Accepted Manuscript Title: Motor competence and health related physical fitness in youth: a systematic review Author: Maria Teresa Cattuzzo Rafael dos Santos Henrique Alessandro Hervaldo Nicolai R´e Ilana Santos de Oliveira Bruno Machado Melo Mariana de Sousa Moura Rodrigo Cappato de Ara´ujo David Stodden PII: DOI: Reference:
S1440-2440(14)00631-8 http://dx.doi.org/doi:10.1016/j.jsams.2014.12.004 JSAMS 1123
To appear in:
Journal of Science and Medicine in Sport
Received date: Revised date: Accepted date:
16-6-2014 15-11-2014 6-12-2014
Please cite this article as: Cattuzzo MT, Henrique RS, R´e AHN, Oliveira IS, Melo BM, de Sousa Moura M, Ara´ujo RC, Stodden D, Motor competence and health related physical fitness in youth: a systematic review, Journal of Science and Medicine in Sport (2014), http://dx.doi.org/10.1016/j.jsams.2014.12.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Motor competence and health related physical fitness in youth: a systematic review
2 Maria Teresa Cattuzzo1, PhD,
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Rafael dos Santos Henrique1,
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Alessandro Hervaldo Nicolai Ré2, PhD,
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Ilana Santos de Oliveira1,
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Bruno Machado Melo1,
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Mariana de Sousa Moura1,
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Rodrigo Cappato de Araújo1, PhD,
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David Stodden3, PhD,
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Institution: University of Pernambuco, Recife, PE, Brazil / University of South Carolina, Columbia,
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SC, US
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14 Affiliations:
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Marques, 310, CEP 50100-130, Recife, PE, Brazil. Phone 55 81 3183-3354
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Béttio, 1000, Prédio A1 - Sala 104-J - CEP 03828-000 - Ermelino Matarazzo - São Paulo, SP, Brazil
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Phone: 55 11 3091-8808
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University of South Carolina, Columbia, SC, US, 29208.
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Higher School of Physical Education, University of Pernambuco, Recife, PE, Brazil; Rua Arnobio
School of Arts, Sciences and Humanities- EACH/USP, University of São Paulo. Rua Arlindo
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Department of Physical Education and Athletic Training. Blatt Physical Education Center,
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Address correspondence to: Maria Teresa Cattuzzo, Av. Fernando Simoes Barbosa, n.374 apt.502,
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CEP 51020-390, Recife, PE, Brazil [[email protected]], 803-348-5034
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Word count: 3961
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Motor competence and health related physical fitness in youth: a systematic review
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Abstract
30 Objective. This study aimed to review the scientific evidence on associations between motor
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competence (MC) and components of health related physical fitness (HRPF), in children and
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adolescents.
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Design: systematic review
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Methods: Systematic search of Academic Search Premier, ERIC, PubMed, PsycInfo, Scopus,
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SportDiscus, and Web of Science databases was undertaken between October 2012 and December
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2013. Studies examining associations between MC and HRPF components (body weight status,
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cardiorespiratory fitness, musculoskeletal fitness and flexibility) in healthy children and adolescents,
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published between 1990 and 2013, were included. Risk of bias within studies was assessed using
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CONSORT and STROBE guidelines. The origin, design, sample, measure of MC, measure of the
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HRPF, main results and statistics of the studies were analyzed and a narrative synthesis was
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conducted.
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Results. Forty-four studies matched all criteria; 16 were classified as low risk of bias and 28 as
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medium risk. There is strong scientific evidence supporting an inverse association between MC and
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body weight status (27 out of 33 studies) and a positive association between MC and cardiorespiratory
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fitness (12 out of 12 studies) and musculoskeletal fitness (7 out of 11 studies). The relationship
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between MC and flexibility was uncertain.
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Conclusions. Considering the noted associations between various assessments of MC and with
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multiple aspects of HRPF, the development of MC in childhood may both directly and indirectly
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augment HRPF and may serve to enhance the development of long-term health outcomes in children
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and adolescents.
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Keywords: Motor skills; Health behavior; Physical activity; Child development; Adolescent
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development; Pediatric obesity.
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1. Introduction Health-related physical fitness (HRPF) is demonstrated by a variety of factors including body weight status, cardiorespiratory fitness, musculoskeletal fitness (muscular strength and endurance)
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and flexibility and are related to health outcomes and/or health markers in youth1,2. Healthy levels of
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HRPF allow individuals to perform physical activities with vigor and promote resistance to fatigue.
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Positive trajectories of HRPF in children and adolescents require an understanding of behavioral
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attributes and causative mechanisms that promote these outcomes3.
A recently developed theoretical model has emphasized the role of developing motor
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competence (MC) on the development of HRPF, physical activity (PA) and obesity prevention
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throughout childhood4. However, the association between MC and aspects of HRPF across childhood
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and adolescence has not been thoroughly examined. The field of motor development as a distinct
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discipline gained widespread attention in the 1970’s and, over the next few decades, promoted the
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development of various process (i.e., technique) and product (i.e., outcome) oriented assessments. In
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general, assessments vary in their purported measurement of “motor skill” or MC and the language
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expressing the nature of MC has not been consistent across studies (e.g., fundamental movement skill,
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motor development, motor proficiency, motor coordination, motor ability, and motor fitness).
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Stodden et al.4 defined an important aspect of general MC as proficiency in fundamental
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motor skills including locomotor and object control skills. MC also has been defined as the degree of
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skilled performance in a wide range of motor tasks as well as the movement coordination and control
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underlying a particular motor outcome5. Although language and assessments describing and defining
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MC vary in the literature, in this paper the term MC is used as a global term to encompass all forms of
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goal-directed tasks involving coordination and control of the human body. In addition, the
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development of MC also may be essential in the promotion of an active lifestyle in childhood and
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adolescence6. Importantly, a recent meta-analysis indicated that school- and community-based
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programs that include developmentally appropriate FMS learning experiences delivered by physical
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education specialists are a critical medium for the development of MC in youth7.
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In 2010, Lubans et al.6 conducted a review on the association of fundamental movement skills
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with health-related variables including HRPF. They reported a consistent positive association between
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4 cardiorespiratory fitness and MC and an inverse association between MC and weight status.
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Improving HRPF levels across childhood and adolescence is important from a public health
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perspective6, specifically from an intervention standpoint, as it will further promote lifelong physical
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activity and health7. As there has been increasing interest in the health-related benefits of different
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components of HRPF1,8 and their relationship to motor competence, the aim of this systematic review
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was to examine the scientific evidence on associations among MC, and components of HRPF in
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children and adolescents.
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2. Methods
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A systematic literature search was carried out for articles examining associations of MC and HRPF components (body composition, cardiorespiratory, muscle strength and endurance and
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flexibility) in childhood and adolescence, published between January 1990 and December 2013.
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Cross-sectional, longitudinal, experimental and quasi-experimental studies were considered for the
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purpose of this review. The study was conducted and reported according to the PRISMA statement9.
