Thermal, electrical, and mechanical modalities are routinely used by clinicians for immediate and short-term pain modulation following musculoskeletal injury. Although the long-term treatment outcomes have not been established for many modalities, the modulation of pain through therapeutic modalities during or immediately after treatment is supported.1–4 Specifically, transcutaneous electrical nerve stimulation (TENS)1–4 and massage5–7 have been found to be useful in modulating pain during their application.
An alternative modality called “soft tissue oscillation therapy” has gained popularity for its proposed therapeutic benefits in pain modulation and improved healing following musculoskeletal injury.8 Soft tissue oscillation therapy uses a form of electrotherapy combined with manual therapy/massage. Rather than the standard stationary electrodes used with TENS, soft tissue oscillation therapy is applied through a non-conductive treatment capacitor, creating an electrostatic field between the treatment capacitor and the patient. One capacitor is held by the clinician and one is held by, or connected to, the patient. Because the electrical current is not conducted through the tissue, a magnetic field is purportedly created between the capacitor and the patient. Furthermore, it is suggested that by alternating the polarity of this magnetic field, a biophysical “kneading” occurs within the tissue from the charged particles being attracted and repelled.9
Regardless of its true biophysical effects, soft tissue oscillation therapy is commonly used for pain reduction. To deliver the treatment, clinicians often use their hands as the active capacitor instead of a probe, thereby combining the delivery of the oscillation therapy with a therapeutic massage. In addition to the delivery vehicle, the treatment parameters specific to the electrical current frequency, intensity, and duration can be modified to attempt to achieve the desired effect. Although researchers have suggested that soft tissue oscillation therapy is an effective treatment adjunct for a host of indications, including lymphatic drainage,9 edema removal,10 fibromyalgia pain,11 and even burn healing,12 there is limited research on orthopedic injuries. Whereas Aliyev8 concluded that soft tissue therapy has positive effects on sports-related injuries, there appeared to be methodological issues that minimize the generalizability of those results.
Therefore, it seems that soft tissue oscillation therapy has been incorporated into clinical practice for the treatment of musculoskeletal injuries, even though there is limited evidence to support its short-term efficacy as a pain-modulating intervention. The purpose of our study was to examine the immediate and short-term effects of soft tissue oscillation therapy on musculoskeletal pain.
We used a randomized, blinded, repeated measures design. The independent variables were the treatments (soft tissue oscillation with effleurage and effleurage alone) and time (before, during, and after treatment; and sessions 1 through 5). The dependent variable was pain intensity as quantified by the numeric rating scale.
Thirty-one healthy, physically active adults volunteered to participate (17 women and 14 men; age: 21.30 ± 1.47 years). Participants completed a history form that addressed their physical activity level, current health status, injury history, and any adverse responses to intense resistance training or electrical modalities. The physical activity minimum inclusion criterion was participation in some combination of aerobic physical activity for a minimum of 30 minutes a day, 5 days a week or a vigorous intensity aerobic activity for a minimum of 20 minutes a day, 3 days a week.13,14 Participants provided informed consent in accordance with our insitutional review board approved protocol. During the study, participants were asked to avoid analgesics (ie, massage, ice, exercise, stretching, pain medication, or other modalities) and exercise (ie, weight lifting, cardiovascular exercise, etc.).
We delivered soft tissue oscillation therapy using a commercially available unit (Dynatron X5 Soft Tissue Oscillation Therapy Unit; Dynatronics Corporation, Salt Lake City, UT). We measured pain intensity using a 10-point numeric rating scale from 0 to 10 (0 = no pain, 10 = worst possible pain).15 We asked participants to quantify their pain by circling the number that best represented their pain.
We collected data over a maximum of six sessions, including the delayed onset muscle soreness (DOMS) induction session followed by five treatment sessions at 48, 72, 96, 120, and 144 hours. The participants continued treatments until the fifth treatment session or until they rated their pain as “0” on the numeric rating scale, at which point their participation was considered complete.
