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Improved cognitive performance in preadolescent Danish children after the school-based physical activity programme “FIFA 11 for Health” for Europe – A cluster-randomised controlled trial

Improved cognitive performance in preadolescent Danish children after the school-based physical... Objective: Recent studies have shown promising effects of physical activity on cognitive function, but there is a need to investigate this link in real-life settings such as schools. Hence, the objective of the present pilot study was to investigate whether the school-based physical activity programme “FIFA 11 for Health” for Europe could improve cognitive performance in preadolescent Danish children. Methods: The pilot study used an 11-week cluster-randomised intervention study design. School classes were randomly assigned to either a control group (CG) (n = 93 children, age = 11.8, s= 0.2 years), which performed the obligatory daily school-based physical activity (5 × 45 minutes per week); or an intervention group (IG) (n = 838 children, age = 11.9, s = 0.4 years), which substituted 2 × 45 minutes per week of the daily school physical activity with the “FIFA 11 for Health” for Europe programme. The programme combines small-sided football games, drills and health education. Cognitive performance was evaluated at baseline and follow-up. Results: The IG improved their cognitive performance compared to the CG for psychomotor function (56, s = 22 ms, p < .001), attention – – (39, s = 17 ms, p = .012) and working memory (79, s = 35 ms, p = .020). Conclusion: This pilot study provides evidence x x that the school-based physical activity programme “FIFA 11 for Health” for Europe can improve cognitive performance in preadolescent Danish schoolchildren. Future studies should attempt to disentangle the effects of “FIFA 11 for Health” for Europe on cognitive performance by investigating the characteristics of the programme’s physical activity. Keywords: Cognition, small-sided football, soccer, drills, health Highlights Physical activity has been shown to positively affect cognitive performance in children, but information about the effect of school-based physical activity programmes is lacking. The present pilot study investigated the effect of participating in the school-based physical activity concept “FIFA 11 for Health” For Europe on cognitive performance in preadolescent children. Participation in “FIFA 11 for Health” for Europe improved performance in tests of attention, working memory and psychomotor function. 1. Introduction An emerging field of research has been focusing on the (Diamond & Ling, 2016; Donnelly et al., 2016;Geert- positive relationship among physical activity, cognitive sen et al., 2016; Hillman, Erickson, & Kramer, 2008; function and academic achievement in children Vazou, Pesce, Lakes, & Smiley-oyen, 2016). Cognitive Correspondence: Rune Rasmussen Lind Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, Denmark. E-mail: [email protected] © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Improved cognitive performance in preadolescent Danish children 131 function is regarded as a predictor of and a prerequi- Although a growing body of research is emerging, site for academic learning and achievement (Alloway the field is still in its infancy. Consequently, there are &Alloway, 2010; Blair & Peters Razza, 2007). several limitations. Most importantly, there is a Especially, executive function (EF) has been identified myriad of methodologies and outcome measures, to play a critical role in learning and academic achieve- which makes comparison between studies difficult ments during childhood (Van der Niet, Hartman, (Donnelly et al., 2016). Furthermore, both time con- Smith, & Visscher, 2014). This knowledge has led to straint and expenses limit studies of brain structure multiple studies seeking to improve cognitive function and function. However, school-based programmes through different types of physical activity interven- also provide a unique opportunity to affect both a tions. These studies have documented positive large and wide population of children. Therefore, the effects on cognitive performance in children after ecologically valid settings applied in these studies are acute (Budde, Voelcker-Rehage, Pietraßyk-Kend- a great strength (Donnelly et al., 2016). Furthermore, ziorra, Ribeiro, & Tidow, 2008; Drollette et al., as recent evidence indicates, children do not meet the 2014; Hillman et al., 2009) and chronic (Fisher physical activity recommendations (Kolle, Andersen, et al., 2011; Hillman et al., 2014; Mullender- & Anderssen, 2010; Verloigne et al., 2012), which Wijnsma et al., 2016) physical activity. Even though not only has a negative health effect (Klakk et al., physical activity consists of both quantitative (e.g. 2014) but might also influence children’s cognitive intensity and duration) and qualitative (e.g. cognitive health negatively (Hillman et al., 2008). Therefore, and motor demands) characteristics, most of the more knowledge and studies of the impact of school- studies have focused on the quantitative characteristics based physical activity programmes are critical to of the physical activity (Drollette et al., 2014;Fisher ensuring and promoting adequate development of et al., 2011; Hillman et al., 2009) which have been cognitive function in children. shown to positively affect the central nervous system “FIFA 11 for Health” for Europe is a school-based through physiological responses to the physical activity physical activity programme that focuses on health (Hillman et al., 2008). Besides studies of quantitative education through small-sided football games and characteristics, recent studies have also highlighted drills. The physical activity in the programme focuses the positive effect of the qualitative characteristics of on both quantitative elements (i.e. small-sided football the physical activity, suggesting that the type of activity with high-intensity interval training) and qualitative is also important (Budde et al., 2008; Gallotta et al., elements (i.e. drills and team games that challenge 2015; Jäger et al., 2014; Pesce et al., 2009). The motor and cognitive skills) through 2 × 45 minutes assumption behind this cognitive stimulation hypoth- (two sessions) of on-pitch activities per week for 11 esis is that coordinatively demanding and non-auto- weeks. Each football session is related to a health mated movement and sports actions engage the message developed in relation to a communicable or same brain regions that are used to control higher non-communicable disease. The programme is deliv- order cognitive processes (Tomporowski et al., ered by schoolteachers trained in “FIFA 11 for 2015). One proposed physical activity that complies Health” using an engaging and age-, gender- and with this is team games (Diamond & Ling, 2016). culture-sensitive format. The original “FIFA 11 for Using knowledge of the effect of the quantitative as Health” programme revealed positive effects on prea- well as qualitative characteristics of physical activity dolescent children’s health knowledge in multiple on cognitive performance, recent studies have countries (Fuller et al., 2010;Fuller et al., 2015). A applied different types of chronic physical activity pro- subsequently modified programme for the European grammes in ecologically valid school settings and context has also shown positive effects on health found promising results. These results range from knowledge, body composition, blood pressure and improved academic performance (Beck, Lind, Geert- cardiovascular fitness in preadolescent Danish chil- sen, Lundbye-jensen, & Wienecke, 2016;Mullen- dren (Fuller et al., 2016; Ørntoft et al., 2016). der-Wijnsma et al., 2016), improved inhibition Consequently, the objective of the present pilot study ability (Crova et al., 2014; Hillman et al., 2014)to was to investigate the effect of the modified “FIFA 11 improved shifting performance (Schmidt, Jäger, for Health” for Europe programme on cognitive per- Egger, Roebers, & Conzelmann, 2015). The types of formance in preadolescent Danish schoolchildren. chronic physical activity vary from motor-enriched learning activities (Beck et al., 2016), physical active school lessons (Mullender-Wijnsma et al., 2016), cog- 