付記する学位プログラム名: グローバル生存学大学院連携プログラム / 京都大学 / 0048 / 新制・課程博士 / 博士(工学) / 甲第21057号 / 工博第4421号 / 新制||工||1687(附属図書館) / 京都大学大学院工学研究科社会基盤工学専攻 / (主査)教授 寶 馨, 教授 田中 茂信, 准教授 佐山 敬洋 / 学位規則第4条第1項該当 / Doctor of Philosophy (Engineering) / Kyoto University / DFAM

Bakgrund: Padeltennis, en sport som på kort tid ökat explosionsartat i Sverige och lockat till sig många utövare- unga som gamla, tränade som otränade, kvinnor som män. Att börja med en ny sport kan innebära nya påfrestningar på kroppen, däribland många repetitiva slag som kan leda till överbelastningsskador samt akuta skador som det visat sig i studier för idrottare. Målet med denna studie är att öka kunskapen för det skadeförebyggande arbetet samt rehabiliteringsprocessen för denna målgrupp. Syfte: Syftet med studien var att undersöka skadepanorama samt identifiera de främst förekommande skadelokalisationerna inom padeltennis för att kartlägga och analysera skadorna i förhållande till kön, ålder och nivå hos padeltennisspelare. Metod: En kvantitativ kunskapsansats med retrospektiv design valdes. Insamlingen av data skedde genom delning av en egenutformad digital enkät både genom sociala medier samt padelhallar runt om i landet. Resultat: 610 personer deltog i studien varpå 56,5% uppgav att de haft en skada till följd av padelspel det senaste året. Den kroppsdel som varit mest utsatt för överbelastningsskador var armbåge medan fot/fotled hade flest akuta skador. Analys av skadefrekvensen visade ingen märkbar skillnad bland könen, däremot hade de äldre åldersgrupperna samt de högre spelarnivåerna något större skadefrekvens. Konklusion: Denna studie kan ses som ett första steg för ett skadeförebyggande arbete inom padel. Likt andra studier visar denna att skador inom padel förekommer, dock behövs det fler standardiserade studier inom ämnet för att lättare jämföra resultat av framtida undersökningar.

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Despite substantial healthcare costs, patient outcomes are sub-optimal in the United States and Canada compared to other countries that spend proportionally less on healthcare. This has led to recognition of the need to improve healthcare value, utilization of tools including clinical practice guidelines and development of initiatives such as the Choosing Wisely Campaign to achieve this goal. In spite of the intuitive appeal of these interventions designed to increase physician awareness of evidence and empower patients to engage in shared decision-making, they have had limited success in changing practice and physician prescribing behaviours. Using a mixed-methods approach, this thesis represents a purposeful attempt to understand the failure of existing approaches through an examination of the factors that influence clinical decision making. Specifically, the thesis integrates quantitative and qualitative methodologies to develop a deeper understanding of clinical decision-making. Consisting of a clinical vignette based survey, the quantitative study explores decision-making in four specific commonly encountered case contexts. After choosing the preferred management option, participants rated the influence of different factors on their decisions. Follow-up questions explored knowledge, attitudes and practices regarding incorporating cost considerations into decision-making. The results of the study were explored further in the qualitative component of the mixed study. The results indicate that clinical decision-making is influenced by an interrelated set of socioecological factors with evidence and clinical practice guidelines playing a secondary role. Because lack of knowledge is not a major factor in guideline discordant care, strategies to improve knowledge will have minimal effect in improving care. The qualitative study included an inquiry into the need for teaching and learning on the topic of cost and cost-effectiveness and sought input from physicians working in diverse settings on methods and topics that need to be included in medical education. The contributions of this thesis include a deeper understanding of the factors that influence clinical decision-making and suggestions for enhancing medical education. / Thesis / Doctor of Philosophy (PhD) / Despite the highest health-care expenditure in the world, patient health outcomes are suboptimal in the United States (US). Additionally, out-of-pocket patient costs are increasingly a cause of financial distress to American patients. Although Canada spends comparatively less than the US on healthcare, it is one of the top ten countries for healthcare spending as a proportion of the gross domestic product. In spite of this level of spending, patient outcomes in the US and Canada are worse when compared to many other economically developed countries that spend relatively less on healthcare. A substantial portion of healthcare spending is for services that do not improve patient outcomes while services proven to improve patient outcomes are underused. Utilizing sequential quantitative and qualitative studies this thesis is a purposeful attempt to identify and examine the factors that influence clinical decision making by physicians. The knowledge gained in this study may help inform the development and evaluation of strategies targeted at increasing adoption of evidence-based practices leading to improved health-outcomes at affordable costs.