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Both process- and product-oriented assessments of MC were used for this review. Seven electronic
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databases were systematically searched: Academic Search Premier, ERIC, PsycInfo, PubMed,
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Scopus, SportDiscus and Web of Science. Search strategies included the combination of variations
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between two groups of key-words/terms including, but not limited to the following examples: 1 – MC
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(“motor competence”; “motor development”, “gross motor skill”, “fundamental motor skill”,
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“fundamental movement skill”, “fundamental movement”, “basic motor skill”, “basic movement
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skill”, “basic movement”, “movement skill”, “motor coordination”, “motor ability”, “locomotor
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skill”, “manipulative skill”, “object control”, “balance”, “hop”, “jump”, “throw” and “kick”; and 2 –
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HRPF (“physical fitness”, “body composition”, “body weight status”, “BMI”, “body fat”,
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“cardiorespiratory fitness”, “cardiorespiratory endurance”, “muscle strength”, “muscular endurance”,
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“flexibility” and “pliability”). Terms were combined using the logical operators available as search
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tools. The authors also consulted experts in the field to include any additional studies published or
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accepted after December, 2013. The authors believed the inclusion of recent studies was important as
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interest in this topic has recently gained momentum in the scientific community. The search for articles and removal of duplicates was performed by one author (RSH). The
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selection of studies by titles and abstracts was carried out independently for two authors (RSH and
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BMM) according to the following inclusion criteria: a) participants aged between 3 and 18 years
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without physical or cognitive impairment; b) quantitative analysis of relationships between at least
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one measure of MC and HRPF; c) published in indexed journals in English. Studies that evaluated
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only fine motor skills or only subjects with overweight/obesity were not included. Review articles,
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validation studies, conference abstracts, monographs, dissertations and theses were not included.
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Reference lists from identified studies were examined for additional relevant studies. The extraction
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of data informed: a) author(s)/year/location; b) design/sample/age; c) type (product or process) and
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measure of MC; d) measure of the HRPF; e) statistics and f) main results.
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The risk of bias within studies was assessed using guidelines from STROBE and CONSORT,
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based on Lubans et al.6. A score of 0 (absent or inadequately described) or 1 (present and properly
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described) was assigned to six questions and are described in Table 1. A score for each article ranged
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from zero to six points. Studies with scores ≤ 2 were considered high risk of bias, studies that
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achieved 3-4 points were classified as medium risk and those that had scores of 5-6 were classified as
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low risk of bias. Two independent researchers performed this step (RSH and ISL), and the lead
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researcher solved the disagreements (MTC).
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The judgment of overall scientific evidence was based on Lubans et al. 7 with the following
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criteria adopted: (a) Lack of scientific evidence, if less than 33% of the studies indicated a significant
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association between variables or none of the studies deemed as low risk of bias found a significant
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association; (b) Uncertain evidence, if 34-59% of the studies indicated a significant association
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between variables and at least one of them was deemed low risk of bias; (c) Positive evidence, if 60-
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100% of the studies indicated a significant association between variables and 34-59% of the studies
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deemed low risk of bias found a significant association (in the same direction); (d) Strong evidence, if
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60-100% of the studies indicated a significant association between variables (in the same direction)
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and more than 59% of the studies deemed low risk of bias (score ≥ 5) found a significant association.
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3. Results The initial search identified 6,478 possible references (Figure 1). Forty-five studies were selected to read in full with the risk of bias evaluated independently by two researchers (see
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Supplementary material 1). Only one article demonstrated a risk score of 2 and was classified as high
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risk of bias10. It was subsequently excluded at this stage. Since we wished to address scientific
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evidence, we decided to remove the high risk of bias studies from data analysis, which could affect
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the results. Thus, the final sample in this review included 44 studies. 36% of the studies (n =16)
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demonstrated a score of 5 and were classified as low risk of bias and the remaining 64% were
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classified as medium risk of bias (n = 28). Reporting statistical power was the main limiting factor in
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terms of risk of bias as only 5 studies (11%) fulfilled this criterion (Supplementary material 1).
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Figure 1. Flow chart showing number of articles selected for systematic review
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Supplementary material 1. Assessment of risk of bias within studies
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The details of selected studies are presented in the Supplementary material 2. Most studies
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(82%) employed a cross-sectional design, and the remaining 18% were longitudinal. Sample sizes
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ranged from 18 participants11 to 7,17512; 19 (43%) of the studies evaluated only children, 21 (48%)
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children and adolescents and 4 (9%) only adolescents. Studies were conducted in Australia13-23,
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United States24-32, Belgium5,33-36, Portugal12,37-40, Norway11,41-43, Iran44-46, Germany47,48, Brazil49,
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Canada50, Denmark51, Italy52 and South Africa53. Most studies (68%) examined associations between
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MC (i.e., subscale score, index score or individual component scores) and individual aspects of HRPF
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using correlation and/or regression analyses. Some studies also analyzed data according to: (a) results
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on differences between groups11,15,19,23,33,34 or (b) other statistical calculations such as multilevel
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analysis with hierarchical models32,37,38.
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Supplementary material 2.
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7 165 Twenty-six of 44 studies used product measures (i.e., outcomes) to assess MC. The
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Köperkoordination-Test für Kinder was the test most commonly used (n=9). Five studies used the
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Bruininks-Oseretsky Test of Motor Proficiency. The Movement Assessment Battery for Children (first
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or second version) was used in five studies. The McCarron Assessment of Neuromuscular
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Development, the Stay in Step and the Battery for Measuring Motor Performance of Preschool
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Children were each used in one study. Four studies assessed MC using individual skill scores.
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The remaining studies (n=18) assessed MC using process-oriented measures (i.e., qualitative
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movement patterns). Seven studies used the Get-skilled Get-Active process-oriented checklists. Five
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studies used the Test of Gross Motor Development first or second version. Two used the South
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Carolina Physical Education Assessment Program. Two studies used the Peabody Developmental
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Motor Scales and the Ohio State University Scale of Intra Gross Motor Assessment was used in two
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studies.
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Those studies that used overall measure of fitness as the total score Test of Physical Fitness11,41,43 and FITNESSGRAM24,25,32, all found a positive relationship between MC and HRPF.
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Associations between individual components of HRPF and MC are described below. In studies involving body weight status (n=33), 31 (94%) used BMI. Skinfold thickness was
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measured in three studies37,51,53 and one study used bioelectrical impedance35. Twenty-seven (82%)
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studies that assessed body weight status noted an inverse relationships with MC. In contrast, six
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studies demonstrated no significant associations between MC and body composition15,18,24-26,31.
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Noting that only low risk of bias studies should be included to assign scientific evidence,
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Table 1, summarized the distribution of studies by components and the assessment of level of
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scientific evidence in accord with risk of bias. Assessment of risk of bias within of the body weight
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status studies indicated ten studies were classified as low risk5,12,15,19,23,34,36,37,38,51 and 23 were
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classified as medium risk16-18,20,21,24-29,31,33,35,40,44-49,52,53. Nine of 10 studies with a low risk of bias
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demonstrated an inverse association with MC. Thus, according to the established criteria, there is
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strong evidence of an inverse association between MC and body weight status in childhood and
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adolescence.
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Table 1. Distribution of the studies that investigated MC and health-related HRPF components by risk
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of bias within studies and the level of scientific evidence.
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studies)11,13-17,22,24,30,36,39,50 or as part of a composite HRF assessment (6 studies) 11,24,25,32,41,43 with all
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studies demonstrating a positive association with MC. Ten studies13-15,17,22,24,25,36,50 used the
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Progressive Aerobic Cardiovascular Run, three studies used the six-minute walk/run11,41,43, two studies
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used the one mile run/walk test37,39, one used half-mile walk/run30 and one study used a bicycle
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ergometer test16. Of the 12 studies that independently assessed the association MC with
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cardiorespiratory fitness, seven were considered as low risk of bias (see Figure 3)11,13-15,22,36,39. Thus,
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there was strong evidence for a positive association between cardiorespiratory fitness and MC.
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Muscle strength and endurance are both expressions of musculoskeletal fitness1 and were
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analyzed together. Eleven (25%) of 44 studies assessed at least one outcome of musculoskeletal
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fitness. Abdominal endurance tests (i.e., sit-ups/curl-ups) were implemented in five studies16,25,32,36,39.
