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The effect of exercise intervention on balance and executive function in children with autism spectrum disorder: a meta-analysis

BMC Sports Science, Medicine and Rehabilitation volume 17, Article number: 80 (2025) Cite this article

Abstract

Objective

This study primarily evaluated the the effects of exercise intervention on balance and executive function in children with autism spectrum disorder (ASD).

Methods

Search for eligible studies through four databases, and then proceed with screening. The inclusion criteria are as follows: (1) Children with ASD; (2) Age 3–18 years; (3) Randomised Controlled Trial; (4) The intervention group received exercise training; (5) Conducted pre- and post-test, which include balance and executive function. Use the Cochrane bias risk assessment tool to evaluate the quality of the selected study. Select Standardized Mean Difference (SMD) as the appropriate effect scale index.

Results

Twelve of the selected articles involved 288 males and 108 females. The findings demonstrated that the exercise group (EG) benefited more from the improved balance than its control group (CG) counterpart [SMD = 0.86 (0.56, 1.16), p < 0.05, I2 = 37%]. Furthermore, subgroup analysis revealed that exercise interventions lasting over eight weeks significantly enhanced balance [SMD = 1.19 (0.79, 1.58), p < 0.05, I2 = 17%]. However, exercise interventions lasting less than or equal to 8 weeks did not have a significant impact on balance [SMD = 0.41 (− 0.06, 0.87), p = 0.09, I2 = 0%].

Conclusion

Exercise interventions can better improve the balance and behavioural inhibition of children with ASD compared to CG. Nevertheless, physical training prescribed for more than eight weeks led to a more significant improvement in balance than interventions performed for shorter periods.

Peer Review reports

Introduction

Social communication and motor behaviour with limited, repetitive sensory conduct are the predominant fundamental attributes of autism spectrum disorder (ASD) [1]. Physically, the illness can manifest as compromised executive function and balance, leading to postural stability issues and increased injury risks [2, 3–4]. The postural symptoms have also been demonstrated to continue into adulthood and are distinguished by an abnormally early plateau during adolescence [5].

Children participating in different exercise intervention programmes can have improved motor skills, balance, and fitness levels [6,7,8]. Exercise reportedly positively affects and assists children with ASD with daily tasks requiring strength, endurance, flexibility, and stability [9]. Furthermore, physical training can boost the self-confidence of the children [10].

Nine weeks of psychomotor [11] and 12 weeks of structured circular [12] trainings have led to longer-term alterations in postural stability in children with ASD. The data offer preliminary evidence that balance can be enhanced in individuals suffering from the disorder. Nevertheless, Milajerdi et al. revealed that an eight-week motion-sensing tennis game training did not improve the balance skills of children with ASD [6]. Speculation may be due to differences in evaluation methods and shorter intervention times. As such, the influence of exercise on children with ASD remains unclear.

A meta-analysis study involving 15 reports focusing on balance parameters indicated that any physical intervention strategy is advantageous for children with ASD [7]. Nonetheless, the reviewed studies did not employ randomised controlled trials (RCT). On the one hand, RCT outperform other research designs in minimizing bias and establishing causal relationships. On the other hand, The reliability of the results of the single arm meta-analysis is also low due to children’s rapid growth and development. As such, this study included RCT reports to determine the effects of exercise intervention on balance and executive function in children with ASD.

Materials and methods

Protocol and registration

The current study registered the review procedure applied with the International Prospective Register of Systematic Reviews on December 17th, 2024 (registration number: CRD 42024628585).

Data sources and study selection

During the initial phases of this study, Scopus, PubMed, Web of Science, and EBSCO databases were searched, spanning January 2004 to December 2024. The search was completed on December 18th, 2024. The terms “ASD”, “autism”, “training”, “exercise”, “balance“, “children”, and “executive function” were applied during the searches. The search plan and outcomes acquired from each database are summarised in Appendix A.

Two investigators independently analysed each selected title and abstract before assessing complete papers according to the inclusion and exclusion criteria. The criteria are discussed in next section of this article. The main information extracted from the included literature includes age, gender, intervention duration, exercise protocol, and index. Any disputes among the investigators were resolved by inviting a third investigator to attain a consensus. Figure 1 illustrates the article selection process employed in the current study. This systematic review and meta-analysis was conducted per the guideline suggested by the preferred reporting items for systematic reviews and meta-analyses (PRISMA).

