Group-based Classes Research Articles

Keep it Movin’: Design and methods of a church-based physical activity program to improve physical function among midlife and older black adults

BackgroundOlder Black adults have high rates of physical function (PF) limitations. Physical activity (PA) is effective for improving PF and reducing mobility disability risk; however, community-based PA interventions focused on improving PF for older Black adults are lacking. Given the importance of churches as trusted institutions in Black communities, church-based interventions developed through community collaborations may help increase access to PA interventions. MethodsKeep it Movin’ is a church-based cluster randomized controlled trial testing the effectiveness of a 24-week group-based (intervention arm) versus a self-guided (comparator arm) program in improving PF among Black adults aged ≥ 40 years with PF limitations (short physical performance battery [SPPB] score ≤ 9). A church-wide virtual walking program is available to congregants in both arms. The intervention arm receives weekly group-based classes held at the church that include education, goal setting, and structured PA (walking, lower-extremity strength, balance, and stretching). The comparator arm receives educational materials about PA appropriate for people with PF limitations. Outcomes are assessed at 6 (program completion) and 12 months (maintenance). The primary outcome is PF change as measured by the SPPB at 6 months. Secondary outcomes include change in moderate-to-vigorous PA, social support and self-efficacy for PA, quality of life, and self-reported PF. Factors related to successful adoption, implementation, and maintenance are assessed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ConclusionThis is the first study to evaluate the effectiveness of a group-based PA program delivered in Black churches to improve PF.

Modifying Whole Health Services for Successful Telehealth Delivery: Lessons from Veterans Health Administration's Rapid Transition During the COVID-19 Pandemic.

Introduction: The Veterans Health Administration (VHA) is shifting care from a disease-oriented to health-creating approach that aims to provide whole person care. This Whole Health (WH) system combines person-centered care with delivery of WH services (e.g., health coaching, well-being education and skill-building classes, and evidence-based complementary and integrative health therapies), alongside conventional medical services. During the COVID-19 pandemic, WH services were modified for delivery through telehealth (teleWH). This article characterizes modifications to WH services made to maintain continuity during the transition to telehealth formats. Materials and methods: We conducted semistructured qualitative interviews with a purposive sample of 51 providers delivering teleWH services at 10 VHA medical centers. We examined WH service modifications as well as facilitators and barriers to those modifications using rapid coding and directed content analysis. Results: Modifications were driven by (1) preparing for teleWH service delivery and (2) improving teleWH service delivery. To prepare for teleWH services, modifications were prompted by access, readiness, and setting and resources. Modifications to improve the delivery of teleWH services were motivated by engagement, community-building, safety, and content for a teleWH environment. One-on-one teleWH services required the fewest modifications, while more significant modifications were needed for well-being, skill-building, and movement-based groups, and reconfiguration of manual therapies. Discussion: Findings highlighted the need for modifications to ensure that teleWH services are accessible and safe and support interpersonal relationships between patients and providers, as well as in group-based classes. Successfully delivering teleWH services requires proactive preparation that considers access, readiness, and the availability of resources to engage in teleWH services. Tailoring strategies and considering the unique needs of different teleWH services are critical. Conclusions: The COVID-19 pandemic catalyzed teleWH service implementation, utilization, and sustainment. The challenges faced and modifications made during this transition provide lessons learned for other health care systems as they attempt to implement teleWH services.

Effects of Mindfulness Training and Exercise on Cognitive Function in Older Adults

