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Running head: ENDURANCE EXERCISE BASED TEST
Effect of standard land based endurance exercise versus pool based exercise
on pain and fitness in patients with cardiac disease and osteoarthritis
Name
Institution:
Date:
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Abstract
The study used a sample population N = 18 whereby 9 represented the land based therapy
groups and the other 9 represented the poll base therapy grouped. Poll based therapy registered
higher mean results changes as compared to land based and hence was found to be more
effective than land based therapies. Additionally, it was established that both positively impact
on management of pain and fitness for patients suffering fro osteoarthritis and cardiac disease.
Further the study also established that no tangible evidence exist which could link the exercise
successes to either gender. Rather, there is a uniform effect across all the gender.
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Table of Contents
Abstract ...................................................................................................................................... 2Introduction ................................................................................................................................ 4Statement of the problem ............................................................................................................ 6Research questions ...................................................................................................................... 6Objective and hypothesis of study ............................................................................................... 7Literature review ......................................................................................................................... 8
Background information ......................................................................................................... 8Clinically most important effects of exercise therapy and the size of effects ............................ 9Cardiovascular diseases......................................................................................................... 10Postoperative Outcomes ........................................................................................................ 12Literature gaps ...................................................................................................................... 12
Research methodology .............................................................................................................. 13Methods ................................................................................................................................ 13
Subjects............................................................................................................................. 13Design ............................................................................................................................... 13Timeline ............................................................................................................................ 14Specific Procedures ........................................................................................................... 14
Data Analysis............................................................................................................................ 16Discussion and conclusion ........................................................................................................ 19
Discussion............................................................................................................................. 19Conclusion ............................................................................................................................ 19
References ................................................................................................................................ 21
Appendix 1: Tabulated data ...................................................................................................... 23Appendix 2: Independent sample test results ............................................................................. 24
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Introduction
Cardiac disease and osteoarthritis are considered chronic diseases. Such diseases have
limited treatment resources within the healthcare system. Benefits arising from exercise therapy
in management of the diseases ranks among the widely researched areas within the field in the
recent past. Most researchers have emphasized on the importance of conducting randomized
controlled clinical trials in order to draw conclusive evidence on the success of these treatments.
Plausible recognition of such benefits can only be ascertained through identification of the
benefits associated with the same. The importance of exercise to such patients cannot be
underestimated more so considering that exercise related complications often plague the patients.
Guidelines for safe training programs is therefore of necessity (MacWilliam, 1996). However,
little research has been conducted as to the forms of exercise therapy which yield best results. A
case of interest is the effect of standard land based endurance exercise versus pool based
exercise) on pain and fitness in patients with cardiac disease and osteoarthritis.
Exercise therapy for chronic illness like cardiac disease and osteoarthritis are most
condition specific or aerobic. An example of such a test is the generalized aerobic training which
causes systematic effects e.g. insulin sensitivity enhancement in management of diabetes
mellitus. Condition specific training on the other hand includes specific designed movements
aimed at enhancing physical health of patients. These include low back strengthening exercises
for patients with low back pain. Generally, the recent past has seen a sharp increase in
randomized clinical trials aimed at widening the understanding of physical exercise therapies in
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a number of subjective symptoms ranging from sleep problems, general fatigue, joints stiffness,
gastrointestinal problems as well as depression and anxiety. In the recent past, these conditions
have been more common and of concern to clinical practitioners. In Norway for instance, a large
female population aged between 20 and 49 (13%) were found to suffer conditions characteristic
of broad pain and general fatigue resulting from either osteoarthritis or cardiac disease (Kettunen
& Kujala, 2004). The etiology and pathogenesis of these ailments remain rather vague hence
making it almost impossible to effect causal treatments. Symptomatic treatments employed
including sedatives and anti-depressants are often associated with pain modulation impacts.
Various pharmacological and non-medical management options have been attempted and various
studies indicate that aerobic exercise programs successfully enhance patients physical capacity.
