{"paper_id":"8a4102a9-95de-4330-a381-c687ee11b827","body_text":"Weber et al. Sports Medicine - Open          (2024) 10:103  \nhttps://doi.org/10.1186/s40798-024-00776-8\nREVIEW ARTICLE\nRole of Cardiorespiratory Fitness, Aerobic, \nExercise and Sports Participation in Female \nCognition: A Scoping Review\nSports, Fitness, and Cognition\nVinicius Muller Reis Weber1,2,3*  , Marcos Roberto Queiroga1,2, Jessica L. Puranda3, Kevin Semeniuk3, \nMeaghan Lindsay Macdonald3, Diego Bessa Dantas1,2, Danilo Fernandes da Silva4 and Kristi Bree Adamo3 \nAbstract \nBackground The impact of cardiorespiratory fitness (CRF) on cognition is thought to be mediated by brain-derived \nneurotrophic factor. Aerobic exercise can increase CRF through various activities, including sports participation. The \nrelationship between these factors in females has yet to be elucidated.\nObjective This review aims to map the current literature on the effects of aerobic exercise, sports participation, \nand CRF in healthy adult females, with sub-topics of pregnancy and menstrual cycle periodicity.\nMethods A scoping review of the literature was conducted following PRISMA guidelines and the PCC mnemonic \n(population, concept, and context). The following five databases were screened: CINAHL, Medline, Web of Science, \nSPORTDiscus, and Scopus. Eligible articles included healthy adult females, investigated aerobic exercise, sports partici-\npation or CRF, and linked outcomes to cognition. Data from included manuscripts was extracted and analyzed. Two \nsub-population groupings (pregnant individuals and menstrual cycle) were established to further aid the interpreta-\ntion of the findings.\nResults Of the 300 titles and abstracts screened, 74 were eligible for full-text screening, and 28 were included \nin the scoping review. Of the 28 included, 14 did not control for or report on menstrual cycle phase or sex hormones.\nConclusion This scoping review found an inverse ‘U’ relationship between aerobic exercise and cognition, demon-\nstrating an optimal dose of aerobic exercise to benefit cognitive functions. As estrogen may impact the relationship \nbetween CRF and neural growth factors, more research is needed on this pathway, independent of the menstrual \ncycle, to determine potential beneficial effects. It is currently unknown whether sports participation can indepen-\ndently impact cognition.\nKey Points \n•  Regular sports participation enhances executive functions, brain activation, and BDNF levels.\n•  Both acute and chronic aerobic exercise improve cognition, but excessive exercise can reduce BDNF and impair \ncognitive performance. Highlighting the possible inverted “U” theory.\nOpen Access\n© The Author(s) 2024. Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.\nSports Medicine - Open\n*Correspondence:\nVinicius Muller Reis Weber\nviniciusweber1994@gmail.com\nFull list of author information is available at the end of the article\n\nPage 2 of 16Weber et al. Sports Medicine - Open          (2024) 10:103 \nBackground\nLow levels of cardiorespiratory fitness (CRF) have det -\nrimental effects on population health and have been \nexacerbated with the rise in sedentary behavior during \nthe COVID-19 pandemic [1–3]. Low levels of CRF are \nassociated with obesity [4], metabolic syndrome [5], poor \nbone health [6], and anxiety and depression [1, 7, 8]. Per-\ntaining to mental health, CRF is directly related to the \nexpression of the molecule brain-derived neurotrophic \nfactor (BDNF) [9–11]; where low levels of this protein are \nassociated with major depression [11, 12].\nBDNF contributes on neuroprotection, neurogenesis, \nmemory consolidation, brain excitability, and neural con-\nnectivity [13–15]. Moreover, the effects of CRF on cogni -\ntion seem to be mediated by BDNF levels [16, 17]. When \nexamining aspects of cognition, the executive function \nappears to be most influenced by CRF [18–20]. Executive \nfunction refers to series of cognitive processes respon -\nsible for action plans and decision making; its features \ninclude domains such as inhibitory control (i.e., inhibit \ndistraction stimulus that can lead to a wrong action), \nworking memory, and mental flexibility [21, 22], and are \nessential for daily tasks (e.g., managing money; managing \nhome) [23] as well as academic achievement [24].\nOne way to improve CRF is by engaging in habitual \naerobic exercise [25]. A category of aerobic exercise is \nsports participation. Individuals exposed to sports train -\ning that involve physical exertion, especially aerobic exer-\ncises, usually exhibit increased CRF [26, 27]. More than \nthat, sports participation can be divided in open (i.e., \nbasketball, soccer, hockey) and closed skills sports (i.e., \nswimming, running). Open skill sports are those which \nplayers are required to consistently react and adapt to an \nunpredictable environment. Whereas closed skill sports \nare defined by sports with a stable environment, during \nwhich players have a predetermined movement pattern \n[28].\nMore than being physically demanding, sports par -\nticipation can also require the high utilization of differ -\nent cognitive aspects (e.g., attention, inhibitory control, \ncognitive flexibility) [29]. To significantly improve sports \nperformance it is necessary to integrate these cognitive \nfunctions and enhance the top-down processing (i.e., uti -\nlize past experiences to guide an activity or reaction) [30, \n31]. During sports participation, players must be atten -\ntive to different environmental changes, and adapt to \ncomplex and quickly changing conditions [22]. However, \nthere is a lack of literature examining the relationship \nbetween sport-based and non-sport physical activity and \ncognition [32]. What remains to be clarified or deter -\nmined is whether or not engaging in sports participation \noffers cognitive advantages over regular engagement in \nphysical activity, since executive functions are correlated \nto health related variables (i.e. physical fitness) [29].