Fig. 1
figure 1

Flow diagram of the search results using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA)

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Inclusion and exclusion criteria

For this review, six inclusion criteria were set. Only articles involving ASD patients between 3 and 18 years old were included. The reports must also employ RCT and exercise training as the intervention and record balance and behavioural inhibition (BI), flexibility (FL) and working memory (WM) as the outcomes. The main methods used to assess balance were single leg standing time, Movement Assessment Battery for Children scale, Berg Balance Scale, Peabody motor development scale scores. The main methods of assessing executive functioning include Flanker task, Wisconsin Card Sorting Test, Hearts & Flowers test, The Behavior Rating Inventory of Executive Function and Go/No-Go task. Furthermore, only full-text papers in English were reviewed. Conversely, grey literature, including abstracts, conference proceedings, and poster presentations, was not considered.

Quality assessment

The quality of the selected reports in this study was established with the Cochrane risk of bias tool [13]. The evaluation encompassed assessment outcome and participants and personnel blinding, incomplete data, random sequence generation, selective reporting, and allocation sequence concealment [14]. In this study, two co-authors analysed the quality of each report independently. Meanwhile, another author assisted in resolving disagreements to attain a consensus. The quality of each article was then rated “Yes”, “No”, or “Unclear”.

Risk of bias analysis

This meta-analysis performed sensitivity evaluation by excluding an article at a time to determine the stability of the findings. Subsequently, funnel plots were utilised to establish publication bias of the reviewed articles.

Data evaluation

Review Manager (RevMan) version 5.4.1 (The Cochrane Collaboration, Copenhagen, 2020) was employed in this review to determine the influences of the interventions. The procured data were then standardised by converting the median (range) figures into mean ± standard deviation. The data conversion is carried out on specialized online websites(http://vassarstats.net/median_range.html). If relevant data were undisclosed, the authors of the papers were formally emailed for clarification.

Heterogeneity between outcomes was determined by statistical analysis of I2, which indicates the level of heterogeneity between the studies under review; if I2 is less than 50%, it represents less heterogeneity and a fixed-effects model can be used. On the contrary, I2 greater than 50% represents greater heterogeneity and a random effects model is used. The funnel plot method was also applied to assess publication bias analysis, while the mean difference was determined through the Forest plot technique. The uncertainty level for this study was at a 95% confidence interval (CI).

Results

Eligibility of studies

Table 1 lists the 12 articles that evaluated the influences of exercise on balance and executive functions in children with ASD. All reviewed reports only recorded baseline and final data post-intervention. The studies were also ethically approved by their respective institutions. Furthermore, the two researchers recorded a 0.94 Cohen kappa coefficient.

Table 1 Characteristics of included studies
Full size table

Twelve of the selected articles involved 288 males and 108 females. Among the reviewed publications, eight documented balance aspects and five reported the executive function. Based on the results, the studies were conducted at a minimum of 13 weeks and a 5-month maximum intervention period.

Quality assessment

The selected articles recorded a relatively notable quality, as demonstrated in Fig. 2. Most of the papers (67.9%) also exhibited a low bias risk. Conversely, a small percentage of the articles (11.9%) indicated a significant bias risk, while the remaining reports (20.2%) were unclear.

Fig. 2
figure 2

Analysis of risk of bias according to the Cochrane collaboration guideline

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Quantitative synthesis

The influences of the intervention on the balance (Fig. 3) among children with ASD in the exercise group (EG) and control group (CG) were compared in eight selected studies [6, 11, 12, 15,16,17,18,19]. The findings demonstrated that the EG benefited more from the improved balance than its CG counterpart [SMD, 0.86 (0.56, 1.16), p < 0.05, I2 = 37%]. Furthermore, subgroup analysis revealed that exercise interventions lasting over eight weeks significantly enhanced balance [SMD, 1.19 (0.79, 1.58), p < 0.05, I2 = 17%]. However, exercise interventions lasting less than or equal to 8 weeks did not have a significant impact on balance [SMD, 0.41 (− 0.06, 0.87), p = 0.09, I2 = 0%].

