one aspect of cognitive control) using a computer-based stimulus-response protocol in 241 individuals aged 15-71. Their results indicate that greater amounts of physical activity are related to decreased response speed across task conditions requiring variable amounts of inhibition, suggesting a generalized relationship between physical activity and response speed. In addition, the authors found physical activity to be related to better accuracy across conditions in older adults, while no such relationship was observed for younger adults. Of interest, this relationship was disproportionately larger for the condition requiring greater amounts of inhibition in the older adults, suggesting that physical activity has both a general and selective association with task performance ( Hillman et al., 2006 ).

With advances in neuroimaging techniques, understanding of the effects of physical activity and aerobic fitness on brain structure and function has advanced rapidly over the past decade. In particular, a series of studies ( Colcombe et al., 2003 , 2004 , 2006 ; Kramer and Erickson, 2007 ; Hillman et al., 2008 ) of older individuals has been conducted to elucidate the relation of aerobic fitness to the brain and cognition. Normal aging results in the loss of brain tissue ( Colcombe et al., 2003 ), with markedly larger loss evidenced in the frontal, temporal, and parietal regions ( Raz, 2000 ). Thus cognitive functions subserved by these brain regions (such as those involved in cognitive control and aspects of memory) are expected to decay more dramatically than other aspects of cognition.

Colcombe and colleagues (2003) investigated the relationship of aerobic fitness to gray and white matter tissue loss using magnetic resonance imaging (MRI) in 55 healthy older adults aged 55-79. They observed robust age-related decreases in tissue density in the frontal, temporal, and parietal regions using voxel-based morphometry, a technique used to assess brain volume. Reductions in the amount of tissue loss in these regions were observed as a function of fitness. Given that the brain structures most affected by aging also demonstrated the greatest fitness-related sparing, these initial findings provide a biological basis for fitness-related benefits to brain health during aging.

In a second study, Colcombe and colleagues (2006) examined the effects of aerobic fitness training on brain structure using a randomized controlled design with 59 sedentary healthy adults aged 60-79. The treatment group received a 6-month aerobic exercise (i.e., walking) intervention, while the control group received a stretching and toning intervention that did not include aerobic exercise. Results indicated that gray and white matter brain volume increased for those who received the aerobic fitness training intervention. No such results were observed for those assigned to the stretching and toning group. Specifically, those assigned to the aerobic training intervention demonstrated increased gray matter in the frontal lobes, including the dorsal anterior cingulate cortex, the supplementary motor area, the middle frontal gyrus, the dorsolateral region of the right inferior frontal gyrus, and the left superior temporal lobe. White matter volume changes also were evidenced following the aerobic fitness intervention, with increases in white matter tracts being observed within the anterior third of the corpus callosum. These brain regions are important for cognition, as they have been implicated in the cognitive control of attention and memory processes. These findings suggest that aerobic training not only spares age-related loss of brain structures but also may in fact enhance the structural health of specific brain regions.

In addition to the structural changes noted above, research has investigated the relationship between aerobic fitness and changes in brain function. That is, aerobic fitness training has also been observed to induce changes in patterns of functional activation. Functional MRI (fMRI) measures, which make it possible to image activity in the brain while an individual is performing a cognitive task, have revealed that aerobic training induces changes in patterns of functional activation. This approach involves inferring changes in neuronal activity from alteration in blood flow or metabolic activity in the brain. In a seminal paper, Colcombe and colleagues (2004) examined the relationship of aerobic fitness to brain function and cognition across two studies with older adults. In the first study, 41 older adult participants (mean age ~66) were divided into higher- and lower-fit groups based on their performance on a maximal exercise test. In the second study, 29 participants (aged 58-77) were recruited and randomly assigned to either a fitness training (i.e., walking) or control (i.e., stretching and toning) intervention. In both studies, participants were given a task requiring variable amounts of attention and inhibition. Results indicated that fitness (study 1) and fitness training (study 2) were related to greater activation in the middle frontal gyrus and superior parietal cortex; these regions of the brain are involved in attentional control and inhibitory functioning, processes entailed in the regulation of attention and action. These changes in neural activation were related to significant improvements in performance on the cognitive control task of attention and inhibition.

Taken together, the findings across studies suggest that an increase in aerobic fitness, derived from physical activity, is related to improvements in the integrity of brain structure and function and may underlie improvements in cognition across tasks requiring cognitive control. Although developmental differences exist, the general paradigm of this research can be applied to early stages of the life span, and some early attempts to do so have been made, as described below. Given the focus of this chapter on childhood cognition, it should be noted that this section has provided only a brief and arguably narrow look at the research on physical activity and cognitive aging. Considerable work has detailed the relationship of physical activity to other aspects of adult cognition using behavioral and neuroimaging tools (e.g., Boecker, 2011 ). The interested reader is referred to a number of review papers and meta-analyses describing the relationship of physical activity to various aspects of cognitive and brain health ( Etnier et al., 1997 ; Colcombe and Kramer, 2003 ; Tomporowski, 2003 ; Thomas et al., 2012 ).

Child Development, Brain Structure, and Function

Certain aspects of development have been linked with experience, indicating an intricate interplay between genetic programming and environmental influences. Gray matter, and the organization of synaptic connections in particular, appears to be at least partially dependent on experience (NRC/IOM, 2000; Taylor, 2006 ), with the brain exhibiting a remarkable ability to reorganize itself in response to input from sensory systems, other cortical systems, or insult ( Huttenlocher and Dabholkar, 1997 ). During typical development, experience shapes the pruning process through the strengthening of neural networks that support relevant thoughts and actions and the elimination of unnecessary or redundant connections. Accordingly, the brain responds to experience in an adaptive or “plastic” manner, resulting in the efficient and effective adoption of thoughts, skills, and actions relevant to one's interactions within one's environmental surroundings. Examples of neural plasticity in response to unique environmental interaction have been demonstrated in human neuroimaging studies of participation in music ( Elbert et al., 1995 ; Chan et al., 1998 ; Münte et al., 2001 ) and sports ( Hatfield and Hillman, 2001 ; Aglioti et al., 2008 ), thus supporting the educational practice of providing music education and opportunities for physical activity to children.

Effects of Regular Engagement in Physical Activity and Physical Fitness on Brain Structure

Recent advances in neuroimaging techniques have rapidly advanced understanding of the role physical activity and aerobic fitness may have in brain structure. In children a growing body of correlational research suggests differential brain structure related to aerobic fitness. Chaddock and colleagues (2010a , b ) showed a relationship among aerobic fitness, brain volume, and aspects of cognition and memory. Specifically, Chaddock and colleagues (2010a) assigned 9- to 10-year-old preadolescent children to lower- and higher-fitness groups as a function of their scores on a maximal oxygen uptake (VO 2 max) test, which is considered the gold-standard measure of aerobic fitness. They observed larger bilateral hippocampal volume in higher-fit children using MRI, as well as better performance on a task of relational memory. It is important to note that relational memory has been shown to be mediated by the hippocampus ( Cohen and Eichenbaum, 1993 ; Cohen et al., 1999 ). Further, no differences emerged for a task condition requiring item memory, which is supported by structures outside the hippocampus, suggesting selectivity among the aspects of memory that benefit from higher amounts of fitness. Lastly, hippocampal volume was positively related to performance on the relational memory task but not the item memory task, and bilateral hippocampal volume was observed to mediate the relationship between fitness and relational memory ( Chaddock et al., 2010a ). Such findings are consistent with behavioral measures of relational memory in children ( Chaddock et al., 2011 ) and neuroimaging findings in older adults ( Erickson et al., 2009 , 2011 ) and support the robust nonhuman animal literature demonstrating the effects of exercise on cell proliferation ( Van Praag et al., 1999 ) and survival ( Neeper et al., 1995 ) in the hippocampus.

