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Effect of SNAGS Mulligan Technique On Chronic Cervical Radiculopathy: A Randomized Clinical Trial
Effect of SNAGS Mulligan Technique On Chronic Cervical Radiculopathy: A Randomized Clinical Trial
787
788 Effect of SNAGS Mulligan Technique on Chronic Cervical Radiculopathy
manual therapy highlights the value of movement tation session about the nature of the study, they
in maintaining health and strength of collagenous, were randomly assigned to two groups. Study
muscular and bony tissue. Mulligan's principle group was consisted of 25 patients (14 females
techniques are natural apophyseal accessory glides and 1 1 males) with mean age, body mass, height,
(NAGS) and sustained natural apophyseal accessory and BMI values of 47.8 ±4.83 years, 169.44±5.76
glides (SNAGS). In SNAGS the patient attempts cm, 77.28±7.54kg, and 26.93 ±2.44kg/m 2 respec-
to actively move a painful or stiff joint through its tively. This group received conventional physical
range of motion whilst the therapist overlays an therapy program for chronic cervical radiculopathy
accessory glide parallel to the treatment plane [4] . in addition to Mulligan technique SNAGs.
Somatosensory Evoked Potential testing (SSEP) All participants were referred from the same
has been successfully utilized in clinical medicine orthopedic surgeon who was informed of patient
for the past twenty years. Evoked potentials are inclusion and exclusion criteria. Patients were
used to evaluate the functioning of the sensory included in the study if they were diagnosed as
neural pathways. The validity, reliability and sen- unilateral cervical radiculopathy at level of C5/C6
sitivity of SSEP exams have been well documented and/or C6/C7, in chronic stage, and BMI ranged
[5] . These tests are often used in the operating room from 25 to 30kg/m 2 . Prior to the study patients
to monitor the functional integrity of the neurolog- were excluded if they have spinal canal stenosis,
ical pathways during surgical procedure and to rheumatoid arthritis, vestibular insufficiency, med-
determine the effectiveness of the surgical proce- ical “red flags” eg. tumor, fracture, myelopathy,
dure [6] . osteoporosis, underwent to any cervical spine
The Dermatomal Somatosensory Evoked Po- operations, peripheral neuropathy, ligaments laxity,
tential (DSEP) study is a method for evaluating any contra indications to manual therapy.
the abnormality of the somatosensory tract, which Study design and randomization:
extends from the peripheral nerve to the cerebral
cortex. In 1947, Dawson first reported the evoked The study was designed as a prospective rand-
potentials in humans. Since then, it has been re- omized clinical trial in which patients were assigned
ported to be effective in identifying lesions and randomly into two groups. Randomization was
then determining their locations in various damage used to eliminate the researches' bias and was
sites, such as peripheral neuropathies, radiculopa- carried out by a blinded and an independent re-
thies, spinal cord injuries, central nervous system search assistant who used flipping a coin method
disorders, and cerebral damage [7] . to assigned the patient randomly.
Four standard landmarks are required to locate with pulse width 100-150, pulse rate 60-100hz,
all positions necessary for DSSEPs. The nasion and output adjust to the most comfortable intensity
(bridge of the nose) and inion (posterior bony level. Patients were seated on chair during session.
protuberance over the inferior aspect of the occiput) Two electrodes paraspinal on upper fibers of tra-
are two anatomic landmarks along the skull s mid
' pezius of the affected side and the other two elec-
sagittal plane. Those regions where the ears attach trodes on dermatome according of the affected
to skull just anterior to tragus form the second pair level of spine C5/6 and/or C6/C7 were used. Pa-
of landmarks in the frontal plane. The point at tients received 30 minutes per session for three
which the line extending between the two ears sessions per week for four weeks [10] .
cross the previously defined mid-point of the sag-
gital line joining the nasion and inion designates Stretching exercises for neck muscles:
the vertex of the skull constitute an electrode site Upper trapezius muscles stretching: The patient
called the CZ. Ten percent of the total distance sat on a stool in an erect position. The therapist
between the nasion and inion, superior to nasion, stood behind the patient with one hand on the
constitutes and electrode site called FpZ. Twenty patient's shoulder for stabilization, while the other
percent of total distance between the above two was on the side of the patient's head. The stretching
sites, nasion and inion, from CZ toward the nasion was applied by moving the head in side bending
designates the 2 inches recording site C3, C4. The with holding for 30 seconds and rest for 30 seconds
cortical responses were amplified, average and and repeated three times to both sides.
