Abstract

Background: Chronic neck pain (CNP) is a prevalent musculoskeletal condition that significantly affects quality of life and functional capacity. Among the various physiotherapy interventions available, Mulligan Sustained Natural Apophyseal Glides (SNAGs) and the McKenzie Method (Mechanical Diagnosis and Therapy) are commonly employed manual therapy techniques. However, direct comparisons of their clinical effectiveness remain limited. Objective: To compare the effectiveness of Mulligan SNAGs and the McKenzie Method as adjuncts to standard physiotherapy in reducing pain, improving function, enhancing range of motion (ROM), and promoting psychological wellbeing in patients with CNP. Methods: A randomized clinical trial was conducted on 56 participants with chronic neck pain, divided equally into two intervention groups: Mulligan SNAGs and McKenzie Method, both combined with standard physiotherapy. Interventions were applied five times weekly for four weeks. The outcome measures included the Numerical Pain Rating Scale (NPRS), neck pain and disability scale-Gujarati version (NPAD-G), WHO-5 Well-Being Index, cervical ROM, and Global Rating of Change (GRoC). Assessments were conducted at baseline, 2 weeks, and 4 weeks. Results: Both groups showed statistically significant within-group improvements across all outcome measures (p < 0.05). Pain intensity, functional disability, and psychological well-being improved notably with increased cervical ROM and high patient satisfaction. However, the between-group differences were not statistically significant (p > 0.05). Conclusion: Mulligan SNAGs and the McKenzie Method are both effective adjuncts to standard physiotherapy for managing chronic neck pain. Both techniques can be selected based on patient preference, therapist expertise, and clinical presentation.

