The prevalence of work-related muscle pain (WRMP) is large in the general population in the industrialized world. Despite significant advances over recent years in some research areas, the mechanisms of why WRMP occurs and the pathophysiological mechanisms behind the disorders are still unclear. One suggested explanation is that WRMP is caused initially by a limitation of the local muscle circulation and oxidative metabolism. There is a lack of objective methods to gauge the development and diagnosis of WRMP. Near infrared spectroscopy (NIRS) is a non-invasive technique that allows for determinations of oxygenation and blood flow. The purpose of this thesis was to evaluate NIRS (1) as a method for measuring muscle oxygenation and hemodynamics for the extensor carpi radialis (ECR) and trapezius descendens muscles (TD), and (2) to investigate whether variables measured by NIRS differed between patients diagnosed with WRMP and healthy subjects. Several variables of NIRS were produced and investigated. These included muscle oxygenation (StO2%), changes during contractions (ΔStO2%) and StO2% recovery (Rslope), total hemoglobin (HbT) as an indication of blood volume and its changes during contractions (ΔHbT). In addition, for the ECR, by applying an upper arm venous occlusion (VO) HbTslope increase as a surrogate of blood flow, and for both VO and arterial occlusion (AO) HHbslope increase (i.e. deoxyhemoglobin slope) as a surrogate of oxygen consumption were variables of interest. A first objective was to determine how StO2% and HbT responded to various contraction forces and how it related to muscle activation measured by electromyography (EMG). For both muscles isometric contractions of 10, 30, 50 and 70% of maximal voluntary contraction (MVC) were maintained for 20 s each by healthy males and females; additionally a 10% MVC contraction was sustained for 5 min. For the different contraction levels, predictable relationships were seen between ΔStO2% and force, and between ΔStO2% and EMG RMS amplitude. The general trend was a decrease in ΔStO2% with increasing force and increasing EMG. Females showed a tendency for a higher oxygen use (i.e., drop in StO2%) for the ECR over force levels than males and a higher RMS% MVC for the TD. For the 10% MVC contraction sustained for 5 min gender specific changes over time for HbT and RMS for the ECR, and for StO2% for the TD muscle were seen. A second objective was to determine the day-to-day reliability of NIRS variables for the ECR and TD muscles at group level (Pooled data) and at gender level (males and females). Measurements were performed on two occasions separated by 4-6 days and intraclass correlation coefficients (ICC) and limits of agreement (LOA) were determined as reliability and reproducibility indicators, respectively. Variables tested were ΔStO2% during submaximal isometric contractions of 10, 30, 50 and 70% MVC and StO2% recovery (Rslope) after contractions and after AO. For the ECR, HbTslope as an indication of blood flow (using VO) and HHbslope as a surrogate of oxygen consumption for both VO and AO were computed. For ΔStO2% for the ECR the highest ICC was at 30% MVC for both the pooled data and at gender level. For the TD ICCs were comparably high for 30, 50, 70 % MVC (for both muscles the ΔStO2% at 10% MVC showed the lowest ICC). Further, females showed a higher ICC than males for contraction levels of 50 and 70% MVC. For both muscles, LOA for ΔStO2% was lowest at 10% and highest at 50 and 70% MVC. For the ECR Rslope ICCs were high for all contraction levels, but was lower for AO; LOA was lowest at 70% MVC. For the TD, Rslope ICCs were also high for all contraction levels and LOA was lowest at 30 % MVC. ICC for HbTslope was the lowest of all variables tested. For HHbslope ICC was higher for AO than for VO, and LOA was lower for AO. A third objective was to determine if there were differences between healthy subjects and patients diagnosed with WRMP in ΔStO2% and ΔHbT responses during varying submaximal contractions (10, 30, 50 and 70% MVC), and StO2% recovery (Rslope) immediately after contractions and AO. Additional variables tested in the ECR at rest were HHbslope to indicate oxygen consumption (using AO) and HbTslope as an indication of blood flow. There were no differences between groups in ΔStO2% and ΔHbT variables during the contractions or Rslope in the recovery after contractions or AO. Furthermore, HbTslope was not different between groups However, oxygen consumption for the ECR and StO2% for the TD at rest were significantly greater for healthy subjects compared to patients. A fourth objective was to determine if there were differences in StO2% and HbT between healthy subjects and WRMP patients during a 12 min sustained contraction of 15 % MVC. In addition, the protocol included a recovery period of 30 min. Prior to contraction, as well as during the recovery period, HbTslope as a surrogate of blood flow was determined for the ECR. Neither the ECR nor the TD exhibited significant differences between groups for StO2% and HbT during the contraction. For the TD patients showed a lower StO2% value at rest and throughout the contraction than healthy subjects. For the ECR HbT during the sustained contraction the general trend was an initial decrease with gradual increase throughout the contraction for both groups. For HbTslope no differences were seen between patients and healthy subjects before the sustained contraction and during the recovery period for both muscles. NIRS is deemed a suitable technique for assessing physiological measurements of the upper extremity, including for day-to-day testing. NIRS was not able to distinguish between the patients with WRMP and controls. A concern in the thesis is the characteristics of the patient group in being equally active in recreational sports, actively working, and similar in muscle strength as controls. Thus, applying NIRS for studying a more severe patient group could yield different results.