\nDuring aerobic exercise, skeletal muscle contractions \nupregulate BDNF release [33, 34], which can result in \nBDNF being stored in blood platelets [35]. Addition -\nally, blood platelets promote homeostasis by repairing \nvessels, promoting clotting, and increasing inflamma -\ntory responses [36]. There is an effect of CRF on platelet \nactivity owing to muscular and vascular adaptations to \nhabitual physical activity/training [37, 38]. Moreover, in \nanimals models, circulating BDNF can cross the blood–\nbrain barrier, and peripheral BDNF (e.g. serum BDNF) \nis strongly related to the amount of BDNF in the brain \n[39]. Another protein related to cardiorespiratory fitness \n(CRF), muscle contraction, and brain health is vascular \nendothelial growth factor (VEGF). VEGF plays a cru -\ncial role in promoting angiogenesis. Increasing VEGF \ndynamics with exercise [40], may enhance cerebral blood \nflow, which is essential for supporting neurogenesis [41].\nExposure to aerobic exercise results in hormonal \nchanges. Strenuous activities can increase cortisol levels, \ncatecholamine release, and decrease energy resources. \nThese alterations in whole body homeostasis can over -\nstimulate cognitive functions. For example, during a \nstrenuous exercise, the body increases catecholamine \nlevels and glucose consumption [42]; these patterns can \nresult in neural noise due to high levels of catechola -\nmines [9, 43] or decreasing brain excitability by decreas -\ning energetic resources during/after intense activities \n[44, 45]. Therefore, determining what the optimal dose of \naerobic exercise for improvements in cognitive function \nis necessary.\nBiological sex is an important consideration when \nexamining CRF as well as aspects of cognition as there \nare known between-sex differences. These differences \noccur mainly because of sex hormones since estrogen is \nstrongly related to BDNF [46]. Also, engaging in exer -\ncise may have more significant impacts on cognition in \nfemales [47]. The promotion of cognitive health with \nexercise during adulthood may be protective against the \ndeleterious effects of age, reduction of sex hormones and \nchemical dysregulations on cognitive functions [9, 29, \n• Hormonal changes during the menstrual cycle and pregnancy affect cognitive functions and BDNF levels, \nwith exercise offering possible protective effects.\nKeywords Executive function, Cognition, Sports, Fitness, Aerobic exercise, Female\n\nPage 3 of 16\nWeber et al. Sports Medicine - Open          (2024) 10:103 \n \n47]. During adulthood, menstruation and pregnancy are \nuniquely female experiences that may play a role in cog -\nnitive functions and hormone release. All these aspects \nmust be addressed to elucidate the possible female-cen -\ntric impact of CRF/aerobic activity on cognitive-related \noutcomes. Cognitive-related outcomes are measures/\neffects related to the function of brain and mental pro -\ncess which encompass cognitive function, growth factors \nand other biomarkers that may influence cognitive func -\ntion and brain imaging.\nThe available literature predominantly focuses on males \nor mixed samples, creating a gap in research regarding \nthe effects of CRF, aerobic exercise, and cognition specifi-\ncally in the female population. It is important to highlight \nthat males and females experience significantly different \nimpacts on cognition [32, 47] and CRF [48] through their \nlifespan. These differences complicate the application of \nfindings across the sexes. Therefore, the purpose of this \nstudy is to map the research done and identify the gaps \nrelated to the effects of aerobic exercise, sports participa -\ntion, and cardiorespiratory fitness on cognition in healthy \nadult females, with sub-topics related to menstrual cycle \nperiodicity and pregnancy. Considering the wide scope \nof our topic and the limited existing literature, a scoping \nreview is one of the most suitable methods for identifying \nand analyzing gaps in the literature [49].\nMain Text\nMethods\nInclusion and Exclusion Criteria\nA scoping review was conducted, using the PCC mne -\nmonic (population, concept, and context) to develop the \nresearch question [49], to elucidate the state of the litera -\nture on the relationship between aerobic exercise, sports \nparticipation, cardiorespiratory fitness, and cognition in \na healthy female population. This study followed the rec -\nommendations of PRISMA-ScR checklist [50].\nEligible articles included the following aspects: (1) \nhealthy adult female individuals; (2) investigated any aer -\nobic exercise, sports participation, or cardiorespiratory \nfitness; and (3) the outcomes were linked to cognition. \nArticles that included male participants, pathology, ani -\nmals, elderly, and when the objective of the study was to \nverify the effects of illicit or admissible/legal drug use on \ncognition, were excluded.\nSearch Strategy\nThe initial search was performed on October 30th, \n2022, and a second search, to refine the articles was per -\nformed on September 13th, 2023. The following data -\nbases were screened: Cinahl, Medline, Web of Science, \nSport Discus, and Scopus. The keywords, MeSH terms, \nand Boolean operators used to facilitate the search are \ndetailed in Table 1. For this review no restriction for lan -\nguage and date was utilized. The articles eligible for the \ntitle/abstract screening were transferred to Covidence, \nand duplicate articles were automatically removed. Two \nreviewers independently screened the manuscripts by \ntitle and abstract; if any conflict was identified, a third \nreview was consulted. The reference lists of included \narticles were checked for potentially relevant studies that \nmet our inclusion criteria.\nData Extraction and Synthesis\nAfter reviewing the full text, information was extracted \nfrom the included manuscripts utilizing the Covidence \nsoftware, and the following information was summa -\nrized: author, country, study design, study population, \noutcomes, and summary of main findings. To address \nthe research question, the reviewers grouped the findings \nby the predictor variables (i.e., aerobic exercise, sports \nparticipation, and cardiorespiratory fitness) to summa -\nrize the main findings. The two reviewers also analyzed \nthe relationship between aerobic exercise, sports par -\nticipation, cardiorespiratory fitness, and cognition in two \nfemale sub-populations (i.e., pregnant individuals, indi -\nviduals with menstrual cycle variations). The sub-popu -\nlation groupings were used to aid in the interpretation of \nfindings to answer the research question.