Obesity is one of the most important health problems in both developing and developed countries   . Prevalence of obesity, particularly in children and adolescents, has gradually increased in recent years    .
Excess of weight leads to more stress on musculoskeletal system and this causes both musculoskeletal injuries and postural deformities   . Motor performances of children are also negatively affected by excess weight  . In- adequate physical activity of overweight children leads to impaired postural control so more extremity injuries and more fractures are observed in this population    . As a result of these issues, overweight and obese children have lower level of health related QoL than their peers with normal weight  .
Within the obesity treatment, planning a diet program and increasing physical activity are the basic approaches. Inactive life in childhood may cause various problems like obesity and cardiovasculary diseases. A new diagnosis called “Ex- ercise-Deficit Disorder” has been generated to emphasize this life style  . Par- ticipating in physical activity alone will not be a sufficient intervention to pre- vent or treat childhood obesity. However, it may support weight loss and de- crease cardiovasculary risk in the case of obesity   .
When the roles of physiotherapists in managing childhood obesity are inves- tigated, they treat the pain developing from musculoskeletal system of obese children, try to prevent postural problems and plan effective exercise programs  . Doing regular exercise contributes to treat childhood obesity and to solve the problems coming from obesity such as, musculoskeletal problems and low level of QoL   .
Group exercises had positive effects on metabolic risks and cardiorespiratory fitness of obese children. Moreover, when group exercise was conducted ac- companied with the music, children were found to be more physically active  .
Furthermore, Kuni et al. stated that postural control of overweight children was improved by the combination of ball games and diet program  . Among many team sport branches, basketball can be popularly played by both genders and various motor skills like endurance, strength and speed can be improved by playing it   . Elsayed (2014) included 12 obese and overweight children in basketball group and included 12 peers in control group and revealed that body composition and motor skills significantly increased in the basketball group, while no change was determined in their control group  . They did not inves- tigate the effects of basketball on QoL of these children.
The roles of active physiotherapy programs and sport programs on the mana- gement of the problems arising from childhood obesity should be determined. Although the effects of exercise and various sport branches on decrease obesity and obesity related problems were discussed, the effects of group exercises man- aged by physiotherapists and team sports on QoL of obese children are not clear. This study aims to compare the effects of physiotherapy group exercise and bas- ketball education on the level of QoL of these children.
2. Materials and Methods
Six primary state schools which were close to the research area were included to provide regular participation of all children. The parents and their childen aged 10 years old were asked to permit the height and weight measurements. After the Body Mass Index values were obtained, 81 children were found to be adequate to be invited.
The inclusion criteria were as follows (1) children who were born in 2006, (2) children whose BMI values were ≥95. Percentiles, (3) a report which was given by a doctor states that the child could participate in aerobic exercise, (4) children who had not continued to a diet program for 3 months, (5) children who had not participated regularly in any sport or exercise for 6 months. The children who had any disease requiring use of medicine, who had any pain preventing doing exercise or sport, and who had any neuromuscular disease were excluded from the study. A flowchart of the participation of children in the study is shown in Figure 1.
45 children (25 girls, 20 boys) were found to be appropriate to participate in the study and were assessed in the same week. Informed consent approved by the Hacettepe University Ethical Committee (registration number GO 16/53) was obtained from both the child and the parents of each child. Following the first assessments, children were randomly distributed to the physiotherapy group, basketball group, and control group.
During the 12-week intervention, one child from the physiotherapy and two children from the basketball left the programs because of their intensive school program. Therefore, 13 children in each group completed the intervention dura- tion and 42 children, in total, were reassessed in the end of 12 weeks.
Demographic characteristics of children and information about using the tech- nological devices were recorded.
Health related QoL of the children were assessed using the PedsQL-Child Form  . The inventory has 23 items and its subheadings are physical health, emo- tional functioning, social functioning, and school functioning. The score ranges from 0 to 100 and high scores indicate the high level of QoL  . Its Turkish re- liability and validity were shown in the study by Memik et al  . The ques- tionnaire was translated by three investigators and the internal reliability of the physical health, emotional functioning, social functioning, and school function- ing subheadings was r = 0.737, r = 0.687, r = 0.663, and r = 0.591, respectively.
