京都大学 / 新制・論文博士 / 博士(医学) / 乙第13571号 / 論医博第2297号 / 新制||医||1069(附属図書館) / (主査)教授 川上 浩司, 教授 渡邉 大, 教授 村井 俊哉 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

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<p><strong>Background: </strong>Walking dysfunction is one of the most disabling and persistent of stroke-related sequela. Theory- and research-derived motor learning principles (MLPs) offer an ideal theoretical framework for the development and evaluation of walking-skill focused interventions.</p> <p><strong>Purpose: </strong>To: 1) appraise the degree of adherence to motor learning principles (MLPs) in current post-stroke walking-skill training research; 2) describe the Motor Learning Walking Program (MLWP), a novel, MLPs-framed walking training program; and 3) compare the MLWP to an alternate theory-framed walking-focused intervention in community-dwelling individuals within one year of stroke.</p> <p><strong>Methods: </strong>A scoping review methodology was used to identify the prevalent theoretical frameworks in current post-stroke walking training literature, and to appraise the adherence to selected MLPs in walking-focused interventions. A randomized controlled trial (n=71) was conducted to compare the MLWP to a body-weight-supported treadmill training (BWSTT) intervention.</p> <p><strong>Results: </strong>In the scoping review of 27 walking-focused studies, a minority of investigators explicitly stated a theoretical-framework. Application of MLPs was inconsistent across interventions. In the randomized controlled trial, both intervention groups improved walking function after 5 weeks of training however, there were no significant between-group differences in the primary and secondary outcomes.</p> <p><strong>Conclusions:</strong> To date, there has been limited integration of MLPs into post-stroke walking-skill training literature. This randomized controlled trial is unique in its comparison of two theoretically divergent, yet equally intense, walking-training interventions. While the results were equivocal, future research should continue to explore the impact of application of MLPs on walking-skill recovery after stroke.</p> / Doctor of Philosophy (PhD)

<p>Upper respiratory tract infection (URTI), which presents clinically as the common cold, is the most common form of respiratory illness experienced by humans and is a major cause of morbidity and hospitalizations. Currently, URTI prevention focuses on hand hygiene with some consideration given to other lifestyle factors such as sleep, nutrition, and exercise. Identifying additional interventions for the prevention of URTI could reduce the burden of this disease.</p> <p>In this thesis, I examine the role of vitamin D3 supplementation and tap water gargling for the prevention of URTI. I employ experimental and observational study designs to assess the effect of these interventions on the risk of URTI in the context of a randomized controlled trial of 600 participants, and a longitudinal cohort of 416 participants. Further, I investigate the association between modifiable lifestyle factors and risk of URTI using data from the longitudinal cohort. Data from this study is also used to explore statistical methods for the analysis of repeated events.</p> <p>When evaluating self-reported, clinical URTI, all analyses supported the use of vitamin D3 supplementation to reduce the risk of URTI. However, this finding was only statistically significant in the analysis of the longitudinal cohort study; results from the RCT indicated that vitamin D3 supplementation statistically significantly reduced the risk of laboratory confirmed infections but had a non-significant benefit for clinical infections. Gargling did not reduce the risk of clinical or laboratory confirmed infections.</p> / Doctor of Philosophy (PhD)

<p><em>Background:</em> There is a shifting culture toward evidence-based plastic surgery. The use of high-quality evidence in patient decision-making is essential. To help achieve this goal the best evidence in the field needs to be identified, and the validity of this evidence verified.</p> <p><em>Objective:</em> This systematic review was designed to evaluate the plastic surgery literature by focusing on the prevalence of, and examining key components of quality of, Randomized Controlled Trials (RCTs) comparing surgical interventions.</p> <p><em>Methods: </em>An electronic search of the pertinent plastic surgery literature identified all RCTs published from 2000 to 2013 that compared one surgical intervention to another surgical intervention. Working in teams of two investigators independently, and in duplicate, assessed each manuscript for potential relevance and performed data extraction. Descriptive statistics, theory-driven multinomial regression, and independent samples t-test were used for data analysis.</p> <p><em>Results:</em> Of the 1664 hits obtained, 173 RCTs were included. These RCTs demonstrated the following data: 35% of RCTs performed and reported randomization properly, and 12% of RCTs reported proper allocation concealment methods. Outcome assessors were blinded in 48 (34%) RCTs, and patients blinded in 45 (26%) RCTs. Multinomial regression demonstrated that trials reporting an a <em>priori</em> sample size are significantly more likely to have a low risk of bias. One-third of trials did not state a primary outcome. The mean and median sample sizes were 73 and 43 patients respectively. Funding and conflict of interest reporting improved over time.</p> <p><em>Conclusions:</em> This systematic review establishes a baseline of the quality of evidence that currently guides practice for surgical interventions in plastic and reconstructive surgery. For the readers of plastic surgery literature to have confidence in the literature, risks of bias should be minimized and transparently reported. This will encourage plastic surgeons to apply the results and findings from published RCTs in their practice, providing patients them with the best possible treatments.</p> / Master of Science (MSc)

