Research Article

The short and mid-term effects of Mulligan concept in patients with chronic mechanical neck pain

Konstantinos Zemadanis*

Published: 16 April, 2018 | Volume 2 - Issue 1 | Pages: 022-035

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. NAG, SNAG and self-SNAG joint mobilization in a nine-sessions protocol implemented to the study group, while SHAM-Mulligan techniques applied to control group. Self-reported questionnaires Numeric Pain Rating scale (NPRT) and Neck Disability Index (NDI) were used for the measurement of pain and disability levels respectively. Possible Interactions among Factors (TIME X GROUP) and simple effects in three-time measurements of pre, post and one-month follow-up concerning NDI and NPRS variables, were detected with Mixed-ANOVA test.

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<.001), compared to baseline scores. Follow-up also differed compared to post-treatment score (p<.001). SHAM-Mulligan control group had no significant differences in dependent variables at any level of TIME factor (p>.001). Significant differences were found between groups according to second and third measurement phase (p<.001).

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.

Summary: Mobilization techniques of SNAGs, NAGS and self-SNAGs reduces pain and improve function in patients with mechanical neck pain. Taken into consideration the safety and simplicity of application, future studies are encourage to examine the underline mechanism of action.

Read Full Article HTML DOI: 10.29328/journal.jnpr.1001018 Cite this Article Read Full Article PDF


Mechanical neck pain; Chronic; Manipulation; Mobilization; Mulligan concept; SNAG; NAG; Self-SNAG



