An investigation of cortical inhibition in acute and chronic pain

Musculoskeletal disorders are a leading cause of disease burden worldwide. Alarmingly, the prevalence and socioeconomic impact of these conditions is rising. Pain is a common and disabling feature of many musculoskeletal disorders. While significant individual burden is evident at all stages of pain, socioeconomic costs increase dramatically when pain becomes chronic (> 3 months). Therapies that reduce the duration and severity of chronic pain are needed to lessen the individual and socioeconomic burden of these conditions. However, current interventions achieve limited success. The lack of effective therapies is hypothesised to be caused, in part, by a limited understanding of the neurophysiology of chronic musculoskeletal pain and the mechanisms driving the transition to chronicity. Recent advances in technology provide evidence of structural and functional changes in brain regions, including the primary motor cortex (M1), in response to musculoskeletal pain. Lasting changes in the excitability, topography and organisation of M1 have been hypothesized to underpin symptom chronicity in musculoskeletal disorders, however the mechanisms underlying these changes remain unclear. Inhibitory intracortical networks modulate the excitability, organisation and output of extrinsically projecting M1 neurons, and are well positioned to influence the cortical response to pain. Yet, the effect of acute and chronic muscle pain on inhibitory intracortical networks has not been fully elucidated. Thus, the overall aim of this thesis was to contribute to the body of knowledge on the intracortical response to musculoskeletal pain using i) acute experimental pain models in healthy individuals and ii) clinical populations living with chronic pain. The findings from the four studies conducted in this thesis provide novel insight into the intracortical response to acute and chronic musculoskeletal pain. As each of the mechanisms investigated are thought to be mediated by distinct neuronal populations, these findings suggest that the intracortical response to musculoskeletal pain is extensive and diverse. Observations of opposing changes in short- and long interval intracortical inhibition in the acute (increased inhibition) and chronic (decreased inhibition) stages of pain suggest that these forms of inhibition could play a role in the transition to chronicity. However, study 3 and 4 did not detect a correlation between intracortical inhibition and measures of pain and disability in LE and LBP, respectively. While this suggest that changes in intracortical activity may not contribute directly to symptoms of chronic pain and motor dysfunction, there is the possibility of a non-linear relationship between these variables. When the findings are taken together, changes in intracortical inhibition in pain suggest the enactment of a cortically driven motor strategy to protect painful tissues from further insult. While beneficial in the short term when the need to protect the tissues is high, failure to return to normal intracortical function in the long-term could lead to pain persistence through altered tissue loading. Large, longitudinal trials examining the transition from acute to chronic pain are necessary to confirm these hypotheses. If confirmed, future therapies which target maladaptive intracortical change could lead to greater improvements in pain and function for individuals experiencing chronic musculoskeletal pain

The Birth of the Bryn Mawr College Black Studies Program and the Herbert Aptheker Appointment

In 1969, Bryn Mawr College hired the notorious Communist Herbert Aptheker to teach the inaugural course in what would become the Black Studies Program. Using primary sources, this essay examines the decision to hire Aptheker and what this decision can tell us about campus politics during the late-60’s/early-70’s. A sharp divide can be seen between conservative and leftist students, parents, alumnae, and even those unassociated with the College who felt it their civic or academic duty to object to or approve of the decision to hire Aptheker. As an institution of learning, Bryn Mawr’s decision of how to teach about those whose experiences have been marginalized deals with questions of who is telling whose history and how that history will be told – in particular, whether to instate a Black Studies Program with courses integrated into the general College curriculum, or have the courses separated in a potential Black Studies Department. Ultimately, this essay argues that the melee surrounding the Aptheker appointment was a product of the racial tension on-campus and amongst those with a stake in the History the College was constructing

What if something goes wrong? A grounded theory study of parents’ decision-making processes around mode of breech birth at term gestation

