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© 2017 EDIZIONI MINERVA MEDICA Online version at http://www.minervamedica.it
The Journal of Sports Medicine and Physical Fitness 2018 ????;58(??):000-000 DOI: 10.23736/S0022-4707.17.07245-0
ORIGINAL ARTICLE
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Cognitive and personality factors in the regular practice of martial arts Rosa A. FABIO, Giulia E. TOWEY *
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Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy
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*Corresponding author: Giulia E. Towey, Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, via Concezione 6-8, 98122 Messina, Italy. E-mail:
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artial arts can be described as various codified combat systems that originated in the Far East, commonly considered by the Asian culture as a way of living, promoting discipline and greater values. Martial arts involvement is considered controversial, especially if we consider the literature about the psychological benefits of this practice; some claim that long term practice leads to positive benefits in terms of well-being, self-confidence, self-esteem, and discipline,1-4 while others focus on the possibility of enhancing aggressiveness and antisocial behavior.5-7 For many years the influence of martial arts has not been analyzed in a scientific way in the western world, mainly because of the difficulty in extracting the real
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BACKGROUNDː The effects of regular practice of martial arts is considered controversial and studies in this field limited their attention to singular psychological benefits. The aim of this study is to examine the relationship between the regular practice of martial arts and cognitive and personality factors, such as: attention, creativity and school performance, together with, self-esteem, self-efficacy and aggression. METHODSː The design consists in a factorial design with two independent variables (groups and age levels) and seven dependent variables (attention, creativity, intelligence, school performance, self-esteem, self-efficacy and aggression). Seventy-six people practicing martial arts were compared with a control group (70 participants) not involved in any martial arts training. Martial artists were divided into groups of three levels of experience: beginners, intermediate and experts. Each completed a battery of tests that measured all the cognitive and personality factors. RESULTSː Martial artists presented a better performance in the attentional and creativity tests. All the personality factors analyzed presented a significant difference between the two groups, resulting in higher levels of self-esteem and self-efficacy, and a decrease of aggressiveness. CONCLUSIONSː Regular practice of martial arts can influence many functional aspects, leading to positive effects on both personality and cognitive factors, with implications in psychological well-being, and in the educational field. The results were discussed with reference to theories claiming that regular activity has a differential positive effect on some aspects of cognition. (Cite this article as: Fabio RF, Towey GE. Cognitive and personality factors in the regular practice of martial arts. J Sports Med Phys Fitness 2018;58:______. DOI: 10.23736/S0022-4707.17.07245-0) Key words: Attention - Aggression - Cognition - Martial arts - Motor activity.
benefits in terms of psychological changes. The first studies that analyze the social-psychological effects of martial arts go back to the late ‘60s and early ‘70s; these focused on personality factors that influenced the type of martial arts chosen and how the practice could change the artists over a period of time. Studies found an improvement in a number of personality traits, nevertheless, authors noted greater variety of hostile modes of expression in both beginners and advanced practitioners.8 It is probable that this was the turning point in which the attention shifted to the influence of martial arts on aggressiveness that characterized most of the research of recent years. In general, however, studies concluded that longer training leads to a decrease in the
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perseverance and math abilities. The European Physical Education Association (EUPEA), indicated that in the majority of countries, martial arts are introduced during physical education classes in secondary schools because it is believed that it provides educational opportunities for pupils.18 Consistent with this assumption, Åberg et al.,19 demonstrated that changes in physical achievement between the ages of 15 and 18, predicted cognitive performance later. Moreover, this study found a positive association between cardiovascular fitness and intelligence and predicted educational achievements later in life.19 Traditional martial arts are distinguished by exercises consisting in sequences of movements and patterns describing battle against an unspecified number of imaginary opponents,20 named differently by various martial arts (Kata or Forms). Moreover they are characterized by combat exercises with two or more opponents, in which you have to focus attention on many stimuli (to avoid attacks and find the right time to respond), these are called “Kumitè” o simple combat. This suggests that they include cognitive as well as physical components.20 It is known that there is a parallelism between cognitive processes of varying degrees of complexity; many influence each other, allowing athletes to operate in complex situations. Cognitive factors are essential in order to analyze, select and respond to environmental stimuli (attention), any interruption in one of these processes can have negative effects on sport performance. For example the breadth of attention is essential in sport, and it is directly associated with the creative performance: The more stimulus the athlete is able to pay attention to, the more are the connections that he can create between them.21,22 Memmert,22 in a longitudinal study that analyzed this relation, showed that the group focused on training to gain a broader breadth of attention, significantly improved their creative performance. Nevertheless, it seems that the exposure to aerobic exercise may have the same effect; Tuckman et al.23 demonstrated, in a randomized controlled trial, that taking part in a physical education program for several weeks, improves creativity in school children. As it has been pointed out, athletes in order to generate original solutions, have to be able to perceive different stimuli in complex environments and consider the information to generate an action plan.24 Martial arts athletes are capable of using research patterns and fo-
