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Indian Journal of Physiotherapy and Occupational Therapy

The effectiveness of self snags over conventional physiotherapy management in chronic neck pain among computer professionals

Author(s): Shilpi Chhabra, Deepti Chhabra, Jatinder Sachdeva, Amit Chaudhary

Vol. 2, No. 3 (2008-07 - 2008-09)

Shilpi Chhabra, Deepti Chhabra, Jatinder Sachdeva, Amit Chaudhary

Department of Therapies and Health Sciences, Faridabad Institute of Technology, Faridabad, Haryana

Abstract

Objective: To prove the effectiveness of self SNAGS over conventional Physiotherapy management in chronic neck pain among Computer Professionals.
Methods: A structured questionnaire was used to obtain information from 38 Computer users, using for at least 4-5 hours per day from various Software Companies. The incidence of neck pain, range of motion and disability in the experiment group (receiving self SNAGS along with conventional management) was compared with the incidence in the treatment group (only conventional management) over a period of one month. Subjects reported symptoms in a weekly diary. Participants with neck pain for more than 3 months were considered symptomatic.
Results: Though, pain scores showed significant improvement with p=0.03 while cervical rotation of right side showed significant improvement at p= 0.04 during follow up period in experimental group statistically, there was not much significant difference in the incidence of disability and neck range of motion between two groups. Clinically, the results depicted that experimental group was superior to treatment group.
Conclusion: This study depicted that group receiving self SNAGS showed better carry over effect during treatment phase and more during follow up phase as compared to group receiving conventional physiotherapy alone. Hence, self SNAGS can be incorporated as a treatment tool for chronic neck pain patients. Further studies may require with subjects as general population with chronic neck pain or as a rationale for adapting the specific intervention according to the repeated assessment findings.

Introduction

The use of the computer is improving the quality of health care systems as well as the efficiency of the workers on one hand but on the other hand, as one uses computers for many hours continuously, he or she may notice increasing aches and pains in some parts of the body, usually, musculoskeletal in nature.

Pain in the neck has become one of the leading problems nowadays. Neck flexion, forward head posture, scapular retraction, forward stoop posture are some of the faulty postural alignment, resulting in neck pain due to increased cervical muscle activity to support head in forward position and results in increase in fatigue.

Neck pain may lasts for few days and considered as acute neck pain and may result from facet syndrome or muscular rheumatism. But if it persists for a longer time i.e more than 3 months, it becomes chronic and presents a greater problem. It may also result in restricted movements of neck. Pain in the neck arises from musculoskeletal impairment and physical therapies such as manipulative therapy, therapeutic exercise, electrophysiological agents have traditionally been the treatments of choice. But concrete data is not available regarding the efficacy of modern manual techniques over conventional physiotherapy. Hence, the present study involves the comparison for the efficacy of modern manual therapy (Mulligan’s self SNAGS) over conventional therapy for chronic neck pain in computer professionals.

Mulligan’s concept of mobilization with movements (MWMs), first used in cervical spine, carry the acronym, SNAGS, stands for sustained natural apophyseal glides, used to improve function, restriction or pain in flexion, extension, rotation, side flexion of cervical spine. Self treatment using SNAGS with a small hand towel can also be beneficial. Mulligan proposed that when an increased in pain free range of movement occurs with a SNAG, also influences the entire spinal functional unit. Clinically, SNAG on a painful mobile level may not always achieve a full pain free movement whereas restricting the movement of a painful mobile segment or gliding a nearby stiff segment does achieve the desired result.

It was hypothesized that self SNAGS in conjunction with conventional physiotherapy management would be more beneficial in alleviating pain and improving neck function than conventional physiotherapy management alone among Computer professionals. If proved effective, SNAGS can be then incorporated as specific treatment tool for patients with chronic neck pain.

It is clear from the literature available, that though neck pain is a common complaint among computer professionals and the computer technology is advancing at a faster pace, little is done in preventing the ailments that are associated with its use. There is lack of evidence based studies in this area. Therefore, due to an almost complete lack of empirical evidence supporting the clinical use of self SNAGS for chronic neck pain, this study is being conducted.