2. Methods nitively challenging and engaging activities (Crova 2.1. Participants et al., 2014; Schmidt et al., 2015), and team-oriented activities aiming at improving cardiovascular fitness Twenty-six Danish schools encompassing 67 fifth- (Hillman et al., 2014). grade classes expressed an interest in participating 132 R. R. Lind et al. in and were provided with comprehensive infor- over the 11 weeks. The week was divided into a mation about the pilot study. From these, 52 classes 45-minute “play football” period (teaching football were accepted into the pilot study. Geographically, skills and playing small-sided football) and a 45- the distribution of the classes was 7 from Jutland, 6 minute “play fair” period (teaching a health from Funen, 11 from the Capital Region of Copenha- message and health behaviours). The two sessions gen, 26 from the remaining part of Zealand and sur- within a week had to be separated by at least 1 rounding islands and 2 from the island Bornholm. day. All teachers involved in the pilot study from The pilot study was designed as a cluster-randomised both CG and IG participated in a 2.5-day workshop controlled trial with individual classes as clusters. A runbystaff from theUniversityofSouthern member of our research group randomly assigned Denmark and football coaches from the Danish each class to either a control group (CG) or an inter- Football Association. The purpose of this workshop vention group (IG) in a 1:9 ratio (Figure 1). The ratio was to give the teachers an in-depth understanding was found necessary to ensure high commitment by of the standardised “FIFA 11 for Health” for the schools to the programme, as they signed up for Europe programme manual, covering the philos- the programme voluntarily and all expected to be in ophy behind the programme, demonstrations of the intervention group. In all, 931 children (475 football skills and background health knowledge girls, mean age: 11.9 ± 0.0) were included in the information. Moreover, the aim was to ensure a pilot study after obtaining written consent, corre- controlled, engaging and informative presentation sponding to 81.7% of the children invited (see for 10–12-year-old children. During the 11-week Table I for demographic characteristics). The pilot intervention and control period, the teachers study was approved by the Ethical Committee of trained 20–25 children per session in accordance Copenhagen, Denmark (H-16026885) and carried with previous studies (Fuller et al., 2016;Ørntoft out in accordance with the Helsinki Declaration II. et al., 2016). 2.4. Test battery 2.2. Design The test battery consisted of measurements of the The pilot study, completed between August and children’s cognitive performance and body compo- December 2016, consisted of a teacher workshop, sition. The battery was completed over two separate baseline testing, intervention period (11 weeks) and test days. It was ensured that no scheduled physical follow-up testing. The teacher workshop took place activity was carried out before the children performed before the intervention period. The baseline testing the cognitive test battery. was conducted for both IG and CG, who completed a test battery assessing their cognitive function and body composition. During the intervention period, 2.5. Cognitive performance IG completed 22 sessions of FIFA 11 for Health for Europe (see later). Each week included two 45- 2.5.1. Procedure and description. The children’s cog- minute sessions that replaced two of the five obliga- nitive performance was assessed using the English tory 45-minute sessions of physical activity per day version of the Cogstate Brief Battery, which is an for Danish schools. In weeks 1–11, CG continued objective computer-based cognitive test battery with the normal obligatory weekly physical activity addressing psychomotor function, attention, (5 × 45 minutes per week). The pilot study con- working memory and visual learning in preadolescent cluded with follow-up testing for both IG and CG. children (Cromer, Harel et al., 2015). The cognitive test battery was completed individually in the class- room on a laptop or stationary computer with a 2.3. The “FIFA 11 for Health” for Europe screen, mouse, keyboard, headset and internet programme access. The overall testing time was around 50 Previous studies have thoroughly described the minutes. Although the cognitive battery was verified structure, content and implementation procedure for unsupervised use among young adults (Cromer, of the “FIFA 11 for Health” programme in its orig- Schembri, Harel, & Maruff, 2015), the teachers inal form (Fuller et al., 2010) and with the modified administered the battery and provided a unique user- content adjusted for Denmark (Fuller et al., 2016; name and login for each child both at baseline and Ørntoftetal., 2016). In this study, the modified follow-up. The teachers had been given a cognitive version of “FIFA 11 for Health” for Europe was test manual and were thoroughly instructed in the used. Each of the 11 weeks consisted of two 45- cognitive testing procedure during the 2.5-day minute football sessions, totalling 990 minutes teacher workshop. Improved cognitive performance in preadolescent Danish children 133 Figure 1. Flow diagram for the pilot study. CG, control group; IG, intervention group. The cognitive test battery consisted of four differ- 2.5.2. Measures ent tasks: detection (DET), identification (IDN), 2.5.2.1. Psychomotor function and one back (OBK) and one card learning (OCL). At attention. The DET and IDN tasks were both a the beginning of the test battery, the children measure of attention and alertness. DET was based learned to respond by using the Yes and No response on a simple reaction time paradigm defined as the buttons. The K button on the keyboard was used as average speed to initiate a motor response following Yes and the D button as No. In general, all four presentation of a visual stimulus. The DET task dis- tasks followed the same format. Firstly, task infor- played a single playing card (i.e. the black joker) as mation was provided and then the children were pre- the visual stimulus of the task. The question to be sented with a pack of face-down playing cards on answered was: Has the card turned over? The chil- their computer screen. When the top card in the dren had to respond by pressing Yes as soon as they pack flipped over to reveal its face (e.g. ace of detected the playing card flipping over to reveal the spades, 8 of hearts, 7 of clubs), the children had to face of the card. IDN used a choice reaction time respond Yes or No as quickly and accurately as poss- paradigm. The IDN task had two possible stimuli, ible in accordance with the instructions for the par- which were either a black or red joker. The children ticular task (see below). After the response, the had to respond by pressing Yes or No to the question: face-up card moved away from the pack and the Is the card red? The average speed (ms) of correct reverse of the next card in the pack became visible answers was logged as the effect outcome for both (i.e. next trial). tasks. Table I. Demographic characteristics of all the children combined and by control group (CG) and intervention group (IG) All CG IG Number of participants (n) 931 93 838 Gender (% boys) 49 44 49 Age (years) 11.9 ± 0.4 11.8 ± 0.2 11.9 ± 0.4 BMI (weight/height ) 18.5 ± 3.2 19.3 ± 3.7 18.4 ± 3.2 Weight (kg) 42.1 ± 9.8 43.8 ± 11.1 41.9 ± 9.7 Height (cm) 150.2 ± 7.2 150.0 ± 7.2 150.2 ± 7.3 Note. Data reported as raw mean values ± SD. No significant between-group differences were observed for any of the measures. BMI, body mass index. 