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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 73-76

Cognition-engaging physical exercise for improving cognitive impairments in attention-deficit hyperactivity disorder: A behavioral medicine approach

1 International Graduate School of Neuroscience, Ruhr-University Bochum; Department of Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, Dortmund, Germany
2 Department of Psychology, Shahid Beheshti University, Tehran, Iran; Department of Psychology, Regensburg University, Regensburg, Germany

Date of Submission10-Sep-2019
Date of Acceptance11-Oct-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Mohammad Ali Salehinejad
International Graduate School of Neuroscience, Ruhr-University Bochum, Bochum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_54_19

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Cognitive impairment is a common deficit in psychological, neurological, and psychosomatic disorders. Recent studies suggest physical exercise as a new method for enhancing cognition, but not all types of physical exercises are beneficial to cognition. We propose cognition-engaging physical exercises (CEPEs) framework for purposefully and selectively enhancing cognition, which could have promising clinical implications in behavioral medicine. Here, we present results of the CEPE intervention in a patient with attention-deficit hyperactivity disorder (ADHD) in comparison with a control case who underwent treadmill exercise. Preliminary results show discernible increased accuracy and decreased response time in working memory and response inhibition task performance after CEPE but not treadmill exercise. We discuss the reason why CEPE could be more beneficial as compared to non-CEPE. Moreover, clinical implications of CEPE in behavioral medicine are discussed.

Keywords: Attention-deficit hyperactivity disorder, behavioral medicine, cognitive enhancement, physical activity

How to cite this article:
Salehinejad MA, Nejati V. Cognition-engaging physical exercise for improving cognitive impairments in attention-deficit hyperactivity disorder: A behavioral medicine approach. Heart Mind 2019;3:73-6

How to cite this URL:
Salehinejad MA, Nejati V. Cognition-engaging physical exercise for improving cognitive impairments in attention-deficit hyperactivity disorder: A behavioral medicine approach. Heart Mind [serial online] 2019 [cited 2023 Apr 1];3:73-6. Available from: http://www.heartmindjournal.org/text.asp?2019/3/2/73/271534

  Introduction Top

Cognitive impairment is a common deficit in psychological, neurological, and psychosomatic disorders. Recent studies propose physical exercise as a new method for enhancing cognitive functions.[1] Physical exercise prepares brain by facilitating physiological mechanisms (i.e., increase of brain-derived neurotrophic factor, vascularization, neurogenesis, plasticity, and structural and functional changes), leading to general enhancement of cognitive functions. However, not all types of physical exercises benefit cognition similarly because different types of physical training affect different neurocognitive networks. Therefore, it might be more efficient to design modality-specific physical exercises for some cognitive processes, such as executive functions (EFs) that are shown to benefit from exercises with specific parameters.[2]

We designed a novel framework for improving cognition called cognition-engaging physical exercises (CEPEs). CEPEs are purposeful physical exercises that require body movements based on cognitive paradigms. EFs are the primary candidate for developing CEPE as they can be improved in both supramodal and modality-specific ways.[3],[4] Based on this assumption, CEPE is expected to selectively and purposefully enhance the functionality of EF domains. For example, resistance exercises as compared to aerobic exercises have no cognition-improving effects and even enhancing effects of acute exercises on cognition are not specific to some aspects of information processing which are facilitated by aerobic exercise.[5],[6] The most prominent effects of physical exercises on EFs are observed in at least two periods of lifespan: in old age and childhood.[7] Although previous studies on aerobic exercises that are usually more cognition-demanding were close to this idea, designing physical exercise based on cognitive paradigms is a novel approach.

Attention deficit-hyperactivity disorder (ADHD), as a major neurodevelopmental disorder, characterized by various cognitive dysfunctions. The most well-documented cognitive concept of ADHD is the EFs theory[8] according to which the decisive factor in ADHD pathophysiology is impaired executive control or the ability to purposefully monitor, manage, and modify behaviors. Some EFs play a more crucial and fundamental role, including cognitive flexibility, inhibitory control, and working memory (WM), which is why they have been mostly targeted by novel treatment options.[9],[10] We chose WM and inhibitory control because, first of all, they are among the most documented deficits in ADHD[11] and, second, designing CEPE based on these paradigms is more feasible. Here we present a case report of an ADHD child who underwent CEPE intervention and compared the results with his control counterpart who did a treadmill running exercise as a control intervention.

