Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2008

Open Access 01-12-2008 | Research article

The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system

Authors: Maria Moutzouri, Evdokia Billis, Nikolaos Strimpakos, Polixeni Kottika, Jacqueline A Oldham

Published in: BMC Musculoskeletal Disorders | Issue 1/2008

Login to get access

Abstract

Background

Mulligan's mobilisation techniques are thought to increase the range of movement (ROM) in patients with low back pain. The primary aim of this study was to investigate the application of the Mulligan's Sustained Natural Apophyseal Glide (SNAG) technique on lumbar flexion ROM. The secondary aim was to measure the intra- and inter-day reliability of lumbar ROM employing the same procedure.

Methods

49 asymptomatic volunteers participated in this double-blinded study. Subjects were randomly assigned to receive either SNAG mobilisation (n = 25), or a sham mobilisation (n = 24). The SNAG technique was applied at the L3and L4 spinal levels with active flexion in sitting by an experienced manual therapist. Three sets of 10 repetitions at each of the two spinal levels were performed. The sham mobilisation was similar to the SNAG but did not apply the appropriate direction or force. Lumbar ROM was measured by a three dimensional electronic goniometer (Zebris CMS20), before and after each technique. For the reliability, five measurements in two different days (one week apart) were performed in 20 healthy subjects.

Results

When both interventions were compared, independent t tests yielded no statistically significant results in ROM between groups (p = 0.673). Furthermore no significant within group differences were observed: SNAG (p = 0.842), sham (p = 0.169). Intra- and inter-day reliability of flexion measurements was high (ICC1,1 > 0.82, SEM < 4.0°, SDD<16.3%) indicating acceptable clinical applicability.

Conclusion

While the Zebris proved to be a reliable device for measuring lumbar flexion ROM, SNAG mobilisation did not demonstrate significant differences in flexion ROM when compared to sham mobilisation.

