Official Title of Study: -

INFLUENCE OF AEROBIC EXERCISE ON

INHIBITORY CONTROL OF EXCUTIVE

FUNCTION IN SPASTIC HEMIPLEGIC

CEREBRAL PALSY: A Randomized

Controlled Trail

Document Date: - 01/08/2019.

Human Subjects protection review board

approval date: - 31/03/2019

INFLUENCE OF AEROBIC EXERCISE ON INHIBITORY CONTROL

OF EXCUTIVE FUNCTION IN SPASTIC HEMIPLEGIC CEREBRAL

PALSY: A Randomized Controlled Trail

Abstract

Background: Inhibitory control of executive functions (EF) is one of the main specific

cognitive impairments that affect children with cerebral palsy, cognitive skills begin

to develop in infancy and continuing through the pre-school years, childhood and into

adolescence it changes across the lifespan of an individual and has great effect on

their participation and quality of life. Aim: The aim of study was to assess the

influence of aerobic exercise on inhibitory control of executive functions in spastic

hemiplegic cerebral palsy. Methods: Sixty children with spastic hemiplegic cerebral

palsywere enrolled in this studyand were assessed for eligibility. Their aged ranged

fromseven and eleven years. They were assignedrandomly into twoequal

groups.Group (A) the study group received aerobic exercise in addition to selected

physical therapy program. And group (B) the control group received the same

selected physical therapy program only. The treatment was conducted for one hour,

three times / weak for three successful months. Eriksen flanker test and StroopColor-

Word test were used to assess inhibitory control of EF pre and post treatment.

Results:Post treatment there was significant increase in accuracy inEriksen flanker

test and StroopColor-Word test and decrease in reaction time ( congurant and

incongurant)only in study group, P< 0.05. Conclusion:Aerobic exercise has

significant effect on inhibitory control of executive functions in spastic hemiplegic

cerebral palsy. Key words: Hemiplegic cerebral palsy,inhibitory control of executive

functions and aerobic exercise.

Introduction:

Cerebral palsy (CP) isa group of permanent disorders of the development

of movement and posturecausing activity limitation. It is the most

common cause of physical disability that attributed to non-progressive

neurological condition that occur in the developing fetal or infant brain.[1]

Motor impairment has frequently been associated with secondary

disturbances as communication,sensation, perception, behavior and

cognition, as well as the presence of epilepsy, disequilibrium[2], and

secondary musculoskeletalproblems[3].Hemiplegic CP is a subtype in

which one side of the body is involved. It affects about 1 in 1,300 live

births[4].It is characterized by a clinical pattern of unilateral motor

impairment[5]. The severity of motor impairment varies widely,

dependingon the site and severity of brain lesion[6, 7].Early brain injury

impacts concomitantly on motor, function and cognitive

development[8].Cognitive ability is a mental process of acquiring

knowledge and understanding through acquired knowledge and

experience[9].

Executive function (EF) constitutes a set of cognitive processes

that comprise distinct yet highly interrelated components such as

cognitive flexibility, inhibitory control, and working memory [10].Because

EF is involved in the regulation of both thought and action, the behavioral

manifestations of EF can be assessed [11], including difficulty switching

between tasks, difficulty initiating new nonroutine actions, and a lack of

impulse control [12].EF have received considerable interest and are strong

predictors of children`s early school success and it includes intentional

shifting/flexibility, working memory, and inhibitory control[13].

Inhibitory control referred to as response inhibition, is one of the

separable cognitive processes thought to comprise the construct of

executive function. In the past, inhibitory control was thought to emerge

only in middle to late childhood, corresponding with improvements in the

child’s ability to execute complex, higher-order integrative tasks [14].

Aerobic exercise refers to exercise that involves or improves

oxygen consumption by the body. It is the type of activity that uses large

muscle groups. Its performance is in a continuous and rhythmic way with

a main goal to make the heart and lungs work harder than they do when

the person at rest [15].Aerobic exercise produces vascular changes,

including an increase in oxygen saturation, promotes angiogenesis, and

increases cerebral blood flow (CBF) in areas related to cognitive function

[16]. Aerobic exercise training improves cerebral perfusion[17]and

metabolism [18], resulting in the reduction in Aβ load [19], up-regulation of

neurotrophins[18], and hippocampal neurogenesis and volume [20].