  Case Report Top

Two school-age ADHD children were examined and participated in this case study. Both experimental (male, age = 10 years) and control case (male, age = 11 years) were right-handed and had normal vision [Table 1]. Given that participants were under the legal age, their parents were instructed about experimental procedures and gave their informed consent before participation of their children.
Table 1: Demographic information

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Diagnostic assessment

ADHD diagnosis was according to the DSM-5 diagnostic criteria examined by a professional child psychiatrist. In addition, symptoms' severity was confirmed based on the SWAN Rating Scale and both parent and teacher version of the Swanson, Nolan, and Pelham Rating Scale IV Questionnaire. Scores higher than 1.67 are indicative of clinical significance, and the cutoff point for inattention and hyperactivity/impulsivity subscales is 1.78 and 1.44, respectively.

Cognitive measures

WM performance was assessed using the visual “N-back” task. In this task, the target was any picture that was identical to the one it preceded one trial back (i.e., 1-back task). Each participant completed three runs of the task; each run consisted of 30 stimuli, lasting around 6 min in total. The stimuli consisted of 10 different images, and each image was randomly repeated three times in each run. Accuracy and response time (RT) are the outcome measures of interest in this task. Inhibitory control was measured using the Go/No-Go task. This task consisted of 50 stimuli (planes with7 cm × 7 cm size) that required response execution (i.e., Go trials) on 75% of trials and the inhibition of a response (No-Go) on the remaining 25%. Participants were presented with a plane which appeared on the screen in four directions, up, down, left, and right. They were instructed to press the button aligned with the plane (the Go condition), but to withhold pressing any button when the sound “Beep” was heard (the No-Go condition). The correct response to No-Go stimuli examines prepotent response inhibition as an index of inhibitory control. This task takes about 7 min to complete.

Therapeutic intervention

The experimental case underwent 10 sessions (2 sessions weekly) of CEPE intervention. The intervention included two CEPEs that were designed based on the inhibitory control (Go/No-Go) and WM paradigms. In the inhibitory control CEPE, the experimenter claps his hands once or twice in random order and subjects are asked to do jumping jacks in the air after one clap of the experimenter (Go responses) and remain inactive after two clapping of the experimenter (No-Go responses). The number of single clapping and the interval of double clapping can be increased and decreased, respectively, for modulating exercise difficulty. The exercise for improving WM included a banner with a series of footprint on the margin. A number was written in each footprint, and the subjects had to walk on the footprints and tell the sum of the numbers under their feet after taking each step. The accuracy and RT were recorded by the therapist in each round. The numbers that were written on the banner were 0–4 in the initial stage and changed to 5–9 in the next stages for making the task more challenging. Both CEPE exercises took 30 min in total. The control case underwent 10 sessions (same duration) of treadmill running exercise (5 min warm-up, 20 min running, and 5 min cool-down) as the control intervention. WM and inhibitory control were measured before the intervention, immediately after the intervention, and 1 month following the intervention.

  Results and Outcomes Top

The descriptive statistics including mean score in the EFs task before, immediately after, and 1-month follow-up the intervention are presented in [Figure 1] and [Table 1]. As [Figure 1] depicts, WM accuracy and RT are, respectively, increased and decreased in the participant who did CEPE after the intervention and 1-month following the intervention. Such improvement of performance is not observed in the control case that simply did treadmill running exercise. The similar pattern is seen for the inhibitory control performance. The CEPE case has increased No-Go accuracy immediately after the intervention (M = 100) which was extended up to 1 month (M = 100) compared to the baseline (M = 95). In contrast, inhibitory control was surprisingly impaired in the control condition. Regarding the RT, both cases show shorter RT in the postintervention and follow-up measurement; however, unlike the No-Go accuracy which was impaired, RT is shorter in the control participant.
Figure 1: Performance in the WM and response inhibition tasks following CEPE and treadmill running exercise in two ADHD children. RT = Response time, CEPE = Cognition-engaging physical exercise, WM = Working memory

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  Discussion Top

Results of this case report showed that CEPE, compared to noncognitive physical activity (treadmill running in this case), improved WM and inhibitory control. The purposeful physical exercises that require body movements based on cognitive paradigms, specifically EFs, are a key aspect for the success of the intervention. Based on this assumption, CEPE is expected to selectively and purposefully enhance the functionality of EF domains relevant for cognitive processes (i.e., inhibitory control, attention shifting, and updating). The suggested underlying mechanisms could be that CEPE (a) facilitates the neuroplastic capacity of the brain due to physical activity and recruits neural circuitries associated with supramodal EFs, (b) provides cognitive activation of the targeted EFs which is not achieved by general physical exercises and (c) and finally is in line with the notion that cognition is body based (i.e., embodied cognition) and activates sensorimotor representations of each EF domain through movement in the environment.

These mechanisms may also implicate that enhancing effects of CEPE for EFs are related to the way their representations are activated in the brain. On one hand, there seem to be supramodal representations of EFs which are relevant for motor and cognitive performance, independent of specific EFs, and these benefit from physical activity and movement inherent in CEPE (i.e., supramodal representation of EFs). On the other hand, CEPE with its specific parameters activates respective representations of each EF domain which are modality-specific.

