Physiotherapy Theory and Practice

An International Journal of Physiotherapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

The effect of sustained natural apophyseal

glide (SNAG) combined with neurodynamics
in the management of a patient with cervical
radiculopathy: a case report

Sudarshan Anandkumar

To cite this article: Sudarshan Anandkumar (2015) The effect of sustained natural apophyseal
glide (SNAG) combined with neurodynamics in the management of a patient with cervical
radiculopathy: a case report, Physiotherapy Theory and Practice, 31:2, 140-145, DOI:
10.3109/09593985.2014.971922

To link to this article: https://doi.org/10.3109/09593985.2014.971922

Published online: 20 Oct 2014.

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ISSN: 0959-3985 (print), 1532-5040 (electronic)

Physiother Theory Pract, 2015; 31(2): 140–145

! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.971922

CASE REPORT

The effect of sustained natural apophyseal glide (SNAG) combined

with neurodynamics in the management of a patient with cervical
radiculopathy: a case report
Sudarshan Anandkumar, MSc PT, BPT, PGDSTT, C-OMPT, MIAP, MMTFI

National Sports Medicine Center, Mylapore, Chennai, Tamil Nadu, India

Abstract Keywords
This case report describes a 47-year-old female who presented with complaints of pain in the Cervical radiculopathy, mobilization,
Downloaded by [La Trobe University] at 01:56 04 January 2018

right elbow radiating down to the thumb. Physical examination revealed symptom reproduc- mulligan, MWM, neurodynamics, SNAG
tion with Spurling A test, upper limb neurodynamic testing-1 and right cervical rotation along
with reduced symptoms with neck distraction. Clinical diagnosis of cervical radiculopathy (CR) History
was made based on a clinical prediction rule. This case report speculates a potentially first-time
description of successful conservative management of CR in a patient utilizing simultaneous Received 10 February 2014
combination of sustained natural apophyseal glide and neurodynamic mobilization. Immediate Revised 5 July 2014
improvements were seen in pain, cervical range of motion and functional abilities. The patient Accepted 7 August 2014
was discharged from physical therapy by the second week after four treatment sessions with Published online 17 October 2014
complete pain resolution maintained at a four-month follow-up period.

