Mindfulness-Based Stress Reduction (MBSR ...

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live online to individuals who have experienced a traumatic brain injury or stroke. ..... online course used the Adobe Connect platform for online meetings.
Mindfulness DOI 10.1007/s12671-015-0406-7

ORIGINAL PAPER

Mindfulness-Based Stress Reduction (MBSR) Delivered Live on the Internet to Individuals Suffering from Mental Fatigue After an Acquired Brain Injury Birgitta Johansson 1 & Helena Bjuhr 1 & Magdalena Karlsson 1 & Jan-Olof Karlsson 2 & Lars Rönnbäck 1

# Springer Science+Business Media New York 2015

Abstract An acquired brain injury often leads to long-lasting mental fatigue, which can have a considerable effect on work and social interactions. Fortunately, the Mindfulness-Based Stress Reduction (MBSR) program has been found to alleviate mental fatigue. The purpose of this feasibility study was to evaluate the success of an interactive MBSR program delivered live online to individuals who have experienced a traumatic brain injury or stroke. We included the following three groups in our study: an Internet group, a face-to-face MBSR group, and an active control group who took weekly walks in natural environments. Thirty-four participants completed the study, and all were suffering from long-lasting mental fatigue after either a traumatic brain injury (16 participants) or a stroke (18 participants). However, seven did not accept to attend an Internet MBSR, and Internet was the only choice for others. We found that, according to the Mental Fatigue Scale (MFS), the program leads to significantly reduced mental fatigue in the Internet group compared with the face-to-face and the control group. Individuals in the MBSR groups also exhibited an improved ability to process two temporally close targets (attentional blink task), while this was not detected in the control group. In conclusion, we believe that it is possible for individuals suffering from mental fatigue after an acquired brain injury to obtain positive results through enrollment in a live, interactive, online

* Birgitta Johansson [email protected] 1

Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Per Dubbsgatan 14, 1tr, 413 45 Gothenburg, Sweden

2

Department of Economics and Informatics, University West, Trollhättan, Sweden

MBSR program. This is promising, as the Internet is accessible to many individuals, irrespective of where they live. Further randomized control studies comparing are warranted.

Keywords Mindfulness . Internet . Mental fatigue . Attention . TBI . Stroke

Introduction Fatigue is a major complaint after traumatic brain injury (TBI) (Belmont et al. 2006) or stroke (Staub and Bogousslavsky 2001). Mental fatigue can be deeply overwhelming and can have a very detrimental impact on quality of life. It is characterized by limited energy reserves for accomplishing ordinary everyday activities, in addition to increased irritability, sensitivity to stress, difficulty concentrating, and emotional instability (Johansson et al. 2009; Johansson et al. 2010; Lindqvist and Malmgren 1993; Rödholm et al. 2001). For many people, mental fatigue associated with a brain injury may become a long-lasting problem that has a substantial impact on the ability to resume work, studies, and social activities. Currently, there is no effective therapy for mental fatigue. Generally, patients are advised to adapt to the decrease in available energy by doing one thing at a time, taking regular breaks and not overexerting themselves. This is very hard to learn independently, and it can take several years of considerable effort, frustration, despair, and depression for patients to find an appropriate balance between rest and activity. Although the origin of mental fatigue is not known, it may be associated with dysfunctional astrocytes, which are the most abundant support cells in the brain (Ronnback and Hansson 2004; Rönnbäck and Johansson 2012). Following brain injury, neuroinflammation downregulates astroglial glutamate transport systems. If this is not completely restored during recovery, the patient