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levels of aggressiveness independent of gender.9-11 Recently attention has shifted to the therapeutic effects of martial arts practice, such as: a decrease in depression and anxiety, an increase in well-being, general stress management, and exercise self-efficacy.2 Learning a sport such as martial arts, which presents a large number of techniques gathered in a program with increasing difficulty, implicates both cognitive and emotional dimensions. Complex motor abilities are influenced by emotional factors such as self-esteem and self-efficacy, in so much as they can influence the way we see ourselves and our capacities.12 Nevertheless, as it has been pointed out, many studies that evaluated personality changes in martial artists, focused on aggression, considering to a lesser extent other psychological changes of this practice. Athletic involvement is associated with an increase of self-esteem and an improvement of self-image;13 for example, in one of the early studies, Richman et al.3 using the Rosenberg Self-Esteem Scale, found that Karateka showed an increase in self-esteem directly proportional to the belt rank. Perceived self-efficacy refers to what an individual believes he can accomplish using his or her skills under certain circumstances.14 This belief is the key factor of human agency. People with high self-efficacy are those who are more likely to engage a task, even if perceived as being difficult, instead of avoiding it. Today most scientists believe that exercise can increase self-efficacy and self-concept; a recent study that had the aim of investigating the influence of these parameters in a group of martial artists, found that both self-concept and selfefficacy were higher in this group as opposed to the non martial artists.15 The importance of evaluating both emotional and cognitive factors, especially in the developmental age, was highlight by some longitudinal studies. Lakes et al.16 noted that martial artists who practice tae know do (a Korean martial art), in a school context, after 3 moths, showed greater improvement in the three domains analyzed (cognitive, affective, and physical): cognitive self-regulation, affective self-regulation, prosocial behavior, classroom conduct, and performance in mental math tests. Moreover, Diamond et al.,17 in their review regarding the development of executive functions, observed that children who received traditional Tae-Kwon-Do training improved their physical condition, and also gained in self-control, inhibitory control,
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mances for the cognitive variables analyzed (attention, creativity, and school profit); 2) that there are differences between the various levels of experience, expecting higher performances for the experts. Furthermore, the same trend is expected for the personality factors, in particular, higher levels of self-esteem and self-efficacy, and lower levels of aggression for martial artists, the influence of experience on the same parameters.
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Materials and methods Participants
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The Human Ethics Committee of the Department of Cognitive Sciences, Psychology, Education and Cultural Studies of the University of Messina approved the study protocol on the 21st November 2015 (n° 27502113); all participants were informed that the study was an investigation of the effect of martial arts practice, therefore we informed the parents of under age children who gave a written consent. Participants (N.=146; ageyears M =14.88, SD =6.21) were male (N.=107;) and female (N.=39), graduated from university (N.=7) or from high school (N.=20), and those remaining were students. The subjects were divided into two main groups: experimental group (people who practice martial arts; N.=76; ageyears M =15.27, SD =6.62) and control group (not practicing any martial art; N.=70; ageyears M =14.5, SD =6.07). Participants of the experimental group practiced three different types of martial arts (karate, kung fu and ju jitsu), mainly considered traditional styles. The traditional approach is less focused on competitive aspects and more centered on discipline and conflict avoidance. Moreover within the experimental group, people were divided into three levels: beginners, intermediate and experts. Beginners, had not more that two years practice; intermediate had at least three to six years practice and experts were those who had more than seven years practice. The control group was composed of subjects who were not involved in martial arts, but the under age children, were all participants in different school team sports (basketball, volley ball and gymnastics), while the adults were in independent teams, practicing: soccer, tennis and swimming. The two groups (experimental vs. control) were matched for age, gender and IQ (Table I). The participants completed a battery of tests together with a questionnaire created ad hoc asking for their
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cusing attention on more areas, and this ability is higher for experts as opposed to intermediate or low levels of experience; this finding has been tested on a group of martial artists in a common situation which they attend frequently.25 Eighteen participants (six for each level) were video-recorded while they were asked to carry out a task in which they had to solve a combat situation, and the image was projected on to a screen. The participants had to respond to attacks using a joystick. The data was analyzed, and they discovered that experts adopted a more efficient search pattern and they also focused on different display areas than the novice.25 It is known that physical activity has a positive effect on mind and body, and it seems that regular activity is able to alter the structure and function of the brain.26 Physical exercise is associated with the increase in the activity of specific cerebral