Background compression and associated noxious inflammatory chemical

stimuli around the nerve root (Nee and Butler, 2006). This can
One-third of North American adults are affected by neck pain and
cause neural oedema, hypoxia and fibrosis ultimately resulting
related disability in a given year (Croft et al, 2001) with 25% of
in reduced viscoelastic property and gliding ability of the nerve
the out-patients being referred for physical therapy treatment of
(Nee and Butler, 2006).
cervical pain (Childs, Fritz, Piva, and Whitman, 2004). Cervical
Various treatment approaches for CR include: pharmacological
radiculopathy (CR) is a common cause for neck pain caused by
management (e.g. nonsteroidal anti-inflammatory drugs and oral
disorder of the cervical nerve roots (Kim and Kim, 2010) with
steroids); injections (e.g. cervical epidural steroid injections);
a high incidence occurring in the fourth and fifth decade of life
surgeries (e.g. anterior cervical discectomy with fusion) and
(Wainner and Gill, 2000). CR has an annual incidence of
rehabilitation (e.g. physical therapy) (Caridi, Pumberger, and
approximately 83 per 100 000 (Radhakrishnan, Litchy, O’Fallon,
Hughes, 2011; Roth et al, 2009). Physical therapy management of
and Kurland, 1994) and the most commonly involved levels in the
CR may include postural education, exercises (e.g. core muscle
spine are C6 and C7 nerve roots (Wainner and Gill, 2000).
strengthening of the neck), traction and manual therapy (in the
Impingement of cervical nerve roots causing CR can be due
form of soft tissue mobilization, neurodynamic mobilization
to cervical disc herniation (with the disc herniating into the
techniques and various thrust or non-thrust joint mobilization
intervertebral foramen) and lateral canal stenosis (osteophytes,
procedures) (Boyles et al, 2011; Young et al, 2009). Techniques
ligamentum flavum hypertrophy or zygapophyseal joint hyper-
like neurodynamic mobilization are aimed at normalizing the
trophy encroaching upon the intervertebral foramen) (Ferrara,
function and improving the gliding ability of the nerve root,
2012). Other causes of CR described in the literature are:
forming an important treatment procedure in CR (Boyles et al,
vertebral artery loop formation (Kim, Lee, Cheh, and Lee, 2010);
2011; Coppieters and Butler, 2008).
vertebral arterio-venous fistula (Morello et al, 1992); cysts (Miwa
Recently, Mulligan’s concept has become an important treat-
et al, 2004); lipomas (Rao, Dworecka, and Hermann, 1982) and
ment tool that many manual physical therapists use in their
tumor (Al-Khayat et al, 2007; Castillo et al, 1988).
clinical practice and includes many techniques such as sustained
Radicular symptoms experienced by patients may involve a
natural apophyseal glides (SNAGs) and natural apophyseal glides
dermatomal (pain or pins and needles) or myotomal pattern
that target the spine (Exelby, 2002). This treatment approach is
(muscle weakness) and reduced or absent reflexes corresponding
believed to cause immediate improvement in symptom free range
to the impinged nerve root (Caridi, Pumberger, and Hughes,
of motion (ROM) available in the joints (Exelby, 2002; Mulligan,
2011). Compression of cervical nerve root in the intervertebral
2003). The integrated use of Mulligan’s concept along with other
foramen can cause pain due to mechanical irritation or
manual therapy approaches has been suggested in the literature for
the treatment of various orthopaedic dysfunctions in clinical
practice (Exelby, 1995). This case report speculates a potentially
Address correspondence to Sudarshan Anandkumar, National Sports first-time description of successful conservative management of
Medicine Center, Mylapore, Chennai, Tamil Nadu, India. E-mail: CR in a patient utilizing simultaneous combination of SNAGs and
anandkumar.sudarshan@gmail.com neurodynamic mobilization.
 DOI: 10.3109/09593985.2014.971922
Case description
A 47-year-old female, bank official by profession, presented with
complaints of difficulty in doing her desk work for more than
30 min and looking over her right shoulder while driving due to a
shock like intermittent electric pain for the past 3 months. She
also complained of pain while doing overhead activities such as
reaching for objects on the shelf and pushing a shopping cart.
Onset of pain was insidious in nature which was initially localized
to the right elbow (Figure 1). However, two months prior to
