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Sedentary time, breaks in sedentary time, moderate-to-vigorous physical activity and metabolic risk in young adults at high risk
S162
Thursday 1 November Posters / Journal of Science and Medicine in Sport 15 (2012) S127–S187
pressure <140 mmHg systolic and <90 mmHg diastolic, fasting blood glucose <6.1 mmol/L, HDL cholesterol >0.9 mmol/L in males and >1.0 mmol/L in females, and fasting triglycerides <1.7 mmol/L Results: The cohort includes 2047 men and women aged 46–74 years of whom 1593 (77.8%; 95% CI 75.9%–79.6%) are overweight or obese. The overall prevalence of metabolically healthy overweight and obese in middle-aged Irish population is 34.2% (n = 700; 95% CI 32.1%–36.3%). The prevalence was higher in women (32%; 95% CI 29.2%–34.9%) than in men (36.3%; 95% CI 33.4%–39.3%). Among overweight and obese, moderate and high physical activity levels were significant predictors of metabolic health (OR = 1.47; 95% CI 1.15–1.88, OR = 1.40; 95% CI 1.07–1.83). In a multivariate model, adjusted for age, gender, smoking and education, both moderate and high physical activity remained significant predictors of metabolic health [OR 1.53; 95% CI 1.18–1.98 and OR 1.70; 95% CI 1.27–2.28]. Overweight and obese women were twice as likely to be metabolically healthy than overweight and obese men [OR 2.05; 95% CI 1.63–2.59]. Discussion: Physical activity provides protection against metabolic abnormalities among the overweight and obese. Current recommendations for physical activity should continue to be advised and further research should be undertaken in the area of physical activity and metabolic health. http://dx.doi.org/10.1016/j.jsams.2012.11.395 393 Identifying physically inactive Parkinson’s Disease patients M. Dontje 1,2,∗ , M. de Greef 3 , A. Speelman 4 , M. van Nimwegen 4 , W. Krijnen 1 , R. Stolk 2 , Y. Kamsma 3 , M. Munneke 4,5 , C. van der Schans 1 1
Hanze University of Applied Sciences, Research and Innovation Group in Health Care and Nursing, Groningen, The Netherlands 2 University of Groningen, University Medical Center Groningen, Department of Epidemiology, The Netherlands 3 University of Groningen, Center for Human Movement Sciences, The Netherlands 4 Radboud University Nijmegen Medical Center, Nijmegen Center for Evidence Based Practice, Department of Neurology, The Netherlands 5 Radboud University Nijmegen Medical Centre; Nijmegen Centre for Evidence Based Practice; Scientific Institute for Quality of Healthcare, the Netherlands Introduction: Daily physical activity is commonly measured with self-reports, but these include a risk for validity problems. In this study, Parkinson’s Disease (PD) patients were screened on the basis of their self-reported daily physical activity. Daily physical activity of patients who reported themselves to physically inactive was additionally measured in a performance-based way. The aim of this study was to examine the performance-based level of daily physical activity, thereby examining whether self-reports of daily physical activity are an appropriate tool to identify actual physically inactive PD patients. Methods: Daily physical activity of 586 PD patients, who reported themselves to be physically inactive, was measured with the Direct-Life accelerometer for 7 consecutive days. Primary outcome was daily energy expenditure in kilocalories. According to the 30-minutes daily physical activity guideline, the self-reported physically inactive patients were classified as ‘physically active’, ‘semi-active’ or ‘physically inactive’ based on their performancebased measurements. Results: In total, 329 patients had sufficient accelerometer data for further analyses. Median daily energy expenditure was 498 kcal
