1Department of Rehabilitation Medicine, Myongji Hospital, Goyang, Korea
2Department of Rehabilitation Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
Correspondence: Aram Kim Department of Rehabilitation Medicine, Myongji Hospital, Hanyang University College of Medicine, 55 Hwasu-ro 14beon-gil, Deogyang-gu, Goyang 10475, Korea. Tel: +82-31-810-7949 Fax: +82-31-810-6457 E-mail: akimrm0520@gmail.com
• Received: September 7, 2025 • Revised: October 30, 2025 • Accepted: November 13, 2025
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To investigate the effects of small group speech therapy consisting of two children in aspects of language and social development and identify powerful predictors for maximal therapeutic gains of two-person small-group speech therapy (2-SST).
Methods
We retrospectively reviewed the medical records of 51 children, who had participated in 2-SST. Language and social abilities of children were assessed using multiple scales at initial and follow-up visits after participating in 2-SST program. Receptive and expressive language were measured using the Preschool Receptive-Expressive Language Scale and the Receptive-Expressive Vocabulary Test, while social abilities were assessed with the Social Maturity Scale.
Results
Participants in the 2-SST showed significant improvements in all categories of receptive/expressive language and social abilities. Multivariable linear regression analysis revealed that the same diagnosis and baseline receptive language ability difference and intellectual ability difference from paired-child were powerful predictors of improvement in receptive language ability. Younger age (≤5 years) was a powerful predictor of improvement in expressive language ability. Older age (>5 years) was an independent predictor of improvement in social ability.
Conclusion
The 2-SST can be an appropriate delivery model to improve language and social skills with advantages of both individual and group speech therapy. For maximal therapeutic gains of 2-SST, same diagnosis, similar language and cognitive level with paired-child, and age should be considered depending on the more specific goals of treatment.
Speech and language delays/disorders can result from a primary (unknown cause) or secondary condition, such as autism, hearing impairment, global developmental delay, behavioral or emotional difficulties, and neurological impairment [1]. Persistent speech and language delay can lead to socio-emotional challenges, difficulties in reading and writing, and long-term limitations in education and vocational performance [2]. A previous study suggested that the “wait-and-see” approach to language development is not recommended, as early intervention of speech therapy (ST) can help improve children’s speech and language development, their ability to communicate, their ability to effectively interact with peers, and strengthen their social skill [3,4]. ST should be individualized to the child’s current language level, with a speech-language pathologist (SLP) determining the treatment scope and promoting its functional application in daily life. However, there is still an ongoing debate regarding the structured protocol such as the timing of intervention, specific disorders, duration/intensity of treatment, and delivery model of treatment for pediatric language delay/disorder [5]. Regarding the delivery model, ST typically involves one-on-one delivery model (individual ST) between an SLP and a patient, however, group-delivery model (group ST) is also implemented depending on the situation. Group ST can be beneficial in terms of social skills, cooperation, and attention, and it may be more cost-effective and resource-efficient than individual ST [6]. While group ST is widely used, there is an ongoing debate concerning its effectiveness compared to that of individual ST. Some studies have suggested that group ST was more effective compared to individual ST for improving expressive language, while showing no significantly effect on receptive language in school-age children [7]. Another study indicated that individual ST resulted in greater improvements in expressive language compared to weekly group ST in preschool children [8]. A previous work found no significant difference in effects between individual ST and group ST in school-age children [6]. The heterogeneity of research outcomes can be influenced by various factors, including age, social differences, regional differences, and composition of the ST program. While adult population with neurological language disorders benefit from structured treatment protocols, those for pediatric population with language disorders remain less established in intervention delivery. Furthermore, previous studies have focused only on the outcome measures of speech and language skills except for social skills, even though recent advances in intervention for children with language disorders highlight the importance of addressing comorbidity, particularly the relationship between language and socio-emotional skills [9]. This study was conducted under the hypothesis that two-person small-group speech therapy (2-SST) would be an efficient delivery model of treatment that has the advantages of both individual ST and group ST in aspects of language and social development. The outcomes of treatment were often linked to many factors other than delivery model, and SLPs should consider various factors, such as the matched diagnosis, age, personality, and learning style of paired patients. There is limited knowledge concerning the key factors that contribute to the maximal gains of group ST. In this study, we aimed to investigate the effects of 2-SST on language and social development in children with language disorders. Furthermore, we aimed to identify powerful predictors that are key factors resulting maximal therapeutic gains of 2-SST.
