Effects of exergaming on executive functions of children: A meta-analysis

doi:10.21203/rs.3.rs-2699616/v1

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Effects of exergaming on executive functions of children: A meta-analysis

https://doi.org/10.21203/rs.3.rs-2699616/v1

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Journal Publication

published 13 Oct, 2023

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Objectives

Quantitatively assess the impact of exergaming on executive functions in pediatric populations based on existing research.

Methods

A meta-analysis was performed in databases of China National Knowledge Infrastructure, Wan Fang, Web of Science, Embase and PubMed, from January 2010 to February 2023, following the PRISMA guidelines. The Review Manager 5.3 was used to analyze the included articles, and the effects were calculated as standardized mean difference (SMD).

Results

A total of 11 experimental studies with children (n = 515) were included. The effects [SMD(95%CI)] of exergaming on children’s cognitive flexibility, inhibition control and working memory were 0.34(0.16, 0.51), 0.55(0.33, 0.77), and 0.32(0.09, 0.55), respectively.

Conclusions

Exergaming has the potential to improve executive functions in children aged 4–12 years old, particularly in children with special needs. More studies with rigorous designs are warranted to investigate the specific parameters of exergaming intervention.

Active video game

Cognitive flexibility

Inhibition control

Physical activity

Working memory

Executive functions refer to the planned, organized, and focused control process for the goal of a complex cognitive task[1], which includes three core functions (i.e., inhibition control, working memory, and cognitive flexibility) and other higher-level functions such as reasoning, planning, and problem-solving[2]. They are a set of cognitive skills that allow children to plan, focus, remember instructions, and multitask[3]. Research evidence suggests that executive functions are essential in children’s development as they play a pivotal role in helping children learn how to regulate their behavior, think flexibly, and stay organized[4, 5]. They help children learn how to make decisions, problem solve, improve academic performance[6], and improve the ability of some special children to control stressful activities with less misbehavior[7]. In addition, executive functions can also affect children's food intake and physical and mental health in the future[8, 9]. Therefore, executive function is of great significance to children’s development. Children can better control their behavior, follow directions, and remember important information by developing strong executive functions. Executive functions can help them in their journey to success in school and life. The earlier the children develop the executive function, the more conducive to their daily life and learning performance in the future.

Physical activity plays an important role in the development of executive functions in children[10]. Research has shown that regular physical activity can improve children's executive functions, such as memory, planning, and problem-solving[6, 11]. Physical activity increases blood flow to the brain, which helps to enhance cognitive activities. It also helps to reduce stress and anxiety, both of which can interfere with executive functions[12]. Furthermore, physical activity helps to build strong connections between neurons, which is important for developing executive functions[13]. Therefore, children need to engage in regular physical activity to improve their executive functions. Among various physical activity programs, exergaming has been increasingly studied in children and adults in recent years[14–16]. Exergaming is a video game activity based on motion-sensing technology and devices, which can read and interpret the user's body movements and give feedback via the screen[17].

In the past decade, with the continuous development and progress of human-computer interaction technology, active video games such as Kinect and Wii games have been increasingly and widely used in physical activity to promote health or physical rehabilitation. Children do not need to use traditional controllers such as a keyboard and mouse. They can participate in games through their body movements, which is easier to bring an immersive experience[18]. Research has found that exergaming can lead to improved physical fitness, motor skills[19], and even academic performance in children. Furthermore, exergaming may enhance children's executive functions more than traditional non-exercise video games or single aerobic exercise sessions[20, 21]. Overall, the research has found that exergaming can be a beneficial activity great option for promoting children’s cognition and physical activity[22]. It is essential to provide opportunities for children to participate in this type of play.