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Five studies used an upper extremity strength/endurance test (i.e., push-ups)24,25,32,36,39. Four studies
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used throwing a tennis ball as far as possible with one hand11,15,41,43, three used a medicine ball
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toss11,41,43, and another used the basketball chest pass16. Five studies used standing long jump11,15,36,41,43
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to examine lower extremity strength and one implemented isokinetic testing (Cybex 6000) of the
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quadriceps and hamstrings42. Two studies used a handgrip test32,36.
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Of the 11 studies that used a specific measure for musculoskeletal fitness, seven showed a
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positive association between MC and muscle strength/endurance11,15,16,24,36,39,42. Of the seven studies
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that showed a positive correlation between muscle strength/endurance, four were classified as low risk
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of bias (see Figure 3)11,15,36,39. Thus, there is strong scientific evidence for a positive association
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between musculoskeletal fitness and MC.
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Five (12%) of 44 studies investigated flexibility. Four studies used one specific measure of
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flexibility16,24,36,39 and one study considered flexibility as part of a HRPF index score25. Four studies
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used the sit and reach test to assess flexibility16,24,25,36 and the shoulder reach measure was used in one
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study16. One study also evaluated trunk lift as their measure of flexibility39.
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Among the four studies that assessed flexibility in isolation, one study (25%) did not find a relationship between MC and flexibility24 and the other three studies found a low positive
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association16,36,39. Two studies were classified as low risk of bias36,39. Such results indicate uncertainty
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with regard to evidence for an association between MC and flexibility.
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4. Discussion
The main purpose of this review was to provide an evaluation of studies assessing
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associations between MC and various HRPF components. Overall, there was strong evidence for an
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inverse association between MC and body weight status and positive associations with
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cardiorespiratory fitness, and musculoskeletal fitness in children and adolescents. These results
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expand on the findings of Lubans et al.6 and more comprehensively addressed the question by
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including studies that assessed MC from a more broadly-defined perspective.
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The inverse relationship between body weight status and MC may be partially explained by
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increased fat mass that may be detrimental to MC performance where the entire or majority of body
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mass is projected37. In addition, increased mass may promote inefficient movement patterns of object
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projection skills that inherently demand high segmental velocities33. Thus, these inverse relationship
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may represent a reciprocal mechanism of the dynamic interactions present in open system54, also
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called positive feedback. This feedback mechanism operates progressively across time, demonstrating
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an increased strength of association between variables as individuals develop. This explanation
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parallels the recursive effects proposed by Stodden et al.4 whereby weight status both contributes to
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and is a result of the combination of the development of MC and HRPF. An unhealthy weight status
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also increases the likelihood of disengagement in PA, further hindering the development of MC and
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HRPF. This negative recursive relationship may be perpetuated across adolescence, and even into
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adulthood29. The opposite recursive effect also may occur with higher MC and a healthy weight status
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promoting increased musculoskeletal and cardiorespiratory fitness that allows children to be more
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active, helping to further enhance motor skill development in a variety of contexts4.
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10 These trends have been demonstrated in various cross-sectional and longitudinal studies. In a
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large cross-secitonal study, D'Hondt et. al.34, demonstrated negative associations between gross motor
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coordination (KTK performance) and weight status that progressively increased across age (5-12 yrs).
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A recent longitudinal study5 also demonstrated an increasingly widening gap in BMI status in children
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as a function of their differential gross motor coordination levels. Alternatively, the transition to
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adolescence demonstrated a marked decline in associations between MC and body weight status in
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two studies12,21. It is important to note that BMI has limitations in accurately predicting % body fat
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during the transition into adolescence; thus, this is a limitation for studies using BMI as a predictor for
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overweight/obese status at this age. A more valid predictor of % body fat may provide a clearer
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picture of the relationship between MC and body weight status trajectories across childhood and
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adolescence12. Also, the typical variability in intra- and inter-individual growth and maturation
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patterns that occur during the transition to adolescence should be considered as they may
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differentially influence the relationship between HRPF and MC in childhood and adolescence12.
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The strong evidence for a positive association between MC and musculoskeletal fitness and between MC and cardiorespiratory fitness also can be explained by patterns of engagement in
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physical activities that promote HRPF. Sport participation may serve to concomitantly enhance MC
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and multiple aspects of HRPF5,55. In fact, many ballistic skills performed in sports (e.g., throwing,
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kicking, striking, jumping, running and hopping) inherently demand high levels of physical effort and
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neuromuscular coordination and control, favoring the development of both HRPF and MC56.
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Specifically, ballistic skills demand high concentric and eccentric muscle activity, high body weight
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loading and demonstrate high joint angular velocities and power outputs57, thereby promoting muscle
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strength. Furthermore, activities inherently involving fundamental locomotor and object control skills
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(e.g., practice and performance of sports, physical education and leisure games) are generally
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associated with repetitive movement that enhances cardiorespiratory development. Lastly, the sports
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environment is sufficiently challenging to further promote the acquisition of motor skills.
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It seems logical that the co-development of multiple HRPF attributes and MC are inherently
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linked via both direct (i.e., neuromuscular mechanisms) and indirect pathways (i.e., increased choices
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of physical activities that relate to cardiorespiratory endurance development). As movement patterns
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11 of many HRPF and MC tasks include multi-joint movements that manipulate many degrees of
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freedom within the body, the combination of isometric, concentric and eccentric muscle activity
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requires a high degree of both inter- and intramuscular coordination and control. For example, several
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field-based HRPF test items that assess musculoskeletal (e.g., push-ups, curl-ups, pull-ups) and
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cardiorespiratory fitness (PACER) inherently demand a certain level of coordination and control that
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has to be learned, as many of these tasks involve complex movements. In essence, HRPF tests that
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require dynamic muscle contractions to promote movement (e.g., pull-ups or curl-ups), isometric
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stabilization of body segments (e.g., core musculature - push-ups or plank) or rapid concentric and
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eccentric contractions of musculature at multiple joints (e.g., locomotion associated with
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cardiorespiratory endurance tests) to effectively perform the task demand the learning of appropriate
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coordination and control demonstrated via inter- and intra-neuromuscular development. This type of
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language is more commonly associated with the development of gross motor coordination and/or
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fundamental motor skills, but the underlying acquisition/learning of neuromotor coordination and
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control to effectively demonstrate the goal of the movement remains the same.
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Neural maturation is an additional factor to be considered when addressing the expression of
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muscular strength as children age and as their ability to control force in a given task improves58. Thus,
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tests involving multi-joint movements, whether deemed “motor” or “fitness” tests, involve similar
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neuromuscular constraints to effectively generate and apply force and to produce effective
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coordination patterns (i.e., manipulate multiple degrees of freedom) to accomplish the goal of the
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task. Thus, promoting both HRPF and MC would seem to be an optimal strategy for intervention56
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that would favorably impact the overall functional physical capabilities of an individual. Based on
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associational evidence noted in most cross-sectional and longitudinal studies, as well as experimental
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evidence56 this supposition seems to be supported. In addition, development of both MC and HRPF
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may also influence healthy weight trajectories across time as the metabolic cost associated with
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training and performance of MC and HRPF in various contexts with high levels of effort are
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substantial37.
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The lack of studies assessing associations between MC and flexibility does not allow
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conclusions to be drawn about their relationship. Children with low MC have heterogeneous fitness
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profiles, and extreme ranges of flexibility and inflexibility can be observed in these children. As hyper
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flexibility reduces stability around the joint, it may make controlled movement more difficult. In
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contrast, hypo flexibility limits the range of movement of joints and therefore restricts movement15. In
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addition, flexibility tends to be joint specific and may be related to maturational effects.
