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

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?

Study Overview

• Status: Not yet recruiting
• Conditions: Chronic Neck Pain With Mobility Deficits; Chronic Neck Pain With Mobility Deficits (> 3 Months)
• Intervention / Treatment: Diagnostic test: 1- The Biodex Balance System (BBS); Diagnostic test: 2-The Numerical Pain Rating Scale (NPRS); Diagnostic test: 3- The Neck Disability Index (Arabic version) for functional disability; Diagnostic test: 4- Digital Inclinometer for Cervical Range of Motion; Diagnostic test: 5- Arabic Tampa Scale of Kinesiophobia (TSK-11); Diagnostic test: 6- Overhead LASER pointer for Cervical proprioception; Other: Mulligan Cervical SNAG Technique Protocol; Other: Conventional therapy group

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.

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

Contacts and Locations

• Study Contact: Name: Menna-Allah A Elnaggar, demonstrator; Phone Number: +201069014391; Email: me370433@gmail.com
• Study Contact Backup: Name: Rewan M Aloush, Teaching Assistant; Phone Number: +201024232512; Email: rewan.aloush@gmail.com

Study Locations

• Egypt
  • Gamasa, Egypt
    • Faculty of Physical Therapy Delta University
    • Principal Investigator: Dr. Akram fathy abdulhamid, Assistant Professor
    • Sub-Investigator: Mohamed Behiry, Assistant Professor
    • Sub-Investigator: Mahmoud Nabhan, lecturer

Participation Criteria

Eligibility Criteria

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

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Group A will include 22 patients with chronic neck pain with mobility deficits; 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	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
Other: Group B = 22 patients with chronic neck pain with mobility deficits; 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.	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: 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

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
A) Postural Stability (Biodex Balance System)	Overall Stability Index (OSI) - total amount of platform deviation.; Anterior-Posterior Stability Index (APSI) - sagittal plane sway.; Medial-Lateral Stability Index (MLSI) - frontal plane sway. These indices are mathematically defined in research: APSI and MLSI Calculated from the deviation of platform angles along X and Y axes (Higher scores = worse balance Reliability Evidence; ICC OSI = 0.92, APSI = 0.89, MLSI = 0.93; Indicates excellent reliability for research. For chronic cervical pain with hypomobility, the most appropriate Biodex protocol (supported by evidence) is: Static Postural Stability Test:; Platform locked; 3 trials × 20 s; Eyes open; Compute OSI, APSI, MLSI Dynamic Postural Stability Test; Platform level 8 (commonly used mid-level); 3 trials × 20 s; Eyes open A) Compute OSI, APSI, MLSI	before the intervention, after 8 weeks, and at a 4-week follow- up.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Numerical Pain Rating Scale (NPRS)	The NPRS is an 11-point self-reported scale (0-10) for pain intensity.; Ask the patient to rate their pain intensity on a scale from 0 = no pain to 10 = worst possible pain.; It can assess current pain, pain in the last 24 hours .; The scale is valid, reliable, and widely used in clinical and research settings. Standard instructions to participants "Please rate your pain intensity on a scale from 0 to 10, where 0 means no pain at all, and 10 means the worst pain imaginable." This standardized wording is supported by multiple trials.	before the intervention, after 8 weeks, and at a 4-week follow- up.
Neck Disability Index (Arabic Version)	The Arabic NDI is validated and used widely in neck pain research.; The patient completes 10 items, each scored 0-5.; Total scores range from 0-50 (or converted to %).; Disability categories:0-4: No disability5-14: Mild15-24: Moderate25-34: Severe Procedure; Provide the patient with the questionnaire.; Explain each item when needed (common in Arabic versions).; Sum the scores and classify disability.	before the intervention, after 8 weeks, and at a 4-week follow- up.
Digital Inclinometer for Cervical ROM	Multiple studies describe standardized inclinometer protocols Devices show good validity compared with 3D motion capture; Patient is usually seated upright with feet on the floor.; Place the inclinometer on the vertex of the head aligned with T1 or other fixed reference, depending on the device.; Measure flexion, extension, lateral flexion, and rotation.; Perform 3 trials per direction and use the mean.	before the intervention, after 8 weeks, and at a 4-week follow- up.
Tampa Scale of Kinesiophobia (TSK-11, Arabic Version)	Kinesiophobia was assessed using the Arabic version of the Tampa Scale of Kinesiophobia (TSK-AV-11), which is a valid and reliable tool for evaluating fear of movement in Arabic-speaking patients. It consists of 11 items scored on a 4-point Likert scale, with higher scores indicating greater fear of movement Brief and validated for chronic pain including neck pain Contains 11 items, each scored 1 (strongly disagree) to 5 (strongly agree). Procedure; Provide the questionnaire.; Ensure the patient answers all 11 items.; Sum all item scores (minimum 11, maximum 55).; Higher scores = higher kinesiophobia	before the intervention, after 8 weeks, and at a 4-week follow- up.
Overhead Laser Pointer for Cervical Proprioception (Joint Position Error Test)	Setup; Attach a laser pointer to the patient's forehead or headband; Place a target on the wall at a distance of 90 cm.; Align the laser to the center of the target at the neutral head position. Testing procedurePatient sits upright, eyes closed (no visual feedback allowed)Patient moves head:Rotation rightRotation leftFlexionExtensionPatient returns to what they believe is the original neutral position.Record the deviation in degrees from the center of the target.Repeat 3-5 trials per direction; average the error	before the intervention, after 8 weeks, and at a 4-week follow- up.

Collaborators and Investigators

• Sponsor: Menna Allah Ahmed Marei Elnaggar

Study record dates

Study Major Dates

• Study Start (Estimated): August 20, 2026
• Primary Completion (Estimated): October 20, 2026
• Study Completion (Estimated): November 1, 2026

Study Registration Dates

• First Submitted: June 23, 2026
• First Submitted That Met QC Criteria: June 23, 2026
• First Posted (Actual): June 29, 2026

Study Record Updates

• Last Update Posted (Actual): June 29, 2026
• Last Update Submitted That Met QC Criteria: June 23, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: SNAG; chronic neck pain with mobility deficits; MULLIGAN
• Other Study ID Numbers: Mulligan on chronic neck pain

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No