seeking physical therapy care, the pain increased in its intensity
and was also felt to radiate down to the tips of her right thumb
(Figure 1). She said that her pain was brought on when she lay
down with no pillows in her bed and was completely relieved
when she placed two pillows immediately under her neck,
indicating a mild irritability. There was no history of clicking in
her neck as well as no numbness, tingling or pins and needles
sensation, and hypersensitivity in her extremities.
Her occupational demands were nearly eight hours of
continuous desk work in front of the computer. For the past one
week, she experienced a mild continuous burning sensation in
her right elbow and stiffness in her neck (Figure 1) while working
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at the desk for more than 30 min. She reported that the stiffness
Figure 1. Symptom distribution marked in the body chart (burning
sensation marked as red, pain marked as blue and stiffness in the neck
marked as orange).
Table 1. Values for comparable signs given in degrees (measured at baseline and immediately after each treatment session).
Range of motion Baseline
Cervical flexion 50
Cervical extension 55
Right cervical rotation 25
Left cervical rotation 75
Right cervical lateral flexion 20
Left cervical lateral flexion 21
ULNT-1 testing of right elbow extension range 70
up to symptom reproductiona
a
ULNT-1 testing of left side revealed normal neurogenic response at 0 of elbow extension.
Effect of sustained natural apophyseal glide 141
in her neck was relieved by taking a walk. The 24 h pattern of
symptom behaviour revealed that her pain increased over the
course of the day and reduced quickly in the evenings (taking
about 15 min) after she returned home from work.
The patient reported that normal bowel and bladder function-
ing with no disturbance of her sleep and appetite. She did not have
difficulty in gripping objects and denied any weakness in her
hands or disturbances in her gait. Coughing as well as the valsalva
manoeuvre did not reproduce the patients radiating pain. There
was no history of fever, malaise or weight loss. The past medical
history was insignificant and the patient did not take any pain
relieving medication for the current problem. No imaging
investigations were done for the patient’s current problem.
Clinical findings
On observation, postural analysis revealed a forward head posture
with increased thoracic kyphosis and protracted shoulders.
However, it must be noted that the reliability of forward head
posture analysis is low, having a kappa value of 0.1 (95%
confidence interval [CI]: 0.2, 0.00) (Cleland, Childs, Fritz,
and Whitman, 2006). No tenderness was elicited when the neck,
elbow, wrist and hand were palpated.
A neurological screening of the upper quarter was first done
where the deep tendon reflexes, myotomes and dermatomes were
tested. The examination findings were unremarkable. Hoffman’s
reflex was negative and a flexor plantar response was obtained
when the Babinski sign was examined.
Peripheral joint screening in the form of active ROM and
resisted isometric testing of the hand, wrist, elbow and shoulders
did not reproduce the patient’s symptoms. Active ROM testing of
the thoracic spine was found to be pain free. Next, ROM testing of
the cervical spine was carried out using a universal goniometer,
which has a good to high reliability (Youdas, Carey, and Garrett,
1991). The values obtained for the cervical ROM measurements
at baseline are given in Table 1. End available ranges of right
cervical rotation and right cervical lateral flexion reproduced the
patient’s pain while cervical extension increased the burning
sensation in the elbow. Muscle length testing of the upper quarter
revealed tightness of the right upper trapezius and bilateral
pectoralis minor.
Segmental mobility of the occipito-atlantal joint and atlanto-
axial joint was found to be full and pain free (Flynn, Whitman,
and Magel, 2000). Passive accessory intervertebral movement
testing using the posterior–anterior glide was carried out for the
cervical spine on the spinous process (Maitland, Hengeveld,
Banks, and English, 2005). At the right C5–C6 articular pillar
level, the patient’s symptoms were reproduced with a grade 4
posterior–anterior glide. It must be noted that the posterior–
anterior cervical gliding test showed a high sensitivity (100%) but
