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

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

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),

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.

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

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.

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),

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

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

The NPRS is an 11-point self-reported scale (0-10) for pain intensity.

1. Ask the patient to rate their pain intensity on a scale from 0 = no pain to 10 = worst possible pain.
2. It can assess current pain, pain in the last 24 hours .
3. 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.

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 disability
  • 5-14: Mild
  • 15-24: Moderate
  • 25-34: Severe Procedure
• Provide the patient with the questionnaire.
• Explain each item when needed (common in Arabic versions).
• Sum the scores and classify disability.

Multiple studies describe standardized inclinometer protocols

Devices show good validity compared with 3D motion capture

1. Patient is usually seated upright with feet on the floor.
2. Place the inclinometer on the vertex of the head aligned with T1 or other fixed reference, depending on the device.
3. Measure flexion, extension, lateral flexion, and rotation.
4. Perform 3 trials per direction and use the mean.

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

1. Provide the questionnaire.
2. Ensure the patient answers all 11 items.
3. Sum all item scores (minimum 11, maximum 55).
4. Higher scores = higher kinesiophobia

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 procedure

  1. Patient sits upright, eyes closed (no visual feedback allowed)

  2. Patient moves head:

     1. Rotation right
     2. Rotation left
     3. Flexion
     4. Extension
  3. Patient returns to what they believe is the original neutral position.
  4. Record the deviation in degrees from the center of the target.
  5. Repeat 3-5 trials per direction; average the error