Submitted in fulfilllment of the requirements for the Masters in Nursing degree, Durban University of Technology, 2014. / Introduction Work-related musculoskeletal disorders are the most commonly reported work-related illnesses impacting on the quality of life of nurses. Absenteeism, work restriction, loss of income and disability are related outcomes. Nurses are at a higher risk of work-related musculoskeletal disorders (WMSD) compared to other healthcare professionals because of the nature of their duties. Problem statement The relationship between work-related musculoskeletal disorders, absenteeism and visits to the staff clinic by nurses has not been established in South Africa. Purpose The purpose of this study was to determine the prevalence of WMSD in nurses and its relationship to absenteeism and visits to the staff clinic by nurses in a selected eThekwini District hospital. Research method A cross-sectional quantitative descriptive survey was conducted in two stages namely the prospective cross-sectional survey of nurses and the retrospective review of records. A random sample of 231 nurses was selected, proportionally, from all nursing ranks and invited to fill in the self-administered musculoskeletal questionnaire. Results The lifetime prevalence of WMSD in nurses in this study was 77% with the twelve months prevalence of 67% and the seven days prevalence of 43%. The prevalence of low back pain was higher (21% for twelve months and 47% for seven days) than that of other body regions with a higher tendency (65%) of WMSD affecting more than two body regions. Although the prevalence and patterns of WMSD was almost the same across all nursing ranks, nurses working in the Out Patients Department reported the highest prevalence (22%). There was no significant relationship between age, gender and smoking; however, a strong correlation between WMSD and participation in physical exercise, work task and workload was noted. No relationship could be established between WMSD and staff visits to the staff clinic as well as amount of sick leave taken. Conclusion This study showed that WMSD is high in the selected hospital. Nurses working in the Outpatients department reported the most WMSD; body parts affected was not related to age, gender, nurse rank or unit in which the nurse worked. There is a problem of under- reporting of WMSD. Nurses working in this hospital have an option of attending their private health service providers even following a WMSD. In these cases the staff clinic is unable to keep accurate statistics of WMSD, conduct reviews and proper management of the WMSD.

<p>This study investigates the use of formulaic language in spoken French produced by native and non-native speakers. It aims at describing the development of formulaic sequences in learners ranging from beginners to very advanced users. It draws on data from the InterFra corpus, which includes both formal and semi-formal learners. Four measures are used to characterize this development: extent of formulaic language used, category distribution, type / token ratio and frequency of types. </p><p>It has been shown that a user’s knowledge of formulaic sequences impacts heavily on language proficiency and idiomaticity. Because these sequences follow neither grammatical nor lexical rules, they constitute the last threshold for advanced L2 learners. In second language acquisition, the term formulaic sequence not only applies to strict idiomatic constructions, but it is also used to refer to sequences that appear to be acquired in a holistic manner during the first phases of acquisition. A categorization is therefore proposed that can account for native and non-native usage of formulaic sequences (prefabs). Five categories of prefabs are included: Lexical, Grammatical, Discourse, Situational and Idiosyncratic. </p><p>The extent of a learner’s use of formulaic language increases as the learner progresses, the largest amount found in the production of native speakers and very advanced learners. The learner’s distribution of categories moves towards native speaker distribution, albeit slowly. Situational and Idiosyncratic prefabs are found to characterize the early phases of acquisition, while Lexical prefabs are mastered later and are a major difficulty for L2 learners. Only very advanced learners who have spent considerable time in France produce the same proportion of Lexical prefabs as native speakers. Discourse prefabs constitute the most important category for all groups, including natives and non-natives. It can therefore be postulated that the main function of formulaic sequences in spoken French is that of discourse structuring and speech management. The development and use of formulaic language is explained within a framework of Frequency Effects. Coupled with other factors, frequency can account for why Lexical prefabs are hard to acquire and why formulaic sequences take a long time to master.