Effectiveness of Mulligans Spinal Monilization with Arm Movements and Sustained Natural Apophyseal Glides in reducing pain and functional disabilities in patients with Cervical Radiculopathy:A comparative study

INTRODUCTION: Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or arthritic bone spurs. Those can be compression, irritation, traction, and a lesion on the nerve root caused by a herniated disc, foraminal narrowing or degenerative spondylotic change leading to stenosis of the intervertebral foramen. [1, 2]

Typical symptoms of cervical radiculopathy are: irradiating arm pain corresponding a dermatomal pattern, neck pain, paraesthesia, muscle weakness in a myotomal pattern, headaches, scapular pain, sensory and motor dysfunction in upper extremities and neck. [1, 2]

Physical therapy interventions often used for the management of cervical radiculopathy include cervical traction, postural education, exercise, electrical modalities like IFT and TENS, and manual therapy applied to the cervical spine and thoracic spine. [3] 3

The Mulligan concept has its foundation built on Kaltenborn’s principles of restoring the accessory component of physiological joint movement. Mulligan proposed that injuries or sprains might result in a minor positional fault to a joint, thus altering the biomechanics at the joint, causing restrictions in physiological movement. Mobilization of the spine maybe done in the functional, weight bearing position by applying the force parallel to the spinal facet planes. It maybe oscillatory (Natural Apophyseal Glides- NAGs) or a sustained glide maintained coupled with the patient performing the offending spinal movement (Sustained NAGs- SNAGs). [1]

In 1990, Brian Mulligan introduced a technique known as: spinal mobilisations with limb movements (SMWLMs). Here, a sustained transverse glide is applied to the spinous process of a vertebra while the restricted peripheral upper or lower limb movement is performed, actively or passively. The foremost emphasis remains that the mobilization must result in symptom-free movement. Mulligan proposed that utilization of these mobilization techniques was indicated when peripheral joint limitation of movement is spinal in origin. [1]

SMWAM amalgamates the concept of neurodynamics with Mulligan’s concept that minor positional faults of joints can occur following injuries and strains, whereby joints are no longer aligned in their natural, congruent position, but are subtly maligned. IN the case of radiating pain, neural tissues may be adhered to surrounding structures, resulting in lack of sliding and gliding, and hence giving 4

additional stretch to the nerve. Due to transverse glide, the vertebral body rotates towards the same side, resulting in opening of foramina on the affected side. Adding arm movement with opened foramina will result in mobilization of neural tissues. [4, 5, 6] 5

**NEED FOR THE STUDY:**The Mulligan concept is now an integral component of many manual physiotherapists clinical practice. Studies have been conducted measuring the efficacy of SNAGS, showing the beneficial effects.

Spinal mobilisation with arm movements (SMWAMs) can be used for restricted upper limb movements that could be as a result of a spinal joint dysfunction or abnormal neural dynamics. However, data regarding the effects of SMWAM is scarce.

This study aims to gain data regarding the effectiveness of Mulligan SMWAM and to obtain a comparison between the effects of the both techniques, thereby providing clinical therapists an evidence-based better choice of treatment. 6

AIM: To compare the effects of SMWAM and SNAGS on pain, ROM and function in patients with cervical radiculopathy**.**

**OBJECTIVES:**1. To find the effect of SMWAM on pain, cervical ROM and functional outcome in patients with cervical radiculopathy.

2. To find the effect of SNAGS on pain, cervical ROM and functional outcome in patients with cervical radiculopathy.

3. To compare the effects of SMWAM and SNAGS in patients with cervical radiculopathy**.** 7

**RESEARCH QUESTION:**Which of the two techniques is better in relieving pain, improving ROM and function, in patients with cervical radiculopathy- SMWAM or SNAGS?

**HYPOTHESIS:**There is significant difference between SMWAM and SNAGS in relieving pain, improving ROM and function in patients with cervical radiculopathy.

**NULL HYPOTHESIS:**There is no significant difference between SMWAM and SNAGS in relieving pain, improving ROM and function in patients with cervical radiculopathy.

**METHODOLGY:**STUDY DESIGN: Experimental study

METHOD OF SAMPLING: Simple Randomisation using computer generated random table

SAMPLE SIZE: 40 (20 in each group)

MATERIALS USED: Universal Goniometer

INCLUSION CRITERIA: ï‚· Age group from 30 to 60 years.

ï‚· Males and females both included.

ï‚· NRS score 4 to 7. (Moderate pain).

ï‚· Diagnosed cases of unilateral cervical radiculopathy.

 Subjects with Spurling‘s test positive.

ï‚· Subjects with ULTT-1, 2 positive.

EXCLUSION CRITERIA: ï‚· Spondylolisthesis

ï‚· Cervical spine fracture

ï‚· Bilateral Radiculopathy

ï‚· Any Spinal Surgery

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PROCEDURE: •Post approval by the institutional ethical committee, patients will be assessed for eligibility and informed consent will be obtained from the subjects who fulfil the inclusion criteria.

•Patients will be assigned into two groups by computerised random sampling.

•Group A will be given SMWAM and exercise therapy.

•Group B will be given SNAGS and exercise therapy.

•A pre-treatment NRS, Cervical range of motion using universal goniometer and Neck Disability Index will be performed and documented.

•Patients will receive treatment for 3 sessions for 1 week.

•A post treatment NRS, Cervical range of motion and Neck Disability Index will be performed in both the groups.

**OUTCOME MEASURES:**1. Numerical rating Scale

2. Cervical ROM using Universal Goniometer.

3. Neck Disability Index.