Sustained Natural Apophyseal Glides Research Articles

Effectiveness of Gong's mobilization in cervical spondylosis: a prospective comparative study

Background: Cervical spondylosis is a general term that refers to the degenerative changes that develop either spontaneously with age, or secondarily as the result of trauma or other pathological condition. The symptoms of cervical spondylosis include pain which might be radiating or localized in the neck, limitation of neck movements, postural abnormalities. The aim of this preliminary study was to investigate effectiveness of Gong’s Mobilization in the relief of pain, improvement in range of motion and functions in individuals with cervical spondylosis. Methods: Thirty subjects (19 male and 11 female) randomly allocated in two groups (Group A and B) using the coin method. Group A received Gong’s mobilization along with hydro collator packs and isometric exercises, group B received Sustained Natural Apophyseal Glides (SNAGs) along with hydro collator packs and isometric exercises. The treatment period lasted 4 weeks in total. Pain on visual analogue scale, Range Of Motion (ROM) by universal goniometer and functional disability on neck disability index was assessed on day one pre and post intervention at the end of two weeks and end of 4 th week. Results: The findings of this study suggest that both the interventions are effective in reducing pain, improving ROM and decreasing the level of disability but particularly the Gong’s mobilization is more effective (P <0.01) in correcting posture, reducing pain, improving ROM and decreasing the level of disability. Conclusions: Gong’s mobilization can be utilized in the treatment of cervical spondylosis.

Effects of cervical sustained natural apophyseal glide on forward head posture and respiratory function.

[Purpose] To determine the effects of cervical sustained natural apophyseal glide on forward head posture and respiratory function. [Subjects and Methods] Thirty male and female adults in their 20s with forward head posture were included in the study. The subjects were divided randomly into experimental and control groups (n=15 each). Subjects in the experimental group performed cervical sustained natural apophyseal glide three times/week for four weeks while subjects in the control group did not perform the intervention. The craniovertebral angle, forced vital capacity and forced expiratory volume in the first second, as well as the % predicted value of each measurement were assessed to determine the changes in respiration functions before and after the exercise. [Results] The craniovertebral angle four weeks after the experiment was increased in the experimental group, whereas the control group showed no significant difference compared to baseline. The forced vital capacity, forced expiratory volume in the first second, and the % predicted values thereof were significantly increased in the experimental group four weeks after the experiment, but not in the control group. [Conclusion] Cervical sustained natural apophyseal glide was determined to be effective in improving neck posture and respiratory functions for patients with forward head posture.

Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial

Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. This study investigated the effects of sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) on cervicogenic dizziness compared to a placebo at 12 months post-treatment. Eighty-six participants (mean age 62 years, standard deviation (SD) 12.7) with chronic cervicogenic dizziness were randomised to receive SNAGs with self-SNAGs (n = 29), PJMs with range-of-motion (ROM) exercises (n = 29), or a placebo (n = 28) for 2–6 sessions over 6 weeks. Outcome measures were dizziness intensity, dizziness frequency (rated between 0 [none] and 5 [>once/day]), the Dizziness Handicap Inventory (DHI), pain intensity, head repositioning accuracy (HRA), cervical spine ROM, balance, and global perceived effect (GPE). At 12 months both manual therapy groups had less dizziness frequency (mean difference SNAGs vs placebo −0.7, 95% confidence interval (CI) −1.3, −0.2, p = 0.01; PJMs vs placebo −0.7, −1.2, −0.1, p = 0.02), lower DHI scores (mean difference SNAGs vs placebo −8.9, 95% CI −16.3, −1.6, p = 0.02; PJMs vs placebo −13.6, −20.8, −6.4, p < 0.001) and higher GPE compared to placebo, whereas there were no between-group differences in dizziness intensity, pain intensity or HRA. There was greater ROM in all six directions for the SNAG group and in four directions for the PJM group compared to placebo, and small improvements in balance for the SNAG group compared to placebo. There were no adverse effects. These results provide evidence that both forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.

