Implementing integrated online prevention to reduce the risk of both obesity and eating disorders, in the school setting, is a promising approach. The challenge is to develop highly user-friendly and motivating programs, to foster adherence and effectiveness. The purpose of this study was to evaluate the usability of such a universal prevention program for students aged 14–19 years, and to address engagement issues. A mixed-methods approach was chosen, consisting of a think-aloud task, a semi-structured interview, and a questionnaire including items on sociodemographic characteristics and the System Usability Scale (SUS). Usability tests were conducted in two rounds, with five adolescents participating per round. Mean score in the SUS was 92.5 of 100 points (range 85–100), in the second round, after some adaptations from the participants’ feedback. In the course of the think-aloud tasks and interviews, five major themes emerged—visual design, navigation, mode of transfer, content, and engagement conditions. Interesting headlines, gamification, and monitoring tools are crucial for engagement. Apart from the importance of using the program during school hours, the study showed that problems currently perceived as important by the target group, need to be considered and addressed, prior to offering them prevention programs, which highlights the importance of a user-centered design. Prevalence rates of overweight and obesity, worldwide, have increased drastically ,2; conseGiven the shared risk factors for eating disorders and being overweight, researchers have called for integrated approaches to prevention . Such apDue to their scalability, their potential to reach a large number of people, and relatively low costs, online programs seem to have a high potential to tackle this public health challenge . EspeciaMore than 95% of European adolescents and young adults between 16 and 24 years, are using the Internet regularly, therefore, Internet-based or mobile phone applications/platforms could be a key resource in providing health information to adolescents . As for Accordingly, this study aimed to evaluate the usability of a school-based online intervention program for adolescents, as well as to address engagement issues, to reduce dropout rates in the “Healthy Teens @ School” study, a multi-country cluster RCT . The intPotential participants were recruited via social media (Facebook). Girls and boys aged between 14 and 18 years, from different schools in Vienna, were invited to take part in a study aiming to test the prototype of an online program for promoting healthy habits in pupils. The inclusion criteria for this usability study reflected the target population of the “Healthy Teens @ School” program that was designed for students between 14 and 19 years. Participants were offered gift cards of € 20 for their participation.Following the principles of usability evaluation, we conducted usability tests in two rounds, with five participants per round. A sample size of five participants per round was regarded as sufficient to detect more than 85% of usability problems. Including more participants would have required more resources in terms of time and money, while only producing repetitive information ,33. In t“Healthy Teens @ School” is a ten-week online program (one online-module per week) designed to promote a healthy lifestyle and reduce eating disorder risk and obesity risk. Based on a screening questionnaire, which includes the assessment of eating behaviors, eating disorder risk, weight status, weight/shape concerns, physical activity habits, stress coping, depression, anxiety, self-esteem, and quality of life, the participants get access to the online program and are assigned to either one of two program tracks. Adolescents with normal weight (with and without eating disorder risk) are assigned to the “Healthy habits” track, overweight adolescents (>85th sex-age-specific BMI percentile) are assigned to the “Weight management” track. In ten modules, the students learn about building a healthy lifestyle, about balanced nutrition and physical activity habits, about ways of improving their body image and body satisfaction, as well as ways of improving media literacy. Whereas the content in the “Healthy habits” track is framed towards building a healthy lifestyle, the content in the “Weight management track” is framed more towards maintaining a healthy weight. In the course of the three preceding focus groups, especially stress in school turned out to be a major issue for the students . As a reThe program is provided on an online platform hosted by Minddistrict GmbH. The users log on the platform via an e-mail address and a self-chosen password. From the user’s dashboard, the screening questionnaire and program modules can be accessed; students can see new tasks assigned and they have the possibility to contact the study team via a messaging function. Screenshots of the user’s dashboard and the program module including the app-diary are provided in The program can be accessed within and outside school lessons, via different devices, like computers, tablets, and smartphones . For thiWe conducted an evaluation study focusing on aspects of usability and engagement, following the study protocol of Nitsch et al. .Prior to testing, informed consents of the participants and legal representatives were obtained, and the researcher explained the procedure. The usability testing sessions consisted of three parts, (a) program use while performing the think-aloud technique, (b) a semi-structured interview, and (c) completion of a questionnaire, including sociodemographic questions and the System Usability Scale . The thFollowing the think-aloud task, a semi-structured interview was conducted. The interview guide included questions about expectations towards the program, impressions of the program, questions about program content, the diary, motivation for completing the program, and if the participant would recommend the program to others.Subsequent to the semi-structured interview, the participants were asked to complete questions on sociodemographic characteristics, their current Internet use, as well as the SUS questionnaire . The SUSThe usability testing sessions took 55 to 90 min, in which participants had the possibility to familiarize themselves with the program and answer the questions. The testing sessions were conducted from January till February 2017, and took place at the FernFH Distance Learning University of Applied Sciences in Vienna and at the Medical University of Vienna.The study protocol was approved by the Ethics Commission of the Medical University of Vienna .Both, the think-aloud task and the interviews, were videotaped and audiotaped, then transcribed verbatim, including the non-verbal reactions of the participants, based on the video recordings and the observer notes. The transcripts were coded and analyzed, using NVivo 11. Thematic analysis  was usedAll ten participants were students between 14 and 18 years old  = 1.2), attending different high schools in Vienna. In the first usability test round, four male students and one female student took part, and in the second round, four female students and one male student participated. Their BMI ranged from 18.8 to 24.2 . None of the participants had a diagnosed psychiatric disorder or received psychotherapeutic treatment. In the IES which was defined as the main outcome of the intervention, eight participants had average scores and two participants had above-average scores .Regarding the SUS-questionnaire, the usability of the program was in the acceptable range (SUS-Score > 70) in the first round, and in the excellent range (SUS-Score > 85) in the second round. The average SUS score was 84 (range from 67.5 to 97.5), in the first round, and improved to an average SUS score of 92.5 (range from 85 to 100) of 100 points, in the second usability test round.By using the think-aloud tasks and the semi-structured interviews, we were able to identify five central themes, referring to visual design, navigation, mode of transfer, content, and engagement conditions.“youthful”, “cool”, “pretty”, “appealing”, and “clearly arranged” and reminded some participants of social media platforms and search engines: “The landing page looks up-to-date, similar to social media and Facebook and instant messaging design, appealing to teenagers (...) I also liked the layout and pictures” . The program’s color design was rated ambivalent by the participants. Some liked the variation, others recommended a reduction in colors or a more targeted use of colors. “Maybe, there should be less red, because I know, especially on a bright website, red indicates that there is something very important or wrong” . Some students observed, that the font size was too small in some areas. All participants mentioned, that they like the layout of the diary, regardless of using it on the computer or via the app. They were also motivated to complete the diary because they liked the visualization of their improvement in healthy habits over time. Furthermore, participants liked the absence of advertising elements in the program.Most of the students liked the visual design of the “Healthy Teens @ School” program, especially the pictures and graphics were highlighted as positive. The layout of the program was perceived as easy” and “self-explanatory”. However, it seemed to be a challenge to create a secure password. Only one of ten participants managed to include all demanded aspects  at the first attempt.The majority of the students described the navigation of the program as “helpful”, “reasonable for orientation”, and “well-illustrated”. Others said, that they would not need such a video, stating young people prefer to try out programs and do not want to watch videos about the navigation: “I think, it is self-explanatory (…). And I think, most teenagers would prefer to simply try it out instead of watching some explanation for a long time. Okay, actually, it’s not so long, but I think, that most people would just try it out” . After showing the tutorial video in the second usability round we could monitor more targeted approaches to find the diary, the different modules and an overall improvement in the platform navigation. A participant even mentioned that “you will instantly find your way”  in the program.In the think-aloud sessions we observed some challenges finding the next module or the diary function. Some asked for help, others found the next module or the diary after repeatedly trying. Consequently, we produced and included a tutorial video lasting five minutes for the second usability test round. This video included a short introduction to the navigation and the functions of the program and the platform. Most participants liked the tutorial video, they described it as “This theme refers to the way the content and information is communicated to the user. After completing the screening questionnaire, some participants were irritated by certain questions of the IES, which sounded similar and felt like a repetition to them.During the first test round, participants had to scroll to the top several times, as due to its length, the response options of the IES questionnaire did not fit on one screen, after a certain number of items. Therefore, prior to the second test round, we divided a long block of questions into two smaller parts, in order to ensure that the response options were visible at all times. Negated questions were harder to understand for some students. One person said that sometimes the wording in the IES questionnaire was unclear  or students indicated questions that appeared strange to them. Furthermore, some participants mentioned that the open question asking to describe a personal stress inducing problem (out of the KIDCOPE-questionnaire), was somewhat confusing, since the subsequent set of questions, directly referring to the mentioned problem, were not always fitting.