</p> / The thesis is published and can be purchased by Peter Lang http://www.peterlang.com/index.cfm?vID=11369&vLang=E&vHR=1&vUR=1&vUUR=38

Bakgrund: Idag finns en begränsad vetskap hur svenska elitsatsande barn och ungdomar som klättrar upplever smärta i fingrarna eller vilka träningsvanor de har. Detta kan leda till ökad risk av överbelastningsskador. En ökning av stressfrakturer på fingrarnas tillväxtzoner i de yngre åldrarna visar en felaktig utveckling. Fingerträning bör inte förekomma hos barn och ungdomar under 18 år. Syfte: Att kartlägga barn och ungdomars upplevda smärta i fingrarna och deras träningsvanor samt att undersöka samband mellan smärtupplevelse och träningsvanor. Material och metod: Utövarna har fyllt i en enkät gällande smärtupplevelse i fingrarna under 2016. Vidare undersöktes specifik fingerträning och övriga träningsvanor. Deltagarna delades in i ålderskategorier 9-13 år samt 14-19 år och kön. Resultat: Utav 86 deltagare genomförde 63 enkätundersökningen. Majoriteten 68.3 % använde specifika fingerträningsmetoder. Hos pojkar och den äldre ålderskategorin hade 30 % upplevt så mycket smärta i fingrarna att det påverkat deras träning negativt. 79.4 % av deltagarna tar hjälp av tränare. Det fanns ett starkt signifikant positivt samband (r = 0.355) mellan antalpass per vecka och upplevelse av smärta i fingrarna. Det var även en starkt signifikant negativ korrelation (r =-0.450) mellan att ta hjälp av tränare och ålder. Konklusion: Majoriteten av deltagarna använder sig av specifik fingerträning trots rekommendationerna att inte använda detta. Hälften upplever någon forma av smärta i fingrarna. Majoriteten har en tränare, vilken har ansvar för träningen. Tränaren behöver bli bättre på att övervaka individernas träningsvanor och deras fysiska status. Föräldrar, individ och tränaren behöver samarbeta bättre för säkrare träningsformer. / Background: There is limited knowledge of Swedish young elite level climbers and their experienced pain in the fingers and training habits. An increased expose of an overload injuries is at risk. Epiphyseal fractures of fingers growth zones reveals that the sport is developing in an unwanted way. Despite recommendations of specific finger training should not be a part of the training it is still common. Objective: To identify experience of pain in the fingers and training habits and to analyze the relationship between pain perception and exercise habits. Materials and Methods: The examined group filled out a questionnaire retrospective of their experience of pain in the fingers and exercise habits during 2016. The participants were divided into age categories (9-13 years and 14-19 years) and sex. Results: Out of a total 86 participants 63 completed the questionnaire. The majority 68.3 % used specific finger training methods. The boys and the older age group, 30 %, experienced so much pain in the fingers that it affected their training negatively. 79.4 % of participant’s took help from a coach in their training. There was a highly significant positive correlation (r=0.355) between the number of workouts per week and the experience of pain in the fingers. There was also a highly significant negative correlation between the use of trainers and age (r=-0.450). Conclusion: The majority of participants use specific finger exercise despite recommendations not to use it. Furthermore the majority have a coach. The coach is responsible for the training and need to be better of monitoring the individual's exercise habits and their physical status (injuries, strengths, weaknesses). Parents, the climber and their coach need to work better and closer together to increase safer training methods.