METHODS
Study design
This single-center retrospective study analyzed the data from the Department of Physical Medicine and Rehabilitation of Myongji Hospital from 2015 to 2023. The medical records of patients were retrospectively reviewed to analyze the clinical information, including age, sex, diagnosis, cognitive abilities, and assessment results of language and social skills. Data were collected retrospectively; therefore, informed consent was not obtained. Nevertheless, the Institutional Review Board (IRB) of Myongji Hospital approved the use of these data for research purposes (IRB No. MJH 2023-12-022).
Participants and service information
We obtained data from 132 children with participating 2-SST between 2015 and 2023. All patients were evaluated by an SLP and were included in the study if they met the following inclusion criteria: (1) age≥36 months; (2) language development delay below -1 standard deviation on the Preschool Receptive-Expressive Language Scale (PRES); (3) with no reported hearing loss or cleft lip/palate; (4) participation in 2-SST program; and (5) with parents or legal guardians who are proficient in the Korean language; (6) with adequate clinical data and test results necessary for the analysis.
The 2-SST involved matching of two children who visited our center. The procedure was conducted once a week for 1 h. The 2-SST focused on six key areas: (1) conversation skills (techniques for initiating, maintaining, transitioning, and ending conversations); (2) verbal and non-verbal communication skills (techniques, such as making requests, making statements, addressing/greeting, asking questions, explaining, agreeing/disagreeing, expressing emotions/empathizing, and giving/receiving instructions); (3) mind reading (activities included taking the perspective of others, understanding and exploring emotions, empathizing, and self-regulation); (4) storytelling and speaking skills (sharing their experiences with others and covering storytelling grammar including story themes, characters, chronological ordering, and cause and effect relationships); (5) higher level of language skills (problem-solving using language, inference skills, flexible thinking, listening monitoring skills, and imparting diverse background knowledge); and (6) play skills (playing together, sharing play, cooperating, resolving conflicts, sequencing/waiting, creating/following rules, acknowledging wins, and keeping secrets). The language and social abilities were measured to evaluate the 2-SST using several evaluation tools as follows:
(1) Korean version of PRES [10]: PRES is a test primarily conducted in Korea when language delay is suspected in preschool aged children [11]. The test consists of 90 items, with 45 items in the receptive language area (PRES-RC) and 45 items in the expressive language area (PRES-EC). Each item includes cognitive concepts and semantic language abilities, articulation and syntactic language abilities, and pragmatic language abilities. The results can be interpreted using either raw scores or percentile scores. In this study, raw scores were used for analysis due to the limitation of percentile scores calculation in children with scores below the lowest value provided in the age-specific normative table.
(2) Korean Receptive-Expressive Vocabulary Test (REVT) [12]: REVT is a vocabulary development test administered in Korea when the child is aged >30 months. It comprises expressive (REVT-RC) and receptive language items (REVT-EC), totaling 185 items. Raw scores were used for analysis.
(3) Korean Social Maturity Scale (SMS) [13]: SMS is a widely used test to assess subjects in terms of social and personal skills. It has six domains and 117 items, including self-help, self-direction, locomotion, occupation, communication, and social relation functioning. It provides the social quotient (SQ; social age/chronological age×100).
