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Year : 2019  |  Volume : 19  |  Issue : 3  |  Page : 86-91

Effect of modified lumbar-sustained natural apophyseal glides (Snags) in nonspecific low back pain

1 Department of Physiotherapy, School of Physiotherapy, Mayo Hospital, Lahore, Pakistan
2 Department of Rehabilitation Sciences, The University of Faisalabad, Faisalabad, Pakistan

Date of Submission10-Oct-2019
Date of Decision18-Jul-2020
Date of Acceptance23-Jul-2020
Date of Web Publication21-Aug-2020

Correspondence Address:
Dr. Nimra Arshad
The University of Faisalabad, Faisalabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjsm.sjsm_16_19

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Context: Low back pain (LBP) is one of the commonly prevailing disorders, and the leading source of causing disability globally. Spinal mobilization is commonly used in the clinical practice. According to some studies, it is evident that mobilization to the spine can be helpful in lessening pain.
Aims: The purpose of the current study was to check the comparative effectiveness of Maitland Grade 1 and 2 mobilizations with mulligan snags mobilization in the treatment of nonspecific LBP.
Subjects and Methods: A sample of 40 patients (mean age 35.25 years) who met with the inclusion conditions were recruited in the current study. Twenty patients each were divided into both treatment groups. Written informed consent took from each individual participating and divided randomly into two groups. In “Group A” Maitland technique, Grade 1 and Grade 2 were applied, whereas in “Group B” mulligan snags mobilization technique was applied along with infrared therapy as baseline treatment for 2 weeks. Oswestry disability questionnaire and the Numeric Pain Rating Scale (NPRS) were used for assessment pre- and post-treatment.
Statistical Analysis: SPSS version 21 was used. The Independent t-test was used between-group comparison and paired sample t-test was used for within-group comparison.
Results: Mean difference between pre- and post-treatment values for NPRS and Oswestry Disability Index in Group A was 4.40 ± 1.31 and 24.95 ± 7.702, respectively, whereas in Group B was 3.20 ± 1.105 and 22.60 ± 9.202, respectively, with significant value of P= 0.003.
Conclusions: It was concluded that mulligan mobilization is more effective than Maitland mobilization for LBP treatment. Mulligan mobilization not only decreased pain but also improved the functioning of the spine.

Keywords: Maitland mobilization, nonspecific low back pain, Numeric Pain Rating Scale, oswestry disability questionnaire, sustained natural apophyseal glides

How to cite this article:
Manzoor T, Arshad N, Nasir N, Zia A. Effect of modified lumbar-sustained natural apophyseal glides (Snags) in nonspecific low back pain. Saudi J Sports Med 2019;19:86-91

How to cite this URL:
Manzoor T, Arshad N, Nasir N, Zia A. Effect of modified lumbar-sustained natural apophyseal glides (Snags) in nonspecific low back pain. Saudi J Sports Med [serial online] 2019 [cited 2023 Sep 21];19:86-91. Available from: https://www.sjosm.org/text.asp?2019/19/3/86/292945

  Introduction Top

Nonspecific low back pain (LBP) is defined as the LBP without any recognizable or known pathology (a symptom for which we are currently unable to identify a pathology) such as bone disorder in the spine (fracture), radicular nerve compression, slipped intervertebral disc, lumbar canal stenosis, inflammatory disorder of the spine (ankylosing spondylitis), cauda equine syndrome, congenital back disorder, infection in the spine, tumor, and osteoporosis.[1]

LBP is a disease that affects nearly 80% population from all over the world.[2] Moreover, mare commonly, the suffering population is nonspecific LBP which represents no known cause.[3] The fifth most common reason to consult a general physician is LBP, and it is the second commonly prevailing cause for less efficiency in various work stations.[4]