Introduktion: Idag klassificeras akuta skador generellt som allvarligare än överbelastningsskador då akuta skador ofta leder till längre tid borta från idrotten. Denna form av kategorisering av allvarlighetsgrad inom forskning har dock påvisats vara problematisk då det ofta exkluderar överbelastningsskador. Detta trots att dem med överbelastningsskador ofta lider av långa perioder med smärta, nedsatt funktion och försämrad prestation. Viktigt oavsett vilken skada en person har drabbats av är följsamhet till rehabilitering. Följsamhet till rehabilitering har visats vara beroende av ett flertal olika faktorer bland annat upplevelsen av skadan och smärta. Syfte: Undersöka ifall det finns signifikanta skillnader mellan följsamhet till rehabiliteringsträning, upplevelse av skadan och högst upplevd nivå av smärta beroende på om en idrottsskada uppstått akut eller av överbelastning. Deltagare: 51 personer besvarade enkäten varav 39 stycken (14 kvinnor och 25 män) inkluderades i studien. De inkluderade var mellan 16 och 35 år gamla, led av en idrottsskada samt hade ett rehabiliteringsprogram för att behandla skadan. Baserat på deltagarnas diagnos samt beskrivning av skadan grupperades dem antingen in i kategorin akuta skador eller överbelastningsskador. Metod: Ett frågeformulär baserat på två validerade enkäter, Rehabilitation Adherence Questionnaire och Cognitive Appraisal Health Scale samt skattning av högst upplevd smärta distribuerades till föreningar och på sociala medier. För att undersöka ifall det fanns signifikanta gruppskillnader mellan dem med akuta skador och överbelastningsskador genomfördes t-test och MANOVA. Resultat: Det fanns inga signifikanta skillnader mellan grupperna på någon av de undersökta variablerna. Kategorin hot närmade sig signifikansnivå (p=0,071) där dem med akuta skador värderade sin skada som mer hotfull än dem med överbelastningsskador. Konklusion: Endast beroende på om en skada uppstått akut eller på grund av överbelastning verkar inte vara avgörande för en persons följsamhet till rehabilitering, upplevelse av skada eller högst skattad nivå av smärta. / Introduction: Acute injuries are generally classified as more severe than overuse injuries due to the fact that they often lead to longer time away from sport. This type of classification of severity in research is not deemed appropriate since it often excludes people suffering from overuse injuries. People with overuse injuries usually stay in their sport but participates with pain, reduced function and performance. Purpose: The purpose of this study was to examine significant differences between adherence to rehabilitation, cognitive appraisal and perceived pain depending on if a sport injury has occurred acute or due to overuse.   Participants: 51 participants answered the questionnaire and 39 (14 women and 25 men) of these were included in the study. The participants were between 16 and 35 years old, suffered from a sport injury and had a rehabilitation program to treat their injury. Based on the diagnosis and description of the injury the participants were separated into two groups, either acute injury or overuse injury. Method: A questionnaire including two validated questionnaires, the Rehabilitation Adherence Questionnaire and Cognitive Appraisal Health Scale and an estimation of highest experienced pain were distributed among different sport teams and social media. To investigate if there were any significant differences between the two groups on the examined variables several t-tests and one ANOVA was completed. Results: No significant differences were found between the two groups on any of the examined variables. The category threat on the Cognitive Appraisal Health Scale were close to significance (p=0,071) and suggests that people who suffer from an acute injury found their injury to be more threatful. Conclusion: If a sport injury has occurred acute or because of overuse doesn't seem to be a singular determinant factor that affects adherence to rehabilitation, cognitive appraisal or perceived pain

This study investigates the use of formulaic language in spoken French produced by native and non-native speakers. It aims at describing the development of formulaic sequences in learners ranging from beginners to very advanced users. It draws on data from the InterFra corpus, which includes both formal and semi-formal learners. Four measures are used to characterize this development: extent of formulaic language used, category distribution, type / token ratio and frequency of types. It has been shown that a user’s knowledge of formulaic sequences impacts heavily on language proficiency and idiomaticity. Because these sequences follow neither grammatical nor lexical rules, they constitute the last threshold for advanced L2 learners. In second language acquisition, the term formulaic sequence not only applies to strict idiomatic constructions, but it is also used to refer to sequences that appear to be acquired in a holistic manner during the first phases of acquisition. A categorization is therefore proposed that can account for native and non-native usage of