Episodic memory and executive function are essential aspects of cognitive functioning that decline with aging. This decline may be ameliorable with lifestyle interventions. To determine whether mindfulness-based stress reduction (MBSR), exercise, or a combination of both improve cognitive function in older adults. This 2 × 2 factorial randomized clinical trial was conducted at 2 US sites (Washington University in St Louis and University of California, San Diego). A total of 585 older adults (aged 65-84 y) with subjective cognitive concerns, but not dementia, were randomized (enrollment from November 19, 2015, to January 23, 2019; final follow-up on March 16, 2020). Participants were randomized to undergo the following interventions: MBSR with a target of 60 minutes daily of meditation (n = 150); exercise with aerobic, strength, and functional components with a target of at least 300 minutes weekly (n = 138); combined MBSR and exercise (n = 144); or a health education control group (n = 153). Interventions lasted 18 months and consisted of group-based classes and home practice. The 2 primary outcomes were composites of episodic memory and executive function (standardized to a mean [SD] of 0 [1]; higher composite scores indicate better cognitive performance) from neuropsychological testing; the primary end point was 6 months and the secondary end point was 18 months. There were 5 reported secondary outcomes: hippocampal volume and dorsolateral prefrontal cortex thickness and surface area from structural magnetic resonance imaging and functional cognitive capacity and self-reported cognitive concerns. Among 585 randomized participants (mean age, 71.5 years; 424 [72.5%] women), 568 (97.1%) completed 6 months in the trial and 475 (81.2%) completed 18 months. At 6 months, there was no significant effect of mindfulness training or exercise on episodic memory (MBSR vs no MBSR: 0.44 vs 0.48; mean difference, -0.04 points [95% CI, -0.15 to 0.07]; P = .50; exercise vs no exercise: 0.49 vs 0.42; difference, 0.07 [95% CI, -0.04 to 0.17]; P = .23) or executive function (MBSR vs no MBSR: 0.39 vs 0.31; mean difference, 0.08 points [95% CI, -0.02 to 0.19]; P = .12; exercise vs no exercise: 0.39 vs 0.32; difference, 0.07 [95% CI, -0.03 to 0.18]; P = .17) and there were no intervention effects at the secondary end point of 18 months. There was no significant interaction between mindfulness training and exercise (P = .93 for memory and P = .29 for executive function) at 6 months. Of the 5 prespecified secondary outcomes, none showed a significant improvement with either intervention compared with those not receiving the intervention. Among older adults with subjective cognitive concerns, mindfulness training, exercise, or both did not result in significant differences in improvement in episodic memory or executive function at 6 months. The findings do not support the use of these interventions for improving cognition in older adults with subjective cognitive concerns. ClinicalTrials.gov Identifier: NCT02665481.

Investigating group-based classes ('weaning workshops') to support complementary infant feeding in Irish primary care settings: a cross-sectional survey.

This study aims to (1) investigate current practice regarding 'weaning workshops' to support complementary infant feeding delivered within Irish primary care, (2) explore the experiences and opinions of community dietitians regarding optimal content and modes of delivery of weaning workshops and (3) identify the key factors to be considered in the development and implementation of weaning workshops delivered within primary care. Cross-sectional survey. Irish primary care. Forty-seven community-based dietitians. Sixteen dietitians reported that workshops were run in their area with variable frequency, with ten reporting that workshops were never run in their area. Participants reported that mostly mothers of medium socio-economic status (SES) attended weaning workshops when infants were aged between 4 and 7 months, and that feedback from workshop attendees was predominantly positive. Dietitians identified that key factors to be considered in future development and delivery of weaning workshops are (1) workshop characteristics such as content, timing and venue, (2) organisational characteristics such as availability of resources and multidisciplinary involvement and (3) attendee characteristics such as SES. This study highlights substantial variability regarding provision of weaning workshops in Ireland, and a lack of standardisation regarding the provider, content and frequency of workshops where workshops are being delivered. The study also provides unique insights into the experiences and opinions of primary care community dietitians regarding the development and delivery of weaning workshops in terms of optimal content and delivery options. These perspectives will make a valuable contribution given the dearth of evidence in this area internationally.

The Social Divisions of Politics: How Parties’ Group-Based Appeals Influence Social Group Differences in Vote Choice

Social groups often differ in vote choice, but differences vary significantly between elections. Recent work argues that political parties shape group differences by the policies they propose. I posit that differences also depend on how parties use group-based appeals. This proposition is tested with a unique data set on group-based appeals, policy-based appeals, and voter preferences in Britain from 1964 to 2015. Focusing on social class as one prominent group membership, I show how class differences in vote choice respond to policy-based as well as group-based class appeals: the gap between voters from opposing classes widens or narrows depending on how much the Labour Party emphasizes “old” symbolic ties to workers and “new” ties to businesses. These effects are robust and compare to the policy effects highlighted in previous work. Overall, this implies a revised view on how political parties influence the social divisions of electoral politics.