In a second investigation ( Chaddock et al., 2010b ), higher- and lower-fit children (aged 9-10) underwent an MRI to determine whether structural differences might be found that relate to performance on a cognitive control task that taps attention and inhibition. The authors observed differential findings in the basal ganglia, a subcortical structure involved in the interplay of cognition and willed action. Specifically, higher-fit children exhibited greater volume in the dorsal striatum (i.e., caudate nucleus, putamen, globus pallidus) relative to lower-fit children, while no differences were observed in the ventral striatum. Such findings are not surprising given the role of the dorsal striatum in cognitive control and response resolution ( Casey et al., 2008 ; Aron et al., 2009 ), as well as the growing body of research in children and adults indicating that higher levels of fitness are associated with better control of attention, memory, and cognition ( Colcombe and Kramer, 2003 ; Hillman et al., 2008 ; Chang and Etnier, 2009 ). Chaddock and colleagues (2010b) further observed that higher-fit children exhibited increased inhibitory control and response resolution and that higher basal ganglia volume was related to better task performance. These findings indicate that the dorsal striatum is involved in these aspects of higher-order cognition and that fitness may influence cognitive control during preadolescent development. It should be noted that both studies described above were correlational in nature, leaving open the possibility that other factors related to fitness and/or the maturation of subcortical structures may account for the observed group differences.

Effects of Regular Engagement in Physical Activity and Physical Fitness on Brain Function

Other research has attempted to characterize fitness-related differences in brain function using fMRI and event-related brain potentials (ERPs), which are neuroelectric indices of functional brain activation in the electro-encephalographic time series. To date, few randomized controlled interventions have been conducted. Notably, Davis and colleagues (2011) conducted one such intervention lasting approximately 14 weeks that randomized 20 sedentary overweight preadolescent children into an after-school physical activity intervention or a nonactivity control group. The fMRI data collected during an antisaccade task, which requires inhibitory control, indicated increased bilateral activation of the prefrontal cortex and decreased bilateral activation of the posterior parietal cortex following the physical activity intervention relative to the control group. Such findings illustrate some of the neural substrates influenced by participation in physical activity. Two additional correlational studies ( Voss et al., 2011 ; Chaddock et al., 2012 ) compared higher- and lower-fit preadolescent children and found differential brain activation and superior task performance as a function of fitness. That is, Chaddock and colleagues (2012) observed increased activation in prefrontal and parietal brain regions during early task blocks and decreased activation during later task blocks in higher-fit relative to lower-fit children. Given that higher-fit children outperformed lower-fit children on the aspects of the task requiring the greatest amount of cognitive control, the authors reason that the higher-fit children were more capable of adapting neural activity to meet the demands imposed by tasks that tapped higher-order cognitive processes such as inhibition and goal maintenance. Voss and colleagues (2011) used a similar task to vary cognitive control requirements and found that higher-fit children outperformed their lower-fit counterparts and that such differences became more pronounced during task conditions requiring the upregulation of control. Further, several differences emerged across various brain regions that together make up the network associated with cognitive control. Collectively, these differences suggest that higher-fit children are more efficient in the allocation of resources in support of cognitive control operations.

Other imaging research has examined the neuroelectric system (i.e., ERPs) to investigate which cognitive processes occurring between stimulus engagement and response execution are influenced by fitness. Several studies ( Hillman et al., 2005 , 2009 ; Pontifex et al., 2011 ) have examined the P3 component of the stimulus-locked ERP and demonstrated that higher-fit children have larger-amplitude and shorter-latency ERPs relative to their lower-fit peers. Classical theory suggests that P3 relates to neuronal activity associated with revision of the mental representation of the previous event within the stimulus environment ( Donchin, 1981 ). P3 amplitude reflects the allocation of attentional resources when working memory is updated ( Donchin and Coles, 1988 ) such that P3 is sensitive to the amount of attentional resources allocated to a stimulus ( Polich, 1997 ; Polich and Heine, 2007 ). P3 latency generally is considered to represent stimulus evaluation and classification speed ( Kutas et al., 1977 ; Duncan-Johnson, 1981 ) and thus may be considered a measure of stimulus detection and evaluation time ( Magliero et al., 1984 ; Ila and Polich, 1999 ). Therefore the above findings suggest that higher-fit children allocate greater attentional resources and have faster cognitive processing speed relative to lower-fit children ( Hillman et al., 2005 , 2009 ), with additional research suggesting that higher-fit children also exhibit greater flexibility in the allocation of attentional resources, as indexed by greater modulation of P3 amplitude across tasks that vary in the amount of cognitive control required ( Pontifex et al., 2011 ). Given that higher-fit children also demonstrate better performance on cognitive control tasks, the P3 component appears to reflect the effectiveness of a subset of cognitive systems that support willed action ( Hillman et al., 2009 ; Pontifex et al., 2011 ).

Two ERP studies ( Hillman et al., 2009 ; Pontifex et al., 2011 ) have focused on aspects of cognition involved in action monitoring. That is, the error-related negativity (ERN) component was investigated in higher- and lower-fit children to determine whether differences in evaluation and regulation of cognitive control operations were influenced by fitness level. The ERN component is observed in response-locked ERP averages. It is often elicited by errors of commission during task performance and is believed to represent either the detection of errors during task performance ( Gehring et al., 1993 ; Holroyd and Coles, 2002 ) or more generally the detection of response conflict ( Botvinick et al., 2001 ; Yeung et al., 2004 ), which may be engendered by errors in response production. Several studies have reported that higher-fit children exhibit smaller ERN amplitude during rapid-response tasks (i.e., instructions emphasizing speed of responding; Hillman et al., 2009 ) and more flexibility in the allocation of these resources during tasks entailing variable cognitive control demands, as evidenced by changes in ERN amplitude for higher-fit children and no modulation of ERN in lower-fit children ( Pontifex et al., 2011 ). Collectively, this pattern of results suggests that children with lower levels of fitness allocate fewer attentional resources during stimulus engagement (P3 amplitude) and exhibit slower cognitive processing speed (P3 latency) but increased activation of neural resources involved in the monitoring of their actions (ERN amplitude). Alternatively, higher-fit children allocate greater resources to environmental stimuli and demonstrate less reliance on action monitoring (increasing resource allocation only to meet the demands of the task). Under more demanding task conditions, the strategy of lower-fit children appears to fail since they perform more poorly under conditions requiring the upregulation of cognitive control.

Finally, only one randomized controlled trial published to date has used ERPs to assess neurocognitive function in children. Kamijo and colleagues (2011) studied performance on a working memory task before and after a 9-month physical activity intervention compared with a wait-list control group. They observed better performance following the physical activity intervention during task conditions that required the upregulation of working memory relative to the task condition requiring lesser amounts of working memory. Further, increased activation of the contingent negative variation (CNV), an ERP component reflecting cognitive and motor preparation, was observed at posttest over frontal scalp sites in the physical activity intervention group. No differences in performance or brain activation were noted for the wait-list control group. These findings suggest an increase in cognitive preparation processes in support of a more effective working memory network resulting from prolonged participation in physical activity. For children in a school setting, regular participation in physical activity as part of an after-school program is particularly beneficial for tasks that require the use of working memory.

Adiposity and Risk for Metabolic Syndrome as It Relates to Cognitive Health

A related and emerging literature that has recently been popularized investigates the relationship of adiposity to cognitive and brain health and academic performance. Several reports ( Datar et al., 2004 ; Datar and Sturm, 2006 ; Judge and Jahns, 2007 ; Gable et al., 2012 ) on this relationship are based on large-scale datasets derived from the Early Child Longitudinal Study. Further, nonhuman animal research has been used to elucidate the relationships between health indices and cognitive and brain health (see Figure 4-4 for an overview of these relationships). Collectively, these studies observed poorer future academic performance among children who entered school overweight or moved from a healthy weight to overweight during the course of development. Corroborating evidence for a negative relationship between adiposity and academic performance may be found in smaller but more tightly controlled studies. As noted above, Castelli and colleagues (2007) observed poorer performance on the mathematics and reading portions of the Illinois Standardized Achievement Test in 3rd- and 5th-grade students as a function of higher BMI, and Donnelly and colleagues (2009) used a cluster randomized trial to demonstrate that physical activity in the classroom decreased BMI and improved academic achievement among pre-adolescent children.

Relationships between health indices and cognitive and brain health. NOTE: AD = Alzheimer's disease; PD = Parkinson's disease. SOURCE: Cotman et al., 2007. Reprinted with permission.