DOMS Induction. The first session included obtaining consent, history, baseline pain assessment, DOMS induction, and pain assessment following exercise. Using the numeric rating scale, participants were asked to rate the pain they experienced while performing two arm curls with their non-dominant arm while holding a 2.27 kg (5 lb) weight. All arm curls were performed with participants seated behind an arm curl bench supporting their upper arm, which prevented elbow hyperextension and shoulder movement. Next, each participant underwent the DOMS induction protocol to the elbow flexors on the non-dominant arm.14 We first determined the starting weight by establishing each participant's one repetition maximum (1RM) for elbow flexion (arm curls) and then subtracting 2.27 kg. The participants then performed the DOMS induction protocol, which included three steps: (1) sets of 10 concentric arm curls with their starting weight followed by 30 seconds of rest, repeated until failure, (2) 1 minute of rest, and (3) eccentric arm curls until complete failure. The weight for the eccentric arm curls began with the participant's 1RM plus 2.27 kg, moving from full elbow flexion to full extension over 5 seconds.14 At the end of each repetition, the weight was removed, the participant's elbow was passively flexed, and the eccentric arm curls were repeated with the same weight for 10 repetitions with 1 minute of rest or until failure. Failure was defined as the inability to control the eccentric contraction for 5 seconds. Immediately following failure, the weight was reduced by 2.27 kg and cycles of 10 eccentric repetitions/1-minute rest were resumed. The DOMS induction protocol was concluded once 50 repetitions were completed.14 Immediately following the DOMS induction protocol, participants rated their pain bilaterally using the numeric rating scale.
Confirming DOMS. The purpose of the second session was to confirm the presence of DOMS 48 hours after the first session and to subsequently begin treatments. To confirm onset of DOMS, participants performed two arm curls with a 2.27 kg weight and then rated their pain, first with the dominant arm and then the non-dominant arm. DOMS was confirmed if session 2's non-dominant arm pain score was greater than session 1's pain scores and session 2's dominant arm pain score. No participants had to be excused for failure to achieve DOMS.
Treatments. If DOMS was confirmed, the participant was assigned to either the effleurage or the soft tissue oscillation group and the first treatment was initiated. We stratified group assignments to ensure equal gender representation within each group; both groups contained 8 women and 7 men. Both treatment conditions were delivered over the biceps brachii muscle belly region at a low frequency of 200 Hz for 15 minutes, in accordance with the manufacturer's instructions and parameters for acute pain management. The treatments were delivered by the principal investigator, an athletic trainer with experience using the soft tissue oscillation modality. The participants rested their arms on a treatment table with their elbows extended and were asked to relax their elbow flexors. Talc powder was then applied to the desired area to maintain a dry contact surface.
The soft tissue oscillation group received the low frequency (200 Hz) soft tissue oscillation therapy for 15 minutes, with the principal investigator's hands serving as the capacitor while using an effleurage-like technique. Wearing non-latex examination gloves as an insulator, the principal investigator wore the active electrode on the palmer surface of one wrist while the participant held a probe in the dominant hand to complete the treatment circuit.9 The electrical current was then delivered through both of the principal investigator's hands while moving distal to proximal over the participant's elbow flexors. In accordance with the manufacturer's recommendation, the amount of mechanical pressure applied with the hands was consistent with effleurage with slightly more pressure to ensure firm and constant skin contact. The effleurage-only treatment was identical to the soft tissue oscillation treatment. The machine was turned on, but no current was actually delivered. Although there is a slight vibratory sensation when a treatment is actually delivered, the effleurage-only group was not aware of this, and therefore not aware that anything was different or missing from a standard application. Pain was assessed prior to, during, and after each treatment using the numeric rating scale. To assess pain during the treatment, at the halfway point of the treatment (7.5 minutes), the participant grasped a 2.27 kg hand weight and performed two arm curls while the treatment was still being applied, then verbally provided a pain rating using the numeric rating scale.
