Background: Low back pain (LBP) is a leading cause of disability worldwide. Mulligan's Sustained Natural Apophyseal Glides (SNAGs) are manual therapy techniques shown to reduce pain and improve function in LBP. However, whether applying SNAGs in loaded (weight-bearing) versus unloaded (non-weight-bearing) positions yields superior clinical outcomes remains unclear.
Objective: To compare the effects of lumbar SNAGs applied in loaded versus unloaded positions on pain, disability, and function in individuals with chronic non-specific LBP.
Methods: A randomized, single-blind, parallel-group clinical trial will recruit 34 participants with chronic LBP. Participants will be allocated to receive SNAGs in either loaded or unloaded positions, combined with a standardized exercise program, for 6 sessions over 1 week. The primary outcome is pain intensity (Numeric Pain Rating Scale) and lumbar flexion range of motion. Secondary outcomes include disability (Oswestry Disability Index). Outcomes will be measured at baseline and immediately post-treatment. Data will be analyzed using linear mixed models on an intention-to-treat basis.
Conclusion: This trial will determine whether a loaded SNAG application provides superior benefits compared to unloaded SNAG in the treatment of chronic LBP. Findings may guide clinical decision-making and optimize manual therapy application.
Chronic non specific low back pain for 6 weeks or more
Who scored between three and six on a visual analogue scale (VAS)
Restriction of the movement was only in flexion ROM
Pregnancy,
Obese,
Infectious conditions of the spine,
Autoimmune disorders,
Parallel
Loaded-SNAG
Procedure/Surgerypatients will receive SNAGs from standing (Loaded-SNAG), step-stance, or functional position that provokes symptoms. A specialized Mulligan belt was used around the patient's waist and the therapist's hips. The mobilizing force was applied parallel to the facet joint plane (cephalic direction) and over the spinous processes of the respective symptomatic spinal levels. The therapist's hand's ulnar aspect was used over the spinous process of the superior vertebra of the involved segment for flexion glide. The therapist applies accessory glide to targeted zygapophyseal level while the patient actively performs symptomatic movement (e.g., forward flexion), performing repetitions with the therapist maintaining the glide.
Unloaded-SNAG
Procedure/Surgerypatients will receive unloaded SNAG from quadruped position to reduce the axial loading. The therapist applies the equivalent accessory glide at the symptomatic spinal level while the patient performs the symptomatic movement (modified to be non-weight-bearing).
Pain intensity
Visual analogue scale (VAS), which is a 10-cm line, 0 denotes no pain and 10 the most intense agony.
Lumbar flexion ROM
The BROM is an electronic goniometer that will be used to evaluate the range of motion for trunk flexion
Functional disability
The functional level was assessed using a validated Arabic version of the Oswestry Disability Index (ODI). A total score will be calculated, the percentage of disability (score obtained divided by 50 and multiplied by 100) ranged from 0% (no disability) to 100% (complete disability).
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