Strength training is widely used to increase performance in sports with high physical demands. The use of drugs such as anabolic steroids among athletes is a wellknown phenomenon, and the effects of these drugs on physical performance documented. The studies presented in this thesis focused on the mechanisms of muscle fiber hypertrophy in the vastus lateralis and the trapezius muscles of strength trained elite athletes. The main hypothesis was that the muscle adaptations to strength training and anabolic steroids are muscle specific. Biopsies were obtained from the trapezius and the vastus lateralis from three groups of elite power lifters. Nine used drugs, ten did not and seven had previously used drugs. Six sedentary males served as controls. The biopsies were frozen and cut in serial cross sections. Histological and immunohistochemical staining techniques were used to analyze muscle fiber morphology and pathology. Fiber type distribution, fiber area, myonuclei number and distribution, satellite cell number and proportion of split fibers were counted and compared for the two muscles within and between the groups. The main findings were that: a) Muscle fiber hypertrophy by strength training is further increased by anabolic steroids. b) The number of nuclei per muscle fiber is higher in power lifters using anabolic steroids compared to non-steroids using lifters. c) Among power lifters who have withdrawn from anabolic steroid usage and training for several years, the number of myonuclei, both subsarcolemmal and internal, remains high. d) In active power lifters, anabolic steroids have no further effect on the number of satellite cells per fiber. e) Power lifters have a high proportion of split fibers. High intensity resistance training increases muscle strength and banned substances such as testosterone and anabolic steroids can enhance the training effects. The studies on muscle cell morphology presented in this thesis reveals that anabolic steroids and testosterone increases muscle fiber size and adds more nuclei to the muscle cell. Based on the morphological appearance of muscle sections from doped and nondoped power lifters, we conclude that testosterone and anabolic steroids enhances the hypertrophic effects of training without adding new features. The addition of myonuclei by training and doping appears to be longer lasting in some muscles than in others. The high proportion of split fibers in power lifter is probably due to high mechanical stress. The findings and conclusions in this thesis raise questions regarding relevant suspension times for athletes caught with banned substances in the body.