Four-Week, Home-Based, Robot Cognitive Intervention for Patients with Mild Cognitive Impairment: a Pilot Randomized Controlled Trial.

Background and PurposePrevious studies suggest that cognitive intervention can mitigate the development of dementia in patients with mild cognitive impairment (MCI). However, the previous cognitive intervention was mostly provided as a group session, in which MCI patients sometimes had difficulty in regularly attending sessions or were reluctant to participate in group-based classes. Additionally, experienced instructors for traditional cognitive intervention may be unavailable in some chronic-care facilities or community centers. Considering these reasons, we have developed 5 programs for home-based cognitive intervention using a personal robot for MCI patients. In this preliminary study, we aimed to demonstrate the effects of our newly developed home-based cognitive intervention with robots on cognitive function in MCI patients.MethodsWe conducted a single-blind randomized controlled trial enrolling 46 MCI patients. Participants were randomized into 2 groups: the robot cognitive intervention (robot) (n=24) group and without cognitive intervention (control) (n=22) group. The interventions comprised 60-min sessions per day for 4 weeks. The primary outcome was the change in cognitive function measured using the Cambridge Neuropsychological Test Automated Battery.ResultsThere were no significant baseline demographic or clinical differences between the robot and control groups. After the 4-week cognitive intervention, the robot group showed greater improvement in working memory than did the control group.ConclusionsOur home-based cognitive intervention with a personal robot improved the working memory in MCI patients. Further studies with larger samples and longer study periods are required to demonstrate the effects of these programs in other cognitive domains in MCI patients.

Mixed methods pilot study of a low-carbohydrate diabetes prevention programme among adults with pre-diabetes in the USA

Objectives(1) To estimate weight change from a low-carbohydrate diabetes prevention programme (LC-DPP) and (2) to evaluate the feasibility and acceptability of an LC-DPP.Research designSingle-arm, mixed methods (ie, integration of quantitative...

A Parenting Behavior Intervention (the Strengthening Families Program) for Families: Noninferiority Trial of Different Program Delivery Methods

BackgroundThe Strengthening Families Program (SFP) is an evidence-based parent training and youth life skills and drug prevention program traditionally delivered in group settings. Families attend parent and youth classes conducted by trained facilitators. Recently, a 2-disk home-use DVD series was created with the same SFP skills as the group classes for parents and the youth to watch together at home. Additional lesson material was added that included healthy brain development, school success, anger management, dangers of alcohol and drugs, and mindfulness. The SFP DVD reduces SFP delivery costs for agencies and logistic burdens to families. Creative applications of the DVD include holding SFP DVD family discussion groups of multiple families and using SFP DVD video clips as part of a shorter 10-week group class version for parents and the youth.ObjectiveThis study aimed to examine three different DVD implementation scenarios using a noninferiority trial, contrasting target outcomes with an age-matched sample culled from a national norm database of families who completed a standard SFP 14-week class.MethodsThe partial eta-square was used to compare effect sizes between the different delivery modalities for relevant programmatic outcomes. We adjusted the effect sizes by demographic measures to determine whether there were site-specific features influencing program outcomes.ResultsFor the unadjusted effect size comparisons, 13 of the 15 indicated that the home-use DVD outperformed group norms with an average 0.13 effect size estimate difference across the comparisons (28% improvement in the effect size for DVD condition). Comparisons of the home-use DVD condition with the mixed DVD use conditions showed no discernable pattern where one condition consistently outperformed another. Adjusted effect sizes still reinforced the superiority of the DVD conditions; however, there was some shrinkage in the effect sizes as expected with the inclusion of relevant covariates.ConclusionsThe home-use DVD shows that it is possible to effectively deliver an affordable family-based intervention using alternative technology outside of the traditional group-based class format. In almost all of the comparisons, the DVD conditions outperformed the group norms, underscoring that low-cost DVDs or viewing the videos on the Web may provide a useful surrogate for costly group-based formats. Future studies may want to improve on the quasi-experimental design by examining programmatic differences based on delivery format using a randomized controlled trial, thus strengthening the causal framework regarding program effects. In addition, the assessment protocol relied on retrospective reporting, which, although this can limit response shift bias, does not separate data collection in time as with a true pre- and posttest design.