“There was a bit too much written text, but the texts were not always the same, and addressed you directly” . An aversion for long texts became also apparent in the think-aloud sessions, where many participants only skimmed or even skipped longer texts. On the contrary, interactive tools like quizzes and questions were always noticed and used and rated as positive: “It is better than just reading tips, (…) that you can fill out things and instantly get feedback” . Accordingly, the students underlined the importance of the “gamification” of the program; they liked to do quizzes to repeat the content or knowledge games, instead of reading long texts with detailed information and complex wording. For example, one girl argued that interactive tools might also be helpful with regard to concentration: “You can’t finish it [the program] in five minutes; instead you really have to take your time, sit down and read it in detail. Maybe it should be a bit shorter, so that you don’t have to read that much, yeah, more quizzes, and just make it simpler, so you don’t have to concentrate so hard” . Furthermore, the participants said that they liked to explore new things in the program and that they like being addressed personally with “you” or “your”. Since text passages without interesting headlines were partially only skimmed and students stated that significant headlines motivated them to read text passages, we added more headings after the first round.In the interviews, participants criticized the long text passages, very detailed information and suggested shorter texts and sentences: “It is done real quick, it takes less time than a normal diary entry. Well, on the smartphone it is quick, you can do it on the subway or on the way home, that’s fine, that’s convenient” .The diary tool was considered as interesting and useful, especially regarding the possibility to visualize habits over time. In the second round, the diary function was available on the computer and additionally on the app. Both modes were rated as positive, but two advantages of the app were highlighted—the app appeared more game-like and chances of using the app more frequently were rated higher, since it is more convenient to use the program on the smartphone: helpful”, “informative”, “diversified”, “good to read” and “meaningful”. One participant said that the program “is cool” because “it is not counseling, not like at the psychologist or the doctor, you don’t feel sick (...) it is a kind of help but not in an uncomfortable way (…) not bad for your self-worth” .In general, the students denoted the information delivered in the different parts of the “Healthy Teens @ School” program as “I think, it fits me well, and it came across very personal and that I find really cool, I mean that was really cool. And for me personally, it is real fun to fill out quizzes and to get such feedback. That is fun, that is cool” .The explanation and the outcome of the feedback were described as fitting to the person and very informative: “I didn’t know much yet, for example the daily food requirement, how many snacks you should eat, what and how much food you should eat to be balanced, in school and at home”.The provided information in the modules was described as meaningful and interesting. Some students expressed that they have already heard about some of the information, but it was also nice to hear familiar content again. Some parts of the content were new to them. For example, most participants stated that they already knew about the food pyramid or learned about it in school. The information on how many portion sizes a day is recommended for the different food groups, and how portion sizes can be measured, was perceived as new and interesting: “if you do that (the program), then you want that something changes. If you wouldn’t want to change something, then you would not do it” . The possibility to use the program, including the diary, on different devices like computer, smartphone, and tablet was very attractive for the users and might also improve the adherence of participants. Especially, the smartphone version of the program was described as “user friendly”, “comfortable” and “always within reach”. For example, one participant said that she would use the program “more likely on the smartphone as it’s always in reach. And I do not have to turn on the computer, enter the password and so on (…) but your smartphone is always there. You can also do it on the way” . Another participant found that he personally would prefer doing the program “on the computer because there is a keyboard and I prefer that, but for many others at my age the smartphone is the number one and they would prefer doing it on their smartphone” .The participants stated that they would use the program in their daily routine, if they feel that they need it and would recommend the program to colleagues and friends, if they had psychological or health problems or if they think the content would be interesting for them. Some students indicated that they like the program because it was informative, exciting, easy and fast to use. The motivation to complete the program was the desire for a change in daily lifestyle and the personal feedback received. For example, one participant stated that “Since a lack of time also seemed to be an important aspect for students, they positively highlighted the length of the program modules. The majority of the participants indicated that over the course of 10 weeks, investing 20 to 30 min once a week, seems to be feasible.“I would do it, I’m not sure if the other students would do it as well, but when it takes place in school instead of a regular class, then I think they would. It depends on how the first five modules are, if I would do it at home as well” . On the other hand, although the school was generally described as an adequate setting for using the program, the school setting itself raised many issues in connection with the topic of stress. For example, in the course of the usability session, students were asked to describe a recent problem that bothered them and nine out of ten participants gave an example of school-related stress, including “work overload”, “exam stress”, stress related to bad grades and interpersonal problems with classmates. During the think-aloud task, many participants emphasized consequences of school stress, for example influencing their overall well-being: “I’m not feeling well at the moment, because I have school stress” . Another participant highlighted that stress has a negative effect on his leisure activities: “I have too much schoolwork and don’t have much free time to do anything else” . This finding is especially important, since it validates and highlights the results of the pre-study, in which focus groups with students were conducted and stress turned out to be a major issue as well [would recommend [the program] to students experiencing stress or health problems; but rather not to others” .The possibility of using the program within school lessons turned out to be an important factor in terms of engagement. On the one hand, all participants stated, that if they had the chance to do the program in class, they would use it regularly. However, in most cases the program simply turned out to be a better alternative than regular school lessons:  as well . One parThe aim of this usability study was to evaluate and advance the usability and engagement aspects of an unguided online intervention program for promoting a healthy lifestyle and to reduce the risk for eating disorders and obesity among adolescents. Additionally, we aimed to validate the results of preceding focus groups with representatives of the target group. The application of a mixed methods research design not only allowed us to gain deeper insights regarding the students’ perception of online health promotion and prevention programs and their media usage, but also to improve and test the program in a very effective way. In this usability study, we found five major themes—visual design, navigation, mode of transfer, content, and engagement conditions.Especially, the findings of the current study regarding the design, navigation, and the mode of transfer of online interventions are comparable to other studies. For example, one major finding was the fact that the participants disliked reading long texts and preferred multimedia content, which was also a result in similar studies ,43,44. TSince some participants tended to skim or skip long texts, it is crucial to visually distinguish important from less important text parts . We trieSimilar to the study of Nitsch et al. , some paFurthermore, especially for adolescents, the integration of interactive and gamification elements seems to be an essential prerequisite . ChangesWe observed that time was a crucial factor for using the program or recommending it to others. The length of the weekly modules was described as suitable and the daily diary was evaluated as very good and realistic, regarding regular program use. Accordingly, the participants mentioned the importance of different user devices. The possibility to use the online intervention program, including the diary, on the computer, smartphone, and the tablet increases the accessibility.Another motivating point was that the program addressed the users personally with “you”. In the diary the participants liked the possibility to visualize habits over time and mentioned this as a factor for using the diary regularly or daily.A crucial factor in terms of engagement and regular program use was the possibility of working with the program in the school setting, and not in the free time. This result can also be confirmed by various other studies, for example Neil et al.  highlighHowever, when implementing interventions in particular settings, confounding or contextual factors concerning the setting itself need to be considered as well. The present study showed that the school setting raised various issues related to the topic of stress. For example, when students were asked about a recent problem, the majority of the participants mentioned a school-related problem. Accordingly, the problems currently perceived as important by the target group, need to be considered and addressed, prior to offering them programs for health-related issues, which they might not even think of, or are interested in. The results of this study, as well as our previous research on engagement issues, suggest that framing a program, primarily designed to reduce eating disorder and obesity risk, towards stress and stress reduction, might help to improve engagement. Stress turned out to be a major issue for adolescents who participated in our study, and this might also motivate them to use the program. Furthermore, program content covering a balanced nutrition, physical activity, and body image, can easily be linked to the topic of stress, for example, by highlighting the association between high levels of stress and fast eating or the benefits of regular physical activity for stress reduction. On the other hand, providing adolescents with helpful coping strategies, might prevent them from resorting to negative behavioral patterns, like self-blame or emotional eating. Furthermore, participating in a program labeled as a stress-reduction program might also be less stigmatizing than participating in a program for preventing eating disorders and obesity, since almost every adolescent experiences stress in some way or another. This was also an issue in another study where adolescents said that the terms describing mental disorders sounded daunting. They recommended that the program title and content should be framed positively  . GeneralIn this context, the value of user-centered design needs to be highlighted, since it does not only allow us to tailor interventions to the users’ needs, but also offers a high potential to improve the translation of evidence-based health research into particular settings . MoreoveBesides the usability and engagement issues, which were addressed in the present study, further steps are necessary to ensure a successful and sustainable implementation of online prevention programs in school settings. Strong evidence for the effectiveness and cost-effectiveness of such programs are an important prerequisite for long-term implementation, not only according to various stakeholders in the school setting, but also from an ethical point of view . TherefoThe participants completed only the first part of the assessments and the program modules. Therefore, results can only partly be generalized to the other assessment questionnaires or modules. However, the evaluation of engagement and usability issues of the users’ first interaction with the program proved to be a suitable method, in order to determine future participant behavior . MoreoveNot all of the feedback of the participants could be implemented in the second round and subsequently for the actual clinical trial, due to multiple reasons. Although much of the criticism about some questions seemed legitimate, the used questionnaires were standardized questionnaires that could not be changed, simplified, or shortened. Some problems or barriers were related to the navigation which was not intuitive in some aspects and led to the need to try out a few times. Since our possibilities to change these aspects, which were linked to the functions of the Minddistrict platform, were limited, we tried to tackle these issues by providing the tutorial video and additional information on the navigation in the text.Another major limitation might be the gender imbalance of the test rounds. In the first round, four boys and one girl participated and in the second round four girls and one boy took part. We tried to reach a balance of gender per round, but due to time collisions and short-term illness of two participants, this was not feasible.This usability and engagement study was conducted in preparation for a randomized controlled trial of the unguided online program “Healthy Teens @ School”, taking place in the school setting. This study helped us to improve the usability of our online program, prior to the program start, in five major areas—visual design, navigation, mode of transfer, content, and engagement conditions. Furthermore, the results of this study contribute towards a wider research base, showing that usability and engagement issues in this first phase of the users’ interaction with the program is not only inextricably linked, but is essential for identifying future engagement and adherence issues. Especially, the users’ current needs have to be evaluated and addressed. As the results of this study showed, the engagement issues of this particular target group were closely linked to specific setting-related issues, such as stress in school or the possibility to use the program during school hours. This implies that the involvement and participation of the target group in the development of online interventions, should be an essential part in future research designs. Especially for prevention interventions, intrinsic motivation plays a major role, since members of the potential target group usually do not feel a certain urge or level of suffering that motivates them to use an online program. Additionally, from a public health perspective, it is important to point out the benefits of such programs for the target group. In this context, user centered-designs do not only help to improve the usability and adherence of online programs but also their overall effectiveness.