(IQR 280). Of these, 42.kcal (IQR 89) or 9.7 minutes (IQR 19.7) were spent on moderately intensive physical activities and 1.8 kcal (IQR 15.5) or 1.4 minutes (IQR 1.8) on vigorously intensive physical activities. Only one patient was physically active, 55 (17%) were semi-active and 273 (83%) were physically inactive. Discussion: Most PD patients who reported to be physically inactive, were able to make an appropriate estimation of their true daily physical activity level. This indicates that self-reported daily physical activity is a valid screening tool to identify actual physically inactive PD patients. http://dx.doi.org/10.1016/j.jsams.2012.11.396 394 Sedentary time, breaks in sedentary time, moderate-tovigorous physical activity and metabolic risk in young adults at high risk C. Edwardson 1,2,3,∗ , E. Wilmot 1,3,4 , T. Yates 1,4 , J. Henson 1,3 , T. Gorely 1,2 , M. Davies 1,3,4 , K. Khunti 1,5 , M. Nimmo 1,2 , S. Biddle 1,2 1
Leicester-Loughborough Lifestyle NIHR Biomedical Research Unit School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK 3 Leicester Diabetes Centre, Leicester General Hospital, University Hospitals of Leicester, UK 4 Department of Cardiovascular Sciences, University of Leicester, UK 5 Department of Health Sciences, University of Leicester, Leicester, UK 2
Introduction: Evidence suggests that sedentary behaviour is detrimental for health and this association may be independent of physical activity levels. Sedentary behaviour, however, has typically been measured using self-report and accelerometers. These methods have substantial limitations. Inclinometers are able to provide a more accurate assessment of sitting time by measuring body posture. Using inclinometers (activPALTM ) to measure sedentary behaviour and ActiGraph accelerometers to measure moderate-to-vigorous physical activity (MVPA), this study was to examined the association between objectively measured sedentary time, breaks in sedentary time, MVPA and metabolic risk in a sample of young adults identified as being at a high risk of developing type 2 diabetes. Methods: 82 women and 33 men (mean age 32.7 ± 5.6 years, mean; BMI 34.4 ± 5.1 kg/m2 ) were recruited from general practices based on known risk factors such as obesity. Sedentary (sitting/lying activity) time and breaks in sedentary time were measured using the activPALTM inclinometer. MVPA was assessed by ActiGraph accelerometer. Both devices were worn for 10 consecutive days. Fasting plasma glucose, 2-h plasma glucose (measured using an oral glucose tolerance test), waist circumference, blood pressure, and blood lipids were measured using standardised criteria. Linear regression models (adjusted for age, gender, ethnicity, smoking status, social deprivation) examined the associations of sedentary time, breaks in sedentary time, MVPA and metabolic risk variables Results: Sedentary time was positively associated with 2h plasma glucose (=0.22, p = 0.026), triacylglycerols (=0.19, p = 0.037) and total cholesterol (=0.19, p = 0.046). However, after further adjustment for MVPA models were no longer statistically significant. Breaks in sedentary time were not associated with any metabolic risk factors. MVPA was negatively associated with fasting plasma glucose (=-0.20, p = 0.042), triacylglycerols (=-0.31, p = 0.001), systolic blood pressure (=-0.22, p = 0.012) and diastolic blood pressure (=-0.34, p = 0.001). After further adjustment for sedentary time and BMI, all associations remained significant
Thursday 1 November Posters / Journal of Science and Medicine in Sport 15 (2012) S127–S187
(=-0.30, p = 0.002; =-0.29, p = 0.005; =-0.23, p = 0.018; =-0.31, p = 0.003 respectively). Discussion: These results suggest that sedentary time is linked to metabolic risk factors but this relationship is not independent of MVPA in this young at risk population. MVPA was strongly linked to metabolic risk and suggests the promotion of physical activity should remain the primary focus in this population.
