DOCSLIB.ORG

The Neurobiology of Meditation for the Control of Pain

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Neurobiology of Meditation for the Control of Pain i Université de Montréal The neurobiology of meditation for the control of pain par Joshua A. Grant Département de Physiologie Faculté de médicine Thèse présentée à la Faculté des études supérieures et postdoctorales en vue de l‟obtention du grade de Ph.D. en sciences neurologiques Janvier 2011 © Joshua Grant 2011 ii Université de Montréal Faculté des études supérieures et postdoctorales Cette thèse intitulée: The neurobiology of meditation for the control of pain présentée par: Joshua A. Grant a été évaluée par un jury composé des personnes suivantes: Trevor Drew, président-rapporteur Pierre Rainville, directeur de recherche Adrianna Mendrek, membre du jury Catherine Bushnell, examinateur externe John Kalaska, représentant du doyen de la FES iii Résumé La douleur est une expérience multidimensionnelle comportant des aspects sensoriels, émotionnels et cognitifs. Il a été montré que cette expérience peut être modulée par des facteurs psychologiques ou des interventions cognitives comme l‟attention, la distraction, l‟hypnose ou les attentes. La tradition orientale suggère également que la pratique de la méditation pourrait avoir des effets analgésiques. D‟un point de vue théorique, plusieurs mécanismes pourraient expliquer ces effets. Cependant, très peu d‟études ont testé ces hypothèses. Les études présentées dans cette thèse avaient donc pour objectif d‟examiner les mécanismes analgésiques de la méditation. Dans un premier temps, une étude psychophysique a été réalisée afin de comparer les réponses à la douleur entre des adeptes de la méditation Zen et des sujets contrôles, dans différentes conditions attentionnelles. Durant la condition attentionnelle de type « mindful », les adeptes de la méditation ont présenté une plus faible sensibilité à la douleur, des réponses attentionnelles à la douleur atypiques et une diminution de la perception de la douleur associée à l‟entraînement à la méditation. Une deuxième étude a été réalisée en imagerie par résonance magnétique fonctionnelle (IRMf) avec des groupes de participants similaires. Dans une condition sans méditation, les adeptes de la méditation ont présenté de plus fortes réponses nociceptives dans les régions primaires de la douleur. Les régions cérébrales associées aux processus d‟évaluation, à la mémoire et aux émotions ont quant à elles montré une diminution d‟activité. De plus, cette diminution était plus importante chez les adeptes de la méditation les plus expérimentés et elle était associée à des iv évaluations de douleur plus faibles. Par ailleurs, des changements de connectivité fonctionnelle entre le cortex préfrontal et une région primaires de la douleur étaient associés à la sensibilité à la douleur chez les adeptes de la méditation. Finalement, une étude d‟imagerie cérébrale structurale (publiée comme deux études séparées) a été réalisée pour examiner les différences d‟épaisseur corticale entre les groupes, pour des régions associées à la douleur. Les adeptes de la méditation ont présenté une épaisseur plus importante de matière grise dans plusieurs régions associées à la douleur et l‟attention. De plus, ces différences étaient associées à une mesure expérientielle de l‟attention, à la sensibilité à la douleur et à l‟expérience de méditation. Dans l‟ensemble, ces résultats suggèrent que la méditation pourrait influencer la perception de la douleur par des changements fonctionnels et physiques dans le cerveau. De plus, le patron d‟activation et la modulation de l‟expérience paraissent uniques en comparaison à ceux d‟autres interventions, ce qui suggère qu‟un état de détachement et un focus mental favorisent la dissociation entre les aspects désagréables et sensoriels d‟un stimulus nociceptif. Mots-clés: douleur, nociception, méditation, Zen, mindfulness, modulation de la douleur, IRMf, émotion, auto régulation, attention v Abstract Pain is a multidimensional experience involving sensory, emotional and cognitive components. It is well known that mental factors or interventions such as attention, distraction, hypnosis or expectation can modulate painful experience. Traditional claims from the East suggest meditative practice may also have analgesic effects. Theoretically there are multiple avenues by which such practices could act, however little work has been done in this regard. The works presented in this dissertation were intended to address this paucity of research by contrasting pain perception in practicing meditators and non-meditating control participants. A psychophysical pain study was first conducted with practitioners of Zen meditation contrasting their responses to pain with control subjects during different attention conditions. Meditators were found to have lower baseline pain sensitivity, atypical attention-related pain responses and training-related reductions of pain ratings during mindful attention. A second study, with