areas, such as the prefrontal cortex which is responsible for the regulation of complex cognitive processes, such as executive functions and attention. A recent study, that had the aim of comparing the brain’s electrical activity in martial arts athletes, found that there were significant differences between experts and novices in the event-related brain potentials (ERPs) that underlie sustained attention. The results reflected better-controlled attention in skilled athletes, associated with the activation of the structural areas responsible (frontal and limbic lobes).27A metaanalysis by Colcombe and Kramer28 highlighted that physical activity provides general benefits across multiple aspects of cognition; nevertheless, it is possible that different types of sports may influence different abilities, as has been proposed in the “selective improvement hypothesis” by Kramer et al.29 Not many studies have analyzed, on a neuropsychological level, the effects of martial arts on cognition; it is still unclear which factors influence these effects (e.g. type of sport, duration, intensity, sport preference), and it is still an open issue whether the complexity of the motor activity, such as martial arts, could have major effects on a broader level, in comparison to relatively simple sport activities.30 In view of the above literature that shows the possibility that martial arts practice can have positive effects on the artists, the objective of this research is to investigate if there are differences between people practicing martial arts and people who are not involved in any martial arts training. In particular it was hypothesized that: 1) martial arts practitioners present higher perfor-
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15.27 (6.62) 14.5 (6.07)
103.2 (8.6) 102.6 (7.5)
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training experience in terms of years of practice and belt rank. The second of these variables was not used in the analysis because the different martial arts styles did not allow a correspondence between the colors of the belts. Having a large age range, the participants were divided into three groups: —— group 1: 7≤years≤11; —— group 2: 12≤years≤16; —— group 3: ≥17 years. Procedure
Materials
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The sample of the experimental group, was selected from two sport centers of the Thieu Lam School located in the province of Messina (Sicily), who were all affiliated to the F.I.W.U.K-CONI federation. The rest were chosen randomly in different Italian areas during several worldwide competitions, that were affiliated to the same federation and to the W.T.K.A. Control group participants were selected from different school levels, and they were matched for age, gender and IQ. To collect the data and information we used a series of questionnaires that were administrated and self-completed after we obtained the authorization of the parents of under age children. After explaining the procedure, we checked if there were any doubts, and each subject independently completed the self-reports. The Raven’s matrices, the Torrance Test of Creative Thinking and the Trail Making Test were administrated individually with the experimenter. All the questionnaires were completed in isolated areas, and extra help was granted to subjects under the age of 12.
A questionnaire was created to obtain the necessary information that helped to divide the subjects into the different group levels and chronological ages. The school achievement of the last grade attended, was obtained for all the participants; moreover martial artists had to specify the years of practice and the belt level.
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The Raven’s Advanced Progressive Matrices (APM) 31 and the Coloured Progressive Matrices (CPM)32 were used to evaluate the intelligence, necessary to match the two groups (experimental and control group). We used the Trail Making Test (TMT)33 that is primarily a test that measures visual attention and motor speed. The TMT provides information on visual search, scanning, speed of processing, mental flexibility, and executive functions. The test has two parts: Part A involves a series of numbers and the participant is required to draw lines connecting the numbers in sequential order (i.e. 1-2-3, etc.). Part B involves a series of numbers and letters and the participant is required to alternately connect letters and numbers in sequential order as rapidly as possible. The score on each part represents the amount of time required to complete the task, expressed in seconds. The TMT is sensitive to cognitive flexibility, in fact the scores in version B, or the difference in scores between versions B and A, are often of greater interest because they have been postulated to reflect aspects of executive functioning, such as planning and switching. Many studies have tried to clarify the processes underlying the TMT scores and have used the test to obtain normative data on different populations (healthy adults vs. clinical population, different age groups, and various races). For example Tombaugh 34 supplied normative data using a large sample size and verified kurtosis and Skewness (0.04 and 0.45) indexes. For the evaluation of creativity we used the Torrance Test of Creative Thinking (TTCT)35 and Alternative Uses Task (AUT).36 The first of these, designed to evaluate creative thinking, includes a figural and verbal subtest. The TTCT-figural (that was used in this research) has two parallel forms, A and B, and consists of three activities that have to be completed within 10 minutes. Both forms are oriented to assess three principal cognitive processes of creativity: fluency, flexibility and originality. The first of these evaluates the number of relevant ideas; the flexibility refers to the variety of categories of relevant responses, while the originality subscale refers to the number of statistically infrequent ideas. With reference to the validity of the TTCT, the interrater reliabilities obtained using Cronbach’s alpha range from 0.78 to 0.88, while the test-retest reliability coefficients range from 0.50 to 0.93.37 Another test used for the evaluation of divergent thinking was the AUT, in which participants are asked to list, for every common
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Table I.—Characteristics of the two groups participating in the experiment.