Exercise increases serum calcium levels, which can then be transported to

the brain to activate the rate limiting enzyme for catecholamine

(dopamine and norepinephrine) synthesis. Both norepinephrine and

dopamine are neurotransmitters [21].Aerobic exercise is an efficient

strategy to positively influence executive control during [22].and after

exercise [23].

Subjects and methods:

A pretest-posttest randomized controlled study was conducted in

outpatient clinic in faculty of physical therapy, Cairo university. Informed

consent was provided for each child from their parents. The procedures

followed were in accordance with the Institutional Ethical Committee

Clearance No:P.T.REC/012/002278

Subjects:Sixty children with spastic hemiplegic cerebral palsy were

enrolled in this study and were assessed for eligibility. Their aged ranged

from seven and eleven years, they were from both sexes, they have left

side hemiplegic cerebral palsy and they were able to walk independently.

We excluded children with visual or auditory problems,children with

history of drug intake that may affect the cognitive function, medically

unstable children especially with cardiovascular disorders and

uncooperative children.

They were assigned randomly into two equal groups. Group (A) the study

group received aerobic exercise in addition to selected physical therapy

program. And group (B) the control group received the same selected

physical therapy program only. The treatment was conducted one hour,

three times / weak for three successful months.

Materials for evaluation:

Eriksen Flanker test and Stroop Color-Word test were used to assess

inhibitory control of EF pre and after treatment.

1) Eriksen Flanker Test: Modified Eriksen Flanker task that has

been widely employed to examine the inhibitory aspect of

executive function [24]. The Flanker task consisted of 20 trials

consisted of two trial types, with either congruent reaction time

(CRT) or incongruent reaction time (iCRT) to certain visual

stimuli. The congruent trial was a horizontally arranged array of

arrows presented in the same direction. The incongruent trial had a

similar array of arrows, but the middle arrow, the target, was

displayed in the opposite direction. Participants were asked to

respond to the direction of the target arrow within the array of

arrows by pressing the corresponding right or left finger button as

quickly and accurately as possible. The accuracy percentage and

reaction times of correct responses on both congruent and

incongruent trials were identified as metrics of behavioral

cognitive performance.

2) Stroop Color-Word Test:One measure of executive function is

the color word Stroop Test, originally developed in 1935 by Stroop

to measure selective attention and cognitive flexibility. It is most

often described as measuring the individual’s ability to shift

cognitive set [25]; it is believed to provide a measure of cognitive

inhibition[26], or the ability to inhibit an over learned (i.e., dominant

response) in favor of an unusual one [25]. The Color–Word task on

which the individual is shown the names of colors printed in

conflicting ink colors(e.g., the word “blue” in red ink) and the

participants were asked to respond to is asked to name the color of

the ink rather than the word by pressing the corresponding first

letter of the color if red press(r) button if yellow press (y)button if

orang press (o) button if purple press (p)button if green press

(g)button if blue press (b) button as quickly and accurately as

possible [27].The Strooptest consisted of 20 trials consisted of two

trial types,with either normal congruent reaction time (CRT) or

incongruent reaction time (iCRT) to certain visual. The normal

trial was when color of the ink is the same color of the word and

The interfere trial the color of the ink not the same as the color of

word . The accuracy percentage and reaction times of correct

responses on both congruent and incongruent trials were identified

as metrics of behavioral cognitive performance.