Fig. 3
figure 3

Forest plot portraying the effects of EG vs. CG intervention on the balance

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The effects of the interventions on the EG and CG on BI (Fig. 4a), FL (Fig. 4b), and WM (Fig. 4c) were compared in four [20,21,22,23], three [6, 20, 21] and two [20, 22] of the articles reviewed, respectively. The findings demonstrated that the EG recorded superior BI to the CG [SMD, − 1.26 (− 2.38, − 0.14), p < 0.05, I2 = 92%]. Nonetheless, no considerable variations were documented between the groups regarding FL [SMD, 0.95 (− 0.02, 1.92), p = 0.06, I2 = 85%] and WM [SMD, 2.96 (− 1.83, 7.75), p = 0.23, I2 = 98%].

Fig. 4
figure 4

Forest plot portraying the effects of EG vs. CG intervention on the behavioural inhibition, flexibility and working memory

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Publication bias analysis

In this systematic review, 12 articles were selected, almost the minimum sample number preferred for the funnel plot method. However, according to reports, funnel plots with small sample sizes can also reflect publication bias [24]. Based on Figs. 5 and 6, the publication bias results demonstrated a symmetrical distribution, indicating a minimal publication bias probability.

Fig. 5
figure 5

Funnel plot of publication bias in the EG vs. CG intervention for the balance

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Fig. 6
figure 6

Funnel plot of publication bias in the EG vs. CG intervention for the behavioural inhibition, flexibility and working memory

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Sensitivity assessment

The meta-analysis recorded insignificant alterations in each category after the type of analysis was adjusted, the effect size was modified, and individual articles were removed. Therefore, the sensitivity analysis verified the reliability of the findings.

Discussion

The results indicate that exercise can improve the balance and executive function of children with ASD. Although heterogeneity is low (I2 = 37% < 50%), further analysis is necessary to clarify the impact of intervention measures on heterogeneity. Meanwhile, through exploration of multiple factors, it was found that the duration of intervention may be an important factor affecting the heterogeneity of results. A previous study involving 19 tissues and 25 molecular platforms showed that many of the exercise-induced adaptive molecular changes do not emerge until 8 weeks after the exercise intervention [25]. Therefore, we conducted subgroup analysis with an intervention time of 8 weeks as the dividing point, and the results showed that exercise training beyond 8 weeks can improve balance, while shorter periods of time can reduce effectiveness. The discovery provided a critical value of the dose-response relationship for enhancing the balance function in children with ASD through exercise. Consequently, considering the effects of intervention duration on exercise effectiveness is vital when formulating exercise prescriptions and conducting research.

Balance management integrates three primary sensory inputs: visual, vestibular, and somatosensory systems [26]. Children suffering from motor dysfunction and disrupted balance are more vulnerable to falls during daily activities and may face escalated impairment in communication and interaction skills development [27]. The results of this review and previous analyses [12, 19] indicated that exercise training of over eight weeks enhanced balance in children with ASD.

In an investigation conducted by Ansari et al. [19], 20 children ASD patients were prescribed 10 weeks of aquatic exercises. The regime was performed twice weekly for 60 min each session. The children in the study had orientation and basic and free swimming training. According to the results, the intervention was conducive to enhancing the children’s ability to maintain static and dynamic balance. In another study, Arslan et al. [12] employed structured circular training, totalling 12 weeks for three times a week. The program primarily included balance, strength, and jumping training. The report evaluated the ability of children with ASD to maintain balance on a balance beam. The EG recorded improved standing time compared to the CG, supporting the conclusion of this review.

Numerous exercise-based interventions [7, 19] were reportedly effective in improving balance in children with ASD. Nevertheless, determining the optimal intervention parameters was challenging due to inconsistent intervention plans and varied exercises applied. The outcomes of this meta-analysis revealed that only physical training performed over eight weeks had significant positive effects. The observation might be attributable to body function improvement through exercise requiring long-term accumulation. As such, physical training under eight weeks was not effective.

The mechanisms behind exercises in enhancing balance in children with ASD have not been fully understood. Nevertheless, evidence suggests that improved balance is related to visual, vestibular, and proprioceptive sense alterations [28]. Postural sway during sensory stimulations increases due to sensory stimuli changes [29, 30] arising from balance system adjustments to retain an upright posture [31]. In addition, structural changes in the brains of children with ASD may lead to many subtle deficiencies in motor control, including postural instability, which may ultimately interfere with balance and cognitive development. The improvement of neuroplasticity through exercise may also be one of the mechanisms [32]. Exercise rehabilitation may improve early signs of central nervous system abnormalities, thereby enhancing behavioral inhibition and balance function [33].