According to the literature, by engaging in exergaming, children can develop their executive functions in a fun, interactive way[22]. The games involve physical activity, which helps to increase focus, stimulate the brain, and develop coordination. In addition, the games can help to improve concentration, self-control, and decision-making skills[23]. Children can also develop their ability to switch between tasks quickly and efficiently through exergaming, which can be an invaluable skill as they grow and transition into school. Many studies considered exergaming as a favorable approach to improving children’s executive functions. However, the effectiveness of exergaming on executive functions remains unclear and the findings are inconclusive. Therefore, this meta-analysis quantitatively assesses the impact of exergaming on executive functions in pediatric populations, including health and special children. This review attempts to provide a comprehensive review and discussion of the common goals, methods, and findings within the field of exergaming and children’s executive functions to identify new gaps in knowledge need exploration. We strive to provide a quantitative comparison of executive functions as a result of exergaming from recent literature and assess the different findings for statistical significance.

This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P) reporting guidelines[24]. The registration number is CRD42023401526.

2.1 Data source

The electronic databases of China National Knowledge Infrastructure (CNKI, in Chinese), Wan Fang (in Chinese), Web of Science (in English), Embase (in English), and PubMed (in English) were searched for studies investigating the influence of exergaming on children’s executive function. The publication time of articles was from January 2010 to February 2023. The key search terms were (“exergame” OR “active video game” OR “video game”) AND “child” AND (“executive function” OR “cognitive functions” OR “inhibition control” OR “working memory” OR “cognitive flexibility”).

2.2 Literature inclusion and exclusion criteria

2.2.1 Subjects: Healthy children or special children aged 4-12 years. Healthy children: no previous history of neurological or psychiatric disorders. Special children: children diagnosed with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), or other disorders by clinical or parental reports.

2.2.2 Intervention: Exergaming or active video games, such as using Microsoft Kinect, or Nintendo Wii exergaming console.

2.2.3 Outcomes: Executive function and its three components (i.e., cognitive flexibility, inhibition control, working memory).

2.2.4 Exclusion criteria: Subjects included adults only; article types were limited to review studies, dissertations, conference reports, book chapters, or policy documents; the intervention measures were either non-exergaming or unknown; outcomes did not include executive functions or their components; and data was either missing or incomplete.

2.3 Literature screening and data extraction

After removing duplicates, all titles and abstracts were independently screened by two researchers (JC, XW) based on inclusion and exclusion criteria. The full texts of the papers were screened based on the initial screening. The opinions of the third author (SY) would be consulted if there was an inconsistency in screening until a consensus was reached.

2.4 Literature quality assessment

Two researchers (JC, XW) assessed the literature quality with the Jadad scale[25] and the Cochrane risk of bias assessment tool after full-text reading. The Jadad scale is scored by evaluating the generation of random sequences, randomization hiding, blindness ("appropriate"=2, "unclear"=1, "inappropriate"=0), and withdrawal ("described=1", "not described"=0). A score of 0-3 is deemed low quality, and a score of 4-7 is regarded as high quality. The Cochrane library systematic review manual was divided into seven areas. The two researchers (JC, XW) independently evaluated the potential biases of the study, such as selection bias, measurement bias, implementation bias, follow-up bias, bias report and other biases. In disagreement, the literature risk bias was determined through a collective discussion.

2.5 Statistical analysis

Review Manager 5.3 was used to summarize and statistically analyze the results of all included studies. Standardized mean difference (SMD) was chosen as the effect size, and 95% confidence intervals (CI) were calculated. Heterogeneity analysis was carried out, and I² = 0 indicated no heterogeneity. The random effect model was used when I² was more significant than or equal to 50%. The intermediate variables causing heterogeneity were found and determined by subgroup analysis. A statistically considerable level was set at p < 0.05.

3.1 Literature selection flow and result

Upon searching of relevant databases, 4366 Chinese and English articles were identified; however, after eliminating duplicates, 4261 remained. After applying the inclusion and exclusion criteria, 11 papers were ultimately selected for the meta-analysis. The screening process is shown in Fig. 1.

3.2 Basic characteristics of included studies

The sample size of this study was 515 participants aged 4 to 12 years old, with 260 belonging to the experimental group and 255 to the control group. The experimental group underwent exergaming, while the control group did conventional lifestyle or traditional sports activities. Further details can be found in Table 1.

