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

Overview

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?

Detailed 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.

Interventions

• Diagnostic test 1- The Biodex Balance System (BBS)
  The Biodex Balance System SD Model 950-441(Biodex Medical Systems, Inc.) is a multi-dimensional (static and dynamic) postural control assessment and training system. It provides objective, valid, and reliable measures of a patient's ability to balance on stable and unstable surfaces. It measures the overall Stability Index (OSI), anterior/posterior stability index (APSI), and medial/lateral stability index (MLSI). Its intraclass correlation coefficient (ICC) reliability is R = 0.92 (OSI), R = 0.
• Diagnostic test 2-The Numerical Pain Rating Scale (NPRS)
  The Numerical Pain Rating Scale (NPRS) is a unidimensional measure of pain intensity that serves as a segmented numerical version of the visual analog scale (VAS). It consists of an 11-point scale where the respondent selects a whole number from 0 to 10 that best reflects the intensity of their pain, with 0 representing "no pain" and 10 representing the "worst imaginable pain" . The NPRS has demonstrated high construct and criterion validity for assessing pain severity in patients with chronic
• Diagnostic test 3- The Neck Disability Index (Arabic version) for functional disability
  Neck disability index (NDI) is self-reported assessment includes ten items: pain severity, personal care, lifting, work, headaches, concentration, sleeping, driving, reading, and recreation. Higher scores imply a greater level of disability. Arabic version of the NDI was used to assess Arabic patients with neck pain, as the Arabic version of the NDI is reliable and valid
• Diagnostic test 4- Digital Inclinometer for Cervical Range of Motion
  A digital inclinometer is a handheld electronic device used to objectively measure the degrees of spinal curvature by detecting inclination relative to the force of gravity.In cervical spine assessment, it is used to quantify movements including flexion, extension, lateral flexion, and rotation.The digital inclinometer is recognized as a highly valid and reliable instrument for measuring cervical range of motion (CROM). Recent studies have reported excellent intra-rater and inter-rater reliabili
• Diagnostic test 5- Arabic Tampa Scale of Kinesiophobia (TSK-11)
  The TSK-11 is a shortened, 11-item version of the original Tampa Scale, designed to assess kinesiophobia. Defined as an irrational and debilitating fear of physical movement resulting from a feeling of vulnerability to painful injury or re-injury . The Arabic version was developed to provide a linguistically and culturally adapted tool for assessing fear-avoidance beliefs in Arabic-speaking populations. The Arabic version of the TSK-11 has been cross- culturally validated and demonstrates strong
• Diagnostic test 6- Overhead LASER pointer for Cervical proprioception
  An overhead LASER pointer will be used to assess cervical proprioception by performing the Cervical Joint Position Error (JPE) test. The Joint Position Sense Error (JPSE) is considered one of the essential measures to clinically assess cervical proprioception. The test has good (ICC: 0.77-0.78)
• Other 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
• Other Conventional therapy group
  Based on the American Physical Therapy Association (APTA) Clinical Practice Guidelines for Neck Pain with Mobility Deficits, participants in the conventional therapy group received a multimodal treatment program consisting of mobility exercises, strengthening and endurance training, stretching exercises, and patient education * Cervical and thoracic mobility exercises. * Strengthening and endurance exercises for the deep cervical flexors, cervical extensors, and scapulothoracic muscles. * Stret

Primary outcome measures

• A) Postural Stability (Biodex Balance System) [Time frame: before the intervention, after 8 weeks, and at a 4-week follow- up.]

Secondary outcome measures (5)

• Numerical Pain Rating Scale (NPRS) [Time frame: before the intervention, after 8 weeks, and at a 4-week follow- up.]
• Neck Disability Index (Arabic Version) [Time frame: before the intervention, after 8 weeks, and at a 4-week follow- up.]
• Digital Inclinometer for Cervical ROM [Time frame: before the intervention, after 8 weeks, and at a 4-week follow- up.]
• Tampa Scale of Kinesiophobia (TSK-11, Arabic Version) [Time frame: before the intervention, after 8 weeks, and at a 4-week follow- up.]
• Overhead Laser Pointer for Cervical Proprioception (Joint Position Error Test) [Time frame: before the intervention, after 8 weeks, and at a 4-week follow- up.]

Eligibility criteria

Inclusion criteria

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

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

Exclusion criteria

• The patients will be excluded if they present with:

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

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Egypt · 1 center

• Faculty of Physical Therapy Delta University — Gamasa

Identifiers

NCT: NCT07673575 · Mulligan on chronic neck pain

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