Our aim was to determine whether 2-SST has a significant therapeutic effect on children with language disorders. To assess therapeutic gains of language development, we analyzed the pre- and posttreatment scores using PRES and the REVT. Additionally, considering the potential impact of 2-SST on children's social and adaptive development, we also analyzed scores from the SMS-SQ.
Statistical analysis
All analyses were performed using SPSS (version 28.0 for Windows, IBM Corp.). Descriptive statistics were used to report the characteristics of the study sample. The Shapiro–Wilk test was used to examine the normality of distribution for each measurement. A paired t-test and Wilcoxon signed-rank tests were used to analyze differences in outcome measures between pre-treatment (T0) and post-treatment (T1). Pearson’s correlation analysis and Spearman’s correlation were used to determine linear relationships between the effectiveness of 2-SST and clinical variables, such as age, sex, and differences of language and social skills with paired-child. Subsequently, multivariable regression analysis through stepwise selection was used to identify independent prognostic factors of outcome measures. The factors were classified into two categories as follows: (1) baseline clinical variables: sex, age, age-group (≤5 or >5 years), intelligence quotient (IQ), baseline PRES, REVT, SQ, and treatment duration; (2) Difference from paired-child: sex, age, diagnosis, IQ, baseline PRES, REVT, and SQ. The level of significance was set at p<0.05 for all analyses.
RESULTS
Demographic characteristics
A total of 132 children who participated in 2-SST were screened and a total of 51 children with pre- and posttreatment evaluation results were enrolled in this study. The demographic characteristics of the participants are summarized in Table 1. The mean age of the participants was 5.43±1.39 years. There were 16 participants who were diagnosed with primary language disorder (specific language impairment, SLI and the others had a secondary language disorder (non-SLI) including diseases as follow; cerebral palsy (spastic diplegic cerebral palsy, spastic hemiplegic cerebral palsy), intellectual disability, genetic disease (Prader-Willi syndrome, Down syndrome, Tuberous sclerosis, CATCH22 syndrome), Attention deficit hyperactivity disorder, Epilepsy, and Autism spectrum disorder. The intellectual ability was 78.00±0.96 in the IQ of Wechsler test [14] and participants participated in 2-SST for 6.08±5.72 months.
Difference between pre- and post-2-SST
Pre- and posttreatment analyses of language skills showed statistically significant increase in all items, including PRES-RC (T1–T0: 6.98±11.62 points; p<0.001), PRES-EC (T1–T0: 7.46±8.98 points; p<0.001), REVT-RC (T1–T0: 16.25±22.64 points; p<0.001), and REVT-EC (T1–T0: 15.94±22.87 points; p<0.001). Additionally, there was a significant difference between T0 and T1 in SQ of SMS (T1–T0: 12.77±21.06; p<0.001) (Table 2, Fig. 1).
Correlation between clinical variable and effectiveness of 2-SST
The correlation between the outcome measures (language and social developmental therapeutic gain) and clinical variables is shown in Table 3. Among the clinical variables, age and baseline language skills were correlated with developmental gain in all language skill tests (PRES-RC, PRES-EC, REVT-RC, and REVT-EC) after 2-SST. We did not find significant correlation between clinical variables and social developmental gain in SMS test after 2-SST.
Predictor of degree of improvement in 2-SST
Stepwise multivariable regression analysis revealed that same diagnosis (β=-21.430, p<0.001) and baseline PRES-RC difference (β=-0.227, p<0.001) and IQ-difference (β=-0.226, p=0.036) from paired children were independent predictors of improvement in PRES-RC. Younger age (≤5 years) was an independent predictor of improvement in PRES-EC (β=-7.500, p=0.046). Older age (>5 years) was an independent predictor of improvement in SQ (β=34.117, p=0.034). The absence of multicollinearity was confirmed in this study (Fig. 2).