Trial registration

Current Controlled Trials NCT00678093.
Appendix
Available only for authorised users
Literature
1.
Waddel G: Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine. 1987, 12: 632-44. 10.1097/00007632-198709000-00002.CrossRef
2.
Sullivan MS, Shoaf LD, Riddle DL: The relationship pf lumbat flexion to disability in patients with low back pain. Phys Ther. 2000, 80: 240-50.PubMed
3.
Susan H, Picavet J, Jan SA, Schouten G: Physical Load in Daily Life and Low Back Problems in the General Population – The MORGEN Study. Prev Med. 2000, 31: 506-512. 10.1006/pmed.2000.0737.CrossRef
4.
Lee EC, Simmonds MJ, Novy DM, Jones S: Self-reports and clinician-measured physical function among patients with low back pain: A comparison. Arch Phys Med Rehabil. 2001, 82: 227-231. 10.1053/apmr.2001.18214.CrossRefPubMed
5.
Neumann WP, Wells RP, Norman RW, Kerr MS, Frank J, Shannon HS: Trunk posture: reliability, accuracy, and risk estimates for low back pain from a video based assessment method. International Journal of Industrial Ergonomics. 2001, 28: 355-365. 10.1016/S0169-8141(01)00042-7.CrossRef
6.
O'Brien T, Vicenzino B: A study of the effects of Mulligan's mobilization with movement treatment of lateral ankle pain using a case study design. Man Ther. 1998, 3: 78-84. 10.1016/S1356-689X(98)80022-2.CrossRef
7.
Folk B: Traumatic thumb injury management using mobilization with movement. Man Ther. 2001, 6: 178-182. 10.1054/math.2001.0414.CrossRefPubMed
8.
Vicenzino B, Paungmali A, Buratowski S, Wright A: Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Man Ther. 2001, 6: 205-212. 10.1054/math.2001.0411.CrossRefPubMed
9.
Horton S: Acute locked thoracic spine: treatment with a modified SNAG. Man Ther. 2002, 7: 103-107. 10.1054/math.2002.0456.CrossRefPubMed
10.
Kochar M, Dogra A: Effectiveness of a specific physiotherapy regimen on patients with tennis elbow – Clinical study. Physiotherapy. 2002, 88: 333-341. 10.1016/S0031-9406(05)60746-8.CrossRef
11.
Konstantinou K, Foster N, Rushton A, Baxter D: The use and reported effects of mobilization with movement techniques in low back pain management; a cross-sectional descriptive survey of physiotherapists in Britain. Man Ther. 2002, 7: 206-214. 10.1054/math.2002.0469.CrossRefPubMed
12.
Collins N, Teys P, Vicenzino B: The initial effects of a Mulligan's mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther. 2004, 9: 77-82. 10.1016/S1356-689X(03)00101-2.CrossRefPubMed
13.
Mulligan BR: Manual Therapy: "Nags", "Snags" "Mwms". 2004, New Zealand: Wellington, 4
14.
Wilson E: The Mulligan concept: NAGS, SNAGS and mobilizations with movement. Journal of Bodywork and Movement Therapies. 2001, 5: 81-88. 10.1054/jbmt.2000.0191.CrossRef
15.
Exelby L: The Mulligan concept: Its application in the management of spinal conditions. Man Ther. 2002, 7: 64-70. 10.1054/math.2001.0435.CrossRefPubMed
16.
Konstantinou K, Foster N, Rushton A, Baxter D, Wright C, Breen A: Flexion Mobilizations With Movement Techniques: the Immediate Effects on Range of Movement and Pain in Subjects With Low Back Pain. J Manipulative Physiol Ther. 2007, 30: 178-185. 10.1016/j.jmpt.2007.01.015.CrossRefPubMed
17.
Gracovetsky S, Newman N, Pawlowsky M: A Database for Estimating Normal Spinal Motion Derived from Non-invasive Measurements. Spine. 1995, 20: 1036-1046. 10.1097/00007632-199505000-00010.CrossRefPubMed
18.
Marras WS, Ferguson SA, Gupta P, Bose S, Parnianpour M, Kim JY: The quantification of low back pain disorder using motion measures. Methodology and Validation. Spine. 1999, 24: 2091-2100. 10.1097/00007632-199910150-00005.CrossRefPubMed
19.
Joseph KF, Kippers V, Richarsdon CA, Parnianpour M: Range of motion and Lordosis of the lumbar spine. Reliability of Measurement and Normative Values. Spine. 2001, 26: 33-60.
20.
Perret C, Poiraudeau S, Fermanian J, Colau MML, Benhamou MAM: Validity, reliability and responsiveness of the Fingertip-to-floor test. Arch Phys Med Rehabil. 2001, 82: 1566-70. 10.1053/apmr.2001.26064.CrossRefPubMed
21.
Lehman GJ: Biomechanical assessments of lumbar spinal function. How low back pain sufferers differ from normals. Implications for outcome measures research. Part 1: Kinematic Assessments of lumbar function. J Manipulative Physiol Ther. 2004, 27: 57-62. 10.1016/j.jmpt.2003.11.007.CrossRefPubMed
22.
Rae PS, Waddell G, Venner RM: A simple technique for measuring lumbar spinal flexion. Its use in orthopaedic practice. J R Coll Surg Edinb. 1984, 29: 281-4.PubMed
23.