\nTable 1 Search strategy for Medline\nKey term Search strategy Retrieved articles\nAerobic Exercise (\"Sports\" OR \"Sport\" OR “Athletes” OR “Physical Fitness” OR “Cardiorespiratory Fitness” OR “Aerobic Exercise”) 370,317\nCognitive outcomes (\"Brain-Derived Neurotrophic Factor\" OR \"Nerve Growth Factors\" OR \"Vascular Endothelial Growth Factors\" \nOR \"Executive Function\" OR \"Inhibitory Control\" OR “Stroop Task” OR \"Working Memory\" OR \"receptor TrkB\" \nOR “Cognitive Flexibility”)\n135,124\nFemales (\"Woman\" OR \"Female\" OR “Pregnant women” OR “Menstrual Cycle” OR “Reproductive Health”) 9,913,245\nAbove searches combined with AND 1456\nAND NOT (“Male” OR “Elderly” OR “Aged” OR “Older” OR “Children” OR “Child” OR “Adolescents” OR “Concussion” \nOR “Dementia” OR “Alzheimer”)\n97\n\nPage 4 of 16Weber et al. Sports Medicine - Open          (2024) 10:103 \nResults\nThe database search and references screening identified \na total of 435 articles (427 from database search and 8 \nfrom references screening), of which 135 were dupli -\ncates. A total of 300 titles and abstracts were screened, \nand 74 studies were eligible for full-text screening. Of the \nremaining articles identified, 28 studies were included in \nthe scoping review. All stages of the screening process are \npresented in Fig. 1.\nOf the 28 articles included, 14 did not control for or \nreport information on the menstrual cycle phase or sex -\nual hormones of the participants included. Additional \ninformation and a summary of the findings from indi -\nvidual studies can be found in Tables  2 and 3. Table  2 \nsummarizes the association between aerobic exercise, \nsports participation, cardiorespiratory fitness, and cog -\nnition in a healthy female population. Table  3 includes a \nsummary of the effect of pregnancy and menstrual cycle \nperiodicity on the relationship between aerobic exercise, \nsports participation, cardiorespiratory fitness, and cogni -\ntion in a healthy female population.\nCardiorespiratory Fitness and Cognitive‑Related Outcomes\nA limited number of studies (n = 4) were found that \nexamined the effects of cardiorespiratory fitness on \nmarkers of cognition [20, 51–53]. All assessed cardi -\norespiratory fitness by maximal oxygen consumption \n (VO2max), during a graded exercise test, and none of \nRecords iden/g415fied through  \ndatabase search:\nn = 42 7\nSupplementary searches:\nreference screenin g\nn = 8\nSELECTIONINCLUDED ELIGIBILITY IDENTIFICATION\nDuplicates removed from \ndatabase search:\nn = 135\nTitles/abstracts screened :\nn = 30 0\nExcluded based on \n/g415tles/abstracts:\nn = 22 6\nFull-text assessed for  \neligibility:\nn = 74\nFull-text ar/g415cles excluded, with reason:\nn = 46\nInappropriat eo utcome s( 7)\nInappropriate popula/g415on (i.e.,\nmenopause, mal ea nd female in the  \nsame sample, mice, rats) (36)\nInappropriate type of study (i.e.,  \nreview, abstracts )( 3)\nStudies included in review:\nn = 28\nFig. 1 PRISMA flow diagram\n\nPage 5 of 16\nWeber et al. Sports Medicine - Open          (2024) 10:103 \n \nTable 2 - Characteristics of studies analyzing the effects of cardiorespiratory fitness, aerobic exercise and sports on cognition\nAuthor (year)/country Study type Total sample Context Cognitive outcome Main findings\nCardiorespiratory fitness and cognitive outcomes in healthy female individuals\nScott et al. [20] USA Cross-sectional 120 Cardiorespiratory fitness Executive function VO2 peak is positively associates \nto attention (P < 0.01), shifting \n(P < 0.01) and working memory \n(P < 0.01)\nLi et al. [52] China Cross-sectional 24 Cardiorespiratory fitness Executive function and Brain \nimages\nHigh-fit group showed greater \nbrain activation in the anterior \ncortex and has higher accuracy \n(t(11) = 2.315; p = 0.03)\nSchmalhofer., [50] Germany Cross-sectional 822 Cardiorespiratory fitness Serum BDNF (pg/ml) VO2 peak is positively associated \nwith BDNF\n(β: 2.35; CI: 1.17 – 3.52)\nCui et al. [51] China Cross-sectional 115 Cardiorespiratory fitness \nand acute moderate exercise \n(30 min)\nInhibitory control and Brain \nimages\nAcute exercise decreases the RT \nof low-fit group\nHigh-fit group showed greater \nbrain activation than the low-fit \ngroup in the post-rest imaging, \nmainly in the anterior cortex\nAerobic exercise and cognitive outcomes in healthy female individuals\nNofuji et al. [53] Japan Cross-sectional 8 controls\n8 physically active\nAcute low, moderate, and maxi-\nmum aerobic exercise (30 min)\nSerum BDNF (pg/ml) BDNF increased immediately \nafter maximal and moderate exer-\ncise for the sedentary and active \ngroups (p < 0.01)\nBDNF decreased for active group \nafter 30 (-15%) and 60 min (-25%) \nof maximum exercise\nSchmidt-kassow et al. [54] \nGermany\nCross-sectional 20 Acute low-intensity and high-\nintensity aerobic exercise \n(30 min)\nSerum BDNF (pg/ml) Increase of BDNF during high \nintensity exercise\nExercise: 31,392.1\nbaseline: 30,221.5\nLi et al. [57] China Cross-sectional 15 Acute moderate-intensity aero-\nbic exercise (30 min)\nfMRI, working memory Acute exercise activates prefrontal \ncortex but not changes working \nmemory performance (P > 0.05)\nLieberman et al. [59] USA Longitudinal 109 Basic combat training (BCT)/\nMilitary (10 weeks)\nReaction time, Working memory Increase in RT after BCT\nd: 0.47; P = 0.016\nHwang et al. [55] USA Cross-sectional 14 Acute high-intensity aerobic \nexercise (20 min)\nSerum BDNF (pg/ml) Increase of BDNF immediately \nafter high intensity exercise \nand decreases during recovery\nExercise: 23,492\nBaseline: 20,989\nRecovery: 19,919\n\nPage 6 of 16Weber et al. Sports Medicine - Open          (2024) 10:103 \nTable 2 (continued)\nAuthor (year)/country Study type Total sample Context Cognitive outcome Main findings\nLowe et al. [58] Canada Cross-sectional 51 Acute moderate-intensity aero-\nbic exercise (20 min)\nInhibitory control Better performance after acute \nexercise (F(1,49) = 13.729, \nP = 0.001)\nJürimäe