396
http://dx.doi.org/10.1016/j.jsams.2012.11.397
1
395 The DALICO Study R. Ekesbo 1,∗ , E. Stenman 1 , M. Leijon 1 , K. Sundquist 1 , S. Calling 1 , C. Bergmark 2 , U. Gerdtham 3 1
Centre of Primary Health Care Research, Lund University Dalby Health Care Centre, Dalby, Sweden 3 Dept of Health Economics, Lund University 2
Introduction: Physical activity as a treatment is gravely underused in health care. One problem is determining the appropriate level of activity for the individual patient; another is maintaining activity over time. We have chosen to introduce a computer-based questionnaire to give the health-care provider a better overview of the patient’s health status, activity level and motivation to change. This information will enable the care-giver (physiotherapist, psychologist, physician, etc.) to tailor the intervention to his/her patients. The primary aim is to monitor the effect of intervention on physical activity (measured in met-minutes) and to detect changes in metabolism over time. An additional major goal is to postpone medical treatment. Methods: At the health care centre in Dalby, Sweden, patients with newly diagnosed hypertension or type II diabetes are being continually enrolled in the study. All participants undergo 24-h ambulatory blood pressure monitoring. A parallel group at a nearby health care centre constitutes a control group. Participants are asked to fill in a questionnaire assessing levels of physical activity and attitudes towards physical activity, and undergo a 6-minute walking test as basic data for physical fitness. Following this, motivational interviewing by specially trained staff takes place, e.g. to identify hindrance for physical activity. Clinical data (blood pressure, ECG, lab tests) and data on quality of life are also being collected. Results: As of March 2012, 33 patients had been recruited to the study (27 in the intervention group and 6 in the control group). 15 patients declined to participate, in most cases due to lack of time. 2 patients dropped out of the study because of difficulty completing the computer interview. We have encountered no problems with patients’ ability to follow the protocol. At the time of writing, individual patients had participated in the study for up to 15 months. All patients who have participated for 6 months or longer have reported increased physical activity, regardless of the activity level at the start of the study. Discussion: The intervention may improve disease control and quality of life, and reduce medication costs. Our results further suggest that physical activity can be a treatment method in many conditions, and thus highlight its importance. A health economics analysis will follow, possibly showing better health economics overall with this treatment concept. However, additional scientific evidence is needed before physical activity can be used as a treatment method within the entire health care system. http://dx.doi.org/10.1016/j.jsams.2012.11.398
S163
The effect of exercise consultation and exercise therapy on quality of life in women with type 2 diabetes: A randomized clinical trial S. Firouzinezhad 1,∗ , H. Dadgostar 2,∗ , M. Ansari 3 , A. 4 5 3 Mahmoudpour , M. Moradi-Lakeh , G. Radmehr , M. Khamseh 6 Department of Sports and Exercise Medicine, Hazrat Rasool Akram Hospital, Tehran, Iran 2 Department of Sports and Exercise Medicine,Tehran University of Medical Scienses 3 Sports Medicine Research Center, Tehran University of Medical Sciences 4 Department of Physical Education and Sports Sciences,Tehran University 5 Department of Community Medicine, Tehran University of Medical Sciences 6 Endocrine Research Center, Tehran University of Medical Sciences Introduction: Diabetes is a progressive chronic disease that affects various aspects of human life. Sedentary lifestyle and obesity are important risk factors of Diabetes Mellitus; therefore, lifestyle modification and exercise therapy has a crucial role in prevention and treatment of diabetes. In review of insufficient studies in this field in Iran, the objective of this research is to compare the effect of supervised group exercise therapy with home-based exercise therapy on quality of life in Iranian women with type 2 diabetes. Methods: One-hundred and two diabetic women were randomly enrolled in exercise program and divided in two groups; supervised and home-based group. All patients received diabetes education namely self-care, diet and the role of exercise as a component for disease control. Quality of life components (using the Short Form Health Survey (SF-36)), biochemistry tests (Total cholesterol, LDL, HDL, FBS, HbA1c) and anthropometric parameters (height, weight, waist circumference, BMI, skin folds) were assessed at first and after 6 weeks of study. The women registered in supervised group exercise therapy received eighteen sessions of strength training program for six weeks, also they were encouraged to perform their endurance exercise. The home- based group received educational booklet with administrating exercise program for exercising individually. To evaluate duration and intensity of daily walking, all patients were provided with Pedometer device. Mann-Whitney test was used to analyse the effect of exercise therapy on anthropometric parameters (weight, waist circumference, BMI, skin folds), biochemistry tests (Total cholesterol, LDL, HDL, FBS, HbA1c) and steps number, also using Paired sample T-test for analysing quality of life components. Results: Although, there was significant reduction in FBS and HBA1c (P < 0.05) in supervised group after intervention,we could not find any significant difference between supervised and home based group in fasting glucose, HbA1c, HDL cholesterol and LDL cholesterol levels. About psychometrics outcomes, supervised group compared to home based group showed better result in seven scales(physical functioning, physical role functioning, vitality, social role functioning, emotional role functioning, mental health) of Short Form Health Survey (SF-36) (P < 0.05). Discussion: These outcomes show the positive effect of supervised group exercise therapy on quality of life and better control of diabetes in short time period. If supervised group exercise program for diabetic patients continue for longer time period, Its effect on most assessed parameters in this research may be more significant than home based exercise program. http://dx.doi.org/10.1016/j.jsams.2012.11.399
Thursday 1 November Posters / Journal of Science and Medicine in Sport 15 (2012) S127–S187
pressure <140 mmHg systolic and <90 mmHg diastolic, fasting blood glucose <6.1 mmol/L, HDL cholesterol >0.9 mmol/L in males and >1.0 mmol/L in females, and fasting triglycerides <1.7 mmol/L Results: The cohort includes 2047 men and women aged 46–74 years of whom 1593 (77.8%; 95% CI 75.9%–79.6%) are overweight or obese. The overall prevalence of metabolically healthy overweight and obese in middle-aged Irish population is 34.2% (n = 700; 95% CI 32.1%–36.3%). The prevalence was higher in women (32%; 95% CI 29.2%–34.9%) than in men (36.3%; 95% CI 33.4%–39.3%). Among overweight and obese, moderate and high physical activity levels were significant predictors of metabolic health (OR = 1.47; 95% CI 1.15–1.88, OR = 1.40; 95% CI 1.07–1.83). In a multivariate model, adjusted for age, gender, smoking and education, both moderate and high physical activity remained significant predictors of metabolic health [OR 1.53; 95% CI 1.18–1.98 and OR 1.70; 95% CI 1.27–2.28]. Overweight and obese women were twice as likely to be metabolically healthy than overweight and obese men [OR 2.05; 95% CI 1.63–2.59]. Discussion: Physical activity provides protection against metabolic abnormalities among the overweight and obese. Current recommendations for physical activity should continue to be advised and further research should be undertaken in the area of physical activity and metabolic health. http://dx.doi.org/10.1016/j.jsams.2012.11.395 393 Identifying physically inactive Parkinson’s Disease patients M. Dontje 1,2,∗ , M. de Greef 3 , A. Speelman 4 , M. van Nimwegen 4 , W. Krijnen 1 , R. Stolk 2 , Y. Kamsma 3 , M. Munneke 4,5 , C. van der Schans 1 1
Hanze University of Applied Sciences, Research and Innovation Group in Health Care and Nursing, Groningen, The Netherlands 2 University of Groningen, University Medical Center Groningen, Department of Epidemiology, The Netherlands 3 University of Groningen, Center for Human Movement Sciences, The Netherlands 4 Radboud University Nijmegen Medical Center, Nijmegen Center for Evidence Based Practice, Department of Neurology, The Netherlands 5 Radboud University Nijmegen Medical Centre; Nijmegen Centre for Evidence Based Practice; Scientific Institute for Quality of Healthcare, the Netherlands Introduction: Daily physical activity is commonly measured with self-reports, but these include a risk for validity problems. In this study, Parkinson’s Disease (PD) patients were screened on the basis of their self-reported daily physical activity. Daily physical activity of patients who reported themselves to physically inactive was additionally measured in a performance-based way. The aim of this study was to examine the performance-based level of daily physical activity, thereby examining whether self-reports of daily physical activity are an appropriate tool to identify actual physically inactive PD patients. Methods: Daily physical activity of 586 PD patients, who reported themselves to be physically inactive, was measured with the Direct-Life accelerometer for 7 consecutive days. Primary outcome was daily energy expenditure in kilocalories. According to the 30-minutes daily physical activity guideline, the self-reported physically inactive patients were classified as ‘physically active’, ‘semi-active’ or ‘physically inactive’ based on their performancebased measurements. Results: In total, 329 patients had sufficient accelerometer data for further analyses. Median daily energy expenditure was 498 kcal