Flow chart

Fig 1, flow chart

Assessed for

eligibility (n= 66)

Randomized

(n=60)

Allocation

Allocated to intervention (n=30)

reasons) (n= 0 )

Allocated to intervention (n=30)

Did not receive allocated intervention (give reasons) (n=0 )

Excluded (n=6)

(n=3)

Analysis

Analysis

Analysed (n=30)

Excluded from analysis

(n=0)

Analysed (n=30)

Excluded from analysis

(n=0)

Methods of Treatment Group (A) which is the study group received 20 min. selectedphysical

therapy program which contain strengthening exercises for upper limb

and lower limb muscles, stretching exercises for elbow extensors, hand

supinator, wrist extensors, knee extensors and ankle dorsiflexors,

balancing exercises, coordination exercises and gait training exercises in

open environment. In addition toaerobic exercise on a bicycleergometer

for 40 min. Bicycle ergometer (Monark Rehab trainer model 88E) was

used to train children in study group. It is a stationary bicycle with an

ergometer (electronically braked) to measure the work done by the

exerciser. It is equipped with an electronic meter showing pedal

revolutions per minute, total pedal revolutions and time function. It

provides low-impact, safe, and effective cardiovascular exercise. This

low-impact movement does not put much stress on joints.

Before starting the training procedure each child was instructed to wear

comfortable training suit and shoes and to sit vertically on the bicycle

ergometer seat with erect back. Extra strap was placed on child's feet to

provide complete fixation on ergometer pedal. The exercise on bicycle

was done under supervision of researcher to ensure correct and accurate

application.

In the first week, children bicycled to tolerance at 40% to 50% max HR,

and then progressed to the 70% max HR in the second week. Intensity of

aerobic exercise was systematically progressed for each child by

increasing resistance to maintain conditioning at 70% of max HR.

maximum HR calculated from the following equation: max HR=220-age

[28].The first five minutes of each session were dedicated to warmingup

exercise on the bicycle in the form of slow progression exercise (to

decrease the risk of musculoskeletal injury and cardiovascular

complications), followed by the active phase of exercise for 30 min., and

finally cooling down phase for five min. with intensity and speed

decreased gradually until reaching the resting heart rate (RHR) [29].

Group (B): which is the control group received the same selected physical

therapy program only for one hour.The treatment was conducted one

hour, three times / weak for three successful months.

Statistical analysis

For analysis of data in the present study, SPSS software version 21 was

used for data analysis. Descriptive statistics was used to identify the mean

and standard deviation for each variable. Paired t-test was used to test pre

and post changes in each group of the study.

Results:

The mean values of age and grade in study group (A) were 9.77±1.135

and 4.77±1.135 respectively and in control group (B) were9.2±1.243 and

4.2±1.243respectively.There was no significant difference between the

two groups in theirmean values of ages and grades (P > 0.05).

In the study group (A) the number of boys was 21 (70%) and the number

of girls was 9 (30%), while in the control group (B) the number of boys

was 17 (56.7%)and the number of girls was 13 (43.3%)there was no

significant difference between the two groupsingender distribution.

There was no significant difference in pre treatment values Flanker test

accuracy,CRT and iCRTand stroop test accuracy,CRT and iCRTbetween

two groups P > 0.05. While there was significant difference in post

treatment values Flanker test accuracy,CRT and iCRT and stroop test

accuracy,CRT and iCRTbetween two groups P<0.05in favor of the study

group(A).

The mean values of the Flanker test accuracy,CRT and iCRT post

treatment in study group (A) were 90± 10.91, 1161± 291.7and 1417±

588.1respectively, andin control group (B) were 82± 10.88, 1489±

509and 1792± 755.7 respectively. Comparison of the mean value of each

test in study group (A) with the corresponding mean value in control

group (B) revealed significant difference of all variables (p< 0.05) in

favor of study group (A).

The mean values of the Stroop test accuracy,CRT and iCRT post

treatment in study group (A) were 83.5± 11.15, 2240± 947.7and 2647±

729.9respectively, and in control group (B) were 75.67± 12.37, 2752±

911.1and 2990± 558.4 respectively. Comparison of the mean value of

each test in study group(A)with the corresponding mean value in control

group revealed significant difference of all variables (p< 0.05) in favor of

study group (A).

There was a significant increasein post treatment valuesof Flanker test

accuracy 16.17 and stroop test accuracy 13.33 while P-value was 0.0001

and the percentage of improvement was 21.9% and 18.9% respectively.

