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IRCT20260529069564N3 IRCT 2026-07-08 Gujranwala Institute of Medical and Emerging Sciences (GIMES) Comparing Mulligan Mobilization and Myofascial Release Techniques for Neck Pain in University Students Effects of Natural Apophyseal Glides, Sustained Natural Apophyseal Glides, Myofascial Release, and Combined Therapy on Mechanical Neck Pain in University Students: A Randomized Controlled Trial 2025-01-01 anticipated 120 Complete https://irct.ir/trial/90599 interventional Randomization: Randomized, Blinding: Single blinded, Placebo: Not used, Assignment: Parallel, Purpose: Treatment, Other design features: Single-blind, three-arm, parallel-group randomized controlled trial with 1:1:1 allocation ratio. Participants were randomly assigned using a computer-generated random sequence with allocation concealment through sealed opaque envelopes. Outcome assessors were blinded to group allocation. Interventions were delivered three times per week for 4 weeks, Randomization description: Participants were randomized in a 1:1:1 ratio into three intervention groups: Group A (Natural Apophyseal Glides and Sustained Natural Apophyseal Glides), Group B (Myofascial Release Technique), and Group C (Combined NAGs/SNAGs and Myofascial Release Technique). Individual participants were used as the unit of randomization. In randomization tool, we used Microsoft Excel 365 (RAND function) to generate the random allocation sequence. A simple randomization method was employed using a computer-generated random number sequence. The random allocation sequence was generated independently prior to participant enrolment using computer software. No stratification factors were applied during randomization. Allocation concealment was ensured through the use of sequentially numbered, sealed, opaque envelopes containing group assignments. After confirming eligibility and obtaining informed consent, each participant was assigned to a study group by opening the next envelope in sequence. Outcome assessors were blinded to group allocation; however, due to the nature of the interventions, participants and treating physiotherapists could not be blinded, Blinding description: Blinding procedures were implemented as follows: Participants were blinded to group allocation and were not informed about the specific therapeutic approach assigned to them (NAGs/SNAGs, Myofascial Release, or combined therapy). All interventions were presented as standard physiotherapy techniques to minimize expectation bias. The principal investigator and treating physiotherapists were not blinded due to the nature of manual therapy interventions and their role in delivering treatment. Outcome assessors were blinded to group allocation and were not involved in the treatment process. They performed all baseline and post-intervention assessments independently without access to randomization codes or group assignments. Data analysts/statisticians were blinded to group allocation during data analysis by using coded group labels (A, B, and C) until completion of statistical analysis. The Data and Safety Monitoring Board was not involved in intervention delivery and remained independent of treatment allocation and outcome assessment. Manuscript writers were not involved in outcome assessment and were blinded to group coding during initial statistical interpretation. N/A Condition 1: Mechanical (non-specific) neck pain with associated disability and reduced cervical range of motion in university students. Condition 2: M54.2 - Cervicalgia (Neck pain) M25.60 - Stiffness of unspecified joint, not elsewhere classified (to represent the restriction in cervical range of motion). Intervention 1: Intervention (Group 1): Participants receive Mulligan Concept manual therapy comprising Natural Apophyseal Glides (NAGs) followed by Sustained Natural Apophyseal Glides (SNAGs) for mechanical/non-specific neck pain. NAGs are applied to hypomobile or symptomatic cervical segments (C2–C7) identified during segmental assessment. Participants are treated in a neutral sitting position while the physiotherapist stands behind or beside the participant and applies an antero-superior glide to the cervical articular pillar using the thumb reinforced by the fingers. Passive, pain-free, mid-range oscillatory mobilizations are performed in 3 sets of 8–10 oscillations, with 30 seconds of rest between sets, for approximately 10–12 minutes. Following NAGs, SNAGs are applied to the symptomatic cervical segment. During SNAGs, the physiotherapist maintains a sustained accessory glide along the facet joint plane while the participant actively performs the restricted cervical movement (flexion, extension, or rotation). If the movement is pain-free, gentle end-range overpressure is added. Six to ten repetitions