Sustained Natural Apophyseal Glides With and Without Integrated Neuromuscular Inhibition Technique in Neck Pain

Effects of Sustained Natural Apophyseal Glides With and Without Integrated Neuromuscular Inhibition Technique on Pain, Range of Motion, and Function in Patients With Chronic Mechanical Neck Pain

The study was conducted to determine the effects of Sustained Natural Apophysial Glide with and without Integrated Neuromuscular Inhibition Technique on pain, range of motion and function in patients with chronic mechanical neck pain

Study Overview

• Status: Completed
• Conditions: Chronic Mechanical Neck Pain
• Intervention / Treatment: Other: Sustained Natural Apophyseal Glides; Other: Integrated Neuromuscular Inhibition Technique; Other: Standardized Physiotherapy Treatment

• Study Type: Interventional
• Enrollment (Actual): 44
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Punjab Province
    • Lahore, Punjab Province, Pakistan
      • Lahore General Hospital,Lahore

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age ranged from 18 to 45 years and both genders.
• Patient having neck-pain symptoms for more than 3 months duration.
• Spurling test, distraction test, upper limb tension test and shoulder abduction test negative upon assessment.
• The participants should have MTrPs in any one of these following cervical muscles which include levator scapulae, upper trapezius, splenius capitis and sternocleidomastoid muscles which may be active or latent.
• A score greater than twenty percent on NDI.
• Jump Sign when pressure is applied.
• Positive Simons criteria which contains following these 5 characteristics :(1) Pain on palpation (2) pain that is radiating (3) Tightened cord like structure in muscle fiber that is detectable upon palpation(4) Reduced Flexibility of that muscle (5) 'twitching response' on needling.
• Participants who described pain which is felt between spinous process of 1st thoracic vertebrae and superior nuchal line in posterior or posterolateral part of neck

Exclusion Criteria:

• Recent fracture, trauma (whiplash injury) and surgery in and around the shoulder and neck
• Neural disorders due to prolapsed intervertebral disc
• Carcinoma, Heart diseases, Metabolic disease in bone and joints
• Patients having history of osteoporosis, prolong steroid and analgesics use
• Unstable spine and open sores, Localized infection in neck
• Vertebrobasilar insufficiency.
• Cervical radiculopathy and myelopathy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Sustained Natural Apophyseal Glides With Integrated Neuromuscular Inhibition Technique	Other: Sustained Natural Apophyseal Glides; SNAGs were applied in three sets, with repetitions progressively increased from 6 to 10 over a period of four weeks, administered three times per week.; Other: Integrated Neuromuscular Inhibition Technique; The integrated neuromuscular inhibition technique comprised three steps: ischemic compression, strain-counterstrain technique, and muscle energy technique. The technique was applied to the upper trapezius, levator scapulae, sternocleidomastoid, and splenius capitis muscles. Muscle selection was based on palpatory examination performed prior to each treatment session. Each treatment session lasted 10 minutes, during which all three steps were repeated three times within a single session. The intervention was delivered three times per week for four weeks, resulting in a total of 12 treatment sessions.; Other: Standardized Physiotherapy Treatment; Standardized physiotherapy included the application of an electrical hot pack at moderate intensity for 10 minutes. Transcutaneous electrical nerve stimulation (TENS) delivered in continuous mode at a frequency of 100 Hz for 15 minutes. Passive stretching was performed for cervical muscles prone to tightness, including the levator scapulae, sternocleidomastoid, upper trapezius, and scalene muscles, with a 30-second hold, three sets of ten repetitions, and a one-minute rest between sets. Scapular stabilization exercises, comprising shoulder shrugging and scapular retraction, were performed for 15 repetitions with a 6-second hold. Neck isometric exercises were repeated ten times with a 6-second hold. Cervical stabilization exercises were performed in two sets of ten repetitions per session, with each repetition held for ten seconds, a forty-second rest between repetitions, and a two-minute rest between sets.
Active Comparator: Sustained Natural Apophyseal Glides	Other: Sustained Natural Apophyseal Glides; SNAGs were applied in three sets, with repetitions progressively increased from 6 to 10 over a period of four weeks, administered three times per week.; Other: Standardized Physiotherapy Treatment; Standardized physiotherapy included the application of an electrical hot pack at moderate intensity for 10 minutes. Transcutaneous electrical nerve stimulation (TENS) delivered in continuous mode at a frequency of 100 Hz for 15 minutes. Passive stretching was performed for cervical muscles prone to tightness, including the levator scapulae, sternocleidomastoid, upper trapezius, and scalene muscles, with a 30-second hold, three sets of ten repetitions, and a one-minute rest between sets. Scapular stabilization exercises, comprising shoulder shrugging and scapular retraction, were performed for 15 repetitions with a 6-second hold. Neck isometric exercises were repeated ten times with a 6-second hold. Cervical stabilization exercises were performed in two sets of ten repetitions per session, with each repetition held for ten seconds, a forty-second rest between repetitions, and a two-minute rest between sets.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Numeric Pain Rating Scale	Numeric Pain Rating Scale is utilized to evaluate pain.This is a scale between 0 and 10 where 0 denotes no pain and 10 denotes the worst pain whereas 1-3 denotes mild pain 4-6 denotes moderate pain and 7-10 denotes severe pain.	From enrollment to end of treatment at 4th weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Neck Disability Index	The Neck Disability Index is a self-reported questionnaire used to assess neck-related functional disability. It consists of 10 items addressing pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Each item is scored on a 6-point scale (0-5), with a total score ranging from 0 to 50, where higher scores indicate greater disability. Scores are categorized as no disability (0-4), mild disability (5-14), moderate disability (15-24), severe disability (25-34), and complete disability (≥35).	From enrollment to the end of treatment at 4th weeks
Range of Motion Cervical Spine (Flexion)	Changes in cervical spine flexion range of motion at baseline and 4th week of intervention was measured using goniometer	From enrollment to the end of treatment at 4th week.
Range of Motion Cervical Spine (Extension)	Changes in cervical spine extension range of motion at baseline and 4th week of intervention was measured using goniometer.	From enrollment to the end of treatment at 4th week
Range of Motion Cervical Spine (Lateral Flexion) Right Side	Changes in cervical spine lateral flexion on right side range of motion at baseline and 4th week of intervention was measured using goniometer.	From enrollment to the end of treatment at 4th week
Range of Motion Cervical Spine (Lateral Flexion) Left Side	Changes in cervical spine lateral flexion on left side range of motion at baseline and 4th week of intervention was measured using goniometer.	From enrollment to the end of treatment at 4th week
Range of Motion Cervical Spine (Rotation) Right Side	Changes in cervical spine rotation on right side range of motion at baseline and 4th week of intervention was measured using goniometer	From enrollment to the end of treatment at 4th week
Range of Motion Cervical Spine (Rotation) Left Side	Changes in cervical spine rotation on left side range of motion at baseline and 4th week of intervention was measured using goniometer	From enrollment to the end of treatment at 4th week

Collaborators and Investigators

• Sponsor: Riphah International University
• Investigators: Principal Investigator: Syed Shakil ur Rehman, Ph.D, Riphah International Universirty