The One-to-One program aims to reduce criminal recidivism among prisoners shortly awaiting release, and among probationers. Of 1,484 program participants in Sweden, 776 contained adequate data for analysis. Pre- and post-program scores were available for the Alternative Thinking Test, Levenson's Locus of Control Scale, Skill Survey, Citizen Scale, and Problem Checklist, all areas addressed in the program. This study examined predictive properties of test scores and background characteristics regarding recidivism, as well as differences between sub-groups. All post-tests indicated pro-social changes. Older participants were more likely to complete the program. The most potent predictor for non-recidivism was program completion, with non-completers 64% more likely to re-offend. Significant associations occurred between recidivism and the tests measuring skill improvement over time, chance locus of control pre- and post-program, and attitudes and values , partly supporting the theory behind the program. In the OTO-program the focus lies on finding examples from daily life and on giving homework, which gives the client an opportunity to practice actual execution of the problem solving skills . The forIn an effort to ensure the quality of the programs offered, the Swedish Prison and Probation Service has adopted the "what works" initiative and consequently aims to implement only evidence-based programs, with 17 programs currently accredited . One of Most evaluations of offending behavior programs focus on one outcome measure only; i.e., either recidivism as a binomial variable, or psychological change of some kind . As the We aim to explore whether background data or test data have predictive properties regarding completion and recidivism and whether test outcome scores differ significantly between completers/non-completers and recidivists/non-recidivists. The specific research questions were whether a) test scores differed significantly in the entire cohort over time; b) whether completers and non-completers differed in background data and pre-test scores and, where available, whether program completers differed from norm data c) whether recidivists and non-recidivists differed significantly in background data and test scores d) whether non-completion of the OTO program could be predicted by background data and pre-program scores; and e) whether recidivism rates could be predicted by background data, pre- and post-program scores, and/or change scores over time for pre-/post-tests.The data for this study were collected by the Swedish Prison and Probation Service. The original data set consisted of 1,484 participants who entered the program between 2000 and 2008. The program was formally accredited in 2003 and by 2008 it was offered in 27 of 60 probation units in Sweden and 11 of 55 prisons . ClientsOf the 1,484 cases included in the data set, 687 lacked pre- or post-test data and were excluded. Due to inconsistencies in the data, such as dates, number of sessions, completer/non-completer status, and multiple registrations a further 21 cases were excluded. The final data set consisted of 776 cases see Figure 1Participant characteristics were available regarding age, gender, program completion, and recidivism up to 5 years following program participation. When starting the program participants were 27.92 years old on average [standard deviation (sd) = 9.33]. Almost all participants were male (92.3%). Of the 776 participants, 483 were completers and 293 were non-completers see Table 1.The primary outcome measure was recidivism, defined as relapse into criminal behavior, which had been noted in the criminal justice system in terms of trial and reconviction during the follow-up period after the intervention. The terms recidivism, reconviction, and reoffense are used interchangeably.Secondary outcome measures are scores on five different tests used within the OTO program as a basis for counselor-participant discussions in the sessions. No psychometric data were available from Swedish samples on these tests, but they were retained to facilitate international comparability. optional thinking skill as defined by The Alternative Thinking Test (ATT) was developed as a means to measure the ability to generate solutions to problems, the The Levenson Locus of Control Scale (LLOCS) is a well-researched test for measuring participants' views of their locus of control. The LLOCS scale consists of 24 items scored from -3 to +3, with 8 items in three subscales: Internal, Powerful Others, and Chance (IPC). The test is scored by adding 24 points to each subscale, yielding scores ranging from 0 to 48 for each subscale. As these scores are mutually independent, any combination of scores is possible. Norms based on an undergraduate U.S. student sample n=161) with a mean age of 23.1 years yielded mean (sd) scores of 34.4 (5.4) on the Internal subscale, 24.4 (6.8) on the Powerful Others subscale, and 24.8 (6.1) on the Chance subscale , and an 1 with a The Skill Survey measures strengths and weaknesses in the participant's social skill set. The survey consists of 20 items, selected from 50 items presented in the Prepare Curriculum . Each itThe Citizen Scale is a subset of a larger test designed by Anne Schneider , used inThe Problem Checklist (PCL) consists of 110 items used to assess the presence of criminogenic problems in the participant's life and divided into 11 subscales which reflect specific problem areas: work and unemployment, accommodation, money and financial pressures, alcohol, substance use, gambling, physical and mental health, social relationships, peer group pressure, family relationships, and family offending. Participants score each item from 0 to 10, where 0 means that the problem described in the item is not a problem for the participant, and 10 means that the problem is very serious; total scores including all subscales range from 0 to 110. The list was developed for the OTO program based on items generated by probation officers in Kent and thereafter modified and translated by the Swedish Prison and Probation Service. Within the program, the checklist is delivered in three parts during the first three sessions of the assessment part of the program. The checklist is also given in its entirety during session 19 as a post-test to see if there is any reduction in problem perception. Feedback regarding the division into subscales is revealed to the participant after the last module has been delivered. Within the OTO program, a pilot study showed that lower PCL scores at pre-test were associated with lower reconviction rates, and a later study showed significant positive post-program changes over time for all subscales on perceived problems .The structure of the One-To-One program is briefly outlined in Written informed consent was given by the participants for the use of data for research purposes, according to a routine established by the Swedish Prison and Probation Service. Data were provided by agreement between the Service and author PP, in a file where personal identifiers such as civic registration number and name had been removed. For research purposes, data such as age, gender, time of attending the program, and classification of the offense were retained in the data file.d . For pre-program tests, data for 5–204 cases were missing and for post-program tests 7–83 cases were missing see Figure 1Comparisons between the 687 excluded cases and the 776 cases that remained available for further analysis see Figure 1All paired t-tests comparing pre- and post-program scores over time yielded significant differences, using the multistage Bonferroni corrected p-value of 0.001 Table 4.Only age at program end showed a significant difference between program completers and dropouts , where program completers were on average 2.96 years older than non-completers.Comparisons of pre- and post-program scores for program completers who were later reconvicted (recidivists) with non-recidivist program completers showed significant differences for the Levenson Chance subscale and the Citizen Scale pre- and post-program tests and for number of previous convictions. Recidivists scored higher on the LLOCS Chance subscale pre- and post-program tests and lower on both pre- and post-program tests for the Citizen Scale. Recidivists also had a significantly higher number of previous convictions see Table 5.Comparison of pre- and post-program scores on the three LLOCS sub-scales for program completers with cross-sectional student test means  showed t2 = 1.03, df = 1, p = 0.311) nor for recidivism . Gender was therefore not included as a predictor in the logistic regression analyses below. The predictor variables retained were age and all pre-program tests.Predictor variables were initially evaluated to identify whether any association existed with the dependent variables (DVs) of program completion and recidivism. For gender, no association was identified, neither for program completion , accounting for between 11.1 and 15.9% of the variance. Overall, 73.8% of the predictions of completion status were correct, with 95.7 of the completers correctly predicted, but only 18.5% of the dropouts. Only the age variable was significant for predicting non-completion, both age at the beginning of the program (B = 0.40) and at the end (B = 2.57), meaning that for every increase of 1 year in age at the end of the program, the chance for completion increased by a factor of 2.57.For program completion, a total of 554 cases were included in the analysis, and the full model was significant . This model accounted for between 8.8 and 12.5% of the variance, with 94.5% of non-recidivists successfully predicted but only 17.9% of recidivists accurately predicted. Overall, 71.0% of the predictions were accurate. For recidivism among program completers, predictor variables consisted of pre- and post-program scores, the difference between pre- and post-program scores, and the categorical variables of program completion and age as predictor variables. As the predictor variables were as many as 50, a forward conditional analysis was used in order to find the model best predicting the DV. The best-fit model included age at the end of the program, the pre-program LLOCS Chance subscale, the post-program PCL money and financial problems subscale, and the difference over time between pre- and post-program Skill Survey scores. An enter method logistic regression including only these four variables was performed in order to include a maximum of cases with valid data. A total of 365 cases were analyzed and the full model was significant . This model accounted for between 11.1 and 15.9% of the variance, with 95.7% of non-recidivists successfully predicted but only 18.5% of recidivists accurately predicted. Overall, 73.8% of the predictions were accurate. The significant variables were: the PCL pre-program money and financial pressures and physical and mental health subscales, the LLOCS pre-program Chance subscale, and completion statusnot being reconvicted (odds ratio 1.02). Higher scores on the LLOCS Chance subscale were associated with being reconvicted (odds ratio 1.05), and program completers were less than half as likely to be reconvicted  using pre-program data, age and program completion status as predictor variables. A total of 554 cases were analyzed and the full model was significant , which has been used in adult populations e.g.,  and has The concept of psychological change leading to reduced recidivism is not new, but empirical findings are scarce on mechanisms driving such change and its translation to desistance from criminal recidivism. Much of the literature on the concept derives from theory on the Psychology of Criminal Conduct (PCC) originally described by Andrews and Bonta in several editions of their seminal book with this name e.g., . A recenThe raw data supporting the conclusions of this manuscript will be made available by the authors to any qualified researcher.Authors PP and AB conceived the study design, and PM and MG carried out the analyses within their thesis work for the MSc degree in Clinical Psychology, under AB's supervision. This manuscript, based on the thesis originally written by PM and MG, was revised and edited by AB with input from PP, PM, and MG. All authors approved the final manuscript and are accountable for its contents.AB was funded for salary by Swedish Research Council grant nr K2012-61-P-22131-01-6. She participated in this work within the frame of the Swedish program grant "Responding to and Reducing Gambling Problems—Studies in Help-seeking, Measurement, Comorbidity and Policy Impacts" (REGAPS), financed by the Swedish Research Council for Health, Working Life and Welfare (Forte), grant number 2016-07091. Other authors were funded within their employment.PP is the author of the One-to-One program, and trained criminal justice staff (1990 – 2003) to deliver it in the UK, Sweden, and Norway. He has no current involvement with the program in any of those locations. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Knee osteoarthritis (OA) is prevalent and often associated with meniscal tear. Physical therapy (PT) and exercise regimens are often used to treat OA or meniscal tear, but, to date, few programs have been designed specifically for conservative treatment of meniscal tear with concomitant knee OA. Clinical care and research would be enhanced by a standardized, evidence–based, conservative treatment program and the ability to study the effects of the contextual factors associated with interventions for patients with painful, degenerative meniscal tears in the setting of OA. This paper describes the process of developing both a PT intervention and a home exercise program for a randomized controlled clinical trial that will compare the effectiveness of these interventions for patients with knee pain, meniscal tear and concomitant OA.This paper describes the process utilized by an interdisciplinary team of physical therapists, physicians, and researchers to develop and refine a standardized in-clinic PT intervention, and a standardized home exercise program to be carried out without PT supervision. The process was guided in part by Medical Research Council guidance on intervention development.The investigators achieved agreement on an in-clinic PT intervention that included manual therapy, stretching, strengthening, and neuromuscular functional training addressing major impairments in range of motion, musculotendinous length, muscle strength and neuromotor control in the major muscle groups associated with improving knee function. The investigators additionally achieved agreement on a progressive, protocol-based home exercise program (HEP) that addressed the same major muscle groups. The HEP was designed to allow patients to perform and progress the exercises without PT supervision, utilizing minimal equipment and a variety of methods for instruction.This multi-faceted in-clinic PT program and standardized HEP provide templates for in-clinic and home-based care for patients with symptomatic degenerative meniscal tear and concomitant OA. These interventions will be tested as part of the Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial.clinicaltrials.gov with registration No. NCT03059004 on February 14, 2017. TeMPO was also approved by the Institutional Review Board at Partners HealthCare/Brigham and Women’s Hospital.The TeMPO Trial was first registered at  Symptomatic knee osteoarthritis (OA) and its attendant pain and functional limitations affect approximately 14 million adults in the United States (US) . MeniscaClinicalTrials.gov Registration No. NCT03059004) to evaluate the outcomes of in-clinic physical therapy intervention and self-guided home exercise program for persons with meniscal tear in the setting of OA. The TeMPO trial study protocol has been published previously and meets the SPIRIT  guidelines for reporting clinical trial study protocols [Our research team has launched a clinical trial entitled the Treatment of Meniscal Tears in Osteoarthritis (TeMPO) (rotocols . HoweverThis paper reports our process for developing an in-clinic PT intervention and a self-administered home exercise program (HEP) for the TeMPO Trial using a dual approach of best available published evidence and clinician experience in our field of interest. We sought to describe our process in sufficient detail such that it could be replicated and modeled by other groups seeking to develop a rigorous trial intervention in the absence of clear clinical recommendations. Our process aligns with many aspects of the Medical Research Council (MRC) guidance . In partThe two main goals of the project were: 1) to create a PT intervention that utilized best published evidence available and consensus from an expert panel of experienced PTs, physicians and researchers and 2) to create a self-administered progressive HEP that could be performed at home without any direct contact by a physical therapist in a target population of adults with degenerative meniscal tear and concomitant knee OA. For this reason, we will refer to the programs in this manuscript as the TeMPO in-clinic intervention and the TeMPO HEP.The development of the TeMPO in-clinic and HEP programs consisted of six phases. In phase one, a core group of physical therapists, physicians and research methodologists invited a group of physical therapists from four academic US centers to form an expert panel that would guide the creation of both TeMPO programs. This group communicated extensively on conference phone calls and attended in person meetings throughout the trial development.The second phase involved a review of relevant literature on physical therapy interventions and strengthening programs designed for patients with both degenerative meniscal tear and concomitant knee OA. In the third phase, the research team administered an e-mail survey to a convenience sample of experienced physical therapists in several US states to gain a better understanding of the types of PT treatments used in our target population.In the fourth phase, the initial expert panel was expanded to add more orthopaedic surgeons, rheumatologists, researchers and physical therapists from the four study sites to form the trial research team. This expanded panel participated in a series of conference calls and two in person meetings to develop, review, and revise the components of the TeMPO program. These calls emphasized both the validity of the intervention elements as well as their feasibility. As many of the panel members had extensive clinical experience as well as trial experience, they were able to ensure that the interventions would be feasible both for the study as well as for subsequent clinical application.During the fifth phase, the research team and physical therapists created a standardized instructional video and hard copy program booklet to guide patients who would be completing the TeMPO exercises without direct physical therapist supervision. The team also created a Manual of Operations of the physical therapy in-clinic intervention for the TeMPO trial. Phase six included focus group sessions with the research team and potential patients to solicit feedback for final edits to the TeMPO exercise program and its instructional materials.The initial core group of 10 members included physical therapists, rheumatologists and methodologists from four collaborating US sites including Brigham and Women’s Hospital in Boston, MA, Cleveland Clinic in Cleveland, OH, University of Buffalo Medical Center in Buffalo, NY and University of Pittsburgh in Pittsburgh, PA. One member was from Melbourne, Australia. This core expert panel developed the foundation of the TeMPO interventions. Additional physical therapists, orthopedic surgeons, methodologists, an exercise physiologist and research staff -- numbering about 20 individuals -- were invited to further develop the TeMPO interventions. The full 30-member panel attended the two in person meetings. The clinicians involved in this process had extensive experience with the target population and as a result were able to ensure that the interventions would be feasible for implementation in trials, clinical practice and self-administered home programs.Research staff in conjunction with the physical therapists performed a literature review to identify studies that addressed the efficacy of PT in persons with degenerative meniscal tear and concomitant OA. The search words included: “meniscal tear,” “osteoarthritis,” “physical therapy,” “exercise,” and “rehabilitation.” We also searched for studies of manual therapy used in the treatment of knee OA without specific mention of meniscal tear and the use of manual therapy in reported clinical guidelines. Specific search terms included “meniscectomy,” “knee OA,” “joint mobilization,” “manual therapy,” “physical therapy,” “stretching,” and “massage.” We conducted these searches within Google Scholar and PubMEd and also examined professional organization websites.We administered a survey regarding current PT clinical practice for patients with meniscal tear in the setting of concomitant OA to a convenience sample of experienced physical therapists across the US. The survey clinicians were identified by our expert panel and their professional contacts from regions throughout the US. Respondents provided information on 1) the therapeutic exercises they used for patients with knee OA and meniscal tear; (2) the number of minutes dedicated to therapeutic exercise in a typical PT session with this patient group; (3) the use of manual therapy administered by a physical therapist  (4) minutes dedicated to manual therapy when indicated in a typical PT session; and (5) any other interventions typically utilized in this patient population such as thermal agents, cryotherapy or ultrasound  because our approach permitted more fluid and interactive discussions than are generally afforded by more formal approaches.After the final in person meeting, a core group of PTs video-taped the TeMPO Home Exercise Program. Research Assistants and PTs created instructional TeMPO exercise pamphlets for future patients and a manual of operations for physical therapists conducting the in-clinic TeMPO PT intervention. Once the videos, pamphlets, and the manual for operations were completed, they were reviewed by the expert panel and by a focus group of potential patients. Edits and revisions were made accordingly to improve the clarity of the materials. Final materials for the TeMPO home exercise programs were created in various learning mediums including USB flash drive, website, and hard copy pamphlets. The HEP pamphlet and links