EFFECT OF MULLIGAN CERVICAL SUSTAINED NATURAL APOPHYSEAL GLIDE ON POSTURAL STABILITY IN PATIENTS WITH CHRONIC NECK PAIN

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

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),

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

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.

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.

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)

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.

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