Publications and helpful links

General Publications

• Lytras DE, Sykaras EI, Christoulas KI, Myrogiannis IS, Kellis E. Effects of Exercise and an Integrated Neuromuscular Inhibition Technique Program in the Management of Chronic Mechanical Neck Pain: A Randomized Controlled Trial. J Manipulative Physiol Ther. 2020 Feb;43(2):100-113. doi: 10.1016/j.jmpt.2019.03.011. Epub 2020 May 30.
• Ali Ismail AM, Abd El-Azeim AS, El-Sayed Felaya EE. Integrated neuromuscular inhibition technique versus spray and stretch technique in neck pain patients with upper trapezius trigger points: a randomized clinical trial. J Man Manip Ther. 2024 Apr;32(2):141-149. doi: 10.1080/10669817.2023.2192899. Epub 2023 Mar 23.
• Abd El-Azeim A, Grase M. Efficacy of Mulligan on electromyography activation of cervical muscles in mechanical neck pain: randomised experimental trial. Physiotherapy Quarterly. 2023;31(4):7-14.
• Shelke A, B AP, M GB, Kumaran SD, G PR. Immediate effect of craniocervical flexion exercise and Mulligan mobilisation in patients with mechanical neck pain - A randomised clinical trial. Hong Kong Physiother J. 2023 Dec;43(2):137-147. doi: 10.1142/S1013702523500154. Epub 2023 Jun 21.
• Ozlu O, Sahin M. The effect of mulligan mobilization technique application in addition to conventional physiotherapy on pain and joint range of motion in people with neck pain. J Bodyw Mov Ther. 2024 Jul;39:225-230. doi: 10.1016/j.jbmt.2024.02.009. Epub 2024 Mar 5.
• Ferdinand R, Kohilavani S. TO COMPARE THE EFFECTIVENESS OF INTEGRATED NEUROMUSCULAR INHIBITION TECHNIQUE VERSUS BOWEN TECHNIQUE ON UPPER TRAPEZIUS TRIGGER POINT IN SUBJECTS WITH MECHANICAL NECK PAIN
• Dhami H, Kaur J, Kaur M. Comparison of Integrated Neuromuscular Inhibition Technique versus Myofascial Release of Upper Trapezius on Neck Range of Motion and Dysfunction in Individuals with Nonspecific Neck Pain. Indian Journal of Physiotherapy & Occupational Therapy. 2022;16(4).
• Abhilash P. Comparison between immediate effect of integrated neuromuscular inhibition technique and active release technique on chronic neck pain and upper trapezius trigger points. 2024.
• Thakur R, Mande P, Lokwani M. Effectiveness of Integrated Neuromuscular Inhibition Technique and Instrument Assisted Soft Tissue Mobilisation in the Management of Upper Trapezius Myofascial Trigger Points. Indian Journal of Physiotherapy & Occupational Therapy. 2022;16(4).
• Shaukat S, Kiran Q, Hanif A, Saleem I, Paracha MS, Batool T. Role of Integrated Neuromuscular Inhibition Technique in Managing Upper Trapezius Trigger Points in Non-Specific Neck Pain: A Randomized Controlled Trial. Journal of Health, Wellness, and Community Research. 2025:e51-e.
• Tank KD, Choksi P, Makwana P. To study the effect of muscle energy technique versus mulligan snags on pain, range of motion and functional disability for individuals with mechanical neck pain: a comparative study. Int J Physiother Res. 2018;6(1):2582-87.
• Kocaman H, Yıldız NT, Canlı M, Alkan H. COMPARISON OF THE EFFECTS OF MULLIGAN MOBILIZATION TECHNIQUE COMBINED WITH CERVICAL STABILIZATION EXERCISES WITH THE EFFECTS OF CERVICAL STABILIZATION EXERCISES ALONE IN CHRONIC NECK PAIN: RANDOMIZED CONTROLLED STUDY. Karya Journal of Health Science. 2023;4(3):227-34.
• Malik SZ, Haider R, Razzaq A, Rehman AU, Zahra S. Comparison of MET and Mulligan Mobilization Snags in Reducing Neck Pain and Improving Functional Activities in Chronic Mechanical Neck Pain Patients. Journal of Health, Wellness and Community Research. 2025:e567-e.
• Naz S, Jamali N, Iftikhar A, Nawaz H, Iqbal T, Ghafoor F. Compare the Effectiveness of Mulligan (Nags & Snags) and McKenzie (Self-Stretching) On Improving the Pain and Functional Ability in Patient with Chronic Neck Pain: Effectiveness of Mulligan and McKenzie in Patient with Chronic Neck Pain. Pakistan Journal of Health Sciences. 2023:47-52

Study record dates

Study Major Dates

• Study Start (Actual): August 18, 2025
• Primary Completion (Actual): November 18, 2025
• Study Completion (Actual): November 18, 2025

Study Registration Dates

• First Submitted: February 4, 2026
• First Submitted That Met QC Criteria: February 4, 2026
• First Posted (Actual): February 11, 2026

Study Record Updates

• Last Update Posted (Actual): February 11, 2026
• Last Update Submitted That Met QC Criteria: February 4, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Range of Motion; Integrated Neuromuscular Inhibition Technique; Neck pain; Trigger points; Sustained Natural Apophyseal Glides
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Neck Pain
• Other Study ID Numbers: REC/RCR & AHS/24/0175

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No