Non-specific neck pain is a common problem that doesn't have a specific cause like an injury or disease. It usually includes neck pain, reduced movement, poor posture like forward head position, and some level of disability that can make daily activities difficult. Physiotherapists often use hands-on techniques like Strain Counterstrain (SCS) and SNAGs (Sustained Natural Apophyseal Glides) to help reduce pain, improve movement, and correct posture. This study aims to find out if adding SNAGs (Sustained Natural Apophyseal Glides) to the usual Strain Counterstrain (SCS) treatment helps more than SCS alone in patients with neck pain. We will measure changes in pain levels, neck movement, posture (craniovertebral angle), and daily life impact (NDI) over a four-week treatment program.
•Both Males and Females (20)
Age 18 and 60 years
pain intensity 3-6 rating on NPRS
Pain localized to cervical or upper trapezius
• Cervical radiculopathy(20)
History of whiplash injury
History of cervical and thoracic spine surgery
Neck pain associated with vertigo(20)
Parallel
Strain Counterstrain + SNAG with Common Treatment
Other interventionGroup A (Experimental Group) will receive both Strain Counterstrain (SCS) and SNAGs (30). They will attend 12 sessions in total, three times per week for four weeks. First, the SCS technique will be applied to the upper trapezius, levator scapulae, and scalene muscles. The patient will lie on their back or side while the therapist finds tender points and positions the neck to reduce tension, holding that position for 90 seconds before gently returning it to neutral and checking for pain. After this, SNAGs (Sustained Natural Apophyseal Glides) will be applied, targeting spinal segments like C2-C3 for rotation and C5-C6 for flexion or extension. While the patient sits upright, the therapist will apply a sustained glide on the vertebra as the patient moves the neck in the limited direction. Each movement will be repeated 6-10 times and followed by a reassessment
Strain Counterstain (SCS) only
Other interventionGroup B (Control Group) will receive only the Strain Counterstrain (SCS) technique without SNAGs (31). The same neck muscles will be targeted, and the patient will lie in a similar position while the therapist identifies tender points and performs the SCS technique. No joint glides or mobilization will be applied in this group. Both groups will receive a total of 12 sessions over four weeks, with each session lasting about 40 minutes. Pre- and post-treatment assessments will be carried out to measure changes in pain (using NPRS/VAS), cervical ROM, craniovertebral angle (CVA), and neck-related disability (using the Neck Disability Index - NDI).
Numeric pain rate scale (NPRS)
Patient level of pain will be assessed using this scale. This scale ranges from 0 to 10. 0 indicates "no pain" and 10 indicates "worst pain".(25) NPRS shows strong construct validity and correlates well with other pain scales like the Visual Analog Scale (VAS) and McGill Pain Questionnaire. It is especially useful for tracking changes in pain over time.(13) The NPRS demonstrates excellent test-retest reliability with an intraclass correlation coefficient (ICC) of \~0.95 in patients with chronic musculoskeletal pain.(26) The MCID for NPRS is generally considered to be 2 points, meaning a change of 2 or more points is considered clinically meaningful in musculoskeletal pain patients
Neck Disability index (NDI)
This questionnaire will be used to assess disability. It comprises of 10 items; 7 related to daily living activities, 2 related to pain and 1 related to concentration. Each item is scored from 0 to 5. Total score is expressed as a percentage, with higher scores related to greater disability(28) Its construct validity has been supported through correlations with pain intensity, cervical range of motion, and quality-of-life measures (13). It shows excellent test retest reliability, with an ICC of 0.89-0.98 in patients with mechanical or non-specific neck pain (26)The Minimal Detectable Change (MDC) for NDI has been reported to be 5 points, while the MCID is commonly considered to be around 7-10 points for clinical relevance in chronic musculoskeletal pain
Universal Goniometer (UG)
It will measure range of motion of neck (29) A universal goniometer will be used to measure active cervical range of motion (CROM) in flexion, extension, lateral flexion, and rotation. This tool is portable, affordable, and easy to use in clinical and research settings. The validity of goniometry in measuring cervical ROM has been confirmed through comparisons with CROM devices and motion sensors, showing strong correlations (r \> 0.85) in neck mobility measurement (27). Goniometer-based cervical ROM assessments demonstrate good to excellent reliability, with ICC values ranging from 0.79 to 0.96, depending on the plane of movement and rater experience
Craniovertebral Angle (CVA)
It is used to measure the degree of forward head posture, which is common in people with neck pain. A smaller CVA indicates a more forward head position, while a larger angle reflects a more neutral, healthy posture .To measure CVA, a lateral photograph is taken while the patient stands in a relaxed position. The angle is formed between a horizontal line passing through the C7 vertebra and a line connecting C7 to the tragus of the ear. This measurement is usually done using image analysis software or mobile applications like Posture Screen or ImageJ. Studies have shown that CVA measurement is a reliable and valid method for assessing head posture. It has good intra-rater and inter-rater reliability, with Intraclass Correlation Coefficients (ICC) ranging from 0.88 to 0.98 (8, 15).The Minimal Detectable Change (MDC) for CVA varies across studies but is generally estimated to be about 3-4 degrees, making it a sensitive tool for detecting postural improvements
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