et al. [56] Estonia Cross-sectional 15 Acute sub-maximal exercise (1 h) Plasma VEGF (pg/ml) VEGF significant increases \nimmediately after post-exercise \ncompared to pre-exercise\nCV: 1.70\nES: 0.19\nRentería et al. [60] USA Randomized controlled trial 17 Short-term HIIT program \n(4 weeks) and GXT\nSerum BDNF (pg/ml) HIIT increases BDNF before GXT \ncompared to control (P < 0.05)\nDecreases of BDNF after GXT \nfor HIIT group are higher \n(P < 0.001)\nLuo et al. [61] China Randomized controlled trial 70 HICT program (12 weeks) Inhibitory control Faster incongruent RT after HICT \n(d:0.38; P = 0.047)\nAerobic exhaustion exercise and cognitive outcomes in healthy female individuals\nBue-estes et al. [62] USA Cross-sectional 26 Maximal aerobic exercise Reaction time, Working memory, \nVisual spatial Memory\nWorking memory significantly \nlower when intensity was up to \n50% of  VO2 max\nHigher working memory \nafter recovery time (after 30 min)\nGarcía-Suárez et al. [63] Mexico Cross-sectional 17 Acute effect of GXT and HIIT Serum BDNF (ng/ml), cortisol \n(μg/dl)\nHIIT increases BDNF post-exercise\nd: 0.17\nGXT decreases BDNF post-exercise\nd: -0.26\nThe ratio of cortisol and BDNF \nincreases after exertion\nConkright et al. [64] USA Cross-sectional 15 Physical exertion (TMT) / Military \n(3 days)\nPlasma BDNF (pg/ml) and Serum \ncortisol (μg/dl)\nTMT did not change BDNF levels\nTMT increases cortisol (p: < 0.05)\nArmstrong et al. [65] UK Cross-sectional 10 Physical exertion (3-h loaded \nmarch)/ Military\nInhibitory control, working \nmemory, military tasks\nHigh and Very-high loaded \nreduced working memory\nInhibitory control was reduced \nin high loaded\nSports practice and cognitive outcomes in healthy female individuals\nSchor et al. [66] Brazil Cross-sectional 15 professional judo fighters Training session and GXT Plasma BDNF (pg/ml) BDNF increases after both tests\nDelta BDNF was higher dur-\ning training session (P = 0.003)\n\nPage 7 of 16\nWeber et al. Sports Medicine - Open          (2024) 10:103 \n \nTable 2 (continued)\nAuthor (year)/country Study type Total sample Context Cognitive outcome Main findings\nShi et al. [67] China Cross-sectional 20 soccer athletes\n15 aerobic athletes\n15 controls\nsports practice Inhibitory control and fMRI The soccer and aerobic groups \npresented with lower RT than con-\ntrol. However, the soccer group \npresented with lower inhibitory RT\nThe soccer group presented \nmore activation of basal nuclei \nthan aerobic groups\nPradas et al. [68] Spain Cross-sectional 14 padel athletes Competition Blood BDNF ng/ml Padel competition increased \nBDNF (pre: 1531.12 × post: \n1769.56; d:1.527; p < 0.05)\nYu et al. [69] China Cross-sectional 38 ice hockey Skill level fNIRS and executive function The accuracy and reaction \ntime is better for elite players \n(p = 0.001). Also, the elite group \nhad higher activation of prefron-\ntal (p = 0.026) and frontal cortex \n(p = 0.03)\nBDNF, brain derived neurotrophic factor; fMRI, functional magnetic resonance imaging; fNIRS, functional near-infrared spectroscopy; GXT, graded exercise texting; HICT, high-intensity circuit training; HIIT, high-intensity \ninterval training; N.S., not significant; RT, reaction time; VEGF, vascular endothelial growth factor;  VO2 max, maximum oxygen consumption;  VO2 peak, peak oxygen consumption\n\nPage 8 of 16Weber et al. Sports Medicine - Open          (2024) 10:103 \nTable 3 - Characteristics of studies analyzing the effects of menstrual cycle and pregnancy on the relationship between cardiorespiratory fitness, aerobic exercise, and sports \nwith cognition\nEUM, eumenorrheic; AM, amenorrheic; BDNF, brain derived neurotrophic factor; GXT—grade exercise testing; FOL, Follicular phase; HIIE, high intensity interval exercise; LUT, luteal phase; RT, reaction time; VEGF, vascular \nendothelial growth factor;  VO2 max, maximum oxygen consumption\nAuthor (year) country Study type Total Sample Context Cognitive outcome Main findings\nRelationship between cardiorespiratory fitness, aerobic exercise, cognitive outcomes, and menstrual cycle periodicity\nMelin et al. [70] Denmark and Swe-\nden\nCross-sectional 16 EUM\n14 AM\nAcute maximal aerobic exercise (2 \nbouts)\nBDNF (μg/L), Cortisol (nmol/L) Acute exercise increased cortisol \n(+ 98.6) and BDNF (+ 96.5) only in AM \ngroup\nNose et al. [71] Japan Cross-sectional 132 EUM\n63 AM\nElite Athletes Serum BDNF (ng/ml), serum estra-\ndiol (pg/ml)\nAM presented lower BDNF than EUM \n(median: 22.9 × 25.2)\nA significant relationship \nbetween BDNF and estradiol (r: \n0.209)\nDirk et al. [72] Canada Longitudinal 15 EUM Acute aerobic exercise during Fol-\nlicular and Luteal Phase (20 min)\nInhibitory control RT Acute exercise decreased RT \nfor both menstrual phases (P:0.003)\nMenstrual phase did not impact RT\nPoli et al. [73]\nBrazil\nLongitudinal 14 EUM Acute HIIE during Follicular \nand Luteal Phase (20 min)\nInhibitory control, serum BDNF \n(pg/ml)\nBDNF increased after HIIE \nfor both conditions (LUT: + 8.22; \nFOL: + 7.29)\nVO2max is related to ΔBDNF \nafter HIIE during follicular phase (r: \n-0.539)\nRelationship between cardiorespiratory fitness, aerobic exercise, cognitive outcomes, and pregnancy\nRojas-Vega et al. [74] Germany Cross-sectional 20 3rd trimester Sub maximum GXT (150 bpm) pre- \nand post-partum\nSerum BDNF (ng/dl), VEGF (pg/ml), \ncortisol (μg/dl)\nBDNF increased during sub-maxi-\nmum exercise for pregnant individu-\nals (p = 0.048)\nBDNF is higher and cortisol is lower \nafter childbirth (p < 0.001)\nLeMoyne et al. [76] Canada Cross-sectional 52 pregnant (1st trimester 15, \n2nd trimester:18; 3rd trimester: \n10)\n15 control\nCardiorespiratory fitness Inhibitory control Inhibitory control is negatively \nimpacted by pregnancy (F: 2.86; \np = 0.04).  