Such exercises were also found to modulate pain and fatigue suffered by the aforementioned
group of patients.
It is on the above mentioned basis that patient rehabilitation programs in management of
osteoarthritis and cardiac disease have incorporated exercise based approaches. Clinical
experiences indicate that patients suffering the aforementioned conditions often prefer exercising
in warm water pools. Various researchers have likewise suggested a number of benefits
associated with pool-based aerobic exercise. However, aerobic exercise impacts have mostly
been reported in reference to land based exercise. Whether or not better effects are achieved
through poll based training remains rather vague and not widely researched on. This study aims
to assess the differences in efficacy of subjecting patients to pool-based and land-based aerobic
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Statement of the problem
An increasing number of patients suffering from osteoarthritis and cardiac diseases are
recorded each year. Estimates indicate that the current numbers could double by 2016 (Jones,
2008). The increase is attributed to aging effects, prosthetic advancements and an enlarged
population of young persons undergoing operations. Long waits of person awaiting hip or knee
joint replacements have been recorded across various countries globally. These people
experience high pain levels as they await the procedure. The pain profoundly affects the quality
of life they live. In some instances, the pain is believed to increase disability of the affected
parties. The importance of engaging practices which could effectively lower such pains is of
profound importance. Few studies have successfully demonstrated the best approach with regard
to land based and poll based aerobic exercises. However various researchers and medical
scholars acknowledge that patients have demonstrated positive results after being placed on
exercise based interventions. The optimal content of these interventions however remain
uncertain and in dire need of research. Limited studies have compared land-based and pool-
based exercise, and hence little is known regarding the differences associated with the effects of
the two. Research in this area is therefore critical to improvement of preoperative and
management procedures of those suffering osteoarthritis and cardiac disease.
Research questionsTo effectively ascertain or reject the hypothesis, this study will seek to answer the
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2. Is land based therapy more effective than poll based therapy in treatment of patients
with osteoarthritis and coronary disease?
3. Does the effect of exercise treatment differ across gender?
Objective and hypothesis of study
With much elaborated in stating the problem to be addressed by this study, its aim will
simply be determination whether land based exercise is more effective than poll based exercise
in pain and fitness management in patients suffering from osteoarthritis and cardiac disease.
Study hypothesis will therefore be stated as follows:
Land-based exercise aerobic exercise yields better results than pool-based aerobic
exercise in pain and fitness management for patients suffering from osteoarthritis and cardiac
disease.
This will be the null hypothesis; the alternative hypothesis will state that:
Pool-based exercise aerobic exercise yields better results than land-based aerobic
exercise in pain and fitness management for patients suffering from osteoarthritis and cardiac
disease.
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Literature review
Background information
Various published and unpublished literature materials exist on exercise therapy in
management of osteoarthritis and cardiac disease (Metsios et al, 2008). Most such research is
based systematic evaluation of randomized clinical trials investigating the impact of exercise
therapy amongst patients suffering from chronic ailments (Takken, 2008; Bartels et al., 2007;
Kettunen & Kujala, 2004). Most findings as mentioned earlier, lack statistical power to support
their findings and have hence been deemed as weak in authority. Systematic reviews however
recognize and appreciate the use of both qualitative and quantitative techniques in drawing
conclusions with respect to area of study. The choice of technique to adopt is often dependent on
the data intended for study. What is however clear, is the fact that researchers in this field have
used cross-cutting analysis techniques in statistical polling of their findings. While in most
similar researches evidential systematic reporting lacks, exercise therapy effects have often been
reported using specific meta-analyses. Various scholars have emphasized the critical importance
attached to choice of summary meta-analyses statistics and hence methodological quality. It is
also important to mention that various researches have produced biased results as a result of
poorly designed and reported trials which have ultimately misled policy makers within the
medical field. This section takes the reader through a series of existing literature opinions and
findings with respect to the area of study. It is important to reiterate that final conclusions will