DISCUSSION
In this study, children who participated in 2-SST showed significant improvements in all categories of language skills, including receptive/expressive language abilities (PRES and REVT), supporting the findings of a previous study about group ST [15]. Furthermore, we identified that 2-SST was effective for improvement in social and adaptive function assessed by SMS. Through correlation analysis between therapeutic gain and various clinical variables, we identified a significant association between therapeutic gain in language skill and age. Subsequently, we classified participants into two age groups (based on the early intervention threshold of 5 years) and this categorical variable was included in a multivariable regression analysis. The multivariable linear regression analysis results showed that the same diagnosis and small difference in baseline receptive language and intellectual ability with paired-child were powerful predictors associated with improvement in receptive language. In addition, younger age (≤5 years) was found to be a powerful predictor associated with improvement in expressive language ability. In contrast, older age (>5 years) was an independent predictor of improvement in SQ.
While there is robust evidence from large-scale clinical trials and established treatment protocols for structured ST in adults with neurological disorders, the pediatric population lacks comparably robust evidence and standardized protocols [16-18]. The establishment of structured protocols in pediatric ST remains challenging due to the high developmental and etiological heterogeneity, limited larger-scale evidence (research ethics and practical limitation), and variability in intervention contexts by SLP. Consequently, clinical researchers have sought alternative methodologies for determining best practice [19,20]. To our knowledge, this is the first study to investigate the association between clinical variables and language/social gains by small-group ST as delivery model in children with language disorders.
The providers of pediatric health care services have the responsibility for prescribing physical, occupational, and speech therapies for children with temporary or permanent disabilities, and in particular, SLPs work with them to improve their verbal language skills or alternative communication techniques in children with language delay [21]. Though ST is usually targeted with the conventional one-on-one delivery model (individual ST), the group delivery model (group ST) is often observed as a beneficial intervention to primarily promote the generalization of skills [22]. However, previous studies have found mixed results concerning the delivery models that promote the best outcomes for advancing language development for children with language disorders. Individual ST has shown to be more beneficial at eliciting more new words, improving repetition, and increasing verbal communication. Group ST was found to be better at increasing the diversity of expressive modalities, increasing the purposes of communication, and improving performance in everyday life [15]. Previous studies have reported that it is critical that structured language intervention extends into functional ways to promote the generalization of language skills into realistic communication environment. Our results showed the advantage of 2-SST delivery model in both language and social skills by allowing more opportunities for social interaction with peers. The 2-SST can be the appropriate option for individualizing the treatment program with the benefit of both individual and group STs. For children transitioning from individual to group ST, 2-SST (consisting two children) may play a pivotal role in starting basic interaction with peers before extending the social interaction in a large group, mimicking a realistic communication environment. Thus, 2-SST can be considered as an effective delivery model for both language and social skills.
Furthermore, we can search for the factors responsible for improvement when enrolling children in 2-SST and incorporate these factors into 2-SST. Our results suggest that 2-SST can be a suitable option in children with same diagnosis, similar language and cognitive level as their paired-children, for advancing receptive language development. In addition, younger age (corresponding to early intervention) facilitate greater improvement in expressive language. Early intervention corresponds to the services provided for children with disability from birth to the age of 5 years (toddler-preschool era), and the benefits of receiving early intervention services have been widely reported [23]. Our results were consistent with those presented in earlier studies concerning the benefits of early ST intervention. In contrast, when the main goal is to improve social and adaptive skills, the 2-SST seems to be more efficient in older-age children. In conclusion, it is necessary to consider the diagnosis, cognitive, language ability with paired children, and age, as important when enrolling children into 2-SST.