Table 1

The characteristics of included studies
Studies	Subjects			Intervention				Outcome indicator
Studies	N (Int./con.)	Countries	Disorders	Measures	Cycle (week)	Frequency (times/week)	Duration (min/time)
Benzing 2019(26)	51 (28/23)	Switzerland	ADHD	The experimental group: A specific genre of exergaming for XBOX Kinect "Shape Up". The control group: non-exergaming.	8	3	≥ 30	Cognitive flexibility: Flanker task Inhibition control: Simon task Working memory: CSBT
Dovis 2015(27)	61 (31/30)	Netherlands	ADHD	The experimental group: A specific genre of exergaming for “Brain game Brian" (BGB). The control group: Exergaming without working memory engagement.	5	/	35–50	Cognitive flexibility: TMT Inhibition control: Stop task. Working memory: CBTT
Xiong 2019(21)	60 (30/30)	China	Normal	The experimental group: Any genre of exergaming for Wii sports. The control group: Traditional physical activity.	8	5	20	Cognitive flexibility: DCCS
Homa 2020(28)	37 (17/20)	Iran	ASD	The experimental group: A specific genre of exergaming for XBOX Kinect tennis. The control group: Non-exergaming.	8	3	35	Cognitive flexibility: WCST
Benzing 2018(29)	46 (24/22)	Switzerland	ADHD	The experimental group: A specific genre of exergaming for XBOX Kinect “Shape Up”. The control group: Non-exergaming.	1	1	15	Cognitive flexibility: Flanker task Inhibition control: Simon task Working memory: CSBT
Flynn 2018(30)	76 (35/41)	USA	Normal	The experimental group: A specific genre of exergaming for Nintendo dance game "Hottest Door Party 2”. The control group: Non-exergaming.	1	1	60	Cognitive flexibility: Flanker task Inhibition control: flanking fish Working memory: Rule shift test
Gao 2019(20)	32 (18/14)	USA	Normal	The experimental group: Exergaming of Leap TV (dance and PE). The control group: Non-exergaming.	12	5	30	Cognitive flexibility: DCCS
Fronza 2020(31)	48 (25/23)	USA	Normal	The experimental group: Exergaming 1 (Athletics and football) exergaming2 (Skiing, tennis and darts). The control group: Non-exergaming.	9	2	20–30	Cognitive flexibility: Track test part
Liu 2022(32)	48 (24/24)	China	Normal	The experimental group: Exergaming of Just Dance. The control group: Non-exergaming.	4	5	30	cognitive flexibility: DCCS inhibition control: Go/No-Go task. working memory: Mr. Ant task
Chang 2022(33)	32 (16/16)	China	ADHD	The experimental group: Exergaming of Wii sports. The control group: Non-exergaming.	12	3	60	cognitive flexibility: WCST Inhibition control: Stroop task
Nekar 2022(34)	24 (12/12)	Korea	ASD	The experimental group: A specific genre of exergaming for UINCARE. The control group: Non-exergaming.	4	2	15	Cognitive flexibility: WCST Inhibition control: Stroop task Working memory: Digit memory Test
ASD, autism spectrum disorder; ADHD, attention deficit hyperactivity disorder; DCCS, Dimension Change Card Sorting Task; TMT, Trail Making Test; CSBT: Color Span Backwards Task; WCST: Wisconsin Card Sorting Test; CBTT: Corsi Block Tapping Task.

3.3 Risk of bias results assessment

3.3.1 Jadad scale assessment: 5 papers scored 7, 1 paper scored 6, 2 papers scored 4, 2 papers scored 2, and 1 paper scored 1.

3.3.2 Cochrane risk of bias assessment: Eleven studies employed experimental methods, two of which did not mention the use of randomization. Seven studies described hidden allocation schemes, while the other seven were double-blind. Even though all studies experienced a loss of follow-up with some subjects, they all provided explanations and processed the data accordingly as depicted in Fig. 2.

3.3.3 Bias Test: The results of the publication bias test are shown in Fig. 3. Most of the scatter points are distributed inside the funnel plot and are symmetrical, except for one study on inhibition control.