The efficacy of Sustained Natural Apophyseal Glides with and without Isometric Exercise Training in Non-specific Neck Pain

To determine the efficacy of Sustained Natural Apophyseal Glides (SNAGs) with and without Isometric Exercise Training Program (IETP) in Non-specific Neck Pain (NSNP) Methods: This randomized control trial of one year duration was conducted at out-patient department of Physiotherapy and Rehabilitation, Khyber Teaching Hospital (KTH) Peshawar, Pakistan from July 2012 to June 2013. The sample of 102 patients of NSNP were randomly selected through simple random sampling technique, and placed into two groups. The SNAGs manual physical therapy technique with IETP was applied on 51 patients in group A and SNAGs manual physical therapy techniques was applied alone on 51 patients in group B. The duration of intervention was 6 weeks, at 4 times per week. The Neck Disability Index (NDI) and Visual Analog Scale (VAS) for neck pain were assessment tools used for all patients before and after 6 weeks of physical therapy intervention. All the patients were assessed through NDI and VAS before intervention and at the completion of 6 weeks program. The data of all 102 was analyzed by SPSS-20 and statistical test was applied at 95% level of significance determine the efficacy of both the treatments interventions and compare with each other. The patients in group A, treated with SNAGs and followed by IETP for 6 weeks, demonstrated more improvement in pain and physical activity as assessed by VAS (p=0.013) and NDI (p=0.003), as compared to the patients treated with SNAGS alone, as pain and function assessed by VAS (p=0.047) and NDI (p=0.164). In group A the NDI score improved from 40 to 15 and VAS from 7 to 4, while in group B the NDI score improved from 42 to 30 and VAS from 7 to 4. Patients with non-specific neck pain treated with SNAGs manual physical therapy techniques and followed by IETP was more effective in reduction of pain and enhancement of function, as compared to those patients treated with SNAGs manual physical therapy techniques alone.

Effects of Cervical Spine Manual Therapy on Range of Motion, Head Repositioning, and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

ObjectiveTo evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness. DesignRandomized controlled trial with 12-week follow-up using blinded outcome assessment. SettingUniversity School of Health Sciences. ParticipantsParticipants (N=86; mean age ± SD, 62.0±12.7y; 50% women) with chronic cervicogenic dizziness. InterventionsParticipants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks. Main Outcome MeasuresCervical ROM, head repositioning accuracy, and balance. ResultsSNAG therapy resulted in improved (P≤.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, −7.5°; 95% confidence interval [CI], −13° to −2.0°) and right rotation (mean difference, −6.8°; 95% CI, −11.5° to −2.1°) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy. ConclusionsSNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.

The effect of sustained natural apophyseal glides on headache, duration and cervical function in women with cervicogenic headache.

The objective of this study is to investigate the effect of sustained natural apophyseal glides (SNAGs) on pain and headache duration in women with cervicogenic headache. The method of this study is a single blind and randomized controlled trial. Forty patients with headache were divided randomly into the SNAGs group (n= 20), and control group (n= 20). The expectation of this study was that the SNAGs group, with facilitatory glide, has full range of movement without pain. Sustained end range holds or overpressure can be applied to the physiological movement and subjects in the control group received just light contact to the occipital area for the same amount of time as the SNAGs group, which is three times per week for a period of four weeks. Visual Analogue Scale (VAS), Headache Duration and Neck Disability Index (NDI) were evaluated by patients before and after the intervention. NDI in the SNAGs group showed significantly greater improvement, compared to the control group, in which only the SNAGS placebo technique was applied. In addition, a significantly greater improvement on the visual analogue scale was also observed in the SNAGs group compared with the control group (P< 0.05). In conclusion, the SNAGs technique can help middle aged female patients suffering from cervicogenic headache for relief of cervical pain and headache. It can also be used in physiotherapy on headache.

Is one better than another?: A randomized clinical trial of manual therapy for patients with chronic neck pain

Our purpose was to compare the effectiveness of three manual therapy techniques: high velocity, low amplitude (HVLA), mobilization (Mob) and sustained natural apophyseal glide (SNAG) in patients with chronic neck pain (CNP). The randomized controlled trial included patients with mechanically reproducible CNP, who were randomized to the treatment group. Outcome measures were the Visual Analogue scale (VAS), Neck Disability Index (NDI), Global Rating of Change (GROC) and Cervical Range of Motion (CROM). Two-way repeated measures analysis of variance compared outcomes at baseline, at the end of treatment and 1, 2 and 3 months after treatment. A total of 51 subjects completed the trial. No significant differences were found between HVLA, Mob and SNAG at the end of treatment and during the follow-up in any of the analysed outcomes. There were no differences in satisfaction for all techniques. The results lead to the conclusion that there is no long-term difference between the application of HVLA, Mob and SNAG in pain, disability and cervical range of motion for patients with CNP.