formulaic sequences (prefabs). Five categories of prefabs are included: Lexical, Grammatical, Discourse, Situational and Idiosyncratic. The extent of a learner’s use of formulaic language increases as the learner progresses, the largest amount found in the production of native speakers and very advanced learners. The learner’s distribution of categories moves towards native speaker distribution, albeit slowly. Situational and Idiosyncratic prefabs are found to characterize the early phases of acquisition, while Lexical prefabs are mastered later and are a major difficulty for L2 learners. Only very advanced learners who have spent considerable time in France produce the same proportion of Lexical prefabs as native speakers. Discourse prefabs constitute the most important category for all groups, including natives and non-natives. It can therefore be postulated that the main function of formulaic sequences in spoken French is that of discourse structuring and speech management. The development and use of formulaic language is explained within a framework of Frequency Effects. Coupled with other factors, frequency can account for why Lexical prefabs are hard to acquire and why formulaic sequences take a long time to master. / The thesis is published and can be purchased by Peter Lang http://www.peterlang.com/index.cfm?vID=11369&vLang=E&vHR=1&vUR=1&vUUR=38

Abstract The study aims to discuss how English article system is acquired by Mandarin-Chinese speakers at two domains, semantic domain and sentence level, by analyzing oral-story-telling data produced by forty 19-to-20-year old college students in Taiwan (20 males and 20 females), divided into low proficiency and high proficiency levels based on their results of Michigan Listening Comprehension Test. The production data was classified into four semantic types marked by a combination of two universal semantic concepts, specificity and definiteness for the purpose of examining Fluctuation Hypothesis (FH) proposed by Ionin (2004), who argued that L2 access to Universal Grammar by predicting L2 learners without article system will fluctuate between two parameter settings of specificity and definiteness. It is found that overuse of the did occur in [+specificity, -definiteness] contexts where target use is a, particularly for low-level learners. Besides, to closely probe into how L1 Mandarin-Chinese speakers use articles in L2 grammar within Ionin¡¦s framework, a model for linguistic properties marking specificity and definiteness in Chinese was proposed so as to compare the differences between English article system and Chinese classifier system, arguing that the interference of L1 may take place at semantic domain by L1 Mandarin-Chinese speakers. The evidence that the substitution of nage for definite article the in [+specificity, +definiteness] contexts and that of numeral one yige for indefinite article a in only [+specificity, -definiteness] and [-specificity, -definiteness] contexts sheds the light on the possibility of the occurrence of L1 transfer at the semantic domain. As for article use in sentential positions, due to definiteness effect and subject indefinite effect in Chinese, it is predicted that L1 Mandarin-Chinese speakers would drop articles more often in preverbal positions than in postverbal positions. The result showed that low-level learners did drop more articles in preverbal positions than in postverbal positions, but advanced learners showed the contrast, which implies that the beginners are easily governed by the definiteness effect, that is, L1 is at play at the initial state of L2 grammar. Overall, the advanced learners used articles more accurately than the low-level learners did, suggesting that the advanced Mandarin-Chinese L2 English learners may gradually reset the parameter of L2 grammars in acquiring English article system. Furthermore, different error types produced by the participants were classified in the study and provided with theoretical discussion. A surprising finding is that the low-level learners highly misused the Cinderella for Cinderella in the data. Such error production may show the evidence of L2 access to UG since the Cinderella cannot be used in English and there is no determiner the projecting in Chinese proper name. The overuse of the further illustrates the existence of projecting D for L1 Chinese learners. The acquisition rate of article use was measured by SOC (Suppliances in Obligatory Contexts) and TLU (Target-Like-Use). The results showed that the most difficult article use for both proficiency levels is zero article Ø. The advanced learners can use the more accurately than the learners at proficiency level due to the high occurrences of overgeneralization of the by the low-proficiency levels. In general, the result of the current study bears on the issue of accessibility of UG and the possibility of parameter (re-) setting. It is also shown that L1 plays a significant role in L2 article use not only at the semantic domain but also at the sentential level by L1 Mandarin-Chinese speakers, especially for those at the initial state of L2 grammar.