similar groups of subjects, employed functional magnetic resonance imaging (fMRI) during the perception of pain. In a non-meditative state, meditators were found to have stronger nociceptive- related brain activity in primary pain regions while simultaneously exhibiting reductions of activation in brain areas associated with appraisal, memory and emotion. These later effects were largest in the most advanced practitioners and were associated with the lowest pain ratings. Importantly, changes in functional connectivity between prefrontal cortex and a primary pain region predicted baseline pain sensitivity in the meditation group. Finally, a structural imaging experiment (published as two separate reports) was conducted to examine whether grey matter vi thickness may differ, in pain-relevant ways, between the groups. Meditators were found to have thicker regional grey matter in several pain and attention-related regions which corresponded both with an experiential measure of attention, pain sensitivity and meditation experience. Taken together these results suggest meditation may influence pain perception through functional as well as physical effects on the brain. The pattern of brain activity and experience modulation appears to be unique, when contrasted with previously studied interventions, and suggests that adopting a non-elaborative but focused mental stance may allow one to dissociate the bothersome qualities from the sensory aspects of a noxious stimulus. Key words: pain, nociception, meditation, Zen, mindfulness, pain modulation, fMRI, emotion, self regulation, attention vii Table of Contents Résumé..................................................................................................... iii Abstract.................................................................................................... v Table of Contents..................................................................................... vii List of Tables........................................................................................... ix List of Figures.......................................................................................... x Abbreviations........................................................................................... xi Dedication................................................................................................ xiii Acknowledgements.................................................................................. xiv Forward.................................................................................................... xv GENERAL INTRODUCTION................................................................ 1 The Neurobiology of Pain................................................................ 2 Brain Imaging and Pain Modulation................................................. 5 Introduction to Meditation................................................................ 10 Science and Meditation..................................................................... 14 Meditation and Pain.......................................................................... 17 Hypotheses........................................................................................ 18 References......................................................................................... 20 ARTICLES.............................................................................................. 27 Article #1 - Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study........................................ 28 Article #2 - A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators.................................................................................. 65 Article #3 - Cortical thickness and pain sensitivity in Zen meditators......................................................................................... 103 viii Article #4 - Associations between cortical thickness, attentional absorption and prior mental training: possible implications for disorders of attention........................................................................ 137 GENERAL DISCUSSION...................................................................... 163 Summary of Our Results.................................................................. 164 Attention........................................................................................... 165 Mindfulness...................................................................................... 169 Meditation and Pain.........................................................................
Load more

Recommended publications
  • The Effects of a Brief Mindfulness-Based Meditation Intervention on Chronic Pain" (2016)
