Efficacy of mulligan's self-sustained natural apophyseal glides in decreasing pain, disability, and improving neck mobility among the nursing professional suffering from work-related neck pain

Shagun Aggarwal; Meenakshi Verma

doi:10.4103/amhs.amhs_8_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 6 | Issue : 1 | Page : 48-53

Efficacy of mulligan's self-sustained natural apophyseal glides in decreasing pain, disability, and improving neck mobility among the nursing professional suffering from work-related neck pain

Shagun Aggarwal, Meenakshi Verma
Department of Physiotherapy, Institute of Applied Medicines and Research, Ghaziabad, Uttar Pradesh, India

Date of Web Publication

11-Jun-2018

Correspondence Address:
Dr. Shagun Aggarwal
Department of Physiotherapy, Institute of Applied Medicines and Research, Duhai, Ghaziabad, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/amhs.amhs_8_18

Abstract

Background and Aim: Prevalence of neck pain in nursing professionals (NPs) is much higher than in the general population. However, concrete evidence is not available regarding the efficacy of the therapeutic intervention for treating neck pain among them. The purpose of this study was to compare the efficacy of Mulligan's self-sustained natural apophyseal glides (SNAGs) and conventional physiotherapy in the management of work-related neck pain (WRNP) among the NPs. Materials and Methods: A total of 38 NPs with WRNP were recruited using the simple random sampling (lottery method) to participate in this two group such as pretest–posttest and single-blinded randomized controlled study from recognized tertiary care teaching hospital. Recruited NPs were randomly allocated into two groups such as Group A and Group B. NP in Group A taught self-SNAGs with a towel and instructed to perform 10 repetitions ×1 set/two hour ×4 times/day for 5 days/week ×2 weeks. Whereas in Group B, NPs received conventional physiotherapy treatment, consist of neck isometrics, and performed for 10 s ×10 repetitions ×1 set/day ×5 days/week ×2 weeks. Both groups were asked to use the hot pack for 15 min, before their intervention. Visual Analog Scale (VAS) score, neck disability index (NDI), and cervical range of motion (ROM) were documented at baseline, 2^nd-week postintervention, and 4^th-week follow-up period and analyzed. Results: Group A revealed statistical significance difference (P < 0.05) in VAS, NDI, and neck ROM when compared to Group B. Conclusion: Mulligan's self-SNAGs have proved to be more beneficial over the conventional physiotherapy in the management of WRNP among the NPs.

Keywords: Cervical pain, cervicalgia, cervicodynia, physical therapy techniques, range of motion

How to cite this article:
Aggarwal S, Verma M. Efficacy of mulligan's self-sustained natural apophyseal glides in decreasing pain, disability, and improving neck mobility among the nursing professional suffering from work-related neck pain. Arch Med Health Sci 2018;6:48-53

How to cite this URL:
Aggarwal S, Verma M. Efficacy of mulligan's self-sustained natural apophyseal glides in decreasing pain, disability, and improving neck mobility among the nursing professional suffering from work-related neck pain. Arch Med Health Sci [serial online] 2018 [cited 2023 Mar 31];6:48-53. Available from: https://www.amhsjournal.org/text.asp?2018/6/1/48/234114

Introduction

Nursing is a health-care profession focused on the care of individuals, families, and communities, and hence, they may attain, maintain, or recover optimal health and quality of life from conception to death.^[1],[2] The nurses have to do lots of physical works such as pulling or pushing of patient with the outstretched arm/shoulder and excessive forward flexion of spine cases and increased stress at the neck. Furthermore, the prehistory of neck pain may multiply the morbidity.^[3] Even though neck pain is less frequent than low back pain, it becomes an important cause of sickness and absence for their duty.^[4],[5],[6]

It has been reported that the prevalence of neck pain in nursing professionals (NPs) is much higher than in the general population.^[1],[7],[8] Therapeutic intervention for treating neck pain can include heat, massage, stretching, strengthening, precautions, and newer techniques such as manual or mechanical traction and modern manual therapy techniques such as McKenzie or Mulligan, etc. However, concrete data are not available regarding the efficacy of modern manual techniques over conventional therapy.^[9] Hence, this study was aimed to compare the efficacy of modern manual therapy and Mulligan's self-sustained natural apophyseal glides (SNAGs) over conventional therapy for chronic neck pain in NPs.^{[9],[10],[11]}