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Clinically most important effects of exercise therapy and the size of effects
Exercise therapy positively affects peoples physical health via specific disease treatment
approaches. A consistent approach shown by evaluation of various researches conducted to date
indicate that aerobic capacity and functionality as well as muscle strength capacity can be great
enhanced through incorporation of exercise training among patients suffering from chronic
ailments (MacWilliam, 1996); Metsios et al.: 2008; Takken, 2008; Lloyd-Williams, Mair &
Leitner, 2009). This is a finding critical to medical practitioners considering that the proportion of
aged person sis increasing and exercise therapy could play a fundamental role in reducing
disability and dependency with community. Discovery that aerobic training exercises
consistently enhances physical performance capability in addition to maximizing oxygen intake
capacity amongst chronically ill patients is important in re-designing of management initiatives
of various illnesses. It is important to mention that low aerobic fitness has often been mentioned
as a leading cause of mortality amongst chronically ill patients. The same is true amongst healthy
people. According to Jones (2008) Intensive training is effective in improving physical health
and fitness amongst patients suffering from osteoarthritis and cardiac ailment as well as healthy
persons. However, little research have yet specified the intensity of training that would be
appropriate for long term prognosis of the aforementioned ailments. Research has also
established that other cardio-metabolic risk factors are also beneficiaries of such trainings
(Roddy, Zhang, & Doherty, 2009; Lange, 2008; Bartels et al., 2007; Kettunen & Kujala, 2004).
Perhaps of interest is the discovery that visceral fat among adults and childrens body fat are
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Various literatures have however offered vital information regarding effects of the two
approaches in management/treatment of cardiac disease and osteoarthritis.
Cardiovascular diseases
Based on findings of Joliife et al, (2006), exercise therapy successfully reduces effect of
coronary heart disease and hence all cause mortality by up to 27% and up to 31% for total
cardiac mortality. However, he mentions that the same can not be said for non-fatal myocardial
infarction. In another research by Taylor et al (2004), it was established that the effect of
endurance trainings alongside psychological and educational dissemination confirmed the
findings by Joliife et al. this is in respect to exercise based rehabilitation and cardiac mortality
evaluations. Reviewing 16 other RCT based research resources indicated that exercise
training/therapy enhanced heart rate variability amongst patients diagnosed with heart failure
problems.
An evaluation of 14 clinical trial results showed positive effect of physical training
among cardiac disease and osteoarthritis patients. However, two of the trials returned
inconclusive results. Their interpretations were however biased towards positive effect based on
the findings of majority of the trials reviewed. It is important to mention that most researches are
based on findings from patients with no co-existing illnesses i.e. either predominantly suffering
from osteoarthritis only or cardiac disease alone. In a similar study by Rees et al. (2007) the
findings confirmed the earlier assumption that exercise training enhances uptake of oxygen
h i ll ill i I ddi i k h d l f d h bi
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Despite the inconsistent findings recorded in Smart and Marwicks research, most
research works on aerobic physical exercise on intermittent claudication have shown that training
exercises improves the overall physical conditions of patients suffering from cardiac disease.
The general resulting scenario is that aerobic exercise improves patients pain management and
overall fitness on patients suffering cardiac disease (Fransen, McConnell, & Bell, 2008).
Osteoarthritis
A review of 32 RCT statistics based research indicate that land based exercise improved
management to patient self-reported pain as well as physical fitness of patients suffering from
osteoarthritis. More positive effects are recorded in cases where aerobic exercise is used as an
intervention with increased number of supervision sessions compared to non-supervised sessions. On
most researches, aerobic walking and low limb strengthening, alleviated pain and positively impacted
on patients overall fitness. Additionally, the effect recorded in management of hip osteoarthritis
showed similar results to case of knee osteoarthritis. In a rather unique research by Roddy, Zhang &
Doherty (2009), where land based exercise was compared to aquatic exercise, the effects were rather
similar. However no research has been able to offer conclusive evidence as to the effect of exercise
on osteoarthritis progression.
Based on more than 10 RCTs, a conclusion is drawn that exercise therapy successfully
enhances aerobic capacity alongside muscle strength in patients diagnosed with rheumatoid arthritis.