3.4 Integration of research evidence

A total of 11 papers (including 254 children in the experimental group and 254 children in the control group) were included in the meta-analysis on cognitive flexibility. The results showed that SMD = 0.34, 95%CI: 0.16, 0.51, p < 0.001, as shown in Fig. 4. The results of analysis on inhibition control showed that SMD = 0.55, 95%CI: 0.33, 0.77, p < 0.001. The results of analysis on working memory showed that SMD = 0.32, 95%CI: 0.09, 0.55, p < 0.001. No significant heterogeneity (I² < 50%, p > 0.05) was observed in the subgroup meta-analysis on executive functions.

In all aged subgroups of children, the improvement effects of exergaming on executive functions were statistically significant (p < 0.01), but not for working memory in children aged > 6 years (p > 0.05).See Table 2. The effects of exergaming on cognitive flexibility (in both healthy and special children) and inhibition control in special children were statistically significant ( p < 0.05). All levels of exercise-intensity exergaming had statistically significant effects (p < 0.05) on children's executive functions except for working memory in the medium-high intensity group. The study showed that children's cognitive flexibility was significantly improved when exposed to 15–20 minutes of the activity (p < 0.01). Furthermore, children's inhibition control and working memory improved when exposed to 20–30 minutes of the action (p < 0.01). Finally, cognitive flexibility and inhibition control were improved when exposed to more than 30 minutes of the action (p < 0.05). The effect was significant for children’s cognitive flexibility (p < 0.05) when the intervention was over 6 weeks. The significant effects (p < 0.01) on cognitive flexibility, inhibition control, and working memory were observed in subgroups of 2–6 weeks, but not in those ≤ 1 week.

Table 2

Subgroup analysis of children’s age and disorder status, exercise intensity, intervention duration and cycle
Variables	Subgroup category	Cognitive flexibility							Inhibition control							Working memory
Variables	Subgroup category	SMD	95%CI	Z	P	Model	Studies	Sample size	SMD	95%CI	Z	P	Model	Studies	Sample size	SMD	95%CI	Z	P	Model	Studies	Sample size
Age	4–6 years	0.47	0.14, 0.81	2.76	0.00	Fixed	3	140	1.02	0.41, 1.62	3.29	0.00	Fixed	1	48	0.79	0.20, 1.38	2.63	0.00	Fixed	1	48
Age	> 6 years	0.28	0.08, 0.49	2.69	0.00	Fixed	8	368	0.48	0.24, 0.72	3.92	0.00	Fixed	6	283	0.23	-0.02,0.48	1.84	0.07	Fixed	5	251
Disorder status	Normal	0.26	0.01, 0.50	2.06	0.04	Fixed	5	264	0.63	-0.05, 1.32	1.81	0.07	Random	2	124	0.44	-0.19,1.07	1.37	0.17	Random	2	124
Disorder status	Special	0.42	0.17, 0.68	3.25	0.00	Fixed	6	244	0.54	0.26, 0.82	3.78	0.00	Fixed	5	207	0.27	-0.03,0.57	1.79	0.07	Fixed	4	175
Exercise intensity	Moderate	0.37	0.14, 0.61	3.09	0.00	Fixed	6	287	0.73	0.42, 1.03	4.64	0.00	Fixed	4	179	0.43	0.13, 0.73	2.84	0.00	Fixed	4	179
Exercise intensity	Medium-high	0.29	0.03, 0.56	2.15	0.03	Fixed	5	221	0.36	0.03, 0.68	2.17	0.03	Fixed	3	152	0.15	-0.20,0.51	0.84	0.40	Fixed	2	120
Intervention duration	15–20 min	0.53	0.17, 0.88	2.93	0.00	Fixed	3	130	0.88	-0.20, 1.96	1.59	0.11	Random	2	70	0.48	-0.56,1.53	0.96	0.36	Random	2	70
	20–30 min	0.28	-0.07, 0.62	1.59	0.11	Fixed	3	133	1.02	0.41, 1.62	3.29	0.00	Fixed	1	48	0.79	0.20, 1.38	2.63	0.00	Fixed	1	48
	> 30 min	0.27	0.02, 0.52	2.09	0.04	Fixed	5	245	0.41	0.14, 0.68	2.95	0.00	Fixed	4	213	0.20	-0.09,0.49	1.33	0.18	Fixed	3	181
Intervention cycle	≤ 1 week	0.18	-0.18, 0.54	0.98	0.33	Fixed	2	122	0.34	-0.02, 0.70	1.85	0.06	Fixed	2	122	0.09	-0.27,0.45	0.50	0.62	Fixed	2	44
	2–6 weeks	0.51	0.16, 0.86	2.85	0.00	Fixed	3	133	0.86	0.50, 1.22	4.66	0.00	Fixed	3	133	0.59	0.24, 0.94	3.32	0.00	Random	3	133
	> 6 weeks	0.33	0.08, 0.58	2.56	0.01	Fixed	6	253	0.40	-0.06, 0.85	1.72	0.09	Fixed	2	76	0.17	-0.42,0.76	0.56	0.57	Fixed	1	151
SMD, standardized mean difference.