low specificity (41%) for determining intervertebral joint
hypomobility at the C5–C6 level (Rey-Eiriz et al, 2010).
Furthermore, segmental lateral glide mobility testing of the
First session Second session Third session Fourth session
52 51 52 51
54 57 56 56
65 76 78 78
75 75 75 75
22 22 23 22
20 22 23 23
10 0 0 0
 142 S. Anandkumar
lower cervical spine revealed hypomobility on the right C5–C6
level. This method of testing has been determined to be valid in
determining intervertebral dysfunctions (Fernández-de-las-Peñas,
Downey, and Miangolarra-Page, 2005).
The Spurling A test and neck distraction test as described by
Wainner et al. (2003) were carried out on the patient. The
Spurling A test reproduced the patient’s symptoms of pain and
increased the burning sensation in the elbow when the neck was
side-flexed to the right and compressed with approximately 7 kg
force. The distraction test was carried out with the patient in
supine lying where a distraction force of approximately 14 kg
applied at the neck completely relieved the patients burning
sensation in the elbow.
The upper limb neurodynamic testing 1 (ULNT-1) was carried
out with the patient in supine lying. After scapula depression, the
shoulder was abducted to 110 . Next, the forearm was supinated,
wrist and fingers extended, and shoulder laterally rotated. As the
elbow was extended to 70 (measured with a universal goniom-
eter), the patient’s symptoms of pain and burning sensation were
reproduced which increased with contralateral neck left lateral
flexion. Releasing the distal component of wrist and finger
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extension completely relieved the patient’s symptoms.
Evaluation and diagnosis
Peripheral source of pain was ruled out in this patient as the
screening of peripheral joints did not reproduce any symptoms.
A clinical diagnosis of CR was made for this patient based on a
test item cluster suggested by Wainner et al. (2003). The
components of the test item cluster includes: a positive Spurling
A test and ULNT-1 reproducing the patient’s symptoms; distrac-
tion test reducing the patient’s symptoms; and ipsilateral cervical
rotation active ROM less than 60 . When all the four criteria are
positive, the test item cluster has a specificity of 99% and positive
likelihood ratio of 30.3 for ‘‘ruling in’’ CR (Wainner et al, 2003).
Based on the clinical findings, this patient satisfied the clinical
prediction rule required for the diagnosis of CR with the four test
items suggested by Wainner et al. (2003) being positive. Taking
into consideration the subjective and objective findings, it was
hypothesized that the C6 nerve root was being compromised at
the C5/C6 level.
Outcome measures
Numeric Pain Rating Scale (NPRS), Patient-Specific Functional
Scale (PSFS) and Neck Disability Index (NDI) were used as
outcome measures for the patient and were recorded at baseline
and at the beginning of each treatment session for two weeks.
NPRS is a reliable and valid tool to measure pain intensity,
with a clinically meaningful change being two points (Childs,
Piva, and Fritz, 2005). The patient was asked to rate her least pain,
worst pain and average pain on a scale ranging from 0 to 10
(0 representing no pain and 10 representing worst imaginable
pain) for the past 24 h. The average of these scores was calculated
with the patient obtaining a score of 7/10 at baseline.
PSFS is an 11 point self-reported numeric scale which is used
to assess for patient’s functional disability with ‘‘0’’ indicating
inability to perform activity and ‘‘10’’ indicating ability to
perform activity prior to symptom onset. It is a valid and reliable
tool to measure functional limitation with the minimum clinically
important difference being measured to be two points (Cleland,
Fritz, Whitman, and Palmer, 2006). On initial evaluation, the
patient rated desk work for more than 30 min, driving, overhead
activities, shopping for grocery and household chores, each at
4/10 in the PSFS.
The NDI is a 10-item questionnaire used to measure the
patient’s disability, each scored from 0 to 5 (Vernon and
Physiother Theory Pract, 2015; 31(2): 140–145
Mior, 1991). The NDI has a maximum score of 50 points, with
the scores being doubled to interpret the total as a percentage
of perceived disability. It is a valid and reliable tool with the
minimal detectable change estimated as 9% (Westaway, Stratford,