THE EFFECTS OF HOME-BASED COGNITIVE INTERVENTION WITH ROBOTS ON COGNITIVE PERFORMANCE IN PATIENTS WITH MILD COGNITIVE IMPAIRMENT

Previous studies showed that cognitive intervention helped mitigating the development of dementia in patients with mild cognitive impairment (MCI). However, the cognitive intervention programs of the previous studies were mostly provided as a group-session in a local hospital, which often made patients with MCI having difficulty in regularly attending sessions or reluctant to participate in group-based classes. In addition, traditional cognitive intervention usually needs experienced instructors, but those qualified instructors may be unavailable in some chronic care facilities or community centers. For this reason, we have developed a total of 20 programs for home-based cognitive intervention with robots for the patients with MCI. The purpose of this study was to demonstrate the effects of our newly developed home-based cognitive training with robots on the cognitive performance in patients with MCI. A single-blind randomized controlled trial was conducted in 48 volunteers aged 60 years or older with mild cognitive impairment. Participants were randomized into two groups: 24 with robot intervention, and 24 without cognitive training. The interventions consisted of 60-min-session per day for 4 weeks. The primary outcome was the changes in cognitive function measured by Cambridge Neuropsychological Test Automated Battery. There were no demographic differences between the robot intervention and the control groups. The robot intervention group showed a greater improvement in the attention function than the control group after 4-week training. Our home-based cognitive training with robots helped improve attention in patients with MCI. The further study with larger samples for a longer duration would be warranted to demonstrate the effects of those programs in other cognitive domains in MCI patients.

Interpreting RCT, process evaluation and case study evidence in evaluating the Integrated Group Reading (IGR) programme: a teacher-led, classroom-based intervention for Year 2 and 3 pupils struggling to read

ABSTRACT Almost 20% of English pupils still experience difficulties with reading despite the use of a predominantly phonics-based approach that works well for most children, but not for all; therefore, other approaches need to be explored. The Integrated Group Reading (IGR) programme involves an inclusive approach to targeted teaching led by class teachers using group-based class organisation and the integration of diverse, research-based approaches (language and phonics-based). IGR has been evaluated in 34 English schools across 5 varied local authority areas using a cluster randomised design and a process evaluation. IGR was found to support enjoyment of reading and attain as much reading gains as the more phonics-oriented programmes used in the control classes. Following its use there were gains in teachers’ self-efficacy in teaching reading, and no negative effects on the class (non-IGR) pupils’ reading skills were found. This study shows what a more inclusive approach to targeted reading intervention can achieve through a well-resourced programme. Questions can be asked about the interpretation of randomised controlled trial (RCT) findings when it comes to classroom-based educational interventions, and about teacher choice in opting for alternative teaching approaches.

Effects of yoga on oxidative stress, motor function, and non-motor symptoms in Parkinson\u2019s disease: a pilot randomized controlled trial