Aging and age-related frailty are important public health problems. There is a need to develop rehabilitation interventions to reduce the prevalence and disabling effects of frailty. This thesis reports the rationale and design of two studies and findings of three studies aimed to optimize health outcomes of frail older adults and their caregivers. The second chapter describes the protocol of the first network meta-analysis to determine the comparative effect of interventions targeting the prevention or treatment of frailty. In the third chapter, the results of frailty network meta-analysis were presented and 89 RCTs were included. The review shows that physical activity and medication management are the most effective frailty interventions. The fourth chapter describes a protocol of pilot randomized controlled trial (RCT) to examine a preoperative multi-modal frailty intervention in pre-frail/frail older adults undergoing elective joint replacements. The fifth chapter describes the results of a subgroup analysis of a RCT examining the effect of complex primary care intervention to support caregivers of frail older adults. There were no differences between caregivers of frail older adults and non-caregivers in quality of life, social support, hospitalization, and emergency department visits. The sixth chapter examines the construct validity and discriminative properties of the fracture rating scale (FRS) (a tool designed for fracture risk assessment in long term care (LTC)). The FRS is a valid tool for identifying LTC residents at different risk levels for hip fracture in three Canadian provinces. The work presented in this thesis is proposing and examining the comparative effect of frailty interventions, a preoperative frailty intervention/ model, a primary care intervention to identify and support caregivers, and a predictive tool to optimize care planning of LTC residents. These findings will support the rehabilitation and care program for older adults and their caregivers and improve their health outcomes. / Thesis / Doctor of Philosophy (PhD) / There is a need to develop rehabilitation interventions to reduce the prevalence and disabling effects of frailty. This thesis reports the rationale and design of two studies and findings of three studies aimed to improve health outcomes of frail older adults and their caregivers. The second and third chapters of this thesis describe the protocol and results of a review aims to identify the effect of interventions targeting frailty, the review found that physical activity and medication management are the most effective frailty interventions. The fourth chapter describes a study examining the possibility of comparing a complex intervention to usual care in frail older adults undergoing joint replacements. The fifth chapter showed that a primary care intervention did not improve the caregivers’ health outcome. The sixth chapter presents the fracture rating scale, a valid tool for identifying Long-term care residents at risk of hip fracture in three Canadian provinces. These findings aim to improve the care for older adults and their caregivers.