Burdett RG, Brown K, Fall MP: Reliability and Validity of Four Instruments for Measuring Lumbar Spine and Pelvic Positions. Phys Ther. 1986, 66: 677-685.PubMed
24.
Mayer RS, Chen I, Lavender SA: Variance in the Measurement of Sagittal Lumbar Spine Range of Motion Among Examiners, Subjects and Instruments. Spine. 1995, 20: 1489-1493.CrossRefPubMed
25.
Mayer TG, Kondraske G, Beals S: Spinal Range of Motion. Spine. 1997, 22: 1976-1984. 10.1097/00007632-199709010-00006.CrossRefPubMed
26.
Rainville J, Sobel JB, Hartigan C: Comparison of Total Lumbosacral Flexion and True Lumbar Flexion Measured by a Dual Inclinometer Technique. Spine. 1994, 19: 2698-2701.CrossRefPubMed
27.
McGill KP, Callagha MJ: Intratester and intertester reproducibility of the lumbar motion monitor as a measure of range, velocity and acceleration of the thoracolumbar spine. Clin Biomech. 1996, 11: 418-421. 10.1016/0268-0033(95)00056-9.CrossRef
28.
Troke M, Moore AP, Maillardet FG: A new, comprehensive normative database of lumbar spine ranges of motion. Clin Rehabil. 2004, 15: 371-379. 10.1191/026921501678310171.CrossRef
29.
Barret C, Singer K, Day R: Assessment of combined movements of lumbar spine in asymptomatic and low back pain subjects using a three dimensional electromagnetic tracking system. Man Ther. 1999, 4: 94-99. 10.1054/math.1999.0175.CrossRef
30.
Vogt L, Banzer W: Measurement of lumbar spine kinematics in incline treadmill walking. Gait Posture. 1999, 9: 18-23. 10.1016/S0966-6362(98)00038-1.CrossRefPubMed
31.
Mannion A, Troke M: A comparison of two motion analysis devices used in the measurement of lumbar spinal mobility. Clin Biomech. 1999, 14: 612-9. 10.1016/S0268-0033(99)00017-0.CrossRef
32.
Strimpakos N, Sakellari V, Gioftsos G, Kapreli E, Oldham J: Cervical joint position sense: an intra- and inter-examiner reliability study. Gait Posture. 2006, 23: 22-31. 10.1016/j.gaitpost.2004.11.019.CrossRefPubMed
33.
Schuit D, Petersen C, Johnson R, Levine P, Knecht H, Goldberg D: Validity and reliability of measures obtained from the OSI CA-6000 Spine Motion Analyzer for lumbar spinal motion. Man Ther. 1997, 2: 206-15. 10.1054/math.1997.0301.CrossRefPubMed
34.
Howell DC: Power. Statistical Methods for Psychology. 2007, Thomson Wadsworth. USA, 213-229. Sixth
35.
36.
Keeley J, Mayer T, Cox R, Gatchel R, Smith J, Mooney V: Quantification of lumbar function. Part 5: reliability of range of motion measures in the sagittal plane and an in vivo torso rotation measurement technique. Spine. 1986, 11: 31-5. 10.1097/00007632-198601000-00009.CrossRefPubMed
37.
Alaranta H, Hurri H, Heliovaara M, Soukka A, Harju R: Flexibility of the spine: normative values of goniometric and tape measurements. Scand J Rehabil Med. 1994, 26: 147-54.PubMed
38.
Dopf CA, Mandel SS, Geiger DF, Mayer PJ: Analysis of spine motion variability using a computerised goniometer compared to physical examination. A prospective clinical study. Spine. 1994, 19: 586-95. 10.1097/00007632-199403000-00015.CrossRefPubMed
39.
McGregor AH, McCarthy ID, Hughes SP: Motion characteristics of the lumbar spine in the normal population. Spine. 1995, 20: 2421-8. 10.1097/00007632-199511001-00009.CrossRefPubMed
40.
Esola MA, McClure PW, Fitzgerald GK, Siegler S: Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain. Spine. 1996, 21: 71-8. 10.1097/00007632-199601010-00017.CrossRefPubMed
41.
Lyles KW, Gold DT, Shipp KM, Pieper CF, Martinez S, Mulhausen PL: Association of osteoporotic vertebral compression fractures with impaired functional status. Am J Med. 1993, 94: 595-601. 10.1016/0002-9343(93)90210-G.CrossRefPubMed
42.
Smidt GL, Van Meter SE, Hartman MD, Messaros SE, Rubsam DL, Anderson KW: Spine configuration and range of motion in normals and scoliotics. Clin Biomech. 1994, 9: 303-309. 10.1016/0268-0033(94)90043-4.CrossRef
43.
Purser JL, Pieper CF, Duncan PW, Gold DT, McConnell ES, Schenkman MS: Reliability of physical performance tests in four different randomized clinical trials. Arch Phys Med Reahabil. 1999, 80: 557-561. 10.1016/S0003-9993(99)90199-5.CrossRef
44.
Hashimoto T, Oha F, Shigenobu K, Kanayama M, Harada M, Ohkoshi Y: Mid-term clinical results of Graf stabilization for lumbar degenerative pathologies a minimum 2-year follow-up. Spine J. 2001, 1: 283-289. 10.1016/S1529-9430(01)00028-6.CrossRefPubMed
45.
Chromy CA, Carey MT, Balgaard KG, Iaizzo PA: The potential use of axial spinal unloading in the treatment of adolescent idiopathic scoliosis: A case series. Arch Phys Med Reahabil. 2006, 87: 1447-53. 10.1016/j.apmr.2006.08.325.CrossRef