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Limitations Although this review was comprehensive, studies published in languages other than English
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were not included and publication bias related to selective reporting of only positive associations may
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be a possibility. Besides, the inherent limitations of cross-sectional and longitudinal study designs,
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which were noted in most studies in this review, preclude making definitive conclusions regarding
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causality relating to the development of MC and HRPF. However, we are dealing with developmental
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phenomena and, as such, the most parsimonious explanation relating to the development of MC and
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various aspects of HRPF over time may be that they demonstrate a recursive relationship, as proposed
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by Stodden et al.4. In addition, if a child attains a certain level of proficiency in motor skills and
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develops appropriate fitness habits, he/she may overcome a hypothesized Seefeldt’s “proficiency
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barrier” that may be related to lifespan trajectories of MC and HRPF59. Thus, promoting both MC and
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HRPF early in life may augment the potential to develop and sustain appropriate healthy behavior
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habits across time that will contribute to a lifelong active and healthy lifestyle31.
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The previously noted similarities in neuromuscular function associated with MC and HRPF
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activities is related to the diverse and sometimes overlapping nature of HRPF and MC tests used by
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researchers. Overall, at least 11 different assessments of MC and at least eight HRPF test batteries (as
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well as various combinations of individual HRPF assessments) were used in the literature cited in this
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review. Adding further confusion to these measurement issues, the tennis ball and medicine ball
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throw, the standing long jump, and grip strength tests have been used interchangeably as either
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measures of HRPF or MC15,31.
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Another important limitation involved in evaluating the relationship between MC and HRPF
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involves the amount of body mass manipulated in the performance of many MC and HRPF tests.
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Manipulating increased mass, specifically related to increased body fat, generally would be
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detrimental to performance. Obese children generally perform worse on field tests in which they are
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13 required to move mass against gravity (e.g., KTK, PACER, push-ups, sit-ups, pull-ups), as compared
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to healthy weight children. Alternatively, the composition of lean mass, as a major component of total
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mass, has two important characteristics that relate to force/torque production (i.e., strength),
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specifically in childhood and adolescence. Overall increased lean mass provides more physiological
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cross-sectional area to promote the generation of force. However, overall lean mass represents only
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one part of the equation when describing the functionality of mass. As previously mentioned, the
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functionality of increased mass associated with increasing age also depends on the development of
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inter- and intra-muscular coordination (i.e., motor unit recruitment, motor unit firing rate, optimal co-
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activation of agonist/ antagonist muscles, and synergistic muscle contractions60, which also is
341
critically important to the development of MC. Unfortunately, the contribution of increased lean mass
342
(physiological) and the inherent neuromuscular coordination and control associated with lean mass on
343
force/torque output (i.e., strength) on both HRPF and MC is not well understood60. This complex
344
issue may have significant implications across age, specifically during the transition into adolescence.
345
Therefore, the use of BMI as a measure of body weight status in many studies in this review limits our
346
understanding of the contributory effects of overall increased mass (i.e., lean mass, neuromuscular
347
coordination and body fat) to both MC and aspects of HRPF. The use of direct measurements of
348
cardiorespiratory fitness such as breath-by-breath gas analysis during a maximal endurance test on a
349
treadmill or cycle ergometer, as well as the mediating effect of an individual’s PA levels, may help to
350
elucidate more precisely the strength of this association.
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Several other factors can influence associations between MC and HRPF. The intensity of
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exercise, quality of instruction and time spent in practice are important factors that contribute to the
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development of both constructs6,7. In addition, maturational variables and % body fat also may have
354
influences on both MC and HRPF and future studies evaluating the relationship between MC and
355
HRPF should control for these factors. Finally, there was a very small proportion of the studies (11%)
356
meeting the criterion of estimating statistical power. However, based on the rather consistent
357
statistically significant findings in the vast majority of studies in this review, adequate power and the
358
noting of significant associations were demonstrated.
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Conclusion
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The results of this systematic review demonstrate strong evidence indicating that the development of MC is inversely associated with body weight status and positively associated with
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cardiorespiratory fitness and musculoskeletal fitness across childhood and adolescence. The
363
association between flexibility and MC proved to be uncertain. It also is worthy to note that
364
associations between MC and HRPF were, in general, the same in boys and girls. The inherent
365
complexity associated with the development of MC and HRPF and the previously discussed
366
limitations in how these distinct, yet related constructs are assessed in children and adolescents make
367
it difficult to truly understand the nature of their differences and similarities. Furthermore, all MC and
368
HRPF tests are complex human movements that are similarly influenced by physiological,
369
maturational, psychological, sociological and environmental constraints as individuals grow and
370
develop. Overall physical development involving both constructs promote increased functional
371
capacity of individuals that may promote positive lifespan trajectories of functional capability and
372
may contribute to long-term health outcomes.
M Based on the results of this review, we believe the focus of future interventions should be directed at concomitantly promoting motor competence and health-related physical fitness in
377
an environment that is developmentally appropriate for children and adolescents as this may
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Practical Implications
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be the most advantageous path to promote both constructs and promote overall functional capabilities.
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Providing educational information to inform physical education teachers and sport coaches on
381
the importance of developing both MC and HRF is critical to promote maximal changes in
382 383
these variables in a variety of physical activity settings. We suggest the terms “strength” and “coordination” should not be seen as separate constructs,
384
rather they should be seen as parallel goals, along with the development of cardiorespiratory
385
endurance, to promote functional capabilities in children that allow them to be able to pursue
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many different types of physical activities that are health-enhancing and developmentally
387
appropriate56. The development of both motor competence and health-related physical fitness may promote
388 389
positive and sustainable trajectories of health and lead to long term health outcomes.
390 Acknowledgments - This research was supported by post-doctorate grant (for Maria Teresa
392
Cattuzzo), Science Without Borders Program, Coordination for the Improvement of Higher Education
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Personnel/Research National Council, Brazil (process: BEX 2568/13) and FAPESP no.1250620-2 (for
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Alessandro Hervaldo Nicolai Ré).
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1
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Number of records identified through database searching = 6.478 articles Academic Search Premier = 2.138 ERIC = 339 PubMed = 824 PsycInfo = 372 Scopus = 819 SportDiscus = 580 Web of Sience = 1406
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Records after duplicates removed = 4.592
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Full text assessed for eligibility = 84 Full text records identified through other sources = 12
us
Number of records excluded = 4.508 (By title and abstracts analysis)
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Number of records excluded = 51 1 - idade superior 15 - Mc not assessed 19 - Não avaliou relação entre MC and HRPF 2 - special population 7 - other languages 7 - other
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Number of studies included in qualitative analysis = 45 Number of records removed = 1 (Score ≤ 2 in the qualitative analysis)
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Number of studies included in this systematic review = 44
Figure 1. Flow chart showing number of articles selected for systematic review
Page 20 of 21
2 Table 1. Distribution of the studies that investigated MC and Health-Related Physical Fitness component by risk of bias (low or medium) within studies and the level of scientific evidence. Health-Related
Studies that
Physical Fitness
demonstrated
component
association
Body weight status
Yes: 27 (81%)
Studies by risk of
Low risk of bias studies that showed
Level of
bias
significant association
evidence
Low: 9 (29%)
Yes: 8 (89%) (inverse association)
Medium: 22 (71%)
No: 1 (11%)
Low: 7 (63%)
Yes: 7 (100%) (positive association)
Medium: 5 (37%)
No: 0 (0%)
Low: 4 (57%)
Yes: 4 (100%) (positive association)
Medium: 3 (42%)
No: 0 (0%)
Low: 2 (50%)
Yes: 2 (100%)
Medium: 2 (50%)
No: 0 (0%)
Cardiorespiratory
Yes: 12 (100%)
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Strong
(n=33)
Musculoskeletal
Yes: 7 (63,6%)
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Strong
fitness (n=12)
Uncertain
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Yes: 3 (75%)
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Flexibility (n=4)
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Strong
fitness (n=11)
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S1440-2440(14)00631-8 http://dx.doi.org/doi:10.1016/j.jsams.2014.12.004 JSAMS 1123
To appear in:
Journal of Science and Medicine in Sport
Received date: Revised date: Accepted date:
16-6-2014 15-11-2014 6-12-2014
Please cite this article as: Cattuzzo MT, Henrique RS, R´e AHN, Oliveira IS, Melo BM, de Sousa Moura M, Ara´ujo RC, Stodden D, Motor competence and health related physical fitness in youth: a systematic review, Journal of Science and Medicine in Sport (2014), http://dx.doi.org/10.1016/j.jsams.2014.12.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 1
Motor competence and health related physical fitness in youth: a systematic review
2 Maria Teresa Cattuzzo1, PhD,
4
Rafael dos Santos Henrique1,
5
Alessandro Hervaldo Nicolai Ré2, PhD,
6
Ilana Santos de Oliveira1,
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Bruno Machado Melo1,
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Mariana de Sousa Moura1,
9
Rodrigo Cappato de Araújo1, PhD,
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David Stodden3, PhD,
an
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Institution: University of Pernambuco, Recife, PE, Brazil / University of South Carolina, Columbia,
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SC, US
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14 Affiliations:
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1
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Marques, 310, CEP 50100-130, Recife, PE, Brazil. Phone 55 81 3183-3354
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2
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Béttio, 1000, Prédio A1 - Sala 104-J - CEP 03828-000 - Ermelino Matarazzo - São Paulo, SP, Brazil
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Phone: 55 11 3091-8808
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3
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University of South Carolina, Columbia, SC, US, 29208.