  1. Blanpied P, Gross A, Elliott J, Devaney L. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017; 47: 1-8.
  2. Genebra C, Maciel N, Bento T. Prevalence and factors associated with neck pain: a population-based study. Braz J Phys Ther. 2017; 21: 274-280. Ref.: https://goo.gl/Q48z59
  3. Binder A. Neck Pain. Clinical Evidence. 2008; 8: 108-113. Ref.: https://goo.gl/TrFRzs
  4. Carroll L, Cassidy J, Peloso P. Methods for the best evidence synthesis on neck pain and its associated disorders: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008; 33: 33-38. Ref.: https://goo.gl/hSb2cf
  5. Hoy D, March L, Woolf A, Blyth F, Brooks P, et al. The global burden of neck pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014; 73: 1309-1315. Ref.: https://goo.gl/vrpppo
  6. Cross KM, Kuenze C, Grindstaff TL, Hertel J. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in pa­tients with mechanical neck pain: a systematic review. J Orthop Sports Phys. 2011; 41: 633-642. Ref.: https://goo.gl/ErWkcG
  7. Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med Rehabil Clin N Am. 2011; 22: 367-382. Ref.: https://goo.gl/jJBxyD
  8. Haldeman S, Carroll L, Cassidy JD. Findings from the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Dis­orders. J Occup Environ Med. 2010; 52: 424-427. Ref.: https://goo.gl/nKfxHV
  9. Hurwitz E, Carragee E, van der Velde G, Carroll L. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2009; 33: 123-152. Ref.: https://goo.gl/a1cx64
  10. Clair D, Edmondston S, Allison G. Physical therapy treatment dose for non-traumatic neck pain: a comparison between two patient groups. J Orthop Sports Phys Ther. 2006; 36: 867-875. Ref.: https://goo.gl/Qak6Hv
  11. Sarig-Baha H. Evidence for exercise therapy in mechanical neck disorders. Man Ther. 2003; 8: 10-20. Ref.: https://goo.gl/mbF5Wy
  12. Paksaichol A, Janwantanakul P, Purepong N, Pensri P, van der Beek AJ. Office workers’ risk factors for the development of non-specific neck pain: a systematic review of prospective cohort studies. Occup Environ Med. 2012; 69: 610-618. Ref.: https://goo.gl/LKfZgM
  13. Guzman J, Hurwitz EL, Carroll LJ, et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. Spine 2008; 33: S14-23. Ref.: https://goo.gl/3QVQoz
  14. Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007; 87: 513-524. Ref.: https://goo.gl/3QVQoz
  15. Kay T, Gross A, Goldsmith C. Exercises for mechanical neck disorders. 2012. Cochrane Database Syst Rev. 2005; 20: CD004250. Ref.: https://goo.gl/uq6H5H
  16. Vernon H, Humphreys K, Hagino C. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. J Manipulative and Physiological Therapeutics. 2007; 30: 215-227. Ref.: https://goo.gl/2rwRDH
  17. Franke H, Franke J, Fryer G. Osteopathic manipulative treatment for chronic nonspecific neck pain: A systematic review and meta-analysis. International Journal of Osteopathic Medicine. 2015; 18: 255-267. Ref.: https://goo.gl/e15acB
  18. Mulligan BR. Manual Therapy ‘‘NAGS’’, ‘‘SNAGS’’, ‘‘MWMS’’ etc., 4th edition. Plane View Services Ltd., New Zealand: Wellington. 1999. 1-142.
  19. Exelby L. The locked lumbar facet joint: intervention using mobilizations with movement. Man Ther. 2001; 6: 116-121. Ref.: https://goo.gl/qrmmND
  20. Leaver A, Refshauge K, Maher C, Latimer J. Efficacy of manipulation for non-specific neck pain of recent onset: design of a randomised controlled trial. BMC Musculoskelet Disord. 2007; 8: 18. Ref.: https://goo.gl/qrmmND
  21. Griswold D, Learman K, O'Halloran B, Cleland J. A preliminary study comparing the use of cervical/upper thoracic mobilization and manipulation for individuals with mechanical neck pain. J Man Manip Ther. 2015; 23: 75-83. Ref.: https://goo.gl/2vJSFk
  22. Cleland J, Whitman J, Fritz J, Palmer J. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: A case series. J Orthop Sports Phys Ther. 2005; 35: 802-811. Ref.: https://goo.gl/yh2wqx
  23. Kaltenborn F, Evjenth O, Kaltenborn T, Morgan D, Vollowitz E. Manual mobilization of the joints, vol. II: the spine. 2003. Ref.: https://goo.gl/mdzHaq
  24. Moulson A, Watson T. A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Man Ther. 2006; 11: 214-224. Ref.: https://goo.gl/65Pjuz
  25. Masaracchio M, Cleland J, Hellman M, Hagins M. Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2013; 43: 118-27. Ref.: https://goo.gl/z8Cv9G
  26. Leaver A, Maher C, Herbert R, Latimer J, Mc Auley JH, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010; 91: 1313-1318. Ref.: https://goo.gl/v3KEXJ
  27. Slaven E, Goode A, Coronado R. The relative effectiveness of segment specific level and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis. J Man Manip Ther. 2013; 21: 7-17. Ref.: https://goo.gl/1ywxiH
  28. Vernon H. The Neck Disability Index: state-of-the-art, 1991-2008. J Manipulative Physiol Ther. 2008; 31: 491-502. Ref.: https://goo.gl/EcGoML