and Binkley, 1998). At baseline, a score of 48% was obtained
in the NDI.
Intervention
Based on the clinical diagnosis of CR, intervention consisted
of simultaneous combination of SNAGs and neurodynamics,
postural correction and exercise therapy. The patient was seen
two times a week for two weeks. The treatment sequence was as
given below.
Week 1 (first and second sessions)
In the first session, the patient sat with the right upper limb being
supported and placed in a ULNT-1 position (Figure 2). At 50 of
elbow extension, the patient’s symptoms of burning sensation at
the elbow and pain down the right thumb increased. From this
position, the elbow was slightly flexed to approximately 5 where
her pain disappeared. Next, a unilateral SNAG towards the
patient’s eyeball was given at the right C5/C6 articular pillar
level where the C5 facet was glided supero-anteriorly over C6
(Figure 2). As this immediately reduced the burning sensation at
the elbow, the patient was encouraged to rotate her neck to the
right and simultaneously extend her elbow while the SNAG was
sustained. At the end available pain free range at the neck, the
patient was encouraged to give overpressure with the left hand.
The patient returned her neck and elbow to the starting position
and the same treatment procedure was repeated for six times
and three sets (Mulligan, 2003).
At the end of three sets, two comparable signs, namely active
ROM of cervical spine and range of elbow extension up to
symptom reproduction during standard ULNT-1 testing in supine
lying as measured by a universal goniometer were reassessed.
Significant improvement in both these measures was found where
the active ROM of cervical right rotation increased to 65 and
elbow extension increased to 10 before symptom reproduction in
the standard ULNT-1 testing position (Table 1).
The patient was advised on postural correction of her forward
head posture and protracted shoulders. She was also educated
upon adopting ergonomic principles during desk work (e.g. using
a desk and chair of appropriate height).
Figure 2. Patient position during application of SNAG combined with
neurodynamic mobilization.
 DOI: 10.3109/09593985.2014.971922
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Figure 3. Graph showing improvements in NPRS score for pain intensity.
Figure 4. Graph showing progression of PSFS scores.
In the second session which was held three days later, the
patient noticed that her burning sensation had become intermittent
in nature and occurred occasionally during the day when she
strained herself with cooking. As the patient reported significant
functional improvement, the same treatment was carried out.
Active ROM of cervical right rotation increased to 76 and
complete elbow extension was achieved with minimal symptom
reproduction in the ULNT-1 position. As a part of home
programme exercise, the patient was taught gentle self stretching
exercises to her right upper trapezius and bilateral pectoralis
minor (30 s hold, 6 times, once a day).
At the end of the first week, significant changes were noticed
in all the three outcome measures (Figures 3–5). The pain
intensity, as measured by NPRS had reduced to 2.2 points and
PSFS had increased to 7/10, both exceeding the minimum
clinically important difference value. The scores obtained on the
NDI had reduced to 16% of self perceived disability.
Week 2 (third and fourth sessions)
In the third session, the same line of management as the previous
sessions was carried out. The patient had minimal intermittent
Effect of sustained natural apophyseal glide 143
Figure 5. Graph showing improvements achieved in NDI.
burning sensation in the elbow with pain reducing to 1.2/10 in the
NPRS. The patient rated her functional disability as measured by
PSFS and NDI to be 9/10 and 4%, respectively. After the fourth
session, the patient was completely pain free and fully functional
in her activities without any discomfort. The patient was
reassessed once every two weeks for a month and a follow-up
after four months revealed that the patient was completely
functional and pain free.
Discussion
This case report describes the diagnosis of CR using the clinical
prediction rule put forth by Wainner et al. (2003) and physical
therapy management using SNAGs combined with neurodynamic
mobilization. As the patient showed immediate improvements in
pain, ROM and functional abilities, the author persisted with the