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Results
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The first part of the results concern the differences between the two groups (experimental and control), while the second part refers to differences between the levels of experience within the experimental group. With reference to the first part, regarding the attention parameter, an analysis of variance was performed considering each subtest of the TMT and the difference between the second and the first subtest (TMT B-A). Table II summarizes the means and standard deviations of each subtest separately for the experimental group and the control group and for each age level considered. Regarding TMT-A the interaction groups x age levels shows significant effect, F (1, 137) =3.22, P=0.04, d =0.58, this means that with the increase in age people who practice martial arts solve the TMT-A in less time than the control group. The same result was obtained in the second subtest (TMT-B), that is characterized by two different types of stimuli, F (1, 137) =4.11, P7
4.41 4.5 6.25 9.79 10.47 11.95
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62.03 (16.57) 129.15 (35) 28 (13.81) 61.12 (16.46) 26 (2.09) 68.83 (11.14) 42.18 (11.25) 92.28 (15.97) 31.27 (7.24) 71.3 (21.75) 26.08 (7.12) 51.5 (14.6) 30.04 (11.96) 62.21 (19.46) 21.74 (5.38) 53.3 (22.93)
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Table V.—Means and standard deviations of parameters not influenced by age in relation to the years of practice.
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Table IV.—Means and standard deviations of cognitive parameters in relation to years of practice and age.*
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*Values are expressed as mean (SD).
Torrance Test of creative thinking Flexibility Fluidity
and cognitive and personality factors. More in depth the purpose was to evaluate if there are any differences between people practicing martial arts and people who are not involved in any martial arts training, with regard to a series of factors, in particular: attention, creativity, school performance, self-esteem, self-efficacy and aggression. Moreover, comparing beginners, intermediate and experts, it was possible to analyze if there are any differences in relation to the athletes expertise for both the cognitive and personality variables. Results demonstrate significant differences between the two groups,
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martial arts, many studies have analyzed the implication of such a sport in developmental age, considering the effects on aggression,6 self-regulation 16 and the relationship with academic achievement.17, 26 These authors found, among other benefits, positive effects of martial arts in school-based programs, since training produces an improvement not only of physical condition but of various aspects of the individual’s development.16 Consistent with previous researchers, who claim a positive effect on school achievement,17 the results in the present study showed that people attending regular martial arts training presented higher levels of math performance. Concerning the personality factors, it was pointed out that the interest has been mainly directed towards the effects of long term practice on aggressiveness.5, 7, 9, 10 The findings in the present study support those that claim that martial arts practice can be considered a resocialization method for reducing aggression.44 The results obtained demonstrate a decrease in different forms of aggression: physical aggression, verbal aggression, anger and hostility. Martial arts involvement has been considered, on the other hand, an example of how competitive sports can lead in time to an increase of aggressiveness and antisocial behavior;5 according to the “social learning theory”, the authors often claim that aggressiveness can be learned within the environment that suggests this behavior. The findings confirmed how the exposition and the understanding in time of the principals that are behind these disciplines, can result in a decrease of aggressiveness. In the present research martial artists not only present lower levels of aggression as opposed to the control group, but also it seems that physical aggression is positively influenced by the level of experience: With the advancement through the belt ranks, martial artists learn to control their aggressiveness. The same result was found by Skelton, et al.11 who investigated the relationship between aggressive behavior and the advancement through the belt ranks among children practicing tae know do; the trend analysis resulted in a significant reduction of aggression. The authors assume that martial arts is a way to acquire emotional and behavioral self-control. Consistent with the idea that long term practice leads to positive psychological benefits, the present study analyzed the effect of this practice on two emotional factors, such as self-esteem and self-efficacy, that can influence performance as well as the way we see our-