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may exhibit impaired extracellular glutamate clearance, along with slightly increased extracellular glutamate levels, slight astrocyte swelling, and impaired glucose uptake (Hansson and Rönnbäck 2004; Johansson and Rönnbäck 2014b). Persistence of this neuronal activity state may result in an energy crisis (Rönnbäck and Johansson 2012). Some researchers have suggested that mental fatigue after TBI is related to increased brain activity, as measured by functional magnetic resonance imaging (fMRI) in terms of processing speed over time (Kohl et al. 2009). Johansson et al. (2012) reported a significant improvement in both mental fatigue and processing speed after people suffering from metal fatigue after TBI or stroke completed a Mindfulness-Based Stress Reduction (MBSR) program. This improvement has several potential explanations, including reduced inflammation with improved cellular efficacy, improved attention, reduced emotional burden and stress, and an improved ability to pace oneself in accordance with one’s mental and physical capabilities. Additional studies have reported reduced fatigue after MBSR in patients suffering from fatigue after cancer (Carlson and Garland 2005) and chronic fatigue syndrome (Surawy et al. 2005). Recently, general interest in mindfulness methods has increased, along with the number of individuals who want to attend mindfulness programs. However, difficulty travelling to the locations where MSBR courses are held may prevent some individuals from attending. With the increasing use of the Internet, many persons are able to obtain access to mindfulness courses, irrespective of where they live. Mindfulness programs have been delivered on the Internet in studies about anxiety disorder (Boettcher et al. 2014), stress (Glück and Maercker 2011; Krusche et al. 2012; Morledge et al. 2013), and irritable bowel syndrome (Ljótsson et al. 2010). These studies included mindfulness interventions with self-guided programs. However, MBSR is performed in groups, and the group environment is thought to be important for sharing experiences with others and learning from group dialogue (McCown et al. 2011). The aim of this feasibility study was to evaluate whether an MBSR program could be successfully delivered live online. Thus, we included a face-to-face MBSR group and an active control group. All participants were suffering from longlasting mental fatigue after TBI or stroke. To the best of our knowledge, no prior evaluation of a live online MBSR program with a full curriculum has been conducted in this or any other patient groups.

Method Participants The participants included in the study were recruited either from an advertisement in a local daily newspaper or from

information published on our website (www.mf.gu.se). We conducted an initial screening of potential participants via a telephone conversation. We used the following inclusion criteria: Participants were healthy men and women between 20 and 65 years of age, they had been employed prior to suffering a stroke or traumatic brain injury (TBI), they had recovered from any neurological symptoms, and they had been suffering from pathological mental fatigue for at least 6 months before inclusion in the study. Our exclusion criteria included comorbidity, including psychiatric or neurological disorders, a history of alcohol or drug abuse, significant cognitive impairment (according to a clinical interview or performance lower than 2 standard deviations below the mean on the neuropsychological test Digit Symbol-Coding from the WAIS-III scale included in the present study), and having previously attended an MBSR program. The participants were interviewed by a neurologist (L.R.), who investigated the extent of their acquired brain injury, comorbidity, and medication. If participants used medicine regularly, they were included if they had used it for at least 6 months prior to this study. The data from these interviews were used to determine whether the potential participants matched the inclusion or exclusion criteria for the current study. Among those with a mild TBI, they all had been diagnosed acutely with a concussion. Mental fatigue is a common long-term symptom that appears after both mild and moderate TBI or after a stroke (Belmont et al. 2006; Johansson et al. 2009; Staub and Bogousslavsky 2001). It can be long-lasting with improvement during the first year and may show no further changes after that point (Bushnik et al. 2008). In our clinical experience, mental fatigue can be chronic; we have had long-term contact with patients who have shown no further improvement after the first year. It is not easy to distinguish mild from moderate TBI after several years have passed, as it is difficult to make predictions about the long-term consequences at the initial diagnosis (Reitan and Wolfson 1999). From our experience with patients who have suffered a TBI or stroke, mental fatigue can be the dominant long-term symptom. Additionally, the extent of long-term mental fatigue is not related to the severity of the injury or stroke (Johansson et al. 2009; Johansson and Rönnbäck 2012). For instance, transient ischemic attack and minor stroke can result in a high level of mental fatigue (Winward et al. 2009). Thus, we did not emphasize the specific severity of the original diagnosis when designing our inclusion and exclusion criteria. We delivered written information about the study to 51 participants. Of these, 38 participants enrolled in the study: 18 who had suffered a TBI and 20 who had suffered a stroke. This experiment was conducted in compliance with the Declaration of Helsinki (1975). All participants provided informed consent. The study was approved by the Ethical Review Board, Gothenburg, Sweden.

