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ISSN: How to cite this article: Zemadanis K. The short and mid-term effects of Mulligan concept in patients with chronic mechanical neck pain. J Nov Physiother Rehabil. DOI: This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Mechanical chronic neck pain is very common musculoskeletal dysfunction among people, manifesting one or more pain-induced movements and disability impairments. Clinical guidelines suggest passive cervical mobilization and thoracic manipulation as manual therapy interventions.
Mulligan concept has positive effect in patients with lumbar and thoracic spine mechanical chronic pain. Study objective was to investigate possible clinical effects of Mulligan techniques in patients with cervical pain according to pain and disability status. Methods: forty participants diagnosed with mechanical chronic cervical pain, randomly assigned into experimental and control group.
Results: Baseline scores of pain and disability resulted in no differences between groups. A significant Group and Time factors interaction founded and simple main effects analysis showed that Mulligan concept-group had significant improvement in post-intervention NPRT and NDI scores p.
Significant differences were found between groups according to second and third measurement phase p Conclusion: Our findings suggest that Mulligan concept techniques improve symptoms of pain and disability in chronic mechanical neck pain patients in short and mid-term effect level.
Taken into consideration the safety and simplicity of application, future studies are encourage to examine the underline mechanism of action. It is well known that neck pain is one of the most common musculoskeletal disorders among people, especially in those professionals who are spending most of the time in non-active positions like sitting [1,2]. Epidemiology of neck pain lies in a rate of about two thirds of people at some stage, especially in middle age [3,4].
Global Burden of Disease study, ranked neck pain 4th highest in terms of disability as measured by years lived with disability YLD , and 21st in terms of overall burden . Mechanical nonspecific cervical pain is of cervical vertebrae movement originated and differentiated from other non-structural and non-anatomical causes . Implicating joint structures related are cervical facets, capsule, cartilage and ligaments, having no specific, identifiable etiology .
Predisposing factors of chronicity includes sporting or occupational activities, poor posture and psychological stress [3,]. Natural history of symptoms may be stable or recurrent, characterized by periods of improvement followed by periods of worsening .
Female sex and prior history of neck pain are the strongest and most consistent risk factors for new-onset neck pain in office workers and the general population . Manual therapy in a form of passive manipulation and mobilization is a main conservative treatment approach and has been incorporated in clinical guidelines for chronic neck pain  especially in multimodal protocols that includes exercise .
Examining the effect of manual therapy in mechanical chronic neck pain, clinical evidence is of moderate to high quality .
However, methodologic heterogeneity of parameters regarding small sample sizes, different comparison groups, and lack of long-term measurements, place the need for larger and high-quality randomized controlled trials . Mulligan therapy in the field of manual therapy consists of functional painless techniques that are included in people with spinal pain patients showing immediate symptoms alleviation [18,19]. According to this, it is important to investigate the impact of this concept on a subgroup of patients with mechanical neck pain, based on RCT.
Taken the current knowledge into consideration, research hypothesis stated that we expected to find a clinical and statistical difference between groups GROUP-Factor and within repeated measures TIME-factor of pain and disability score, after the implementation of intervention. The objective of the study was to examine the short and mid-term effect of Mulligan concept NAG, SNAG and self-SNAG joint mobilization techniques in patients with chronic mechanical cervical pain according to pain and functional status.
The study design was a parallel group, double-blind controlled experimental trial. The sample consisted of 40 patients aging years old, with chronic mechanical neck pain who met the study inclusion criteria. Patients recruited from January to May , from a private physiotherapeutic clinic in collaboration with the Experimental Physiology Laboratory of Medical School Faculty at National and Kapodistrian University of Athens.
After the initial examination by an orthopedic physician, all patients with clinical features of mechanical neck pain, referred for physiotherapy in a private clinic. An experienced specialist in manual therapy examination and treatment, performed a complete physical evaluation of muscle strength, joint mobility and neurodynamic examination of cervical and cervicothoracic region.