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indicating that there is a link between the regular practice of martial arts and different functional aspects. The ability to allocate attention is essential in sport, so it is easy to assume that athletes increase there ability to modulate attention; skilled athletes in sports that involve rapid changes in visual information may be able to allocate their attention more effectively than people who do not engage in similar tasks.40 Visual attention abilities have been frequently tested in athletes using variations of the spatial cuing paradigm;41 in particular in a study carried out on a group of boxers, Ripoll et al.,25 found that experts adopted a more efficient search pattern, and revealed fewer but longer fixations than the novice. In the present study, using the TMT, which evaluates different aspects of visual attention (e.g. speed of processing), results demonstrate that subjects who practice martial arts not only obtain higher performances, but it seems that visual attention increases in time independent of age. The findings agree with recent research carried out on martial artists that show better performance in visual selective attention tasks.27 Martial arts are in fact a dynamic sport in which you need fast reaction times (RTs) and the ability to allocate attention to different stimuli that present themselves simultaneously; high-level performance is characterized by techniques that need to be explosive and therefore linked to RT.42 To our knowledge there are not many studies that have specifically payed attention to the creativity in sport, but researchers have shown a positive relation between creative performance and breadth of attention.43 A wide breadth of attention makes it possible to associate different stimuli that may initially appear irrelevant 22 creating more connection between them.21 Creativity was tested in the present study through two different tests that made it possible to gather information about three parameters: fluency, flexibility and originality. Martial artists presented better performances in the originality parameter which increases with years of practice, together with the flexibility. It seems that the two groups differ not for the number of ideas or the numbers of categories used, rather more for the quality of their production (uncommon responses). Even if there are no overall differences between the two groups for the flexibility, within the group of martial artists, this seems to increase in time with regular practice. Because of the frequent involvement of children in
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Limitations of the study
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Although the results are consistent with our hypothesis, there are a few limitations and perspectives on future research that should be considered. Firstly, the study is a cross-sectional design, and therefore does not rule out changes due to selection bias, and more importantly does not warrant causal attributions. This limitation has been partially addressed by the large sample size, however only longitudinal research may reveal any information about the direction of the relationships between long-term martial art practice and psychological benefits. Secondly, it is possibile that factors that have not been taken into account could explain the differences between the two groups; however, the probability of this happening was partially reduced by matching the participants for different important variables. A further limitation was the subjective nature of some of the data collected, which relied on self-report questionnaires. Further studies are needed to address these limitations, for example longitudinal design studies that include the evaluation of neuropsychological parameters. Moreover, new studies should further investigate the relationship between personality and cognitive factors, embracing a theoretical view, in order to understand how different types of sports can lead to different outcomes.
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cording to theories claiming that regular activity has a positive effect on some aspects of brain functions and cognition. There is an increasing amount of studies which examine the relationship between regular physical activity, brain development and functioning in childhood and adulthood.48,49 In particular, recent neuropsychological research, that has specifically analyzed the effects of martial arts practice on different cognitive abilities (e.g. attention), referred differences in the neural mechanisms during controlled attention, which may be directly influenced by sport expertise.27 Future research should try to identify the mechanisms that stand behind the improvement of cognitive abilities in order to predict sports that are able in time to stimulate such improvements.