Figure 1. The flowchart of children’s participation.
The physiotherapy group exercises and basketball program continued 12 weeks  . Both interventions continued 60 minutes, 3 times a week. “Participa- tion Certificates” were presented in randomly chosen intervention day of every week to children in order to motivate their participation in their physical activi- ty.
2.3. Group Exercise Program Accompanied by Physiotherapist
Theraband and exercise mat were used as materials in the exercises. The colors of the therabands changed every four week. “Yellow” was the beginning thera- band and used in the first four weeks. “Red” theraband was used during 4 - 8 weeks and “green” was the color of theraband during last four weeks. Repetition numbers of exercises were 8 - 10 in the first four weeks and were then increased to 12 - 15. Exercises were conducted accompanying with the music.
In the first 15 minute, children were asked to move their shoulders, knees, fingers, feet and to jogging in place, jumping like shooting a basket to motivate aerobic activity. The songs like “shoulder-knees and toes” were chosen for the beginning exercises. Then, the second part of the group exercise session lasted 35 minutes. The gastrocnemius and quadriceps femoris muscles were stretched. Various standing positions like Tandem or single leg were used to improve bal- ance. After standing position, children were asked to take their personal mats and therabands and body weight were used to strength muscles. At the end of the session, children were asked to stretch the muscles of columna vertebralis, neck muscles and lumbar extansors, and to do breathing exercises so cooling down was provided during 10 minutes.
2.4. Basketball Education
Basketball education was given to the children by a specialist trainer. Basketball trainer created the program by using the literature related to obese children  .
10 minute running and stretching were conducted for both warming and cooling in the beginning and ending of every session. Pass Exercises, Dribble exercises, Defence, Stopping exercises, Shot exercises, Weave, Drill, Fast Break, Attack exercises, and Game were taught to the children.
2.5. Control Group
16 obese children who did not participate in any physical activity during 12 weeks were included in the control group and they were assessed before and af- ter 12 weeks
3. Statistical Analysis
SPSS 19 statistical software package (IBM SPSS Statistics 19, SPSS inc., an IBM Co., Somers, NY) was used for statistical analysis. Difference at p < 0.05 level was considered to be statistically significant. Mean ± Standard Deviation (X ± SD) was used to indicate the continuous variables acquired by the measurements. Percentage (%) was calculated to indicate the descriptive variables. Since the data was normally distributed, One Way Variance Analysis was used to compare the variables among groups. Dependent t test was also conducted to compare the results within the groups over time.
45 children participated in the study. The groups were not homogeny according to the gender (p < 0.05). No significant difference was found in the technological use of the children (p > 0.05) (Table 1). 34 of 45 children regularly used techno- logical devices and most of them used them to play game and follow social me- dia.
The BMI values were calculated as 25.83 ± 2.76 kg/m2 in physiotherapy group, 25.05 ± 2.77 kg/m2 in basketball group, and 25.12 ± 2.79 kg/m2 in control group. The groups were found to be homogeny with these beginning values (p = 0.708).
Table 2 shows the beginning scores of the quality of life of children which were similar among groups (p > 0.05). The lowest scores were acquired from the “emotional functioning” subheading of all groups.
When the results were observed within groups following 12-week interven- tion, there was significant increases in the physical health (p = 0.001) and emo- tional functioning (p = 0.007) subheadings of the PedsQL in the group of physiotherapy (Table 3). Except this result, no significant changes were found in both basketball and control groups (p > 0.05) (Table 3). The children in the basketball group had slight decreases in the physical health, emotional function- ing and school functioning, whereas there was a slight decrease in physical health of children of the control group.
When the groups were compared following 12 weeks, no difference was found in any subheading of PedsQL (p > 0.05) (Table 4).
Table 1. Sociodemographic information of the groups.
Table 2. Comparison of the quality of life of the groups before 12 weeks.
Table 3. Comparison of the quality of life within the groups before and after 12 weeks.
Table 4. Comparison of the quality of life of the groups after 12 weeks.