    Gardner-Webb University Digital Commons @ Gardner-Webb University Nursing Theses and Capstone Projects Hunt School of Nursing 12-2016 The ffecE ts of a Brief Mindfulness-Based Meditation Intervention on Chronic Pain Jolena B. Allred Gardner-Webb University Follow this and additional works at: https://digitalcommons.gardner-webb.edu/nursing_etd Part of the Psychiatric and Mental Health Nursing Commons, and the Public Health and Community Nursing Commons Recommended Citation Allred, Jolena B., "The Effects of a Brief Mindfulness-Based Meditation Intervention on Chronic Pain" (2016). Nursing Theses and Capstone Projects. 236. https://digitalcommons.gardner-webb.edu/nursing_etd/236 This Dissertation is brought to you for free and open access by the Hunt School of Nursing at Digital Commons @ Gardner-Webb University. It has been accepted for inclusion in Nursing Theses and Capstone Projects by an authorized administrator of Digital Commons @ Gardner-Webb University. For more information, please see Copyright and Publishing Info. The Effects of a Brief Mindfulness-Based Meditation Intervention on Chronic Pain by Jolena B. Allred A capstone project submitted to the faculty of Gardner-Webb University Hunt School of Nursing In partial fulfillment of the requirements for the degree of Doctorate of Nursing Practice Boiling Springs 2016 Submitted by: Approved by: ___________________________ _____________________________ Jolena B. Allred Anna S. Hamrick, DNP, FNP-C, ACHPN ___________________________ _____________________________ Date Date Approval
    [Show full text]
  • Library of Research Articles on Veterans and Complementary and Integrative Health Therapies
    The VA Office of Patient Centered Care and Cultural Transformation’s and VA Complementary and Integrative Health Evaluation Center’s Library of Research Articles on Veterans and Complementary and Integrative Health Therapies April, 2020 1 Library of Research Articles on Veterans and Complementary and Integrative Health Therapies We are pleased to announce the VA Office of Patient Centered Care and Cultural Transformation’s (OPCC&CT) and VA Complementary and Integrative Health Evaluation Center’s (CIHEC) “Library of Research Articles on Veterans and Complementary and Integrative Health Therapies”. The Library is comprised of two sections: 1) Articles organized by type of CIH therapies, among the nine therapies that the VA considers medical treatments and 2) Articles organized by type of health outcome, among nine outcomes (i.e., pain, anxiety, depression, post-traumatic stress disorder (PTSD), substance/opioid abuse, stress and wellbeing, insomnia, suicide, and Veteran caregiver wellbeing and VA employee wellbeing). The Library provides the citation (with links to either the actual article or to its page in PubMed) as well as the abstract, if available. Although every attempt was made to include all relevant studies conducted, it is possible we missed some and will gladly include additional studies when found. The Library will be updated biannually, with the next update available in June 2020. It can be found at the OPCC&CT website at https://www.va.gov/wholehealth/ and the CIHEC website at https://www.hsrd.research.va.gov/centers/cshiip.cfm. For questions on the Library, please contact both Stephanie L. Taylor, PhD (Director of CIHEC) [email protected] and Mr.
    [Show full text]
  • Mindfulness Meditation Is Related to Sensory‐Affective Uncoupling Of
    Received: 2 December 2019 | Revised: 18 March 2020 | Accepted: 14 April 2020 DOI: 10.1002/ejp.1576 ORIGINAL ARTICLE Mindfulness meditation is related to sensory-affective uncoupling of pain in trained novice and expert practitioners Jelle Zorn | Oussama Abdoun | Romain Bouet | Antoine Lutz Lyon Neuroscience Research Centre, INSERM U1028, CNRS, UMR5292, Lyon Abstract 1 University, Bron Cedex, Lyon, France Background: Mindfulness meditation can alleviate acute and chronic pain. It has been proposed that mindfulness meditation reduces pain by uncoupling sensory and Correspondence Antoine Lutz, Director of Research at affective pain dimensions. However, studies to date have reported mixed results, the Lyon Neuroscience Research Center, possibly due to a diversity of styles of and expertise in mindfulness meditation. DYCOG Team, INSERM U1028 - CNRS Furthermore, the interrelations between mindfulness meditation and pain catastro- UMR5292, Centre Hospitalier Le Vinatier (Bât. 452), 95 BdPinel, 69675 BronCedex, phizing during acute pain remain little known. France. Methods: This cross-sectional study investigated the effect of a style of mindfulness Email: [email protected] meditation called Open Monitoring (OM) on sensory and affective pain experience Funding information by comparing novice (2-day formal training; average ~20 hr practice) to expert prac- The study was funded by a European titioners (>10.000 hr practice). We implemented a paradigm that was designed to Research Council Consolidator Grant awarded to Antoine Lutz (project BRAIN amplify the cognitive-affective aspects of pain experience by the manipulation of and MINDFULNESS, number 617739). pain anticipation and uncertainty of stimulus length (8 or 16 s thermal pain stimuli). We collected pain intensity and unpleasantness ratings and assessed trait pain cata- strophizing with the Pain Catastrophizing Scale (PCS).