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Higher School of Physical Education, University of Pernambuco, Recife, PE, Brazil; Rua Arnobio
School of Arts, Sciences and Humanities- EACH/USP, University of São Paulo. Rua Arlindo
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Department of Physical Education and Athletic Training. Blatt Physical Education Center,
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Address correspondence to: Maria Teresa Cattuzzo, Av. Fernando Simoes Barbosa, n.374 apt.502,
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CEP 51020-390, Recife, PE, Brazil [[email protected]], 803-348-5034
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Word count: 3961
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Page 1 of 21
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Motor competence and health related physical fitness in youth: a systematic review
28 29
Abstract
30 Objective. This study aimed to review the scientific evidence on associations between motor
32
competence (MC) and components of health related physical fitness (HRPF), in children and
33
adolescents.
34
Design: systematic review
35
Methods: Systematic search of Academic Search Premier, ERIC, PubMed, PsycInfo, Scopus,
36
SportDiscus, and Web of Science databases was undertaken between October 2012 and December
37
2013. Studies examining associations between MC and HRPF components (body weight status,
38
cardiorespiratory fitness, musculoskeletal fitness and flexibility) in healthy children and adolescents,
39
published between 1990 and 2013, were included. Risk of bias within studies was assessed using
40
CONSORT and STROBE guidelines. The origin, design, sample, measure of MC, measure of the
41
HRPF, main results and statistics of the studies were analyzed and a narrative synthesis was
42
conducted.
43
Results. Forty-four studies matched all criteria; 16 were classified as low risk of bias and 28 as
44
medium risk. There is strong scientific evidence supporting an inverse association between MC and
45
body weight status (27 out of 33 studies) and a positive association between MC and cardiorespiratory
46
fitness (12 out of 12 studies) and musculoskeletal fitness (7 out of 11 studies). The relationship
47
between MC and flexibility was uncertain.
48
Conclusions. Considering the noted associations between various assessments of MC and with
49
multiple aspects of HRPF, the development of MC in childhood may both directly and indirectly
50
augment HRPF and may serve to enhance the development of long-term health outcomes in children
51
and adolescents.
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Keywords: Motor skills; Health behavior; Physical activity; Child development; Adolescent
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development; Pediatric obesity.
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1. Introduction Health-related physical fitness (HRPF) is demonstrated by a variety of factors including body weight status, cardiorespiratory fitness, musculoskeletal fitness (muscular strength and endurance)
58
and flexibility and are related to health outcomes and/or health markers in youth1,2. Healthy levels of
59
HRPF allow individuals to perform physical activities with vigor and promote resistance to fatigue.
60
Positive trajectories of HRPF in children and adolescents require an understanding of behavioral
61
attributes and causative mechanisms that promote these outcomes3.
A recently developed theoretical model has emphasized the role of developing motor
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competence (MC) on the development of HRPF, physical activity (PA) and obesity prevention
64
throughout childhood4. However, the association between MC and aspects of HRPF across childhood
65
and adolescence has not been thoroughly examined. The field of motor development as a distinct
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discipline gained widespread attention in the 1970’s and, over the next few decades, promoted the
67
development of various process (i.e., technique) and product (i.e., outcome) oriented assessments. In
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general, assessments vary in their purported measurement of “motor skill” or MC and the language
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expressing the nature of MC has not been consistent across studies (e.g., fundamental movement skill,
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motor development, motor proficiency, motor coordination, motor ability, and motor fitness).
an
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Stodden et al.4 defined an important aspect of general MC as proficiency in fundamental
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motor skills including locomotor and object control skills. MC also has been defined as the degree of
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skilled performance in a wide range of motor tasks as well as the movement coordination and control
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underlying a particular motor outcome5. Although language and assessments describing and defining
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MC vary in the literature, in this paper the term MC is used as a global term to encompass all forms of
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goal-directed tasks involving coordination and control of the human body. In addition, the
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development of MC also may be essential in the promotion of an active lifestyle in childhood and
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adolescence6. Importantly, a recent meta-analysis indicated that school- and community-based
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programs that include developmentally appropriate FMS learning experiences delivered by physical
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education specialists are a critical medium for the development of MC in youth7.
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In 2010, Lubans et al.6 conducted a review on the association of fundamental movement skills
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with health-related variables including HRPF. They reported a consistent positive association between
Page 3 of 21
4 cardiorespiratory fitness and MC and an inverse association between MC and weight status.
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Improving HRPF levels across childhood and adolescence is important from a public health
85
perspective6, specifically from an intervention standpoint, as it will further promote lifelong physical
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activity and health7. As there has been increasing interest in the health-related benefits of different
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components of HRPF1,8 and their relationship to motor competence, the aim of this systematic review
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was to examine the scientific evidence on associations among MC, and components of HRPF in
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children and adolescents.
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2. Methods
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A systematic literature search was carried out for articles examining associations of MC and HRPF components (body composition, cardiorespiratory, muscle strength and endurance and
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flexibility) in childhood and adolescence, published between January 1990 and December 2013.
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Cross-sectional, longitudinal, experimental and quasi-experimental studies were considered for the
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purpose of this review. The study was conducted and reported according to the PRISMA statement9.
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Both process- and product-oriented assessments of MC were used for this review. Seven electronic
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databases were systematically searched: Academic Search Premier, ERIC, PsycInfo, PubMed,
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Scopus, SportDiscus and Web of Science. Search strategies included the combination of variations
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between two groups of key-words/terms including, but not limited to the following examples: 1 – MC
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(“motor competence”; “motor development”, “gross motor skill”, “fundamental motor skill”,
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“fundamental movement skill”, “fundamental movement”, “basic motor skill”, “basic movement
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skill”, “basic movement”, “movement skill”, “motor coordination”, “motor ability”, “locomotor
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skill”, “manipulative skill”, “object control”, “balance”, “hop”, “jump”, “throw” and “kick”; and 2 –
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HRPF (“physical fitness”, “body composition”, “body weight status”, “BMI”, “body fat”,
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“cardiorespiratory fitness”, “cardiorespiratory endurance”, “muscle strength”, “muscular endurance”,
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“flexibility” and “pliability”). Terms were combined using the logical operators available as search
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tools. The authors also consulted experts in the field to include any additional studies published or
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accepted after December, 2013. The authors believed the inclusion of recent studies was important as
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interest in this topic has recently gained momentum in the scientific community. The search for articles and removal of duplicates was performed by one author (RSH). The
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selection of studies by titles and abstracts was carried out independently for two authors (RSH and
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BMM) according to the following inclusion criteria: a) participants aged between 3 and 18 years
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without physical or cognitive impairment; b) quantitative analysis of relationships between at least
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one measure of MC and HRPF; c) published in indexed journals in English. Studies that evaluated
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only fine motor skills or only subjects with overweight/obesity were not included. Review articles,
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validation studies, conference abstracts, monographs, dissertations and theses were not included.