This meta-analysis provides an overview of the current research on the impact of exergaming on children’s executive functions. Its main objective is to review and synthesize the findings of recent experimental exergaming studies. Eleven studies met the inclusion criteria and were included in our final analysis[20, 21, 26–34]. Overall, our data suggested that exergaming interventions could significantly improve executive functions (e.g., cognitive flexibility, inhibition control, and working memory) in healthy and special children aged 4–12 years old. Findings indicated significant improvements, yet more than one-quarter of the studies was deemed at risk for bias, particularly regarding performance bias.

Our sub-population analysis results show that the efficacy of exergaming on special children appears to be more consistent than that of healthy, typical children. This might be because special child typically has a lower initial level of executive function[35, 36], so they may experience more significant gains from an exergaming intervention than healthy children. For example, due to the late development of the frontal cortex in children with ASD and ADHD, the activity in the cerebellum and prefrontal lobes is weaker, leading to more inadequate executive functions[37]. Meanwhile, exercise may enhance children’s co-activation between the cerebellum and the dorsolateral prefrontal cortex[38]. Previous studies have suggested that those with lower starting cognition performance have more significant potential for enhancement, whereas those with higher starting performance have limited chances for further optimization [39]. Thus, the degree of improvement may be relatively small for healthy children due to the ceiling effect.

In this study, the findings indicated that exercising through exergaming at moderate intensity may provide better benefits for enhancing executive functions in children compared to exercising at a medium-high intensity. Previous meta-analysis studies found that engaging in physical activity at a moderate intensity level showed an improvement in executive function that was greater than when physical activity was done at a vigorous intensity[38, 40]. Another study in long-term exercise training found that, under the same mental state, the group that exercised at a higher intensity saw greater benefits in terms of improved executive functions than the group that exercised at a lower intensity[21]. Thus, further research is necessary to gain greater clarity on this topic. Regarding the effects of intervention duration and frequency, our findings indicated that children’s executive functions were not improved by exergaming with a session time of fewer than 20 minutes or a frequency of no more than one week, except for cognitive flexibility.

This review’s major strength is that it provides the first comprehensive overview of the latest research on how exergaming programs affect the executive functions of healthy and special needs children. However, this study has a few limitations: First, the investigation into the effects of exergaming on children’s executive function is limited, which means that the potential moderating variables such as intervention intensity, frequency and duration have not been able to be adequately looked at. Additionally, different studies have employed various tools to measure executive functions, which could generate inaccurate results. The current experimental evidence has demonstrated that exergaming can positively affect children’s inhibition control, working memory, and cognitive flexibility. Nevertheless, more randomized controlled studies with standardized evaluation methods and processes are necessary to provide more accurate evidence of the potential benefits of exergaming to promote children’s cognition.

Acknowledgments

We would like to thank the parents of the preschoolers for their participation in this study.

Authors’ contributions

SY and JC conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript. JC and XW were in charge of the collected data. XZ and ZG reviewed and revised the manuscript. All authors have read and approved the final manuscript.

Funding

The study was supported by the Public Welfare Research Project of Jiaxing (2020AD30028).

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Ethics approval was obtained from the Ethics Committee of The First Hospital of Jiaxing (LS2019-107). All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). Informed consent was obtained from parents or legal guardians of the participants whose age was below 16.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Effects of exergaming on executive functions of children: A meta-analysis

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