    [Show full text]
  • The Science of Energy Therapies and Contemplative Practice a Conceptual Review and the Application of Zero Balancing
    FEATURES The Science of Energy Therapies and Contemplative Practice A Conceptual Review and the Application of Zero Balancing ■ Sallie Stoltz Denner, MSN, CCIT, CZB, CRNA The topic of energy therapies is prompted by the increasing attention of healthcare practitioners and consumers to Eastern philosophies and ancient healing practices. This article includes a conceptual framework of quantum physics principles providing the basis of interpretation of energetic phenomena, along with the exploration of theoretical concepts involving energy as a communicational network. An overview of the contemplative tradition of meditation indicates its necessity as a requisite element of energy therapies, the practice combining a knowledge base of the core scientific precepts with the experience of restorative strategies. The relevance of energy therapies as a path to self-transcendence along with the application of a specific touch technique, Zero Balancing, is highlighted. KEY WORDS: energy medicine, energy psychology, entrainment, mindfulness-based stress reduction, psychoneuroimmunology, putative energy fields, quantum physics, self-transcendence, stress, transcendental meditation, Zero Balancing Holist Nurs Pract 2009;23(6):315–334 Our traditional medical model designed to address Ironically, a contributing factor is medical progress diseases once manifested, rather than to promote itself: As people live longer, they develop many optimal health and prevent reoccurrence, delivers stress-related diseases, such as heart disease, stroke, treatment more relevant to acute illnesses than diabetes, Alzheimer disease, and cancer. Stress in our chronic. Amazingly, the US healthcare industry lives tends to be viewed as a detriment, but in actuality spends $1.6 trillion annually, and yet, we rank 12th out it really implies any necessary adaptation, even one of 13 industrialized countries in 16 major indicators.
    [Show full text]
  • Reducing Chronic Pain Using Mindfulness Meditation: an Exploration of the Role Of
    Reducing Chronic Pain Using Mindfulness Meditation: An Exploration of the Role of Spirituality By Al-Noor Mawani A Thesis submitted to the Faculty of Graduate Studies of The University of Manitoba In partial fulfillment of the requirements of the degree of Doctor of Philosophy Department of Psychology University of Manitoba Winnipeg Copyright © 2009 by Al-Noor Mawani Mindfulness meditation and pain 2 Table of Contents Abstract ............................................................................................................................... 4 List of Tables ...................................................................................................................... 5 Reducing Chronic Pain through Mindfulness Meditation: An Exploration of the Role of Spirituality........................................................................................................................... 6 Relevance of Spirituality to Canadian context ................................................................ 7 Relevance of Spirituality to Chronic Pain Management ................................................. 8 Established views of Chronic Pain .................................................................................. 9 Assessment of Pain ........................................................................................................ 14 Psychological treatment of Chronic Pain ...................................................................... 16 Holistic care and change ...............................................................................................
    [Show full text]
  • (Māori and Sahaj Marg Raja Yoga). by Janine Joyce
    Human Spirituality and Coming Together in Peace, Looking Through Two Lenses (Māori and Sahaj Marg Raja Yoga). by Janine Joyce A thesis submitted for the Degree of Doctor of Philosophy at the University of Otago, Dunedin, New Zealand November 2014 ii Abstract This project explored the experiences of ordinary men and women involved in spiritual practices in order to understand the phenomenon of spiritual heart and any implications for outer peace. The primary question asked of informants was what was spiritual brotherhood? Very early in the process the research question refined itself to ask about spiritual brothersisterhood, as the connotation of brotherhood was excluding for the female informants. In order to understand both the question and perhaps the phenomenon; participants from two communities became involved. Both communities were viewed as having expert knowledge about indigenous spirituality. One group came from a purposive sample of practitioners from the multi-cultural global Sahaj Marg community of Raja Yoga practitioners. The other group belonged to the Aotearoa New Zealand Māori community and had close whānau (family), kinship and iwi (tribal) connections. An indigenous perspective reminds us all of our roots, when we, in our present day lives, often forget these. The willingness of this group to guide this project and be involved was very welcome. Informants in this study identified a universal thread of awareness that revealed itself to each one as a practical knowledge of the spiritual heart. Informants in both groups experienced an ongoing transcendental connection through the spiritual heart, to a unified field of consciousness that they called respectively: Master, tūpuna (ancestors), and atua (forces that generate and animate particular realms of reality).