Mostly LBP is noted in the middle-aged population in their 30–50 years, and it is equivalent in both genders but women age 40 and above are mostly victimized by this.[5] According to LBP definition, it is the pain that is described somewhere between the inferior end of the rib cage to the inferior end of the gluteal region whether the pain is referred to as the lower extremity or not.[6]

Physiotherapy has been commonly used for the treatment of LBP. This stereotypically includes different kinds of treatment strategies, but mostly involves exercises, counseling, different manual mobilizations, the McKenzie technique, core stability and abdominal exercise interventions, transcutaneous electrical nerve stimulation, different kinds of therapeutic modalities including short-wave diathermy, interferential therapy, ultrasound as well as numerous other nonfrequently used treatments.[7]

A modified lumbar Sustained Natural Apophyseal Glide (SNAG) is an existing Mulligan mobilization technique performed with a combination of joint glide and physiological spinal movement. The glide can be applied to the spinous processes, facets, or unilaterally over the transverse processes with the radial border of your hand while the patient performs the active exercise.[8]

Postero-anterior mobilization is most commonly utilized by physiotherapists in the diagnosis and assessment of LBP and involves the application of posteroanterior (PA) force by physiotherapists over the lumbar spinous processes of the patient lying in the prone or side-lying position. During the performance of this treatment, the physiotherapist pursues to regulate the mechanical reaction of the spine in relation to the quantity of force applied to the resultant displacement; consequently, it helps in estimation in the stiffness of the subsequent movement. Information getting from this maneuver can impact many clinical decision-making outcomes, comprising of the decision at which spinal level treatment should be applied and what dosage and frequency should be kept.[9],[10]

LBP is a very familiar problem in all age groups. It leads to multiple dysfunctions depending upon the severity of pain. It may limit the spinal range of motion and leads to functional dependency. The outcome of this study is of great value in treating LBP which is a great contribution to the health-care system.

  Subjects and Methods Top

After the approval from the ethical committee of institute, the study was conducted at Mayo Hospital Lahore, Pakistan. Forty participants with chronic nonspecific LBP were nominated. Initially, consent form available in the English language was distributed among the population of interest to acknowledge their interest in the study by their willingness. All procedure were explained to participants about screening form its questions, complete information about the condition of interest, an intervention which was used and its significance on them and all about measuring tools. Demographic data were also obtained from participants, including name, age, and gender. Opaque-concealed envelops were used for allocation. Twenty patients were assigned through random allocation to each of the two groups. Allocation of patients in two groups had done by the computerized generated list. Consent was obtained from each patient through a consent form. Patients were included in the study having nonspecific LBP for more than 3 months of duration and age of 30–50 years. Both males and females patients were included. The exclusion criteria were patients with a medical record of spine pathology, patients who have undergone spinal surgery, patients with a history of osteoporosis, history of vertebral fracture, and patients having any signs of radiculopathy, neurogenic claudication. After the physical examination by the therapist, the data were collected. The data comprised of demographic data, including age, sexual category, past medical history, socioeconomic status, marital status, and educational status, length of inception nature, and location of symptoms. Both groups received conventional therapy as a baseline, which remained the same throughout the study. Conventional therapy included a hot pack for 15 min. Group A received conventional therapy and Maitland Grade 1 and 2 mobilizations while Group B received conventional therapy and Mulligan snags mobilization. Treatment duration was 30 min for one session. They were followed 3 days a week for 2 weeks [Flow chart 1]. Patients who received the intervention of Maitland mobilization and mulligan mobilization was questioned for pain and disability by the Numeric Pain Rating Scale (NPRS) and Oswestry scale. Data were analyzed using the SPSS software version 21 by IBM company, USA. A paired sample t-test was utilized for within-group comparison and an independent-sample t-test was utilized for between-group comparisons.

  Results Top

Data were analyzed using the SPSS software version 21. The results were obtained using the SPSS version 20. The test applied includes independent and paired sample t-test for comparison of different groups. The t-test measurements were used to evaluate the clinical assessment parameters over time observation. Descriptive statistics were also used.