• 1.   Gross A.R., Paquin J.P., Dupont G., Blanchette S., Lalonde P., Cristie T., et al. Exercises for mechanical neck disorders: A Cochrane review update. Manual therapy. 2016; 24: 25-45.
• 2.   Blanpied P.R., Gross A.R., Elliott J.M., Devaney L.L., Clewley D., Walton D.M., et al. Neck Pain: Revision 2017. The Journal of orthopaedic and sports physical therapy. 2017; 47(7): A1-a83.
• 3.   Pool J.J., Ostelo R.W., Hoving J.L., Bouter L.M., de Vet H.C. Minimal clinically important change of the Neck Disability Index and the Numerical Rating Scale for patients with neck pain. Spine (Phila Pa 1976). 2007; 32(26): 3047-51.
• 4.   Buyukturan O., Buyukturan B., Sas S., Karartı C, Ceylan İ. The Effect of Mulligan Mobilization Technique in Older Adults with Neck Pain: A Randomized Controlled, Double-Blind Study. Pain Research and Management. 2018; 2018: 2856375.
• 5.   Elkeblawy M., Abdel-Aal N., Samy H. Mulligan Sustained Natural Apophyseal Glides Versus Thoracic Manipulation On Mechanical Neck Pain: A Randomized Controlled Study. Türk Fizyoterapi ve Rehabilitasyon Dergisi/Turkish361 POTJ/Volume 18 Number 4 / October - December 2025 Journal of Physiotherapy and Rehabilitation. 2021; 32: 17665-75.
• 6.   Vicenzino B., Hing W., Rivett D., Hall T. Mobilisation with Movement: the Art and the Science 2011.
• 7.   Jung Y.W. Effects of McKenzie Exercise on the Functional Recovery and Forward Head Posture of Chronic Neck Pain Patients. Journal of the Korean Society of Physical Medicine. 2006; 1.
• 8.   Arshad N., Ahmad A., Ali B., Imran M., Hayat S. Comparison Between Mckenzie Extension And Neck Isometric Exercises in the Management Of Nonspecific Neck Pain: A Randomized Controlled Trial. Khyber Medical University Journal. 2020; 12(1): 6-9.
• 9.   May S., Aina A. Centralization and directional preference: A systematic review. Manual therapy. 2012; 17(6): 497-506.
• 10.   Young I.A., Cleland J.A., Michener L.A., Brown C. Reliability, construct validity, and responsiveness of the neck disability index, patient-specific functional scale, and numeric pain rating scale in patients with cervical radiculopathy. Am J Phys Med Rehabil. 2010; 89(10): 831-9.
• 11.   Alansari S.M., Youssef E.F., Shanb A.A. Efficacy of manual therapy on psychological status and pain in patients with neck pain. A randomized clinical trial. Saudi medical journal. 2021; 42(1): 82-90.
• 12.   Diab R.H., Hamed R.H., Mustafa IMJIJPR. Efficacy of McKenzie protocol on non-specific neck pain. 2016; 4(5): 1631-38.
• 13.   Kim J.H., Lee H.S., Park S.W. Effects of the active release technique on pain and range of motion of patients with chronic neck pain. Journal of physical therapy science. 2015; 27(8): 2461-4.
• 14.   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. Manual therapy. 2006; 11(3): 214-24.
• 15.   Ozlu O., Sahin M. The effect of mulligan mobilization technique application in addition to conventional physiotherapy on pain and joint range of motion in people with neck pain. Journal of bodywork and movement therapies. 2024; 39: 225-30.
• 16.   Clare H.A., Adams R., Maher C.G. A systematic review of efficacy of McKenzie therapy for spinal pain. The Australian journal of physiotherapy. 2004;50(4):209-16.
• 17.   Manzoor A., Anwar N., Khalid K., Haider R., Saghir M., Javed M.A. Comparison of effectiveness of muscle energy technique with Mulligan mobilization in patients with non-specific neck pain. JPMA The Journal of the Pakistan Medical Association. 2021; 71(6): 1532-24.
• 18.   Seo S.C., Choi J.Y., Joo M.Y., Kim J.H., Chang S-KJPtrs. Effects of sling exercise and McKenzie exercise program on neck disability, pain, muscle strength and range of motion in chronic neck pain. 2012; 1: 40-8.
• 19.   Coulter I.D., Crawford C., Hurwitz E.L., Vernon H., Khorsan R., Suttorp Booth M., et al. Manipulation and mobilization for treating chronic low back pain: A systematic review and meta-analysis. Spine J. 2018; 18(5): 866-79.
• 20.   Topp C.W., Østergaard S.D., Søndergaard S., Bech P. The WHO-5 Well-Being Index: a systematic review of the literature. Psychotherapy and psychosomatics. 2015; 84(3): 167-76.
• 21.   Gatchel R.J., Peng Y.B., Peters M.L., Fuchs P.N., Turk D.C. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological bulletin. 2007; 133(4): 581-624.
• 22.   Thompson D.P., Oldham J.A., Woby S.R. Does adding cognitive-behavioural physiotherapy to exercise improve outcome in patients with chronic neck pain? A randomised controlled trial. Physiotherapy. 2016; 102(2): 170-7.
• 23.   O’Sullivan P.B., Caneiro J.P., O’Keeffe M., Smith A., Dankaerts W., Fersum K., et al. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther. 2018; 98(5): 408-23.
• 24.   Naz S., Jamali N., Iftikhar A., Nawaz H., Iqbal T., Ghafoor F. Compare the Effectiveness of Mulligan (Nags & Snags) and McKenzie (Self-Stretching) On Improving the Pain and Functional Ability in Patient with Chronic Neck Pain: Effectiveness of Mulligan and McKenzie in Patient with Chronic Neck Pain. Pakistan Journal of Health Sciences. 2023; 4(08): 47-52.
• 25.   Alarab A., Talahma I., Awwad H., Sharawi A., Amro O., Hilal R., et al. Mulligan technique versus McKenzie technique on patients with non- specific neck pai with Upper Limb Movement and McKenzie Exercises with Neural Mobilizations in Patients with Cervical Spondylitis. International Archives of Medicine. 2018; 5: 146-55.
• 27.   Garcia J.D., Arnold S., Tetley K., Voight K, Frank R.A. Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence? Frontiers in neurology. 2016; 7: 40.
• 28.   Celenay S.T., Kaya D.O., Akbayrak T. Cervical and scapulothoracic stabilization exercises with and without connective tissue massage for chronic mechanical neck pain: A prospective, randomised controlled trial. Manual therapy. 2016; 21: 144-50.
• 29.   Verhagen A.P., Bierma-Zeinstra SM, Burdorf A., Stynes S.M., de Vet H.C., Koes B.W. Conservative interventions for treating workrelated complaints of the arm, neck or shoulder in adults. The Cochrane database of systematic reviews. 2013; 2013(12): Cd008742.
• 30.   Dworkin R.H., Turk D.C., Wyrwich K.W., Beaton D., Cleeland C.S., Farrar J.T., et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008; 9(2): 105-21.
• 31.   Ylinen J., Häkkinen A, Nykänen M, Kautiainen H, Takala EP. Neck muscle training in the treatment of chronic neck pain: a three-year follow-up study. Eura Medicophys. 2007; 43(2):161-9.
• 32.   Cook C. The lost art of the clinical examination: an overemphasis on clinical special tests. Journal of Manual & Manipulative Therapy. 2010; 18(1): 3-4.
• 33.   Fritz J.M., Cleland J.A., Childs J.D. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. The Journal of orthopaedic and sports physical therapy. 2007; 37(6): 290-302.
• 34.   Straus S.E., Glasziou P., Richardson W.S., Haynes R.B. Evidence-Based Medicine: How to Practice and Teach EBM: Elsevier; 2018.
• 35.   Foster N.E., Anema J.R., Cherkin D., Chou R., Cohen S.P., Gross D.P., et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018; 391(10137): 2368-83.
• 36.   Kamper S.J., Maher C.G., Hancock M.J., Koes B.W., Croft P.R., Hay E. Treatmentbased subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best practice & research Clinical rheumatology. 2010; 24(2): 181-91.
• 37.   Bialosky J.E., Beneciuk J.M., Bishop M.D., Coronado R.A., Penza C.W., Simon C.B., et al. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of orthopaedic and sports physical therapy. 2018; 48(1): 8-18.
• 38.   van Dongen J.M., Ketheswaran J., Tordrup D., Ostelo R., Bertollini R., van Tulder MW. Health economic evidence gaps and methodological constraints in low back pain and neck pain: Results of the Research Agenda for Health Economic Evaluation (RAHEE) project. Best practice & research Clinical rheumatology. 2016; 30(6): 981-93.

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