Methodology

Recruitment and allocation

The study protocol was approved by the University Research and Ethics Committee (IAMR/2016/24) and the study was conducted strictly in accordance with the guidelines of Helsinki declaration, revised 2013.^[12] A total of 38 NPs were recruited using the simple random sampling (lottery method) to participate in the two groups such as pretest–posttest and single-blinded randomized controlled study from the recognized tertiary care teaching hospital. The recruited nurses were treated in the physiotherapy outpatient department affiliated with recognized tertiary care teaching hospital. The nurses who were not being treated for their work-related neck pain (WRNP) were recruited. While the nurses who had any history of upper extremity or neck injury, recent fracture of <6 months, and with hypermobile joints were excluded from the study. Signed informed consent was obtained from all the recruited nurses before the study commencement.

After the demographics, recruited nurses were randomly divided into two groups such as Group A and Group B using block randomization. There were five blocks with the matrix design of 5 × 8, where eight being rows. Each block contained eight chits (four chits for each group), except the fifth block, which has only six chits (three chits for each group), totaling 38. The participants were allotted to the group based on the randomly chosen chit. Once the block was allotted, the next row block was opened. Thus, equal number of participants was assigned to each group over time. The participants in Group A received self-SNAG mobilization. While in Group B, the participants received conventional physiotherapy treatment. Both groups received the above-said intervention for 2-week period and 2-week follow-up period (no intervention period). The consolidated standards of reporting trials ^[13] flow chart describing the details of the study is displayed in [Figure 1].

Figure 1: Consolidated Standards of Reporting Trials diagram describing the study flow

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Exercise intervention in Group A

Recruited nurses in Group A were taught self-SNAGS for cervical extension and rotation of cervical. Self-SNAGS requires the only equipment and small hand towel. The selvage on one side of the towel is hooked under the spinous process. The ends of the towel on the same selvage side were firmly held, and pull was exerted toward the treatment plane in the direction of movement, as shown in [Figure 2] and [Figure 3]. These interventions were provided 10 repetitions ×1 set/two hour ×4 times/day for 5 days/week ×2 weeks. Before performing self-SNAGs, the hot pack was placed for 15-min duration around the cervical region. Ergonomic advice was incorporated into their treatment regime.

Figure 2: Nursing professional performing Mulligan's self-sustained natural apophyseal glides for neck extension (a and b) and rotation (c and d)

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Figure 3: Mean Visual Analog Scale score at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Exercise intervention in Group B

In Group B, the NPs were asked to perform cervical isometric exercises for neck flexors, extensors, and rotators. Each isometric exercise was performed for 10 s ×10 repetitions ×1 set/day ×5 days/week ×2 weeks. Before the commencement of exercise, they were instructed to apply hot pack for 15 min around the cervical region. Group B also received ergonomic advice to prevent the abnormal neck posture during working hours.

Outcome measures

Both groups were measured for their level of pain (Visual Analog Scale [VAS]), disability (neck disability index [NDI]),^[14] and range of motion (ROM) using universal goniometer (degree of extension, lateral flexion, and rotation of neck) between Group A and Group B at baseline, 2^nd-week postintervention, and 4^th-week follow-up period.

Data analysis

The collected demographic and outcome measures were assessed for their normality using Shapiro–Wilk test. As the data follow a normal distribution, all the descriptive were expressed in mean ± standard deviation. Paired t-test was adopted to find the differences within Group A and Group B for preintervention and postintervention changes. While independent t-test was used to compare the changes in mean values of pain (VAS), disability (NDI), and ROM (extension, lateral flexion, and rotation of neck) between Group A and Group B at baseline, 2^nd-week postintervention, and 4^th-week follow-up period. Data were analyzed using statistical software, Statistical Package for Social Science (SPSS), and IBM SPSS version 20.0 (IBM Corp., Armonk, NY, USA). A value of P ≤ 0.05 was considered to be statistically significant.

Results

A total of 38 participants (37.6 ± 2.4-year-old; 165.3 ± 6.4 cm; 63.1 ± 7.6 kg; and 24.1 ± 2.4 kg/m ²) were identified as potential participants for this study and were randomly allocated into two groups such as Group A and Group B. Among them, 47% were female and 53% were male. The respondents had a mean of 8.2 ± 1.8 years of experience with an average of 7.5 ± 0.5 h spent in hospital per day. The detailed demographic characteristics of the nurses recruited are displayed in [Table 1]. Two dropouts were noted in Group A and one dropout in Group B was analyzed using intention-to-treat analysis.^[15],[16] There exists no significance difference between the two groups. Between the session and group comparison at baseline, 2^nd-week postintervention, and 4^th-week follow-up period for the outcome measures VAS [Figure 3], NDI [Figure 4], NE [Figure 5], NLLF [Figure 6], NRLF [Figure 7], NLR [Figure 8], and NRR [Figure 9] were displayed. In all the outcome measures, Group A shows statistically significant (P< 0.05) improvement when compared to Group B.