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Three groups began the study simultaneously: a face-to-face MBSR group, an MBSR group who attended live meetings on the Internet (Internet group 1), and a control group who met for eight weekly walking meetings. The control group was later offered the opportunity to complete the Internet-delivered MBSR program (Internet group 2). We allowed seven participants to join the face-to-face MBSR group due to personal reasons, including not wanting to attend an Internet group or having difficulty with using a computer for long periods. It was difficult to recruit the number of participants needed in the Gothenburg region. Mindfulness is not common in Sweden, and there are no special clinics for people suffering from long-term symptoms following a brain injury. Patients generally seek medical attention at primary healthcare centers. Therefore, we included participants from other areas of Sweden in the Internet group. Thus, the study was not entirely randomized, as this would have greatly decreased the number of participants in each group. We did, however, randomize the participants when possible (Table 1). We found that age, TBI/ stroke, gender, education, time since injury, and working capacity did not differ significantly between the groups (Table 1). All participants were assessed before the start of the study and in the period following treatment. The participants in the walking group who joined MBSR Internet group 2 were assessed a third time, after completing the MBSR program. Procedure MBSR Face-to-Face Our MBSR intervention was based on Kabat-Zinn’s MBSR program (Kabat-Zinn 2001). The participants attended eight Table 1 Demographic data with mean values (standard deviation is included in brackets) and frequencies for those who completed the program

Numbers Numbers randomized Dropouts Age Tbi/stroke Gender (females/males) Education

Time since injury (months) Working, % of full-time (40 h/week) before brain injury/stroke Working, % of full-time after brain injury/stroke

weekly 2.5-h sessions and one full-day 7-h session between the sixth and seventh sessions. The MBSR course is educational and experiential, and it includes formal and informal meditation, group dialogue, and the presentation of didactic material by the teacher. The formal practices taught include the body scan, designed to systematically cultivate an awareness regarding each area of the body without the tensing and relaxing of muscle groups associated with progressive relaxation, sitting meditation, which emphasizes an awareness of the breath and encourages a systematic widening of the field of awareness to include all four foundations of mindfulness (awareness of the body, feeling tone, mental states, and mental contents), and mindful hatha yoga. The abovementioned practices require about 45–50 min each. The program also included two short sitting meditation sessions, lasting 5 and 20 min, respectively. During the full-day session, we introduced the participants to walking meditation, loving-kindness meditation, and mountain meditation. Home practice was supported by instructional videos accessible on the website and CDs, and the participants received written didactic material. The participants were encouraged to practice 6 days/week. They were also encouraged to introduce mindfulness into their daily living. Specifically, they were encouraged to engage in informal practices, including activities carried out every day, and to do these mindfully while giving their full attention to the task at hand. Our teaching intentions included encouraging participants to experience new possibilities for life satisfaction, experience bodily sensations and emotions as a whole, and move toward life acceptance. Kindness and compassion skills were embedded in the entire program (McCown et al. 2011).

MBSR group, face-to-face

MBSR Internet 1

Walking

p value

12 5 0 48.0 (9.4) 7/5 11/1 1 elementary

13 0 3 46.3 (11.5) 6/7 11/2 1 elementary

9 5 1 51.2 (10.6) 3/6 6/3 4 high school

0.567 0.523 0.319 0.323

4 high school

2 high school

5 university

7 university 120.5 (152.0)

10 university 76.2 (75.5)

50.1 (47.3)

0.305

range 11-513 100 (0)

range11-283 92.3 (19)

range 8-168 100 (0)

0.192

29.2 (38)

46.1 (47)

15.6 (34)

0.229

p values from the statistical comparison between the groups (ANOVA, chi-square) are included in the table