In the early nineties cannabinoid receptors, the main target for Δ9-tetrahydrocannabinol (THC), the psychoactive component of marijuana were identified. Shortly after their endogenous ligands, N-arachidonoylethanolamine (anandamide, AEA) and 2-diacylglycerol (2-AG) were characterized. The enzymes primarily responsible for catalysing the degradation of AEA and 2-AG are fatty acid amide hydrolase (FAAH) and monoacylglycerol lipase (MGL) respectively. AEA is a member of the N-acylethanolamine (NAE) class of lipids, which depending on the acyl chain length and number of double bonds can act as ligands for a variety of biological targets. Exogenous cannabinoids have long been reported to have analgesic effects, however the clinical usefulness of such substances is limited by their psychoactive effects. Inhibition of endocannabinoid degradation would mean enhancing the therapeutic effects without producing these unwanted side effects. In order to succeed in developing such compounds the pharmacology of the enzymes responsible for the degradation of endocannabinoids has to be thoroughly understood. When the preclinical part of this thesis was planned, FAAH had been well characterized whereas little was known as to the pharmacology of MGL. A series of compounds were tested in this first study aiming to find MGL-selective compounds. Although no compounds showed selectivity for MGL over FAAH, several interesting agents affecting both enzymes were identified. In order to increase the knowledge concerning which patient group would benefit from such treatment strategies it is important to investigate in which pain states the endocannabinoids/NAEs are altered. Thus the general aim of the clinical part of this thesis was to investigate the levels of endocannabinoids/NAEs in the interstitium of the trapezius muscle in women suffering from chronic neck/shoulder pain (CNSP) and chronic wide spread pain (CWP) and in healthy pain-free controls. Furthermore for the CNSP the effect of training, which is a commonly recommended treatment for these patients, on the levels of endocannabinoids/NAEs was also investigated. Microdialysis technique in the trapezius muscle was used for sampling and masspectrometry was used for analysing. Two NAEs, N-palmitoylethanolamine (PEA) and N-stearoylethanolamine (SEA), could be repeatedly measured. The levels of these two lipids were significantly higher in CNSP compared to CON. The result showed also that PEA and SEA mobilize differently in CWP compared to both CNSP and CON. Taken together the results presented in thesis represent an early characterization of the pharmacology of MGL and provides novel information on NAEs in chronic muscle pain.

Introduction: Occupational drivers of terrain vehicles are exposed to several risk factors associated with musculoskeletal symptoms in the lower back as well as in the neck and upper limbs. Vibration has been suggested to be a main risk factor. These drivers are exposed to both whole-body vibration (WBV) and hand-arm vibration (HAV). Aim: This study establishes the association between driving terrain vehicles and musculoskeletal disorders (MSDs) in the neck and upper limbs as well as hand-arm vibration syndrome (HAVS). In addition, this study examines the effect on muscles in the neck and upper limbs of the type of vibration exposure that occurs in occupational driving of terrain vehicles. Methods and results: In Paper I, a cross-sectional questionnaire study on occupational drivers of terrain vehicles, increased Prevalence Odds Ratios (POR) were found for numbness, sensation of cold and white fingers (POR 1.5-3.9) and for MSDs in the neck (POR 2.1-3.9), shoulder (POR 1.8-2.6) and wrist (POR 1.7-2.6). For the shoulders, neck and elbow, there appears to be a pattern of increased odds with increasing exposure time. In Paper II, an experimental study on the trapezius muscle, which included 20 men and 17 women, the mean frequency of the electromyography signal (EMGMNF) decreased significantly more in a three minute sub-maximal contraction without vibration (-3.71Hz and -4.37Hz) compared to with induced vibration (-3.54Hz and -1.48Hz). In Paper III, a higher initial increase of the mean of the root-mean-square of the electromyography signal (EMGRMS) was seen in a three minute sub-maximal contraction with vibration exposure compared to without vibration (0.096% vs. 0.045%). There was a larger mean EMGMNF decrease for NV compared to V in the total three minutes, and a larger decrease also in the first time period was seen for the NV compared to V. A small gender effect was also noticed. In Paper IV, the combination of HAV and WBV was studied in laboratory settings and resulted in a higher trapezius EMGRMS compared to the HAV and WBV separately. Conclusion: Occupational drivers of terrain vehicles are likely to experience symptoms related to HAVS and musculoskeletal symptoms in the neck and upper limbs. Local vibration does not seem to have any negative acute effects on trapezius muscle fatigue. Vibration exposure seems to cause an initial increase in muscle activity in the trapezius that could be related to recruitment on new motor-units. A combination of HAV and WBV causes a larger muscular demand on the trapezius muscle.