134 R. R. Lind et al. 2.5.2.2. Working memory. The OBK task, to the model to account for dependencies between which uses an n-back paradigm, was deployed as a measurements on the same subjects, municipalities, measure of working memory. The children were schools and school classes. A visual inspection of introduced to 52 standard playing cards as possible residual plots and normal probability plots was used stimuli and had to respond to the question: Is this for model validation. To investigate the hypotheses card the same as the previous card? They pressed of this study, specific sets of comparisons between either Yes or No. The average duration (ms) of and within groups were considered and analysed correct answers was logged as the effect outcome. using global F-tests. Subsequently, linear mixed model-based t-tests were used for pairwise compari- sons. Adjustment for multiplicity of these pairwise 2.5.2.3. Visual learning. The OCL task comparisons was carried out using the ‘single-step’ assessed visual learning and applied a pattern separ- adjustment, which achieved a less conservative ation paradigm. The children were presented with adjustment than Bonferroni adjustment by utilising 52 standard playing cards as possible stimuli, one at correlations between tests. All demographic charac- a time, and had to respond to the question: Have teristics are reported as raw mean values with SD. you seen this card before? (in the current task). A significance level of 0.05 was applied. They pressed Yes if they thought the current card had previously been presented during the task and No if they did not think they had seen it before. For 3. Results example: If the first three cards shown (in order) were (1) king of hearts, (2) queen of spades and (3) 3.1. Cognitive performance king of hearts, then the answers would be (1) No, The mean performance figures in the cognitive tests (2) No and (3) Yes. The average accuracy (%) of before and after the intervention period for CG and answers was logged as the effect outcome. The IG are presented in Figure 2. selected effect outcomes of each task were based on previous studies using the Cogstate® Brief Battery (Cromer, Schembri et al., 2015; Cromer, Harel 3.2. Psychomotor function and attention et al., 2015; Louey et al., 2014). In the DET task, a significant group–time interaction was found [F =13.06, p < .001]. IG improved 1,1232 2.6. Body composition their reaction time from baseline to follow-up whereas CG decreased their performance (Figure 2(A)). As pre- 2.6.1. Procedure and measures. The measurement of sented in Figure 2(A), the change in mean psychomo- body composition was collected as a part of the chil- tor function performance was greater for IG dren’s demographic data. Trained staff from the Uni- compared to CG 56, s = 22 ms (p < .001). A signifi- versity of Southern Denmark administered the tests cant group–time interaction was found [F = 1,1255 with the support of the responsible teachers. The chil- 6.31, p = .012] in the IDN task. From baseline to dren’s weight (kg) was measured using an InBody 230 follow-up, IG improved their attention performance multifrequency body composition analyser (Biospace, (Figure 2(B)). Furthermore, the change in mean atten- California, USA), while their height (cm) was assessed tion performance was significantly greater for IG com- with 0.5-cm precision using a Tanita Leicester porta- pared to CG 39, s = 17 ms (p = .012) (Figure 2(B)). ble altimeter (Tanita, Amsterdam, the Netherlands). 3.3. Working memory 2.7. Statistical analysis In OBK a significant group–time interaction was All statistical analyses were carried out in the open- found [F = 5.41, p = .02]. IG improved their 1,1215 access software R Studio (R Core Team, Vienna, performance from baseline to follow-up, which is Austria). Demographic characteristics are reported shown in Figure 2(C). The change in mean as raw mean values with SD. Differences between working memory performance was also significantly groups in age, height, weight and BMI were analysed greater for IG compared to CG 79, s =35 ms using model-based t-tests; the gender distribution (p = .02) (Figure 2(C)). was analysed using a chi-squared test. Cognitive per- formance at baseline and follow-up are shown as raw mean values with s . Data from the cognitive test 3.4. Visual memory battery were analysed using linear mixed models with group–time (baseline/follow-up) interactions No significant group–time interaction was found and age as fixed effects. Random effects were added [F = 0.39, p = .532] in the OCL task. Nor was 1,1231 Improved cognitive performance in preadolescent Danish children 135 Figure 2. Performance in the cognitive test battery. The baseline and follow-up performance in the cognitive test battery is displayed as mean values with s for psychomotor function (A), attention (B), working memory (C) and visual learning (D). Control group (CG); Intervention group (IG). Indicates significant within group difference from baseline to follow-up. # Indicates significant between-group difference in the changes between time points (p < .05). any significant improvement observed for either IG of the modified “FIFA 11 for Health” for Europe pro- or CG from baseline to follow-up (Figure 2(D)). gramme on health knowledge, psychosocial and phys- iological health (Fuller et al., 2016; Ørntoft et al., 2016), these results suggest that “FIFA 11 for Health” for Europe could also improve the cognitive 4. Discussion performance of preadolescent children. The objective of the present study was to investigate the effect of the modified “FIFA 11 for Health” for Europe programme on cognitive performance in preadoles- 4.1. Attention and alertness cent Danish schoolchildren. The main findings of the pilot study were that IG improved their working Attention, including alertness, has been proposed as memory (OBK), attention and alertness (DET and an intermediary of hippocampal-dependent declara- IDN) performance from baseline to follow-up, and tive memory formation (Aly & Turk-Browne, that these improvements were significantly greater 2016), possibly associated with schema-dependent compared to CG. These results add to the emerging academic learning and cognitive performance (van research showing that school-based chronic physical Kesteren, Rijpkema, Ruiter, Morris, & Fernández, activity programmes can positively affect cognitive per- 2014). We may therefore speculate that enhanced formance in children (Donnelly et al., 2016). Further- attention performance can lead to an improved aca- more, together with previously reported positive effects demic learning in preadolescent schoolchildren. In 136 R. R. Lind et al. the current study, attention and alertness were colleagues (2016) found a positive effect on working enhanced following the 11-week intervention for IG memory performance from both the cardiovascular compared to CG. These findings accord with pre- exercise and the motor-demanding activity. vious research investigating the effect of physical Additionally, the improvement was greater for the activity interventions on these cognitive domains in motor-demanding activity than for the cardiovascular preadolescent children (Chang, Tsai, Chen, & exercise. A newly published intervention study also Hung, 2013; Gallotta et al., 2015; Hillman et al., reported positive effects on working memory per- 2009, 2014; Schmidt, Benzing, & Kamer, 2016). In formance after 22 weeks of 5 × 30 minutes of particular, Gallotta and co-workers (2015) found aerobic exercise and cognitively engaging physical positive effects from a 5-month school-based coordi- activities for preadolescent children (van der Niet native physical activity intervention on attention in et al., 2016). In combination, these studies indicate obese children. A 9-month after-school physical a positive effect of cardiovascular exercise and activity programme focusing on improving aerobic motor- and cognition-demanding physical activity fitness also enhanced attention in preadolescent chil- programme on cognitive performance. The “FIFA dren (Hillman et al., 2014). These behavioural 11 for Health” for Europe programme consisted of results were supported by changes in electrophysio- small-sided football games and football drills. The logical biomarkers mediating attention and alertness rules, pitch size and game format of the small-sided and were in line with previous findings of studies football games changed from session to session, investigating the electrophysiological mechanism of ensuring that activities were novel and diverse the effect of physical activity on cognitive perform- throughout the 11-week intervention. Furthermore, ance (Chang et al., 2013; Drollette et al., 2014; each week a new football skill was introduced, ensur- Hillman et al., 2009). However, future studies ing that the activity had coordinative complexity. By should still try to elucidate the specific electrophysio- applying a combination of cardiovascular exercise logical adaptations following chronic physical