Objective. To explore factors that influence parents' decision-making for mode of breech birth at term gestation. Design. A grounded theory study conducted using a constructivist approach. Semi-structured telephone interviews were recorded and transcribed verbatim and analysed using the software NVivo for Mac version 11.4.0. Setting. England, UK. Participants. Twelve parents with breech presentation confirmed by ultrasound at ≥36+0 weeks gestation were recruited from several UK social media forums. Findings. Two core themes impacting on a parent's decision-making process for term breech birth were identified. Firstly, a framework of potential influences including partner and relationship, family and friends, health professionals, own birth culture, self, shared experiences and the time available for decision-making. Secondly, mortality salience, or parental focus on risk of potential injury or death associated with birth, was found to be central to every participant's narrative. Key conclusions. This study highlights the individuality and wider framework of parent's decision-making influences for term breech birth, and demonstrates to care providers the conflicted emotions that may be experienced. The findings of this study may guide midwives and other professionals in providing person-centered, non-judgmental, balanced and evidence-based mode of term breech birth counselling. Implications for practice. Health professionals should adopt a parentcentred approach to counselling for mode of term breech birth, considering parents' wider influences in their decision-making and the fear of injury or death surrounding both vaginal breech birth and caesarean section. They can also facilitate parents to understand the influences that might be guiding their own decision-making

The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease

Shared decision making in advanced chronic kidney disease (CKD) requires unbiased information on survival and person-centred outcomes known to matter to patients: quality of life, symptom burden and support from family and healthcare professionals. To date, when deciding between dialysis and conservative care, patients have had to rely on evidence from small observational studies. Clinicians recognize that like is not being compared with like in these studies, and interpret the results differently. Furthermore, support differs considerably between renal units. What patients choose therefore depends on which renal unit they attend. To address this, a programme of work has been underway in the UK. After reports on survival and symptoms from a small number of renal units, a national, mixed-methods study-the Conservative Kidney Management Assessment of Practice Patterns Study-mapped out conservative care practices and attitudes in the UK. This led to the Prepare for Kidney Care study, a randomized controlled trial comparing preparation for dialysis versus preparation for conservative care. Although powered to detect a positivist 0.345 difference in quality-adjusted life years between the two treatments, this trial also takes a realist approach with a range of person-centred secondary outcomes and embedded qualitative research. To understand generalizability, it is nested in an observational cohort study, which is nested in a CKD registry. Challenges to recruitment and retention have been rapidly identified and addressed using an established embedded mixed methods approach-the QuinteT recruitment intervention. This review considers the background to and progress with recruitment to the trial

Policy Handbook: Learning from long-term research to better manage biodiversity in Australia

This handbook describes the key findings and messages from each of the chapters of the book, Biodiversity and Environmental Change. This booklet to provide summary information for policy makers and the general public. The booklet contains overview information on two ecosystems not mentioned in the LTERN Brochure, these are the: Chenopod and Acacia Shrublands, and Tussock Grassland. There is also a simplified explanation of concepts in ecology, discussion on the value of long-term research, a list of known and common threats to Australian biodiversity and discussion on the cultural barriers to effective environmental management in Australia.Australian Government’s Terrestrial Ecosystem Research Network (www.tern.org.au). This is an Australian research infrastructure facility established under the National Collaborative Research Infrastructure Strategy and Education Infrastructure Fund–Super Science Initiative through the Department of Industry (formerly the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education

Women’s experiences of needing abortion care whilst incarcerated: A systematic review of the international literature

Incarcerated women are confined in institutions designed to punish. These sites often ignore the complex mental and physical health needs of people who are incarcerated. Despite the World Health Organization stressing the need for access to reproductive healthcare in carceral institutions, stigma surrounding abortion care and health inequalities create contextually specific issues for incarcerated people seeking to access these services. There is also a dearth of research conducted directly with incarcerated women, trans men and non-binary people to examine their experiences of abortion. A systematic review of international peer-reviewed and grey literature was completed to summarise existing evidence from research conducted on the experiences of needing abortion care whilst incarcerated. Various experiences were identified including: conditions of confinement shaping abortion decisions; bureaucratic obstacles to accessing abortion services; incarcerated women, carceral staff and carceral healthcare staff’s lack of understanding of abortion rights and procedures; and a scarcity of support and empathy, including experiences of stigmatisation and lack of confidentiality. There exists a significant gap in research examining the experiences of incarcerated people who may need an abortion, emphasising the need for international collaboration and advocacy to address systemic issues that extend beyond local contexts