ObjectiveTo examine the feasibility, acceptability, and preliminary effects of Hatha yoga on oxidative stress, motor function, and non-motor symptoms among individuals with Parkinson’s disease (PD).MethodsThe study has a pilot randomized controlled trial design with two arms: an immediate treatment group and a wait-list control group. The yoga-for-PD program was implemented via twice weekly 60-min group-based classes for 12 weeks. Participants were assessed at baseline, 12 weeks, and 6 months post-intervention. Outcome measures included oxidative stress, motor function, physical activity, cognitive function, sleep quality, and quality of life. Data on program acceptability and yoga adherence were collected during the intervention and at 6 months post-intervention.ResultsParticipants (n = 20) had a mean age of 63 years (SD 8, range 49–75) and disease duration 4.8 years (SD 2.9, range 1–13). All participants had mild-moderate disease severity; 18 (90%) were on dopaminergic medications. Seventeen participants (85%) attended at least 75% of the classes and 4 (20%) attended all classes. Most participants (n = 17) reported they “definitely enjoyed” the intervention program. No adverse events were reported. At 12 weeks, there were no major differences in blood oxidative stress markers between the two groups. Motor function based on the Unified Parkinson’s Disease Rating Scale was better in the treatment group, but their scores on sleep and outlook in Parkinson’s Disease Quality of Life (PDQUALIF) Scale and the physical activity levels based on the Longitudinal Aging Study Amsterdam Physical Activity Questionnaire were worse than those of the control group. In within-group comparisons, motor function, cognitive function, and catalase improved but three PDQUALIF domains (social and role function, sleep, and outlook) and physical activity level worsened by the end of the yoga intervention program compared to baseline. The response rate for the 6-month follow-up survey was 74% (n = 14) with six participants (43%) who signed up for a yoga class and four (29%) who practiced it independently. Health problems were the main barrier to yoga practice.ConclusionYoga is feasible and acceptable and may serve as a complementary method for improving motor function in PD. Further research using a larger sample size is needed to determine its impact on oxidative stress and non-motor symptoms.Trial registrationClinicalTrials.gov Registration Number: NCT02509610031.

Injury surveillance of female adult Zumba® dancers.

We sought to describe the patterns of injury and to establish the injury incidence rates associated with Zumba®. Zumba® dancers were invited to complete an anonymous web-based survey containing 13 demographic background and 14 (1 year retrospective) injury history questions. Inclusion criteria stated that the respondents had to be aged 18-64 years and currently involved in group-based classes of Zumba®, either as a registered instructor or class participant. Binomial logistic regression analysis was used to predict the odds of injury during Zumba® and Mann-Whitney Tests were employed to ascertain differences between groups. The survey response rate was 74%. The final sample of respondents (N.=138; female=100%) included 19 registered instructors and 119 class participants, of which 58% and 16%, respectively, sustained ≥1 injury during Zumba® in the past year. The odds of injury was 7 (95% CI 2-19) times greater (P<0.01) for registered instructors than for class participants. Zumba® dancers had a 17 (95% CI 7-28) % greater (P<0.01) odds of injury for every 1 hour of non-Zumba®-related moderate to vigorous physical activity (MVPA) engagement per week. The injury incidence rate for registered instructors and class participants was 5.7 (95% CI 3.1-8.2) and 3.9 (95% CI 2.5-5.3) injuries per 1000 hours of exposure, respectively. Zumba® presents a low risk of injury; for registered instructors, the increased risk of injury is likely due to the high total volume of MVPA participated in weekly.

Group-based exercise combined with dual-task training improves gait but not vascular health in active older adults without dementia

BackgroundGait abnormalities and vascular disease risk factors are associated with cognitive impairment in aging. ObjectiveTo determine the impact of group-based exercise and dual-task training on gait and vascular health, in active community-dwelling older adults without dementia. MethodsParticipants [n=44, mean (SD) age: 73.5 (7.2) years, 68% female] were randomized to either intervention (exercise+dual-task; EDT) or control (exercise only; EO). Each week, for 26 weeks, both groups accumulated 50 or 75min of aerobic exercise from group-based classes and 45min of beginner-level square stepping exercise (SSE). Participants accumulating only 50min of aerobic exercise were instructed to participate in an additional 25min each week outside of class. The EDT group also answered cognitively challenging questions while performing SSE (i.e., dual-task training). The effect of the interventions on gait and vascular health was compared between groups using linear mixed effects models. ResultsAt 26 weeks, the EDT group demonstrated increased dual-task (DT) gait velocity [difference between groups in mean change from baseline (95% CI): 0.29m/s (0.16–0.43), p<0.001], DT step length [5.72cm (2.19–9.24), p =0.002], and carotid intima-media thickness [0.10mm (0.003–0.20), p=0.04], as well as reduced DT stride time variability [8.31 coefficient of variation percentage points (−12.92 to −3.70), p<0.001], when compared to the EO group. ConclusionsGroup-based exercise combined with dual-task training can improve DT gait characteristics in active older adults without dementia.