    [Show full text]
  • Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation
    5540 • The Journal of Neuroscience, April 6, 2011 • 31(14):5540–5548 Behavioral/Systems/Cognitive Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation Fadel Zeidan,1 Katherine T. Martucci,1 Robert A. Kraft,2 Nakia S. Gordon,3 John G. McHaffie,1 and Robert C. Coghill1 Departments of 1Neurobiology and Anatomy and 2Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, and 3Psychology Department, Marquette University, Milwaukee, Wisconsin 53233 The subjective experience of one’s environment is constructed by interactions among sensory, cognitive, and affective processes. For centuries, meditation has been thought to influence such processes by enabling a nonevaluative representation of sensory events. To better understand how meditation influences the sensory experience, we used arterial spin labeling functional magnetic resonance imaging to assess the neural mechanisms by which mindfulness meditation influences pain in healthy human participants. After4dof mindfulness meditation training, meditating in the presence of noxious stimulation significantly reduced pain unpleasantness by 57% and pain intensity ratings by 40% when compared to rest. A two-factor repeated-measures ANOVA was used to identify interactions between meditation and pain-related brain activation. Meditation reduced pain-related activation of the contralateral primary somato- sensory cortex. Multiple regression analysis was used to identify brain regions associated with individual differences in the magnitude of meditation-related pain reductions. Meditation-induced reductions in pain intensity ratings were associated with increased activity in the anterior cingulate cortex and anterior insula, areas involved in the cognitive regulation of nociceptive processing. Reductions in pain unpleasantness ratings were associated with orbitofrontal cortex activation, an area implicated in reframing the contextual evaluation of sensory events.
    [Show full text]
  • The Psychology of Meditation: Research and Practice
    The Psychology of Meditation Research and Practice The Psychology of Meditation Research and Practice Edited by Michael A. West 1 1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2016 The moral rights of the author have been asserted First Edition published in 2016 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2015947534 ISBN 978–0–19–968890–6 Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct.
    [Show full text]
  • Dhyana and Samadhi in Advaita - Their Effect on Mind and Body - Their Role and Relevance in Jnana Marga -- Dr
    dhyAna and samAdhi in Advaita - Their Effect on Mind and Body - Their role and relevance in jnAna mArga -- Dr. Ramesam Vemuri. May 2016 • Introduction • Concepts and Clarifications General Outline • Meditation, Mind and Brain (To be interspersed with • dhyAna and samAdhi in Advaita Discussions) -- Defintions -- Role and Relevance in The Knowledge Path (jnAna mArga) -- Short Exercises 2 What is it we are concerned with here? • jIvabrahmaikyatva jnana • Not a goal to be reached Realization of • Not a result or fruit of an Action Taken “I am brahman” • Not something you have to acquire • Not something Unknown to you • It is more like dropping a veiling curtain • You are already what you seek 3 Advaita is not about Goals and Gains Advaita is about “Remembering” who you are 4 Inquiry into the Ultimate Truth: • The sine qua non are a healthy body and a sane mind in the pursuit of inquiring the ultimate Reality • Body needs balanced and nutritious food and reasonable physical exercise. • Mind needs calm and positive thoughts and some “exercise.” • The exercise for the mind is dhyAna. 5 Meditation and Brain The Indian Seers and Sages had known the efficacy of meditation in influencing the behavior, temperamental attitude and bodily health of a person ever since the Vedic times. Various techniques of meditation taking the breath, thought or a mantra as a prop were extensively developed and people were taught to seamlessly sew these practices into their daily routine like having a bath or eating food. 6 A working definition for the Mind: Mind is what the brain does There is nothing fancy or mysterious about mind.