Methods

A convenience sample of subjects was solicited from various Software Companies. Inclusion criteria included any person (20- 50 years) using Computer for at least 4-5 hours per day, complaining of neck pain for the last three months. Exclusion criteria included pregnant women, persons with rheumatoid arthritis, ankylosing spondylitis, tumors, vertebro basilar insufficiency symptoms, fracture or dislocation, recent undergone surgery or any acute inflammatory problem.

Materials: Universal Goniometer, Visual analog scale, neck disability index, hot packs and hand towel.

Procedure

Participants were recruited from Software Companies (n=38, age range= 20-50 years, mean age= 35 years, male or female) and asked to fill questionnaire form about musculoskeletal symptoms and intensity or severity of pain experienced. Subjects were then allocated into two groups, Group A, where subjects were taught carefully self SNAGS for extension, rotation and lateral flexion of cervical spine with the help of hand towel along with hot packs and advised on correct posture during work hours. Subjects in Group B were just asked to take hot packs for 15-20 minutes at night and postural advice given.

For cervical extension

  • Towel is held on the cervical spine and the selvage on one side is hooked under the spinous process.
  • The patient grips each end of the towel and pulls up along the treatment plane as he or she extends the neck.
  • Extension overpressure must be applied at the end range by patient or by someone in the patient’s household and sustained until neck returns to neutral position.
  • Repeat it 6-10 times and can be repeated every two hours.
  • If there is pain experienced by the patient while performing SNAGS, stop the treatment immediately and try other levels until they get it right. For cervical rotation
  • The selvage on one side of the towel is hooked under the spinous process.
  • For right rotation, grasp the left side of the towel with right hand and the right side of the towel with the left hand.
  • The left arm (beneath) is hooked on the back of the chair to stabilize the arm. The right hand now pulls the towel up in the direction of facet joint or towards the direction of eyeball and patient rotates his/ her head to the right.
  • Overpressure is then applied at the end range and sustained for few seconds until neck returns to neutral position.
  • Repeated 6-10 times, every 2 hours. For lateral flexion
  • Similar done as cervical rotation, only difference is while towel is being pulled, patient side flexes the neck and then overpressure applied at the end range.
  • Repeated 6-10 times, every 2 hours.

Postural advice has been given to subjects to prevent bad posture. Participants were advised to:

- Keep the spine upright while sitting on chair during work hours.
- Keep the shoulders straight and retracted.
- Take frequent breaks between work hours.

Outcome Measures- Pain and Range of motion were recorded on day 0, day 16 and day 31 whereas disability scores were recorded on day 0 and day 31.

Results

A total of 38 subjects were identified as potential participants for this study and were allocated to the experimental and treatment groups. The mean age of the respondents was 40.8 years, with 53% females and 47% males. The respondents had a mean of 9 years of experience with an average of 7 hours spent on computer per day.

The data obtained was tabulated and statistically analyzed using SPSS 14.0 package. Due to nature of outcome measures i.e pain, disability and neck range of motion, parametric statistical tests, independent t sample test and paired t test were used.

Subjects showed marked reduction in pain intensity when compared to baseline value. The improvement is almostwhereas disability scores were recorded on day 0 and day 31.

Independent t sample test was used for between group analyses while paired t test was used for within group analysis for all the outcome measures. Significant level was defined at p< 0.05 and the 95% confidence interval.

Graph 1: Line Diagram showing comparison between groups for pain scores.

Though, pain scores showed significant improvement with p= 0.03 while cervical rotation of right side showed significant improvement at p= 0.04 during follow up period in experimental group statistically, there was not much significant difference in the incidence of disability and neck range of motion between two groups. Clinically, the results depicted that experimental group was superior to treatment group.

similar in both the groups but experimental group is more superior to treatment group in treatment as well as follow up phase.

Discussion

The proposed study suggests that the technique of self SNAGS can be incorporated as a treatment tool for Computer professionals during their work hours, along with the application of hot packs as well as postural advice. It resulted in an overall improvement in pain, functional outcome and range of motion for neck extension, lateral flexion and rotation, as tested. The significant improvement was seen clinically for all the outcome measures, as reported by subjects receiving self SNAGS. Early recovery from pain with lesser number of sessions of self SNAGS and improvement in neck range of motion was reported by the subjects in experimental group. It is clearly seen from the graphs that consistent and significant improvement had occurred during the treatment phase as well as follow up phase of the intervention. This improvement possibly may be attributed to the fact that the accessory glide component of a cervical SNAG could ameliorate any of these problems either by separating the facet surfaces and releasing the entrapped meniscoid, or by allowing the entrapped meniscoid to return to its intra articular position, or perhaps by stretching adhesions.19

Statistically, there was no significant improvement for disability scores and range of motion for extension and lateral flexion. Though reduction of pain and increase in range of motion for rotation were statistically significant too. This may be due to poor patient compliance towards home program or because of certain abnormal work postures during work hours.