While there was a significant decrease in post treatment values of

Flanker test CRT 406, iCRT410and the percentage of improvement was

25.91% and 22.44% respectivelyand also there was a significant decrease

in post treatment values of stroop test CRT 741 iCRT 360 and the

percentage of improvement was 24.88% and 11.97% respectively while

P-value was 0.0001.

Variable

Study Group (A) Control Group (B)

Pre

treatme

nt

Post

treatm

ent

Difference

(% change)

t-value

P-value

Pre

treatme

nt

Post

treatm

ent

Difference

(% change)

t-value

P-value

Mean±S

D Mean±S

D Mean±S

D Mean±S

D

Flanker

test

accuracy

73.83±

10.4

90±

10.91

16.17

(21%)

12.8

2

0.0001

**

78.5±

11.9

82±

10.88

3.5

(4.46%)

1.966 0.0589

Flanker

test

CRT

1567±

369.2

1161±

291.7

406

(25.91%) 6.13

8

0.0001

***

1588±

438.6

1489±

509

99

(6.23%) 1.741 0.0923

Flanker

test

iCRT

1827±

779.6

1417±

588.1

410

(22.44%) 2.74

0.0104

*

1847±

787.6

1792±

755.7

55

(2.98%)

0.506

4 0.6164

Stroop

test

accuracy

70.17±

8.758

83.5±

11.15 13.33

(18.9%)

7.10

2

0.0001

**

73.17±

9.048

75.67±

12.37 2.5

(3.42%)

1.525 0.1380

Stroop

test

CRT

2982±

992

2240±

947.7

741

(24.88%) 4.96

9

0.0001

***

2923±

895.5

2752±

911.1

171

(5.85%) 1.36 0.1842

Strooptes

t Icrt 3007±

885.1

2647±

729.9

360

(11.97%)

2.74

9

0.0102

*

3118±

746.3

2990±

558.4

128

(4.1%)

1.257 0.2187

Non-significant: p< 0.05*Significant: p>0.05

Discussion:

This study was conducted to assess the influence of aerobic exercise on

inhibitory control of EFin spastic hemiplegic cerebral palsy. The children

that was selected in this study have left side hemiplegic cerebral palsy

that agreed withGodefroy&Bogousslausky 2007[30]who concluded that

damage in right hemisphere, hemi-spatial neglect is the most frequent

deficit where there is impaired or lost ability to react to or to process

sensory stimuli in the hemispace opposite to the lesion side. This

visuospatial perceptual deficits can affect different cognitive activities

which show up as difficulty copying designs, making constructions,

discriminating pattern of faces , selecting the correct sleeve and self-

monitoring left side or covering the paretic shoulder.

In the current study, selection of hemiplegic cerebral palsied

children comes in agreement withBodimeade et al.[31]who concluded that

although disruptions in motor functioning are often the most recognizable

feature of CP, executive function impairment is also a central feature of

CP when compared EF in children with CP (mean age 11 y/o) to typically

developing controls.

The choice of using a bicycle ergometer for aerobic exercise

training instead of a treadmill was because safety was our foremost

concern for the participants. The bicycles were powered by participants

and easy for them to get on and off, which reduced fall risk, a prevalent

problem in the study population

The present study was revealed significant improvement of all

measured variables of inhibitory control of EF after three successful

months that agreed withRenaud, et al. 2010[32] who observed that only 3

months of well-structured and supervised exercise is associated with a

significant improvement in attention and executive functions.

The results of the present study revealed significant improvement

of all measured variables in study group (A)as there wassignificant

increase in accuracy and decrease reaction time congurant and

incongurantthat mean improvement of inhibitory control of EFthis was

attributed to aerobic exercise.

The results of the present study proved that there was no significant

improvement in all measured variables of Flanker test accuracy,CRT and

iCRTin the control group (B), while there was significant improvement in

all measured variables of Flanker test accuracy,CRT and iCRTin the

control group (A). This improvement may be attributed to the

physiological effect of aerobic exercise on brain as it increases the

cerebral tissue oxygenation, blood flow velocity and cerebral metabolism

and homeostasis which in turn improve the speed of information

processing, motor learning, implicit memory and executive function. This

result agreed with McAuley et al., 2004[33], Kluding et al., 2011[34],

Barbara et al., 2009[35] and Rand et al., 2010[36]. Improvement in

cognitive flexibility was proportional to the degree of exercise Masley et

al., 2009[37].

