Physical activity is often recommended to improve physical, mental, and emotional health. These benefits are needed by all age groups and are well-studied in children and adolescents in physical education courses. However, the literature appears to be lacking in the effects of physical education on adults in Physician Assistant (PA) programs. This manuscript reviews the available literature for an audience of graduate medical educators-specifically PA educators-summarizing some of the key findings in the research among young students and makes a case for similar studies within Physician Assistant programs.
Table of Contents
Physical activity is part of ubiquitous lifestyle advice given in medical and nonmedical settings alike, including educational settings. Aside from the more obvious physical benefits, the rationale for schools to incorporate Physical Education (PE) into the curriculum centers on a body of literature demonstrating student improvement in cognition, executive function, academic achievement, and perhaps behavior. The following review suggests that similar research is needed in the PA educational setting.
There were 250 PA education programs in the United States as of March 2020.1 These programs are designed in the traditional medical model requiring on average 27 months and a minimum of 2000 hours of clinical internships to complete.2 The intensity of these programs, given the material volume and time constraints, is difficult to understate. Because of the intense nature of PA education, nearly all students report feelings of depression at some point in their education, and approximately 47% demonstrate mild to severe depression, and Cocke reports that this rate is higher than the incidence found in the general adult population.3 As such, attending PA school could be considered a risk factor for mental illness. This should cause some concern in light of the research of Jones and Williams who find incoming students to universities (and potentially PA programs) with increasing rates of mental illness (e.g., ADHD, PTSD, and Major Depression) and taking psychoactive prescriptions (Figures 1 and 2).4
PE shows the potential to improve symptoms of mental illness and behavior, in addition to improving cognition, and executive function; the net result of these would appear to be higher academic achievement.5–12 Nevertheless, there appears to be a dearth of literature on the subject when it comes to PA education.
In an attempt to discover what has been written on the subject in the last 20 years, a review of the literature (PubMed, EBSCO, OVID) was performed using the terms “physical,” “fitness,” “academic,” “achievement,” “performance,” “cognitive,” “activity,” and “effects.” The search returned 8 articles relating to human subjects in PubMed, 21 articles in EBSCO, and 7 articles in OVID (there were duplicate articles found in 2 or more of the searches). However, when adding to those terms an age restriction (Adult: 19+ years) or additional search terms such as: “Physician Assistant,” “PA,” “medical school,” “graduate medical education,” “college,” or “university,” 0 articles were returned from the last 20 years. Nevertheless, the available literature, which focuses on children and adolescents, does contain valuable lessons that should prompt further investigation into the effect of PE in PA education.
Effects of Physical Activity on Young Students
Chaddock-Haymann defines cognitive or executive control as the “cognitive processes associated with the control of thought and action and the ability to guide behavior toward specific goals and formulate decisions.” Further, speaking on cognition and memory in physically active children, the authors reported that physical activity leads to improved cognitive ability in 7 to 10-year-old children.5 It may not even be necessary that students have an established pattern of physical activity as Chang et al. have reported that a single bout of physical activity can show improvements in cognition.13 Multiple studies of children and adolescents from around the world show that those who engage in moderate to vigorous physical activity, as part of their curriculum, experience improved cognition, executive function, academic achievement, and perhaps even behavior.5–12
Diamond refers to executive function not as a single entity, but as a cluster of abilities including inhibition or self-control, interference control or selective attention, working memory, and cognitive flexibility.14 Executive function is desirable for learning; and is improvable by physical activity, specifically high-intensity physical activity. This is the subject of an ongoing study by Wassenaar and his colleagues in the United Kingdom (Fit to Study Trial, UK) who are studying thousands of students at dozens of secondary schools to demonstrate the point. Using a control of existing PE programs, they are seeking to compare the effect of high-intensity PE. The experiment is based on prior studies showing physical activity in the school curriculum improves cognition, especially attention and executive function. Thus it should follow that these students will have higher academic achievement from physical activity.6 A similar model might be employed to study adult learners within PA programs. There is also a point to be made for PA students learning to lead their patients into physical activity by example.
The standard for academic achievement has traditionally been the letter grades awarded by educational institutions at the conclusion of the courses it offers. Physical activity also appears to have a positive influence on these measures as well.6 Alvarez-Bueno, in a meta-analysis of physical activity studies of children from ages 4 to 13, found achievement improvements in math, reading, and composition.7 Interestingly, they also note an improvement in child behavior. This gives pause for consideration as PA programs focus on professionalism outcomes (essentially the student’s behavior) for their students in addition to their academic achievement.