A total of 40 participants were included in the study, and most were females having 33 out of 40 [Figure 1].
Figure 1: Pie chart of the Gender of the participants

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The mean age in Group A was 35.85 ± 7.70 and in the Group B was 32.50 ± 7.75 [Table 1].
Table 1: Mean±standard deviation of participants' demographic data

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According to the application of Paired sample t-test showed that pre- and post-treatment comparison of NPRS in Group A has showed that mean NPRS score before the treatment was 6.45 ± 1.276 which was improved to 3.20 ± 1.105. Pre- and post-treatment comparison of NPRS score in Group B has shown that the mean NPRS score before treatment was 7.10 ± 1.832 which was improved to 4.40 ± 1.31 [Figure 2].
Figure 2: Pre- and Post-values of numeric pain rating score in Group A and Group B

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Pre- and post-treatment comparison of Oswestry low back disability questionnaire in Group A has shown that mean Oswestry Disability Index (ODI) score before the treatment was 45.2 ± 16.214 which was improved to 24.95 ± 7.702 Pre- and post-treatment comparison of Oswestry low back questionnaire in Group B has shown that mean ODI score before treatment was 39.30 ± 13.845 which was improved to 22.60 ± 9.202 [Figure 3].
Figure 3: Pre- and post-values of Oswestry low back questionnaire in Group A and Group B

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According to the application of independent samples, the t-test showed that posttreatment comparison of NPRS in both groups has shown that, mean NPRS in Group A was 4.40 ± 1.31 while in Group B was 3.20 ± 1.105, showing that mulligan is more effective in reducing pain with P = 0.003. Posttreatment comparison of ODI in both groups has shown that, mean ODI in Group A was 24.95 ± 7.702, while in Group B was 22.60 ± 9.202, showing that mulligan is more effective in reducing pain with P = 0.003 [Table 2].
Table 2: Comparison of NPRS and ODI scores means±standard deviation in both groups before and after treatment

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  Discussion Top

Although mobilization is often used in the management of low-back pain, there has been highly little investigation of its impact on low-back pain symptoms or the mechanism whereby it achieves these effects. It is frequently proposed that manipulative remedy interventions, such as mobilization, alter symptoms through an impact on the mechanical properties of the spine.[11],[12]

Lately, it is reported in various experimental studies measuring the taxonomy arrangements in patients with persistent chronic LBP that have not to initiate its efficacy in the following grouping arrangements. Apeldoorn along with the co-workers initiated that utilizing the classification based on management arrangement was no differently active than typical physiotherapy exercise upkeep in patients having persistent chronic nonspecific LBP.[13]

Henry et al. did not notice any alterations in the results using both the treatment-Based Cataloging and Movement related Systematic Deficiency arrangements in patients having persistent chronic LBP.[14]

According to a study conducted by Heggannavar and Kale, they concluded that lumber SNAGs application in lion position has an effect on lessened pain and activity restrictions with that it as a positive effect on lumbar flexion range of motion in LBP.[15]

Research conducted in 2017 showed that if the lumbar SNAG program is added to LBP with different stretching and strength interventions proved slightly beneficial in the resolve of LBP with respect to pain and functioning activity level.[16]

The locating that PA stiffness did no longer change after mobilizations in agreement with the most effective previous study comparing the effect of a manipulative remedy intervention on PA stiffness, wherein a PA thrust manipulation becomes discovered to do not have any impact on PA stiffness inside the thoracic spine of symptom-free sufferers.[17]

Javaherian et al. along with his colleagues conducted a research in which he found out the immediate effects of both mobilization techniques in increasing flexion and extension ranges of motion in LBP. In this research, he concluded that SNAG technique has a more powerful impact in increasing flexion range of motion in lumbar spine rather than posterior-anterior mobilization. On the contrary, PA mobilization is effective in increasing the extension range of motion.[18]

The primary objective of this study was to check the effects of Maitland and Mulligan mobilizations at nonspecific LBP, secondary objectives include reduce pain and enhance functional outcomes. This study revealed that mulligan mobilization was more effective to reduce pain, enhance physical outcomes in patients with nonspecific LBP than Maitland mobilizations.