Data Analysis. We used a 2 (arm) × 2 (session 1 vs session 2) within-subjects factorial analysis of variance (ANOVA) to determine whether DOMS was induced and a paired t test for the post-hoc analysis. Then we used a 2 (group) × 5 (session) mixed-design ANOVA to determine whether group assignment had an effect on pain reported at the beginning of each session, prior to the treatment, and over time. We used a 2 (group) × 5 (session) mixed factorial ANOVA to determine whether group assignment had an effect on the perceived pain reported during the treatment session or over time. We used SPSS for MacIntosh software (version 22; IBM Corporation, Armonk, NY) for all statistical analyses, with a P value of .05 or less considered significant. Delta scores were calculated by subtracting the pre-treatment pain scores from the during-treatment pain scores to allow descriptive presentation of the impact of treatment on pain.
One participant from the effleurage-only group was removed and replaced because she indicated that she used nonsteroidal anti-inflammatory drugs during the study. Therefore, our analyses included 30 participants (Table 1).
Confirmation of DOMS
A significant interaction was observed (F (1, 29) = 144.6, P < .05); therefore, simple effects were analyzed. The non-dominant arm showed a significant increase in pain 48 hours after the induction of DOMS (t (29) = 12.0, P < .05), whereas there was no change in pain in the dominant arm (P > .05). All participants rated their dominant arm pain as “0.” Therefore, we concluded that our protocol was effective in inducing DOMS (Figure 1).
Confirmation of delayed onset muscle soreness (DOMS) 48 hours after induction protocol.
Treatment Effect on Pain During Treatments Over Time
The mixed-factorial ANOVA revealed no significant interaction (F (4, 112) = 0.57, P > .05). The main effect for the treatment group was not significant (F (1, 28) = .184, P > .05). Thus, the soft tissue oscillation group did not report less perceived pain while the treatment was being administered when compared to the effleurage-only group. However, there was a significant time effect (F (4, 112) = 50.2, P < .05). Specifically, participants reported less pain during each treatment over time, regardless of group assignment (Figure 2, Table 2).
Mean pain scores reported during each treatment. STO = soft tissue oscillation
Self-reported Pain Before and During Treatment Sessions: NRS Mean ± SD and Delta Scores
Treatment Effect on Pre-treatment Pain Over Time
The mixed-design ANOVA revealed no significant interaction between the soft tissue oscillation group and effleurage-only group over time (F (4, 112) = 0.62, P > .05). There was no treatment effect (F (1, 28) = 0.08, P > .05), but there was a significant time effect (F (4, 112) = 87.6, P < .05). This indicates that although both groups reported less pain over the five treatment sessions, there was no difference in the reported pain levels between the groups (Figure 3, Table 2).
Mean pain scores reported prior to each treatment. STO = soft tissue oscillation
When using a modality to reduce pain following musculoskeletal injury, an important consideration is its effect on pain during the application,2 in addition to its effect on long-term patient outcomes. Our results indicate that soft tissue oscillation therapy delivered with effleurage was not superior to effleurage alone in modulating pain, nor did it shorten the overall length of time participants reported pain.
When used in the treatment of musculoskeletal injury, the purpose of soft tissue oscillation therapy is to modulate pain and improve recovery. Our results seem to contradict previous research most relevant to our study. Based on outcomes from the treatment of 49 injuries to 14 soccer players, Aliyev8 concluded that soft tissue oscillation therapy was effective in modulating pain. Although that study is frequently cited in support of soft tissue oscillation therapy for treating musculoskeletal injury, the results and conclusions are difficult to compare to our study. The study by Aliyev8 used no placebo or control, included multiple injuries from individual patients, used concomitant therapies, and omitted details specific to the timing and collection of the main outcomes. Relative to our design, had we not included a control condition, we could have concluded that soft tissue oscillation therapy with effleurage was effective in relieving pain, when it was actually no better than effleurage alone. Participants in our study indicated that both treatments were effective in relieving their pain, based upon their responses on the numeric rating scale.
