Strain Counter Strain With and Without Sustained Natural Aphophyseal Glide in Non Specific Neck Pain

NCT07725861 | Recruiting

• 1 other identifier: REC/RCR&AHS/25/0133 Hadeel
• Study Type: interventional
• Target: 68
• Locations: 1 country
• Sites: 1

Brief Summary

Non-specific neck pain is a common problem that doesn't have a specific cause like an injury or disease. It usually includes neck pain, reduced movement, poor posture like forward head position, and some level of disability that can make daily activities difficult. Physiotherapists often use hands-on techniques like Strain Counterstrain (SCS) and SNAGs (Sustained Natural Apophyseal Glides) to help reduce pain, improve movement, and correct posture. This study aims to find out if adding SNAGs (Sustained Natural Apophyseal Glides) to the usual Strain Counterstrain (SCS) treatment helps more than SCS alone in patients with neck pain. We will measure changes in pain levels, neck movement, posture (craniovertebral angle), and daily life impact (NDI) over a four-week treatment program.

Conditions

Cervical Pain

Outcome Measures

Primary Outcomes (4)

• Numeric pain rate scale (NPRS)

  Patient level of pain will be assessed using this scale. This scale ranges from 0 to 10. 0 indicates "no pain" and 10 indicates "worst pain".(25) NPRS shows strong construct validity and correlates well with other pain scales like the Visual Analog Scale (VAS) and McGill Pain Questionnaire. It is especially useful for tracking changes in pain over time.(13) The NPRS demonstrates excellent test-retest reliability with an intraclass correlation coefficient (ICC) of \~0.95 in patients with chronic musculoskeletal pain.(26) The MCID for NPRS is generally considered to be 2 points, meaning a change of 2 or more points is considered clinically meaningful in musculoskeletal pain patients

  upto 4 weeks

• Neck Disability index (NDI)

  This questionnaire will be used to assess disability. It comprises of 10 items; 7 related to daily living activities, 2 related to pain and 1 related to concentration. Each item is scored from 0 to 5. Total score is expressed as a percentage, with higher scores related to greater disability(28) Its construct validity has been supported through correlations with pain intensity, cervical range of motion, and quality-of-life measures (13). It shows excellent test retest reliability, with an ICC of 0.89-0.98 in patients with mechanical or non-specific neck pain (26)The Minimal Detectable Change (MDC) for NDI has been reported to be 5 points, while the MCID is commonly considered to be around 7-10 points for clinical relevance in chronic musculoskeletal pain

  Upto 4 weeks

• Universal Goniometer (UG)

  It will measure range of motion of neck (29) A universal goniometer will be used to measure active cervical range of motion (CROM) in flexion, extension, lateral flexion, and rotation. This tool is portable, affordable, and easy to use in clinical and research settings. The validity of goniometry in measuring cervical ROM has been confirmed through comparisons with CROM devices and motion sensors, showing strong correlations (r \> 0.85) in neck mobility measurement (27). Goniometer-based cervical ROM assessments demonstrate good to excellent reliability, with ICC values ranging from 0.79 to 0.96, depending on the plane of movement and rater experience

  Upto 4 weeks

• Craniovertebral Angle (CVA)

  It is used to measure the degree of forward head posture, which is common in people with neck pain. A smaller CVA indicates a more forward head position, while a larger angle reflects a more neutral, healthy posture .To measure CVA, a lateral photograph is taken while the patient stands in a relaxed position. The angle is formed between a horizontal line passing through the C7 vertebra and a line connecting C7 to the tragus of the ear. This measurement is usually done using image analysis software or mobile applications like Posture Screen or ImageJ. Studies have shown that CVA measurement is a reliable and valid method for assessing head posture. It has good intra-rater and inter-rater reliability, with Intraclass Correlation Coefficients (ICC) ranging from 0.88 to 0.98 (8, 15).The Minimal Detectable Change (MDC) for CVA varies across studies but is generally estimated to be about 3-4 degrees, making it a sensitive tool for detecting postural improvements

  Upto 4 weeks

Study Arms (2)

Strain Counterstrain + SNAG with Common Treatment

EXPERIMENTAL

Strain-Counterstrain (SCS) and SNAGs (Sustained Natural Apophyseal Glides) are two highly effective, non-invasive manual therapy techniques used to relieve neck pain. SCS gently relaxes hyperactive muscles by placing the body in a pain-free position, while SNAGs are movement-based mobilizations that restore joint function and reduce pain

Other: Strain Counterstrain + SNAG with Common Treatment

Strain Counterstain (SCS) only

ACTIVE COMPARATOR

Strain-Counterstrain (SCS) is a gentle, passive osteopathic technique that treats neck pain by finding tender points and holding the neck in a highly specific "position of ease" for 90 seconds. This shortens the affected, spasming muscle, allowing the nervous system to reset muscle spindles and break the pain

Other: Strain Counterstain (SCS) only

Interventions

Strain Counterstrain + SNAG with Common Treatment OTHER

Group A (Experimental Group) will receive both Strain Counterstrain (SCS) and SNAGs (30). They will attend 12 sessions in total, three times per week for four weeks. First, the SCS technique will be applied to the upper trapezius, levator scapulae, and scalene muscles. The patient will lie on their back or side while the therapist finds tender points and positions the neck to reduce tension, holding that position for 90 seconds before gently returning it to neutral and checking for pain. After this, SNAGs (Sustained Natural Apophyseal Glides) will be applied, targeting spinal segments like C2-C3 for rotation and C5-C6 for flexion or extension. While the patient sits upright, the therapist will apply a sustained glide on the vertebra as the patient moves the neck in the limited direction. Each movement will be repeated 6-10 times and followed by a reassessment

Strain Counterstrain + SNAG with Common Treatment

Strain Counterstain (SCS) only OTHER

Group B (Control Group) will receive only the Strain Counterstrain (SCS) technique without SNAGs (31). The same neck muscles will be targeted, and the patient will lie in a similar position while the therapist identifies tender points and performs the SCS technique. No joint glides or mobilization will be applied in this group. Both groups will receive a total of 12 sessions over four weeks, with each session lasting about 40 minutes. Pre- and post-treatment assessments will be carried out to measure changes in pain (using NPRS/VAS), cervical ROM, craniovertebral angle (CVA), and neck-related disability (using the Neck Disability Index - NDI).