Recently published reports describe the relationship between adiposity and cognitive and brain health to advance understanding of the basic cognitive processes and neural substrates that may underlie the adiposity-achievement relationship. Bolstered by findings in adult populations (e.g., Debette et al., 2010 ; Raji et al., 2010 ; Carnell et al., 2011 ), researchers have begun to publish data on preadolescent populations indicating differences in brain function and cognitive performance related to adiposity (however, see Gunstad et al., 2008 , for an instance in which adiposity was unrelated to cognitive outcomes). Specifically, Kamijo and colleagues (2012a) examined the relationship of weight status to cognitive control and academic achievement in 126 children aged 7-9. The children completed a battery of cognitive control tasks, and their body composition was assessed using dual X-ray absorptiometry (DXA). The authors found that higher BMI and greater amounts of fat mass (particularly in the midsection) were related to poorer performance on cognitive control tasks involving inhibition, as well as lower academic achievement. In follow-up studies, Kamijo and colleagues (2012b) investigated whether neural markers of the relationship between adiposity and cognition may be found through examination of ERP data. These studies compared healthy-weight and obese children and found a differential distribution of the P3 potential (i.e., less frontally distributed) and larger N2 amplitude, as well as smaller ERN magnitude, in obese children during task conditions that required greater amounts of inhibitory control ( Kamijo et al., 2012c ). Taken together, the above results suggest that obesity is associated with less effective neural processes during stimulus capture and response execution. As a result, obese children perform tasks more slowly ( Kamijo et al., 2012a ) and are less accurate ( Kamijo et al., 2012b , c ) in response to tasks requiring variable amounts of cognitive control. Although these data are correlational, they provide a basis for further study using other neuroimaging tools (e.g., MRI, fMRI), as well as a rationale for the design and implementation of randomized controlled studies that would allow for causal interpretation of the relationship of adiposity to cognitive and brain health. The next decade should provide a great deal of information on this relationship.

• LIMITATIONS

Despite the promising findings described in this chapter, it should be noted that the study of the relationship of childhood physical activity, aerobic fitness, and adiposity to cognitive and brain health and academic performance is in its early stages. Accordingly, most studies have used designs that afford correlation rather than causation. To date, in fact, only two randomized controlled trials ( Davis et al., 2011 ; Kamijo et al., 2011 ) on this relationship have been published. However, several others are currently ongoing, and it was necessary to provide evidence through correlational studies before investing the effort, time, and funding required for more demanding causal studies. Given that the evidence base in this area has grown exponentially in the past 10 years through correlational studies and that causal evidence has accumulated through adult and nonhuman animal studies, the next step will be to increase the amount of causal evidence available on school-age children.

Accomplishing this will require further consideration of demographic factors that may moderate the physical activity–cognition relationship. For instance, socioeconomic status has a unique relationship with physical activity ( Estabrooks et al., 2003 ) and cognitive control ( Mezzacappa, 2004 ). Although many studies have attempted to control for socioeconomic status (see Hillman et al., 2009 ; Kamijo et al., 2011 , 2012a , b , c ; Pontifex et al., 2011 ), further inquiry into its relationship with physical activity, adiposity, and cognition is warranted to determine whether it may serve as a potential mediator or moderator for the observed relationships. A second demographic factor that warrants further consideration is gender. Most authors have failed to describe gender differences when reporting on the physical activity–cognition literature. However, studies of adiposity and cognition have suggested that such a relationship may exist (see Datar and Sturm, 2006 ). Additionally, further consideration of age is warranted. Most studies have examined a relatively narrow age range, consisting of a few years. Such an approach often is necessary because of maturation and the need to develop comprehensive assessment tools that suit the various stages of development. However, this approach has yielded little understanding of how the physical activity–cognition relationship may change throughout the course of maturation.

Finally, although a number of studies have described the relationship of physical activity, fitness, and adiposity to standardized measures of academic performance, few attempts have been made to observe the relationship within the context of the educational environment. Standardized tests, although necessary to gauge knowledge, may not be the most sensitive measures for (the process of) learning. Future research will need to do a better job of translating promising laboratory findings to the real world to determine the value of this relationship in ecologically valid settings.

From an authentic and practical to a mechanistic perspective, physically active and aerobically fit children consistently outperform their inactive and unfit peers academically on both a short- and a long-term basis. Time spent engaged in physical activity is related not only to a healthier body but also to enriched cognitive development and lifelong brain health. Collectively, the findings across the body of literature in this area suggest that increases in aerobic fitness, derived from physical activity, are related to improvements in the integrity of brain structure and function that underlie academic performance. The strongest relationships have been found between aerobic fitness and performance in mathematics, reading, and English. For children in a school setting, regular participation in physical activity is particularly beneficial with respect to tasks that require working memory and problem solving. These findings are corroborated by the results of both authentic correlational studies and experimental randomized controlled trials. Overall, the benefits of additional time dedicated to physical education and other physical activity opportunities before, during, and after school outweigh the benefits of exclusive utilization of school time for academic learning, as physical activity opportunities offered across the curriculum do not inhibit academic performance.

Both habitual and single bouts of physical activity contribute to enhanced academic performance. Findings indicate a robust relationship of acute exercise to increased attention, with evidence emerging for a relationship between participation in physical activity and disciplinary behaviors, time on task, and academic performance. Specifically, higher-fit children allocate greater resources to a given task and demonstrate less reliance on environmental cues or teacher prompting.

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• DOI: 10.1123/APAQ.24.2.103
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Inclusion in physical education: a review of the literature from 1995-2005.

• M. Block , I. Obrusnikova
• Published in Adapted Physical Activity… 1 April 2007

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Teacher socialization in physical education: A scoping review of literature

• Kinesiology and Community Health

Research output : Contribution to journal › Article › peer-review

Occupational socialization theory (OST) has framed research on physical education (PE) teacher recruitment, professional preparation, and ongoing socialization in schools for nearly 40 yr. Using scoping-review methods, the authors sought to understand the current scope of published research on PE-teacher socialization using OST by descriptively and thematically reviewing 111 identified studies published in English-language journals between 1979 and 2015. Results indicate a predominance of qualitative, cross-sectional research related to PE-teacher socialization, most of which was conducted by a relatively small group of scholars. Themes derived from the analysis of study findings communicate the complexity of teacher socialization experiences and are used to develop recommendations for future research and practice that work toward helping improve teachers' lived experiences while creating better contexts in which students can learn. The paper concludes with a discussion of extending OST research to understand the recruitment, professional education, and socialization of kinesiology faculty members and professionals across subdisciplines.

• Instructional practices
• Occupational socialization theory
• Teacher development
• Teacher education

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• Physical Therapy, Sports Therapy and Rehabilitation
• Public Health, Environmental and Occupational Health

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• 10.1123/kr.2018-0003

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• Teacher Socialization Keyphrases 100%
• Scoping Review Keyphrases 100%
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• Occupational Socialization Theory Keyphrases 75%
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T1 - Teacher socialization in physical education

T2 - A scoping review of literature

AU - Richards, K. Andrew R.

AU - Pennington, Colin G.

AU - Sinelnikov, Oleg A.

N1 - Publisher Copyright: © 2019 Human Kinetics, Inc.

PY - 2019/5/1

Y1 - 2019/5/1

N2 - Occupational socialization theory (OST) has framed research on physical education (PE) teacher recruitment, professional preparation, and ongoing socialization in schools for nearly 40 yr. Using scoping-review methods, the authors sought to understand the current scope of published research on PE-teacher socialization using OST by descriptively and thematically reviewing 111 identified studies published in English-language journals between 1979 and 2015. Results indicate a predominance of qualitative, cross-sectional research related to PE-teacher socialization, most of which was conducted by a relatively small group of scholars. Themes derived from the analysis of study findings communicate the complexity of teacher socialization experiences and are used to develop recommendations for future research and practice that work toward helping improve teachers' lived experiences while creating better contexts in which students can learn. The paper concludes with a discussion of extending OST research to understand the recruitment, professional education, and socialization of kinesiology faculty members and professionals across subdisciplines.