displayed using an analysis time of 150ms. Filter
setting of 2Hz to 1KHz was utilized. Surface elec- Stretching exercises for neck rotators: The
trodes secured to the patients by filling the cub patient was seated on a stool. The therapist stood
aspect of the electrode by an electrolyte paste, and behind the patient with one hand on patient's shoul-
then it was firmly pressed against the prepared der whiles the other on head laterally.
skin. Changes in the latency and/or amplitude of
the response can indicate dysfunction in the neural Stretching exercise was applied by application
pathway being monitored. of passive full neck rotation toward right and left
directions as much as possible but within limit of
The site of stimulation for C6 was about 7cm pain. The patient was asked to hold for 30 seconds,
above the styloid process of the radius and for C7 rest for 30 seconds and repeated three times.
between the second and third metacarpal bones. A
bipolar electrode was used for stimulation with Isometric strengthening exercises for neck mus-
inter electrode distance of 2.5cm with the stimula- cles (the exercise was repeated for ten repetitions
tion cathode placed proximally. The sensory thresh- per session).
old for electrical stimulation was determined by Isometric strengthening exercises for neck ex-
increasing the intensity of electrical current until tensors: The patient sits on a stool in an erect
the patient reported its sensation as tolerable and position. The therapist stands behind the patient
painless stimulus intensity was usually set at 2.5 with one hand on the patient's shoulder, while the
times above this level. Recording was done with other on the occipit. The patient asked to push the
9mm diameter tin/lead electrodes affixed with therapist hand, while the therapist resisted the
cream to abraded skin. The recording electrodes movement, so there was no neck movement.
were placed at C3 and C4, while the reference
electrode was placed at Fz and the ground electrode Isometric strengthening exercises for neck ro-
at Fpz. tators: The patient sat on a stool in an erect position.
The therapist stands behind the patient with one
Treatment procedures: hand on the patient's shoulder, while the other was
Both groups (control and study) received con- on the side of the head. The patient asked to push
ventional physical therapy program for neck pain the therapist hand backwards and try to rotate the
which include (hot pack, TENS, stretching and head to right and left, while the therapist resisted
strengthening exercises for cervical spine) three the movement without neck movement.
times per week for one month [9] while the study
group additionally to the traditional physical ther- Isometric strengthening exercises for neck side
apy program received Mulligan technique SNAGS. bending muscles: The patient sits on a stool in an
Electric hot pack was placed over the neck and erect position. The therapist stands behind the
upper part of shoulders musculature. This was patient with one hand on the patient's shoulder,
being applied for ten min. Transcutaneous 2 channel while the other was on the occipit. The patient
Electrical Nerve Stimulation (TENS) was used asked to push the therapist hand and try to side
790 Effect of SNAGS Mulligan Technique on Chronic Cervical Radiculopathy
bend the neck to right and left, while the therapist two tested dependent variables (DSEP latency and
resisted the movement without neck movement. DSEP amplitude). Prior to final analysis, data were
screened for normality assumption, homogeneity
Mulligan technique SNAGS for rotation: of variance, and presence of extreme scores. This
A pilot study was conducted on five patients exploration was done as a pre-requisite for para-
and revealed that rotation Mulligan technique metric calculations of the analysis of difference.
SNAGS was more effective than extension, flexion
and side bending Mulligan techniques SNAGs. Descriptive analysis using histograms with the
So in the current study rotation Mulligan tech- normal distribution curve showed that DSEP laten-
nique for C5/C6 and/or C6/C7 was conducted cy and amplitude was normally distributed and not
accordingly. violates the parametric assumption for the measured
dependent variable. Additionally, testing for the
The patient seated comfortably on a stool. The homogeneity of covariance revealed that there was
therapist stood behind the patient and the medial no significant difference with p-values of >0.05.