Beyond Strength: Participant Perspectives on the Benefits of an Older Adult Exercise Program.

This study examines the expected and experienced benefits among participants in Enhance®Fitness (EF), an evidence-based group physical activity program for older adults. We also describe the implications for program dissemination (reach, implementation, and maintenance) within the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Twenty semistructured interviews were conducted with EF participants enrolled from 2005 to 2012. Interviews were digitally recorded, professionally transcribed, and analyzed using a deductive approach. Participants were motivated to join EF for expected physical benefits and the social environment of a group-based class. Actualized benefits of participation included physical, social, functional, and improved self-image/sense of well-being. Participants valued the practical application of class exercises to daily activities that support independent living, such as lifting objects and completing household chores. Organizations looking to implement EF or improve existing EF classes can improve program reach, implementation, and maintenance by incorporating participants' expressed motivations and valued benefits in program marketing and by improving organizational support to meet participant needs. EF class instructors can tailor their classes to engage participants based on their motivations. Understanding participants' motivations and valued benefits can improve EF dissemination by meeting participant needs with tailored class offerings and organizational needs informed by participant insights that aid program sustainability.

A community-based pilot randomised controlled study of life skills classes for individuals with low mood and depression.

BackgroundCognitive behavioural therapy (CBT) is recommended for the treatment of depression and anxiety. However, access is limited. Low-intensity approaches such as guided CBT self-help (bibliotherapy) can increase access to treatment and is recommended by UK guidelines. No previous research has explored the provision of group-based guidance/support for a bibliotherapy approach for depression and anxiety in community settings. The objective was to carry out a pilot study of a group guided self-help intervention, using community based recruitment methods.MethodA randomised controlled trial comparing an 8 week CBT group guided self-help intervention to usual care. Recruitment and the delivery of the intervention were carried out in Glasgow and Derry/Londonderry in partnership with national depression charities. Fifty-three people were randomised, however we refer only to the forty-six participants who provided baseline data: 16 males and 30 females, aged 16 or over, with a PHQ-9 score of ≥ 5, were recruited from the community. The mean age of the sample was 43.7 (sd = 13) and 93.5% of participants had suffered from low mood for a year or more.ResultsThere was effective recruitment, randomisation, uptake and adherence with 21 Immediate Access (IA) and 25 Delayed Access Control (DAC) participants. The intervention was highly acceptable to participants attending on average 4.46 of the 8 sessions (sd 3.06), 65.2% attended more than half of all sessions. The mean satisfaction on the Client Satisfaction Questionnaire was 28 out of 32 (sd 4.8). The provisional results in the pilot suggest the intervention may improve both anxiety and depression. At three months, data collection was achieved from 74% of participants. The trial successfully provided estimates of the sample size needed for the future planned trial.ConclusionsLow-intensity group-based classes may offer an alternative method of managing depression and anxiety and warrant further research.Trial registrationCurrent Controlled Trials ISRCTN84893887. Registered 3 November 2011.