ORIGINAL ARTICLE: Efficacy of C1-C2 Sustained Natural Apophyseal Glide (SNAG) Versus Posterior Anterior Vertebral Mobilization (PAVMs) in the Management of Cervicogenic Headache

Objectives: To determine the effect of a C1-C2 sustained natural apophyseal glide (SNAG) as compare to posterior anterior (PA) vertebral mobilization on cervicogenic headache.Study Design: Randomized Control Trial.Method: The study was conducted on 60 patients with CGH. In this study, patients were divided into two groups, group A and group B equally. Group A of 30 patients received SNAG and at the same time Group B of 30 patients were treated with PAVMs. A pre tested and structured questionnaire was used to collect data. Data was entered and analyzed by using SPSS 19.Outcome Measures: Pain and disability was measured on Visual Analog Scale (VAS) (0-10) and Neck Disability Index (NDI) before and after the treatment.Results: The study showed significant results for both the interventions in the treatment of CGH but SNAG mobilization has been more effective in reducing pain in CGH patients.Conclusions: On the basis of this study, it is proved that cervical SNAGS is more effective for the treatment of cervicegenic headaches as compared to PAVMs.

Is sustained natural apophyseal glides combined with conventional physiotherapy effective for patients with facet joint syndrome? - a case series

BackgroundChronic back pain has been the nemesis of the human race since the time they evolved and began walking on their two legs; leaving aside the 4 limb locomotion of their predecessors. Varied are the causes of low back ache and facet joint syndrome is one amongst them. Hence this study was undertaken to find out the effectiveness of SNAGS and conventional physiotherapy in patients with lumbar facet joint syndrome.PurposeTo describe the management and outcomes of 4 patients with lumbar facet joint syndrome treated with Sustained Natural apophyseal glides (SNAGs), Therapeutic Ultrasound and lumbar stabilization exercises.Study DesignA case series of consecutive patients with Lumbar facet syndromeCase DescriptionFour consecutive patients (mean age 52 years) who presented with lumbar facet syndrome were treated with two weeks protocol which included Sustained Natural apophyseal glides, Therapeutic Ultrasound (Cont. I-MHz, 2.0-W/cm², l0min) and lumbar stabilization exercises. Follow up was taken 1 week after the end of active intervention. All patients completed Visual analogue Scale (VAS), Modified Oswestery Disability Questionnaire (MODQ), Sorensen Test hold Timing and spinal Range of motion on initial assessment, immediately at the end of active intervention (2 weeks) and at the end of follow up.OutcomeAll four patients showed the mean percentage change in score of VAS 49.87%, MODQ 61.14%, Sorensen test scores 19.63%, Flexion range 9.21% and extend range 17.07% at the end of follow up.All four patients with Lumbar facet joint syndrome treated with sustained natural apophyseal glides (SNAGS), Therapeutic Ultrasound and lumbar stabilisation exercises exhibited reduced pain, reduced disability, improved endurance of back muscles and range of motion at the time follow-up.

Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial

There is short-term evidence for treatment of cervicogenic dizziness with Mulligan sustained natural apophyseal glides (SNAGs) but no evidence for treatment with Maitland mobilizations. The purpose of this study was to compare the effectiveness of SNAGs and Maitland mobilizations for cervicogenic dizziness. A double-blind, parallel-arm randomized controlled trial was conducted. The study was conducted at a university in Newcastle, Australia. Eighty-six people with cervicogenic dizziness were the study participants. Included participants were randomly allocated to receive 1 of 3 interventions: Mulligan SNAGs (including self-administered SNAGs), Maitland mobilizations plus range-of-motion exercises, or placebo. The primary outcome measure was intensity of dizziness. Other outcome measures were: frequency of dizziness, the Dizziness Handicap Inventory (DHI), intensity of pain, and global perceived effect (GPE). Both manual therapy groups had reduced dizziness intensity and frequency posttreatment and at 12 weeks compared with baseline. There was no change in the placebo group. Both manual therapy groups had less dizziness intensity posttreatment (SNAGs: mean difference=-20.7, 95% confidence interval [95% CI]=-33.6, -7.7; mobilizations: mean difference=-15.2, 95% CI=-27.9, -2.4) and at 12 weeks (SNAGs: mean difference=-18.4, 95% CI=-31.3, -5.4; mobilizations: mean difference=-14.4, 95% CI=-27.4, -1.5) compared with the placebo group. Compared with the placebo group, both the SNAG and Maitland mobilization groups had less frequency of dizziness at 12 weeks. There were no differences between the 2 manual therapy interventions for these dizziness measures. For DHI and pain, all 3 groups improved posttreatment and at 12 weeks. Both manual therapy groups reported a higher GPE compared with the placebo group. There were no treatment-related adverse effects lasting longer than 24 hours. The therapist performing the interventions was not blind to group allocation. Both SNAGs and Maitland mobilizations provide comparable immediate and sustained (12 weeks) reductions in intensity and frequency of chronic cervicogenic dizziness.