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Reference lists from identified studies were examined for additional relevant studies. The extraction
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of data informed: a) author(s)/year/location; b) design/sample/age; c) type (product or process) and
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measure of MC; d) measure of the HRPF; e) statistics and f) main results.
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The risk of bias within studies was assessed using guidelines from STROBE and CONSORT,
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based on Lubans et al.6. A score of 0 (absent or inadequately described) or 1 (present and properly
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described) was assigned to six questions and are described in Table 1. A score for each article ranged
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from zero to six points. Studies with scores ≤ 2 were considered high risk of bias, studies that
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achieved 3-4 points were classified as medium risk and those that had scores of 5-6 were classified as
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low risk of bias. Two independent researchers performed this step (RSH and ISL), and the lead
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researcher solved the disagreements (MTC).
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The judgment of overall scientific evidence was based on Lubans et al. 7 with the following
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criteria adopted: (a) Lack of scientific evidence, if less than 33% of the studies indicated a significant
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association between variables or none of the studies deemed as low risk of bias found a significant
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association; (b) Uncertain evidence, if 34-59% of the studies indicated a significant association
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between variables and at least one of them was deemed low risk of bias; (c) Positive evidence, if 60-
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100% of the studies indicated a significant association between variables and 34-59% of the studies
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deemed low risk of bias found a significant association (in the same direction); (d) Strong evidence, if
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60-100% of the studies indicated a significant association between variables (in the same direction)
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and more than 59% of the studies deemed low risk of bias (score ≥ 5) found a significant association.
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3. Results The initial search identified 6,478 possible references (Figure 1). Forty-five studies were selected to read in full with the risk of bias evaluated independently by two researchers (see
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Supplementary material 1). Only one article demonstrated a risk score of 2 and was classified as high
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risk of bias10. It was subsequently excluded at this stage. Since we wished to address scientific
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evidence, we decided to remove the high risk of bias studies from data analysis, which could affect
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the results. Thus, the final sample in this review included 44 studies. 36% of the studies (n =16)
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demonstrated a score of 5 and were classified as low risk of bias and the remaining 64% were
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classified as medium risk of bias (n = 28). Reporting statistical power was the main limiting factor in
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terms of risk of bias as only 5 studies (11%) fulfilled this criterion (Supplementary material 1).
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Figure 1. Flow chart showing number of articles selected for systematic review
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Supplementary material 1. Assessment of risk of bias within studies
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The details of selected studies are presented in the Supplementary material 2. Most studies
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(82%) employed a cross-sectional design, and the remaining 18% were longitudinal. Sample sizes
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ranged from 18 participants11 to 7,17512; 19 (43%) of the studies evaluated only children, 21 (48%)
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children and adolescents and 4 (9%) only adolescents. Studies were conducted in Australia13-23,
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United States24-32, Belgium5,33-36, Portugal12,37-40, Norway11,41-43, Iran44-46, Germany47,48, Brazil49,
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Canada50, Denmark51, Italy52 and South Africa53. Most studies (68%) examined associations between
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MC (i.e., subscale score, index score or individual component scores) and individual aspects of HRPF
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using correlation and/or regression analyses. Some studies also analyzed data according to: (a) results
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on differences between groups11,15,19,23,33,34 or (b) other statistical calculations such as multilevel
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analysis with hierarchical models32,37,38.
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Supplementary material 2.
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7 165 Twenty-six of 44 studies used product measures (i.e., outcomes) to assess MC. The
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Köperkoordination-Test für Kinder was the test most commonly used (n=9). Five studies used the
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Bruininks-Oseretsky Test of Motor Proficiency. The Movement Assessment Battery for Children (first
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or second version) was used in five studies. The McCarron Assessment of Neuromuscular
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Development, the Stay in Step and the Battery for Measuring Motor Performance of Preschool
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Children were each used in one study. Four studies assessed MC using individual skill scores.
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The remaining studies (n=18) assessed MC using process-oriented measures (i.e., qualitative
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movement patterns). Seven studies used the Get-skilled Get-Active process-oriented checklists. Five
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studies used the Test of Gross Motor Development first or second version. Two used the South
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Carolina Physical Education Assessment Program. Two studies used the Peabody Developmental
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Motor Scales and the Ohio State University Scale of Intra Gross Motor Assessment was used in two
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studies.
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Those studies that used overall measure of fitness as the total score Test of Physical Fitness11,41,43 and FITNESSGRAM24,25,32, all found a positive relationship between MC and HRPF.
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Associations between individual components of HRPF and MC are described below. In studies involving body weight status (n=33), 31 (94%) used BMI. Skinfold thickness was
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measured in three studies37,51,53 and one study used bioelectrical impedance35. Twenty-seven (82%)
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studies that assessed body weight status noted an inverse relationships with MC. In contrast, six
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studies demonstrated no significant associations between MC and body composition15,18,24-26,31.
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Noting that only low risk of bias studies should be included to assign scientific evidence,
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Table 1, summarized the distribution of studies by components and the assessment of level of
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scientific evidence in accord with risk of bias. Assessment of risk of bias within of the body weight
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status studies indicated ten studies were classified as low risk5,12,15,19,23,34,36,37,38,51 and 23 were
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classified as medium risk16-18,20,21,24-29,31,33,35,40,44-49,52,53. Nine of 10 studies with a low risk of bias
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demonstrated an inverse association with MC. Thus, according to the established criteria, there is
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strong evidence of an inverse association between MC and body weight status in childhood and
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adolescence.
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8 193 194
Table 1. Distribution of the studies that investigated MC and health-related HRPF components by risk
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of bias within studies and the level of scientific evidence.
196 Sixteen (36%) of 44 studies investigated cardiorespiratory fitness independently (12
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studies)11,13-17,22,24,30,36,39,50 or as part of a composite HRF assessment (6 studies) 11,24,25,32,41,43 with all
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studies demonstrating a positive association with MC. Ten studies13-15,17,22,24,25,36,50 used the
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Progressive Aerobic Cardiovascular Run, three studies used the six-minute walk/run11,41,43, two studies
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used the one mile run/walk test37,39, one used half-mile walk/run30 and one study used a bicycle
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ergometer test16. Of the 12 studies that independently assessed the association MC with
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cardiorespiratory fitness, seven were considered as low risk of bias (see Figure 3)11,13-15,22,36,39. Thus,
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there was strong evidence for a positive association between cardiorespiratory fitness and MC.
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Muscle strength and endurance are both expressions of musculoskeletal fitness1 and were
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analyzed together. Eleven (25%) of 44 studies assessed at least one outcome of musculoskeletal
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fitness. Abdominal endurance tests (i.e., sit-ups/curl-ups) were implemented in five studies16,25,32,36,39.
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Five studies used an upper extremity strength/endurance test (i.e., push-ups)24,25,32,36,39. Four studies
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used throwing a tennis ball as far as possible with one hand11,15,41,43, three used a medicine ball
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toss11,41,43, and another used the basketball chest pass16. Five studies used standing long jump11,15,36,41,43
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to examine lower extremity strength and one implemented isokinetic testing (Cybex 6000) of the
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quadriceps and hamstrings42. Two studies used a handgrip test32,36.