However, appropriate meta-analyses on the same are lacking. In another study based on patients
b l 18 ld d j il idi thi th iti i th f d t f ll
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Whether or not this is true remains an issue that other researches will address in future. However, it is
important to mention a few perspectives held by previous researches touching on the issue.
Postoperative Outcomes
Various medical studies have established that post-operative procedures are influenced by
preoperative procedures. However, most studies have filed to provide adequate information to
support the assumption that preoperative procedures are influenced by aerobic exercises.
However, as logic would dictate, oxygen intake and general body fitness determine post-
operational outcomes and often medics would want someone to be in the best of their health
prior to operation.
Literature gaps
Critical review of literature on land based and aquatic based aerobic therapy reveal a gap
in distinguishing of the individual effects of the procedures. Most if not all the research identified
and evaluated treat the two approaches from a single perspective and hence policy decisions on
which should be given more priority is likely to suffer information inadequacy. The effect of
each approach need to be independently studied and conclusive evidence utilized to back up
conclusions drawn.
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Research methodology
Methods
As earlier mentioned, this research aims to come up with conclusive meta-analyses of the
impact of land-based aerobic exercise in comparison to pool-based aerobic exercise on patients
with cardiac disease and osteoarthritis. To achieve this, a study sample is selected and
appropriate method of conducting the research and analysis are chosen prior to the study as
discussed hereafter.
Subjects
The study involves a parallel group design. The groups are pool-based group of patients
and land-based group. The finings of each group are compared against each other and used to
draw conclusion as to whether the hypothesis stands or not.
Design
Noting that there existed a possibility of some variations, the mean of the two
assessments was considered a more valid approach as compared to a single assessment. Patients
suffering from the two conditions were identified and grouped according to their respective
conditions; the patients were then subjected to respective exercise trainings where one group
underwent poll-based aerobic therapy while the other group underwent land-based aerobic
therapy. The research variables used in the study were identified as shown below:
I d d t i bl
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Pool based endurance exercise
Dependent Variables:
The dependent variables were identified as pain which was measured by the 10cm visual
analog (VAS) and maximal oxygen consumption which was measured using the maximal;
treadmill stress test (MaxVO2).
Pain was measured prior to implementation of respective exercises (PrePain) and after
conclusion of the exercise period (Post pain). Likewise, maximal oxygen consumption was
measured prior to implementation of respective therapy (PreVO2) and after implementation
(PostVO2).
Timeline
The study was run for a period of 20 weeks. Patients were examined at commencement of
the study after which they were subjected to respective therapies. One group underwent pool-
based therapy while the other group underwent land-based therapy. Each group consisted of a set
of patients constituting of 0steathritis patients and cardiac disease patients. The patients were re-
examined at the end of the 20 weeks and the obtained results documented (see attached appendix
1). For consistency, all patients were examined and re-examine by the same physiotherapist.
Specific Procedures
A number of procedures were initiated in order to make data collection and eventually
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unique numbers rather than their individual names. The physiotherapist was then invited to
conduct a post-therapy analysis of the state of patients with respect to pain and maximal oxygen
consumption. 10cm Vas and maximal treadmill tests were applied in measurement of pain and
oxygen consumption respectively. Once the data has been obtained, descriptive statistics will be
used to present eth overall case scenario disregarding the effect the effect of land or pool therapy.
However, a further independent t-test analysis will be performed to determine the individual
effect record for each individual therapy.
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Data Analysis
SPSS 17 data analysis tool pack was used in evaluation of data with respect to the
aforementioned variables.