activity and motor and cognition demands, the “FIFA 11 interventions in children. This would allow us to gain for Health” for Europe programme was consistent further insight into the impact of physical activity on with recent research showing positive effects of the developing brain. Collectively, these studies school-based physical activity programmes on cogni- demonstrate a positive effect of 5–9-month school- tive performance. Moreover, the current study also based physical programmes on attention and alert- indicates that a physical activity programme based ness in preadolescent children. The current study on a well-established team game (football) can have adds to this knowledge and further indicates that a positive effect on cognitive performance in preado- such changes can be seen after only 11 weeks. lescent children. Previously, this has mostly been reported in studies using a specially designed physical activity to either improve fitness status (Hillman et al., 2014) or ensure high levels of cognitive engage- 4.2. Working memory ment (Schmidt et al., 2015) or coordinative demands An important element of cognitive function is (Gallotta et al., 2015). The findings of the current working memory. A part of working memory is pro- study thus add to our knowledge of the effect on cog- posed to be the central executive (executive func- nitive performance of chronic physical activity pro- tions) (Baddeley, 2010), which is responsible for grammes based on team games. Furthermore, as top-down problem solving (Miyake et al., 2000) football is the largest sport in the world measured and is suggested as a predictor of mathematical by number of registered players (FIFA, 2007), the ability (Bull & Scerif, 2001) and academic achieve- “FIFA 11 for Health” for Europe constitutes a ment (Alloway & Alloway, 2010). Therefore, inter- unique possibility to introduce a well-liked physical vention that can positively affects working memory activity school-based programme to the children. positively could therefore lead to better academic This could heighten the schools’ interest in the pro- achievement in preadolescent schoolchildren. A key gramme as well as the feasibility of and engagement finding of the current study was enhanced working in the programme for the children. However, future memory performance in IG compared to CG. Pre- research should try to disentangle both the “FIFA vious studies have also found positive effects of phys- 11 for Health” for Europe programme and, ical activity on working memory performance in especially, the team game (small-sided football) to children (Koutsandréou, Wegner, Niemann, & investigate both the quantitative (e.g. intensity and Budde, 2016; van der Niet et al., 2016). By applying duration) and qualitative (e.g. cognitive and motor 10 weeks of 3 × 45 minutes of after-school cardiovas- demands) characteristics. This would allow us to cular exercise and a motor-demanding activity obtain further understanding of the aspects of team for preadolescent children, Koutsandréou and games that might be responsible for the observed Improved cognitive performance in preadolescent Danish children 137 behavioural effects. This is interesting because pre- health education, can positively affect cognitive per- vious work in the field reports a diversity of results formance, including attention, alertness and from different types of physical activity interventions, working memory, in preadolescent Danish children. suggesting that different characteristics of physical From a practical perspective, implementing the activity intervention can have different effects on cog- modified “FIFA 11 for Health” for Europe pro- nitive performance. Thereby, it will benefit our gramme represents a promising way for schools, in understanding of what type of physical activity to a relative short space of time, to engage with preado- implement in school settings to most effectively lescent children in order to impact cognitive improve cognitive performance. performance. 5. Strength and limitations Acknowledgements This study was strengthened through the ecological Thanks to the participating pupils, teachers and for value of the design, the large sample size and the their contribution. A specially thank to Mariam El- identical demographic characteristics between the Halabi, Mikkel Graack, Anne Sandager & Knud two groups, which further support the success of Ryomfor their assistance during testing sessions, to the cluster-randomisation. The geographical Mikkel Malling Beck for reviewing the manuscript, inclusion of school classes from most of Denmark and to Tina Enestrøm and Kenneth Reeh from the also strengthens the interpretation of the results. Danish Football Association (DBU) for collaboration Moreover, by training the teachers and having them and constructive input. The “FIFA 11 for Health” for follow a standardised programme manual, we con- Europe is supported by a grant from the Nordea Foun- trolled what the children were taught. Furthermore, dation (Nordea-fonden). The modification of the we ensured stability of the intervention by using the ‘FIFA 11 for Health’ programme was funded by the children’s regular teacher and framework (school FIFA Medical Assessmentand Research Centre (F- setting). However, the results of the pilot study MARC) and the Danish Football Association (DBU). should also be viewed with a few limitations in mind. First, for a cluster-randomised study, a larger sample size in CG would have strengthened the Funding interpretation of the results. Furthermore, if practi- This work was supported by The Danish Football Association cally feasible future studies should certainly consider (DBU) 31964; The FIFA Medical Assessment and Research other designs (e.g. cross-over designs). Secondly, the Center (F-MARC) F-MARC Project 31964; Nordea-Fonden 02- 2011-4360. pilot study did not collect any information about the characteristics of the teachers teaching the “FIFA 11 for Health” for Europe. Nor was any delayed cogni- tive testing done, which limits the interpretation of Disclosure statement the results in relation to a potentially sustained No potential conflict of interest was reported by the authors. effect on the children’s cognitive performance. 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Improved cognitive performance in preadolescent Danish children after the school-based physical activity programme “FIFA 11 for Health” for Europe – A cluster-randomised controlled trial

Improved cognitive performance in preadolescent Danish children after the school-based physical activity programme “FIFA 11 for Health” for Europe – A cluster-randomised controlled trial

Abstract

AbstractObjective: Recent studies have shown promising effects of physical activity on cognitive function, but there is a need to investigate this link in real-life settings such as schools. Hence, the objective of the present pilot study was to investigate whether the school-based physical activity programme “FIFA 11 for Health” for Europe could improve cognitive performance in preadolescent Danish children. Methods: The pilot study used an 11-week cluster-randomised intervention study design. School classes were randomly assigned to either a control group (CG) (n = 93 children, age = 11.8, s = 0.2 years), which performed the obligatory daily school-based physical activity (5 × 45 minutes per week); or an intervention group (IG) (n = 838 children, age = 11.9, s = 0.4 years), which substituted 2 × 45 minutes per week of the daily school physical activity with the “FIFA 11 for Health” for Europe programme. The programme combines small-sided football games, drills and health education. Cognitive performance was evaluated at baseline and follow-up. Results: The IG improved their cognitive performance compared to the CG for psychomotor function (56, sx– = 22 ms, p < .001), attention (39, sx– = 17 ms, p = .012) and working memory (79, sx– = 35 ms, p = .020). Conclusion: This pilot study provides evidence that the school-based physical activity programme “FIFA 11 for Health” for Europe can improve cognitive performance in preadolescent Danish schoolchildren. Future studies should attempt to disentangle the effects of “FIFA 11 for Health” for Europe on cognitive performance by investigating the characteristics of the programme’s physical activity.