46.
Meade TW, Dyer S, Browner W, Send T, Frank AO: Low back pain of mechanical origin, randomised control trial of chiropractic and hospital outpatient treatment. BMJ. 1990, 300: 1431-7.CrossRefPubMedPubMedCentral
47.
Grieve GP: Contra-indications to Spinal Manipulation and Allied Treatments. Physiotherapy. 1989, 75: 445-453.CrossRef
48.
Mannion AF, Klein GN, Dvorak J, Lanz C: Range of global motion of the cervical spine: intraindividual reliability and the influence of measurement device. Eur Spine J. 2000, 9: 379-85. 10.1007/s005860000187.CrossRefPubMedPubMedCentral
49.
Castro W, Sautmann A, Schilgen M, Sautmann M: Noninvasive three-dimensional analysis of cervical spine motion in normal subjects in relation to age and sex. Spine. 2000, 25: 443-9. 10.1097/00007632-200002150-00009.CrossRefPubMed
50.
Dvir Z, Prushansky T: Reproducibility and instrument validity of a new ultrasonography-based system for measuring cervical spine kinematics. Clin Biomech (Bristol, Avon). 2000, 15: 658-64. 10.1016/S0268-0033(00)00033-4.CrossRef
51.
Dvir Z, Prushansky T, Peretz C: Maximal versus feigned active cervical motion in healthy patients: the coefficient of variation as an indicator for sincerity of effort. Spine. 2001, 26: 1680-8. 10.1097/00007632-200108010-00010.CrossRefPubMed
52.
Coates JE, McGregor AH, Beith ID, Hughes SPF: The influence of initial resting posture on range of motion of the lumbar spine. Man Ther. 2001, 6: 139-144. 10.1054/math.2001.0397.CrossRefPubMed
53.
Dolan P, Adams MA: Recent advances in lumbar spinal mechanics and their significance for modelling. Clin Biomech (Bristol, Avon). 2001, 16: 8-16. 10.1016/S0268-0033(00)00096-6.CrossRef
54.
Jordan K, Dziedzic K, Jones P, Ong B, Dawes P: The reliability of the three-dimensional FASTRAK measurement system in measuring cervical spine and shoulder range of motion in healthy subjects. Rheumatology. 2000, 39: 382-8. 10.1093/rheumatology/39.4.382.CrossRefPubMed
55.
Youdas J, Carey J, Garrett T: Reliability of measurements of cervical spine range of motion-comparison of three methods. Phys Ther. 1991, 71: 98-104.PubMed
56.
Lee R, Evans J: Load-displacement-time characteristics of the spine under posteroanterior mobilisation. Aust J Physiother. 1992, 38: 115-123.CrossRefPubMed
57.
Calling B, Lee M: Effect of Direction of Applied Mobilization Force on the Posteroanterior Response in the Lumbar Spine. J Manipulative Physiol Ther. 2001, 24: 71-78. 10.1067/mmt.2001.112568.CrossRef
58.
Gardner-Morse MG, Stokes IAF: Structural behavior of human lumbar spinal motion segments. J Biomech. 2004, 37: 205-212. 10.1016/j.jbiomech.2003.10.003.CrossRefPubMed
59.
Zander T, Rohlmann A, Bergmann G: Influence of ligament stiffness on the mechanical behavior of a functional spinal unit. Short communication. J Biomech. 2004, 37: 1107-1111. 10.1016/j.jbiomech.2003.11.019.CrossRefPubMed
60.
Dvorak J, Antinnes J, Panjabi M, Loustalot D, Bonomo M: Age and gender related normal motion of the cervical spine. Spine. 1992, 17: 393-398. 10.1097/00007632-199210001-00009.CrossRef
61.
Mayer T, Brady S, Bovasso E, Pope P, Gatchel J: Noninvasive measurement of cervical tri-planar motion in normal subjects. Spine. 1993, 18: 2191-5.CrossRefPubMed
62.
Hagen K, Harms-Ringdahl K, Enger N, Hedenstad R, Morten H: Relationship between subjective neck disorders and cervical spine mobility and motion-related pain in male machine operators. Spine. 1997, 22: 1501-7. 10.1097/00007632-199707010-00015.CrossRefPubMed
63.
Roebroeck ME, Harlaar J, Lankhorst GJ: The application of generalizability theory to reliability assessment: an illustration using isometric force measurements. Phys Ther. 1993, 73: 386-95.PubMed
64.
Rankin G, Stokes M: Reliability of assessment tools in rehabilitation: an illustration of appropriate statistical analyses. Clin Rehabil. 1998, 12: 187-99. 10.1191/026921598672178340.CrossRefPubMed
65.
Strimpakos N, Sakellari V, Gioftsos G, Papathanasiou M, Brountzos E, Kelekis D: Cervical spine ROM measurements: optimizing the testing protocol by using a 3D ultrasound-based motion analysis system. Cephalalgia. 2005, 25: 1133-45.CrossRefPubMed
66.
Alverman A, Furness A, Wellington L: Measurement of shoulder joint kinaesthesia. Man Ther. 1996, 1: 140-145. 10.1054/math.1996.0262.CrossRef
67.
Petty NJ: The effect of posteroanterior mobilisation on sagittal mobility of the lumbar spine. Man Ther. 1993, 1: 25-9. 10.1054/math.1995.0246.CrossRef
68.
