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

Summary

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?

Conditions

• Chronic Neck Pain With Mobility Deficits
• Chronic Neck Pain With Mobility Deficits (> 3 Months)

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 = 0.89 (APSI), and R = 0.93 (MLSI). Chronic neck pain subjects have demonstrated significantly worse Biodex balance performance across OSI, APSI, and MLSI

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 musculoskeletal disorders. It is considered a valid tool for differentiating pain characteristics between individuals with chronic neck pain and healthy controls. The research suggests that the NPRS is often more responsive to clinical changes and easier for patients to comprehend than the traditional VAS .This scale is characterized by excellent test-retest reliability (ICC: 0.95),

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 reliability (ICC \> 0.85), particularly for cervical rotation and lateral flexion. It is often preferred over traditional goniometry because it provides precise, objective, and quantitative data that is less susceptible to manual measurement error.

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 psychometric properties. It exhibits high internal consistency, with Cronbach's alpha values typically ranging from 0.86 to 0.90, and excellent test-retest reliability. It shows significant concurrent validity, as scores are strongly correlated with pain intensity (NPRS) and functional disability measures like the Neck Disability Index.

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 first, followed by conventional exercises. * Cervical spine: Targeted for joint position sense, pain, and dizziness. Technique variations: • Minor adjustments in force direction to optimize symptom reduction.

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. * Stretching exercises for the upper trapezius, levator scapulae, pectoral, and cervical muscles. * Patient education regarding posture, ergonomics, activity modification, and self-management strategies. Sequencing: • SNAG mobilizations performed at session start, followed by active exercises and stretching Manual therapy timing: • SNAG component adds \~10 minutes to a 20-minute exercise session

Sponsors & Collaborators

• Menna Allah Ahmed Marei Elnaggar

  lead OTHER

Study Design

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

20 Years

Max Age

45 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2026-08-20

Primary Completion

2026-10-20

Completion

2026-11-01

Countries

• Egypt

Study Locations