Appropriate Physical Activity
In reviewing the literature, themes emerge about the type of activities that will produce the results above. Many of the sources cited herein tested or reported on multiple, if not daily, bouts of exercise each week. When exercise bout duration is reported, the length of time varies considerably, yet time may not be as important as the intensity. Moreau (New Zealand) reports a 6-week study of high-intensity activity in children aged 7 to 13 (n = 318). In a multicenter, randomized placebo-controlled study, subjects completed either 10-minute bouts of intense exercise or a computer game or quiz (control). The report demonstrated a significant increase in working memory and focus.15 Similar results are found in a small study wherein Chen (China) randomly assigned third, and fifth graders to acute exercise or control, and executive function were positively influenced.16 Resaland (Norway) completed the Active Smarter Kids (ASK) trial wherein 1115 5th graders were randomly assigned to 300 minutes of vigorous activity and PE per week vs. control (135 minutes). Once again, the results demonstrated improved academic achievement (Reading, Numeracy, English).17 In a meta-analysis of 31 intervention studies from 2000-2017, de Greff noted that studies of moderate to vigorous physical activity resulted in improved attention, executive function, and academic performance which usually lasted “several weeks.” The report also notes that single bouts of exercise did not appear to have a lasting influence on executive function or academic performance.18 The previously mentioned Fit to Study Trial in the UK seeks, among other outcomes, to compare existing PE programs with higher-intensity programs.6 Likewise, the ActiveBrains study lead by Cadenas-Sanchez is investigating a 20-week intervention of 3-5 90 min sessions per week of high-intensity aerobic and muscle-strengthening bouts.19 In the UK, Booth compared patients at 11, 13, and then 16-years-old and in to see if habitual, vigorous activity leads to improved outcomes in the classroom. The research team observed increases in Math and English achievement.20 However, the point should be made that the habitual nature of the activity was what appears to have made the effect durable.
Individual vs Team-Based Activity
One study raises the question as to whether physical activity can be improved by centering it around teams and competition. A small study of Danish 12-year-old children swapped 2 of their 5 bouts of exercise per week with the “FIFA 11 for Health” program. Two times per week, the children would play soccer together, drill, and receive other health education. Compared to the control, the experiment arm saw improved cognitive improvement over control. The authors theorized that coordinated activity among multiple participants might explain the results. Another thought is that the children simply enjoyed that type of activity more than the alternative control.21
This summary provides compelling information to drive decision-making about PE in the curriculum for children and adolescents but is silent on whether similar results could be expected in adult learners—specifically PA students. Further study in this population is
needed, as it is not currently found in the literature searched. It may not be as simple as implementing structured physical activity into the learning day of a PA student. Most programs would likely explain how they balance the quantity of content with the truncated time in which to present it—to say nothing of the time students would say they need for outside study time.
Nevertheless, primary and secondary schools face similar demands, yet the reported evidence demonstrates positive outcomes despite these challenges. In medicine, the oft-repeated phrase “Do No Harm,” teaches the idea to always start from a place that does not place the patient in danger. The literature above suggests that if the time risks assumed with young, vulnerable students were worth the cognitive, executive function, and achievement outcomes, then this may be a worthwhile endeavor to pursue with our healthcare providers.
This review serves as an analysis of the available literature on PE in PA education. Future studies could draw from several of the models described previously in the literature in order to explore the results in a cohort of PA students. Established programs with year-to-year consistency in the curriculum could use prior cohorts as control when comparing academic achievement. While cognitive assessment could be employed pre-and post-intervention on current participants. Another outcome to consider is the effect on the incidence and severity of symptoms of anxiety and depression. Several options for intervention exist, but all should focus on brief, moderate-to-high-intensity interventions applied multiple times per week. This paper has explored interventions applied to cohorts of schoolmates, and thus the chosen intervention would be applied to cohorts of PA students. Exclusion criteria would most obviously include the physical ability to participate safely.
PA education is well-positioned to study the implementation of PE within its curriculum. Given the importance of these students learning well the information presented, the time risk is acceptable. When viewed only through the lens of doing so to help the mental health of the students, it seems justification enough. Further, doing so would seem imperative given that these same students will be expected to sit down with patients and attempt to make the case that their patients, who also lead busy lives, should make the time for physical activity, given all its health benefits. The old phrase “Physician (Assistant) heal thyself” is apropos to the conversation.22 It may be time to begin considering PE for PAs.
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17. on behalf of the ASK study group, Resaland GK, Moe VF, et al. Active Smarter Kids (ASK): Rationale and design of a cluster-randomized controlled trial investigating the effects of daily physical activity on children’s academic performance and risk factors for non-communicable diseases. BMC Public Health. 2015;15(1).
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22. Bible Gateway passage: Luke 4:23 – King James Version. Bible Gateway. https://www.biblegateway.com/passage/?search=Luke+4%3A23&version=KJV. Accessed June 13, 2019.