  29. Stratford P, Riddle D, Binkley J. Using the neck disability index to make decisions concerning individual patients. Physiotherapy Canada. 1999; 51: 107-112.
  30. Jensen M, McFarland C. Increasing the reliability and validity of pain intensity measurement in chronic pain patients. Pain. 1993; 55: 195-203. Ref.: https://goo.gl/Eg2dU9
  31. Childs J, Flynn T, Fritz J, Piva S, Whitman J, et al. Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty. J Orthop Sports Phys Ther 2005; 35: 300-306. https://goo.gl/BBsg5j
  32. Cleland J, Childs J, Whitman J. Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain. Arch Phys Med Rehabil. 2008; 89: 69-74. Ref.: https://goo.gl/bojyi9
  33. Young S, Aprill C, Braswell J, Ogard W. Psychological factors and domains of neck pain disability. Pain Med. 2009; 10: 310-318. Ref.: https://goo.gl/gZt5W4
  34. Pool J, Ostelo R, Hoving J, Bouter L. Minimal clinically important change of the Neck Disability Index and the Numerical Rating Scale for patients with neck pain. Spine. 2007; 32: 3047-3051. Ref.: https://goo.gl/ubie8b
  35. Farrar J, Young J, La Moreaux L. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001; 94: 149-158. Ref.: https://goo.gl/td1r62
  36. Nyberg R, Smith R. The science of spinal motion palpation: a review and update with implications for assessment and intervention. J Man Manip Ther. 2013; 21: 160-167. Ref.: https://goo.gl/RgcbFC
  37. Huijbregts P. Spinal motion palpation: a review of reliability studies. J Man Manip Ther. 2002; 10: 24-29. Ref.: https://goo.gl/wdb585
  38. Lakhani E, Nook B, Haas M, Docrat A. Motion palpation used as a post manipulation assessment tool for monitoring end-feel improvement: a randomized controlled trial of test responsiveness. J Manipulative Physiol Ther. 2009; 32: 549-555. Ref.: https://goo.gl/W1yTFC
  39. Desai N, Khatri S, Keerthi R. Are self-SNAGS effective for chronic neck pain?REVISTA ROMÂNĂ DE KINETOTERAPIE. 2012; 18: 22-29.
  40. Said S, Ali O, Elazm. Mulligan self-mobilization versus Mulligan SNAG on cervical position sense. Int J Physiother. 2017; 4: 93-100. Ref.: https://goo.gl/fXfPgK
  41. Tsakitzidis G, Dankaerts W, Van Royen P. Non-specific neck pain and evidence-based practice. Eur Scientific J. 2013; 9: 1-19.
  42. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. 2004; 29: 1541-1548. Ref.: https://goo.gl/DL7BDg
  43. Sarigiovannis P, Hollins B. Effectiveness of manual therapy in the treatment of non-specific neck pain: a review. Physical Therapy Reviews 2005; 10: 35-50. Ref.: https://goo.gl/Fo7qJJ
  44. Gemmell H, Miller P. Comparative effectiveness of manipulation, mobilisation and the Activator instrument in treatment of non-specific neck pain: a systematic review. Chiropr Osteopat. 2006; 14: 7. Ref.: https://goo.gl/SGcvrL
  45. Cleland J, Flynn T, Childs J. The Audible Pop from Thoracic Spine Thrust Manipulation and Its Relation to Short-Term Outcomes in Patients with Neck Pain. J Manual Manipulative Therapy. 2007; 15: 143-154. Ref.: https://goo.gl/WpLdMa
  46. Hing W, Bigelow R, Bremner T. Mulligan's Mobilization with Movement: A Systematic Review J Manual Manipulative Therapy. 2009; 17: 39-66. Ref.: https://goo.gl/NhGK3i
  47. Abdelhay M, Elgendy M, Lasheen Y. Mulligan versus Maitland mobilization on thoracic kyphotic angle in postural kyphosis. Int J Physiother. 2017; 4: 168-172. Ref.: https://goo.gl/1qua28
  48. Zemadanis K, Sykaras E, Athanasopoulos S, Mandalidis D. Mobilization-with-movement prior to exercise provides early pain and functionality improvements in patients with patellofemoral pain syndrome. J lnt Musculoskeletal Med. 2015; 37: 101-107. Ref.: https://goo.gl/ykXQHi
  49. Snodgrass S, Heneghan N, Tsao H, Stanwell P. Recognising neuroplasticity in musculoskeletal rehabilitation: a basis for greater collaboration between musculoskeletal and neurological physiotherapists. Man Ther. 2014; 19: 614-617. Ref.: https://goo.gl/cJgqHk
  50. Lopez L, Perez J, Gutierez J. Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial. Eur J Phys Rehabil Med. 2015; 51: 121-32. Ref.: https://goo.gl/KoPSqK
  51. Put M, Huber J, Pieniążek M. Randomized Clinical Trial of Multimodal Therapy and Mulligan’s Concept of Manual Therapy for Patients with Chronic Pain Syndrome Caused by Upper Cervical Spine Disorders. Int J Orthop Rehabil. 2016; 3: 40-46.
  52. Leon-Sanchez A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J. 2007; 100: 201-213. Ref.: https://goo.gl/YXwGDZ
  53. Puentedura E, Cleland J, Landers M, Mintken P. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther. 2012; 42: 577-592. Ref.: https://goo.gl/rcXakV
  54. Mulligan BR. Manual Therapy NAGS SNAGS MWMS etc. Wellington, New Zealand: Plane View Services; 2004.
  55. Wilson E. The Mulligan Concept: NAGS, SNAGS, and mobilisations with movement. J Bodywork Movement Therapies. 2001; 5: 81-8.