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Wiley
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© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
ISSN
1536-7290
eISSN
1746-1391
DOI
10.1080/17461391.2017.1394369
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See Article on Publisher Site

Abstract

Objective: Recent studies have shown promising effects of physical activity on cognitive function, but there is a need to investigate this link in real-life settings such as schools. Hence, the objective of the present pilot study was to investigate whether the school-based physical activity programme “FIFA 11 for Health” for Europe could improve cognitive performance in preadolescent Danish children. Methods: The pilot study used an 11-week cluster-randomised intervention study design. School classes were randomly assigned to either a control group (CG) (n = 93 children, age = 11.8, s= 0.2 years), which performed the obligatory daily school-based physical activity (5 × 45 minutes per week); or an intervention group (IG) (n = 838 children, age = 11.9, s = 0.4 years), which substituted 2 × 45 minutes per week of the daily school physical activity with the “FIFA 11 for Health” for Europe programme. The programme combines small-sided football games, drills and health education. Cognitive performance was evaluated at baseline and follow-up. Results: The IG improved their cognitive performance compared to the CG for psychomotor function (56, s = 22 ms, p < .001), attention – – (39, s = 17 ms, p = .012) and working memory (79, s = 35 ms, p = .020). Conclusion: This pilot study provides evidence x x that the school-based physical activity programme “FIFA 11 for Health” for Europe can improve cognitive performance in preadolescent Danish schoolchildren. Future studies should attempt to disentangle the effects of “FIFA 11 for Health” for Europe on cognitive performance by investigating the characteristics of the programme’s physical activity. Keywords: Cognition, small-sided football, soccer, drills, health Highlights Physical activity has been shown to positively affect cognitive performance in children, but information about the effect of school-based physical activity programmes is lacking. The present pilot study investigated the effect of participating in the school-based physical activity concept “FIFA 11 for Health” For Europe on cognitive performance in preadolescent children. Participation in “FIFA 11 for Health” for Europe improved performance in tests of attention, working memory and psychomotor function. 1. Introduction An emerging field of research has been focusing on the (Diamond & Ling, 2016; Donnelly et al., 2016;Geert- positive relationship among physical activity, cognitive sen et al., 2016; Hillman, Erickson, & Kramer, 2008; function and academic achievement in children Vazou, Pesce, Lakes, & Smiley-oyen, 2016). Cognitive Correspondence: Rune Rasmussen Lind Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, Denmark. E-mail: [email protected] © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. Improved cognitive performance in preadolescent Danish children 131 function is regarded as a predictor of and a prerequi- Although a growing body of research is emerging, site for academic learning and achievement (Alloway the field is still in its infancy. Consequently, there are &Alloway, 2010; Blair & Peters Razza, 2007). several limitations. Most importantly, there is a Especially, executive function (EF) has been identified myriad of methodologies and outcome measures, to play a critical role in learning and academic achieve- which makes comparison between studies difficult ments during childhood (Van der Niet, Hartman, (Donnelly et al., 2016). Furthermore, both time con- Smith, & Visscher, 2014). This knowledge has led to straint and expenses limit studies of brain structure multiple studies seeking to improve cognitive function and function. However, school-based programmes through different types of physical activity interven- also provide a unique opportunity to affect both a tions. These studies have documented positive large and wide population of children. Therefore, the effects on cognitive performance in children after ecologically valid settings applied in these studies are acute (Budde, Voelcker-Rehage, Pietraßyk-Kend- a great strength (Donnelly et al., 2016). Furthermore, ziorra, Ribeiro, & Tidow, 2008; Drollette et al., as recent evidence indicates, children do not meet the 2014; Hillman et al., 2009) and chronic (Fisher physical activity recommendations (Kolle, Andersen, et al., 2011; Hillman et al., 2014; Mullender- & Anderssen, 2010; Verloigne et al., 2012), which Wijnsma et al., 2016) physical activity. Even though not only has a negative health effect (Klakk et al., physical activity consists of both quantitative (e.g. 2014) but might also influence children’s cognitive intensity and duration) and qualitative (e.g. cognitive health negatively (Hillman et al., 2008). Therefore, and motor demands) characteristics, most of the more knowledge and studies of the impact of school- studies have focused on the quantitative characteristics based physical activity programmes are critical to of the physical activity (Drollette et al., 2014;Fisher ensuring and promoting adequate development of et al., 2011; Hillman et al., 2009) which have been cognitive function in children. shown to positively affect the central nervous system “FIFA 11 for Health” for Europe is a school-based through physiological responses to the physical activity physical activity programme that focuses on health (Hillman et al., 2008). Besides studies of quantitative education through small-sided football games and characteristics, recent studies have also highlighted drills. The physical activity in the programme focuses the positive effect of the qualitative characteristics of on both quantitative elements (i.e. small-sided football the physical activity, suggesting that the type of activity with high-intensity interval training) and qualitative is also important (Budde et al., 2008; Gallotta et al., elements (i.e. drills and team games that challenge 2015; Jäger et al., 2014; Pesce et al., 2009). The motor and cognitive skills) through 2 × 45 minutes assumption behind this cognitive stimulation hypoth- (two sessions) of on-pitch activities per week for 11 esis is that coordinatively demanding and non-auto- weeks. Each football session is related to a health mated movement and sports actions engage the message developed in relation to a communicable or same brain regions that are used to control higher non-communicable disease. The programme is deliv- order cognitive processes (Tomporowski et al., ered by schoolteachers trained in “FIFA 11 for 2015). One proposed physical activity that complies Health” using an engaging and age-, gender- and with this is team games (Diamond & Ling, 2016). culture-sensitive format. The original “FIFA 11 for Using knowledge of the effect of the quantitative as Health” programme revealed positive effects on prea- well as qualitative characteristics of physical activity dolescent children’s health knowledge in multiple on cognitive performance, recent studies have countries (Fuller et al., 2010;Fuller et al., 2015). A applied different types of chronic physical activity pro- subsequently modified programme for the European grammes in ecologically valid school settings and context has also shown positive effects on health found promising results. These results range from knowledge, body composition, blood pressure and improved academic performance (Beck, Lind, Geert- cardiovascular fitness in preadolescent Danish chil- sen, Lundbye-jensen, & Wienecke, 2016;Mullen- dren (Fuller et al., 2016; Ørntoft et al., 2016). der-Wijnsma et al., 2016), improved inhibition Consequently, the objective of the present pilot study ability (Crova