Mindfulness-based intervention for prodromal sleep disturbances in older adults: Design and methodology of a randomized controlled trial

Sleep problems are prevalent among older adults, often persist untreated, and are predictive of health detriments. Given the limitations of conventional treatments, non-pharmacological treatments such as mindfulness-based interventions (MBIs) are gaining popularity for sleep ailments. However, nothing is yet known about the impact of MBIs on sleep in older adults with prodromal sleep disturbances. This article details the design and methodology of a 6-week parallel-group RCT calibrated to test the treatment effect of the Mindful Awareness Practices (MAPs) program versus sleep hygiene education for improving sleep quality, as the main outcome, in older adults with prodromal sleep disturbances. Older adults with current sleep disturbances will be recruited from the urban Los Angeles community. Participants will be randomized into two standardized treatment conditions, MAPs and sleep hygiene education. Each condition will consist of weekly 2-hour group-based classes over the course of the 6-week intervention. The primary objective of this study is to determine if mindfulness meditation practice as engaged through the MAPs program leads to improved sleep quality relative to sleep hygiene education in older adults with prodromal sleep disturbances.

The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: study protocol for a randomised controlled trial.

BackgroundOsteoarthritis is a leading cause of disability in developed nations. In Australia it afflicts 16.5% of the adult population. Total joint arthroplasty is considered the treatment of choice for end stage osteoarthritis. The number of total joint arthroplasties undertaken in Australia has doubled over the last decade (more than 80,000 procedures in 2011). The incidence of pre-operative psychological distress in this group of patients is reported between 30% and 60% and pre-operative psychological distress is associated with poorer pain and functional outcomes after surgery. This study will use a mindfulness-based psychological intervention to enhance outcomes in people undergoing total joint arthroplasty and, in addition, will test hypotheses about coping with chronic illness in an aged population. This study is the first of its kind and will provide a greater understanding of the role of a mental health enhancement program on the physical recovery of total joint arthroplasty patients.Methods/DesignOne hundred and fifty people with end-stage arthritis on the waiting list for total hip or knee arthroplasty will be recruited and randomly allocated to one of two groups using computer-generated block randomisation. A randomised controlled trial adhering to CONSORT guidelines will evaluate the efficacy of a mindfulness training program (weekly group-based classes in mindfulness practice, 2 ½ hours, for 8 weeks plus a 7-hour Saturday session in Week 6) prior to total joint arthroplasty, compared to a “standard care” group who will undergo routine total joint arthroplasty. Primary outcomes will be evaluated by a blinded examiner at baseline, 3 and 12 months post-surgery, using a validated self-reported pain and physical function scale. Secondary outcomes will include i) a range of validated measures of psychological wellbeing and ii) health economic analysis. All analyses will be conducted on an intention to treat basis using linear regression models. Health economic modelling will be applied to estimate the potential cost-effectiveness of mindfulness training and total joint arthroplasty.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTRN12611001184965). Date of registration; 15th November 2011.

The Behavior of Utility Maximizing Members in a Classroom Group Project: Implications of the Envelope Theorem

In this article we question the prevailing belief that by assigning group-based class projects at the undergraduate level the quality of the finished product will be higher than if each student worked individually, and that professors introduce to the students the value of being a team player. We use a simple utility function and the Envelope Theorem to prove that this may not be the case. The model presented in this article implies that the overall project grade will be a function of the lowest performing student's effort and/or skills, and that low performing students may end up with higher grades at the cost of lower grades for hardworking and high performing students. The implications of our model find support in Ashraf (2004).

(i) Optimizing non-operative care

Summary Surgical treatment of back pain has limited success. It is therefore critical that spinal surgeons (who see most back problems in secondary care) are aware of the results of non-operative treatments. It is now known that most of the predictors of the development of long term distress and disability following an episode of back pain are psychosocial. Factors such as a tendency to low mood, fear avoidance, passivity, and poor sickness absence record, (known as "yellow flags"), all feed into the pain experience and thus should be included in the work up. Detection of multiple factors can inform the surgeon about why the person is in trouble and enable better decision making about the likelihood of a biological intervention being successful. Of the non-operative treatments available, although there is limited evidence for exercise programmes and back schools, many commonly employed approaches such as passive physiotherapy and facet joint injections are of unproved benefit. The treatments with best evidence of effectiveness are intensive interdisciplinary programmes (also known as functional restoration or pain management programmes). These therapies have been shown to be as effective as spinal fusion surgery and should be offered to persons with persistent difficulties before proceeding to fusion surgery.