are performed for each symptomatic movement direction, with each sustained glide maintained for 5–10 seconds, requiring approximately 10–15 minutes. Each treatment session lasts approximately 20–25 minutes and is administered three sessions per week for four consecutive weeks (12 treatment sessions in total) by a licensed physiotherapist trained in the Mulligan Concept. No drugs, injections, or medical devices are used during the intervention. Intervention 2: Intervention (Group 2): Participants received Myofascial Release (MFR) therapy for mechanical/non-specific neck pain. The intervention targets the upper trapezius, levator scapulae, sternocleidomastoid (SCM), sub-occipital muscles, and the cervical and upper thoracic paraspinal muscles. Participants are positioned in either a comfortable short-sitting or prone position depending on the muscle being treated. A licensed physiotherapist applies gentle, sustained manual pressure using the hands, fingers, knuckles, or forearms to areas of fascial restriction and myofascial trigger points. A neutral water-based gel is used as a lubricant to facilitate controlled deep tissue gliding and minimize friction. Myofascial release techniques include sustained trigger point pressure, cross-hand fascial stretching, and longitudinal gliding strokes. Sustained pressure is maintained until a palpable fascial release is achieved, typically 90–120 seconds per restricted point, with 2–3 repetitions for each affected muscle group. Each treatment session focuses on the cervical and upper thoracic region and lasts approximately 10–15 minutes. The intervention is administered three sessions per week for four consecutive weeks (12 treatment sessions in total) by a licensed physiotherapist experienced in manual therapy. No drugs, injections, or medical devices are used during the intervention. Intervention 3: Intervention 3 (Group 3): Participants received a combined manual therapy protocol consisting of Myofascial Release (MFR), Natural Apophyseal Glides (NAGs), and Sustained Natural Apophyseal Glides (SNAGs) for the management of mechanical/non-specific neck pain. The intervention is delivered by a licensed physiotherapist trained in manual therapy and the Mulligan Concept. Each treatment session begins with Myofascial Release (MFR) as a preparatory technique to reduce myofascial restrictions and improve soft tissue mobility. MFR is applied to the upper trapezius, levator scapulae, sternocleidomastoid (SCM), sub-occipital muscles, and cervical and upper thoracic paraspinal muscles. Participants are positioned in either a comfortable short-sitting or prone position depending on the muscle being treated. A neutral water-based gel is used to facilitate tissue gliding. The physiotherapist applies sustained manual pressure using the hands, fingers, knuckles, or forearms, employing trigger point release, cross-hand fascial stretching, and longitudinal gliding techniques. Sustained pressure is maintained for 90–120 seconds per restricted point, with 2–3 repetitions for each affected muscle group, for approximately 10–12 minutes. Following MFR, Natural Apophyseal Glides (NAGs) are applied to symptomatic or hypomobile cervical segments (C2–C7) identified during segmental assessment. With the participant seated in a neutral posture, the physiotherapist applies passive, pain-free, mid-range oscillatory antero-superior glides to the cervical articular pillars using the thumb reinforced by the fingers. NAGs are performed in 3 sets of 8–10 oscillations, with 30 seconds rest between sets. Immediately afterward, Sustained Natural Apophyseal Glides (SNAGs) are performed on the symptomatic cervical level. While the physiotherapist maintains a sustained accessory glide along the facet joint plane, the participant actively performs the restricted cervical movement (flexion, extension, or rotation). If the movement is pain-free, gentle end-range overpressure is applied. Six to ten repetitions are performed for each symptomatic movement direction, with each sustained glide maintained for 5–10 seconds. Each combined treatment session lasts approximately 20–25 minutes and is administered three times per week for four consecutive weeks (12 treatment sessions in total). No medications, injections, electrotherapy, or medical devices are used during the intervention. Yes - There is a plan to make this available What will be shared: De-identified participant dataset, study protocol, statistical analysis plan, informed consent form template, and supporting study documents from the randomized clinical trial evaluating Natural Apophyseal Glides (NAGs), Sustained Natural Apophyseal Glides (SNAGs), and Myofascial Release (MFR) for mechanical neck pain in university students. The dataset will include de-identified individual participant data