et al., 2014; Hillman et al., 2014)to was to investigate the effect of the modified “FIFA 11 improved shifting performance (Schmidt, Jäger, for Health” for Europe programme on cognitive per- Egger, Roebers, & Conzelmann, 2015). The types of formance in preadolescent Danish schoolchildren. chronic physical activity vary from motor-enriched learning activities (Beck et al., 2016), physical active school lessons (Mullender-Wijnsma et al., 2016), cog- 2. Methods nitively challenging and engaging activities (Crova 2.1. Participants et al., 2014; Schmidt et al., 2015), and team-oriented activities aiming at improving cardiovascular fitness Twenty-six Danish schools encompassing 67 fifth- (Hillman et al., 2014). grade classes expressed an interest in participating 132 R. R. Lind et al. in and were provided with comprehensive infor- over the 11 weeks. The week was divided into a mation about the pilot study. From these, 52 classes 45-minute “play football” period (teaching football were accepted into the pilot study. Geographically, skills and playing small-sided football) and a 45- the distribution of the classes was 7 from Jutland, 6 minute “play fair” period (teaching a health from Funen, 11 from the Capital Region of Copenha- message and health behaviours). The two sessions gen, 26 from the remaining part of Zealand and sur- within a week had to be separated by at least 1 rounding islands and 2 from the island Bornholm. day. All teachers involved in the pilot study from The pilot study was designed as a cluster-randomised both CG and IG participated in a 2.5-day workshop controlled trial with individual classes as clusters. A runbystaff from theUniversityofSouthern member of our research group randomly assigned Denmark and football coaches from the Danish each class to either a control group (CG) or an inter- Football Association. The purpose of this workshop vention group (IG) in a 1:9 ratio (Figure 1). The ratio was to give the teachers an in-depth understanding was found necessary to ensure high commitment by of the standardised “FIFA 11 for Health” for the schools to the programme, as they signed up for Europe programme manual, covering the philos- the programme voluntarily and all expected to be in ophy behind the programme, demonstrations of the intervention group. In all, 931 children (475 football skills and background health knowledge girls, mean age: 11.9 ± 0.0) were included in the information. Moreover, the aim was to ensure a pilot study after obtaining written consent, corre- controlled, engaging and informative presentation sponding to 81.7% of the children invited (see for 10–12-year-old children. During the 11-week Table I for demographic characteristics). The pilot intervention and control period, the teachers study was approved by the Ethical Committee of trained 20–25 children per session in accordance Copenhagen, Denmark (H-16026885) and carried with previous studies (Fuller et al., 2016;Ørntoft out in accordance with the Helsinki Declaration II. et al., 2016). 2.4. Test battery 2.2. Design The test battery consisted of measurements of the The pilot study, completed between August and children’s cognitive performance and body compo- December 2016, consisted of a teacher workshop, sition. The battery was completed over two separate baseline testing, intervention period (11 weeks) and test days. It was ensured that no scheduled physical follow-up testing. The teacher workshop took place activity was carried out before the children performed before the intervention period. The baseline testing the cognitive test battery. was conducted for both IG and CG, who completed a test battery assessing their cognitive function and body composition. During the intervention period, 2.5. Cognitive performance IG completed 22 sessions of FIFA 11 for Health for Europe (see later). Each week included two 45- 2.5.1. Procedure and description. The children’s cog- minute sessions that replaced two of the five obliga- nitive performance was assessed using the English tory 45-minute sessions of physical activity per day version of the Cogstate Brief Battery, which is an for Danish schools. In weeks 1–11, CG continued objective computer-based cognitive test battery with the normal obligatory weekly physical activity addressing psychomotor function, attention, (5 × 45 minutes per week). The pilot study con- working memory and visual learning in preadolescent cluded with follow-up testing for both IG and CG. children (Cromer, Harel et al., 2015). The cognitive test battery was completed individually in the class- room on a laptop or stationary computer with a 2.3. The “FIFA 11 for Health” for Europe screen, mouse, keyboard, headset and internet programme access. The overall testing time was around 50 Previous studies have thoroughly described the minutes. Although the cognitive battery was verified structure, content and implementation procedure for unsupervised use among young adults (Cromer, of the “FIFA 11 for Health” programme in its orig- Schembri, Harel, & Maruff, 2015), the teachers inal form (Fuller et al., 2010) and with the modified administered the battery and provided a unique user- content adjusted for Denmark (Fuller et al., 2016; name and login for each child both at baseline and Ørntoftetal., 2016). In this study, the modified follow-up. The teachers had been given a cognitive version of “FIFA 11 for Health” for Europe was test manual and were thoroughly instructed in the used. Each of the 11 weeks consisted of two 45- cognitive testing procedure during the 2.5-day minute football sessions, totalling 990 minutes teacher workshop. Improved cognitive performance in preadolescent Danish children 133 Figure 1. Flow diagram for the pilot study. CG, control group; IG, intervention group. The cognitive test battery consisted of four differ- 2.5.2. Measures ent tasks: detection (DET), identification (IDN), 2.5.2.1. Psychomotor function and one back (OBK) and one card learning (OCL). At attention. The DET and IDN tasks were both a the beginning of the test battery, the children measure of attention and alertness. DET was based learned to respond by using the Yes and No response on a simple reaction time paradigm defined as the buttons. The K button on the keyboard was used as average speed to initiate a motor response following Yes and the D button as No. In general, all four presentation of a visual stimulus. The DET task dis- tasks followed the same format. Firstly, task infor- played a single playing card (i.e. the black joker) as mation was provided and then the children were pre- the visual stimulus of the task. The question to be sented with a pack of face-down playing cards on answered was: Has the card turned over? The chil- their computer screen. When the top card in the dren had to respond by pressing Yes as soon as they pack flipped over to reveal its face (e.g. ace of detected the playing card flipping over to reveal the spades, 8 of hearts, 7 of clubs), the children had to face of the card. IDN used a choice reaction time respond Yes or No as quickly and accurately as poss- paradigm. The IDN task had two possible stimuli, ible in accordance with the instructions for the par- which were either a black or red joker. The children ticular task (see below). After the response, the had to respond by pressing Yes or No to the question: face-up card moved away from the pack and the Is the card red? The average speed (ms) of correct reverse of the next card in the pack became visible answers was logged as the effect outcome for both (i.e. next trial). tasks. Table I. Demographic characteristics of all the children combined and by control group (CG) and intervention group (IG) All CG IG Number of participants (n) 931 93 838 Gender (% boys) 49 44 49 Age (years) 11.9 ± 0.4 11.8 ± 0.2 11.9 ± 0.4 BMI (weight/height ) 18.5 ± 3.2 19.3 ± 3.7 18.4 ± 3.2 Weight (kg) 42.1 ± 9.8 43.8 ± 11.1 41.9 ± 9.7 Height (cm) 150.2 ± 7.2 150.0 ± 7.2 150.2 ± 7.3 Note. Data reported as raw mean values ± SD. No significant between-group differences were observed for any of the measures. BMI, body mass index. 