The improvement of EF afteraerobic exercises may be due to

increases activity in cortical areas associated with cognition, including the

right medial frontal gyrus (BA 46), superior frontal gyrus (BA 8), and

superior parietal lobe (BA 40). It increases the number of

interconnections (synapses) in frontal and parietal gray matter, allowing

for greater systematic recruitment of these areas under higher cognitive

load and also increases prefrontal and anterior cingulate plasticity in the

aging brain to a level more consistent with neurologically intact young

adults This results agreed with(Colcombe and Kramer, 2004).[38].

The results of this study showed that there was significant changes

in all measured variables Stroop test accuracy, CRT and iCRTwhen

comparing pre and post treatment variables between two groups in favor

of the study group (A) this improvement comes in agreement with Pottet

al., (1996) [39], and Ainslie et al., (2008)[40] who reported that aerobic

exercise increases oxygen consumption, reduces blood pressure and

resting heart rate, strengths and enlarges the heart muscle which reflects

on its pumping efficiency leading to increase in global &regional cerebral

blood flow. Plus aerobic exercise was proved to promote angiogenesis

and increase in capillary density.

Gapin et al., 2011[41]also supports the beneficial effects of

physical activity on EF and suggests that effects might be particularly

large for children.

Most studies supported greater improvements of EFafter

moderateto vigorous aerobic exercise in typically developing (TD)

children (Crova et al., 2014[42]; Diamondand Lee, 2011[43]; Verburgh

et al., 2014)[44].

The improvements of EF after sustainedaerobic exercises is (over

months) is required for cognitive improvement this comes in agreement

with Masley2009.[37].

Previous studies have reported improved performance on a variety

of cognitive task categories, including attention, information processing,

memory, and executive function, after a single bout of aerobic exercise

(Audiffren, Tomporowski, &Zagrodnik, 2008[45]; Coles

&Tomporowski,2008[46]; Hillman et al.,2009[47].

The significant improvementin post treatment Stroop test accuracy,

reaction timecongurant andreaction timeincongurantis supported by

EtnierandChang 2009[48]that found a significant improvement in the

Stroop Test after an acute moderate-intensity strength exercise (10 sets of

10 repetitions for six exercises) session in healthy middle-aged (49 ± 9

years) adults. Altogether, these findings reveal the potential of both

aerobic and strength exercise alone in improving executive function.

The potential benefits of physical exercise in promoting increased

EF in our study are consistent with the findings reported in recent

empirical studies on regular aerobic activity and open-skill exercise in

children with and without disabilities(Chang et al., 2014[49]; Guiney and

Machado, 2013[50]; Hilton et al., 2014[51]; Pan et al., 2015[52]; Tsai et

al., 2012[53]).

The results of the present study contradicted with the finding of

Ploughman et al.,(2008)[54] who reported that treadmill exercise did not

cause improvement in cognitive function (including the Trail Making

Test A and B, Symbol Digit Substitution Test, and Paced Auditory

Serial). The discrepancy between the present and Ploughman et

al.[54]study may be attributed to the small sample size and the short

duration of the physical therapy intervention of Ploughman et

al.[54]study. It was assumed thatsustained aerobic exercise (over months)

is required for cognitive improvement(Masley, 2009).[37].

The results of the present study also contradicted with the finding

of Correia et al., (2010)[55]who demonstrated that acute strengthening

exercises do not induce significant alterations in the levels of brain-

derived neurotrophic factor plasma concentrations in healthy individuals.

The discrepancy of results between two studies may be attributed to the

type of exercise program that may be a decisive factor in altering

peripheral brain-derived neurotrophic factor level.

Conclusion: It can be concluded that aerobic exercise has

significant effect on inhibitory control of executive functions in spastic

hemiplegic cerebral palsy children.

References

1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano

D, Dan B, Jacobsson B. A report: The definition and classification

of cerebral palsy April 2006. Dev Med Child Neurol.

2007;109(Suppl. 109):8–14.