Submitted in partial compliance with the requirements for the Doctoral Master's Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2018. / Introduction: Myofascial pain syndrome is a condition of collective sensory, motor and autonomic symptoms caused by myofascial trigger points, which are hyper-irritable foci in a muscle and palpated as a taut, tender, ropey band. There are many types of treatment for myofascial pain syndrome; dry needling is one of the most effective forms. Dry needling involves the insertion of a needle into the myofascial trigger points in order to break up the contractile elements and any somatic components that may contribute to trigger point hyperactivity, and to stimulate sensitive nerve ending in the area. Although therapeutic, an unpleasant side effect of dry needling is the post-needling soreness. Various modalities have been utilised to decrease post-needling soreness, such as ice, heat and action potential simulation, to mention a few, however no study has been conducted to date that documents low intensity laser therapy and its effect on post-needling soreness. This study therefore aimed to evaluate the effect of low intensity laser therapy on post-needling soreness in trigger point 2 of the upper trapezius muscle. Methodology: This study was designed as a randomised, controlled pre-test and post-test experimental trial. Forty participants were randomly allocated into two equal groups of 20 participants each. Group 1 received the needling and laser therapy; Group 2 received needling and placebo laser. Algometer and Numerical Pain Rating Scale 11 (NRS 11) readings were taken immediately before the dry needling procedure; after the laser or placebo laser therapy; and again, at the follow-up visit 24 hours later. Subjects used a 24- hour pain diary which was completed at three-hour intervals, to record any post-needling soreness. The NRS 11 scale was used immediately before the needling and again at the follow-up visit 24 hours later. Results: Statistical analysis was done using SPSS version 24.0 to conduct inferential and deductive statistics. A significance of p=0.05 was set. Baseline demographics and outcome measurements were compared between the two groups using t-tests or ANOVA where appropriate. An inter-group analysis revealed that objectively and subjectively all groups experienced some degree of post-needling soreness, which deceased significantly over time. This decrease of pain was not significantly related to the treatment group, and there is no evidence of the differential time effect with the treatment. An inter-group analysis yielded no statistically significant results regarding the effectiveness of the treatments received by the patients. This could be because of the small sample size or because low intensity laser therapy is not a useful intervention. Conclusion: The results from this study revealed that both treatment groups responded equally in the alleviation of pain. It can thus be concluded that low intensity laser therapy had no significant beneficial effects on post-needling soreness. / M

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2017. / Aim: There is a paucity in the literature regarding the effectiveness of the Impulse Adjusting Instrument® (IAI) in treating myofascial trigger points (MFTPs) and regarding the effectiveness between dry needling and the IAI in the treatment of MFTPs. There are many limitations and an array of contraindications for dry needling. Therefore, an alternative method should be sought as this will be beneficial to the patient. Thus, the aim of this study was to determine the effectiveness of the IAI compared to dry needling in the treatment of MFTPs found in the upper trapezius muscle. Methodology: This study was a randomised single-blinded clinical trial. This study consisted of 41 participants between the ages of 18 and 40 who were divided into two groups. The participants were randomly allocated into their respective groups using a blinded allocation method that was drawn up by the statistician. Groups were divided into dry needling (Group one (n=18)) and IAI (Group two (n=23)) treatment groups. Subjective neck pain level was determined using a numerical pain rating scale (NRS). The neck disability index (NDI) subjectively assessed the effect neck pain had on the participants’ activities of daily living before and after treatment. The Patients Global Impression of Change (PGIC) tool was used to determine the participants’ subjective impression of treatment outcomes since the beginning of the treatment. Objective pain pressure thresholds (PPT) were measured with an algometer. Objective cervical range of motion (CROM) in lateral flexion (LF) was measured with a goniometer. Each participant had four visits over a two week period, which included three treatments and a final visit for final measurements. Data was analysed using IBM SPSS version 23. Repeated measures ANOVA was used to examine the