This study had several limitations. First, in this study, a high proportion of children presented with primary language impairment, which may later be diagnosed as other neurodevelopmental disorders. This is a limitation of retrospective study design and may also result from the etiological and symptom heterogeneity of the pediatric language disorder. Second, it was difficult to analyze all variables that accounted for the efficacy of 2-SST, such as personality and learning style of children, as this study had a retrospective design. Based on this retrospective study on the detailed delivery model and prognostic factors associated with therapeutic gain, further prospective studies with precise diagnostic classification are needed to provide structured guidelines when individualizing ST program by SLPs. Third, the outcome measures include general language skills, including semantics (the rules relating to the meaning of language), syntax (the rules of sentence structure), and pragmatics (the rules within social situations), and we analyzed the social and adaptive skills using SMS. Further studies are needed to evaluate a pragmatics-focused assessment tool for identifying the effectiveness of 2-SST in promoting the functional use of language as a social tool. Finally, our study had a relatively small sample size, mixed disease entities in participants, and no control group. Further studies are needed to include a larger sample size, a more specific disease entity, and a control group to conclusively determine what powerful predictive variables are in 2-SST based on this retrospective study.
In this study, we aimed to assess the effectiveness of 2-SST and determine the variables associated with the language and social development gain. These results indicated that 2-SST can be the appropriate delivery model to improve both language and social skills. For maximal therapeutic gains, children should be matched with children with same diagnosis, similar language, and cognitive level. Age factor should also be carefully considered, depending on the more specific goals of treatment. These results may help clinicians to choose the more detailed and appropriate delivery models and incorporate clinical factors into 2-SST.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
None.
AUTHOR CONTRIBUTION
Conceptualization: Lee YJ, Kim A. Methodology: Lee CH, Lee YJ. Formal analysis: Lee CH, Seong J, Kim J. Project administration: Kim A. Visualization: Lee CH, Seong J. Writing – original draft: Lee CH. Writing – review and editing: Kim A. Approval of final manuscript: all authors.
Fig. 1.
The overview of change after participating in small group-speech therapy: (A) PRES-RC, (B) PRES-EC, (C) REVT-RC, (D) REVT-EC, and (E) SMS-SQ. PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the expressive language area; SMS, Social Maturity Scale; SQ, social quotient.
Fig. 2.
Regression lines predicting therapeutic gains with several variables for (A) PRES-RC, (B) PRES-EC, and (C) SMS-SQ separately. PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; SMS, Social Maturity Scale; SQ, social quotient.
Table 1.
Demographic and clinical characteristics of the participants
Characteristic
Value (n=51)
Age (yr)
5.43±1.39
Sex
Male
24 (47.1)
Female
27 (52.9)
Diagnosis
Specific language impairment
16 (31.4)
Cerebral palsy
10 (19.6)
Intellectual disability
8 (15.7)
Genetic disease
11 (21.6)
Attention deficit hyperactivity disorder
6 (11.8)
Epilepsy
5 (9.8)
Autism spectrum disorder
3 (5.9)
IQ
78.00±0.96
Language skill (point)
PRES-RC
36.43±13.36
PRES-EC
32.85±12.27
REVT-RC
44.38±22.42
REVT-EC
51.64±20.87
Social skill
SQ
65.0±14.40
Duration of 2-SST (mo)
6.08±5.72
Values are presented as mean±standard deviation or number (%).
IQ, intelligence quotient; PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the Expressive language area; SQ, social quotient; 2-SST, two-person small-group speech therapy.
Table 2.
Pre- and postspeech therapy comparison of language skill and SMS
PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the expressive language area; SQ, social quotient.
*Significant difference pre- and post-treatment (p<.05).
Table 3.
Correlations between clinical variable and therapeutic gain in small group-speech therapy
PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; SMS, Social Maturity Scale; IQ, intelligence quotient; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the expressive language area; SQ, social quotient.
*Significant difference pre- and post-treatment (p<0.05).
**Highly significant difference between pre- and post-treatment (p<0.01).
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Effects and Predictors of Two-Person Small Group Speech Therapy in Children With Language Disorder: A Retrospective Observational Study
Fig. 1. The overview of change after participating in small group-speech therapy: (A) PRES-RC, (B) PRES-EC, (C) REVT-RC, (D) REVT-EC, and (E) SMS-SQ. PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the expressive language area; SMS, Social Maturity Scale; SQ, social quotient.