VO2max changes dur-\ning the pregnancy (F:4.61; p = 0.006)\nFerrari et al. [75] Germany Longitudinal 19 intervention\n15 control\nModerate combined exercise \nfrom 14th week to 30th week \nof gestation\nSerum BDNF (pg/ml) BDNF is higher in the exercise group \ncompared to the control group (con-\ntrol: 3371.2 × INT: 6540.7; p < 0.001)\n\nPage 9 of 16\nWeber et al. Sports Medicine - Open          (2024) 10:103 \n \nthese studies controlled for menstrual phase or sexual \nhormones. In one study [51], a positive relationship was \nshown between CRF and serum BDNF. Also, females cat-\negorized as the high-fit group  (VO2max in the 50th per -\ncentile or above) had higher activation of the anterior \ncortex during executive function tasks and better accu -\nracy during rest [52, 53]. Similar to the other findings, \nCRF was related to different aspects of executive func -\ntion, namely working memory and shifting attention [20].\nAerobic Exercise and Cognitive‑Related Outcomes\nThe impact of aerobic exercise on cognition was exam -\nined in nine articles, of which six assessed the effect of \nacute aerobic exercise [54–59] and three assessed the \neffect of chronic aerobic intervention [60–62].\nThe results from four studies showed that an acute (sin-\ngle) bout of aerobic exercise (> 60% of  VO2peak intensity) \ncan increase serum BDNF, vascular endothelial growth \nfactor (VEGF) [54–56] and increase inhibitory control \n(50% of maximum heart rate) [59]. No effects of light-\nintensity aerobic activity were found for neural markers. \nAlso, moderate exercise (60–70% of maximum heart rate) \nappears to modulate brain areas responsible for executive \nfunctions, for example, activating the prefrontal cortex \n[58].\nIn the recovery period (15–30 min) following a graded \nexercise test (GXT), BDNF levels were found to be sig -\nnificantly decreased over those measured at rest [54, 55]. \nDifferent from an acute exercise exposure, high intensity \naerobic training can increase resting levels of BDNF [61] \nand promote faster reaction time during an inhibitory \ncontrol task [62].\nThe effects of strenuous aerobic exercise on cognition \nwere evaluated in four manuscripts [63–66], two of which \nwere conducted among female military members [65, 66]. \nThe results of these studies consistently identified that \nexhaustion following aerobic exercise results in poorer \ncognitive function (i.e., reduced working memory). Addi -\ntionally, two studies found that cortisol levels increased \nafter a bout of maximal exercise [64, 65]. Evidence indi -\ncates that following exhaustive aerobic exercise, work -\ning memory assessments decrease by approximately 20% \ncompared to resting values [63]. Similarly, after 3-h of \nphysical exertion, inhibitory control was reduced by 25% \nwhen compared to a less intense activity [66].\nSports Participation and Cognitive‑Related Outcomes\nFour studies assessed the effects of sports in different \nconditions: (i) martial arts training session [67]; (ii) com -\nparing open and close skills (soccer and endurance ath -\nletes) [68]; (iii) a Padel (racket sport) competition [69]; \n(iv) skill level of ice hockey players [70]. Results showed \nthat in the recovery period recovery (30  min) following \none training session of martial arts [67] and a single Padel \ncompetition [69], serum BDNF levels were significantly \nhigher than at rest. Moreover, differences in response \nwere noted between elite and novice hockey players, with \nelite players showing higher activation of prefrontal and \nfrontal cortex and performing better on executive func -\ntions task than their novice peers [70].\nAnother study compared brain activity and inhibition \ncapacity in participants engaged in open and closed skill \nsports to those in a control group (lack of specific sports \ntraining); sports groups had a better reaction time com -\npared to the control group, independent of the type of \nsport [68]. However, open-skill sports (e.g., soccer) lead \nto higher activation in a particular brain region, the basal \nnuclei (as measured by fMRI) when compared to closed \nskills (e.g., aerobic athlete) [68].\nMenstrual Cycle Influence on the Relationship Between \nCardiorespiratory Fitness, Aerobic Exercise, Sports \nand Cognitive‑Related Outcomes\nRegarding reproductive health, two studies evaluated \ndifferences between eumenorrheic and amenorrheic \n(absence of a menstrual cycle) females [71, 72], and \nanother two assessed the impacts of the menstrual phase \non cognitive-related outcomes [73, 74].\nAfter maximal aerobic exercise, BDNF (+ 96.5%) and \ncortisol only increased in the amenorrheic group [71]. \nAt rest, eumenorrheic females showed higher values of \nBDNF in comparison to those experiencing amenorrhea. \nMoreover, BDNF positively correlates with estradiol, a \nsignificant female reproductive health hormone that is \nhigh in the follicular phase triggering events leading to \novulation. [72]\nWhen analyzing inhibitory control, acute aerobic \nexercise decreased reaction time after exercise, inde -\npendently of the menstrual phase [73]. BDNF increased \nafter a 20-min bout of vigorous physical activity for both \nphases (Luteal and follicular) [74]. Conversely,  VO2max \nis negatively correlated with the change in BDNF after a \nGXT only for follicular phase (r = -0.539) [74].\nPregnancy Influence on the Relationship Between \nCardiorespiratory Fitness, Aerobic Exercise, Sports \nand Cognitive‑Related Outcomes\nThree studies investigated the effects of aerobic fitness \nand exercise on cognitive-related outcomes (biomark -\ners and cognitive function tests) during pregnancy and \nafter childbirth. Among these 3 studies, one evaluated \nthe impact of an acute bout of submaximal exercise on \nBDNF [75]; the second study a 16-week intervention that \nincorporated moderate exercise and BDNF [76]; and the \nlast study investigated the impacts of cardiorespiratory \nfitness on inhibitory control [77].\n\nPage 10 of 16Weber et al. Sports Medicine - Open          (2024) 10:103 \nAfter an acute bout of moderate intensity aerobic exer -\ncise in pregnant females, serum BDNF increased imme -\ndiately after exercise. About 10–12  weeks post-delivery, \nBDNF levels increased and cortisol levels decreased \nduring rest and post-exercise compared to their lev -\nels during pregnancy period [75]. Following a 16  week \nexercise intervention, resting serum BDNF increased \n(+ 1574.1 pg/ml), while the level of BDNF in the control \ngroup, decreased (− 691.9 pg/ml) [76].