Table 1: Overall Descriptive results
Descriptive Statistics
N Minimum Maximum Mean Std. Deviation
PrePain 18 4 8 5.72 1.074
PostPain 18 1 5 2.94 1.056
PreVO2 18 11 17 13.64 1.413
PostVO2 18 13.100 18.800 15.95000 1.593830
Valid N (listwise) 18
The descriptive statistics provide the overall results of the research irrespective of the aerobic
exercise method adopted. It generally confirms the findings of previous research. The mean of
pain recorded prior to introduction of the exercises amongst the patients is 5.72. After
implementation of the exercise, the overall mean of pain recorded reduces to 2.94. This confirms
that exercise reduces pain in patients suffering from osteoarthritis and cardiac disease. In terms
of oxygen, the recorded value prior to implementation of the exercise is 13.64, a value that rise to
15.95 after implementation of the exercise. This one too confirms the findings of previous
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Table 2: Group Statistics Presentation
Group Statistics
Group N Mean Std. Deviation Std. Error Mean
PrePain Land based therapy 9 5.67 1.000 .333
Pool based therapy 9 5.78 1.202 .401
PostPain Land based therapy 9 3.78 .667 .222
Pool based therapy 9 2.11 .601 .200
PreVO2 Land based therapy 9 13.50 1.675 .558
Pool based therapy 9 13.78 1.182 .394
PostVO2 Land based therapy 9 15.12222 1.556260 .518753
Pool based therapy 9 16.77778 1.197683 .399228
The table abode reflects the findings of t-test using SPSS data pack. Mena comparison of
the two therapies are provides. For land-based therapy, prior to implementation, the recorded
means are 5.67 and 13.50 for pre-pain and preVO2 respectively. After implementation, the
values change to 3.78 and 15.122 for pre-pain and preVO2 respectively. Both record positive
outcomes. The same case is witnessed for pool based therapy where prior to implementation
values of 5.78 and 13.50 are recorded for pre-pain and preVO2 respectively. After
implementation the values change to 2.11 and 16.778 pre-pain and preVO2 respectively.
Generally from this presentation, it is evident that pool-based therapy has been able to yield
better results as compared to land-based therapy despite both producing positive results.
Addi i ll h l i h h b i d l i ifi 955 fid
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Table 3: Gender Based Group Statistics
Group Statistics
Gender N Mean Std. Deviation Std. Error Mean
PrePain Male 9 5.33 .500 .167
Female 9 6.11 1.364 .455
PostPain Male 9 2.89 1.054 .351
Female 9 3.00 1.118 .373
PreVO2 Male 9 13.31 .865 .288
Female 9 13.97 1.804 .601
PostVO2 Male 9 15.77778 1.247776 .415925
Female 9 16.12222 1.942793 .647598
While females record higher levels of pain compared to men, they record relatively
higher maximal oxygen circulation. The impact of the exercise though, offers no clear
distinctions as to which groups gains more from exercise. However, one thing that is clear is the
fact that exercise based therapy is effective irrespective of gender affiliation.
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Discussion and conclusion
DiscussionThe findings of statistical analysis confirm earlier stated findings by other researchers
that exercise be it pool-based or land based yields positive results on both patients fitness and
patients. Exercise therapy positively impacts of patient pain management and general fitness
measured by oxygen uptake for purposes of this papers evaluation. The findings are consistent
with previous researches findings. However they bridge the gap that earlier researches have
failed to highlight by creating a distinction between the impacts of pool based therapy against
that of land based therapy. Pool based therapy yields better results. Something of which may be
attributed to patients attitude as earlier it had been mentioned that it was the patients preference.
The finding goes against earlier stated hypothesis that land based therapy yield better results than
pool based therapy. We therefore discard the null hypothesis and adopt the alternative hypothesis
which in this case will read as follows: Pool based therapy yields better results in management of
pain and general fitness of patients diagnosed with osteoarthritis and cardiac disease.
ConclusionIt is important to conclude by mentioning that the research other than expanding what
other researchers have provides a reference point for comparison of the dependent effect of
individual therapies. It recommends a common adoption of pool based therapy over land based
therapies perhaps based on the attitudes associated with the same. The reverence of pool based
therapy by most patients seems to play a fundamental role in realization of the goal of therapy.
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the alternative hypothesis. In general though, exercise in treatment and management of chronic
illnesses is an interesting area that would still require vast research.