IMMEDIATE EFFECTS OF SPINAL MANIPULATION COMPARED TO MULLIGAN SUSTAINED NATURAL APOPHYSEAL GLIDE MOBILIZATION TECHNIQUE IN CERVICAL PAIN

OBJECTIVE To analyze immediate treatment effects of spinal manipulation compared tomulligan sustained natural apophyseal glide mobilization technique in cervical pain. STUDY DESIGN Quasi Experimental Study STUDY SETTINGS &amp; PARTICIPANTS A sample of 150 participants were included in this study and equally divided in two groups. Subjects were randomly assigned to receive either SNAG mobilization (n = 75), or a manipulation (n =75). The SNAG technique was applied at the cervical spinal levels with active flexion in sitting. Manipulation was done by an experienced manual therapist. INTERVENTIONS VAS and Neck disability index (NDI). RESULTS The use of manual therapies decreased the pain intensity in the mulligan and the manipulation group; this difference was statistically significant (p-value&lt;0.05). CONCLUSION It was observed that both the techniques have shown positive results but in comparison, mulligan technique is more effective than manipulation.

Investigation of the Effects of a Centrally Applied Lumbar Sustained Natural Apophyseal Glide Mobilization on Lower Limb Sympathetic Nervous System Activity in Asymptomatic Subjects

ObjectiveThe purpose of this study was to investigate the effects of a manual mobilization technique on indirect measures of sympathetic nervous system activity. MethodsForty-five healthy volunteers participated in this randomized, single-blinded, parallel-group 3-arm design (experimental, sham [placebo], and control group), comprising 15 subjects each. For the experimental group, lumbar mobilization involving an active movement, the Mulligan sustained natural apophyseal glide (SNAG), was applied on L4 spinous process by an experienced manual therapist. Sustained natural apophyseal glides were performed in sitting with active flexion (6 times × 3 sets). The sham technique simulated the SNAG without applying any force. In the control group, participants were placed in a static sitting position throughout the experiment. Measures of skin conductance in the lower limbs (L4 dermatome) were recorded to reflect sympathetic nervous system activity in the preintervention, periintervention, and postintervention periods. Differences in percentage change of skin conductance were analyzed with analysis of variance and post hoc tests. ResultsLumbar SNAG produced sympathoexcitation compared with the control group in the intervention period (P = .04). No significant difference was found between SNAG and sham groups, and no statistically significant difference was found between groups in the final rest period. ConclusionThe results of this study showed that, in asymptomatic participants, both lumbar SNAG and sham techniques performed on L4/5 intervertebral joint with active flexion induced a sympathoexcitatory response in lower limbs compared with the control group.

The Effects of Gong's Mobilization on Cervical Lordosis, Forward Head Posture, and Cervical ROM in Abnormal Posture of the Cervical Spine of College Students

[Purpose] In this study, the effectiveness of Gong's Mobilization and sustained natural apophyseal glides (SNAGS) were compared in college students who had problems with cervical posture and range of motion (ROM) in order to examine the effects of Gong's Mobilization on cervical lordosis, forward head posture (FHP), and cervical ROM. [Subjects] Forty college students in their twenties with problems of cervical posture and ROM were divided into a Gong's Mobilization group (n=20) and a SNAGS group (n=20). [Methods] Gong's Mobilization and SNAGS were administered three times a week for four weeks to each respective group and then changes in cervical lordosis, FHP, and cervical ROM were evaluated. [Results] Gong's Mobilization was effective at increasing cervical lordosis, cervical extension ROM (CER), and ranges of flexion and extension motion (RFEM), as well as decreasing FHP. In contrast, SNAGS was effective at increasing CER and decreasing FHP. [Conclusion] Although both Gong's Mobilization and SNAGS affected cervical posture and ROM, Gong's Mobilization was more effective at increasing cervical lordosis, CER, and RFEM.