134 R. R. Lind et al. 2.5.2.2. Working memory. The OBK task, to the model to account for dependencies between which uses an n-back paradigm, was deployed as a measurements on the same subjects, municipalities, measure of working memory. The children were schools and school classes. A visual inspection of introduced to 52 standard playing cards as possible residual plots and normal probability plots was used stimuli and had to respond to the question: Is this for model validation. To investigate the hypotheses card the same as the previous card? They pressed of this study, specific sets of comparisons between either Yes or No. The average duration (ms) of and within groups were considered and analysed correct answers was logged as the effect outcome. using global F-tests. Subsequently, linear mixed model-based t-tests were used for pairwise compari- sons. Adjustment for multiplicity of these pairwise 2.5.2.3. Visual learning. The OCL task comparisons was carried out using the ‘single-step’ assessed visual learning and applied a pattern separ- adjustment, which achieved a less conservative ation paradigm. The children were presented with adjustment than Bonferroni adjustment by utilising 52 standard playing cards as possible stimuli, one at correlations between tests. All demographic charac- a time, and had to respond to the question: Have teristics are reported as raw mean values with SD. you seen this card before? (in the current task). A significance level of 0.05 was applied. They pressed Yes if they thought the current card had previously been presented during the task and No if they did not think they had seen it before. For 3. Results example: If the first three cards shown (in order) were (1) king of hearts, (2) queen of spades and (3) 3.1. Cognitive performance king of hearts, then the answers would be (1) No, The mean performance figures in the cognitive tests (2) No and (3) Yes. The average accuracy (%) of before and after the intervention period for CG and answers was logged as the effect outcome. The IG are presented in Figure 2. selected effect outcomes of each task were based on previous studies using the Cogstate® Brief Battery (Cromer, Schembri et al., 2015; Cromer, Harel 3.2. Psychomotor function and attention et al., 2015; Louey et al., 2014). In the DET task, a significant group–time interaction was found [F =13.06, p < .001]. IG improved 1,1232 2.6. Body composition their reaction time from baseline to follow-up whereas CG decreased their performance (Figure 2(A)). As pre- 2.6.1. Procedure and measures. The measurement of sented in Figure 2(A), the change in mean psychomo- body composition was collected as a part of the chil- tor function performance was greater for IG dren’s demographic data. Trained staff from the Uni- compared to CG 56, s = 22 ms (p < .001). A signifi- versity of Southern Denmark administered the tests cant group–time interaction was found [F = 1,1255 with the support of the responsible teachers. The chil- 6.31, p = .012] in the IDN task. From baseline to dren’s weight (kg) was measured using an InBody 230 follow-up, IG improved their attention performance multifrequency body composition analyser (Biospace, (Figure 2(B)). Furthermore, the change in mean atten- California, USA), while their height (cm) was assessed tion performance was significantly greater for IG com- with 0.5-cm precision using a Tanita Leicester porta- pared to CG 39, s = 17 ms (p = .012) (Figure 2(B)). ble altimeter (Tanita, Amsterdam, the Netherlands). 3.3. Working memory 2.7. Statistical analysis In OBK a significant group–time interaction was All statistical analyses were carried out in the open- found [F = 5.41, p = .02]. IG improved their 1,1215 access software R Studio (R Core Team, Vienna, performance from baseline to follow-up, which is Austria). Demographic characteristics are reported shown in Figure 2(C). The change in mean as raw mean values with SD. Differences between working memory performance was also significantly groups in age, height, weight and BMI were analysed greater for IG compared to CG 79, s =35 ms using model-based t-tests; the gender distribution (p = .02) (Figure 2(C)). was analysed using a chi-squared test. Cognitive per- formance at baseline and follow-up are shown as raw mean values with s . Data from the cognitive test 3.4. Visual memory battery were analysed using linear mixed models with group–time (baseline/follow-up) interactions No significant group–time interaction was found and age as fixed effects. Random effects were added [F = 0.39, p = .532] in the OCL task. Nor was 1,1231 Improved cognitive performance in preadolescent Danish children 135 Figure 2. Performance in the cognitive test battery. The baseline and follow-up performance in the cognitive test battery is displayed as mean values with s for psychomotor function (A), attention (B), working memory (C) and visual learning (D). Control group (CG); Intervention group (IG). Indicates significant within group difference from baseline to follow-up. # Indicates significant between-group difference in the changes between time points (p < .05). any significant improvement observed for either IG of the modified “FIFA 11 for Health” for Europe pro- or CG from baseline to follow-up (Figure 2(D)). gramme on health knowledge, psychosocial and phys- iological health (Fuller et al., 2016; Ørntoft et al., 2016), these results suggest that “FIFA 11 for Health” for Europe could also improve the cognitive 4. Discussion performance of preadolescent children. The objective of the present study was to investigate the effect of the modified “FIFA 11 for Health” for Europe programme on cognitive performance in preadoles- 4.1. Attention and alertness cent Danish schoolchildren. The main findings of the pilot study were that IG improved their working Attention, including alertness, has been proposed as memory (OBK), attention and alertness (DET and an intermediary of hippocampal-dependent declara- IDN) performance from baseline to follow-up, and tive memory formation (Aly & Turk-Browne, that these improvements were significantly greater 2016), possibly associated with schema-dependent compared to CG. These results add to the emerging academic learning and cognitive performance (van research showing that school-based chronic physical Kesteren, Rijpkema, Ruiter, Morris, & Fernández, activity programmes can positively affect cognitive per- 2014). We may therefore speculate that enhanced formance in children (Donnelly et al., 2016). Further- attention performance can lead to an improved aca- more, together with previously reported positive effects demic learning in preadolescent schoolchildren. In 136 R. R. Lind et al. the current study, attention and alertness were colleagues (2016) found a positive effect on working enhanced following the 11-week intervention for IG memory performance from both the cardiovascular compared to CG. These findings accord with pre- exercise and the motor-demanding activity. vious research investigating the effect of physical Additionally, the improvement was greater for the activity interventions on these cognitive domains in motor-demanding activity than for the cardiovascular preadolescent children (Chang, Tsai, Chen, & exercise. A newly published intervention study also Hung, 2013; Gallotta et al., 2015; Hillman et al., reported positive effects on working memory per- 2009, 2014; Schmidt, Benzing, & Kamer, 2016). In formance after 22 weeks of 5 × 30 minutes of particular, Gallotta and co-workers (2015) found aerobic exercise and cognitively engaging physical positive effects from a 5-month school-based coordi- activities for preadolescent