to the video have been published previously as Additional File I in Sullivan et al., 2018 . The in-The literature search confirmed that neither the American Academy of Orthopedic Surgeons nor the American Physical Therapy Association (APTA) nor any other organization we could identify has developed clinical practice guidelines specifically for rehabilitative management of degenerative meniscal tear in the setting of knee OA , 21. TheThe results of the literature search regarding RCTs of PT and meniscal surgery , 26–32 pOnly one of the 6 trials initially reviewed Table  utilizedA convenience sample of 21 physical therapists across 8 states responded to our survey regarding typical treatments for patients seeking treatment for degenerative meniscal tear in the setting of OA. The 21 physical therapists had a mean of 20 years of experience (range 6 to 38 years) and practiced in 8 states . Thirteen PTs practiced in academic settings, 7 in private practice, and one in both.All 21 respondents indicated that they typically include a strengthening program and 19 of 21 regularly incorporate manual therapy as listed above into their treatment strategy. The respondents reported the mean appointment duration as 41 min (standard deviation (SD) 14), the mean duration of strengthening exercises as 24 min (SD 10) and the mean duration of manual therapy as 12 min (SD 4). The results of these findings were incorporated into the TeMPO in-clinic intervention and home exercise program.The panel defined the research objective as creating an effective, flexible, and realistic in-clinic PT intervention for patients with meniscal tear and concomitant OA pain and an efficacious, standardized, and practical HEP that could be performed independently and safely at home without direct input from a physical therapist. Based on the findings of the expert panel, literature search and the clinical PT practice survey, the panel established components of the TeMPO in-clinic PT intervention and HEP. The targeted muscles for strengthening in both programs included gluteus maximus, gluteus medius, quadriceps, and hamstring muscle groups. The targeted muscles for stretching included quadriceps femoris, hamstrings, and gastrocnemius.Neuromuscular/functional weight bearing exercises were also included Table . ExercisWhile the initial literature review identified just one studies of joint and/or soft tissue mobilization in this population, the expert panel considered the more recent studies of mobilization in OA , the fin. Study participants are instructed to remain at the same level of difficulty until “you can complete 3 sets of 8-12 repetitions without soreness or discomfort.” We also caution study participants not to advance in exercise difficulty if they experience muscle soreness or increased joint pain within 24 h following an exercise session. If TeMPO participants experience pain with any of the HEP, specific guidelines regarding rest, ice and hold on progression are delineated in the pamphlet and videos. Pages vi – ix in the TeMPO Guide to Home Exercises , we insn et al. ) detail The panel carefully considered exercise program duration and repetitions/sets. The panel determined that both the HEP and the in-clinic PT intervention should last no longer than 30 min to optimize adherence and conform to the time frame permissible in routine PT practice in the US. This consideration was informed in part by the emphasis on feasibility in the MRC guidance paper . The panThe panel decided on overall parameters to guide the final form of the HEP: 1) The program should be accessible and safe for persons of varied ages and presenting with a variety of concomitant comorbid conditions; 2) Minimal equipment should be required; 3) Participants should be able to complete the exercises within a fairly short time period, defined as 25 min by the panel; and 4) Participants should be able to progress the program or adjust accordingly through standardized and understandable thresholds.:RecommendationsThe in-clinic PT intervention consists of three primary components: 1) unsupervised bicycle warm up; 2) manual therapy comprising joint mobilization, stretching, and soft tissue mobilization and 3) therapeutic strengthening and functional exercises. The manual therapy portion of the in-clinic PT is utilized by the therapist and includes joint mobilization of patella-femoral, tibio-femoral and tibio-fibular joints; and manual stretching of quadriceps, hamstrings, hip flexors, iliotibial band and gastrocnemius. Soft tissue mobilization includes effleurage, deep friction and petrissage massage of tight muscles. The therapeutic strengthening elements of the intervention recommend use of exercise machines and resistance bands commonly available in PT clinics. Study therapists are also given an extensive list of recommended exercises to choose from in the manual of operations for the TeMPO RCT. The complete list of the recommended in-clinic manual therapy and exercises is available in Additional File III of Sullivan et al.  ExerciseThe TeMPO HEP consists of three primary components: 1) stretching; 2) strengthening; 3) functional activities. TeMPO recommends four 25-min exercise program sessions per week totaling 100 min of exercise. Specific exercises, directions for performance, rationale for progression, adjustments, and how to address pain are explained and easily accessible in a pamphlet and video . All stuTo optimize the home exercise program the regimen includes multiple alternate forms of exercises for each major muscle group to allow someone experiencing difficulty completing a certain exercise to continue participating in the program. Instructions for the use of the incremental ankle weights were included so that the program could be modified to fit the different strength and fitness levels of the patients. To further make the program accessible to various styles of learning, an online and offline video (accessed via USB flash drive) and online and hardcopy pamphlet-based instructional materials were created. Specific guidelines are given about how to safely advance, hold or step back with progressions in addition to how to manage soreness and pain in the pamphlet.The goals of this project were to develop both a standardized in-clinic PT intervention and HEP for persons with symptomatic degenerative meniscal tears in the setting of OA for the TeMPO RCT. We achieved our stated goals by incorporating evidence and input from a variety of sources, including existing literature, an expert panel of experienced clinicians, health care researchers and utilizing survey results from 21 licensed experienced therapists from across the US. We designed a comprehensive and easy to follow self-administered home exercise program that includes stretching, resisted strengthening exercises and guidelines for progression, adjustments and ways to manage soreness and pain. This exercise program requires minimal equipment and can be completed within a reasonable time frame (25 min). Our program specifies the major muscle groups for strengthening, the targeted muscles for stretching, and includes neuromuscular functional training.Overall the PT intervention and home exercise program align with literature describing perioperative meniscectomy rehabilitation programs , 29, 30 One notable addition to the TeMPO program is that we incorporate gluteus medius exercises, which are more often strengthened in the context of hip pain, but have been demonstrated to play a pivotal role in rehabilitation for patients with knee pain . It is uAnother feature of the TeMPO in-clinic PT program is the inclusion of manual therapy, which appears not to have been incorporated in PT regimens assessed previously in this patient population. Manual therapy has been shown to be effective in patients with a variety of knee-related diagnoses , 47 and The TeMPO program was influenced by the work of Roos et al., Bennell et al. and the APTA clinical practice guidelines who outlined PT regimens with neuromuscular strengthening components , 37. ComThis work is unique in that it is the first therapeutic program designed for the rehabilitation of symptomatic meniscal tear in the setting of OA that has been created and vetted by an international coalition of expert health science researchers, orthopaedic surgeons, rheumatologists and physical therapists. In addition, the TeMPO home exercise program is notable for providing a flexible yet standardized set of options that can be undertaken by a patient without input from a physical therapist. The inclusion of a weight progression and alternate exercises makes the HEP accessible across different physical ability levels and disease states while guidelines for excessive soreness and pain during or after exercise improve the safety of the HEP and the ability of patients to perform the exercises independently. The HEP is also unique in that it is accessible via mixed media sources including USB flash drives, online videos, and paper as compared to traditional paper handouts used as home therapy instructions. With the addition of digital components, the TeMPO HEP can be accessed from rural areas as well as densely populated cities.We note that the interventions developed for the TeMPO trial are largely similar to those used for patients with knee OA in the absence of symptomatic meniscal tear. Our expert clinicians noted that the population of patients with both OA and MT may have more heterogenous symptom expression and impairments than those with OA alone (e.g. more swelling). Thus, the TeMPO interventions provide considerable flexibility of the regimen across and within patients.This work has several limitations. For both the expert panel and PT survey, we used a convenience sample of collaborators and their national contacts respectively, which may have affected the viewpoints represented. We acknowledge the tension between personalization and standardization in designing interventions. Physical therapists typically provide individualized programs for patients and sessions can vary across time based on observed impairments and activity limitations. Both the TeMPO HEP and in-clinic PT intervention sacrifice some of this personalization. Here, we provided standardization of a home program and PT in-clinic intervention. The in-clinic PT program included variations for choices of interventions in the PT sessions and alternatives exercises for the HEP to accommodate various abilities.This project describes the process of developing a standardized in-clinic PT program and HEP for the TeMPO RCT. The first is an in-clinic physical therapist directed manual therapy, stretching, strengthening and functional/neuromuscular exercise program that includes weights, machines, and flexible progression guided by physical therapist expertise. The second is a practical HEP that is performed independent of a physical therapist, requires minimal equipment and is comprised of three components: 1) stretching; 2) strengthening; and 3) functional activities. These regimens will form the components of the in-clinic PT intervention and HEP for the TeMPO trial, in which we hope to gain insight into the comparative effectiveness of these interventions and contextual effects for persons with symptomatic degenerative meniscal tear and OA.Additional file 1. Email Survey of Physical Therapists.