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References
Altman, D. et al. (2004).The revised CONSORT statement for reporting randomized trials:
Explanation and elaboration.Ann Intern Med, 43(4), pp.134:663-94.
Bartels, E. et al. (2007). Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane
Database Syst Rev, (4).
Fransen, M., McConnell, S., & Bell M. (2008). Exercise for osteoarthritis of the hip or knee.
Cochrane Database Syst Rev, 4(5), pp 456-476.
Jolliffe, J. et al. (2006). Exercise-based rehabilitation for coronary heart disease. Cochrane Database
Syst Rev, 1.
Jones, C. A, et al. (2008). Health related quality of life outcomes after knee arthroplasties and
cardiac management in a community based population.Journal of Rheumatology, 27(3),
pp. 1745-52.
Kettunen J. & Kujala, U. M. (2004). Exercise therapy for people with rheumatoid arthritis and
osteoarthritis. Scand J Med Sci Sports, 14, pp. 138-42.
Kujala, U. (2004). Evidence for exercise therapy in the treatment of chronic disease based on at least
three randomized controlled trials summary of published systematic reviews. Scand J Med
Sci Sports, 14, pp. 339-45.
Lange, A. (2008). Strength training for treatment of osteoarthritis of the knee: A systematic review.
Arthritis Rheum.Arthritis Care & Research Journal, 59, pp. 1488-94.
Lloyd-Williams, F., Mair F. S., & Leitner, M. (2009). Exercise training and heart failure: a
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Appendix 1: Tabulated data
Group Age Height Weight Gender CardDx 2Dx PrePain PostPain PreVO2 PostVO2
1 66 69 188 1 1 4 5 3 12.2 13.91 78 63 150 2 1 4 6 4 11.4 13.1
1 65 62 122 2 2 4 4 3 14.5 16.6
1 69 64 154 2 3 4 7 4 12.2 13.51 71 68 188 1 1 4 6 5 13.1 14.9
1 73 70 207 1 2 4 5 4 15.1 17.1
1 65 60 111 2 2 4 7 4 16.5 17.31 79 63 136 2 3 4 6 4 14.2 15.1
1 81 71 191 1 2 4 5 3 12.3 14.62 65 68 190 1 1 4 6 2 13.5 15.9
2 77 64 149 2 1 4 7 3 16.5 18.8
2 68 62 120 2 1 4 6 2 14.1 17.5
2 65 66 155 2 2 4 8 1 12.2 15.6
2 73 70 185 1 2 4 6 3 13.5 16.62 72 71 201 1 3 4 5 2 13.4 17.7
2 80 62 110 2 3 4 4 2 14.1 17.6
2 80 69 134 1 2 4 5 2 12.9 16.2
2 66 70 195 1 1 4 5 2 13.8 15.1
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Appendix 2: Independent sample test results
Independent Samples Test
Levene's Test for
Equality of
Variances t-test for Equality of Means
95% Confidence Interval
of the Difference
F Sig. t df Sig. (2-tailed) Mean Diff.e Std. Error Diff. Lower Upper
PrePain Equal variances
assumed
.116 .738 -.213 16 .834 -.111 .521 -1.216 .994
Equal variances not
assumed
-.213 15.488 .834 -.111 .521 -1.219 .997
PostPain Equal variances
assumed
.419 .527 5.571 16 .000 1.667 .299 1.032 2.301
Equal variances not
assumed
5.571 15.831 .000 1.667 .299 1.032 2.301
PreVO2 Equal variances
assumed
2.772 .115 -.407 16 .690 -.278 .683 -1.726 1.171
Equal variances not
assumed
-.407 14.385 .690 -.278 .683 -1.740 1.184
PostVO2 Equal variances
assumed
.598 .451 -2.529 16 .022 -1.655556 .654590 -3.043224 -.267887
Equal variances not
assumed
-2.529 15.015 .023 -1.655556 .654590 -3.050656 -.260455