effect on each outcome measure. Directional trends in effectiveness were drawn up using profile plots to assess the direction and trends of the effects. A p value of < 0.05 was considered to be statistically significant. Results: Intra-group and inter-group statistical analysis revealed all subjective measurements improved in both groups with no significant differences between the groups. With respect to objective measurements, there was no statistical improvement in LF CROM and dry needling had no improvement in PPT. Impulse Adjusting Instrument trigger point therapy showed an increase in PPT, however, when compared to dry needling there was no statistical difference in PPT. Conclusion: The conclusion for this study states that the trends in each of the outcomes suggest that the IAI is as effective as dry needling for the treatment of MFTPs. / M

M.Tech. (Chiropractic) / Purpose: The trapezius muscle is thought to be the muscle most commonly associated with the presence of active myofascial trigger points (MFTP’s). Studies of the trapezius muscle clearly show that muscular activity significantly increases in response to psychological stress. Cervical spine manipulation has been proven to be highly effective in the treatment of active MFTP’s and muscular tension. Progressive muscle relaxation (PMR) therapy is frequently utilized as a relaxation technique in subjects complaining of increased levels of muscular tension, possibly due to an increased perception of psychological stress. Although cervical spine manipulation alone is effective in the treatment of active MFTP’s and muscular tension, chiropractors often search for adjunctive therapies to improve current treatment protocols. The purpose of this study was to determine whether the combination of cervical spine manipulation and PMR therapy is a more efficient, and possibly effective, treatment protocol for active MFTP’s of the trapezius muscle. Method: This study was a comparative study and consisted of two groups of fifteen participants each. All participants were between the ages of eighteen and thirty-five years of age, with a male to female ratio of 1:1. Potential participants were examined and accepted according to the inclusion and exclusion criteria. Group A received chiropractic spinal manipulative therapy of the cervical spine. Group B was the combination group and therefore received chiropractic spinal manipulative therapy of the cervical spine together with the application of PMR therapy. Subjective measurements consisted of a Perceived Stress Scale (PSS) Questionnaire, Visual Analog Pain Scale (VAS) and the Vernon-Mior Neck Pain and Disability Index Questionnaire. Objective measurements consisted of pressure pain threshold algometry readings taken from active trigger points one (TP1) and/or trigger point two (TP2) on the right and/or left side of the upper trapezius muscle.

M.Tech. / Purpose: A study to determine the efficacy of Traumeel® gel using phonophoresis in the treatment of a latent trapezius myofascial trigger point, with regards to pain perception, cervical spine range of motion and pressure pain tolerance.Methods: A single-blinded, controlled study design was utilised. Thirty participants who all presented with a latent trapezius myofascial trigger point were randomly divided into two groups of fifteen. Each individual was subjectively and objectively assessed from baseline values prior to receiving treatment. Group A received ultrasound utilising ultrasound gel over the trapezius myofascial trigger point, as the control group. Group B received phonophoresis with Traumeel® gel over the trapezius myofascial trigger point. All participants received two treatments per week, with a total of seven consultations, over the three week study period. The subjective data was obtained utilising a Numerical Pain Rating Scale (NPRS) whilst a hand held Algometer tested pressure pain tolerance and a Cervical Range of Motion Measuring Instrument (CROM) measured cervical spine range of motion. These were utilised to form the objective data. The Data was analysed using non-parametric tests. The two independent treatment groups were assessed for capability at treatments one, four and seven using the Mann-Whitney U-test (non-parametric version of the independent sample T-test). Changes over the three week period were observed and analyzed using the Repeated Measures test or the Friedman Test (Devey, 2010). Results: In this study ultrasound utilising ultrasound gel had a statistically significant impact on the trapezius myofascial trigger point. Statistical analysis of the Traumeel® gel suggests that there was no statistical significance with regards to any of the treatment parameters or variables measured. Subjectively ultrasound gel proved to be statistically and clinically significant in decreasing the participant’s pain perception. There was no statistical improvement but there was a clinical improvement in the Traumeel® gel group.