This study attempted to identify a specific subgroup of individuals, specifically computer professionals with chronic neck pain using this diagnostic focus and to determine the efficacy of self SNAGS over conventional physiotherapy management alone.

Mulligan (1994 a) has put forward a theory which could help to explain the need for ipsilateral physiological rotation during application of a cervical SNAG. He suggested that the superior facet of the implicated functional spinal unit ipsilateral to the side of the pain may be jammed posteroinferiorly in an extension or ‘closed down’ position, hence, ipsilateral rotation could cause pain due to excessive ‘closing down’ of the zygapophyseal joint. Application of accessory glide component of cervical SNAG may therefore reposition the superior facet superioanteriorly allowing a greater range of pain free ipsilateral rotation. The interventions in the current study, in comparison, were a more realistic representation of a pragmatic approach of the management of chronic neck pain. Both interventions had components of a home program and posture correction in addition to the intervention under study and it is acknowledged that this common component may account for some of the improvement in both the groups. The subjects chosen for this study fulfilled the symptomatic criteria for chronic neck pain.

Graph 2: Graph showing comparison between groups for NDI scores

comparison between groups

Graph 3: Graph showing comparison between groups for ROM extension

comparison between groups

Graph 4: Graph showing comparison between groups for ROM left lateral flexion

comparison between groups

Graph 5: Graph showing comparison between groups for ROM right lateral flexion

comparison between groups

Graph 6: Graph showing comparison between groups for ROM left rotation

comparison between groups

Graph 7: Graph showing comparison between groups for ROM right rotation

comparison between groups

The cause of the subject’s signs and symptoms was postulated to be musculoskeletal because of the behavior of pain and reduced range of motion of cervical spine without radiation of pain and neurological deficit. The risk for neck pain was significant higher for women than men. This agrees with earlier studies.

Due to almost complete lack of empirical evidence supporting the clinical use of cervical SNAGS, a discussion on the functional spinal unit biomechanics and the articular tissues of the mid lower cervical spine is worthwhile.19 Cervical SNAGS are said to have immediate effect (Mulligan 1999), it seems likely that their underlying mechanism is either purely mechanical, reflexogenic (Herzog et al 1999) or a combination of the two, and does not primarily involve chemical processes or natural resolution(Wall, 1992). Mulligan states that cervical SNAGS are specific in their efforts to a single functional spinal unit, potentially excluding mechanisms such as the placebo effect(Wall,1992), the ‘laying on of hands’ (Zusman 1986) and therapist charisma (Hartman, 1985).

It is unlikely that osseous pathology would undergo immediate and prolonged improvement following mobilization, thus implicating soft tissue structures such as meniscoid inclusions, the zygapophyseal joint capsules and intervertebral disk as most likely articular sources for any manually reversible pain.

As self SNAGS and the intervention which we provided to the groups were self practiced by the subjects at home or during their work hours. Supervision for them was not being done everyday. This may have been acted as a confounder. Also, it was not possible to control the use of analgesics due to the ethical consideration. This may also acted as a confounder.

The results of this study are in agreement with the findings that cervical self SNAGS along with the application of hot packs and postural advice can be incorporated as a treatment tool for chronic neck pain.

Due to relatively small sample size, it was not possible to infer patient characteristics corresponding with treatment outcome. Future research is essential for the subjects with chronic neck pain as general population along with large sample size and to further optimize clinical practice. Also, further studies may require more regular assessment during the intervention period to determine the timeframe of improvement and to investigate the outlining of elements of the technique and the rationale for adapting the specific intervention according to the repeated assessment findings.

Conclusion

It was found that group receiving self SNAGS showed better carry over effect during treatment phase and more during follow up phase as compared to group receiving conventional physiotherapy management alone. Thus, the findings of this study suggests that self SNAGS as a treatment technique can be incorporated for chronic neck pain and is more effective than conventional physiotherapy management alone.

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