Despite promising results, we should note that improving effects of CEPE should be experimentally explored in future randomized controlled studies with larger sample sizes. Our report is limited to behavioral data, which prevents interpreting efficacy of the intervention at neural level. Nevertheless, the results of this case report could be regarded as a potential supporting evidence of CEPE for improving executive dysfunctions in the ADHD with potential implications for other population suffering from cognitive impairments. Another potential line of research concerns with noninvasive brain stimulation (NIBS) techniques that have been promisingly used in for studying and improving brain functions in healthy and clinical populations.[12],[13],[14] Given that CEPE can enhance cognition by activating cognition-specific brain regions, combination of this intervention with NIBS techniques that target involved brain regions at neural level can be more beneficial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the children's parents have given consent for images and other clinical information to be reported in the journal. The children's parents understand that the names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Stimpson NJ, Davison G, Javadi AH. Joggin' the noggin: Towards a physiological understanding of exercise-induced cognitive benefits. Neurosci Biobehav Rev 2018;88:177-86.  Back to cited text no. 1
Best JR. Effects of physical activity on children's executive function: Contributions of experimental research on aerobic exercise. Dev Rev 2010;30:331-551.  Back to cited text no. 2
Ghanavati E, Salehinejad MA, Nejati V, Nitsche MA. Differential role of prefrontal, temporal and parietal cortices in verbal and figural fluency: Implications for the supramodal contribution of executive functions. Sci Rep 2019;9:3700.  Back to cited text no. 3
Nejati V, Salehinejad MA, Nitsche MA. Interaction of the left dorsolateral prefrontal cortex (l-DLPFC) and right orbitofrontal cortex (OFC) in hot and cold executive functions: Evidence from transcranial direct current stimulation (tDCS). Neuroscience 2018;369:109-23.  Back to cited text no. 4
Pontifex MB, Hillman CH, Fernhall B, Thompson KM, Valentini TA. The effect of acute aerobic and resistance exercise on working memory. Med Sci Sports Exerc 2009;41:927-34.  Back to cited text no. 5
Tomporowski PD. Effects of acute bouts of exercise on cognition. Acta Psychol (Amst) 2003;112:297-324.  Back to cited text no. 6
Hötting K, Röder B. Beneficial effects of physical exercise on neuroplasticity and cognition. Neurosci Biobehav Rev 2013;37:2243-57.  Back to cited text no. 7
Castellanos FX, Sonuga-Barke EJ, Milham MP, Tannock R. Characterizing cognition in ADHD: Beyond executive dysfunction. Trends Cogn Sci 2006;10:117-23.  Back to cited text no. 8
Nejati V, Salehinejad MA, Nitsche MA, Najian A, Javadi AH. Transcranial direct current stimulation improves executive dysfunctions in ADHD: Implications for inhibitory control, interference control, working memory, and cognitive flexibility. J Atten Disord 2017. doi:10.1177/1087054717730611.  Back to cited text no. 9
Salehinejad MA, Wischnewski M, Nejati V, Vicario CM, Nitsche MA. Transcranial direct current stimulation in attention-deficit hyperactivity disorder: A meta-analysis of neuropsychological deficits. PLoS One 2019;14:e0215095.  Back to cited text no. 10
Sergeant JA, Geurts H, Huijbregts S, Scheres A, Oosterlaan J. The top and the bottom of ADHD: A neuropsychological perspective. Neurosci Biobehav Rev 2003;27:583-92.  Back to cited text no. 11
Vicario CM, Nitsche MA. Transcranial direct current stimulation: A remediation tool for the treatment of childhood congenital dyslexia? Front Hum Neurosci 2013;7:139.  Back to cited text no. 12
Vicario CM, Salehinejad MA, Felmingham K, Martino G, Nitsche MA. A systematic review on the therapeutic effectiveness of non-invasive brain stimulation for the treatment of anxiety disorders. Neurosci Biobehav Rev 2019;96:219-31.  Back to cited text no. 13
Polanía R, Nitsche MA, Ruff CC. Studying and modifying brain function with non-invasive brain stimulation. Nat Neurosci 2018;21:174-87.  Back to cited text no. 14


  [Figure 1]

  [Table 1]

This article has been cited by
1 Transcranial Direct Current Stimulation in ADHD: A Systematic Review of Efficacy, Safety, and Protocol-induced Electrical Field Modeling Results
Mohammad Ali Salehinejad,Vahid Nejati,Mohsen Mosayebi-Samani,Ali Mohammadi,Miles Wischnewski,Min-Fang Kuo,Alessio Avenanti,Carmelo M. Vicario,Michael A. Nitsche
Neuroscience Bulletin. 2020;
[Pubmed] | [DOI]


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