same management in all the four sessions and did not add other
physical therapy treatment strategies such as traction, thrust
manipulation to the thoracic spine or proximal/distal neurody-
namic ‘‘sliders’’. It was decided in consent with the patient that
other treatment strategies would be explored if the simultaneous
combination of SNAG and neurodynamics proved to be ineffect-
ive or if the improvements achieved in pain, ROM and functional
capabilities could not be sustained.
Even though application of a SNAG is a popular manual
therapy technique, the exact mechanism by which it works is
unknown (Vicenzino, Paungmali, and Teys, 2007). The rationale
for the technique was initially based on a biomechanical
explanation where repositioning of the superior articular facet
using a SNAG would cause correction of positional fault, thus
resulting in reduced pain and increased ROM in the neck
(Mulligan, 2003). Furthermore, normal movement in the articular
surface is essential for maintaining the mobility of the adjacent
nerves where altered biomechanics can affect the nerve’s
excursion (Butler, 1991; Exelby, 1995). Thus, restoration of
normal mechanics at the joint interface can normalize the adverse
neurodynamics present as a result of restricted joint movement
(Exelby, 1995, 1996; Wilson, 1994, 1995). In this patient, after a
SNAG was given at the C5/C6 level, immediate improvements in
cervical right rotation and neurodynamic tension during ULNT-1
testing (Table 1) were noted which could be attributed to the
restoration of normal spinal articular mechanics at the facet joint
 144 S. Anandkumar
(Exelby, 1995). The superior and inferior facets in turn form the
posterior boundary for the intervertebral foramen, which is one of
the interfaces which compress the cervical nerve roots (Kim, Lee,
Cheh, and Lee, 2010).
However, in this patient, the theoretical framework suggested
above for the immediate improvements noticed in pain, function
and neural tension may not be plausible. Proposed biomechanical
models have suggested that, for example, a SNAG applied to the
right articular pillar creates a new axis of coupled motion
occurring in the spine during right rotation, which distracts and
opens the opposite zygapophyseal joint and compresses the
ipsilateral zygapophyseal joint (Hearn and Rivett, 2002). This
effect would ideally worsen the symptoms of CR and increase
neural tension due to excessive closing of the interface (i.e.
intervertebral foramen) compressing the nerve root. Also, other
than degenerative cervical spondylotic changes which narrow the
intervetebral foramen, CR can also be caused due to other factors
such as osteophytes and disc herniation (Ferrara, 2012; Kim, Lee,
Cheh, and Lee, 2010). It must be noted that imaging studies were
not done in this patient and hence, the exact cause for CR was
unknown, forming a limitation of this report. Also, the clinical
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diagnosis of CR was based on a clinical prediction rule which is
yet to be validated. Hence, for these reasons, the immediate
improvements seen in right cervical rotation and elbow extension
in ULNT-1 testing could have possibly occurred due to a
neurophysiological basis and not biomechanical correction of
positional fault as suggested by Mulligan (2003).
When cervical SNAGs on the C5/C6 intervertebral joint were
combined with right rotation, sympathoexcitatory responses have
been achieved in asymptomatic subjects, suggesting that the effect
achieved as a result of SNAG is similar to that of manipulation-
induced analgesia through a centrally mediated phenomenon
(Moulson and Watson, 2006). Similar sympathoexcitatory
responses have also been achieved when a mobilization with
movement was done in the peripheral joints where hypoalgesia
was found not involving the endogenous opioid system
(Paungmali, O’Leary, Souvlis, and Vicenzino, 2004; Paungmali,
Vicenzino, and Smith, 2003). Thus, it is possible that the
generalized hypoalgesia produced as a result of cervical SNAG
could have caused immediate improvements in right cervical
rotation ROM. Furthermore, the patient was encouraged to extend
and flex his elbow in the sitting ULNT-1 position. This would
have improved the excursion of the nerve root at the interface,
thus improving its gliding ability and reducing noxious inflam-
matory chemical stimuli, neural oedema and hypoxia (Coppieters
and Butler, 2008; Nee and Butler, 2006).