The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system

BackgroundMulligan's mobilisation techniques are thought to increase the range of movement (ROM) in patients with low back pain. The primary aim of this study was to investigate the application of the Mulligan's Sustained Natural Apophyseal Glide (SNAG) technique on lumbar flexion ROM. The secondary aim was to measure the intra- and inter-day reliability of lumbar ROM employing the same procedure.Methods49 asymptomatic volunteers participated in this double-blinded study. Subjects were randomly assigned to receive either SNAG mobilisation (n = 25), or a sham mobilisation (n = 24). The SNAG technique was applied at the L3and L4 spinal levels with active flexion in sitting by an experienced manual therapist. Three sets of 10 repetitions at each of the two spinal levels were performed. The sham mobilisation was similar to the SNAG but did not apply the appropriate direction or force. Lumbar ROM was measured by a three dimensional electronic goniometer (Zebris CMS20), before and after each technique. For the reliability, five measurements in two different days (one week apart) were performed in 20 healthy subjects.ResultsWhen both interventions were compared, independent t tests yielded no statistically significant results in ROM between groups (p = 0.673). Furthermore no significant within group differences were observed: SNAG (p = 0.842), sham (p = 0.169). Intra- and inter-day reliability of flexion measurements was high (ICC1,1 > 0.82, SEM < 4.0°, SDD<16.3%) indicating acceptable clinical applicability.ConclusionWhile the Zebris proved to be a reliable device for measuring lumbar flexion ROM, SNAG mobilisation did not demonstrate significant differences in flexion ROM when compared to sham mobilisation.Trial registrationCurrent Controlled Trials NCT00678093.

Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness

Cervicogenic dizziness is dizziness described as imbalance occurring together with cervical pain or headache. This study aimed to determine the efficacy of sustained natural apophyseal glides (SNAGs) in the treatment of this condition. A double-blind randomised controlled clinical trial was undertaken. Thirty-four participants with cervicogenic dizziness were randomised to receive four to six treatments of SNAGs ( n=17) or a placebo of detuned laser ( n=17). Participants were assessed by a blinded assistant before treatment, after the final treatment and at 6- and 12-week follow-ups. The primary outcome measures were severity of dizziness, disability, frequency of dizziness, severity of cervical pain, and global perceived effect; balance and cervical range of motion were secondary measures. At post-treatment, 6- and 12-week follow-ups compared to pre-treatment, the SNAG group had less ( P<0.05) dizziness, lower ( P<0.05) scores on the Dizziness Handicap Inventory (DHI), decreased ( P<0.05) frequency of dizziness, and less ( P<0.05) cervical pain. The placebo group had significant ( P<0.05) changes only at the 12-week follow-up in three outcome measures: severity of dizziness, DHI, and severity of cervical pain. Compared to the placebo group at post-treatment and 6-week follow-up, the SNAG group had less ( P<0.05) dizziness, lower ( P⩽0.05) scores on DHI, and less ( P<0.05) cervical pain. Balance with the neck in extension improved ( P⩽0.05) and extension range of motion increased ( P<0.05) in the SNAG group. No improvements in balance or range of motion were observed in the placebo group. The SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction.

Acute neck pain: Cervical spine range of motion and position sense prior to and after joint mobilization

Despite the relatively high prevalence of cervical spine pain, the efficacy of treatment procedures is limited. In the current study, range of motion and proprioception was assessed prior to and after specific cervical spine mobilisation techniques. A 44-year-old male office worker presented with a history of cervical pain of 1 day duration. He had woken with pain, stiffness and a loss of range of motion. Examination findings indicated pain to be at C5–6 on the left side. Measurement of maximal three-dimensional cervical motion was undertaken using a Zebris system. A position matching task tested the individual's ability to actively reposition their head and neck. The treatment undertaken involved grade III down-slope mobilisations on the left side at C5–6 and C6–7 in supine lying. This technique was then progressed by placing the subject in an upright sitting position, and sustained natural apophyseal glides were performed at C6. Immediately following the treatment, the patient reported a considerable decrease in pain, less difficulty in movement and reduced stiffness. Motion analyses showed the most marked percentage improvements in range of motion after treatment were in flexion (55%), extension (35%), left rotation (56%), and left lateral flexion (22%). Ipsilateral lateral flexion with axial rotation was also notably improved following treatment. No change in proprioceptive ability was found following the treatment. The findings showed that the application of standardised specific mobilisation techniques led to substantial improvements in the range of motion and the restitution of normal coupled motion.