Children with ASD have modulating sensory data issues and visual processing deficiencies [34, 35]. Consequently, postural sway in children with ASD rose with visual information unavailability [36]. Stins et al. [27] also reported that children suffering from mild ASD had increased postural instability in the mediolateral direction while their eyes were closed. The data suggested that ASD patients had enhanced dependency on visual input to regulate balance, rendering balance maintenance challenging [27].

Based on autism-related complications and considering the importance of sensory integration signals for maintaining balance in patients of ASD, physical activity interventions could be among the most advantageous and regulatory approaches to minimise balance deficit [37]. Furthermore, relevant reports have noted that muscles are receptors in the central nervous system of the brain. The muscles receive the information mentioned above before providing feedback. Muscle strength also directly affects whether the body can ultimately maintain internal balance [38]. Body flexibility and balance are intimately associated. Improving flexibility can enhance coordination and balance, which are critical for posture control [39]. Exercise is a vital step to enhance muscle strength and body flexibility. As such, physical training might also improve the balance of children with ASD by increasing lower limb muscle strength and flexibility.

BI, WM and FL all fall under the umbrella of executive function. The results of this study show the positive effects of a motor intervention on BI. This is similar to the results of a previous study in which 40 children with ASD in the study by Tse et al. [23] utilized a basketball skill acquisition intervention for 45 min twice a week for 12 weeks. The Go/No-Go test was utilized to assess participants’ BI. The results showed that the exercise group was more effective in improving the level of BI in children with ASD compared to the control group. One possible explanation for the executive function benefits relates to the neurotrophic hypothesis [40,41,42]. According to this hypothesis, physical activity increases metabolic demand and triggers a series of biochemical changes, such as enhanced cerebral blood flow and increased levels of brain-derived neurotrophic factors, which in turn enhances the brain’s plasticity for high-level cognitive activity and subsequently improves executive function [43].

This review has several shortcomings. Firstly, the number of included articles was relatively small, which might not accurately represent the intervention effects on the entire population. This meta-analysis of RCT investigations also included trials involving different ages, statistical and evaluation methods, and exercise intervention details. These differences may limit accurate horizontal comparisons between studies. As such, future reviews can consider incorporating more publications to enhance the credibility of the results. More diverse intervention programs can also be considered, such as transcranial electrical stimulation, cognitive training, and more. Furthermore, more physiological or psychological indicators, such as brain-derived neurotrophic factor, inflammation, anxiety, depression, and sleep status, can be incorporated as research continues. Finally, determining precise dose-response relationships to effectively enhance the balance and executive function of children with ASD would be beneficial.

Conclusion

Exercise interventions can better improve the balance and behavioural inhibition of children with ASD compared to CG. Nevertheless, physical training prescribed for more than eight weeks led to a more significant improvement in balance than interventions performed for shorter periods. It is recommended that clinicians and educators working with children with autism spectrum disorders should be mindful of the impact of intervention duration on intervention outcomes when developing exercise programs, and should try to engage participants in intervention programs of more than 8 weeks.

Data availability

If necessary, it can be obtained from the corresponding author.

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Authors and Affiliations

  1. School of Sport Management, Shandong Sport University, Lichen District, Jinan city, 250102, Shandong, China

    Haixia Li

  2. School of Sport Art, Shandong Sport University, Lichen District, Jinan city, 250102, Shandong, China

    Ruiyun Zhang

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  1. Haixia Li
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Haixia Li wrote the main manuscript text. Haixia Li prepared Figs. 1, 2, 3, 4, 5 and 6; Table 1. Ruiyun Zhang drafted and reviewed the manuscript.

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Correspondence to Ruiyun Zhang.

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Li, H., Zhang, R. The effect of exercise intervention on balance and executive function in children with autism spectrum disorder: a meta-analysis. BMC Sports Sci Med Rehabil 17, 80 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13102-025-01142-1

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13102-025-01142-1

Keywords

BMC Sports Science, Medicine and Rehabilitation

ISSN: 2052-1847

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