Fig. 2. Regression lines predicting therapeutic gains with several variables for (A) PRES-RC, (B) PRES-EC, and (C) SMS-SQ separately. PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; SMS, Social Maturity Scale; SQ, social quotient.
Graphical abstract
Fig. 1.
Fig. 2.
Graphical abstract
Effects and Predictors of Two-Person Small Group Speech Therapy in Children With Language Disorder: A Retrospective Observational Study
Characteristic
Value (n=51)
Age (yr)
5.43±1.39
Sex
Male
24 (47.1)
Female
27 (52.9)
Diagnosis
Specific language impairment
16 (31.4)
Cerebral palsy
10 (19.6)
Intellectual disability
8 (15.7)
Genetic disease
11 (21.6)
Attention deficit hyperactivity disorder
6 (11.8)
Epilepsy
5 (9.8)
Autism spectrum disorder
3 (5.9)
IQ
78.00±0.96
Language skill (point)
PRES-RC
36.43±13.36
PRES-EC
32.85±12.27
REVT-RC
44.38±22.42
REVT-EC
51.64±20.87
Social skill
SQ
65.0±14.40
Duration of 2-SST (mo)
6.08±5.72
Outcome measure
T0
T1
Mean difference
p-value
Language skill (raw scores) (point)
PRES-RC
36.43±13.36
42.80±14.21
6.98±11.62
<0.001*
PRES-EC
32.85±12.27
39.88±15.60
7.46±8.98
<0.001*
REVT-RC
44.38±22.42
56.16±18.10
16.25±22.64
<0.001*
REVT-EC
51.64±20.87
60.59±15.19
15.94±22.87
<0.001*
Social skill
SQ
65.08±14.40
75.55±22.45
12.77±21.06
<0.001*
PRES-RC
PRES-EC
SMS
T1–T0
T1–T0
T1–T0
Clinical characteristic
Age
-0.438**
-0.397**
0.081
Sex
0.087
0.023
0.165
IQ
0.402
0.222
0.276
PRES-RC
-0.582**
-0.491**
-0.060
PRES-EC
-0.406**
-0.478**
-0.028
REVT-RC
-0.433**
-0.353*
0.343
REVT-EC
-0.416*
-0.413*
0.170
SQ
0.040
-0.224
-0.104
Treatment duration
0.044
0.060
0.085
Difference from paired child
Age
-0.231
-0.223
0.063
Sex
0.192
0.177
0.123
IQ
-0.031
0.036
0.127
Diagnosis
0.002
0.171
0.007
PRES-RC
-0.115
-0.097
0.185
PRES-EC
-0.072
-0.083
0.080
REVT-RC
0.697
0.538
0.227
REVT-EC
0.887
0.084
-0.071
SQ
0.360
0.129
0.243
Table 1. Demographic and clinical characteristics of the participants
Values are presented as mean±standard deviation or number (%).
IQ, intelligence quotient; PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the Expressive language area; SQ, social quotient; 2-SST, two-person small-group speech therapy.
Table 2. Pre- and postspeech therapy comparison of language skill and SMS
Values are presented as mean±standard deviation.
PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the expressive language area; SQ, social quotient.
Significant difference pre- and post-treatment (p<.05).
Table 3. Correlations between clinical variable and therapeutic gain in small group-speech therapy
PRES-RC, Preschool Receptive-Expressive Language Scale measuring items in the receptive language area; PRES-EC, PRES measuring items in the expressive language area; SMS, Social Maturity Scale; IQ, intelligence quotient; REVT-RC, Receptive-Expressive Vocabulary Test measuring items in the receptive language area; REVT-EC, REVT measuring items in the expressive language area; SQ, social quotient.
Significant difference pre- and post-treatment (p<0.05).
Highly significant difference between pre- and post-treatment (p<0.01).
