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

NCT07673575 | Not Yet Recruiting

• 1 other identifier: Mulligan on chronic neck pain
• Study Type: interventional
• Target: 44
• Locations: 1 country
• Sites: 1

Brief 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)

Keywords

SNAG; chronic neck pain with mobility deficits; MULLIGAN

Outcome Measures

Primary Outcomes (1)

• 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 Outcomes (5)

• Numerical Pain Rating Scale (NPRS)

  before the intervention, after 8 weeks, and at a 4-week follow- up.

• Neck Disability Index (Arabic Version)

  before the intervention, after 8 weeks, and at a 4-week follow- up.

• Digital Inclinometer for Cervical ROM

  before the intervention, after 8 weeks, and at a 4-week follow- up.

• Tampa Scale of Kinesiophobia (TSK-11, Arabic Version)

  before the intervention, after 8 weeks, and at a 4-week follow- up.

• Overhead Laser Pointer for Cervical Proprioception (Joint Position Error Test)

  before the intervention, after 8 weeks, and at a 4-week follow- up.

Study Arms (2)

Group A will include 22 patients with chronic neck pain with mobility deficits

EXPERIMENTAL

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); 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

Group B = 22 patients with chronic neck pain with mobility deficits

OTHER

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); 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: Conventional therapy group

Interventions

1- The Biodex Balance System (BBS) DIAGNOSTIC_TEST

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

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

2-The Numerical Pain Rating Scale (NPRS) DIAGNOSTIC_TEST

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),

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

3- The Neck Disability Index (Arabic version) for functional disability DIAGNOSTIC_TEST

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

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

4- Digital Inclinometer for Cervical Range of Motion DIAGNOSTIC_TEST

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.

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

5- Arabic Tampa Scale of Kinesiophobia (TSK-11) DIAGNOSTIC_TEST

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.

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

6- Overhead LASER pointer for Cervical proprioception DIAGNOSTIC_TEST

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)

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

Mulligan Cervical SNAG Technique Protocol OTHER

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.

Group A will include 22 patients with chronic neck pain with mobility deficits

Conventional therapy group OTHER

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

Group A will include 22 patients with chronic neck pain with mobility deficits; Group B = 22 patients with chronic neck pain with mobility deficits

Eligibility Criteria

• Age: 20 Years - 45 Years
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64)

You may qualify if:

• 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)

You may not qualify if:

• 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

Sponsors & Collaborators

• Menna Allah Ahmed Marei Elnaggar: lead

Study Sites (1)

Faculty of Physical Therapy Delta University

Gamasa, Egypt

Location

Central Study Contacts

Menna-Allah A Elnaggar, demonstrator

CONTACT

+201069014391; me370433@gmail.com

Rewan M Aloush, Teaching Assistant

CONTACT

+201024232512; rewan.aloush@gmail.com

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR INVESTIGATOR
• PI Title: Demonstrator at Physical therapy for Musculoskeletal disorders and its surgeries , Faculty of Physical Therapy, Delta University

Model Details: Group A (Experimental: Mulligan cervical SNAG plus conventional physiotherapy) or Group B (Control: conventional physiotherapy alone). Outcome assessments will be conducted at three time points: baseline, at eight weeks, immediately after completion of the final intervention session, and after four weeks for a short follow-up assessment (Follow-up assessment will be conducted 4 weeks after completion of the 8-week intervention period to evaluate retention of treatment effects).

Study Record Dates

• First Submitted: June 23, 2026
• First Posted: June 29, 2026
• Study Start (Estimated): August 20, 2026
• Primary Completion (Estimated): October 20, 2026
• Study Completion (Estimated): November 1, 2026
• Last Updated: June 29, 2026

Record last verified: 2026-06

Locations

EG (1)