The exact mechanism by which immediate improvements
brought about by SNAGs are unknown and are believed to be
intricately complex involving many systems, including sym-
pathoexcitation and non-opioid hypoalgesia (Vicenzino,
Paungmali, and Teys, 2007). Integrated use of the Mulligans
concept in other treatment procedures such as neurodynamic
mobilization seems to be an effective option which physical
therapists can utilize while treating patients, forming an implica-
tion for clinical practice. The various techniques used in the
Mulligans concept cause immediate improvements in pain and
ROM (Exelby, 2002). When these are combined with neurody-
namic mobilization, it can result in a superior outcome than the
isolated use of one treatment procedure. Even though immediate
improvements in pain, cervical ROM and function were achieved
in this patient which could be maintained up to a period of four
months, future studies need to substantiate this finding.
Furthermore, the exact mechanism by which improvements in
ROM and pain are brought about with simultaneous combination
of SNAGs and neurodynamic mobilization warrants clinical
research.
Physiother Theory Pract, 2015; 31(2): 140–145
Conclusion
This case report describes the clinical diagnosis of CR using the
clinical prediction rule and management of the same using
simultaneous combination of SNAGs with neurodynamic mobil-
ization. Future studies using larger samples are required to
investigate the exact mechanism by which simultaneous combin-
ation of SNAGs and neurodynamic mobilization can induce
analgesic effects and cause improvements in cervical joint ROM.
Acknowledgments
The author thanks Dr Dimple M, PT, C-OMPT and Dr Judith Aarthi K,
MSc. (Psychology) for their assistance in this manuscript.
Declaration of interest
The author reports no declarations of interest.
References
Al-Khayat H, Al-Khayat H, Al-Baker O, Groof A, Sadeq A, Hayati H,
Zarka ZA 2007 Cervical radiculopathy secondary to Hodgkin’s
lymphoma. Surgical Neurology 67: 540–543.
Boyles R, Toy P, Mellon Jr J, Hayes M, Hammer B 2011 Effectiveness of
manual physical therapy in the treatment of cervical radiculopathy: A
systematic review. Journal of Manual and Manipulative Therapy 19:
135–142.
Butler DS 1991 Mobilisation of the nervous system. Edinburgh, Churchill
Livingstone.
Caridi JM, Pumberger M, Hughes AP 2011 Cervical radiculopathy:
A review. HSS Journal 7: 265–272.
Castillo J, Lema M, Leira R, Antúnez J, Prieto JM, López-Ibor L, Noya M
1988 Cervical radiculopathy caused by Ewing’s tumor. Neurologia 3:
120–123.
Childs JD, Fritz JM, Piva SR, Whitman JM 2004 Proposal of a
classification system for patients with neck pain. Journal of
Orthopaedic and Sports Physical Therapy 34: 686–696.
Childs JD, Piva SR, Fritz JM 2005 Responsiveness of the numeric pain
rating scale in patients with low back pain. Spine 30: 1331–1334.
Cleland JA, Childs JD, Fritz JM, Whitman JM 2006 Interrater reliability
of the history and physical examination in patients with mechanical
neck pain. Archives of Physical Medicine and Rehabilitation 87:
1388–1395.
Cleland JA, Fritz JM, Whitman JM, Palmer JA 2006 The reliability and
construct validity of the Neck Disability Index and patient specific
functional scale in patients with cervical radiculopathy. Spine 31:
598–602.
Coppieters MW, Butler DS 2008 Do ‘sliders’ slide and ‘tensioners’
tension? An analysis of neurodynamic techniques and considerations
regarding their application. Manual Therapy 13: 213–221.
Croft PR, Lewis M, Papageorgiou AC, Thomas E, Jayson MI,
Macfarlane GJ, Silman AJ 2001 Risk factors for neck pain:
A longitudinal study in the general population. Pain 93: 317–325.
Exelby L 1995 Mobilisation with movement: A personal view.
Physiotherapy 81: 724–729.
Exelby L 1996 Peripheral mobilisations with movement. Manual Therapy
1: 118–126.
Exelby L 2002 The Mulligan concept: Its application in the management
of spinal conditions. Manual Therapy 7: 64–70.
Fernández-de-las-Peñas C, Downey C, Miangolarra-Page JC 2005
Validity of the lateral gliding test as tool for the diagnosis of
intervertebral joint dysfunction in the lower cervical spine. Journal of
Manipulative and Physiological Therapeutics 28: 610–616.
Ferrara LA 2012 The biomechanics of cervical spondylosis. Advances in
Orthopedics 2012: 493605.
Flynn TW, Whitman J, Magel J 2000 Orthopaedic manual physical
therapy management of the cervical-thoracic spine and rib cage. San