The parents of overweight and obese children were asked to motivate their chil- dren be more physically active, but no adequate information about the most ap- propriate physical activity was presented to them. This study aimed to determine more effective physical activity in order to increase quality of life in childhood obesity. The impacts of physiotherapy group exercises and basketball as a sport branch on quality of life of obese children were compared. Although no signifi- cant difference was found among groups, the children who participated in the physiotherapy group perceived themselves to be at higher levels of physical health and emotional functioning following 12 weeks.
The intervention programs have continued for 12 weeks. Duration of physical activity ranges from 6 weeks to a year in the literature, but in the review by Kel- ley et al., the effects of exercise programs were investigated in 12 weeks  . Physiotherapy was presented in a group concept as Basketball is a team game. Moreover, various authors compared the effects of group based and individual based physiotherapy on the patients with similar diagnosis    . Both programs were found to be effective, but in some, group exercises had more effects and more cost efficiency. Although studies which investigated the effects of group exercises in obesity were found, physiotherapists did not manage these exercises   . Byun and Lee included 14 obese children in group exercise and 14 obese children in control group, but the details of their methods were not explained  . Thus, as far as we know, this study is the first paper investigating the effects of group based exercise which was controlled by a physiotherapist on obese population.
Age is an important factor which may affect many variables related to body composition so we wanted to eliminate the changes about this and children aged 10 years old were only involved. The other reason to choose the 10 years of age can be explained that according to the Gallahue’s motor development model, children aged 7 - 10 years old are asked to experience every type of sport branch to determine the most appropriate one for them before the specialized stage which covers 11 - 14 years of age  .
Most of the children used technology to play games or to communicate with others. Vandewater et al. stated that time spent on sedantery activities like watching TV causes childhood obesity  . Bhadoria et al. compared the time spent on technology of 451 obese and 451 non-obese children and found that obese children used technology for significantly longer durations  . Achieve- ment of an appropriate use of technology among children is an essential factor to both prevent from obesity and treat obesity  . Thus, our findings also in- dicated that the parents of obese children should be more carefull to provide the correct use of technology of their children.
Simon et al.  indicated low level of health related QoL of obese children and stated the reason as poor body compositon, seconder health problems, and bad feelings as emotional. According to Memik et al.  , healthy children av- eragely had 80 from every subheading of the PedsQL. Thus, similar to Simon et al., the children of this study had lower level of QoL from the healthy children, particulariy in the physical health, emotional functioning and school functioning subheadings.
The “physical health” and “emotional functioning” subheadings of the PedsQL significantly improved in the physiotherapy group. Except this, there was no change when the differences between before and after 12 weeks were investi- gated within the groups or when the findings of the groups were compared fol- lowing 12 weeks. This result shows that physiotherapy which supports mobility of children increased the physical health parameter of QoL of obese children. In addition, exercises were practiced with the music and children did not feel any competition during exercise. On the other hand, some difficulties were observed during the sessions of Basketball as some children reported that their friends did not throw the ball to them so several issues sharing and competitive issues arised. Thus, trainers should be aware of the psychology of overweight or obese children and try to motivate them continue participating in sport. Vella et al. stated that the parents of obese children who regularly do sport perceived higher level of QoL of their children than the parents of obese children who are physi- cally inactive  . Although no randomized controlled study investigated the effects of doing physical activity on the QoL, Bock et al. presented a one year multidisciplinary program including diet, physical activity, and psychological support to obese children and revealed that the same improved subheadings of the QoL to our physiotherapy group increased following this period  . In addition, PedsQL may be inadequate to reveal all effects of physiotherapy and basketball on the population of obese children. A specific QoL questionnaire to them may be developed in future.
To our knowledge, this is the first paper which compares the effects of physiotherapy and a sport branch on children with obesity. However, there are some limitations of this study. Gender distribution of the groups was not ho- mogeny and the sample size was small. Homogen groups with larger sample sizes could reveal more accurate results.
Physiotherapy exercises may increase quality of life of obese children. In conclu- sion, physiotherapists should be more active while choosing appropriate sport branch and also presenting physiotherapy exercises for an obese child to im- prove the quality of life.
We thank to Arkan Arşehit as he managed the basketball education of children.