Other investigators have concluded that soft tissue oscillation therapy is effective for lymphatic drainage,9 edema removal,10 fibromyalgia pain relief,11 and burn healing.12 In contrast to our results, previous studies have reported that patients with lymphedema9 and fibromyalgia11 who were treated with soft tissue oscillation therapy did, in fact, experience pain reduction. However, inconsistencies in research design limit the generalizability of these findings. For instance, Jahr et al.9 used oscillation in conjunction with manual lymphatic drainage, whereas Jones10 examined a single patient who was concomitantly being treated with multilayer lymphedema bandaging. Moreover, Tápanes et al.12 did not examine pain as a treatment outcome.
Based on the delivery of energy, anticipated benefits, and use of massage during our treatment intervention, it seems appropriate to compare our results to those of massage and TENS. Research supports the use of TENS for immediate and short-term modulation of pain due to musculoskeletal injury.1–4,16–19 Moreover, TENS has been found to be effective in addressing pain associated with DOMS.3 Denegar and Perrin3 compared the effects of cold, TENS, cold and TENS, placebo, and control (no treatment) on perceived pain and other variables after inducing DOMS. They found that the cold, TENS, and cold and TENS groups showed a greater decrease in perceived pain than the placebo and control groups.3 However, they did not measure pain during the treatments. Butterfield et al.19 examined the effects of high-volt pulsed electrical stimulation (HVPC) on DOMS-related pain.19 Although the authors concluded that HVPC provided pain relief during the treatment, their methods indicated that pain was measured before and after each treatment, not during, making the application of their results unclear. Additionally, neither the treatment nor placebo groups showed a difference in reported pain at 24 to 72 hours following exercise; therefore, the authors concluded that HVPC was ineffective in providing lasting pain reduction, regaining range of motion, and regaining strength associated with DOMS.19
Massage is also considered to be effective for limiting the pain associated with DOMS.5–7,20 However, previous research has focused primarily on the preventative benefits of massage on pain delivered within hours following exercise rather than the palliative benefits.21 The impact of massage on DOMS pain during treatment has not been addressed. Nevertheless, because soft tissue oscillation therapy is often delivered through an effleurage-like massage and massage has shown some benefit in reducing pain from DOMS, we chose to use effleurage as our comparison treatment. One issue that arises when addressing the impact of a modality on pain is the timing of the pain assessment. Although long-term improvement is ultimately the desired outcome, the effect of any modality on pain during treatment should be considered an important outcome when assessing its clinical value. In light of reviews22,23 questioning the long-term impact of TENS on pain, Bjordal et al.2 called for a paradigm shift that considered the impact of TENS during treatment rather than just its effect on long-term outcomes. Our results suggest that soft tissue oscillation therapy applied with effleurage does not reduce pain during treatment, nor does it reduce the long-term recovery from DOMS relative to an effleurage treatment.
Although our results begin to address the clinical effectiveness of soft tissue oscillation therapy, there were several limitations that offer opportunities for future research. When comparing our results to previous research, it should be emphasized that we focused only on the treatment of pain, resulting from DOMS, delivered with an effleurage-type massage using the clinician's hand as the capacitor. Therefore, our results should be compared accordingly. We did not specifically address the overall prophylactic effects of soft tissue oscillation on pain or the functional limitations that accompany pain due to DOMS. For example, Pearcey et al.24 recently reported that foam rolling was effective in preventing pain from DOMS over the first 72 hours if applied immediately after exercise and throughout the next 48 hours. Ziemann et al.25 reported that whole body cooling over the 5 days immediately following DOMS induction resulted in a reduction in pain from a reduced inflammatory response and muscle damage and an improved lipid profile based on blood level concentrations. Future research should investigate the prophylactic effects of soft tissue oscillation immediately following DOMS induction on pain, function, and the biochemical markers of inflammation and healing.