(IQR 280). Of these, 42.kcal (IQR 89) or 9.7 minutes (IQR 19.7) were spent on moderately intensive physical activities and 1.8 kcal (IQR 15.5) or 1.4 minutes (IQR 1.8) on vigorously intensive physical activities. Only one patient was physically active, 55 (17%) were semi-active and 273 (83%) were physically inactive. Discussion: Most PD patients who reported to be physically inactive, were able to make an appropriate estimation of their true daily physical activity level. This indicates that self-reported daily physical activity is a valid screening tool to identify actual physically inactive PD patients. http://dx.doi.org/10.1016/j.jsams.2012.11.396 394 Sedentary time, breaks in sedentary time, moderate-tovigorous physical activity and metabolic risk in young adults at high risk C. Edwardson 1,2,3,∗ , E. Wilmot 1,3,4 , T. Yates 1,4 , J. Henson 1,3 , T. Gorely 1,2 , M. Davies 1,3,4 , K. Khunti 1,5 , M. Nimmo 1,2 , S. Biddle 1,2 1
Leicester-Loughborough Lifestyle NIHR Biomedical Research Unit School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK 3 Leicester Diabetes Centre, Leicester General Hospital, University Hospitals of Leicester, UK 4 Department of Cardiovascular Sciences, University of Leicester, UK 5 Department of Health Sciences, University of Leicester, Leicester, UK 2
Introduction: Evidence suggests that sedentary behaviour is detrimental for health and this association may be independent of physical activity levels. Sedentary behaviour, however, has typically been measured using self-report and accelerometers. These methods have substantial limitations. Inclinometers are able to provide a more accurate assessment of sitting time by measuring body posture. Using inclinometers (activPALTM ) to measure sedentary behaviour and ActiGraph accelerometers to measure moderate-to-vigorous physical activity (MVPA), this study was to examined the association between objectively measured sedentary time, breaks in sedentary time, MVPA and metabolic risk in a sample of young adults identified as being at a high risk of developing type 2 diabetes. Methods: 82 women and 33 men (mean age 32.7 ± 5.6 years, mean; BMI 34.4 ± 5.1 kg/m2 ) were recruited from general practices based on known risk factors such as obesity. Sedentary (sitting/lying activity) time and breaks in sedentary time were measured using the activPALTM inclinometer. MVPA was assessed by ActiGraph accelerometer. Both devices were worn for 10 consecutive days. Fasting plasma glucose, 2-h plasma glucose (measured using an oral glucose tolerance test), waist circumference, blood pressure, and blood lipids were measured using standardised criteria. Linear regression models (adjusted for age, gender, ethnicity, smoking status, social deprivation) examined the associations of sedentary time, breaks in sedentary time, MVPA and metabolic risk variables Results: Sedentary time was positively associated with 2h plasma glucose (=0.22, p = 0.026), triacylglycerols (=0.19, p = 0.037) and total cholesterol (=0.19, p = 0.046). However, after further adjustment for MVPA models were no longer statistically significant. Breaks in sedentary time were not associated with any metabolic risk factors. MVPA was negatively associated with fasting plasma glucose (=-0.20, p = 0.042), triacylglycerols (=-0.31, p = 0.001), systolic blood pressure (=-0.22, p = 0.012) and diastolic blood pressure (=-0.34, p = 0.001). After further adjustment for sedentary time and BMI, all associations remained significant
Thursday 1 November Posters / Journal of Science and Medicine in Sport 15 (2012) S127–S187
(=-0.30, p = 0.002; =-0.29, p = 0.005; =-0.23, p = 0.018; =-0.31, p = 0.003 respectively). Discussion: These results suggest that sedentary time is linked to metabolic risk factors but this relationship is not independent of MVPA in this young at risk population. MVPA was strongly linked to metabolic risk and suggests the promotion of physical activity should remain the primary focus in this population.