Mw 7.8 and 7.4) that occurred within half an hour after the mainshock. We also find that the change of normal stress on the fault before the earthquake is not uniform but increases in the up-dip portion  of the fault from the hypocenter and decreases in the down-dip portion. We infer that the occurrence of the giant earthquake at the shallow portion of the megathrust may be attributed to the increase of the normal stress there, which leads to an increase of fault shear strength and allows more elastic strain energy to accumulate to prepare for the next big earthquake. Based on these results we propose a new concept of the seismogenic asperity as the area of greater accumulations of shear and normal stresses. The method presented here may be useful for predicting the rupture zone of future large earthquakes.We predict, with a model (earthquake stress model) that inverts the displacements documented at 163 GNSS onshore stations of the GEONET, the change of shear and normal stresses on the megathrust near the Japan Trench over the seven years before the 2011 Mw 9.0 Tohoku-Oki earthquake. We find three areas on the megathrust with greater accumulations of shear and normal stresses before the earthquake, which match the ruptured areas of the mainshock and two largest aftershocks ( It has been used in long-term forecasting of the possible locations and magnitude of future large earthquakes. The major plate boundaries are classified into six categories of seismic potential gaps for large earthquakes2. The mere presence of seismic gaps is not sufficient for predicting future earthquakes was pointed out because some seismic gaps may slip aseismically3. Furthermore, multiple gaps may be present on the same plate boundary, and it is difficult to predict which gap may break in the near future. The state of interseismic locking of subduction megathrusts is commonly used to predict seismogenic zones and has been modeled with the back-slip method4. Using this method, a number of interseismic locking models based on an elastic Earth model were constructed prior to the 2011 Mw 9.0 Tohoku-Oki earthquake at the Japan Trench by inverting geodetic observations and predicted significant interseismic slip deficits down to depths exceeding 40 km, with some extending as deep as ~100 km8. The slip deficits in the depth range of 10–50 km, peaking around 35 km were also predicted using a simplified, layered viscoelastic model9. All the predicted slip deficits centered in fault areas landward of, and thus significantly deeper than, the main rupture area of the 2011 Mw 9.0 Tohoku-Oki earthquake, and they all predicted interseismic creep in the area ruptured by the 2011 earthquake near the trench10.Many attempts have been made to identify the location of the seismogenic zones of oncoming earthquakes. The concept of seismic gap11; the inferred locked asperities are about 25% the size of the rupture areas of the mainshocks. The interseismic GPS data are fitted better12 if the assumption of zero interseismic coupling along the Japan trench is removed.After the Mw 9.0 Tohoku-Oki earthquake, the spatial correlation of interseismic coupling and coseismic rupture extent of the earthquake are studied by inverting GPS data10.The systematic mismatch of the model-predicted locked asperities and the actual rupture zone of the 2011 earthquake may be due to the shortcomings of the kinematic models used in the inversion for the fault slip-deficit; these may include the lack of consideration of the effect of normal stress on the fault, topography, heterogeneity and anisotropy of the earth media13 for determining not only the shear stress change on fault surface but also the normal stress change on the ruptured fault, by which they directly determined the coseismic stress drop of the 2011 Mw 9.0 Tohoku-Oki earthquake from inverting the coseismic GNSS displacements. In this study we use the same method that inverts the displacements  was proposed15. Smaller stresses outside this region are listed in Table Mw 9.0 Tohoku-Oki earthquake13. The normal stress also increases in this zone over the seven years  than that of our seismogenic asperity (~15 km). The agreement of the latter with the rupture area of the mainshock13 is strong evidence for the reliability of the present method. Furthermore, the agreement between the two smaller seismogenic asperities predicted in this study also compare well with the areas of the two largest aftershocks. In addition, the predicted depth of the seismogenic asperity of the mainshock by the contour of zero-shear stress is consistent with that of the rupture termination identified13, marked by black-dish line in Fig. The identification of the seismogenic asperity of the Tohoku-Oki earthquake, with the fault area of greater shear and normal stress accumulations Fig.  has not 19. It may also explain the occurrence of slip acceleration  from the hypocenter and decreases in the down-dip portion. We infer that the tendency for giant earthquakes to occur at the shallow portion of megathrusts may be attributed to the increase of the normal stress there, which leads to an increase of fault shear strength and allows more elastic strain energy to accumulate to prepare for the next big earthquake. Although the present model cannot predict the timing of damaging earthquakes, it may be useful to predict the locations of the seismogenic asperities of future large earthquakes and may thus be useful for suggesting further investigations that may bear on the timing of the earthquake.13, and what mechanism controls the locations of the zero-shear stress and zero-normal stress and their formation. Further studies are obviously required to answer these questions.Several important questions remain unanswered. While the accumulations of stresses on the seismogenic asperity of the main shock seem to be steady over the seven years before the earthquake Fig. , the strXie and Cai13 proposed a method to invert for fault stress change based on an earthquake stress model, by which they inverted the land-based coseismic GNSS displacements to determine the coseismic stress drop associated with the 2011 MW 9.0 Tohoku-Oki earthquake. The model consists of two elastic tectonic blocks in contact along an interface representing the subduction megathrust that hosts the future earthquake. The use of an interface to represent a fault zone may be justified by the scale of the study, which is many orders of magnitude greater than the fault zone thickness23. The normal displacement across the fault is continuous, and the stress vectors on the two sides have the same magnitude but are opposite in direction.13 to invert for the stress change: (1) set up an earthquake stress model in the FEM, which includes an interface (fault); (2) calculate the numerical Green’s function solutions (displacement fields) due to an unit stress on each sub-fault surface; (3) construct the Green’s function matrix by superposition of the sub-fault solutions at specified observation sites; (4) invert for stress accumulation on the fault surfaces with GNSS observations; and (5) determine the seismogenic asperity. The detailed inversion procedure is given in Xie and Cai.We summarize below the inverse methodIn this work, we use the same method and the pre-seismic GNSS data to invert for fault stress accumulation on the megathrust over a period of seven years prior to the Tohoku-Oki earthquake.Mw 9.0 Tohoku-Oki earthquake and two largest aftershocks , with the x- and y-axes being horizontal and normal to and along the Japan Trench, respectively, and the z-axis being vertical  and antenna exchange, annual and semi-annual components, and common-mode errors from original time series using a least square method, with fixed stations at Murakami, Kurokawa, and Shibata in Niigata Prefecture. Additionally, we removed the postseismic displacements associated with the 2003 Tokachi-Oki (Mw 7.8), the 2005 Miyagiken-Oki (Mw 7.1) and the 2008 Miyagi-Iwate nairiku (Mw 6.9) earthquakes. We then obtain the best-fit parameters from the corrected time series at each component at each station, using ABIC31. Finally, we take the difference between the end and the beginning of each year of the best-fit curve to obtain the yearly displacement fields, which are provided in Supplementary Information: Table We use the F3 solution of GNSS data provided by Geospatial Information Authority of Japan. Following Using these parameters, an optimal smoothing factor, and an optimal constraining coefficient (Supplementary Information: Fig. Supplimentary Information


Exposure to environmental contextual changes, such as those occurring after an earthquake, requires individuals to learn novel routes around their environment, landmarks and spatial layout. In this study, we aimed to uncover whether contextual changes that occurred after the 2009 L’Aquila earthquake affected topographic memory in exposed survivors. We hypothesized that individuals exposed to environmental changes—individuals living in L’Aquila before, during and after the earthquake —improved their topographic memory skills compared with non-exposed participants (NEPs) who moved to L’Aquila after the earthquake, as only EPs had to modify their previous cognitive map of L’Aquila. We also hypothesized that memory improvement was selective for the navigational space and did not generalize across other spatial and verbal domains. To test these hypotheses, we compared the topographic and spatial memory skills of 56 EPs without post-traumatic stress disorder (PTSD) symptoms to the skills of 47 NEPs using the Walking Corsi Test  and the Corsi Block-Tapping Test ; EPs and NEPs were matched for gender, education and general navigational skills. A sub-group of participants also underwent the Rey-Auditory Verbal Learning Test . The results showed that only EPs had better performances on topographic learning (TL) assessed using the WalCT rather than spatial learning assessed by the CBT. This outcome suggests the possibility that EPs specifically improved topographic memory. This effect may be due to continuous exposure to environmental