underlying the published results for primary and secondary outcomes (VAS, NDI, and cervical range of motion). When: Data and supporting documents will be available beginning 6 months after publication of the primary study results and will remain available for 5 years following publication. To whom: Data will be available to qualified researchers, clinicians, academic institutions, and healthcare professionals conducting legitimate scientific research. Requests from commercial organizations will be considered on a case-by-case basis. Conditions: Data will be shared for scientifically sound research purposes, including secondary analyses, meta-analyses, and educational or methodological research. Access will be granted following review and approval of a research proposal by the principal investigator. Shared data will be de-identified and may not be used for participant re-identification. Recipients may be required to sign a data-sharing agreement. Where to obtain: Requests should be directed to the corresponding author via email. Data and documents can be obtained upon approval of the request from the study investigators at Gujranwala Institute of Medical and Emerging Sciences (GIMES), Gujranwala, Pakistan. Email: info@gimes.com.pk, and Website: https://gimes.com.pk How to obtain: Interested researchers should submit a written request describing the study objectives, methodology, and intended use of the data. Requests will be reviewed by the principal investigator and research team within approximately 2–4 weeks. Upon approval and completion of any required data-sharing agreement, the requested documents and de-identified dataset will be provided electronically. Comments: No personally identifiable participant information will be shared. Data will be provided in accordance with ethical approval requirements, participant confidentiality protections, and applicable institutional policies.
public Sajjan Iqbal Memon
ST-1/3, Sector 41-B, Korangi Township, Korangi, Karachi
Karachi Pakistan 74900 +92 332 0359073 sajjan.memon@yahoo.com Chiniot General Hospital, Korangi scientific Dr. Noor Fatima
Ali Pur Chatha Road, Near Gujranwala Medical College
Gujranwala Pakistan 52250 +92 324 9970479 doc.nuriya@gmail.com Gujranwala Institute of Medical and Emerging Sciences (GIMES) Pakistan University students aged 18–30 years. Symptoms of mechanical or non-specific neck pain persisting for at least 4 weeks Visual Analog Scale (VAS) score ≥ 3. Neck Disability Index (NDI) score between 10% and 30% (mild to moderate disability). At least 10% limitation in one or more directions of cervical range of motion (ROM) as measured by a bubble inclinometer. Willingness to participate and provide written informed consent. 18 years 30 years Both History of cervical fracture, trauma, or significant neck injury. Presence of cervical radiculopathy, including tingling, numbness, or weakness in the upper limbs. Previous cervical spine surgery. Systemic inflammatory or rheumatologic diseases (e.g., rheumatoid arthritis, fibromyalgia). Receiving concurrent physiotherapy or other rehabilitation treatment for neck pain. Psychiatric illness or cognitive impairment that may interfere with participation or outcome assessment. Refusal or inability to provide informed consent. M54.2 Cervicalgia Rehabilitation Rehabilitation Rehabilitation Intervention (Group 1): Participants receive Mulligan Concept manual therapy comprising Natural Apophyseal Glides (NAGs) followed by Sustained Natural Apophyseal Glides (SNAGs) for mechanical/non-specific neck pain. NAGs are applied to hypomobile or symptomatic cervical segments (C2–C7) identified during segmental assessment. Participants are treated in a neutral sitting position while the physiotherapist stands behind or beside the participant and applies an antero-superior glide to the cervical articular pillar using the thumb reinforced by the fingers. Passive, pain-free, mid-range oscillatory mobilizations are performed in 3 sets of 8–10 oscillations, with 30 seconds of rest between sets, for approximately 10–12 minutes. Following NAGs, SNAGs are applied to the symptomatic cervical segment. During SNAGs, the physiotherapist maintains a sustained accessory glide along the facet joint plane while the participant actively performs the restricted cervical movement (flexion, extension, or rotation). If the movement is pain-free, gentle end-range overpressure is added. Six to ten repetitions are performed for each symptomatic movement direction, with each sustained glide maintained for 5–10 seconds, requiring approximately 10–15 minutes. Each treatment session lasts approximately 20–25 minutes and is administered three sessions per week for four consecutive weeks (12 treatment sessions in total) by a licensed physiotherapist trained in the Mulligan Concept. No