We chose DOMS as our experimental pain model in healthy participants to avoid using an unsubstantiated treatment on patients in a clinical setting. Ideally, the effectiveness of any novel health care intervention is evaluated in patients seeking care for the condition of concern; in this case, musculoskeletal injury. However, because soft tissue oscillation therapy has yet to be substantiated as an effective treatment for musculoskeletal injury, we chose to study healthy participants and employ an experimental pain model (DOMS) rather than provide an unsubstantiated intervention to patients recovering from injury. If it can be established that soft tissue oscillation therapy does not impede recovery from musculoskeletal injury, then future research should focus on its impact on meaningful patient outcomes relative to activity and participation in the clinical setting.
A third consideration when applying our results is the protocol and parameter settings with which we chose to apply the treatment. Although alternative and more intense treatment parameters are possible, both in the delivery of the electromagnetic field and in the pressure applied with the clinician's hands during the application, we chose the recommended settings of 200 Hz (low frequency), applied for 15 minutes, and delivered through an effleurage-like technique. Alternative treatment parameters may produce different treatment outcomes. Our results can be used as a stepping-stone to expand our knowledge of this modality.
Implications for Clinical Practice
The proposed treatment indications of soft tissue oscillation therapy include pain reduction and improved recovery, but our results suggest that it is not more effective than effleurage alone. However, our study has several limitations to consider when applying the results to clinical practice and considering future research. Addressing acute pain following musculoskeletal injury is a paramount concern in early recovery and patient comfort.26 The impact of a pain modulating modality should be considered while the modality is being applied. If a modality provides pain relief and pain relief is a goal of the clinician and valued by the patient, then its use can be justified.
Our results suggest that 15 minutes of low frequency (200 Hz) soft tissue oscillation therapy delivered through effleurage does not provide superior pain relief while it is being applied or immediately after its application, nor does it reduce the overall length of the painful experience as compared to the effleurage treatment. Clinicians should consider alternative interventions when pain is a chief patient complaint and immediate pain reduction is a primary short-term goal. Although it is uncertain whether soft tissue oscillation therapy has any impact on long-term patient outcomes following musculoskeletal injury, we cannot recommend its use for achieving immediate pain relief. If patients value pain relief and clinicians consider pain relief a goal in their treatment, alternative methods should be chosen to optimize patient outcomes.
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|GROUP||MALE||FEMALE||AGE (Y)||HEIGHT (CM)||MASS (KG)|
|STO||7||8||21.1 ± 1.2||169.8 ± 10.1||78.4 ± 18.1|
|Effleurage||7||8||21.5 ± 1.7||174.1 ± 9.2||79.0 ± 15.0|
|Total||14||16||21.3 ± 1.5||172.0 ± 9.9||78.7 ± 16.6|
Self-reported Pain Before and During Treatment Sessions: NRS Mean ± SD and Delta Scores
|SESSION||STO (CM)||PLACEBO (CM)|
|1a||3.93 ± 1.94||2.60 ± 1.55||Δ-1.33||3.53 ± 1.46||2.20 ± 1.26||Δ-1.33|
|2||3.00 ± 1.93||1.93 ± 1.28||Δ-1.07||3.27 ± 1.53||1.80 ± 1.32||Δ-1.47|
|3||1.73 ± 1.22||1.07 ± 0.96||Δ-0.67||1.47 ± 0.83||0.87 ± 0.74||Δ-0.60|
|4||0.67 ± 0.90||0.27 ± 0.46||Δ-0.40||0.53 ± 0.57||0.33 ± 0.49||Δ-0.20|
|5||0.07 ± 0.26||0.00 ± 0.00||Δ-0.07||0.13 ± 0.35||0.13 ± 0.35||Δ0.00|