A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population

Spinal manipulative therapy techniques are commonly employed by physiotherapists in the clinical setting for the management of neuromusculoskeletal pain and dysfunction, although their underlying mechanism is not fully understood. Mulligan's sustained natural apophyseal glides (SNAGs) constitute one of these techniques. This preliminary investigation was undertaken to investigate the relationship between the application of cervical SNAGs to the C5/6 intervertebral joint (with cervical right rotation) and indirect measures of sympathetic nervous system (SNS) activity. Previous investigations have suggested that cervical manipulative therapy techniques, separate to cervical SNAGs, result in a sympatheoexcitatory effect and that this may be instrumental in producing an analgesic response. Sixteen asymptomatic subjects participated in a laboratory-based experiment. A single blind, randomized, within subject, repeated measures study design which included control, placebo and treatment comparisons was used. Measures of skin conductance (SC) and skin temperature (ST) in the right and left upper limbs were used as indicators of SNS activity. The cervical SNAG technique produced a sympathoexcitatory response demonstrated by a significant increase in SC during application of the treatment intervention ( P < 0.0005 ) and for a 2-min period after the intervention ( P = 0.001 ) compared with control. There was also a significant increase in SC for the placebo condition, both during intervention ( P = 0.015 ) and after intervention ( P = 0.011 ) compared with control. There was a statistically significant difference in SC between placebo and treatment conditions for the 2-min period after the intervention had been applied ( P = 0.01 ). A trend did emerge for ST change, illustrating a decrease in ST for the treatment and placebo conditions compared with control, however this did not reach statistically significant levels. There were no apparent left/right upper limb differences for SC and ST for each condition. The results of this study suggest that cervical SNAG techniques, performed on naïve asymptomatic subjects, have a sympathoexcitatory effect as measured by changes in SC and ST. The importance of this sympathoexcitatory effect in relation to potential mechanisms for manipulation induced analgesia are discussed, and further areas of research proposed.

Case report. Clinical instability of the upper cervical spine

A female patient presented with symptoms of unilateral right sided head, face, ear, neck, shoulder and arm pain, as well as subjective sensation of swelling in the right side of the face and anterior triangle of the neck. Whilst testing for upper cervical spine stability using the Sharp Purser test it was found that the majority of the patient's symptoms immediately disappeared. The patient was treated with an upper cervical spine Headache Sustained Natural Apophyseal Glide (SNAG) technique (Mulligan 1995) and upper limb neural mobilizations. This, in combination with a home programme of chin retractions and an auto neural mobilization, completely relieved the patient of all symptoms. A discussion on the causes of the pain, clinical instabilities of the cervical spine and clinical reasoning is presented in this paper.

McKenzie treatment versus mulligan sustained natural apophyseal glides for chronic mechanical low back pain.

Background and Objective:Chronic mechanical low back pain is common among different age groups and genders. Different manual therapy techniques combined with exercise therapy and electrotherapy modalities play an important role in its management. Our objective was to compare the effects of McKenzie extension exercisesprogram (EEP) versus Mulligan Sustained Natural Apophyseal Glides (SNAGs) for chronic mechanical low back pain (CMLBP).Methods:This randomized control trial (RCT) was conducted at Riphah Physical Rehabilitation Centre, Pakistan Railways General Hospital Rawalpindi, from 1st July to 31st December 2014.The inclusion criteria was patients of both gender and age range 30-70 years with minimum 4 weeks history of CMLBP. A total of 37 patients were screened out as per inclusion criteria and randomly placed into two groups. Twenty patients in group A were treated with Mulligan SNAGs and 17 patients in group B with McKenzie EEP for four weeks at two session per week and single session per day. Visual Analogue Scale (VAS), Oswestry Disability Scale (ODI) and lumber Range of Motion (ROM) were used as an assessment tools and were measured at baseline and at the completion 4 weeks intervention. The data was analyzed with SPSS to draw the statistical and clinical significance of both interventions.Results:At the completion of 4 weeks intervention the pre and post statistical analysis revealed that clinically the McKenzie EEP improved pain (mean 9.12 to 1.46) and disability (73.82 to 6.24) slightly more than Mulligan SNAGs (pain: from 8.85 to 2.55, disability 73.75 to 7.05), while the Mulligan SNAGs improved lumbar ROM more effectively than McKenzie EEP in all directions including flexion, extension, side bending and rotation. Statistically there was no significant difference between the effects of two interventions in managing pain and disability, and improving Lumber ROM.Conclusion:McKenzie EEP is clinically slightly more effective in the management of pain and disability as compared with Mulligan SNAGs, while Mulligan SNAGs are more effective in the improvement of lumbar ROM as compared with Mechanize EEP in the management of CMLBP.