children (van der Niet native physical activity intervention on attention in et al., 2016). In combination, these studies indicate obese children. A 9-month after-school physical a positive effect of cardiovascular exercise and activity programme focusing on improving aerobic motor- and cognition-demanding physical activity fitness also enhanced attention in preadolescent chil- programme on cognitive performance. The “FIFA dren (Hillman et al., 2014). These behavioural 11 for Health” for Europe programme consisted of results were supported by changes in electrophysio- small-sided football games and football drills. The logical biomarkers mediating attention and alertness rules, pitch size and game format of the small-sided and were in line with previous findings of studies football games changed from session to session, investigating the electrophysiological mechanism of ensuring that activities were novel and diverse the effect of physical activity on cognitive perform- throughout the 11-week intervention. Furthermore, ance (Chang et al., 2013; Drollette et al., 2014; each week a new football skill was introduced, ensur- Hillman et al., 2009). However, future studies ing that the activity had coordinative complexity. By should still try to elucidate the specific electrophysio- applying a combination of cardiovascular exercise logical adaptations following chronic physical activity and motor and cognition demands, the “FIFA 11 interventions in children. This would allow us to gain for Health” for Europe programme was consistent further insight into the impact of physical activity on with recent research showing positive effects of the developing brain. Collectively, these studies school-based physical activity programmes on cogni- demonstrate a positive effect of 5–9-month school- tive performance. Moreover, the current study also based physical programmes on attention and alert- indicates that a physical activity programme based ness in preadolescent children. The current study on a well-established team game (football) can have adds to this knowledge and further indicates that a positive effect on cognitive performance in preado- such changes can be seen after only 11 weeks. lescent children. Previously, this has mostly been reported in studies using a specially designed physical activity to either improve fitness status (Hillman et al., 2014) or ensure high levels of cognitive engage- 4.2. Working memory ment (Schmidt et al., 2015) or coordinative demands An important element of cognitive function is (Gallotta et al., 2015). The findings of the current working memory. A part of working memory is pro- study thus add to our knowledge of the effect on cog- posed to be the central executive (executive func- nitive performance of chronic physical activity pro- tions) (Baddeley, 2010), which is responsible for grammes based on team games. Furthermore, as top-down problem solving (Miyake et al., 2000) football is the largest sport in the world measured and is suggested as a predictor of mathematical by number of registered players (FIFA, 2007), the ability (Bull & Scerif, 2001) and academic achieve- “FIFA 11 for Health” for Europe constitutes a ment (Alloway & Alloway, 2010). Therefore, inter- unique possibility to introduce a well-liked physical vention that can positively affects working memory activity school-based programme to the children. positively could therefore lead to better academic This could heighten the schools’ interest in the pro- achievement in preadolescent schoolchildren. A key gramme as well as the feasibility of and engagement finding of the current study was enhanced working in the programme for the children. However, future memory performance in IG compared to CG. Pre- research should try to disentangle both the “FIFA vious studies have also found positive effects of phys- 11 for Health” for Europe programme and, ical activity on working memory performance in especially, the team game (small-sided football) to children (Koutsandréou, Wegner, Niemann, & investigate both the quantitative (e.g. intensity and Budde, 2016; van der Niet et al., 2016). By applying duration) and qualitative (e.g. cognitive and motor 10 weeks of 3 × 45 minutes of after-school cardiovas- demands) characteristics. This would allow us to cular exercise and a motor-demanding activity obtain further understanding of the aspects of team for preadolescent children, Koutsandréou and games that might be responsible for the observed Improved cognitive performance in preadolescent Danish children 137 behavioural effects. This is interesting because pre- health education, can positively affect cognitive per- vious work in the field reports a diversity of results formance, including attention, alertness and from different types of physical activity interventions, working memory, in preadolescent Danish children. suggesting that different characteristics of physical From a practical perspective, implementing the activity intervention can have different effects on cog- modified “FIFA 11 for Health” for Europe pro- nitive performance. Thereby, it will benefit our gramme represents a promising way for schools, in understanding of what type of physical activity to a relative short space of time, to engage with preado- implement in school settings to most effectively lescent children in order to impact cognitive improve cognitive performance. performance. 5. Strength and limitations Acknowledgements This study was strengthened through the ecological Thanks to the participating pupils, teachers and for value of the design, the large sample size and the their contribution. A specially thank to Mariam El- identical demographic characteristics between the Halabi, Mikkel Graack, Anne Sandager & Knud two groups, which further support the success of Ryomfor their assistance during testing sessions, to the cluster-randomisation. The geographical Mikkel Malling Beck for reviewing the manuscript, inclusion of school classes from most of Denmark and to Tina Enestrøm and Kenneth Reeh from the also strengthens the interpretation of the results. Danish Football Association (DBU) for collaboration Moreover, by training the teachers and having them and constructive input. The “FIFA 11 for Health” for follow a standardised programme manual, we con- Europe is supported by a grant from the Nordea Foun- trolled what the children were taught. Furthermore, dation (Nordea-fonden). The modification of the we ensured stability of the intervention by using the ‘FIFA 11 for Health’ programme was funded by the children’s regular teacher and framework (school FIFA Medical Assessmentand Research Centre (F- setting). However, the results of the pilot study MARC) and the Danish Football Association (DBU). should also be viewed with a few limitations in mind. First, for a cluster-randomised study, a larger sample size in CG would have strengthened the Funding interpretation of the results. Furthermore, if practi- This work was supported by The Danish Football Association cally feasible future studies should certainly consider (DBU) 31964; The FIFA Medical Assessment and Research other designs (e.g. cross-over designs). Secondly, the Center (F-MARC) F-MARC Project 31964; Nordea-Fonden 02- 2011-4360. pilot study did not collect any information about the characteristics of the teachers teaching the “FIFA 11 for Health” for Europe. Nor was any delayed cogni- tive testing done, which limits the interpretation of Disclosure statement the results in relation to a potentially sustained No potential conflict of interest was reported by the authors. effect on the children’s cognitive performance. 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Journal

European Journal of Sport ScienceWiley

Published: Jan 2, 2018

Keywords: Cognition; small-sided football; soccer; drills; health

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