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Of the 11 studies that used a specific measure for musculoskeletal fitness, seven showed a
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positive association between MC and muscle strength/endurance11,15,16,24,36,39,42. Of the seven studies
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that showed a positive correlation between muscle strength/endurance, four were classified as low risk
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of bias (see Figure 3)11,15,36,39. Thus, there is strong scientific evidence for a positive association
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between musculoskeletal fitness and MC.
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Five (12%) of 44 studies investigated flexibility. Four studies used one specific measure of
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flexibility16,24,36,39 and one study considered flexibility as part of a HRPF index score25. Four studies
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9 220
used the sit and reach test to assess flexibility16,24,25,36 and the shoulder reach measure was used in one
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study16. One study also evaluated trunk lift as their measure of flexibility39.
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Among the four studies that assessed flexibility in isolation, one study (25%) did not find a relationship between MC and flexibility24 and the other three studies found a low positive
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association16,36,39. Two studies were classified as low risk of bias36,39. Such results indicate uncertainty
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with regard to evidence for an association between MC and flexibility.
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4. Discussion
The main purpose of this review was to provide an evaluation of studies assessing
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associations between MC and various HRPF components. Overall, there was strong evidence for an
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inverse association between MC and body weight status and positive associations with
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cardiorespiratory fitness, and musculoskeletal fitness in children and adolescents. These results
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expand on the findings of Lubans et al.6 and more comprehensively addressed the question by
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including studies that assessed MC from a more broadly-defined perspective.
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The inverse relationship between body weight status and MC may be partially explained by
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increased fat mass that may be detrimental to MC performance where the entire or majority of body
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mass is projected37. In addition, increased mass may promote inefficient movement patterns of object
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projection skills that inherently demand high segmental velocities33. Thus, these inverse relationship
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may represent a reciprocal mechanism of the dynamic interactions present in open system54, also
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called positive feedback. This feedback mechanism operates progressively across time, demonstrating
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an increased strength of association between variables as individuals develop. This explanation
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parallels the recursive effects proposed by Stodden et al.4 whereby weight status both contributes to
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and is a result of the combination of the development of MC and HRPF. An unhealthy weight status
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also increases the likelihood of disengagement in PA, further hindering the development of MC and
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HRPF. This negative recursive relationship may be perpetuated across adolescence, and even into
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adulthood29. The opposite recursive effect also may occur with higher MC and a healthy weight status
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promoting increased musculoskeletal and cardiorespiratory fitness that allows children to be more
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active, helping to further enhance motor skill development in a variety of contexts4.
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Page 9 of 21
10 These trends have been demonstrated in various cross-sectional and longitudinal studies. In a
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large cross-secitonal study, D'Hondt et. al.34, demonstrated negative associations between gross motor
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coordination (KTK performance) and weight status that progressively increased across age (5-12 yrs).
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A recent longitudinal study5 also demonstrated an increasingly widening gap in BMI status in children
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as a function of their differential gross motor coordination levels. Alternatively, the transition to
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adolescence demonstrated a marked decline in associations between MC and body weight status in
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two studies12,21. It is important to note that BMI has limitations in accurately predicting % body fat
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during the transition into adolescence; thus, this is a limitation for studies using BMI as a predictor for
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overweight/obese status at this age. A more valid predictor of % body fat may provide a clearer
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picture of the relationship between MC and body weight status trajectories across childhood and
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adolescence12. Also, the typical variability in intra- and inter-individual growth and maturation
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patterns that occur during the transition to adolescence should be considered as they may
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differentially influence the relationship between HRPF and MC in childhood and adolescence12.
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The strong evidence for a positive association between MC and musculoskeletal fitness and between MC and cardiorespiratory fitness also can be explained by patterns of engagement in
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physical activities that promote HRPF. Sport participation may serve to concomitantly enhance MC
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and multiple aspects of HRPF5,55. In fact, many ballistic skills performed in sports (e.g., throwing,
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kicking, striking, jumping, running and hopping) inherently demand high levels of physical effort and
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neuromuscular coordination and control, favoring the development of both HRPF and MC56.
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Specifically, ballistic skills demand high concentric and eccentric muscle activity, high body weight
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loading and demonstrate high joint angular velocities and power outputs57, thereby promoting muscle
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strength. Furthermore, activities inherently involving fundamental locomotor and object control skills
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(e.g., practice and performance of sports, physical education and leisure games) are generally
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associated with repetitive movement that enhances cardiorespiratory development. Lastly, the sports
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environment is sufficiently challenging to further promote the acquisition of motor skills.
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It seems logical that the co-development of multiple HRPF attributes and MC are inherently
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linked via both direct (i.e., neuromuscular mechanisms) and indirect pathways (i.e., increased choices
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of physical activities that relate to cardiorespiratory endurance development). As movement patterns
Page 10 of 21
11 of many HRPF and MC tasks include multi-joint movements that manipulate many degrees of
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freedom within the body, the combination of isometric, concentric and eccentric muscle activity
278
requires a high degree of both inter- and intramuscular coordination and control. For example, several
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field-based HRPF test items that assess musculoskeletal (e.g., push-ups, curl-ups, pull-ups) and
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cardiorespiratory fitness (PACER) inherently demand a certain level of coordination and control that
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has to be learned, as many of these tasks involve complex movements. In essence, HRPF tests that
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require dynamic muscle contractions to promote movement (e.g., pull-ups or curl-ups), isometric
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stabilization of body segments (e.g., core musculature - push-ups or plank) or rapid concentric and
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eccentric contractions of musculature at multiple joints (e.g., locomotion associated with
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cardiorespiratory endurance tests) to effectively perform the task demand the learning of appropriate
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coordination and control demonstrated via inter- and intra-neuromuscular development. This type of
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language is more commonly associated with the development of gross motor coordination and/or
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fundamental motor skills, but the underlying acquisition/learning of neuromotor coordination and
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control to effectively demonstrate the goal of the movement remains the same.
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Neural maturation is an additional factor to be considered when addressing the expression of
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muscular strength as children age and as their ability to control force in a given task improves58. Thus,
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tests involving multi-joint movements, whether deemed “motor” or “fitness” tests, involve similar
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neuromuscular constraints to effectively generate and apply force and to produce effective
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coordination patterns (i.e., manipulate multiple degrees of freedom) to accomplish the goal of the
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task. Thus, promoting both HRPF and MC would seem to be an optimal strategy for intervention56
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that would favorably impact the overall functional physical capabilities of an individual. Based on
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associational evidence noted in most cross-sectional and longitudinal studies, as well as experimental
298
evidence56 this supposition seems to be supported. In addition, development of both MC and HRPF
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may also influence healthy weight trajectories across time as the metabolic cost associated with
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training and performance of MC and HRPF in various contexts with high levels of effort are
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substantial37.
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The lack of studies assessing associations between MC and flexibility does not allow
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conclusions to be drawn about their relationship. Children with low MC have heterogeneous fitness
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profiles, and extreme ranges of flexibility and inflexibility can be observed in these children. As hyper
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flexibility reduces stability around the joint, it may make controlled movement more difficult. In
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contrast, hypo flexibility limits the range of movement of joints and therefore restricts movement15. In
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addition, flexibility tends to be joint specific and may be related to maturational effects.