AB - Occupational socialization theory (OST) has framed research on physical education (PE) teacher recruitment, professional preparation, and ongoing socialization in schools for nearly 40 yr. Using scoping-review methods, the authors sought to understand the current scope of published research on PE-teacher socialization using OST by descriptively and thematically reviewing 111 identified studies published in English-language journals between 1979 and 2015. Results indicate a predominance of qualitative, cross-sectional research related to PE-teacher socialization, most of which was conducted by a relatively small group of scholars. Themes derived from the analysis of study findings communicate the complexity of teacher socialization experiences and are used to develop recommendations for future research and practice that work toward helping improve teachers' lived experiences while creating better contexts in which students can learn. The paper concludes with a discussion of extending OST research to understand the recruitment, professional education, and socialization of kinesiology faculty members and professionals across subdisciplines.

KW - Identity

KW - Instructional practices

KW - Occupational socialization theory

KW - Sociology

KW - Teacher development

KW - Teacher education

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U2 - 10.1123/kr.2018-0003

DO - 10.1123/kr.2018-0003

M3 - Article

AN - SCOPUS:85067174366

SN - 2163-0453

JO - Kinesiology Review

JF - Kinesiology Review

• Open access
• Published: 23 August 2024

The role of emotions in academic performance of undergraduate medical students: a narrative review

• Nora Alshareef 1 , 2 ,
• Ian Fletcher 2 &
• Sabir Giga 2  

BMC Medical Education volume  24 , Article number:  907 ( 2024 ) Cite this article

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This paper is devoted to a narrative review of the literature on emotions and academic performance in medicine. The review aims to examine the role emotions play in the academic performance of undergraduate medical students.

Eight electronic databases were used to search the literature from 2013 to 2023, including Academic Search Ultimate, British Education Index, CINAHL, Education Abstract, ERIC, Medline, APA Psych Articles and APA Psych Info. Using specific keywords and terms in the databases, 3,285,208 articles were found. After applying the predefined exclusion and inclusion criteria to include only medical students and academic performance as an outcome, 45 articles remained, and two reviewers assessed the quality of the retrieved literature; 17 articles were selected for the narrative synthesis.

The findings indicate that depression and anxiety are the most frequently reported variables in the reviewed literature, and they have negative and positive impacts on the academic performance of medical students. The included literature also reported that a high number of medical students experienced test anxiety during their study, which affected their academic performance. Positive emotions lead to positive academic outcomes and vice versa. However, Feelings of shame did not have any effect on the academic performance of medical students.

The review suggests a significant relationship between emotions and academic performance among undergraduate medical students. While the evidence may not establish causation, it underscores the importance of considering emotional factors in understanding student performance. However, reliance on cross-sectional studies and self-reported data may introduce recall bias. Future research should concentrate on developing anxiety reduction strategies and enhancing mental well-being to improve academic performance.

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Introduction

Studying medicine is a multi-dimensional process involving acquiring medical knowledge, clinical skills, and professional attitudes. Previous research has found that emotions play a significant role in this process [ 1 , 2 ]. Different types of emotions are important in an academic context, influencing performance on assessments and evaluations, reception of feedback, exam scores, and overall satisfaction with the learning experience [ 3 ]. In particular, medical students experience a wide range of emotions due to many emotionally challenging situations, such as experiencing a heavy academic workload, being in the highly competitive field of medicine, retaining a large amount of information, keeping track of a busy schedule, taking difficult exams, and dealing with a fear of failure [ 4 , 5 , 6 ].Especially during their clinical years, medical students may experience anxiety when interacting with patients who are suffering, ill, or dying, and they must work with other healthcare professionals. Therefore, it is necessary to understand the impact of emotions on medical students to improve their academic outcomes [ 7 ].

To distinguish the emotions frequently experienced by medical students, it is essential to define them. Depression is defined by enduring emotions of sadness, despair, and a diminished capacity for enjoyment or engagement in almost all activities [ 4 ]. Negative emotions encompass unpleasant feelings such as anger, fear, sadness, and anxiety, and they frequently cause distress [ 8 ]. Anxiety is a general term that refers to a state of heightened nervousness or worry, which can be triggered by various factors. Test anxiety, on the other hand, is a specific type of anxiety that arises in the context of taking exams or assessments. Test anxiety is characterised by physiological arousal, negative self-perception, and a fear of failure, which can significantly impair a student’s ability to perform well academically [ 9 , 10 ]. Shame is a self-conscious emotion that arises from the perception of having failed to meet personal or societal standards. It can lead to feelings of worthlessness and inadequacy, severely impacting a student’s motivation and academic performance [ 11 , 12 ]. In contrast, positive emotions indicate a state of enjoyable involvement with the surroundings, encompassing feelings of happiness, appreciation, satisfaction, and love [ 8 ].

Academic performance generally refers to the outcomes of a student’s learning activities, often measured through grades, scores, and other formal assessments. Academic achievement encompasses a broader range of accomplishments, including mastery of skills, attainment of knowledge, and the application of learning in practical contexts. While academic performance is often quantifiable, academic achievement includes qualitative aspects of a student’s educational journey [ 13 ].

According to the literature, 11–40% of medical students suffer from stress, depression, and anxiety due to the intensity of medical school, and these negative emotions impact their academic achievement [ 14 , 15 ]. Severe anxiety may impair memory function, decrease concentration, lead to a state of hypervigilance, and interfere with judgment and cognitive function, further affecting academic performance [ 16 ]. However, some studies have suggested that experiencing some level of anxiety has a positive effect and serves as motivation that can improve academic performance [ 16 , 17 ].

Despite the importance of medical students’ emotions and their relation to academic performance, few studies have been conducted in this area. Most of these studies have focused on the prevalence of specific emotions without correlating with medical students’ academic performance. Few systematic reviews have addressed the emotional challenges medical students face. However, there is a lack of comprehensive reviews that discuss the role of emotions and academic outcomes. Therefore, this review aims to fill this gap by exploring the relationship between emotions and the academic performance of medical students.

Aim of the study

This review aims to examine the role emotions play in the academic performance of undergraduate medical students.

A systematic literature search examined the role of emotions in medical students’ academic performance. The search adhered to the concepts of a systematic review, following the criteria of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 18 ]. Then, narrative synthesise was done to analyse the retrieved literature and synthesise the results. A systematic literature search and narrative review provide complete coverage and flexibility to explore and understand findings. Systematic search assures rigour and reduces bias, while narrative synthesis allows for flexible integration and interpretation. This balance improves review quality and utility.

Eligibility criteria

Inclusion criteria.

The study’s scope was confined to January 2013 to December 2023, focusing exclusively on undergraduate medical students. The research encompassed articles originating within medical schools worldwide, accepting content from all countries. The criteria included only full-text articles in English published in peer-reviewed journals. Primary research was considered, embracing quantitative and mixed-method research. The selected studies had to explicitly reference academic performance, test results, or GPA as key outcomes to address the research question.

Exclusion criteria

The study excluded individuals beyond the undergraduate medical student demographic, such as students in other health fields and junior doctors. There was no imposed age limit for the student participants. The research specifically focused on articles within medical schools, excluding those from alternative settings. It solely considered full-text articles in English-language peer-reviewed journals. Letters or commentary articles were excluded, and the study did not limit itself to a particular type of research. Qualitative studies were excluded from the review because they did not have the quantitative measures required to answer the review’s aim. This review excluded articles on factors impacting academic performance, those analysing nursing students, and gender differences. The reasons and numbers for excluding articles are shown in Table  1 .

Information sources

Eight electronic databases were used to search the literature. These were the following: Academic Search Ultimate, British Education Index, CINAHL, Education Abstract, ERIC, Medline, APA Psych Articles and APA Psych Info. The databases were chosen from several fields based on relevant topics, including education, academic evaluation and assessment, medical education, psychology, mental health, and medical research. Initially, with the help of a subject librarian, the researcher used all the above databases; the databases were searched with specific keywords and terms, and the terms were divided into the following concepts emotions, academic performance and medical students. Google Scholar, EBSCOhost, and the reference list of the retrieved articles were also used to identify other relevant articles.

Search strategy

This review started with a search of the databases. Eight electronic databases were used to search the literature from 2013 to 2023. Specific keywords and terms were used to search the databases, resulting in 3,285,208 articles. After removing duplicates, letters and commentary, this number was reduced to 1,637 articles. Exclusion and inclusion criteria were then applied, resulting in 45 articles. After two assessors assessed the literature, 17 articles were selected for the review. The search terms are as follows:

Keywords: Emotion, anxiety, stress, empathy, test anxiety, exam anxiety, test stress, exam stress, depression, emotional regulation, test scores, academic performance, grades, GPA, academic achievement, academic success, test result, assessment, undergraduate medical students and undergraduate medical education.