396
http://dx.doi.org/10.1016/j.jsams.2012.11.397
1
395 The DALICO Study R. Ekesbo 1,∗ , E. Stenman 1 , M. Leijon 1 , K. Sundquist 1 , S. Calling 1 , C. Bergmark 2 , U. Gerdtham 3 1
Centre of Primary Health Care Research, Lund University Dalby Health Care Centre, Dalby, Sweden 3 Dept of Health Economics, Lund University 2
Introduction: Physical activity as a treatment is gravely underused in health care. One problem is determining the appropriate level of activity for the individual patient; another is maintaining activity over time. We have chosen to introduce a computer-based questionnaire to give the health-care provider a better overview of the patient’s health status, activity level and motivation to change. This information will enable the care-giver (physiotherapist, psychologist, physician, etc.) to tailor the intervention to his/her patients. The primary aim is to monitor the effect of intervention on physical activity (measured in met-minutes) and to detect changes in metabolism over time. An additional major goal is to postpone medical treatment. Methods: At the health care centre in Dalby, Sweden, patients with newly diagnosed hypertension or type II diabetes are being continually enrolled in the study. All participants undergo 24-h ambulatory blood pressure monitoring. A parallel group at a nearby health care centre constitutes a control group. Participants are asked to fill in a questionnaire assessing levels of physical activity and attitudes towards physical activity, and undergo a 6-minute walking test as basic data for physical fitness. Following this, motivational interviewing by specially trained staff takes place, e.g. to identify hindrance for physical activity. Clinical data (blood pressure, ECG, lab tests) and data on quality of life are also being collected. Results: As of March 2012, 33 patients had been recruited to the study (27 in the intervention group and 6 in the control group). 15 patients declined to participate, in most cases due to lack of time. 2 patients dropped out of the study because of difficulty completing the computer interview. We have encountered no problems with patients’ ability to follow the protocol. At the time of writing, individual patients had participated in the study for up to 15 months. All patients who have participated for 6 months or longer have reported increased physical activity, regardless of the activity level at the start of the study. Discussion: The intervention may improve disease control and quality of life, and reduce medication costs. Our results further suggest that physical activity can be a treatment method in many conditions, and thus highlight its importance. A health economics analysis will follow, possibly showing better health economics overall with this treatment concept. However, additional scientific evidence is needed before physical activity can be used as a treatment method within the entire health care system. http://dx.doi.org/10.1016/j.jsams.2012.11.398
S163
The effect of exercise consultation and exercise therapy on quality of life in women with type 2 diabetes: A randomized clinical trial S. Firouzinezhad 1,∗ , H. Dadgostar 2,∗ , M. Ansari 3 , A. 4 5 3 Mahmoudpour , M. Moradi-Lakeh , G. Radmehr , M. Khamseh 6 Department of Sports and Exercise Medicine, Hazrat Rasool Akram Hospital, Tehran, Iran 2 Department of Sports and Exercise Medicine,Tehran University of Medical Scienses 3 Sports Medicine Research Center, Tehran University of Medical Sciences 4 Department of Physical Education and Sports Sciences,Tehran University 5 Department of Community Medicine, Tehran University of Medical Sciences 6 Endocrine Research Center, Tehran University of Medical Sciences Introduction: Diabetes is a progressive chronic disease that affects various aspects of human life. Sedentary lifestyle and obesity are important risk factors of Diabetes Mellitus; therefore, lifestyle modification and exercise therapy has a crucial role in prevention and treatment of diabetes. In review of insufficient studies in this field in Iran, the objective of this research is to compare the effect of supervised group exercise therapy with home-based exercise therapy on quality of life in Iranian women with type 2 diabetes. Methods: One-hundred and two diabetic women were randomly enrolled in exercise program and divided in two groups; supervised and home-based group. All patients received diabetes education namely self-care, diet and the role of exercise as a component for disease control. Quality of life components (using the Short Form Health Survey (SF-36)), biochemistry tests (Total cholesterol, LDL, HDL, FBS, HbA1c) and anthropometric parameters (height, weight, waist circumference, BMI, skin folds) were assessed at first and after 6 weeks of study. The women registered in supervised group exercise therapy received eighteen sessions of strength training program for six weeks, also they were encouraged to perform their endurance exercise. The home- based group received educational booklet with administrating exercise program for exercising individually. To evaluate duration and intensity of daily walking, all patients were provided with Pedometer device. Mann-Whitney test was used to analyse the effect of exercise therapy on anthropometric parameters (weight, waist circumference, BMI, skin folds), biochemistry tests (Total cholesterol, LDL, HDL, FBS, HbA1c) and steps number, also using Paired sample T-test for analysing quality of life components. Results: Although, there was significant reduction in FBS and HBA1c (P < 0.05) in supervised group after intervention,we could not find any significant difference between supervised and home based group in fasting glucose, HbA1c, HDL cholesterol and LDL cholesterol levels. About psychometrics outcomes, supervised group compared to home based group showed better result in seven scales(physical functioning, physical role functioning, vitality, social role functioning, emotional role functioning, mental health) of Short Form Health Survey (SF-36) (P < 0.05). Discussion: These outcomes show the positive effect of supervised group exercise therapy on quality of life and better control of diabetes in short time period. If supervised group exercise program for diabetic patients continue for longer time period, Its effect on most assessed parameters in this research may be more significant than home based exercise program. http://dx.doi.org/10.1016/j.jsams.2012.11.399