Chronic Neck Pain With Mobility DeficitsSNAG MulliganNCT07673575
EFFECT OF MULLIGAN CERVICAL SUSTAINED NATURAL APOPHYSEAL GLIDE ON POSTURAL STABILITY IN PATIENTS WITH CHRONIC NECK PAIN
A study testing 1- The Biodex Balance System (BBS), 2-The Numerical Pain Rating Scale (NPRS) and 3- The Neck Disability Index (Arabic version) for functional disability in people with Chronic Neck Pain With Mobility Deficits and Chronic Neck Pain With Mobility Deficits (> 3 Months), run by Menna Allah Ahmed Marei Elnaggar at 1 site in Egypt.
Trial 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. Read more about this study
- Who is it for?
- Ages 20 to 45 years
- Conditions the study is for
- Chronic Neck Pain With Mobility Deficits, Chronic Neck Pain With Mobility Deficits (> 3 Months)
- What is being tested?
- 1- The Biodex Balance System (BBS), 2-The Numerical Pain Rating Scale (NPRS) and 3- The Neck Disability Index (Arabic version) for functional disability
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 44 participants
- Where
- 1 siteEgypt
- Study dates
- 20 Jul 2026to 1 Nov 2026
- Phase
- Interventional
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 20 to 45 years
- All sexes
- No healthy volunteers
- Adult
Who may be able to join
- 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
Show all 9Show fewer
- 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)
Who cannot join
- 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
Show all 10Show fewer
- 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
Trial locations and contacts
1 site in 1 country. Contact the study team or a site near you to ask about taking part.
Egypt1 site, 1 recruiting
- Recruiting
Faculty of Physical Therapy Delta University
Gamasa
Dr. Akram fathy abdulhamid, Assistant Professor
Mohamed Behiry, Assistant Professor
About this study
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?
Read the detailed description
Chronic neck pain associated with mobility deficits is a prevalent musculoskeletal condition that extends beyond localized discomfort to involve significant sensorimotor disturbances. The cervical spine plays a pivotal role in postural control due to its high density of mechanoreceptors and its intricate integration with the vestibular and visual systems. Patients with CNP frequently exhibit impaired proprioception and increased postural sway. This leads to a higher risk of falls and functional limitations. If SNAG is proven effective, the results will help clinicians justify the inclusion of Mulligan SNAGs in rehabilitation protocols not only to restore mobility and reduce pain but also to address balance impairments and kinesiophobia in patients with chronic neck pain. From a patient perspective, these improvements may enhance functional performance, confidence during movement, and quality of life. From a socioeconomic perspective, improving functional abilities and reducing disability may decrease healthcare costs, work absenteeism, and the long-term burden associated with chronic neck pain. Scientifically, this study may contribute to the growing body of evidence regarding the sensorimotor and balance-related effects of Mulligan SNAG techniques and provide further insight into the relationship between cervical mobility, postural stability, and kinesiophobia in patients with chronic neck pain.
- Conditions
- Chronic Neck Pain With Mobility Deficits, Chronic Neck Pain With Mobility Deficits (> 3 Months)
- Being tested
- 1- The Biodex Balance System (BBS), 2-The Numerical Pain Rating Scale (NPRS), 3- The Neck Disability Index (Arabic version) for functional disability, 4- Digital Inclinometer for Cervical Range of Motion, 5- Arabic Tampa Scale of Kinesiophobia (TSK-11)
- Keywords
- SNAG, chronic neck pain with mobility deficits, MULLIGAN
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
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
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),
3- The Neck Disability Index (Arabic version) for functional disabilityDiagnostic 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
4- Digital Inclinometer for Cervical Range of MotionDiagnostic 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.
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.
6- Overhead LASER pointer for Cervical proprioceptionDiagnostic 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)
Mulligan Cervical SNAG Technique ProtocolOther
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.
Conventional therapy groupOther
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
| Study group | Role | What they receive |
|---|---|---|
| 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 Receives: 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. Receives: 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 |
What is being measured
The primary outcome is the main question the study is designed to answer.
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
Measured: before the intervention, after 8 weeks, and at a 4-week follow- up.
Secondary outcomes (5)
Numerical Pain Rating Scale (NPRS)
The NPRS is an 11-point self-reported scale (0-10) for pain intensity.
- Ask the patient to rate their pain intensity on a scale from 0 = no pain to 10 = worst possible pain.
- It can assess current pain, pain in the last 24 hours .
- 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.
Measured: before the intervention, after 8 weeks, and at a 4-week follow- up.
Neck Disability Index (Arabic Version)
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.
Measured: before the intervention, after 8 weeks, and at a 4-week follow- up.
Digital Inclinometer for Cervical ROM
Multiple studies describe standardized inclinometer protocols
Devices show good validity compared with 3D motion capture
- Patient is usually seated upright with feet on the floor.
- Place the inclinometer on the vertex of the head aligned with T1 or other fixed reference, depending on the device.
- Measure flexion, extension, lateral flexion, and rotation.
- Perform 3 trials per direction and use the mean.
Measured: before the intervention, after 8 weeks, and at a 4-week follow- up.
Tampa Scale of Kinesiophobia (TSK-11, Arabic Version)
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
- Provide the questionnaire.
- Ensure the patient answers all 11 items.
- Sum all item scores (minimum 11, maximum 55).
- Higher scores = higher kinesiophobia
Measured: before the intervention, after 8 weeks, and at a 4-week follow- up.
Overhead Laser Pointer for Cervical Proprioception (Joint Position Error Test)
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
- Patient sits upright, eyes closed (no visual feedback allowed)
- Patient moves head:
- Rotation right
- Rotation left
- Flexion
- Extension
- Patient returns to what they believe is the original neutral position.
- Record the deviation in degrees from the center of the target.
- Repeat 3-5 trials per direction; average the error
Measured: before the intervention, after 8 weeks, and at a 4-week follow- up.
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted29 Jun 2026
- Study start20 Jul 2026
- Primary completion20 Oct 2026 (estimated)
- Study completion1 Nov 2026 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Chronic Neck Pain With Mobility DeficitsStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- 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).
- Masking
- None (open label)
- Enrolment
- 44 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Menna Allah Ahmed Marei Elnaggar
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor-investigator, Menna Allah Ahmed Marei Elnaggar, Cairo University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07673575
- Sponsor's protocol ID
- Mulligan on chronic neck pain
- Acronym
- SNAG Mulligan
- Status last verified
- Oct 2026
- First submitted
- 23 Jun 2026
- Last updated
- 21 Oct 2026
- Results posted
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No