To synthesize the effectiveness of Mulligan’s techniques (Sustained Natural Apophyseal Glides (SNAGs) or Natural Apophyseal Glides (NAGs)) to decrease pain, disability, or to improve cervical range of motion (CROM) in adults with acute, subacute, and/or chronic NSNP.
This systematic review with meta-analysis involved a comprehensive search of five databases and manual search (updated in April 2024) for studies on Mulligan’s techniques and cervical disorders, without year of publication and language restrictions. Randomized controlled trials (RCT) comparing Mulligan’s techniques to other treatments in adults with NSNP were included. Two independent reviewers conducted the screening, data extraction, and risk of bias (RoB) assessments. Meta-analysis was performed when applicable, otherwise a narrative synthesis was used. The RoB assessment was performed using the Cochrane RoB-2 Tool, and the certainty of the evidence with GRADE approach.
Nineteen studies were included in this review. Mulligan’s techniques were no more effective than other interventions to reduce pain and disability or to improve CROM in adults with acute and subacute NSNP. However, positive results favoring Mulligan's techniques combined with exercises, manual therapy, and conventional therapy (CT) were found for patients with chronic and mixed (acute, subacute, and/or chronic) NSNP. In a meta-analysis (two studies), SNAGs plus exercises was better (statistically and clinically) in reducing pain intensity (standardized mean difference (SMD) [95%CI] = -2.38 [-3.07, -1.69]; I²=32%), and improving neck flexion movement (SMD [95%CI] = 1.73 [0.59, 2.87]; I²=80%) compared to exercises alone. Also, SNAGs plus CT presented better results in neck lateral flexion (right (SMD [95%CI] = 0.90 [0.55; 1.25]; I² =0%) and left (SMD [95%CI] = 1.09 [0.73; 1.45]; I²=0%) and in neck rotation movement (right: SMD [95%CI] = 1.51 [1.13; 1.89]; I² = 66%; left: SMD [95%CI] = 1.84 [1.11; 2.57]; I² = 66%) after treatment compared to CT plus exercises. No difference between Mulligan’s techniques and other treatments was found for neck disability. The overall RoB for most studies (n=15) was classified as high; four studies had some concerns. The quality of evidence was rated very low for all comparisons.
The combination of Mulligan’s techniques with other interventions, particularly CT, exercise, and manual techniques, could benefit patients with chronic or mixed NSNP, comparable or superior to other routinely used techniques. However, when Mulligan`s techniques were applied in isolation, no superior effects were observed when compared to other techniques.
Mulligan's techniques should be combined with other interventions to improve CROM and reduce pain and disability in patients with NSNP which aligns with clinical guidelines’ recommendations. The decision to use Mulligan's techniques should be guided by pain chronicity, treatment’s aim, and desirable target outcome. Better quality RCTs should be performed to increase the certainty in the evidence of the effectiveness of Mulligan’s techniques in patients with NSNP.
Neck Pain
Systematic Review