border of one thumb's distal phalanx is placed on The box and whiskers plots of the tested variable
the articular pillar on the chosen side of the sus- were done. Normality test of data using Shapiro-
pected site of lesion. The thumb nail slope at Wilk test was used, that reflect the data was nor-
approximately 45 degree in the direction of the mally distributed for DSEP latency and DSEP
patient's eyeball. Therapist's other thumb reinforced amplitude. All these findings allowed the research-
this. This means if the patient has lesion at cervical ers to conduct parametric analysis. So, 2 X 2 mixed
C5/C6 so the therapist's thumb was on the cervical design MANOVA was used to compare the tested
5 th articular pillar. However when “SNAGGING” variables of interest at different tested groups and
on the right, the right thumb placed on the right measuring periods. With the initial alpha level set
pillar and push up with the left. When “Snagging” at 0.05.
on the left the left thumb would be on the left
pillar [3] .
Results
The therapist's other fingers comfortably placed
laterally on each side of the neck or upper antero- Baseline and demographic data:
lateral thorax to prevent the neck from flexing. There were no statistically significant differ-
While the facet is being maintained, the patient ences (p>0.05) between subjects in both groups
was asked to turn his head slowly in the restricted concerning age, body mass, height, and BMI
painful direction. As the head rotates, the therapist (Table 1).
follow with his hands to ensure that the mobilization
take place with the movement then get the patient DSEP latency and DSEP amplitude:
to apply sustained overpressure for few seconds Statistical analysis revealed that there were
at approximately 45 degree in the direction of the significant within subject effect (F=113.996, p=
eyeball. Mobilizations was repeated six times and 0.0001) and treatment* time effect (F=45.979, p=
the movements was reassessed [4] . Finally, a home 0.0001) but there were no significant between
program is performed between treatment sessions subject effect (F=2.569, p=0.08). Table (2) repre-
utilizing the SNAGS principles and a towel to sents the mean ± SD and multiple pairwise com-
impart the glide component to maintain gains parisons for all dependent variables in both groups
achieved during treatment. in different measuring periods. Multiple pairwise
comparison tests revealed that there were significant
Statistical analysis: increase of DSEP amplitude in the post-treatment
Statistical analysis was conducted using SPSS condition compared with the pre-treatment one in
for windows, Version 18 (SPSS, Inc., Chicago, both groups. As well as, there were significant
IL). The current test involved two independent reduction of DSEP latency in the post-treatment
variables. The first one was the (tested group); condition compared with the pre-treatment one in
between subject factors which had two levels both groups (p<0.05).
(control group received conventional physical
therapy program for chronic cervical radiculopathy Regarding between subject effects, multiple
and study group received the same conventional pairwise comparisons revealed that there were
physical therapy program in addition to SNAGS significant increase (p<0.05) in DSEP amplitude
Mulligan technique. The second one was the (meas- in the study group compared with control group,
uring periods); within subject factor which had with no significant differences in DSEP latency
two levels (pre, post). In addition, this test involved between both groups.
Wadida H. El-Sayed, et al. 791
Table (1): Descriptive statistics and unpaired t-tests for the mean age, body mass,
height, and BMI of the patients with cervical radiculopathy for both
groups.
Table (2): Descriptive statistics and multiple pairwise comparison tests (post hoc tests) for the
DSEP amplitude and DSEP latency in patients with cervical radiculopathy in pre and
post exercises for both groups.
DSEP latency (ms) 20.64± 1.81 20.22± 1.71 21.61 ± 1.45 19.5± 1.46
DSEP amplitude (microvolt) 1.5±0.7 1.96±0.8 1.34±0.6 3.20± 1.4
Multiple pairwise comparisons between pre and post-treatment values for all dependent variables
Multiple pairwise comparisons between control group and study group for all dependent variables,
pre and post-treatment
Measuring
periods Pre-treatment Post-treatment
Dependent DSEP latency DSEP amplitude DSEP latency DSEP amplitude
variables
Control group vs. 0.05 0.425 0.155 0.001*
study group
*: Significant at the alpha level ( p<0.05).
superior articular facet using a SNAG would cause 2- WOODS B.I. and HILIBRAND A.S.: Cervical radiculop-
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surface is essential for maintaining the mobility SATHIYAVANI D., NAMBI G., et al.: Comparison of
Maitland And Mulligan Mobilization In Improving Neck
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