Strain Counterstain (SCS) only

Eligibility Criteria

• Age: 18 Years - 60 Years
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64)

You may qualify if:

• Both Males and Females (20)
• Age 18 and 60 years
• pain intensity 3-6 rating on NPRS
• Pain localized to cervical or upper trapezius

You may not qualify if:

• Cervical radiculopathy(20)
• History of whiplash injury
• History of cervical and thoracic spine surgery
• Neck pain associated with vertigo(20)
• History of spinal osteoporosis
• Vertebral Fractures
• Tumours
• Diagnosed psychological disorders

Sponsors & Collaborators

• Riphah International University: lead

Study Sites (1)

Ibne sina hospital and research institute.

Multan, Punjab Province, Pakistan

RECRUITING

Related Publications (10)

• Barbosa-Silva J, Luc A, Sobral de Oliveira-Souza AI, Martins de Abreu R, Cipriano J, de Schaetzen M, Pitance L, Armijo-Olivo S. The Effectiveness of Mulligan's Techniques in Non-Specific Neck Pain: A Systematic Review and Meta-Analysis. Physiother Res Int. 2025 Jul;30(3):e70045. doi: 10.1002/pri.70045.

  PMID: 40439260 BACKGROUND

• Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017 Jul;47(7):A1-A83. doi: 10.2519/jospt.2017.0302.

  PMID: 28666405 BACKGROUND

• de Koning CH, van den Heuvel SP, Staal JB, Smits-Engelsman BC, Hendriks EJ. Clinimetric evaluation of active range of motion measures in patients with non-specific neck pain: a systematic review. Eur Spine J. 2008 Jul;17(7):905-21. doi: 10.1007/s00586-008-0656-3. Epub 2008 Apr 22.

  PMID: 18427843 BACKGROUND

• Shukla Yu, Shah D. Effect of Craniocervical Flexion Training in Mechanical Neck Pain on Proprioception, Endurance and Pain -An Interventional Study. International Journal of Health Research. 2020;Vol.5:565.

  BACKGROUND

• Raja G P, Bhat N S, Fernandez-de-Las-Penas C, Gangavelli R, Davis F, Shankar R, Prabhu A. Effectiveness of deep cervical fascial manipulation and yoga postures on pain, function, and oculomotor control in patients with mechanical neck pain: study protocol of a pragmatic, parallel-group, randomized, controlled trial. Trials. 2021 Aug 28;22(1):574. doi: 10.1186/s13063-021-05533-w.

  PMID: 34454582 BACKGROUND

• Bernal-Utrera C, Gonzalez-Gerez JJ, Anarte-Lazo E, Rodriguez-Blanco C. Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial. Trials. 2020 Jul 28;21(1):682. doi: 10.1186/s13063-020-04610-w.

  PMID: 32723399 BACKGROUND

• Cerezo-Tellez E, Torres-Lacomba M, Mayoral-Del-Moral O, Pacheco-da-Costa S, Prieto-Merino D, Sanchez-Sanchez B. Health related quality of life improvement in chronic non-specific neck pain: secondary analysis from a single blinded, randomized clinical trial. Health Qual Life Outcomes. 2018 Nov 6;16(1):207. doi: 10.1186/s12955-018-1032-6.

  PMID: 30400984 BACKGROUND

• Shamsi S, Alyazedi FM, Abdelkader SM, Khan S, Akhtar A. Efficacy of Sustained Natural Apophyseal Glides in the Management of Mechanical Neck Pain: A Randomized Clinical Trial. Indian Journal of Medical Specialities. 2021;12(4):199-206.

  BACKGROUND

• Al Shehri A, Khan S, Shamsi S, Almureef SS. Comparative study of mulligan (snags) and maitland mobilization in neck pain. European Journal of Physical Education and Sport Science. 2018.

  BACKGROUND

• Prayerna B, SuBBiah K, Asser P, MiLaneSe S. Effectiveness of mulligan's sustained natural apophyseal glide (SNAG) over first rib in reducing pain and improving cervical rotation in individuals with mechanical neck dysfunction. Journal of Clinical & Diagnostic Research. 2019;13(3)

  BACKGROUND

MeSH Terms

Conditions

Neck Pain

Interventions

Single Person

Condition Hierarchy (Ancestors)

Pain; Neurologic Manifestations; Signs and Symptoms; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Marital Status; Family Characteristics; Demography; Population Characteristics; Socioeconomic Factors

Study Officials

• Amna Zia, PhD*

  Riphah International University, Lahore

  PRINCIPAL INVESTIGATOR

• Hadeel Mukhtar

  Riphah International University, Lahore

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Amna Zia, PhD*

CONTACT

03244686993; amna.zia@kemu.edu.pk

Samrood Akram, PhD*

CONTACT

03324806143; samrood.akram@riphah.edu.pk

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: July 21, 2026
• First Posted: July 24, 2026
• Study Start: June 20, 2026
• Primary Completion (Estimated): August 20, 2026
• Study Completion (Estimated): September 20, 2026
• Last Updated: July 24, 2026

Record last verified: 2026-07

Data Sharing

• IPD Sharing: Will not share

Locations

PA (1)