Emotions: TI (Emotion* OR Anxiety OR Stress OR empathy) OR emotion* OR (test anxiety or exam anxiety or test stress or exam stress) OR (depression) OR AB ((Emotion* OR Anxiety OR Stress OR empathy) OR emotion* OR (test anxiety or exam anxiety or test stress or exam stress)) (MH “Emotions”) OR (MH “Emotional Regulation”) DE “EMOTIONS”.

Academic performance: TI (test scores or academic performance or grades or GPA) OR (academic achievement or academic performance or academic success) OR (test result* OR assessment*) OR AB (test scores or academic performance or grades or GPA) OR (academic achievement or academic performance or academic success) OR test result* OR assessment*.

Medical Students: TI (undergraduate medical students OR undergraduate medical education) OR AB (undergraduate medical students OR undergraduate medical education), TI “medical students” OR AB “medical students” DE “Medical Students”.

Selection process

This literature review attempts to gather only peer-reviewed journal articles published in English on undergraduate medical students’ negative and positive emotions and academic performance from January 2013 to December 2023. Their emotions, including depression, anxiety, physiological distress, shame, happiness, joy, and all emotions related to academic performance, were examined in quantitative research and mixed methods.

Moreover, to focus the search, the author specified and defined each keyword using advanced search tools, such as subject headings in the case of the Medline database. The author used ‘MeSH 2023’ as the subject heading, then entered the term ‘Emotion’ and chose all the relevant meanings. This method was applied to most of the keywords.

Studies were included based on predefined criteria related to study design, participants, exposure, outcomes, and study types. Two independent reviewers screened each record, and the report was retrieved. In the screening process, reviewers independently assessed each article against the inclusion criteria, and discrepancies were resolved through consensus during regular team meetings. In cases of persistent disagreement, a third reviewer was consulted. Endnote library program was used for the initial screening phase. This tool was used to identify duplicates, facilitated the independent screening of titles and abstracts and helped to retrieve the full-text articles. The reasons for excluding the articles are presented in Table  1 .

Data collection process

Two independent reviewers extracted data from the eligible studies, with any discrepancies resolved through discussion and consensus. If the two primary reviewers could not agree, a third reviewer served as an arbitrator. For each included study, the following information was extracted and recorded in a standardised database: first author name, publication year, study design, sample characteristics, details of the emotions exposed, outcome measures, and results.

Academic performance as an outcome for medical students was defined to include the following: Exam scores (e.g., midterm, final exams), Clinical assessments (e.g., practical exams, clinical rotations), Overall grade point average (GPA) or any other relevant indicators of academic achievement.

Data were sought for all outcomes, including all measures, time points, and analyses within each outcome domain. In cases where studies reported multiple measures or time points, all relevant data were extracted to provide a comprehensive overview of academic performance. If a study reported outcomes beyond the predefined domains, inclusion criteria were established to determine whether these additional outcomes would be included in the review. This involved assessing relevance to the primary research question and alignment with the predefined outcome domains.

Quality assessment

The quality and risk of bias in included studies were assessed using the National Institute of Health’s (NIH) critical appraisal tool. The tool evaluates studies based on the following domains: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases. Two independent reviewers assessed the risk of bias in each included study. Reviewers worked collaboratively to reach a consensus on assessments. Discrepancies were resolved through discussion and consensus. In cases of persistent disagreement, a third reviewer was consulted.

To determine the validity of eligible articles, all the included articles were critically appraised, and all reviewers assessed bias. The validity and reliability of the results were assessed by using objective measurement. Each article was scored out of 14, with 14 indicating high-quality research and 1 indicating low-quality research. High-quality research, according to the NIH (2013), includes a clear and focused research question, defines the study population, features a high participation rate, mentions inclusion and exclusion criteria, uses clear and specific measurements, reports results in detail, lists the confounding factors and lists the implications for the local community. Therefore, an article was scored 14 if it met all criteria of the critical appraisal tool. Based on scoring, each study was classified into one of three quality categories: good, fair or poor. The poorly rated articles mean their findings were unreliable, and they will not be considered, including two articles [ 16 , 19 ]. Seventeen articles were chosen after critical appraisal using the NIH appraisal tool, as shown in Table  2 .

Effect measures

For each outcome examined in the included studies, various effect measures were utilised to quantify the relationship between emotions and academic performance among undergraduate medical students. The effect measures commonly reported across the studies included prevalence rat, correlation coefficients, and mean differences. The reviewer calculated the effect size for the studies that did not report the effect. The choice of effect measure depended on the nature of the outcome variable and the statistical analysis conducted in each study. These measures were used to assess the strength and direction of the association between emotional factors and academic performance.

The synthesis method

The findings of individual studies were summarised to highlight crucial characteristics. Due to the predicted heterogeneity, the synthesis involved pooling effect estimates and using a narrative method. A narrative synthesis approach was employed in the synthesis of this review to assess and interpret the findings from the included studies qualitatively. The narrative synthesis involved a qualitative examination of the content of each study, focusing on identifying common themes. This synthesis was employed to categorise and interpret data, allowing for a nuanced understanding of the synthesis. Themes related to emotions were identified and extracted for synthesis. Control-value theory [ 20 ] was used as an overarching theory, providing a qualitative synthesis of the evidence and contributing to a deeper understanding of the research question. If the retrieved articles include populations other than medical, such as dental students or non-medical students, the synthesis will distinguish between them and summarise the findings of the medical students only, highlighting any differences or similarities.

The Control-Value Theory, formulated by Pekrun (2006), is a conceptual framework that illustrates the relationship between emotions and academic achievement through two fundamental assessments: control and value. Control pertains to the perceived ability of a learner to exert influence over their learning activities and the results they achieve. Value relates to a student’s significance to these actions and results. The theory suggests that students are prone to experiencing good feelings, such as satisfaction and pride when they possess a strong sense of control and importance towards their academic assignments. On the other hand, individuals are prone to encountering adverse emotions (such as fear and embarrassment) when they perceive a lack of control or worth in these particular occupations. These emotions subsequently impact students’ motivation, learning strategies, and, eventually, their academic achievement. The relevance of control-value theory in reviewing medical student emotions and their influence on academic performance is evident for various reasons. This theory offers a complete framework that facilitates comprehending the intricate connection between emotions and academic achievement. It considers positive and negative emotions, providing a comprehensive viewpoint on how emotions might influence learning and performance. The relevance of control and value notions is particularly significant for medical students due to their frequent exposure to high-stakes tests and difficult courses. Gaining insight into the students’ perception of their power over academic assignments and the importance they attach to their medical education might aid in identifying emotional stimuli and devising remedies. Multiple research has confirmed the theory’s assertions, showing the critical influence of control and value evaluations on students’ emotional experiences and academic achievements [ 21 , 22 ].

Data extraction

For this step, a data extraction sheet was developed using the data extraction template provided by the Cochrane Handbook. To ensure the review is evidence-based and bias-free, the Cochrane Handbook strongly suggests that more than one reviewer review the data. Therefore, the main researcher extracted the data from the included studies, and another reviewer checked the included, excluded and extracted data. Any disagreements were resolved via discussion by a third reviewer. The data extraction Table  2 identified all study features, including the author’s name, the year of publication, the method used the aim of the study, the number and description of participants, data collection tools, and study findings.

Finalisation of references and study characteristics

Prisma sheet and the summary of final studies that have been used for the review.

When the keywords and search terms related to emotions, as mentioned above, in the eight databases listed, 3,285,208 articles were retrieved. After using advanced search and subject headings, the number of articles increased to 3,352,371. Similarly, searching for the second keyword, ‘academic performance,’ using all the advanced search tools yielded 8,119,908 articles. Searching for the third keyword, ‘medical students’, yielded 145,757 articles. All terms were searched in article titles and abstracts. After that, the author combined all search terms by using ‘AND’ and applied the time limit from 2013 to 2023; the search narrowed to 2,570 articles. After duplicates, letters and commentary were excluded, the number was reduced to 1,637 articles. After reading the title and abstract to determine relevance to the topic and applying the exclusion and inclusion criteria mentioned above, 45 articles remained; after the quality of the retrieved literature was assessed by two reviewers, 17 articles were selected for the review. The PRISMA flow diagram summarising the same is presented in Fig.  1 . Additionally, One article by Ansari et al. (2018) was selected for the review; it met most inclusion and exclusion criteria except that the outcome measure is cognitive function and not academic performance. Therefore, it was excluded from the review. Figure  1 shows the Prisma flow diagram (2020) of studies identified from the databases.