2. Oskoui, M.; Coutinho, F.; Dykeman, J.; Jette, N.; Pringsheim, T.

An update on the prevalence of cerebral palsy: A systematic review

and meta-analysis. Dev. Med. Child Neurol. 2013, 55, 509–519.

3. Rosenbaum, P.; Paneth, N.; Levinton, A.; Goldstein, M.; Bax, M.;

Damiano, D.; Dan, B.; Jacobsson, B. A report: The definition and

classification of cerebral palsy April 2006. Dev. Med. Child

Neurol. 2007, 49, 8–14.

4. Surman G, Hemming K, Platt MJ, et al. Children with cerebral

palsy: severity and trends over time. PaediatrPerinatEpidemiol.

2009; 23(6):513–521.

5. Garne E, Dolk H, Krägeloh-Mann I, et al. Cerebral palsy and

congenital malformations. Eur J Paediatr Neurol. 2008; 12(2):82–

88.

6. Holmefur M, Kits A, Bergstrom J, Krumlinde-Sundholm L,

Flodmark O, Forssberg H, Eliasson AC. Neuroradiology can

predict the development of hand function in children with

unilateral cerebral palsy. Neurorehabil Neural Repair.

2013;27(1):72–8.

7. Arner M, Eliasson AC, Nicklasson S, Sommerstein K, Hagglund G.

Hand function in cerebral palsy. Report of 367 children in a

population-based longitudinal health care program. J Hand Surg

Am. 2008;33(8):1337–47.

8. Hielkema T, Hadders-Algra M. Motor and cognitive outcome after

specific early lesions of the brain – A systematic review. Dev Med

Child Neurol. 2016;58(Suppl 4):46–52.

9. Mauricio DM. Cognitive representation of “musical fractals”:

Processing hierarchy and recursion in the auditory domain.

Cognition,2017;161, 31-45.

10. McClelland MM, Cameron CE, Duncan RJ, Bowles RP, Acock

AC, Miao A, et al. Predictors of early growth in academic

achievement: The Head-Toes-Knees-Shoulders task. Frontiers in

Psychology. 2014;5:1–14.

11. Becker, DR, Miao, A, Duncan, R. Behavioral self-regulation and

executive function both predict visuomotor skills and early

academic achievement. Early Childhood Research Quarterly,

2014;29: 411–424.

12. Rajendran, G, Mitchell, P Cognitive theories of autism.

Developmental Review. 2007;27: 224–260.

13. Blair, C., &Razza, R. P. Relating effortful control, executive

function, and false belief understanding to emerging math and

literacy ability in kindergarten. Child Development,2007;78, 647-

663.42.

14. Welsh MC, Friedman SL, Spieker SJ. Executive functions in

developing children: Current conceptualizations and questions for

the future. In: McCartney K, Phillips D, editors. Blackwell

handbook of early childhood development. Malden: Blackwell

Publishing; 2006; pp. 167–187.

15. Ainsworth B, Haskell WL, White MC. Compendium of physical

activities: an update of activity codes and MET intensities. Med Sci

Sports Exerc 2000; 32:Pp498-S504.

16. Lojovich M. The Relationship Between aerobic Exercise and

cognition: Is Movement Medicinal? J Head Trauma Rehabil. 2010;

25(3), Pp184-192.

17. Swain RA, Harris AB, Wiener EC, Dutka MV, Morris HD, Theien BE,

Konda S, Engberg K, Lauterbur PC, Greenough WT. Prolonged

exercise induces angiogenesis and increases cerebral blood volume in

primary motor cortex of the rat. Neuroscience. 2003; 117(4): 1037–

46.

18. Dao AT, Zagaar MA, Levine AT, Alkadhi KA. Comparison of the effect

of exercise on late-phase LTP of the dentate gyrus and CA1 of

Alzheimer's disease model. MolNeurobiol. 2016; 53(10): 6859– 6868.

19. Wolf SA, Kronenberg G, Lehmann K, Blankenship A, Overall R,

Staufenbiel M, Kempermann G. Cognitive and physical activity

differently modulate disease progression in the amyloid precursor

protein (APP)-23 model of Alzheimer's disease. Biol Psychiatry. 2006

15; 60(12): 1314– 23.