Given the fact of absence of red flag signs, no imaging was indicated according to relative guidelines . Provocation and alleviation test, as well as Spurling test and upper limb tension tests were performed as special tests for neurological signs and symptoms . All participants randomly allocated in the study and control group, each one of 20 patients via random numbers index cards in sealed opaque envelopes. An examiner experienced in NPRS and NDI measurements performed all measures of pain and functionality status respectively at baseline, after the final session 9th and four weeks after the completion of manual therapy protocol.
Prior to any baseline examination measures, all patients read and signed an informed consent form and filled out a complete self-report demographic questionnaire.
NAGs consists of passive mid to end range oscillatory mobilizations applied anterio-cranially in plane of joint selected. Direction of force is parallel to highly irritable-grossly restricted cervical facet joints. Application dosage was set to 2 — 3 Hertz in three sets of three repetitions. SNAGs are an essential mobilization technique applied in cervical spine and consists of the combination of therapist appropriate sustained accessory zygapophyseal glide and the simultaneously patient active symptomatic movement rotation, flexion, extension, side bending , but in a full range pain free movement.
Overpressure in a pain free manner applied at the end range of motion by the patient. Application dosage was set to six repetitions of three sets, accounted for every painful direction of cervical spine Mulligan.
Overpressure implementation at the end of available range of movement completed the technique. Application dosage was set to three repetitions of three sets and two trials performed to familiarize participants prior to self-treatment. All participants instructed to keep their usual everyday activity, avoiding movements that would possibly exacerbate their main symptoms.
For this reason, techniques were preplanned, but the choice of therapeutic direction was pragmatic and individually accordance. Our approach was symptomatic level treated and not randomly chosen. Specific techniques are more effective than general techniques in cervical spine .
During the procedure, patients were able to control the movement as actively moved in a pain free range of motion. It is a one-dimensional point scale, where patients asked to point out the intensity of current levels of pain over the past 24 hours ranging from 0 no pain to 10 worst pain , . As clinicians, we use manual contact techniques like joint-play and end-feel, in evaluation of manual therapy effect, but these methods still lacks of evidence based support . External validity is negatively affected from many possible confounding factors in highly controlled research settings investigating motion palpation and manual contact .
Lakhani et al. On this base, NDI and NPRS are valid and reliable evidence based subjective self-report tools, measuring pain and functional level in neck patents populations . Groups were equal in size, which maximizes the statistical power. The type of variables determined the analysis of the data.
Normal distribution of pain and functionality for each factor examined with Shapiro-Wilk test of normality, which is more appropriate for small sample sizes Sixty-four 64 participants with mechanical neck pain screened for possible eligibility in the study. Of the total number, 40 patients with a mean age of 37 years old and a mean duration of symptoms of 4 months, met the inclusion criteria, randomized into experimental, and control group.
Demographics including gender, age, height, weight, drug medication, symptom duration are depicted in table 1. There were no significant differences in any of the baseline measurement parameters between the experimental and control group. On the contrary, test sphericity founded significant p 0.
Results showed a significant short and mid-term statistical decrease of pain and function improvement of cervical spine, confirming the initial research hypothesis. The experimental group resulted in significant clinical improvement of post measures comparing baseline, but also in a follow-up measure comparing to post treatment.
This was not the case for control group followed a SHAM Mulligan intervention as no any significant difference was found in post and follow up treatment comparing baseline, but also between groups differences. Studies have shown that manual therapy is more effective in multimodal therapeutic protocols [9,]. Our objective was to identify the independent and unilateral Mulligan clinical effect as a monotherapy, without any simultaneously conservative method.
Mulligan techniques have distinguished as a functional approach producing an immediate pain alleviation and Range of Motion ROM improvements in chronic musculoskeletal conditions mainly in peripheral joints via MWM , but also in lumbar and thoracic spine [19,47]. In cases of successful implementation, patients are encourage to continue the therapeutic protocol adding exercise, reflecting the everyday clinical approach.