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MBSR Internet The live online MBSR meeting included the entire MBSR curriculum, which was delivered in eight 2.5-h weekly sessions and one full-day 7-h session between session 6 and 7 (Internet group 1). The Internet program followed the MBSR curriculum, with formal practices, home practice support, and informal practices, exactly as in the face-to-face group. The online course used the Adobe Connect platform for online meetings. The participants logged in to the study website and were thereafter allowed to connect to the online class. All participants used microphones and web cameras, allowing them to interact and converse with the MBSR teacher. They were also able to establish contact with the other participants in the group, as they could see and hear all the dialogue after the formal practice had taken place. This enabled the members of the Internet group to experience a sense of belonging to a group and also to take part in group discussions. The goal was for them to share experiences and learn from one another in an effort to increase their insights regarding mindfulness. The mindfulness teacher, H. Bjuhr, delivered both the MBSR face-to-face and Internet programs. The Internet course had all the components of a face-to-face group. The groups had their sessions on consecutive days, making it easier for the teacher to deliver the program to both groups in a similar way. Dr. Bjuhr is a clinical psychologist and certified MBSR teacher who was trained at The Center for Mindfulness, University of Massachusetts Medical Center. The MBSR Internet program was delivered using a method that closely resembled the method used by eMindful University (http://emindful.com/courses-2/course-descriptions-emu/ mindfulness-based-stress-reduction-mbsr-ind). Control Program The active control group met once a week for eight 1.5-h sessions of peaceful walking in the Gothenburg Botanical Garden. The pace was adapted to suit the participants. The group was given a formal group leader (M.K.). A short break was included, and the participants were allowed, if they wished, to share and discuss common experiences related to their acquired brain injury. The participants were also encouraged to take daily walks in-between the weekly meetings. The control group was later offered the opportunity to complete the Internet-delivered MBSR program (Internet group 2). Measures The assessments included a self-assessment of mental fatigue (MFS), a measure of levels of depression and anxiety, a measure of self-compassion, and neuropsychological tests. The assessments were performed by a neuropsychologist (B.J., not blinded to group membership). The MFS is a

multidimensional questionnaire (Johansson et al. 2009, 2010; Johansson and Rönnbäck 2014a), with a suggested cutoff score of 10.5 (Johansson and Rönnbäck 2014a). It incorporates affective, cognitive, and sensory symptoms, duration of sleep and day-time variation, and all common symptoms associated with the period after brain injury and stroke (Lindqvist and Malmgren 1993). We used the Comprehensive Psychopathological Rating Scale (CPRS) to measure depression and anxiety (separate scales) (Svanborg and Åsberg 1994). Mild depression has been associated with a rating between 6.6 and 9.5, moderate between 10 and 17, and severe ≥17.5 (Snaith et al. 1986). The CPRS depression scale is identical to the Montgomery Åsberg Depression Rating Scale (MADRS) except that the rating is doubled in the MADRS (Montgomery and Åsberg 1979). Our previous study (Johansson et al. 2012) indicated that the practices of kindness and compassion, explicit teaching and instruction, and exercises in the MBSR program were seen as nourishing and enabled participants to develop a new way of relating to the difficulties they were experiencing. We used the Self-Compassion Scale (SCS) short form to evaluate self-compassion. The short form, which includes 12 questions, has a near-perfect correlation to the full SCS scale (Raes et al. 2011). All of our participants were asked to document the duration of formal home practice completed each day on a form designed for this study. These data were collected after the 8 weeks. The neuropsychological tests used included Digit SymbolCoding from the WAIS-III scale (Wechsler 2003) and the attentional blink task (Dux and Marois 2009; Slagter et al. 2007). In our previous study, we found that Digit SymbolCoding ability improved after an MBSR course (Johansson et al. 2012). The attentional blink task has previously been used to test changes in attention resulting from meditation. Specifically, Slagter et al. (2007) reported that intensive meditation was correlated with reduced brain-resource allocation to the first target in the attentional blink task, resulting in an improved ability to detect the second target. The attentional blink task measures attention and processing speed, both of which may be compromised in individuals suffering from mental fatigue after an acquired brain injury (Johansson et al. 2009; Johansson and Rönnbäck 2012). According to our hypothesis about mental fatigue, brain resources or brain efficiency is impaired, which may substantially affect performance on the attentional blink task. The attentional blink task in this study was based on the description from Slagter et al. (2007). In this computer task, the individual is shown a rapid stream of events, specifically letters, with two targets (digits, Target 1=T1 and Target 2=T2) embedded in the rapid stream. We presented 17 uppercase letters and two digits (15-mm high) in black on a light gray background in random order in the center of the computer screen. Each trial started with