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selves and our abilities. Using two self-reports, differences emerged between the two groups; people who practice martial arts reach higher levels of self-esteem and self-efficacy, but there are no evident differences between beginners, intermediate and experts. The probable explanation, is that, the artists, already at the initial phase of the practice, identifies with the sport itself. Self-esteem and self-efficacy can be conceptualized as multidimensional constructs with several levels, so that if one sub-domain is more important than others, this can influence the global perception of one-self. Indeed the exposure to a positive environment and the perception of is importance may influence martial artists’ selfworth. It is clear that most of the studies in this field have concentrated their attention on particular aspects of martial art practice analyzing singular psychological benefits. According to the idea that physical activity has cognitive, affective, social, and behavioral benefits, the strength of this study was in fact to evaluate various domains. Moreover the novelty of this research was to examine cognitive and personality factors knowing that complex motor abilities are influenced, in different contexts, by affective-cognitive modulation. It is known that the individual’s belief in their abilities (self-efficacy) and the overall opinion we have of ourselves (self-esteem) influence behavioral changes and the achievement motivation. Studies have demonstrated that self-esteem is correlated to creative performance and may influence each other.45 Moreover, the decrease of aggressive behavior can be linked to the increase in cognitive abilities. These results are explained in light of the research that has discovered relationships between specific cognitive abilities and the capacity to inhibit behavior, considering that reactivity is interpreted as impulsive hostile reactions committed with little forethought.46 For example, Franko-Watkins et al.47 found that increased working memory load appeared to decrease random choice rather than elicit impulsive behavior. The findings in the present study, demonstrate that the involvement in martial arts practice is associated with many psychological benefits; the characteristics of the sport environment and the complexity of the motor activity may allow an interrelation between different affective-cognitive aspects (e.g. relationship between creativity/self-esteem, and creativity/attention). The benefits of these sports can be interpreted ac-
Conclusions While only longitudinal studies that examine the changes over time may fully resolve the uncertainties
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1. Duthie RB, Hope L, Barker DG. Selected personality traits of martial artists as measured by the Adjective CheckList. Percept Mot Skills 1978;47:71-6. 2. Wang F, Lee EJ, Wu T, Benson H, Fricchione G, Wang W, et al. The effects of Tai Chi on depression, anxiety, and psychological wellbeing: A systematic review and meta-analysis. Int J Behav Med 2013;21:605-17. 3. Richman CL, Rehberg H. The development of self-esteem through the martial arts. Int. J. Sports Psychol 1986;17:234-9. 4. Konzak B, Klavora P. Some social psychological dimensions of karate participation: An examination of personality characteristics within the training context of a traditional martial art. In: Klavora P, Wipper K, editors. Psychological and sociological factors in sport. Toronto: University of Toronto; 1980. p. 64-86. 5. Endresen IM, Olweus D. Participation in power sports and antisocial involvement in preadolescent and adolescent boys. J Child Psychol Psychiatry 2005;46:468-78. 6. Reynes E, Lorant J. Karate and aggressiveness among eight-year-old boys. Percept Mot Skills 2002;94:1041-2. 7. Reynes E, Lorant J. Effect of traditional judo training on aggressiveness among young boys. Percept Mot Skills 2002;94:21-5. 8. Rothpearl A. Personality traits in martial artists: A descriptive approach. Percept Mot Skills 1980;50:395-401. 9. Kuśnierz C, Cynarski WJ, Litwiniuk A. Comparison of aggressiveness levels in combat sports and martial arts male athletes to nonpractising peers. Arch Budo 2014;10:253-60. 10. Lamarre BW, Nosanchuk TA. Judo-The gentle way: A replication of studies on martial arts and aggression. Percept Mot Skills 1999;88:992-6. 11. Bjorkqvist K, Varhama L. Attitudes toward violent conflict resolution among male and female karateka in comparison with practitioners of other sports. Percept Mot Skills 2001;92:586-8. 12. Bandura A. The exercise of control. New York, NY: Freeman; 1997. 13. Cashmore E. Sport and Exercise Psychology, The Key Concepts. Second edition. New York: Routledge; 2008. 14. Yang CP, Lu FG. Indigenous and Cultural Psychology: Understanding People in Context. Pastoral Psychol 2007;56:105-13. 15. Reishehrei AP, Reishehrei AP, Soleimani EA. Comparison study of self-concept and self-efficacy in martial arts and non martial arts athletics in Iran. Soc Behav Sci 2014;116:5025-9. 16. Lakes KD, Hoyt WT. Promoting self-regulation through schoolbased martial arts training. J Appl Dev Psychol 2004;25:283-302. 17. Diamond A, Lee K. Interventions shown to aid executive function development in children 4-12 Years Old. Science 2011;333:95964. 18. Theeboom M, De Knop P. Asian martial arts and approaches of instruction in physical education. Eur J of Physical Education 1999;4:146-61. 19. Åberg MAI, Pedersenc NL, Toréne K, Svartengren M, Backstrand B, Johnsson T, et al. Cardiovascular fitness is associated with cognition in young adulthood. In: Gage FH, editor. Proc Natl Acad Sci U S A 2009;106:20906-11.
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Article first published online: May 5, 2017. - Manuscript accepted: April 11, 2017. - Manuscript revised: March 2, 2017. - Manuscript received: November 29, 2016.
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