Prisma flow diagram (2020)

Study characteristics

Table  2 , summarising the characteristics of the included studies, is presented below.

Findings of the study

Country of the study.

Many of the studies were conducted in developing countries, with the majority being conducted in Europe ( n  = 4), followed by Pakistan ( n  = 2), then Saudi Arabia ( n  = 2), and the United States ( n  = 2). The rest of the studies were conducted in South America ( n  = 1), Morocco ( n  = 1), Brazil ( n  = 1), Australia ( n  = 1), Iran ( n  = 1), South Korea ( n  = 1) and Bosnia and Herzegovina ( n  = 1). No included studies were conducted in the United Kingdom.

Study design

Regarding study design, most of the included articles used a quantitative methodology, including 12 cross-sectional studies. There were two randomised controlled trials, one descriptive correlation study, one cohort study, and only one mixed-method study.

Population and study setting

Regarding population and setting, most of the studies focused on all medical students studying in a medical school setting, from first-year medical students to those in their final year. One study compared medical students with non-medical students; another combined medical students with dental students.

The study aims varied across the included studies. Seven studies examined the prevalence of depression and anxiety among medical students and their relation to academic performance. Four studies examined the relationship between test anxiety and academic performance in medical education. Four studies examined the relationship between medical students’ emotions and academic achievements. One study explored the influence of shame on medical students’ learning.

Study quality

The studies were assessed for quality using tools created by the NIH (2013) and then divided into good, fair, and poor based on these results. Nine studies had a high-quality methodology, seven achieved fair ratings, and only three achieved poor ratings. The studies that were assigned the poor rating were mainly cross-sectional studies, and the areas of weakness were due to the study design, low response rate, inadequate reporting of the methodology and statistics, invalid tools, and unclear research goals.

Outcome measures

Most of the outcome measures were heterogenous and self-administered questionnaires; one study used focus groups and observation ward assessment [ 23 ]. All the studies used the medical students’ academic grades.

Results of the study

The prevalence rate of psychological distress in the retrieved articles.

Depression and anxiety are the most common forms of psychological distress examined concerning academic outcomes among medical students. Studies consistently show concerningly high rates, with prevalence estimates ranging from 7.3 to 66.4% for anxiety and 3.7–69% for depression. These findings indicate psychological distress levels characterised as moderate to high based on common cut-off thresholds have a clear detrimental impact on academic achievement [ 16 , 24 , 25 , 26 ].

The studies collectively examine the impact of psychological factors on academic performance in medical education contexts, using a range of effect sizes to quantify their findings. Aboalshamat et al. (2015) identified a small effect size ( η 2 = 0.018) for depression’s impact on academic performance, suggesting a modest influence. Mihailescu (2016) found a significant negative correlation between levels of depression/anxiety (rho=-0.14, rho=-0.19), academic performance and GPA among medical students. Burr and Beck Dallaghan (2019) reported professional efficacy explaining 31.3% of the variance in academic performance, indicating a significant effect size. However, Del-Ben (2013) et al. did not provide the significant impact of affective changes on academic achievement, suggesting trivial effect sizes for these factors.

In conclusion, anxiety and depression, both indicators of psychological discomfort, are common among medical students. There is a link between distress and poor academic performance results, implying that this relationship merits consideration. Table  3 below shows the specific value of depression and anxiety in retrieved articles.

Test anxiety

In this review, four studies examined the relationship between test anxiety and academic performance in medical education [ 27 , 28 , 29 , 30 ]. The studies found high rates of test anxiety among medical students, ranging from 52% [ 27 ] to as high as 81.1% [ 29 ]. Final-year students tend to experience the highest test anxiety [ 29 ].

Test anxiety has a significant negative correlation with academic performance measures and grade point average (GPA) [ 27 , 28 , 29 ]. Green et al. (2016) found that test anxiety was moderately negatively correlated with USMLE score ( r = − 0.24, p  = 0.00); high test anxiety was associated with low USMLE scores in the control group, further suggesting that anxiety can adversely affect performance. The findings that a test-taking strategy course reduced anxiety without improving test scores highlight the complex nature of anxiety’s impact on performance.

Nazir et al. (2021) found that excellent female medical students reported significantly lower test anxiety than those with low academic grades, with an odds ratio of 1.47, indicating that students with higher test anxiety are more likely to have lower academic grades. Kim’s (2016) research shows moderate correlations between test anxiety and negative achievement emotions such as anxiety and boredom, but interestingly, this anxiety does not significantly affect practical exam scores (OSCE) or GPAs. However, one study found that examination stress enhanced academic performance with a large effect size (W = 0.78), with stress levels at 47.4% among their sample, suggesting that a certain stress level before exams may be beneficial [ 30 ].

Three papers explored shame’s effect on medical students’ academic achievement [ 24 , 31 , 32 ]. Hayat et al. (2018) reported that academic feelings, like shame, significantly depend on the academic year. shame was found to have a slight negative and significant correlation with the academic achievement of learners ( r =-0.15). One study found that some medical students felt shame during simulations-based education examinations because they had made incorrect decisions, which decreased their self-esteem and motivation to learn. However, others who felt shame were motivated to study harder to avoid repeating the same mistakes [ 23 ].

Hautz (2017) study examined how shame affects medical students’ learning using a randomised controlled trial where researchers divided the students into two groups: one group performed a breast examination on mannequins and the other group on actual patients. The results showed that students who performed the clinical examination on actual patients experienced significantly higher levels of shame but performed better in examinations than in the mannequin group. In the final assessments on standardised patients, both groups performed equally well. Therefore, shame decreased with more clinical practice, but shame did not have significant statistics related to learning or performance. Similarly, Burr and Dallaghan (2019) reported that the shame level of medical students was (40%) but had no association with academic performance.

Academic performance, emotions and medical students

Three articles discussed medical students’ emotions and academic performance [ 23 , 24 , 32 ]. Burr and Dallaghan (2019) examine the relationship between academic success and emotions in medical students, such as pride, hope, worry, and shame. It emphasises the links between academic accomplishment and professional efficacy, as well as hope, pride, worry, and shame. Professional efficacy was the most significant factor linked to academic performance, explaining 31.3% of the variance. The importance of emotions on understanding, processing of data, recall of memories, and cognitive burden is emphasised throughout the research. To improve academic achievement, efforts should be made to increase student self-efficacy.

Hayat et al. (2018) found that positive emotions and intrinsic motivation are highly connected with academic achievement, although emotions fluctuate between educational levels but not between genders. The correlations between negative emotions and academic achievement, ranging from − 0.15 to -0.24 for different emotions, suggest small but statistically significant adverse effects.

Behren et al.‘s (2019) mixed-method study found that students felt various emotions during the simulation, focusing on positive emotions and moderate anxiety. However, no significant relationships were found between positive emotions and the student’s performance during the simulation [ 23 ].

This review aims to investigate the role of emotions in the academic performance of undergraduate medical students. Meta-analysis cannot be used because of the heterogeneity of the data collection tools and different research designs [ 33 ]. Therefore, narrative synthesis was adopted in this paper. The studies are grouped into four categories as follows: (1) The effect of depression and anxiety on academic performance, (2) Test anxiety and academic achievement, (3) Shame and academic performance, and (4) Academic performance, emotions and medical students. The control-value theory [ 20 ], will be used to interpret the findings.

The effect of depression and anxiety on academic performance

According to the retrieved research, depression and anxiety can have both a negative and a positive impact on the academic performance of medical students. Severe anxiety may impair memory function, decrease concentration, lead to a state of hypervigilance, interfere with judgment and cognitive function, and further affect academic performance [ 4 ]. Most of the good-quality retrieved articles found that anxiety and depression were associated with low academic performance [ 16 , 24 , 25 , 26 ]. Moreira (2018) and Mihailescu (2016) found that higher depression levels were associated with more failed courses and a lower GPA. However, they did not find any association between anxiety level and academic performance.