M.Tech. (Chiropractic) / Neck pain is a common and costly complaint in society and many are made to believe that their neck pain is caused by pinched nerve, compressed disk, arthritis or displaced cervical vertebrae, when in reality the pain may be solely due to referral from myofascial trigger points in overworked or traumatized muscles of their upper back and shoulders. Travel and Simons (1999) demonstrated trapezius muscle of the neck, back and shoulder as the main cause of mechanical neck pain and stiffness. The aim of this study was to compare the effects of trigger point therapy using an activator instrument versus myofascial dry needling in combination with cervical spine adjustment in the treatment of those with acute or chronic neck pain associated with active trigger point 1 (TrP 1) or trigger point 2 (TrP 2) of upper trapezius muscle, with regards to pain and disability, pressure pain threshold and cervical spine range of motion. The clinical study consisted of forty participants, from the ages of 18 and 45, randomly allocated into two groups of twenty individuals each. Potential participants were examined and accepted based on inclusion and exclusion criteria. Group 1 received activator trigger point therapy to upper trapezius TrP 1 or 2 with chiropractic adjustment to restricted segments of the cervical spine, and group 2 received myofascial dry needling of upper trapezius TrP 1 or 2 with chiropractic adjustment to restricted segments of the cervical spine. Participants were treated four times over a period of two weeks. Subjective data was collected using the Vernon-Mior Neck Pain and Disability Index and a Visual Analog Scale. Objective data was collected using an algometer to measure pressure pain threshold of trapezius TrPs muscles, and a goniometer to measure cervical spine range of motion. All data was collected at the first and third visits prior to treatment, and at the fifth visit. The statistical analysis was conducted using nonparametric tests. Friedman’s test was used to assess whether neck pain, disability, cervical spine range of motion and pressure pain threshold varied over the three time intervals. Wilcoxon Signed Ranks Pair test was used for assessment of comparability of the results in each group separately, and the Mann-Whitney U test was used for comparison of the accumulated data in the two groups.

M.Tech. (Chiropractic) / Myofascial Pain Syndrome, is a common source of frustration for both healthcare practitioners and patients. It is the second most common reason for patients visiting their health care practitioner and constitutes up to 85% of the reasons for visits to pain clinics (Han and Harrison, 1997). As muscle pain is the most common work-related injury (Hubbard, 1998), it costs billions of dollars in lost revenue every year due to lost productivity (Fricton, 1990). Hong (1994), states that dry needling has been extensively studied and has been shown to decrease or even abolish myofascial pain. However post dry needling soreness is a common side effect of dry needling. Stuart (2010), states that applying kinesio tape® to a musculoskeletal injury during rehabilitation could result in a quicker recovery by allowing the body to biomechanically heal itself. Garcia-Mura et al (2009), results suggest that kinesio tape® is a method highly appropriate in the treatment of myofascial trigger points by normalising muscular function, increasing lymphatic and vascular flow, diminishing pain and aid in the correction of possible articular malalignment. The aim of this study was to determine the effects that kinesio tape® has on the trapezius trigger point one post needling, to determine whether there is an increase in the therapeutic effect of dry needling and an increased recovery time of the myofascial trigger points, with regards to changes in pressure pain threshold, pain and cervical range of motion. Participants for this study were recruited either by an advertisement which was placed on the information board of the Chiropractic Day Clinic at the University of Johannesburg as well as advertisements placed in and around the University of Johannesburg at the Doornfontein Campus. Also, many participants were made aware of this study via word of mouth from candidates already involved in the study. Thirty participants were randomly assigned into one of two groups, each consisting of 15 participants. Group A received dry needling of the trapezius trigger point one followed by the application of kinesio tape® whereas group B received dry needing of trapezius trigger point one only. Participants were treated 5 times with objective and subjective measurements taken at the 1st, 3rd and 5th visits. Objective measurements consisted of readings taken with an algometer and cervical range of motion (CROM) device. The subjective measurements consisted of the Numerical Pain Rating Scale (NPRS) and the Vernon Mior Neck Disability Index. The results of the study showed clinically and statistical significant improvements for both groups in regards to alleviating pain subjectively (Numerical Pain Rating Scale and Vernon-Mior Neck Pain and Disability Index), increasing pressure pain threshold objectively (Algometer) and increasing range of motion objectively (Cervical Range of Motion device). However group A (dry needing and kinesio tape®) showed a greater improvement in both subjective and objective measurements. Based on the results of the study, it could be concluded that both dry needling on its own as well as applying kinesio tape® post dry needling can be effective in the treatment of myofascial trigger points in the upper trapezius muscle, however applying kinesio tape® post dry needling seemed to be more effective.