It has been shown that therapeutic effect of manual therapy is in accordance with dosage and duration of therapy . Therefore, in contrast of other studies , we conducted a series of sessions avoiding of single intervention protocol, to increase the possible therapeutic impact and reinforce generalizability of clinical findings. A number of nine session or more have been investigated in other studies with positive results [40,51].
So far, no adverse effects have been reported in relative studies, concerning Mulligan implementation in the cervical spine and the same was for the current one. Puentendura et al. On the contrary, SNAGs technique is a safe application, where patient is able to control the procedure .
SNAGs are most successful when symptoms provoked by a movement and are not multilevel, where NAGs indicated in more irritating conditions [18,55]. Hall, found significant short and long-term improvements in rotation ROM and pain following upper cervical self-SNAG mobilization in headache patients .
Similar results recorded in a study examining self-SNAG with exercise over SNAG with the same exercise protocol, concluding that are equally effective in chronic neck pain . However, study design did not compare SNAG alone over a control group as a monotherapy, but exercise implementation was a part of all treatment protocol group. We decided to implicate SHAM SNAG as an alternative control therapy, reducing the effect of confounding factors arising from conservative modalities and placebo effect applications.
SHAM mobilization was a part of research protocols accounted for the need of ethical prepositions in clinical trials [22,56,57]. Research results regarding Mulligan therapy and mechanical neck patients are in progress in recent years. Ali et al. Lopez et al.
In our study, control group incorporated in study design to limit confounding factors arising from natural history of pain. Put et al. However, both groups were followed an additional parallel protocol of electrotherapy without control group included. Ahmad et al. Limitations of their study settings were the lack of control group, the absence of detailed report of Mulligan techniques that implemented in participants and also the conventional diathermy and exercise program followed by both experimental group, which could blind the individual effect of mobilization.
Another study compared Maitland with exercise, SNAG with exercise and exercise alone in a two weeks protocol with five sessions per week, resulting in no difference in short-term pain, disability and ROM of patients . On the other hand, Abdelgalil et al. El Sodany et al. Combined therapy groups resulted in better outcome post and follow-up treatment, but no difference was found between study groups. This is in contrast with standard preplanned applications, which can be reproducible, but lack of individual clinical approach, reducing internal validity and increased external validity.
Biomechanical interpretation of Mulligan concept effect still lacks evidence-based support and remaining an intriguing subject. Positional fault theory is unconfirmed .
Cervical SNAGs: A Biomechanical Analysis
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: A sustained natural apophyseal glide SNAG is a mobilization technique commonly used in the treatment of painful movement restrictions of the cervical spine.
Cervical SNAGs: a biomechanical analysis
Cervical SNAGs: a biomechanical analysis.
A sustained natural apophyseal glide SNAG is a mobilization technique commonly used in the treatment ofpainful movement restrictions ofthe cervical spine. In the manual therapy literature, the biological basis and empirical efficacy ofcervical SNAGs have received scant attention. In particular, an examination oftheir potential biological basis in order to stimulate informed discussion seems overdue. This paper discusses the likely biomechanical effects ofboth the accessory and physiological movement components ofa unilateral cervical SNAG applied ipsilateral to the side ofpain when treating painfully restricted cervical rotation. Although a cervical SNAG may clinically be able to resolve painfully restricted cervical spine movement, it is difficult to explain biomechanically why a technique which first distracts opens and then compresses closes the zygapophyseal joint ipsilateral to the side ofpain, and perhaps slightly distracts the uncovertebral cleft, would be superior to a technique which distracts the articular surfaces with both accessory and physiological movement components. Therefore, the reported clinical efficacy of cervical SNAGs cannot be explained purely on the basis ofthe resultant biomechanical effects in the cervical spine. All rights reserved.