By contrast, some studies have suggested that experiencing some level of anxiety reinforces students’ motivation to improve their academic performance [ 16 , 34 ]. Zalihic et al. (2017) conducted a study to investigate anxiety sensitivity about academic success and noticed a positive relationship between anxiety level and high academic scores; they justified this because when medical students feel anxious, they tend to prepare and study more, and they desire to achieve better scores and fulfil social expectations. Similarly, another study found anxiety has a negative impact on academic performance when excessive and a positive effect when manageable, in which case it encourages medical students and motivates them to achieve higher scores [ 35 ].

In the broader literature, the impact of anxiety on academic performance has contradictory research findings. While some studies suggest that having some level of anxiety can boost students’ motivation to improve their academic performance, other research has shown that anxiety has a negative impact on their academic success [ 36 , 37 ]. In the cultural context, education and anxiety attitudes differ widely across cultures. High academic pressure and societal expectations might worsen anxiety in many East Asian societies. Education is highly valued in these societies, frequently leading to significant academic stress. This pressure encompasses attaining high academic marks and outperformance in competitive examinations. The academic demands exerted on students can result in heightened levels of anxiety. The apprehension of not meeting expectations can lead to considerable psychological distress and anxiety, which can appear in their physical and mental health and academic achievement [ 38 , 39 ].

Test anxiety and academic achievement

The majority of the studies reviewed confirm that test anxiety negatively affects academic performance [ 27 , 28 , 29 ]. Several studies have found a significant correlation between test anxiety and academic achievement, indicating that higher levels of test anxiety are associated with lower exam scores and lower academic performance [ 40 , 41 ]. For example, Green et al. (2016) RCT study found that test anxiety has a moderately significant negative correlation with the USMLE score. They found that medical students who took the test-taking strategy course had lower levels of test anxiety than the control group, and their test anxiety scores after the exam had improved from the baseline. Although their test anxiety improved after taking the course, there was no significant difference in the exam scores between students who had and had not taken the course. Therefore, the intervention they used was not effective. According to the control-value theory, this intervention can be improved if they design an emotionally effective learning environment, have a straightforward instructional design, foster self-regulation of negative emotions, and teach students emotion-oriented regulation [ 22 ].

Additionally, according to this theory, students who perceive exams as difficult are more likely to experience test anxiety because test anxiety results from a student’s negative appraisal of the task and outcome values, leading to a reduction in their performance. This aligns with Kim’s (2016) study, which found that students who believed that the OSCE was a problematic exam experienced test anxiety more than other students [ 9 , 22 , 42 ].

In the wider literature, a meta-analysis review by von der Embse (2018) found a medium significant negative correlation ( r =-0.24) between test anxiety and test performance in undergraduate educational settings [ 43 ] . Also, they found a small significant negative correlation ( r =-0.17) between test anxiety and GPA. This indicates that higher levels of test anxiety are associated with lower test performance. Moreover, Song et al. (2021) experimental study examined the effects of test anxiety on working memory capacity and found that test anxiety negatively correlated with academic performance [ 44 ]. Therefore, the evidence from Song’s study suggests a small but significant effect of anxiety on working memory capacity. However, another cross-sectional study revealed that test anxiety in medical students had no significant effect on exam performance [ 45 ]. The complexities of this relationship necessitate additional investigation. Since the retrieved articles are from different countries, it is critical to recognise the possible impact of cultural differences on the impact of test anxiety. Cultural factors such as different educational systems, assessment tools and societal expectations may lead to variances in test anxiety experience and expression across diverse communities [ 46 , 47 ]. Culture has a substantial impact on how test anxiety is expressed and evaluated. Research suggests that the degree and manifestations of test anxiety differ among different cultural settings, emphasising the importance of using culturally validated methods to evaluate test anxiety accurately. A study conducted by Lowe (2019) with Canadian and U.S. college students demonstrated cultural variations in the factors contributing to test anxiety. Canadian students exhibited elevated levels of physiological hyperarousal, but U.S. students had more pronounced cognitive interference. These variations indicate that the cultural environment has an influence on how students perceive and respond to test anxiety, resulting in differing effects on their academic performance in different cultures. Furthermore, scholars highlight the significance of carrying out meticulous instruments to assess test anxiety, which are comparable among diverse cultural cohorts. This technique guarantees that the explanations of test scores are reliable and can be compared across different populations. Hence, it is imperative to comprehend and tackle cultural disparities in order to create efficient interventions and assistance for students who encounter test anxiety in diverse cultural environments. Therefore, there is a need for further studies to examine the level of test anxiety and cultural context.

Shame and academic performance

The review examined three studies that discuss the impact of feelings of shame on academic performance [ 23 , 24 , 48 ]. Generally, shame is considered a negative emotion which involves self-reflection and self-evaluation, and it leads to rumination and self-condemnation [ 49 ]. Intimate examinations conducted by medical students can induce feelings of shame, affecting their ability to communicate with patients and their clinical decisions. Shame can increase the avoidance of intimate physical examinations and also encourage clinical practice [ 23 , 24 , 48 ].

One study found that some medical students felt shame during simulations-based education examinations because they had made incorrect decisions, which decreased their self-esteem and motivation to learn. However, others who felt shame were motivated to study harder to avoid repeating the same mistakes [ 23 ]. Shame decreased with more clinical practice, but shame did not affect their learning or performance [ 48 ]. The literature on how shame affects medical students’ learning is inconclusive [ 31 ].

In the broader literature, shame is considered maladaptive, leading to dysfunctional behaviour, encouraging withdrawal and avoidance of events and inhibiting social interaction. However, few studies have been conducted on shame in the medical field. Therefore, more research is needed to investigate the role of shame in medical students’ academic performance [ 49 ]. In the literature, there are several solutions that can be used to tackle the problem of shame in medical education; it is necessary to establish nurturing learning settings that encourage students to openly discuss their problems and mistakes without the worry of facing severe criticism. This can be accomplished by encouraging medical students to participate in reflective practice, facilitating the processing of their emotions, and enabling them to derive valuable insights from their experiences, all while avoiding excessive self-blame [ 50 ]. Offering robust mentorship and support mechanisms can assist students in effectively managing the difficulties associated with intimate examinations. Teaching staff have the ability to demonstrate proper behaviours and provide valuable feedback and effective mentoring [ 51 ]. Training and workshops that specifically target communication skills and the handling of sensitive situations can effectively equip students to handle intimate tests, hence decreasing the chances of them avoiding such examinations due to feelings of shame [ 52 ].

The literature review focused on three studies that examined the relationship between emotions and the academic achievements of medical students [ 23 , 24 , 32 ].

Behren et al. (2019) mixed-method study on the achievement emotions of medical students during simulations found that placing students in challenging clinical cases that they can handle raises positive emotions. Students perceived these challenges as a positive drive for learning and mild anxiety was considered beneficial. However, the study also found non-significant correlations between emotions and performance during the simulation, indicating a complex relationship between emotions and academic performance. The results revealed that feelings of frustration were perceived to reduce students’ interest and motivation for studying, hampered their decision-making process, and negatively affected their self-esteem, which is consistent with the academic achievement emotions literature where negative emotions are associated with poor intrinsic motivation and reduced the ability to learn [ 3 ].

The study also emphasises that mild anxiety can have positive effects, corroborated by Gregor (2005), which posits that moderate degrees of anxiety can improve performance. The author suggests that an ideal state of arousal (which may be experienced as anxiety) enhances performance. Mild anxiety is commonly seen as a type of psychological stimulation that readies the body for upcoming challenges, frequently referred to as a “fight or flight” response. Within the realm of academic performance, this state of heightened arousal can enhance concentration and optimise cognitive functions such as memory, problem-solving skills, and overall performance. However, once the ideal point is surpassed, any additional increase in arousal can result in a decline in performance [ 53 ]. This is additionally supported by Cassady and Johnson (2002), who discovered that a specific level of anxiety can motivate students to engage in more comprehensive preparation, hence enhancing their performance.