\nExamining inhibitory control responses during preg -\nnancy, Lemoyne and colleagues showed decreased \ninhibitory control and  VO2max across all three trimes -\nters. When  VO2max is inserted as a covariate in analyses, \nit does not change the effect of pregnancy on inhibitory \ncontrol. These results demonstrate that CRF is not the \nexplanatory variable leading to the decrease in inhibitory \ncontrol over the course of pregnancy. Also, the non-preg-\nnant control group had a better reaction time and  VO2max \nthan the pregnant individuals [77].\nDiscussion\nCardiorespiratory Fitness\nThe literature surrounding the relationship between CRF \nand BDNF, found in our scoping review, is inconsistent. \nWhile some studies reported an inverse relationship \nbetween CRF and BDNF [38, 74], another study found \na positive association between these variables [51]. One \nexplanation for the reported inverse relationship could \nbe that BDNF has a fundamental role in tissue repair \nand formation (vessels, cardiac tissue, bones, skeletal \nmuscles), in this sense circulating BDNF can be mobi -\nlized, directed to and taken up by tissues needing repair \nthereby decreasing circulating levels [34, 78, 79]. The \npositive associations observed between CRF and BDNF \nsuggest a connection to increased engagement of muscle-\ntype 1 fibers in the context of aerobic activities. It appears \nthat the BDNF-TrkB complex plays a role in fat oxidation \nprocesses, crucial for energy generation during aerobic \nexercise [33, 51, 80], consequently upregulating circulat -\ning BDNF levels.\nWhen analyzing the relationship between CRF and \nexecutive function, results demonstrated a positive \nimpact of CRF on the activation of the anterior cortex \n[52]. The executive process depends on brain connec -\ntions, mainly between the pre-frontal cortex, hippocam -\npus, and basal ganglia [81]. The release of BDNF can be \nupregulated due to muscular contractions [33] and is \nconsequently linked to CRF. When correlating BDNF \nwith executive functions, it is responsible for synaptic \nplasticity, long-term potentiation, and long-term mem -\nory, promoting higher neuronal activation and improved \nbrain connectivity. This enhancement results in faster \nprocessing of tasks [18, 82–84]. Moreover, increased \nserum BDNF levels are related to a higher hippocampus \nvolume [83]. Taken together these data CRF can increase \nbrain activation and proteins responsible for better cog -\nnitive function.\nThis scoping review found that acute moderate exer -\ncise only changes RT among individuals with low fit -\nness levels [52]. Given there is an inverted-U relationship \nbetween exercise and cognitive functions, stimulation \nof the brain could be dependent on the intensity of the \nbout of exercise [9, 43, 85]. Thus, the cognitive function -\ning of individuals with higher fitness levels may be less \nimpacted by low/moderate physical activity. In this sense, \na higher-fitness individual seems to adapt to metabolic/\nhormonal changes caused by physical activity and needs \nmore stimulus to promote cognitive gains.\nAerobic Exercise\nOur scoping review focused on females found a positive \neffect of acute [56] and chronic [60] aerobic exercise on \ninhibitory control and working memory. The effects of \naerobic exercise on executive functions are linked to an \nincrease in neurotransmitters, which can stimulate cer -\ntain brain areas (e.g., pre-frontal cortex) responsible for \ncognitive functions [86, 87].\nIt was determined that there is a positive effect of acute \naerobic activity on BDNF. In contrast, during recovery, \nmany studies showed lower serum BDNF than baseline \n[54–56, 61]. A potential explanation for lower BDNF \nlevels during the recovery period is that muscle damage, \nwhich increases BDNF levels in muscle tissue as a neces -\nsity for recovery [34, 88], leads to the depletion of stored \nBDNF in platelets. Moreover, in a rat model, the BDNF \nis upregulated in soleus after aerobic exercise [34]. Thus, \nBDNF can bind to TrkB, triggering the repair of damage, \nincreasing muscle regeneration [34, 80], resulting in a \ndecrease in BDNF circulation.\nAcute aerobic exercise can lead to an increase in VEGF \nlevels. VEGF is correlated to metabolic demand, with \nhigher exercise efforts leading to higher circulating VEGF \n[57]. VEGF, stored in muscle fibers, can be secreted dur -\ning an acute muscle contraction, increasing extracellular \nlevels up to five times resting level. This circulating VEGF \nstimulates angiogenesis and consequently increases \noxygen and metabolite delivery [40]. It is important to \nhighlight the effect of VEGF on angiogenesis within the \nhippocampus and, consequently, on neurogenesis [41, \n89, 90]. In animal model, this increase in VEGF facili -\ntates learning and memory, reducing latency during tasks \n[89]. The activation of VEGF on brain can also be result \nfrom lactate-inducing VEGF. During exercise, lactate lev-\nels increase and bind its receptor on the brain (HCAR1). \nWhen HCAR1 is activated, it promotes subsequent acti -\nvation of vascular endothelial growth factor A (VEGFA) \n\nPage 11 of 16\nWeber et al. Sports Medicine - Open          (2024) 10:103 \n \nand, consequently, brain angiogenesis, mainly in the hip -\npocampus. [91].\nA decline in cognitive functions (working memory \nand inhibitory control) and BDNF levels were seen fol -\nlowing exhaustive aerobic exercise. [63, 64, 66]. Moreo -\nver, cortisol and the ratio of cortisol to BDNF increases \nafter exertion [64, 65], this increase in cortisol can act \nas an inhibitor of BDNF synthesis [64, 88]. This finding \nis important because exhaustive exercise upregulates \nplasma cortisol levels, increasing catecholamine synthe -\nsis, leading to neural noise due to overstimulation of the \nbrain [9, 43]. Cortisol can stimulate the release of gluta -\nmate, which binds to NMDA receptors. This interaction \ncan affect synaptic sensitivity and alter BDNF expres -\nsion, primarily by influencing intracellular calcium influx \nthrough NMDA receptors, which can subsequently \nimpact neurogenesis [84, 92, 93]. Moreover, the reduc -\ntion in BDNF after exhaustive exercise could be related \nto a shift in the use of additional resources (e.g., lactate \nfor the ATP synthesis) rather than the syntheses of BDNF \n[45, 94].