Antonio, TX, Manipulations Inc.
Hearn A, Rivett DA 2002 Cervical SNAGs: A biomechanical analysis.
Manual Therapy 7: 71–79.
Kim HS, Lee JH, Cheh G, Lee SH 2010 Cervical radiculopathy caused by
vertebral artery loop formation: A case report and review of the
literature. Journal of Korean Neurosurgical Society 48: 465–468.
 DOI: 10.3109/09593985.2014.971922
Kim KT, Kim YB 2010 Cervical radiculopathy due to cervical
degenerative diseases: Anatomy, diagnosis and treatment. Journal of
Korean Neurosurgical Society 48: 473–479.
Maitland G, Hengeveld E, Banks K, English K 2005 Maidland’s vertebral
manipulation, 7th edn. Edinburgh, Elsevier.
Miwa M, Doita M, Takayama H, Muratsu H, Harada T, Kurosaka M
2004 An expanding cervical synovial cyst causing acute cervical
radiculopathy. Journal of Spinal Disorders and Techniques 17:
331–333.
Morello F, Moro G, Tibaldo M, Siringo G, Faggin W, Franciosi A 1992
Acute cervical radiculopathy due to vertebral A-V fistula. Italian
Journal of Neurological Sciences 13: 603–605.
Moulson A, Watson T 2006 A preliminary investigation into the
relationship between cervical snags and sympathetic nervous system
activity in the upper limbs of an asymptomatic population. Manual
Therapy 11: 214–224.
Mulligan BR 2003 Manual therapy NAGS SNAGS MWMS etc., 5th edn.
Wellington, New Zealand, Plane View Services Ltd.
Nee RJ, Butler D 2006 Management of peripheral neuropathic pain:
Integrating neurobiology, neurodynamics and clinical evidence.
Physical Therapy in Sport 7: 36–49.
Paungmali A, O’Leary S, Souvlis T, Vicenzino B 2004 Naloxone fails to
antagonize initial hypoalgesic effect of a manual therapy treatment for
lateral epicondylalgia. Journal of Manipulative and Physiological
Therapeutics 27: 180–185.
Downloaded by [La Trobe University] at 01:56 04 January 2018
Paungmali A, Vicenzino B, Smith M 2003 Hypoalgesia induced by elbow
manipulation in lateral epicondylalgia does not exhibit tolerance.
Journal of Pain 4: 448–454.
Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT 1994
Epidemiology of cervical radiculopathy. A population-based
study from Rochester, Minnesota, 1976 through 1990. Brain 117:
325–335.
Rao N, Dworecka F, Hermann G 1982 Cervical radiculopathy caused by
lipoma. Patient with multiple congenital skeletal anomalies and
intraspinal and intrathoracic lipomas. New York State Journal of
Medicine 82: 222–225.
Effect of sustained natural apophyseal glide 145
Rey-Eiriz G, Alburquerque-Sendı́n F, Barrera-Mellado I, Martı́n-
Vallejo FJ, Fernández-de-las-Peñas C 2010 Validity of the posterior-
anterior middle cervical spine gliding test for the examination of
intervertebral joint hypomobility in mechanical neck pain. Journal of
Manipulative and Physiological Therapeutics 33: 279–285.
Roth D, Mukai A, Thomas P, Hudgins TH, Alleva JT 2009 Cervical
radiculopathy. Disease-a-Month 55: 737–756.
Vernon H, Mior S 1991 The Neck Disability Index: A study of reliability
and validity. Journal of Manipulative and Physiological Therapeutics
14: 409–415.
Vicenzino B, Paungmali A, Teys P 2007 Mulligan’s mobilization-with-
movement, positional faults and pain relief: Current concepts from a
critical review of literature. Manual Therapy 12: 98–108.
Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S
2003 Reliability and diagnostic accuracy of the clinical examination
and patient self-report measures for cervical radiculopathy. Spine 28:
52–62.
Wainner RS, Gill H 2000 Diagnosis and nonoperative management of
cervical radiculopathy. Journal of Orthopaedic and Sports Physical
Therapy 30: 728–744.
Westaway MD, Stratford PW, Binkley JM 1998 The patient-specific
functional scale: Validation of its use in persons with neck dysfunction.
Journal of Orthopaedic and Sports Physical Therapy 27: 331–338.
Wilson E 1994 Peripheral joint mobilisation with movement and its
effects on adverse neural tension. Manipulative Physiotherapist 26:
35–40.
Wilson E 1995 Mobilisations with movement and adverse neural tension:
An exploration of possible links. Manipulative Physiotherapist 27:
40–46.
Youdas JW, Carey JR, Garrett TR 1991 Reliability of measurements of
cervical spine range of motion – Comparison of three methods.
Physical Therapy 71: 98–104.
Young IA, Michener LA, Cleland JA, Aguilera AJ, Snyder AR 2009
Manual therapy, exercise, and traction for patients with cervical
radiculopathy: A randomized clinical trial. Physical Therapy 89:
632–642.