changes that have required individuals to learn novel paths within the city and integrate novel information, such as “new towns,” into their pre-existing mental representation of the city. Implications and limitations of the study are discussed. The L’Aquila earthquake produced important environmental changes, which encompassed more than 45 towns and small villages. One year after the earthquake, the city center resembled a “ghost town”  and individuals who were not exposed to the earthquake  and moved to the city after the disaster were enrolled in the study. Our hypothesis is as follows: EPs had been exposed to continuous environmental changes soon after the earthquake and in the years following it. Due to the large number of modifications occurring in L’Aquila after the earthquake, EPs may have modified their topographic learning (TL) skills as happens for individuals exposed to other experiences such as geo-caching, orienteering and navigational training. In this light, environmental changes that occurred after the earthquake should have acted as navigational training. It is also possible that an optimal level of stress may have improved general memory skills, as predicted by PTG. In the first case, we would expect to see a specific improvement in TL skills compared with visuospatial and verbal memory skills. Otherwise, we would observe general memory improvement across different verbal and spatial domains.A total of 103 college students participated in this study . They were recruited from the Department of Life, Health and Environmental Science of the University of L’Aquila. Participants were enrolled on a voluntary basis from January 2016 to June 2018. The sample was divided in two groups according to their exposure to the April 6, 2009 earthquake that occurred in L’Aquila, Italy: 56 EPs, including 34 females and 22 males , and 47 NEPs including 32 females and 15 males . The EPs were either in the metropolitan area or a nearby district on April 6, 2009 (from 1.65 km to 20 km from the epicenter of the earthquake). They lived in or nearby L’Aquila before and after the earthquake. The NEPs had never experienced an earthquake, had never been to L’Aquila before the earthquake, and had started to attend the University of L’Aquila only 2–3 years after the earthquake. An initial interview indicated that none of the participants had neurological or psychiatric disorders or alcohol/drug addictions.t(101) = 0.06, p = 0.95), depression (t(101) = 0.88, p = 0.38), anger or irritability (t(101) = −0.75, p = 0.45), intrusive experience (t(101) = 0.42, p = 0.67), defensive avoidance (t(101) = 1.46, p = 0.15), dissociation (t(101) = 0.94, p = 0.35), sexual concerns (t(101) = −0.92, p = 0.36), impaired self-reference (t(101) = −0.20, p = 0.84), dysfunctional sexual behavior (t(101) = −2.39, p = 0.019) and tension-reduction behavior (t(101) = −2.39, p = 0.019). A significant threshold was set at p = 0.05/10 = 0.005 by using Bonferroni’s correction for multiple comparisons.To evaluate the presence and nature of the traumatic events on the participants in the 6 months before testing, a trauma symptom inventory (TSI) was obtained Briere, ; none oft(101) = −1.04, p = 0.3) as demonstrated by scores on a screening test  and 32 NEPs  were also asked to perform a verbal memory test to check verbal memory functioning.All participants signed a written consent form. The experiment was conducted in accordance with the ethical principles for human experimentation outlined in the Declaration of Helsinki. The study was approved by the Institutional Review Board of L’Aquila University.The following tests were administered to all participants:Walking Corsi Test  is a large-scale version of the Corsi Block Tapping Test  fixed on a baseboard (30 × 25 cm) in a scattered array Figure . Two aspTwo aspects of verbal memory were tested: verbal learning (VL) and verbal delayed recall (VDR). The examiner read aloud a list of 15 words at the rate of one per second. The participants were then asked to repeat all of the words from the list that they could remember. This procedure was carried out a total of five times (maximum score: 75). After a 15-min delay, the participants were asked to recall as many words as possible from the first list (maximum score: 15).All participants were tested individually in a quiet laboratory room with artificial lighting and seated facing the examiner on a height-adjustable office chair during the article and pencil tests . They were brought to an adjacent experimental room, without landmarks, where the WalCT and Semmes Test were located.The test administration was randomized for each participant in order to avoid possible mental fatigue and learning facilitation effect during the experiment.All scores were transformed into percentages in order to make them comparable. Two mixed factorial ANOVAs with Group (EPs vs. NEPs) and Apparatus  as the independent variables were performed for the learning and delayed recall scores. The groups’ performances on the VL tasks were also compared using ANOVA 2 × 2.p = 0.05/2 = 0.025, after correcting the p-level for two ANOVAs.A Bonferroni correction was applied using a significance threshold of Descriptive statistics for each variable are shown in Table F = 6.693, p = 0.011; partial η2 = 0.062). Post hoc pairwise comparisons, performed using Bonferroni’s procedure, showed that EPs were better able to learn a navigational path  than the visuospatial sequence . This result was also replicated in the sub-group of participants:  = 6.488, p = 0.011; partial η2 = 0.06; Bonferroni’s correction: p = 0.013). The main effects of Group  = 0.004, p = 0.95) and Task  = 1.33, p = 0.25) were not significant.The mixed factorial ANOVA for learning scores (TL vs. VSL) revealed a significant group-by-task interaction  = 6.63, p = 0.011; partial η2 = 0.011). The delayed recall of the topographic task  was higher than the delayed recall of the visuospatial task . This result was not replicated in the sub-group of participants:  = 1.76, p = 0.19). The main effect of Group  = 0.401, p = 0.53) and the group-by-task interaction  = 0.173, p = 0.68) were not significant.The mixed factorial ANOVA on delayed recall (TDR vs. VSDR) revealed a significant main effect for Task  = 0.0009, p = 0.98; VDR:F = 1.492, p = 0.23).In the sub-group of participants performing VL and VDR, the comparison between EPs and NEPs (two different ANOVAs were performed) revealed no significant effects  nor as tested with the Semmes Test. The enhancement of topographic memory appears to be specific and not generalizable to other forms of memory. These results are in line with the effects of navigational training in toddlers, which have resulted in improving specific aspects of navigational skills without general effects on navigation Turning from the evidence showing alteration of the cerebral network  involved in learning spatial sequences in the environmental space in the presence of PTSD as a consequence of natural disasters (e.g., Piccardi et al., Despite the novelty of these results, it should be recognized that there was no baseline evaluation of topographic memory in the EPs. However, it is unlikely that participants of the exposed group were accidentally recruited with higher topographic memory skills, especially as the scores on the Semmes Test and FSCS were not different between the two groups. However, a longitudinal design that involves testing participants during the aftermath and in the short, medium and long term after trauma exposure is needed to confirm the present data. Moreover, future studies should conduct longitudinal investigations to assess clinical populations with different severities of psychological distress to better understand whether topographic memory should be considered a protective factor to prevent mild cognitive impairments and/or psychological trauma-induced sequelae. The collection of salivary cortisol samples to measure psychological stress may also be useful in future studies as the absence of these physiological measures in the present study do not allow conclusions to be drawn with respect to the mechanisms underlying adaptational plasticity. To fully demonstrate our interpretation, future studies should use a spatial updating task to more directly explore the idea that environmental changes foster the acquisition and storing of new spatial knowledge, thus resulting in an improved cognitive map of the environment. We limited our investigation to TL, which is undoubtedly the process underlying the formation of the mental map, but this is just a small part of the numerous processes underlying spatial navigation.Another limitation of the present study was the absence of measures taken before the earthquake. There is no evidence regarding the EPs’ mental maps before the disaster; therefore, it was not possible to make comparisons with their new mental maps. However, by observing Figure In conclusion, these results may shed light on positive, long-term changes that occur in environmental mental representation mechanisms after exposure to a natural disaster. To our knowledge, this aspect has not been previously investigated and deserves further study to better understand cognitive map formation under post-traumatic stress in the absence of clinical disorders.LP, MP, MB, AMG and SDA conceived and designed the experiment. AB, FB and PC collected data. MP and MB analyzed data and all authors contributed to the writing of the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The results show that after the application of the JUA program there were significant improvements in subjects’ perception of FOF, with this being greater in those who had the highest levels of fear of falling before the intervention.This research analyzes the fall history of a group of elderly people and studies the effects of an intervention program based on Adapted Utilitarian Judo (JUA) to teach fall control in subjects with fear of falling syndrome (FOF). We adopted a quasi-experimental research design with pre-post measurement of the experimental group, in a healthy, pre-fragile sample