EFFECT OF MULLIGAN CERVICAL SUSTAINED NATURAL APOPHYSEAL GLIDE ON POSTURAL STABILITY IN PATIENTS WITH CHRONIC NECK PAIN (SNAG Mulligan)

Menna Allah Ahmed Marei Elnaggar

Status: Not yet enrolling

Conditions: Chronic Neck Pain With Mobility Deficits (> 3 Months); Chronic Neck Pain With Mobility Deficits

Treatments: Diagnostic Test: 3- The Neck Disability Index (Arabic version) for functional disability; Diagnostic Test: 5- Arabic Tampa Scale of Kinesiophobia (TSK-11); Diagnostic Test: 4- Digital Inclinometer for Cervical Range of Motion; Other: Mulligan Cervical SNAG Technique Protocol; Diagnostic Test: 6- Overhead LASER pointer for Cervical proprioception; Other: Conventional therapy group; Diagnostic Test: 1- The Biodex Balance System (BBS); Diagnostic Test: 2-The Numerical Pain Rating Scale (NPRS)

Study type: Interventional

Funder types: Other

Identifiers

NCT07673575

Mulligan on chronic neck pain

Details and patient eligibility

About

This study seeks to address the identified research gap by objectively investigating the effect of Mulligan Cervical SNAGs on postural stability in individuals with chronic neck pain and mobility impairments. The findings aim to provide evidence-based insights into whether restoring joint mobility through this manual intervention can effectively enhance sensorimotor control and balance performance. The study aims to determine if adding SNAG to a conventional exercise program provides superior improvements in balance indices (OSI, APSI, MLSI), Pain, functional disability, Range of motion, Joint position sense, and kinesiophobia compared to exercise alone. The primary purpose of this study is to answer the following research questions:

• Does the application of cervical SNAGs lead to a significant improvement in the postural stability of patients with chronic neck pain with mobility deficits?
• Is there a correlation between the improvement in cervical range of motion (ROM) following SNAGs and the enhancement of postural control performance?

Full description

Chronic neck pain associated with mobility deficits is a prevalent musculoskeletal condition that extends beyond localized discomfort to involve significant sensorimotor disturbances. The cervical spine plays a pivotal role in postural control due to its high density of mechanoreceptors and its intricate integration with the vestibular and visual systems. Patients with CNP frequently exhibit impaired proprioception and increased postural sway. This leads to a higher risk of falls and functional limitations. If SNAG is proven effective, the results will help clinicians justify the inclusion of Mulligan SNAGs in rehabilitation protocols not only to restore mobility and reduce pain but also to address balance impairments and kinesiophobia in patients with chronic neck pain. From a patient perspective, these improvements may enhance functional performance, confidence during movement, and quality of life. From a socioeconomic perspective, improving functional abilities and reducing disability may decrease healthcare costs, work absenteeism, and the long-term burden associated with chronic neck pain. Scientifically, this study may contribute to the growing body of evidence regarding the sensorimotor and balance-related effects of Mulligan SNAG techniques and provide further insight into the relationship between cervical mobility, postural stability, and kinesiophobia in patients with chronic neck pain.

Enrollment: 44 estimated patients

Sex: All

Ages: 20 to 45 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• The patients will be selected according to the following criteria:

  1. Adults aged between 20 and 45 years
  2. Body mass index from 18.5 - 24.99 kg/ m2.
  3. Chronic neck pain lasting ≥3 months
  4. Diagnosis of neck pain with mobility deficits, including restricted cervical ROM, and pain provoked with movement
  5. Presence of cervical hypomobility confirmed by segmental mobility assessment on clinical examination
  6. Pain intensity ≥3/10 on the numerical Pain Rating Scale
  7. Reduced cervical range of motion in at least one direction measured objectively (by digital inclinometer)
  8. Ability to stand independently without assistive devices (required for postural stability assessment)

Exclusion criteria

• The patients will be excluded if they present with:

  1. Specific causes of neck pain, such as fracture, tumor, infection, inflammatory disease, or cervical myelopathy, confirmed by X Ray and physical examination
  2. Cervical radiculopathy or neurological deficits (e.g., dermatomal sensory loss, reflex changes, or muscle weakness)
  3. History of cervical spine surgery or recent trauma (within the last 6 months)
  4. Vestibular disorders or conditions affecting balance (e.g., vertigo unrelated to cervical origin)
  5. Temporomandibular disorders, significant shoulder pathology, and shoulder surgeries that may influence cervical movement or outcomes
  6. Participation in physiotherapy or manual therapy for neck pain within the previous 3 months
  7. Pregnancy or any medical condition contraindicates manual therapy
  8. History of chronic ankle instability
  9. Any lower limb pathology affecting balance

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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44 participants in 2 patient groups

Group A will include 22 patients with chronic neck pain with mobility deficits

Experimental group

Description:

Group A (Experimental: Mulligan cervical SNAG plus conventional physiotherapy) (Mulligan Cervical SNAG Plus Conventional Therapy) Mulligan Cervical SNAG Technique Protocol: * Patient positioning: Seated or standing, with spine in neutral or slight flexion. * Therapist hand placement: Thumb or fingers on the targeted cervical vertebra (e.g., C2-C7 or upper thoracic T1-T4). * Direction of glide: Anterior and upward glide along the plane of the facet joint, synchronized with the patient's active movement (e.g., rotation, extension) * Repetitions: 10 repetitions per session, each held for 10 seconds, with rest intervals * Session structure: SNAG mobilizations performed first, followed by conventional exercises. * Cervical spine: Targeted for joint position sense, pain, and dizziness Conventional Therapy Based on the American Physical Therapy Association (APTA) Clinical Practice Guidelines for Neck Pain with Mobility Deficits, participants in the conventional therapy

Treatment:

Diagnostic Test: 2-The Numerical Pain Rating Scale (NPRS)

Diagnostic Test: 1- The Biodex Balance System (BBS)

Other: Conventional therapy group

Diagnostic Test: 6- Overhead LASER pointer for Cervical proprioception

Other: Mulligan Cervical SNAG Technique Protocol

Diagnostic Test: 4- Digital Inclinometer for Cervical Range of Motion

Diagnostic Test: 5- Arabic Tampa Scale of Kinesiophobia (TSK-11)

Diagnostic Test: 3- The Neck Disability Index (Arabic version) for functional disability

Group B = 22 patients with chronic neck pain with mobility deficits

Other group

Description:

Control Group (Conventional Therapy Only) * Range of motion (ROM) exercises: Cervical flexion, extension, rotation, lateral flexion * Strengthening: Deep cervical flexors, scapular stabilizers * Stretching: Targeting neck and upper back muscles (Upper trapezius stretch - Levator scapulae stretch - Pectoralis stretch) * Patient education: Posture, ergonomics, activity modification. Protocol structure: * Exercises and manual therapy delivered in 20-30 minute sessions * No SNAG mobilizations. Treatment Frequency and Session Duration Typical regimen: * 2 sessions/week for eight weeks. * 16 sessions total. * 4-week follow-up. * Session duration: 20-30 minutes.

Treatment:

Diagnostic Test: 2-The Numerical Pain Rating Scale (NPRS)

Diagnostic Test: 1- The Biodex Balance System (BBS)

Other: Conventional therapy group

Diagnostic Test: 6- Overhead LASER pointer for Cervical proprioception

Diagnostic Test: 4- Digital Inclinometer for Cervical Range of Motion

Diagnostic Test: 5- Arabic Tampa Scale of Kinesiophobia (TSK-11)

Diagnostic Test: 3- The Neck Disability Index (Arabic version) for functional disability