  Conclusions Top

This study concluded that the Mulligan snags technique had shown greater improvement in mean differences as compared to Maitland mobilization when analyzed through NPRS and ODI.


The main limitation of this research was that it was single-centered research, as all the patients were taken from one hospital or center. The time duration to complete this study was limited, and the sample size was for this study was limited too. It was not funded.


In future researchers should study to examine the effectiveness of different techniques, types, grades, and dosages of exercise therapy and should observe long-term effects of treatment protocol by having follow-up data of the patients.


I would like to convey my thanks to all the people who guided and helped my research work with purposeful advice and patience I would also especially like to thanks all those people who willingly participate in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. The Lancet 2012;379:482-91.  Back to cited text no. 1
Waddell G, Somerville D, Henderson I, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine (Phila Pa 1976) 1992;17:617-28.  Back to cited text no. 2
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760-5.  Back to cited text no. 3
Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290:2443-54.  Back to cited text no. 4
Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil 2005;86:1753-62.  Back to cited text no. 5
Dionne CE, Dunn KM, Croft PR, Nachemson AL, Buchbinder R, Walker BF, et al. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976) 2008;33:95-103.  Back to cited text no. 6
Ladeira CE, Samuel Cheng M, Hill CJ. Physical therapists' treatment choices for non-specific low back pain in Florida: An electronic survey. J Manual and Manipulative Therapy 2015;23:109-18.  Back to cited text no. 7
Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075-94.  Back to cited text no. 8
Mehulbhai BP, Sandeep SM. Comparison of effect of pulsed electromagnetic energy therapy v/s hot packs on pain and function in subjects with nonspecific low back pain. Int J Innovative Res Adv Studies (IJIRAS) 2017;4:350-3.  Back to cited text no. 9
da C Menezes Costa L, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO. The prognosis of acute and persistent low-back pain: A meta-analysis. CMAJ 2012;184:E613-24.  Back to cited text no. 10
Grieve GP. Manipulation: A part of physiotherapy. Physiotherapy 1978;64:358-63.  Back to cited text no. 11
Mennell JM. Back pain. Diagnosis and Treatment Using Manipulative Techniques 1960;226:109-15.  Back to cited text no. 12
Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG. Effect of a home program of hip abductor exercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: A clinical trial. Phys Ther 2010;90:895-904.  Back to cited text no. 13
Apeldoorn AT, Ostelo RW, van Helvoirt H, Fritz JM, Knol DL, van Tulder MW, et al. A randomized controlled trial on the effectiveness of a classification-based system for subacute and chronic low back pain. Spine (Phila Pa 1976) 2012;37:1347-56.  Back to cited text no. 14
Heggannavar A, Kale A. Immediate effect of modified lumbar SNAGS in non-specific chronic low back patients: A pilot study. Int J Physiother Res 2015;3:1018-23.  Back to cited text no. 15
Hussien HM, Abdel-Raoof NA, Kattabei OM, Ahmed HH. Effect of Mulligan Concept Lumbar SNAG on Chronic Nonspecific Low Back Pain. J Chiropr Med 2017;16:94-102.  Back to cited text no. 16
Lee M, Latimer J, Maher C. Manipulation: Investigation of a proposed mechanism. Clin Biomech (Bristol, Avon) 1993;8:302-6.  Back to cited text no. 17
Javaherian M, Tajali SB, Moghaddam BA, Keshtkar AA, Azizi M. Immediate effects of Maitland mobilization and Mulligan techniques on flexion and extension range of motion in patients with chronic nonspecific low back pain: A randomized pilot study. J Modern Rehab 2017;11:127-32.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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