Driving is the preferred mode of transportation among community-dwelling older Canadians. Unfortunately, drivers aged 70+ have a high risk of being injured or killed in a collision. Many collisions are caused by poor driving habits, which could be avoided by improving their behind-the-wheel behaviours. The manuscripts in this thesis describe the development of an evidence-based and user-informed driver training program aimed at refreshing older adults’ driving skills. First, a systematic review of older driver training programs was undertaken to examine evidence specific to the impact of this training on improving road safety knowledge, self-perceived driving abilities, and on-road performance. Results highlighted the breadth of approaches used to train older drivers. Interventions were most effective when feedback was tailored to the specific needs of an aging driver. The second manuscript outlines a qualitative descriptive analysis exploring older adults’ motivations to participate in driver training with key stakeholders (i.e., older drivers and service delivery providers). Findings indicated having insight into one’s driving abilities, experiencing a near-miss or crash, as well as an openness to improving behind-the-wheel skills were factors that could influence seeking out and participating in such training. Stakeholders also emphasized considerations for educating older drivers. The final manuscript describes the design and evaluation of a driver training program. In this randomized controlled trial, older drivers watched either a video of tailored feedback on their driving or a generic video on aging-in-place. When the on-road performance was compared between treatment groups, those who received tailored feedback significantly reduced the number of errors they made behind-the-wheel. Ensuring driver training programs are designed to consider the specific needs and preferences of older adults is critical, which can lead to innovations that help maintain driving ability and community mobility in later life. / Thesis / Doctor of Philosophy (PhD) / Being able to drive is important to many older Canadians. Unfortunately, drivers aged 70+ have a high risk of being injured or killed in a car crash. Many crashes could be avoided by improving their driving skills. This thesis describes the development of an older driver training program. The first study examined research evidence on such programs where tailoring feedback was key to improving on-road performance. In the second study, older adults and other stakeholders identified what was important when designing training for aging drivers. They felt the focus should be on areas of improvement as well as strengths when behind-the-wheel. In the final study, older drivers underwent training where they watched either a video with feedback on their driving or a generic video on aging-in-place. Those who received feedback made fewer mistakes behind-the-wheel. Findings emphasize the importance of including older adults’ needs and preferences when designing driver training programs.

Yes / Current NHS policy encourages an integrated approach to provision of mental and physical care for individuals with long term mental health problems. The 'PARTNERS2' complex intervention is designed to support individuals with psychosis in a primary care setting. The trial will evaluate the clinical and cost-effectiveness of the PARTNERS2 intervention. This is a cluster randomised controlled superiority trial comparing collaborative care (PARTNERS2) with usual care, with an internal pilot to assess feasibility. The setting will be primary care within four trial recruitment areas: Birmingham & Solihull, Cornwall, Plymouth, and Somerset. GP practices are randomised 1:1 to either (a) the PARTNERS2 intervention plus modified standard care ('intervention'); or (b) standard care only ('control'). PARTNERS2 is a flexible, general practice-based, person-centred, coaching-based intervention aimed at addressing mental health, physical health, and social care needs. Two hundred eligible individuals from 39 GP practices are taking part. They were recruited through identification from secondary and primary care databases. The primary hypothesis is quality of life (QOL). Secondary outcomes include: mental wellbeing, time use, recovery, and process of physical care. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action, and look for unintended consequences. An economic evaluation will estimate its cost-effectiveness. Intervention delivery and follow-up have been modified during the COVID-19 pandemic. The overarching aim is to establish the clinical and cost-effectiveness of the model for adults with a diagnosis of schizophrenia, bipolar, or other types of psychoses. / PARTNERS2 is funded by the National Institute for Health Research (NIHR) under its Programme Grant for Applied Research Programme (grant number: RP-PG- 200625). This research was also supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust.

Yes / Background: Online communities hold great potential as interventions for health, particularly for the management of chronic illness. The social support that online communities can provide has been associated with positive treatment outcomes, including medication adherence. There are few studies that have attempted to assess whether membership of an online community improves health outcomes using rigorous designs. Objective: Our objective was to conduct a rigorous proof-of-concept randomized controlled trial of an online community intervention for improving adherence to asthma medicine. Methods: This 9-week intervention included a sample of asthmatic adults from the United Kingdom who were prescribed an inhaled corticosteroid preventer. Participants were recruited via email and randomized to either an “online community” or “no online community” (diary) condition. After each instance of preventer use, participants (N=216) were required to report the number of doses of medication taken in a short post. Those randomized to the online community condition (n=99) could read the posts of other community members, reply, and create their own posts. Participants randomized to the no online community condition (n=117) also posted their medication use, but could not read others’ posts. The main outcome measures were self-reported medication adherence at baseline and follow-up (9 weeks postbaseline) and an objective measure of adherence to the intervention (visits to site). Results: In all, 103 participants completed the study (intervention: 37.8%, 39/99; control: 62.2%, 64/117). MANCOVA of self-reported adherence to asthma preventer medicine at follow-up was not significantly different between conditions in either intention-to-treat (P=.92) or per-protocol (P=.68) analysis. Site use was generally higher in the control compared to intervention conditions. Conclusions: Joining an online community did not improve adherence to preventer medication for asthma patients. Without the encouragement of greater community support or more components / Funded by a pilot grant from the University of Leeds School of Psychology. A Fulbright Scholarship from the US-UK Fulbright Commission supported the first author