\nAlthough sex disparities are not the focus of this \nreview, it is important to highlight that studies showed a \ngreater decline in the cognitive function and neurochem-\nical markers of female individuals following exhaustive \nexercise compared to their male counterparts [65, 66]. \nFemales may be more susceptible to negative sequalae \ndue to disparities in physical fitness and metabolic \ndemands [95]. Consideration should be given to sex dis -\nparities when developing training prescriptions.\nSports Participation\nChronic sports participation can improve cognition, pos -\nsibly related to high levels of cardiorespiratory fitness \nthat results from the sports participation [26, 29]. But \nalso, sports participation can be independently related \nto executive functions since it requires higher activation \nof the prefrontal cortex and higher executive function \ndemand than other forms of physical activity [29].\nOf the four studies related to sports participation, one \nstudy compared with controls (non-sports participa -\ntion) [68]. At the same time, other studies analyze the \neffects of a training/competition session [67, 69] and \nthe impact of skill level on cognition [70]. The results of \nthis review showed positive effects of sports participa -\ntion on inhibitory control and serum/plasma BDNF. The \none study examining different types of sports (open and \nclosed skills), showed the aerobic and soccer groups had \nfaster RT during easier tasks) [68]. The values for RT dur-\ning an inhibitory task (harder) were faster for the soccer \ngroup compared to aerobic and control. A possible expla-\nnation for the faster reaction times during inhibitory \ntasks among the soccer group could be better functional \nconnectivity and activation of certain brain areas (e.g., \nthe basal nuclei and the frontal cortex) [68]. The basal \nnuclei are responsible for actions such as motor, spatial, \nvisual, and affective. Specifically, the putamen region of \nthe basal nuclei is responsible for motor and visual tasks, \nbeing activated during sports, and acting for better inhib-\nitory control [68, 96, 97] and these regions are known to \nbe enhanced during sports, mainly for open skill sports \n[68].\nMoreover, the effects of sports participation, mainly \nopen skills sports, on cognitive control may be related to \nmore complex motor tasks that are required for success -\nful performance in the sport. Open sports require atten -\ntion and working memory for real-time decision-making, \nand an increased demand for inhibitory control to ensure \ncorrective action [22, 31, 98, 99].\nIn essence, there is a lack of comprehensive research \nconcerning how sports impact cognition. This gap \nstems from the unique cognitive demands of each sport, \nwhether open or closed, and how they contribute to \nvarious improvements in aerobic fitness. As a result, \nthe exact enhancements in executive functions linked to \nsports participation might not have been fully elucidated \nor might need deeper investigation to consider other \ninfluencing factors [29].\nMenstrual Cycle\nDuring the menstrual phase, oscillation in hormonal \nlevels is noted, and estrogen levels are highest between \n10 and 14 days of the menstrual cycle [100]. Circulating \nestradiol can cross blood–brain barriers, and estrogen \nreceptors (ER) are widely distributed in the brain. ER on \nthe membrane can activate signaling pathways respon -\nsible for neuroprotection and synaptic formation [101, \n102]. Moreover, estradiol can stimulate the brain’s bioen-\nergetic system, improving ATP availability [101]. Estro -\ngen receptors can stimulate the hippocampus, leading to \na beneficial effect related to learning, memory, neuronal \nsurvival, and neuronal activity [46, 102]. A significant \npositive association between serum BDNF and estradiol \nhas been noted [72].\nIt is well known that excessive exercise and weight loss \ncan create an energy deficit that may inhibit the synthe -\nsis of gonadal hormones, causing deficits in sexual hor -\nmones and menstrual dysfunction [103]. Approximately \n25% of runners [103], 15% of ice hockey athletes [104] \nand 10% of futsal athletes can experience amenorrhea \n(absence of menstruation) or an irregular menstrual cycle \n[105]. Among female individuals, reproductive charac -\nteristics have been shown to have an effect on cognition. \nOne study suggested that amenorrheic female athletes \nhad lower levels (at rest) of circulating BDNF compared \nto eumenorrheic female athletes [72]. The presence of \n\nPage 12 of 16Weber et al. Sports Medicine - Open          (2024) 10:103 \nBDNF in the endometrium and the discharge associated \nwith menstruation may justify the presences of lower \nBDNF levels among amenorrheic female individuals. The \nendometrium may be a source of BDNF synthesis [46, \n106] or act as a stimulus for endometrial cell proliferation \n[107]. Given amenorrheic individuals do not shed their \nendometrium cyclically (if at all), there is less demand \nfor BDNF, downregulating circulating BDNF levels, with \nthe possibility to decrease the availability of BDNF for \nthe brain once blood BDNF can cross the blood–brain \nbarrier.\nAnother study found an elevation of BDNF and cortisol \nlevels after aerobic exercise only among amenorrheic ath-\nletes [71], possibly suggesting a lack of aerobic stimulus \nin the eumenorrheic group. Since catecholamines (epi -\nnephrine, norepinephrine, dopamine) are regulated by \ncortisol, and these neurotransmitters/hormones stimu -\nlate brain regions [86] regulating metabolite supply [108] \nthis could be an avenue for the increase in BDNF.\nThis review highlights the effect of acute aerobic exer -\ncise on inhibitory control and serum BDNF during both \nmenstrual phases (follicular and luteal), suggesting a \nbeneficial effect of aerobic exercise, independent of men -\nstrual phase [73, 74]. However, this study did not verify \nthe menstrual phase by hormonal dosage [74]. This is \na short-coming in the study design, as the presence of \nmenstruation does not equate to normal hormone levels \n[100].