20. Pereira AC, Huddleston DE, Brickman AM, Sosunov AA, Hen R,

McKhann GM, Sloan R, Gage FH, Brown TR, Small SA. An in vivo

correlate of exercise-induced neurogenesis in the adult dentate gyrus.

ProcNatlAcadSci U S A. 2007; 104(13): 5638– 43.

21. Sutoo D and Akiyama K. Regulation of brain function by exercise.

Neurobiol Disease. 2003; 13(1): Pp1–14.

22. McMorris, T., & Hale, B. J. Differential effects of differing intensities

of acute exercise on speed and accuracy of cognition: A

meta‐analytical investigation. Brain and Cognition, 80(3), 338– 351.

doi: 10.1016/j.bandc.2012; 09.001.

23. Chang, Y. K., Labban, J. D., Gapin, J. I., &Etnier, J. L. The effects of

acute exercise on cognitive performance: A metaanalysis. Brain

Research, 1453, 87– 101. doi: 10.1016/j.brainres.2012; 02.068.

24. Eriksen, B. A.; Eriksen, C. W. "Effects of noise letters upon

identification of a target letter in a non- search task". Perception and

Psychophysics. 1974; 16: 143–149.

25. Spreen, O., & Strauss, E. A compendium of neuropsychological tests:

Adminsitration, norms, and commentary (2nd

ed.). NY: Oxford

University Press.1998.

26. Archibald, S. J., & Kerns, K. A. Identification and description of new

tests of executive functioning inchildren. Child

Neuropsychology,1999;5, 115–129.

27. Wecker, N. S., Kramer, J. H.,Wisniewski, A., Delis, D. C., & Kaplan, E.

Age effects on executive ability.Neuropsychology,2000; 14, 409–414.

28. Gellish RL. Longitudinal Modeling of the Relationship between Age

and Maximal Heart Rate. Medicine & Science in Sports & Exercise

2007; 39 (5): Pp822-829

29. Wendy Bumgardner. Cardiovascular Exercise Principles and

Guidelines.2007.http://walking.about.com/cs/fitnesswalking/a/cardio.h

tm

30. Godefroy O and Bogousslavsky J. The behavioral and cognitive

neurology of stroke. Cambridge University Press. 2007; P.203.

31. Bodimeade HL, Whittingham K, Lloyd O, Boyd RN. Executive function

in children and adolescents with unilateral cerebral palsy. Dev Med

Child Neurol. 2013; 55:926–33. 10.1111/dmcn.12195

32. Renaud, M., F. Maquestiaux, S. JoncasEffects of three months of

aerobic training on response preparation in older adults. Front. Aging

Neurosci. 2010; 2: 1– 9.

33. McAuley Edward, Arthur F, Stanley J, Colcombe E.Cardiovascular

fitness and neurocognitive function in older Adults: a brief review

(PDF). Brain, Behavior, and Immunity 2004; Pp214–220.

34. Kluding PM, Tsen BY, Billinger SA. Exercise and executive function in

individuals with chronic study: A pilot study. Journal of Neurologic

Physical Therapy 2011; 35: Pp11-17.

35. Barbara Quaney, Lara Boyd, Joan McDowd, Laura Zahner, Jianghua

H, Matthew Mayo Aerobic Exercise Improves Cognition and Motor

Function Poststroke. Neurorehabil Neural Repair 2009; 23(9): Pp879-

885.

36. Rand D, Eng J, Liu-Ambrose, Tawashy AE.Feasability of a 6-month

exercise and recreation program to improve executive functioning and

memory in individuals with chronic stroke. Neurorehabilitation and

Neural Repair 2010; 24: Pp722-729.

37. Masley Steven, Richard Roetzheim, Thomas Gualtieri. Aerobic

Exercise Enhances Cognitive Flexibility. J ClinPsychol Med Settings

2009; 16: Pp186-193.

38. Colcombe SJ, Kramer AF, Erickson KI. Cardiovascular fitness,

cortical plasticity, and aging. Proc Natl AcadSci U S A 2004; 101:

Pp3316-3321.