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the presentation of a 1780-ms fixation cross, followed by the rapid stream of letters, which were randomly selected (except for B, I, O, Q, Å, Ä, Ö). Two randomly selected digits between 2 and 9 were embedded in the letter stream. Each letter or digit was presented for 50 ms and followed by a blank screen for 34 ms. The T1 was always presented as the fifth item in the stream. The temporal distance between digits T1 and T2 was either 252, 504, or 756 ms, and this distance was randomly drawn. There were ten trials for each temporal distance, for a total of 30 trials. The participants were informed that two digits would always be presented, and they were asked to report these digits after each trial at their own pace. If they were unsure, they were asked to guess. After a practice block of eight trials, they performed one run consisting of 30 trials. The primary measure of interest was the percentage of correct T2 reports from the trials in which T1 was accurately identified. Data Analysis We used a general linear model with time as a repeated factor and group as a between factor for the main analysis. Participants with missing data were excluded from the analysis. We conducted a paired t test for each group with the intention of obtaining information about the treatment effects for each group separately. We used a chi-square test for categorical variables and Pearson’s correlation for correlation analysis. SPSS 21.0 was used for statistical calculations.

Results There was no variability in the MFS ratings on mental fatigue at two time points, taken 40 days apart, prior to the intervention, i.e., when they received written information about the study and at pretest (paired t test, p=0.257). We found no differences in the MFS ratings of mental fatigue between these two points. Of the 38 participants included, 34 completed the whole program. There were no dropouts in the face-to-face MBSR group, while there was one dropout in the walking group after the first meeting (male aged 42 years, stroke). He had been offered the opportunity to attend a pharmacological study and chose to participate in that instead. There were three dropouts in the MBSR Internet group 1, all which occurred after the first session, due to lack of motivation or lack of time needed to continue the program (two males aged 26 and 29 years, both TBI, and one woman aged 45 years, stroke). From the walking group, seven of the nine participants attended the MBSR Internet group 2, which followed the eighth week session of walking. The two who choose not to attend the MBSR program declined due to lack of time, one

had planned a long holiday that conflicted with the course schedule, and the other had begun vocational training. We found a significant interaction effect between treatment and MFS rating. The interaction is displayed in Fig. 1. No other interaction effects were found for the variables analyzed (Tables 2 and 3). Paired t tests, which we carried out separately for each group, showed significant improvements for the MBSR Internet 1 group, with reduced MFS, depression, and anxiety ratings and improved processing speed on coding. We found improved temporal attention on the attentional blink task, resulting in more correct T2 responses at the intermediate and the long time intervals (Tables 2 and 3, Fig. 2), and more correct T1 responses at intermediate intervals (p=0.010). The face-to-face MBSR group improved significantly on the attentional blink task and made more correct T2 responses at the intermediate level (Tables 2 and 3, Fig. 1). The walking group improved significantly on coding (Tables 2 and 3). As not all participants were randomized with respect to treatment, we did an intention-to-treat analysis (Detry and Lewis 2014) with only the randomized participants (five in the face-to-face group and five in the walking/control group, Table 1). We detected a significant interaction effect between treatment and MFS rating (F=7.118, p=0.028). In the face-toface group, the MFS rating decreased from 18.4 to 15.1, while ratings in the control group stayed on a similar level: 21.7 from before treatment to 22.7 afterward. The participants in the control group (n=7) who later attended the MBSR program (MBSR Internet 2) exhibited significantly reduced MFS ratings after completion of the course (paired t test, p=0.00, Fig. 1). They also showed improved attentional blink performance with significantly more correct T2 responses at the longest interval after the course (paired t test, p=0.015). The other variables did not change significantly. The total sum of scores on the SCS short form significantly improved after treatment (GLM: factor withingroups, F=7.917, p=0.009). We did not detect any differences between the three groups. A separate analysis of each item on the SCS (corrected for multiple comparisons, p=0.0042) revealed a significant change in the rating on question 8 (F=13.989, p=0.001). Specifically, the participants reported that they more seldom felt alone in their failures after the treatment period. We detected no difference in the amount of time spent on home practice between the MBSR face-to-face group, MBSR Internet 1 group, and the MBSR Internet 2 (Table 4). On average, the participants practiced between 27 and 30 min/ day. There was a vast variation in the amount of daily practice, ranging from those who did not practice at all to those who practiced 52 min/day. Changes in pretest and posttest MFS ratings did not correlate significantly with the total amount of home practice time (r=0.182, all three groups included), or practice measured in minutes/day (r=0.026).