McCollam R, Benson C: Effects of postero-anterior mobilisation on lumbar extension and flexion. J Man Manipulative Ther. 1993, 1: 134-141.CrossRef
69.
Gibson H, Ross J, Allen J: The effect of mobilisation on forward bending range. The Journal of manual and manipulative therapy. 1993, 1: 142-147.CrossRef
70.
Goodsell M, Lee M, Latimer J: Short-term effects of lumbar posterioanterior mobilization in individuals with low back pain. J Manipulative Physiol Ther. 2000, 23: 332-42.CrossRefPubMed
71.
Teys P, Bisset L, Vicenzino B: The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther. 2008, 13: 37-42. 10.1016/j.math.2006.07.011.CrossRefPubMed
72.
Maigne JY, Vautravers P: Mechanism of action of spinal manipulative therapy. Joint Bone Spine. 2003, 70: 336-341. 10.1016/S1297-319X(03)00074-5.CrossRefPubMed
73.
Zusman M: Mechanisms of musculoskeletal physiotherapy. Phys Ther Rev. 2004, 9: 39-49. 10.1179/108331904225003973.CrossRef
74.
Potter L, McCarthy C, Oldham J: Physiological effects of spinal manipulation: A review of proposed theories. Phys Ther Rev. 2005, 10: 163-170. 10.1179/108331905X55820.CrossRef
75.
Wright A: Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Manual Therapy. 1995, 1: 11-16. 10.1054/math.1995.0244.CrossRefPubMed
76.
Moulson A, Watson T: A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limb of an asymptomatic population. Man Ther. 2006, 11: 214-224. 10.1016/j.math.2006.04.003.CrossRefPubMed
77.
Vicenzino B, Paungmali Teys P: Mulligan's mobilisation with movement, positional faults and pain relief: Current concepts from a critical review of literature. Man Ther. 2007, 12: 98-108. 10.1016/j.math.2006.07.012.CrossRefPubMed
78.
Troke M, Moore AP, Cheek E: Intra-operator and inter-operator reliability of the OSI CA 6000 Spine Motion Analyzer with a new skin fixation system. Man Ther. 1996, 1: 92-8. 10.1054/math.1996.0256.CrossRefPubMed
79.
Hardy GL, Napier JK: Inter and intra-therapist reliability of passive accessory movement technique. New Zealand J Physioth. 1991, 22-24.
80.
Hicks G, Fritz JE, Delitto A, Mishock J: Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Arch Phys Med Rehab. 2003, 84: 1858-1864. 10.1016/S0003-9993(03)00365-4.CrossRef
81.
Roussel NA, Truijen SI, Lambeets D, Stassijns G: Reliability of the Assessment of Lumbar Range of Motion and Maximal Isometric Strength in Patients With Chronic Low Back Pain. Arch Phys Med Rehab. 2008, 89: 788-791. 10.1016/j.apmr.2007.09.039.CrossRef
82.
Lee SW, Wong KW, Chan MK, Yeung HM, Chiu JL, Leong JC: Development and validation of a new technique for assessing lumbar spine motion. Spine. 2002, 27: E215-20. 10.1097/00007632-200204150-00022.CrossRefPubMed
83.
Ferguson SA, Marras WS: Revised protocol for the kinematic assessment of impairment. The Spine Journal. 2004, 4: 163-9. 10.1016/j.spinee.2003.05.002.CrossRefPubMed
84.
Nitschke JE, Nattrass CL, Disler PB, Chou MJ, Ooi KT: Reliability of the American Medical Association guides' model for measuring spinal range of motion. Its implication for whole-person impairment rating. Spine. 1999, 24: 262-8. 10.1097/00007632-199902010-00013.CrossRefPubMed
85.
Kachingwe AF, Phillips BJ: Inter- and intrarater reliability of a back range of motion instrument. Arch Phys Med Rehabil. 2005, 86: 2347-53. 10.1016/j.apmr.2005.07.304.CrossRefPubMed
Metadata
Title
The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system
Authors
Maria Moutzouri
Evdokia Billis
Nikolaos Strimpakos
Polixeni Kottika
Jacqueline A Oldham
Publication date
01-12-2008
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2008
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/1471-2474-9-131

Other articles of this Issue 1/2008

BMC Musculoskeletal Disorders 1/2008 Go to the issue

Study protocol

Effects of self-management, education and specific exercises, delivered by health professionals, in patients with osteoarthritis of the knee

Research article

Thoracic costotransverse joint pain patterns: a study in normal volunteers

Research article

Photographic measurement of upper-body sitting posture of high school students: A reliability and validity study

Research article

Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women

Research article

Musculoskeletal symptoms of the upper extremities and the neck: A cross-sectional study on prevalence and symptom-predicting factors at visual display terminal (VDT) workstations

Research article

The relative timing of VMO and VL in the aetiology of anterior knee pain: a systematic review and meta-analysis