Background: Breast cancer is the most frequently diagnosed cancer and a leading cause of cancer death among females, both worldwide and in the UK. Although, UK incidence of breast cancer is rising, breast cancer mortality rates are falling, due largely to early detection and improved treatment. As a result there are more women living with a diagnosis of breast cancer than ever before. Due mainly to side-effects of adjuvant therapy, breast cancer patients may require diagnostic, therapeutic, supportive or palliative services many years post-diagnosis, which poses a major challenge to already stretched healthcare services. Accordingly, effective and inexpensive interventions that can alleviate treatment side-effects, improve health, quality of life and potentially reduce risk of early mortality are required for breast cancer patients. Awareness of the positive influence that physical activity can have on breast cancer development and outcome is an important determinant of physical activity levels. A higher level of physical activity before and after breast cancer diagnosis is related to a lower risk of all-cause and breast cancer-related mortality. Randomised controlled trials have reported beneficial effects of physical activity interventions on outcomes relating to health, quality of life and mortality risk among breast cancer survivors. Aims: The present project aimed to: 1) assess awareness of the role of physical activity on breast cancer risk and the sufficiency of physical activity undertaken in women attending the NHS breast screening programme (NHSBSP), 2) compare physical activity levels of women at different stages of breast cancer pathway, 3) investigate the effects of a low-cost six-month home-based physical activity intervention on physical activity, body mass, health-related quality of life (HRQoL), insulin resistance and blood lipid profiles of breast cancer survivors and 4) assess the effects of our home-based intervention on cardiorespiratory fitness in a subset of breast cancer survivors. Methods: A total of 309 volunteers (188 NHSBSP attendees, 41 breast cancer patients undergoing chemotherapy and 80 post-treatment breast cancer survivors) participated in the current project. Physical activity was assessed via the International Physical activity Questionnaires (IPAQ). In studies one and two, Body mass and body mass index (BMI) were assessed directly in chemotherapy patients and breast cancer survivors, and indirectly from self-reported values in NHSBSP attendees. While in study three, body fat percentage was measured via bioelectrical impedance analysis, HRQoL was assessed using the Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire and fasting blood samples were taken to measure lipid, glucose and insulin concentrations at baseline and post-six month home-based physical activity intervention. In study four, a random subsample of 32 breast cancer survivors undertook an exercise tolerance test to establish peak oxygen uptake values. Results: A high proportion (70%) of NHSBSP attendees engaged in low-moderate levels of physical activity and performed low amounts of recreational physical activity. Attendees demonstrated high awareness (75%) of the role of physical activity in reducing breast cancer risk but those categorised as “low activity” were significantly unaware of insufficiency of activity (p<0.05). Chemotherapy patients and breast cancer survivors had significantly lower levels of total physical activity than NHSBSP attendees (p<0.001 and p<0.05, respectively). The randomised controlled trial revealed significant improvements in total physical activity, body mass (p<0.05), BMI (p<0.05) HRQoL (breast cancer subscale, p<0.01; trial outcome index, p<0.05) and total (p<0.01) and low-density lipoprotein (p<0.05) cholesterol concentrations in the intervention group compared to usual care, and significant improvements in cardiorespiratory fitness (p<0.05) in a subsample of breast cancer survivors allocated to intervention. Conclusions: Physical activity interventions that incorporate strategies aimed at increasing awareness of recommended physical activity guidelines may be required in populations at risk of breast cancer. A relatively large proportion of women at risk of breast cancer may not be sufficiently exposed to the potential benefits of physical activity on breast cancer outcomes. Post-treatment breast cancer patients may be more receptive to physical activity interventions as the negative effects of chemotherapy begin to resolve, and therefore, may benefit from physical activity interventions. Results suggest that a low-cost home-based physical activity intervention with counselling and telephone support can improve the health and HRQoL of breast cancer survivors, which may in turn potentially reduce risk of breast cancer and cardiovascular disease-related mortality. Given the encouraging results and its highly portable and feasible nature, our intervention represents a promising tool for use in health and community settings to benefit large numbers of breast cancer survivors. The current project supports the inclusion of physical activity promotion as an integral component for the management and care of breast cancer survivors.