of 12 women aged 71.5 ± 8 years, chosen using non-probabilistic-incidental accessibility sampling. The WHO questionnaire was used for the functional assessment of the fall. To evaluate FOF, we applied the 16-item version of the Falls Efficacy Scale-International (FES-I), (pretest and posttest). This intervention program was based on Adapted Utilitarian Judo and conducted over 8 weeks, with two 60-minute sessions each week. After analyzing the scores obtained by the subjects in the pre and post FES-I, we found that the intervention with the JUA program had been significant for the experimental group with  A fall is an involuntary event that causes you to lose your balance, with your body hitting the ground or any other firm surface that stops it . The WorOften linked to the risk of falling, appears the fear or dread of falling. Fear of Falling (FOF) is a set of signs and symptoms presented by a person with this problem. As a result, there may be a change in attitude and/or behavior that increases the risk of falling, injury, social isolation, deficits in self-care, anxiety, lack of recreational activities or impaired mobility, among others.Tinetti, Richmond and Powell defined fear of falling (FOF) as the loss of confidence in oneself to avoid a fall when doing daily activities . In the To describe this syndrome, authors began to define it as a psychological consequence or trauma of the fall that led to a decrease in activities and a subsequent loss in the functional capacity of the elderly person. Fear of falling increases with age, the onset of illness, and in those older adults who have fallen in the previous year .t = 2.88, p < 0.001) and between those who avoid activities and those who do not avoid daily activities . Initially, FOF was measured with a single dichotomous question based on a yes/no answer about their fear of falling. This is a simple method but produces good results and is useful when assessing fear of falling in the elderly . Despiter = 0.37 a 0.61); other studies have found that FES can predict whether subjects are likely to fall and decreased functional ability in the individual [To identify the variables that lead to this loss of confidence in the elderly to perform daily activities without falling, other studies have observed moderate correlations between FES scores and balance This study investigated the fall history of a group of elderly people and analyzed the effects of applying an Adapted Utilitarian Judo program to teach fall control on FOF Fear of Falling Syndrome (STAC).Twelve women aged between 57 and 83 took part in this study (mean age of 71.5 ± 8 years). The anthropometric characteristics are adjusted to a weight of between 47.3 and 93.7 (average weight of 74.22 ± 14.61 kg), and a height of between 1.42 and 1.65 (average height of 1.54 ± 0.69 mts). They were selected using non-probabilistic-incidental sampling  for theiAs inclusion criteria, subjects had to be 55 or over and with no diagnosed illnesses that would prevent them from exercising. Subjects were excluded if, for medical reasons, they had been advised against taking physical exercise, had suffered from congestive heart failure, felt chest pain, dizziness or angina during exercise, or had uncontrolled high blood pressure (160/100).Regarding the fall history of the sample , 73% repAs for the type and consequences of the falls , 62% saiFor the functional assessment of the fall, we used the WHO questionnaire  for the ,29 over the course of 8 weeks, with 2 weekly sessions each lasting 60 min. Some contents of a traditional Judo class have been adapted, contextualizing them to a utilitarian work directed to the specific requirements of the Older Adults, and they have been oriented to give a global treatment to the prevention of the falls and their consequences. The proposed exercises have been introduced following a progression of increasing difficulty, which has been graded according to the achievements and advances made by the participants. The repetitions of movements, already known, as well as the introduction of new movements, have been carried out, maintaining the principles of progression, assimilation, and above all, putting the safety of the participants in the program first. All subjects in the sample were informed about the objectives of the study and agreed to participate after giving informed consent.We applied an intervention program based on Adapted Utilitarian Judo (JUA) Likewise, the program complies with the proposals of the Ethics Committee of the Biomedical Research of Andalusia, focused on ensuring the safety of the Older Adult throughout the execution process.JUA is based on the technical contents of traditional Judo, or basics of Kodokan Judo, started in Japan in 1882 by the master Jigoro Kano. The characteristics of Judo techniques  and the ukemis [yoko-ukemi  and ushiro-ukemi  to enable the older person to develop and assimilate an effective, non-injurious technique for falling and rising from the ground. Our methodological proposal [With the focus on the different types of ukemis , we workproposal  concentrukemis to older adults, we proposed activities of assimilation and assisted assimilation [To teach milation , linked For the intervention with the elderly group, we proposed two learning sequences: one autonomous implement-assisted; and the other collaborative partner-assisted (with or without implements). In these exercises, we laid the emphasis on the social and entertaining side of what we were doing.t-test for paired samples to analyze significance in mean difference as it was a small sample size, we considered that the differences were significant when p ≤ 0.05.We conducted a descriptive analysis using the SPSS  statistical program, with the category variables presented in terms of frequencies and percentages, with the mean and standard deviation presented for the numerical variables. We used the To analyze the evolution of scores for each subject, we took into account the cut-off points of the fear of falling using the 16-item version of the FES-I questionnaire . We estaOf all the variables analyzed using the FES-I, p ≤ 0.004).The JUA intervention program was therefore significant for the experimental group as If we analyze the results at group level, as shown in r = 0.962 y con el post-test r = 0.844).The personal Body Mass Index data (BMI) has been correlated through the Pearson correlation coefficient, with the results obtained in the measurements made on the fear of falling syndrome (STAC), and no significant statistical differences were found for this variable (pre-test The main findings of this study are substantial, since the results show that there were significant improvements in individuals’ perception of fear of falling, with these being greater in those subjects who had the highest levels of fear of falling before starting the intervention. As a result, some of the older people who participated in the study were able to return to daily activities that had become difficult for them because of the fear of falling.The results show that the JUA program reduced the fear of falling by 11.9%, dropping from 40.35% before the intervention to 28.39% after participation in the program. As a consequence, we can state that this program substantially reduced the risk of suffering fall episodes, as the FES-I was 18.17 following the intervention, and an FES-I > 26 is a potent predictor of falls .The results obtained in our study coincide with others proposing proprioceptive response strategies, applying therapies such as Tai-Chi that have obtained 11% reductions in the fear of falling, using the Activities-Specific Balance Confidence Scale questionnaire .In most of these studies, fear of falling was reduced by improvement in dynamic balance ,31; howeThere is a direct relationship between the practice of physical activity by older people and the fear of falling . We woulTherefore, it is possible to teach fall control to older adults using the JUA program. Hence, there would seem to be strong reasons for including this program in the contents of structured physical activity for older people, along with work on other qualities, such as strength, which are important for the elderly .It is important to remember that social and recreational programs are more likely to increase the quality of life of subjects . The JUAAs the JUA program is a pioneering protocol for the reduction of FOF in older adults, and due to the characteristics of this protocol, it is difficult to compare this program with others found in the literature to discuss its limitations. We can point out as limitations of our studio the small size of the experimental sample was in part due to the exclusion criteria, since in this type of population we find frequent health problems. We did not gather information about the informal activity of the subjects or make any other measurements such as verifying the perceived quality of life or balance, amongst others. Another perspective to keep in mind in the future would be to collect other data taking into account other variables before and after starting the program such as, for example, carrying out a preliminary evaluation of the strength of arms and legs, of all the subjects participating in the program. Likewise, we adopted a quasi-experimental design, with no control group, so it would be desirable in order to enrich the results of new research, to count on the design with the presence of a Control Group.In conclusion, the results obtained show that the application of a teaching program for the control of falls using JUA in older adults can help reduce FOF and therefore improve the quality of life of these subjects.Looking ahead, there would seem to be a strong argument for including JUA with its innovative, social and entertaining approach, in physical activity programs promoting active ageing and fragility prevention in the elderly. In the light of the initial data obtained in this study, the program appears to provide an effective tool for working on control, and STAC reduction, for care and healthcare professionals working with the elderly.