\nPregnancy\nThe studies in this scoping review reveal decreased cog -\nnitive-related outcomes during pregnancy, characterized \nby reduced baseline BDNF levels, diminished inhibitory \ncontrol, and elevated cortisol levels compared to non-\npregnant individuals [75, 77]. A possible explanation for \nthese lower levels of BDNF [75] and inhibitory control \n[77], could be related to higher levels of cortisol during \npregnancy [75], with the increase in cortisol down-regu -\nlating neurogenesis [92], and affecting neurotransmitters. \nA single bout of aerobic exercise in pregnancy showed a \nsignificant increase immediately after the exercise [75] \nand exposure to a moderate-intensity aerobic exercise \nintervention resulted in increased BDNF levels compared \nto the control group whose levels decreased from base -\nline [76].\nAerobic exercise can increase BDNF levels during preg-\nnancy [76] and can reduce the deleterious effect of preg -\nnancy on BDNF. Moreover, animal studies have shown \nhigher BDNF levels in offspring from mothers who prac -\nticed exercise throughout gestation [76] offering a poten -\ntial intergeneration benefit. Currently, there is a gap in \nthe literature; investigating the effects of aerobic exercise \nor CRF on BDNF levels and its receptor in the human \nplacenta, to determine whether there are better meta -\nbolic and neurotrophic markers in offspring of mothers \nwho practiced exercise throughout gestation [75]. Mater-\nnal adaptations in response to environmental factors \n(e.g., exercise) can be transmitted to the fetus through \nthe placenta, facilitating the provision of nutrients, hor -\nmones, and immunological communications [109, 110]. \nFinally, BDNF/TRkb can contribute to enhanced fetal \ngrowth and may be associated with the management and \nprevention of fetal growth disturbances [111].\nLimitations\nWhile the aim of this scoping review was to summarize \nand unveil gaps in the literature related to the benefit \nof aerobic exercise and sports on cognitive-related out -\ncomes and the possible effect of the menstrual phase \nor pregnancy on these relationships, it is not without \nlimitations. The review did not assess the quality of the \nincluded studies or provide a detailed synthesis of evi -\ndence. Additionally, it did not address the heterogeneity \namong studies. Also, the number of cross-sectional stud -\nies limited the interpretation of causality.\nConclusion\nThe possible pathways and covariates found is this scop -\ning are elucidated in Fig.  2. The scoping review shows \nan inverse ‘U’ relationship between the aerobic exer -\ncise and cognitive functions, demonstrating an opti -\nmal amount and intensity of aerobic exercise to benefit \ncognitive functions. Also, CRF is significantly related to \nserum BDNF, but more information is needed to confirm \nthe beneficial effects of CRF on cognitive-related out -\ncomes independent of the menstrual phase since there is \na possible effect of estrogen on this relationship. Lastly, \nno study was found that clearly illustrates the effects of \nCRF on the BDNF receptor (TrkB) and whether sports \npractice is independently related to cognitive-related out-\ncomes in females.\nFuture Research\nRecommendations relating to further research into the \nroles of cardiorespiratory fitness, aerobic exercise and \nsports practice in female cognition are presented below:\n• Implement precise, objective methods to control for \nmenstrual phases and hormonal variations when \nanalyzing their impact on cognitive performance.\n• Investigate the influence of cardiorespiratory fitness \non estrogen-cognition dynamics.\n• Explore cardiorespiratory fitness as a mediator in \nsports participation and cognitive-related outcomes.\n\nPage 13 of 16\nWeber et al. Sports Medicine - Open          (2024) 10:103 \n \n• Conduct randomized controlled trials to evaluate \nhow aerobic exercise and cardiorespiratory fitness \ninfluence cognitive-related outcomes.\n• Study the interaction between aerobic exercise/cardi-\norespiratory fitness and TRKb\n• Assess the impact of aerobic exercise/cardiorespira -\ntory fitness on BDNF during pregnancy and in the \nplacenta.\nAbbreviations\nATP  Adenosine triphosphate\nBDNF  Brain-derived neurotrophic factor\nCRF  Cardiorespiratory fitness\nER  Estrogen receptors\nfMRI  Functional magnetic resonance imaging\nGXT  Graded exercise test\nHCAR1  Hydroxycarboxylic acid receptor 1\nNMDA  N-Methyl-D-aspartic acid\nPCC  Population, concept, and context\nRT  Reaction time\nTrkB  Tropomyosin receptor kinase B\nVEGF  Vascular endothelial growth factor\nVO2max  Maximal oxygen consumption\nVO2peak  Peak oxygen consumption\nAcknowledgements\nThe authors would like to thank the Coordenação de Aperfeiçoamento de \nPessoal de Nível Superior—Brasil CAPES and the Canadian Institutes of Health \nresearch—CIHR for fellowships provided to the authors.\nAuthor Contributions\nConceptualization: VMRW, MRQ, DBD, JLP; Search: VMRW, DFS; Title, abstract \nand full text screening: VMRW, DBD; Drafting: VMRW, KBA, KS, JLP . Data \nextraction: VMRW, KS, MLM. Figures and Tables: VMRW. Critical Review of the \nmanuscript: MRQ, JLP , MLM, DFS, KS, KBA. All authors read and approved the \nfinal version.\nFunding\nThere is no funding source.\nAvailability of Data and Materials\nThe datasets generated during and/or analyzed during the current study are \navailable from the corresponding author on reasonable request.\nCode Availability\nNot applicable.\nDeclarations\nEthics Approval\nNot applicable.\nConsent to Participate\nNot applicable.\nConsent for Publication\nNot applicable.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthor details\n1 Laboratory of Experimental and Applied Physiology to Physical Activity,  \nUNICENTRO, Street Alameda Elio Antonio Dalla Vecchia, 838, Vila Carli, Guara-\npuava, Paraná  85040-167, Brazil. 2 Associated Graduate Program in Physical \nEducation UEM/UEL, Londrina, Brazil. 3 Faculty of Health Sciences, School \nof Human Kinetics, University of Ottawa, Ottawa, ON, Canada. 4 Sports Studies \nDepartment, Bishop’s University, Sherbrooke, QC, Canada. \nReceived: 21 December 2023   Accepted: 19 September 2024\nReferences\n 1. 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