    [Show full text]
  • 1 Mditate, Inc. Where Meditation Meets the Art and Science of Life
    1100 Quail St, Suite 100 Newport Beach, CA 92660 Where meditation meets the art and science of life While meditation has deep ancient and religious origins, it has recently become popular as a way to de-stress or cope with the whirlwind of modern living - but it is so much more than that. With consistent practice, meditation has profound effects on our physical health. It enhances our well-being and emotional outlook, which in part may account for these beneficial physical effects. Compiled below is only the tip of the iceberg of peer-review, published science supporting meditation. Perhaps it will change the way that you look at ‘just sitting and doing nothing.’ Adam M. Rotunda, M.D. Founder Topic Page Why meditate? 2 Meditation and aging 4 … and brain structure 7 … and mental illness 9 … and the immune system 11 … and cancer patients 12 … and pain 14 … and sleep 16 … and children and adolescents 18 … and the workplace 20 … and gastrointestinal health 22 … and high blood pressure 24 … and the educational system 30 … and the healthcare system 33 1 MDitate, Inc. Who is meditating and why? Cramer H, Hall H, Leach M, et al. Prevalence, patterns, and predictors of meditation use among US adults: a nationally representative survey. Sci Rep. 2016;6:36760. Abstract Emerging evidence suggests substantial health benefits from using meditation. While there are some indications that the popularity of meditation is increasing, little is known about the prevalence, patterns, and predictors of meditation use in the general population. In this secondary analysis of data from the 2012 US National Health Interview Survey (NHIS) (n = 34,525), lifetime and 12-month prevalence of meditation use were 5.2% and 4.1%, respectively.
    [Show full text]
  • The Effects of Beta-Endorphin: State Change Modification Jan G Veening1* and Henk P Barendregt2
    Veening and Barendregt Fluids and Barriers of the CNS 2015, 12:3 FLUIDS AND BARRIERS http://www.fluidsbarrierscns.com/content/12/1/3 OF THE CNS REVIEW Open Access The effects of Beta-Endorphin: state change modification Jan G Veening1* and Henk P Barendregt2 Abstract Beta-endorphin (β-END) is an opioid neuropeptide which has an important role in the development of hypotheses concerning the non-synaptic or paracrine communication of brain messages. This kind of communication between neurons has been designated volume transmission (VT) to differentiate it clearly from synaptic communication. VT occurs over short as well as long distances via the extracellular space in the brain, as well as via the cerebrospinal fluid (CSF) flowing through the ventricular spaces inside the brain and the arachnoid space surrounding the central nervous system (CNS). To understand how β-END can have specific behavioral effects, we use the notion behavioral state, inspired by the concept of machine state, coming from Turing (Proc London Math Soc, Series 2,42:230-265, 1937). In section 1.4 the sequential organization of male rat behavior is explained showing that an animal is not free to switch into another state at any given moment. Funneling-constraints restrict the number of possible behavioral transitions in specific phases while at other moments in the sequence the transition to other behavioral states is almost completely open. The effects of β-END on behaviors like food intake and sexual behavior, and the mechanisms involved in reward, meditation and pain control are discussed in detail. The effects on the sequential organization of behavior and on state transitions dominate the description of these effects.
    [Show full text]
  • Biotransenergetica: a Transpersonal Psychotherapy. a Description of BTE Practices from a Therapist and Client Perspective
    Middlesex University Research Repository An open access repository of Middlesex University research http://eprints.mdx.ac.uk Calabrese, Giovanna (2014) Biotransenergetica: a transpersonal psychotherapy. A description of BTE practices from a therapist and client perspective. Other thesis, Middlesex University / Metanoia Institute. [Thesis] Final accepted version (with author’s formatting) This version is available at: https://eprints.mdx.ac.uk/15779/ Copyright: Middlesex University Research Repository makes the University’s research available electronically. Copyright and moral rights to this work are retained by the author and/or other copyright owners unless otherwise stated. The work is supplied on the understanding that any use for commercial gain is strictly forbidden. A copy may be downloaded for personal, non-commercial, research or study without prior permission and without charge. Works, including theses and research projects, may not be reproduced in any format or medium, or extensive quotations taken from them, or their content changed in any way, without first obtaining permission in writing from the copyright holder(s). They may not be sold or exploited commercially in any format or medium without the prior written permission of the copyright holder(s). Full bibliographic details must be given when referring to, or quoting from full items including the author’s name, the title of the work, publication details where relevant (place, publisher, date), pag- ination, and for theses or dissertations the awarding institution, the degree type awarded, and the date of the award. If you believe that any material held in the repository infringes copyright law, please contact the Repository Team at Middlesex University via the following email address: [email protected] The item will be removed from the repository while any claim is being investigated.
    [Show full text]