Table 1: Demographic characteristic of the participants recruited in Group A and Group B

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Figure 4: Mean neck disability index score at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Figure 5: Mean neck extension range of motion (degrees) at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Figure 6: Mean neck left lateral flexion range of motion (degrees) at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Figure 7: Mean neck right lateral flexion range of motion (degrees) at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Figure 8: Mean neck left rotation range of motion (degrees) at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Figure 9: Mean neck right rotation range of motion (degrees) at baseline, 2^nd-week postintervention, and 4^th-week follow-up period between Group A and Group B

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Discussion

The proposed study suggests that the technique of active SNAGS can be incorporated as a treatment tool for NPs during their work hours, along with the application of hot packs and ergonomic care. It resulted in an overall improvement in pain, functional outcome, and ROM for neck extension, lateral flexion, and rotation. The significant improvement was seen clinically for all the outcome measures in Group A NP receiving self-SNAGs. Early recovery from pain with lesser number of sessions of active SNAGS and improvement in neck ROM was reported by the participant in Group A. It is seen from [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9] that consistent and significant improvement had occurred during the treatment phase and follow-up phase of the intervention. This improvement may be attributed to the fact that accessory glide component of a cervical SNAG could ameliorate any of these problems either by separating the facet surfaces and by releasing the entrapped meniscoid,^[17] by allowing the entrapped meniscoid to return to its intra-articular position, or perhaps by stretching adhesion.^[17],[18] It would be more appropriate to apply the accessory glide ipsilateral to the side of pain before performing physiological movement away from the side of pain (contralateral), as this would cause less joint compression, greater excursion of movement at the symptomatic functional spinal unit, and presumably a greater chance of stretching adhesions and resolving any meniscal entrapment or extrapment.^[18],[19]

Brian Mulligan has put forward a theory which could help to explain the need for ipsilateral physiological rotation during application of a cervical SNAG. He suggested that the superior facet of the implicated functional spinal unit ipsilateral to the side of the pain may be jammed posteroinferiorly in an extension or “closed down” position; hence, the ipsilateral rotation could cause pain due to excessive “closing down” of the zygapophyseal joint. Application of accessory glide component of cervical SNAG may, therefore, reposition the superior facet superioanteriorly, allowing a greater range of pain-free ipsilateral rotation.^[17],[18]

The interventions in the current study, in comparison, were a more realistic representation of a pragmatic approach to the management of chronic neck pain. Both interventions had components of a home program and posture correction in addition to the intervention under study, and it is acknowledged that this common component may account for some of the improvement in both groups.

Due to almost complete lack of empirical evidence supporting the clinical use of cervical SNAGS, a discussion on the functional spinal unit biomechanics and the articular tissues of the mid-lower cervical spine is worthwhile. Cervical SNAGSs are said to have immediate effect,^[18] and it seems likely that their underlying mechanism is either purely mechanical, reflexogenic,^{[17],[19],[20]} or a combination of the two, and does not primarily involve chemical processes or natural resolution.^[17] It is unlikely that osseous pathology would undergo immediate and prolonged improvement following mobilization, thus implicating soft-tissue structures such as meniscoid inclusion, the zygapophyseal joint capsules, and intervertebral disk as most likely articular sources for any manually reversible pain.^{[17],[18],[19],[21]}

This study had few limitations. The generalizability of the results might be affected by the slightly less sample size and performed without sample size estimation. Moreover, the participants in this study represented a random sample of NP recruited from the single center that may have led to some degree of representation bias. Nevertheless, this was the first study to estimate the benefits of SNAGS among NP. We used a very practical and easy-to-administer technique that can be used in future in clinical practice. Further, this study can be extended as multicenter study and among other health professionals. The results of this study are in agreement with the findings that cervical active SNAGS along with the application of hot packs and hot packs could be incorporated as a potential treatment tool for WRNP.

Conclusion

Two-week self-SNAGs have the sufficient potential to decrease neck pain and disability and increase mobility among NP with WRNP than the conventional physiotherapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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