39. Pott F, Jensen K, Hansen H, Christensen NJ, Lassen NA, Secher NH.

Middle cerebral artery blood velocity and plasma catecholamines

during exercise. ActaPhysiolScand 1996; 158(4): Pp349–356.

40. Ainslie PN, James D, Keith P. Elevation in cerebral blood flow

velocity with aerobic fitness throughout healthy human ageing. J

Physiol 2008; 586:Pp4005-4010.

41. Gapin, JI, Labban, JD, Etnier, JL. The effects of physical activity on

attention deficit hyperactivity disorder symptoms: the evidence.

Preventive Medicine,2011;52: S70–S74.

42. Crova, C, Struzzolino, I, Marchetti, R. Cognitively challenging

physical activity benefits executive function in overweight children.

Journal of Sports Sciences,2014;32(3): 201–211.

43. Diamond, A, Lee, K. Interventions shown to aid executive function

development in children 4 to 12 years old. Science, 2011; 333: 954–

969.

44. Verburgh, L, Königs, M, Scherder, EJA. Physical exercise and

executive functions in preadolescent children, adolescents and young

adults: a meta-analysis. British Journal of Sports Medicine,

2014;48(12):1–8.

45. Audiffren, M., Tomporowski, P. D., &Zagrodnik, J. Acute aerobic

exercise and information processing: Energizing motor processes

during a choice reaction time task. ActaPsychologica, 129(3), 410–

419. doi: 10.1016/j.actpsy.2008.09.006 .

46. Coles, K., &Tomporowski, P. D. Effects of acute exercise on executive

processing, shortterm and longterm memory. Journal of Sports

Sciences,2008; 26(3), 333– 344. doi: 10.1080/02640410701591417.

47. Hillman, C. H., Pontifex, M. B., Raine, L. B., Castelli, D. M., Hall, E.

E., & Kramer, A. F. The effect of acute treadmill walking on cognitive

control and academic achievement in preadolescent children.

Neuroscience, 2009; 159(3),1044–1054.doi

10.1016/j.neuroscience.2009.01.057.

48. Etnier J. L.,& Chang Y. K. The effect of physical activity on executive

function: A brief commentary on definitions, measurement issues, and

the current state of the literature. Journal of Sport & Exercise

Psychology, 2009;31(4), 469–483.

49. Chang, YK, Hung, CL, Huang, CJ. Effects of an aquatic exercise

program on inhibitory control in children with ADHD: a preliminary

study. Archives of Clinical Neuropsychology, 2014; 29: 217–223.

50. Guiney, H, Machado, L. Benefits of regular aerobic exercise for

executive functioning in healthy populations. Psychonomic Bulletin

and Review, 2013; 20: 73–86.

51. Hilton, CL, Cumpata, K, Klohr, C. Effects of exergaming on executive

function and motor skills in children with autism spectrum disorder: a

pilot study. American Journal of Occupational Therapy, 2014; 68: 57–

65.

52. Pan, CY, Tsai, CL, Chu, CH. Effects of physical exercise intervention

on motor skills and executive functions in children with ADHD: a pilot

study. Journal of Attention Disorders. Epub ahead of print 2

February.2015; DOI: 10.1177/1087054715569282.

53. Tsai, CL, Wang, CH, Tseng, YT. Effects of exercise intervention on

event-related potential and task performance indices of attention

networks in children with developmental coordination disorder. Brain

and Cognition, 2012; 79: 12–22.

54. Ploughman M, McCarthy J, Bossé M, Sullivan HJ, Corbett D. Does

Treadmill Exercise Improve Performance of Cognitive or Upper-

Extremity Tasks in People With Chronic Stroke? A Randomized Cross-

Over Trial. Archives of Physical Medicine and Rehabilitation 2008;

89(11): Pp2041:2047.

55. Correia PR, Aline P,Felipe M, Marilia A. Acute strength exercise and

the involvement of small or large muscle mass on plasma brain-

derived neurotrophic factor level. Clinics 2010; 65(11): Pp1123-1126.