drugs, injections, or medical devices are used during the intervention. Intervention (Group 2): Participants received Myofascial Release (MFR) therapy for mechanical/non-specific neck pain. The intervention targets the upper trapezius, levator scapulae, sternocleidomastoid (SCM), sub-occipital muscles, and the cervical and upper thoracic paraspinal muscles. Participants are positioned in either a comfortable short-sitting or prone position depending on the muscle being treated. A licensed physiotherapist applies gentle, sustained manual pressure using the hands, fingers, knuckles, or forearms to areas of fascial restriction and myofascial trigger points. A neutral water-based gel is used as a lubricant to facilitate controlled deep tissue gliding and minimize friction. Myofascial release techniques include sustained trigger point pressure, cross-hand fascial stretching, and longitudinal gliding strokes. Sustained pressure is maintained until a palpable fascial release is achieved, typically 90–120 seconds per restricted point, with 2–3 repetitions for each affected muscle group. Each treatment session focuses on the cervical and upper thoracic region and lasts approximately 10–15 minutes. The intervention is administered three sessions per week for four consecutive weeks (12 treatment sessions in total) by a licensed physiotherapist experienced in manual therapy. No drugs, injections, or medical devices are used during the intervention. Intervention 3 (Group 3): Participants received a combined manual therapy protocol consisting of Myofascial Release (MFR), Natural Apophyseal Glides (NAGs), and Sustained Natural Apophyseal Glides (SNAGs) for the management of mechanical/non-specific neck pain. The intervention is delivered by a licensed physiotherapist trained in manual therapy and the Mulligan Concept. Each treatment session begins with Myofascial Release (MFR) as a preparatory technique to reduce myofascial restrictions and improve soft tissue mobility. MFR is applied to the upper trapezius, levator scapulae, sternocleidomastoid (SCM), sub-occipital muscles, and cervical and upper thoracic paraspinal muscles. Participants are positioned in either a comfortable short-sitting or prone position depending on the muscle being treated. A neutral water-based gel is used to facilitate tissue gliding. The physiotherapist applies sustained manual pressure using the hands, fingers, knuckles, or forearms, employing trigger point release, cross-hand fascial stretching, and longitudinal gliding techniques. Sustained pressure is maintained for 90–120 seconds per restricted point, with 2–3 repetitions for each affected muscle group, for approximately 10–12 minutes. Following MFR, Natural Apophyseal Glides (NAGs) are applied to symptomatic or hypomobile cervical segments (C2–C7) identified during segmental assessment. With the participant seated in a neutral posture, the physiotherapist applies passive, pain-free, mid-range oscillatory antero-superior glides to the cervical articular pillars using the thumb reinforced by the fingers. NAGs are performed in 3 sets of 8–10 oscillations, with 30 seconds rest between sets. Immediately afterward, Sustained Natural Apophyseal Glides (SNAGs) are performed on the symptomatic cervical level. While the physiotherapist maintains a sustained accessory glide along the facet joint plane, the participant actively performs the restricted cervical movement (flexion, extension, or rotation). If the movement is pain-free, gentle end-range overpressure is applied. Six to ten repetitions are performed for each symptomatic movement direction, with each sustained glide maintained for 5–10 seconds. Each combined treatment session lasts approximately 20–25 minutes and is administered three times per week for four consecutive weeks (12 treatment sessions in total). No medications, injections, electrotherapy, or medical devices are used during the intervention. Pain Intensity. Timepoint: at baseline (pre-intervention) and within 48 hours after the final session (post-intervention). Method of measurement: Visual Analog Scale (VAS). Functional Disability. Timepoint: at baseline (pre-intervention) and within 48 hours after the final session (post-intervention). Method of measurement: Neck Disability Index (NDI). Cervical range of motion (ROM). Timepoint: at baseline (pre-intervention) and within 48 hours after the final session (post-intervention). Method of measurement: measured using a bubble inclinometer (flexion, extension, right/left lateral flexion, and right/left rotation). Gujranwala Institute of Medical and Emerging Sciences (GIMES) Approved 2025-05-15 Institutional Review Board of Gujranwala Institute of Medical and Emerging Sciences Ali Pur Chatha Road, Near Gujranwala Medical College, Gujranwala Gujranwala Punjab Pakistan