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Limitations Although this review was comprehensive, studies published in languages other than English
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were not included and publication bias related to selective reporting of only positive associations may
311
be a possibility. Besides, the inherent limitations of cross-sectional and longitudinal study designs,
312
which were noted in most studies in this review, preclude making definitive conclusions regarding
313
causality relating to the development of MC and HRPF. However, we are dealing with developmental
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phenomena and, as such, the most parsimonious explanation relating to the development of MC and
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various aspects of HRPF over time may be that they demonstrate a recursive relationship, as proposed
316
by Stodden et al.4. In addition, if a child attains a certain level of proficiency in motor skills and
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develops appropriate fitness habits, he/she may overcome a hypothesized Seefeldt’s “proficiency
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barrier” that may be related to lifespan trajectories of MC and HRPF59. Thus, promoting both MC and
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HRPF early in life may augment the potential to develop and sustain appropriate healthy behavior
320
habits across time that will contribute to a lifelong active and healthy lifestyle31.
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The previously noted similarities in neuromuscular function associated with MC and HRPF
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activities is related to the diverse and sometimes overlapping nature of HRPF and MC tests used by
323
researchers. Overall, at least 11 different assessments of MC and at least eight HRPF test batteries (as
324
well as various combinations of individual HRPF assessments) were used in the literature cited in this
325
review. Adding further confusion to these measurement issues, the tennis ball and medicine ball
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throw, the standing long jump, and grip strength tests have been used interchangeably as either
327
measures of HRPF or MC15,31.
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Another important limitation involved in evaluating the relationship between MC and HRPF
329
involves the amount of body mass manipulated in the performance of many MC and HRPF tests.
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Manipulating increased mass, specifically related to increased body fat, generally would be
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detrimental to performance. Obese children generally perform worse on field tests in which they are
Page 12 of 21
13 required to move mass against gravity (e.g., KTK, PACER, push-ups, sit-ups, pull-ups), as compared
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to healthy weight children. Alternatively, the composition of lean mass, as a major component of total
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mass, has two important characteristics that relate to force/torque production (i.e., strength),
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specifically in childhood and adolescence. Overall increased lean mass provides more physiological
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cross-sectional area to promote the generation of force. However, overall lean mass represents only
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one part of the equation when describing the functionality of mass. As previously mentioned, the
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functionality of increased mass associated with increasing age also depends on the development of
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inter- and intra-muscular coordination (i.e., motor unit recruitment, motor unit firing rate, optimal co-
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activation of agonist/ antagonist muscles, and synergistic muscle contractions60, which also is
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critically important to the development of MC. Unfortunately, the contribution of increased lean mass
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(physiological) and the inherent neuromuscular coordination and control associated with lean mass on
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force/torque output (i.e., strength) on both HRPF and MC is not well understood60. This complex
344
issue may have significant implications across age, specifically during the transition into adolescence.
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Therefore, the use of BMI as a measure of body weight status in many studies in this review limits our
346
understanding of the contributory effects of overall increased mass (i.e., lean mass, neuromuscular
347
coordination and body fat) to both MC and aspects of HRPF. The use of direct measurements of
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cardiorespiratory fitness such as breath-by-breath gas analysis during a maximal endurance test on a
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treadmill or cycle ergometer, as well as the mediating effect of an individual’s PA levels, may help to
350
elucidate more precisely the strength of this association.
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Several other factors can influence associations between MC and HRPF. The intensity of
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exercise, quality of instruction and time spent in practice are important factors that contribute to the
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development of both constructs6,7. In addition, maturational variables and % body fat also may have
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influences on both MC and HRPF and future studies evaluating the relationship between MC and
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HRPF should control for these factors. Finally, there was a very small proportion of the studies (11%)
356
meeting the criterion of estimating statistical power. However, based on the rather consistent
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statistically significant findings in the vast majority of studies in this review, adequate power and the
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noting of significant associations were demonstrated.
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Conclusion
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The results of this systematic review demonstrate strong evidence indicating that the development of MC is inversely associated with body weight status and positively associated with
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cardiorespiratory fitness and musculoskeletal fitness across childhood and adolescence. The
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association between flexibility and MC proved to be uncertain. It also is worthy to note that
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associations between MC and HRPF were, in general, the same in boys and girls. The inherent
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complexity associated with the development of MC and HRPF and the previously discussed
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limitations in how these distinct, yet related constructs are assessed in children and adolescents make
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it difficult to truly understand the nature of their differences and similarities. Furthermore, all MC and
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HRPF tests are complex human movements that are similarly influenced by physiological,
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maturational, psychological, sociological and environmental constraints as individuals grow and
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develop. Overall physical development involving both constructs promote increased functional
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capacity of individuals that may promote positive lifespan trajectories of functional capability and
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may contribute to long-term health outcomes.
M Based on the results of this review, we believe the focus of future interventions should be directed at concomitantly promoting motor competence and health-related physical fitness in
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an environment that is developmentally appropriate for children and adolescents as this may
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Practical Implications
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be the most advantageous path to promote both constructs and promote overall functional capabilities.
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Providing educational information to inform physical education teachers and sport coaches on
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the importance of developing both MC and HRF is critical to promote maximal changes in
382 383
these variables in a variety of physical activity settings. We suggest the terms “strength” and “coordination” should not be seen as separate constructs,
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rather they should be seen as parallel goals, along with the development of cardiorespiratory
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endurance, to promote functional capabilities in children that allow them to be able to pursue
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many different types of physical activities that are health-enhancing and developmentally
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appropriate56. The development of both motor competence and health-related physical fitness may promote
388 389
positive and sustainable trajectories of health and lead to long term health outcomes.
390 Acknowledgments - This research was supported by post-doctorate grant (for Maria Teresa
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Cattuzzo), Science Without Borders Program, Coordination for the Improvement of Higher Education
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Personnel/Research National Council, Brazil (process: BEX 2568/13) and FAPESP no.1250620-2 (for
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Alessandro Hervaldo Nicolai Ré).
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1
ip t
Number of records identified through database searching = 6.478 articles Academic Search Premier = 2.138 ERIC = 339 PubMed = 824 PsycInfo = 372 Scopus = 819 SportDiscus = 580 Web of Sience = 1406
cr
Records after duplicates removed = 4.592
an
Full text assessed for eligibility = 84 Full text records identified through other sources = 12
us
Number of records excluded = 4.508 (By title and abstracts analysis)
ed
M
Number of records excluded = 51 1 - idade superior 15 - Mc not assessed 19 - Não avaliou relação entre MC and HRPF 2 - special population 7 - other languages 7 - other
pt
Number of studies included in qualitative analysis = 45 Number of records removed = 1 (Score ≤ 2 in the qualitative analysis)
Ac ce
Number of studies included in this systematic review = 44
Figure 1. Flow chart showing number of articles selected for systematic review
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2 Table 1. Distribution of the studies that investigated MC and Health-Related Physical Fitness component by risk of bias (low or medium) within studies and the level of scientific evidence. Health-Related
Studies that
Physical Fitness
demonstrated
component
association
Body weight status
Yes: 27 (81%)
Studies by risk of
Low risk of bias studies that showed
Level of
bias
significant association
evidence
Low: 9 (29%)
Yes: 8 (89%) (inverse association)
Medium: 22 (71%)
No: 1 (11%)
Low: 7 (63%)
Yes: 7 (100%) (positive association)
Medium: 5 (37%)
No: 0 (0%)
Low: 4 (57%)
Yes: 4 (100%) (positive association)
Medium: 3 (42%)
No: 0 (0%)
Low: 2 (50%)
Yes: 2 (100%)
Medium: 2 (50%)
No: 0 (0%)
Cardiorespiratory
Yes: 12 (100%)
ip t
Strong
(n=33)
Musculoskeletal
Yes: 7 (63,6%)
cr
Strong
fitness (n=12)
Uncertain
an
Yes: 3 (75%)
Ac ce
pt
ed
M
Flexibility (n=4)
us
Strong
fitness (n=11)
Page 21 of 21