Mindfulness Fig. 1 Mean MFS ratings before treatment and after treatment (test 1 and test 2). Results from the walking group, who later attended the online MBSR course (group 2), are also shown in the figure. As two of the participants in the walking group did not attend the online MBSR course, the mean values are slightly higher. Asterisk indicates significant decrease

Discussion We evaluated the success of a live online MBSR program (containing the entire MBSR curriculum) completed by participants suffering from mental fatigue after an acquired brain injury. Our data indicates that the program was successful in reducing MFS score. MFS score was the only factor found to have an interaction effect, indicating that the groups differed in their response. Indeed, we observed greater improvement in terms of mental fatigue and cognitive function in the Internet group compared with the face-to-face MBSR group. However, this was true for those who specifically accepted the chance to complete an Internet MBSR program. We cannot directly compare the efficacy of the face-to-face and Internet MBSR programs, as this was not a randomized study. We conducted an intention-to-treat analysis with those who were randomly assigned to the face-to face MBSR and the control groups. This analysis indicated that those in the faceto-face MBSR group had reduced mental fatigue compared with those in the control group. When comparing the results Table 2 Mean values (standard deviation is given in brackets) from pretest and posttest

from Internet groups 1 and 2 in the current study with the data from our previous randomized MBSR study, which also included participants who suffered from mental fatigue after TBI or stroke (Johansson et al. 2012), we found a similar level of reduction in mental fatigue, with a 25 % reduction in MFS ratings. Despite the fact that people suffering from mental fatigue after an acquired brain injury often feel that going for a walk is a beneficial experience, we did not find a decrease in MFS ratings in the active control group. When the control group was later offered the opportunity to complete the live Internet MBSR program, they exhibited reduced MFS ratings and improved attention levels to a similar extent as the first Internet MBSR group. We found that the MBSR program decreased symptoms of depression and anxiety, especially for the MBSR Internet 1 group. We included the short form of the Self-Compassion Scale (Neff 2003; Raes et al. 2011) in this study, as lovingkindness and self-compassion are central elements of the MBSR program. We detected an improvement in the total

Variables

MBSR face-to-face pretest/posttest

MBSR Internet 1 pretest/posttest

Control walking pretest/posttest

MFS SCS Depression Anxiety Coding Coding Ssa %T2 252 ms %T2 504 ms %T2 756 ms

19.8 (5.2)/18.0 (6.4) 36.2 (11.6)/40.3 (11.1) 8.3 (3.5)/7.4 (4.9) 8.2 (3.8)/7.1 (4.4) 68.6 (14.8)/71.3 (15.2) 9.9 (2.9)/10.4 (3.0) 43 (22)/48 (40) 57 (25)/73 (19) 67 (18)/81 (19)

20.5 (6.3)/15.9 (6.1) 36.8 (7.1)/39.9 (7.0) 6.6 (2.7)/5.2 (2.6) 8.2 (2.3)/6.0 (2.6) 59.9 (18.6)/66.5 (17.6) 8.3 (2.7)/9.3 (2.9) 45 (8)/48 (35) 60 (39)/86 (21) 68 (27)/80 (24)

19.4 ( 5.9)/19.8 (6.8) 36.0 (11.8)/38.6 (10.0) 6.9 (2.9)/6.9 (2.9) 5.9 (2.8)/4.5 (2.8) 69.2 (21.7)/75.6, 23.1 10.3 (3.9)/11.6 (4.1) 56 (22)/52 (26) 66 (40)/66 (32) 79 (16)/70 (21)

a

Scale score from WAIS-III, adjusted to age, average 8-11. Raw coding score was used for statistical analysis

Mindfulness Table 3 Results (p value) of the general linear model with time as a repeated factor and group as a between factor

Variables

dfa

Time effect

Group effect

Interaction group×time

MBSR face-to-face Paired t test

MBSR Internet 1

Control Walking

0.860 0.960 0.323 0.206 0.458 0.704 0.817 0.995

0.004 0.870 0.303 0.860 0.359 0.855 0.118 0.075

0.126 0.092 0.294 0.115 0.117 0.726 0.038 0.154