The reviewed research reveals a positive correlation between positive emotions and academic performance and a negative correlation between negative emotions and academic performance. These findings align with the control–value theory [ 8 , 22 ], which suggests that positive emotions facilitate learning through mediating factors, including cognitive learning strategies such as strategic thinking, critical thinking and problem-solving and metacognitive learning strategies such as monitoring, regulating, and planning students’ intrinsic and extrinsic motivation. Additionally, several studies found that extrinsic motivation from the educational environment and the application of cognitive and emotional strategies improve students’ ability to learn and, consequently, their academic performance [ 23 , 24 , 32 ]. By contrast, negative emotions negatively affect academic performance. This is because negative emotions reduce students’ motivation, concentration, and ability to process information [ 23 , 24 , 32 ].

Limitations of the study

This review aims to thoroughly investigate the relationship between emotions and academic performance in undergraduate medical students, but it has inherent limitations. Overall, the methodological quality of the retrieved studies is primarily good and fair. Poor-quality research was excluded from the synthesis. The good-quality papers demonstrated strengths in sampling techniques, data analysis, collection and reporting. However, most of the retrieved articles used cross-section studies, and the drawback of this is a need for a more causal relationship, which is a limitation in the design of cross-sectional studies. Furthermore, given the reliance on self-reported data, there were concerns about potential recall bias. These methodological difficulties were noted in most of the examined research. When contemplating the implications for practice and future study, the impact of these limitations on the validity of the data should be acknowledged.

The limitation of the review process and the inclusion criteria restricted the study to articles published from January 2013 to December 2023, potentially overlooking relevant research conducted beyond this timeframe. Additionally, the exclusive focus on undergraduate medical students may constrain the applicability of findings to other health fields or educational levels.

Moreover, excluding articles in non-English language and those not published in peer-reviewed journals introduces potential language and publication biases. Reliance on electronic databases and specific keywords may inadvertently omit studies using different terms or indexing. While the search strategy is meticulous, it might not cover every relevant study due to indexing and database coverage variations. However, the two assessors’ involvement in study screening, selection, data extraction, and quality assessment improved the robustness of the review and ensured that it included all the relevant research.

In conclusion, these limitations highlight the need for careful interpretation of the study’s findings and stress the importance of future research addressing these constraints to offer a more comprehensive understanding of the nuanced relationship between emotions and academic performance in undergraduate medical education.

Conclusion and future research

The review exposes the widespread prevalence of depression, anxiety and test anxiety within the medical student population. The impact on academic performance is intricate, showcasing evidence of adverse and favourable relationships. Addressing the mental health challenges of medical students necessitates tailored interventions for enhancing mental well-being in medical education. Furthermore, it is crucial to create practical strategies considering the complex elements of overcoming test anxiety. Future research should prioritise the advancement of anxiety reduction strategies to enhance academic performance, focusing on the control-value theory’s emphasis on creating an emotionally supportive learning environment. Additionally, Test anxiety is very common among medical students, but the literature has not conclusively determined its actual effect on academic performance. Therefore, there is a clear need for a study that examines the relationship between test anxiety and academic performance. Moreover, the retrieved literature did not provide effective solutions for managing test anxiety. This gap highlights the need for practical solutions informed by Pekrun’s Control-Value Theory. Ideally, a longitudinal study measuring test anxiety and exam scores over time would be the most appropriate approach. it is also necessary to explore cultural differences to develop more effective solutions and support systems tailored to specific cultural contexts.

The impact of shame on academic performance in medical students was inconclusive. Shame is a negative emotion that has an intricate influence on learning outcomes. The inadequacy of current literature emphasises the imperative for additional research to unravel the nuanced role of shame in the academic journeys of medical students.

Overall, emotions play a crucial role in shaping students’ academic performance, and research has attempted to find solutions to improve medical students’ learning experiences; thus, it is recommended that medical schools revise their curricula and consider using simulation-based learning in their instructional designs to enhance learning and improve students’ emotions. Also, studies have suggested using academic coaching to help students achieve their goals, change their learning styles, and apply self-testing and simple rehearsal of the material. Moreover, the study recommended to improve medical students’ critical thinking and autonomy and changing teaching styles to support students better.

Data availability

all included articles are mentioned in the manuscript, The quality assessment of included articles are located in the supplementary materials file no. 1.

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I would like to thank Lancaster university library for helping me to search the literature and to find the appropriate databases and thanks to Lancaster university to prove access to several softwares.

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NA made substantial contributions throughout the systematic review process and was actively involved in writing and revising the manuscript. NA’s responsible for the design of the study, through the acquisition, analysis, and interpretation of data, to the drafting and substantive revision of the manuscript. NA has approved the submitted version and is personally accountable for her contributions, ensuring the accuracy and integrity of the work. IF was instrumental in screening the literature, extracting data, and conducting the quality assessment of the included studies. Additionally, IF played a crucial role in revising the results and discussion sections of the manuscript, ensuring that the interpretation of data was both accurate and insightful. IF has approved the submitted version and has agreed to be personally accountable for his contributions, particularly in terms of the accuracy and integrity of the parts of the work he was directly involved in. SG contributed significantly to the selection of papers and data extraction, demonstrating critical expertise in resolving disagreements among authors. SG’s involvement was crucial in revising the entire content of the manuscript, enhancing its coherence and alignment with the study’s objectives. SG has also approved the submitted version and is personally accountable for his contributions, committed to upholding the integrity of the entire work.

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Alshareef, N., Fletcher, I. & Giga, S. The role of emotions in academic performance of undergraduate medical students: a narrative review. BMC Med Educ 24 , 907 (2024). https://doi.org/10.1186/s12909-024-05894-1

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A Systematic Review of Variables Used in Physical Therapist Education Program Admissions Part 1: Cognitive Variables

Affiliation.

• 1 Andrea N. Bowens is an associate professor in the Department of Physical Therapy, School of Health Professions at the Samford University, Andrea Bowens 800 Lakeshore Drive CHS 2160 Birmingham, AL, USA 35229 ([email protected]). Please address all correspondence to Andrea N. Bowens.
• PMID: 39150255
• DOI: 10.1097/JTE.0000000000000323

Background and purpose: Physical therapist (PT) education programs seek to identify applicants who will be academically successful in the program and pass the licensure examination. Part one of this systematic literature review aimed to understand the value of cognitive variables in PT education admissions.

Methods: The initial literature search identified 1,592 articles in databases and relevant journals. Of the 39 studies meeting the inclusion criteria, 31 reported on cognitive measures.

Results: Seven studies identified one or more sections of the Graduate Record Examination (GRE) as significant predictors of students' academic performance in PT programs. Ten studies reported that one or more sections of the GRE predicted National Physical Therapy Exam (NPTE) performance, wheres 4 studies found no significant relationship. Undergraduate grade point average (GPA) predicted academic performance in the PT program and on the NPTE in more than 10 studies, whereas 4 found no significant relationship. Other components of the academic record, such as prerequisite course grades, undergraduate institution quality, undergraduate degree, and retaking prerequisite courses, had varying relationships with academic and NPTE performance.

Discussion and conclusion: These outcomes appear to inform the policies and processes for admissions into PT education programs, evidenced by customary use of applicants' GRE scores and GPAs in admission decisions. The inclusion of both cognitive measures in admission decisions may help ensure that admitted students successfully manage the academic rigor of doctoral education and pass the NPTE.

Copyright © 2023 Academy of Physical Therapy Education, APTA.

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Conflict of interest statement

The authors report no conflict of interest.

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Nurses’ role in obesity management in adults in primary healthcare settings worldwide: a scoping review.

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Piwowarczyk, E.; MacPhee, M.; Howe, J. Nurses’ Role in Obesity Management in Adults in Primary Healthcare Settings Worldwide: A Scoping Review. Healthcare 2024 , 12 , 1700. https://doi.org/10.3390/healthcare12171700

Piwowarczyk E, MacPhee M, Howe J. Nurses’ Role in Obesity Management in Adults in Primary Healthcare Settings Worldwide: A Scoping Review. Healthcare . 2024; 12(17):1700. https://doi.org/10.3390/healthcare12171700

Piwowarczyk, Emilia, Maura MacPhee, and Jo Howe. 2024. "Nurses’ Role in Obesity Management in Adults in Primary Healthcare Settings Worldwide: A Scoping Review" Healthcare 12, no. 17: 1700. https://doi.org/10.3390/healthcare12171700

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