  56. Hall T, Chan H, Christensen L. Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache. J Orthop Sports Phys Ther. 2007; 37: 100-107. Ref.: https://goo.gl/dM81cU
  57. Eui-Ju Shin, Byoung-Hee Lee. The effect of sustained natural apophyseal glides on headache, duration and cervical function in women with cervicogenic headache.  J Exercise Rehabilitation. 2014; 10: 131-135. Ref.: https://goo.gl/JFyJjc
  58. Ali A, Shakil-ur-Rehman S, Sibtain F. The efficacy of Sustained Natural Apophyseal Glides with and without Isometric Exercise Training in Non-specific Neck Pain. Pak J Med Sci. 2014; 30: 872-874. Ref.: https://goo.gl/dLNJ68
  59. Hussain H, Ahmad A, Amjad F. Effectiveness of Natural Apophyseal Glides Versus Grade I and II Maitland Mobilization in Non-Specific Neck Pain. Annals. 2016; 22: 1-7. Ref.: https://goo.gl/8Y8sNp
  60. Gautam R, Dhamija J, Puri A. Comparison of Maitland and Mulligan mobilization in improving neck pain, ROM and disability. Int J Physiother Res. 2014; 2: 482-487. Ref.: https://goo.gl/oWDGd8
  61. Ahmad R, Asim H, Nasir R. Comparison of Mulligan manual therapy techniques with Kaltenborn manual therapy techniques in patients with nonspecific neck pain in improvement on neck disability index. Int J Sci Res. 2015; 4: 1-4.
  62. Ganesh S, Mohanty P, Pattnaik M. Effectiveness of mobilization therapy and exercises in mechanical neck pain. Physiother Theory Pract. 2015; 31: 99-106. Ref.: https://goo.gl/mbyYbn
  63. Abdelgalil Allam Abdelgalil, Alaa Abdelhakeim Balbaa, Hatem Mohamed Elazizi, Ashraf Abdelaal Mohamed Abdelaal. High Velocity Low Amplitude Manipulation versus Sustained Apophyseal Glides on Pain and Range of Motion in Patients with Mechanical Neck Pain: An Immediate Effect. Int J Adv Res. 2015; 3: 503-513. Ref.: https://goo.gl/U4dRQN
  64. El-Sodany AM, Alayat MSM, Zafer AMI. Sustained natural apophyseal glides mobilization ver­sus manipulation in the treatment of cervical spine disorders: a randomized controlled trial. Int J Adv. 2014; 2: 274-280. Ref.: https://goo.gl/5nXnuu
  65. Vicenzino B, Paungmali A, Teys P. Mulligan's mobilization-with-movement, positional faults and pain relief: current concepts from a critical review of literature. Man Ther. 2007; 12: 98-108. Ref.: https://goo.gl/cDdpqr
  66. Hearn A, Rivett DA. Cervical SNAGs: a biomechanical analysis. Man Ther. 2002; 7: 71-79. Ref.: https://goo.gl/imQF8R
  67. Bialosky J, Bishop M, Robinson M. The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model. Man Ther. 2009; 14: 531-538. Ref.: https://goo.gl/C2wMYN
  68. Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgesic and Sympathoexcitatory Effects of Mobilization with Movement for Lateral Epicondylalgia. Phy Ther. 2003; 83: 374-383. Ref.: https://goo.gl/MRKB5E
  69. Tachii R, Sen S, Arfath U. Short-term effect of sustained natural apophyseal glides on cervical joint position sense, pain and neck disability in patients with chronic neck pain. Int J Therap Rehabilitation Res. 2015; 4: 244-249. Ref.: https://goo.gl/HWQRS1
  70. EL-Sayed W, Mohamed A, Abdel-Monem G. Effect of SNAGS Mulligan Technique on Chronic Cervical Radiculopathy: A Randomized Clinical Trial. Med J Cairo. 2017; 85: 787-793. Ref.: https://goo.gl/1mxY1f
  71. Carroll L, Hogg-Johnson S, van der Velde G. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008; 33: 75-82. Ref.: https://goo.gl/4qifYQ
  72. Chiu T, Leung A. Neck pain in Hong Kong: a telephone survey on prevalence, consequences, and risk groups. Spine. 2006; 31: 540-544. Ref.: https://goo.gl/kRvRQk
  73. Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evi­dence for chronic neck pain. Arthritis Care Res (Hoboken). 2010; 62: 1594-1601. Ref.: https://goo.gl/JuEu5H
  74. Hoving J, de Vet H, Twisk J, Deville W, van der Windt D, et al. Prognostic factors for neck pain in general practice. Pain. 2004; 110: 639-645. Ref.: https://goo.gl/xqqvjP
  75. Kääriä S, Laaksonen M, Rahkonen O, Lahelma E, Leino-Arjas P. Risk factors of chronic neck pain: a prospective study among middle-aged employees. Eur J Pain. 2012; 16: 911-920. Ref.: https://goo.gl/H9n5Kh
  76. MacDermid JC, Walton DM, Côté P, Santaguida PL, Gross A, et al. Use of outcome measures in managing neck pain: an international multidisciplinary survey. Open Orthop J. 2013; 7: 506-520. Ref.: https://goo.gl/yp8JzP
  77. Pérez H, Perez J, f, Martinez A. Is one better than another? A randomized clinical trial of manual therapy for patients with chronic neck pain. Manual Therapy. 2014; 19: 215-221. Ref.: https://goo.gl/NQ3sDg
  78. Reid SA, Rivett DA, Katekar MG, Callister R. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Manual Therapy. 2008; 13: 357-366. Ref.: https://goo.gl/4yQsu2
  79. Thomas L, Rivett DA, Attia J, Parsons M, Levi C. Risk factors and clinical features of craniocervical arterial dissection. Man Ther. 2011; 16: 351-356. Ref.: https://goo.gl/jRNf2f


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