Journal of Orthopedics
Focused mechano-acoustic vibration, SNAGs and home exercise in the treatment of postural neck pain: randomized controlled trial.
Authors:
G. Barassi1, T. Ainslie2, A. Di Iulio3, P.A. Di Felice1, F. Pasquale1, G. Giannuzzo1, A. Younes1, G. Di Sante4 And A. Di Iorio5
Affiliations:
1Physiotherapy, Rehabilitation and Reeducation Center (CeFiRR), School of Medicine and Health Sciences, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy; 2Department of Sport and Health Sciences, Oxford Brookes University, Oxford, United Kingdom;
3Department of Thoracic Surgery, “S.Spirito” Hospital, Pescara, Italy;
4Department of Medical and Oral Sciences and Biotechnologies, Administrative Organization, G. D’Annunzio University, Chieti, Italy;
5Department of Medicine and Aging Sciences, University of Chieti, Chieti, Italy
Corresponding Author:
Giovanni Barassi,
Physiotherapy, Rehabilitation and Reeducation Center (CeFiRR),
School of Medicine and Health Sciences,
Gabriele d’Annunzio University of Chieti-Pescara
Chieti, 66013, Italy
e-mail: g.barassiunich.it@gmail.com
Key words: postural neck pain, home exercise, Mulligan mobilisation, SNAGs, Focused mechano-acoustic vibration, combined approach
The aim of this study is to compare the effects of home exercises in conjunction with SNAGs or with focused mechano-acoustic vibration (FMV) versus home exercise alone, in the treatment of postural neck pain. This randomized control trial evaluated 60 patients with postural neck pain. We randomly divided the patients into three groups: group A (SNAGs and home exercise), group B (FMV and home exercise) and group C (home exercise). The outcome measures were: numerical rating score (NRS), algometer, ROM and muscular rheological parameters were measured twice a week. Posture and functional disability (NDI) were evaluated before and after the six-session intervention period. In the statistical data, the algometer showed better results in groups A and B (4.1±4.0; and 3.3±4.1) than the control group on the right side; similar results were recorded on the left side. Flexion ROM improvement was similar in groups A and B (14.4±7.7 and 14.37±7.7), than controls (4.95±3.4). The NDI was better in group A (12.5±8.7) and B (12.7±4.9) than group C (3.05±1.3) (p ≤ 0.0001 for all). Regarding the NRS, groups A and B were better than controls (p ≤ 0.0002 for all). Right rotation ROM improved more in group A and B (14.4±7.8 and 9.8±6.8) than in group C. The same was recorded for left rotation. In conclusion, SNAGs or FMV combined with home exercise are more effective than home exercise alone in the management of postural neck pain, improving pain, neck mobility and the quality of life.
Neck pain (NP) is one of the most common musculoskeletal symptoms in the general population. It is estimated that up to 67% of adults will experience NP at some stage in their lives, with the overall prevalence in the general population ranging between 0.4% and 86.8% (mean: 23.1%) (1). The most common symptoms related to NP are pain, reduced range of movement, reduced muscular elasticity, stiffness, lower pressure pain threshold in cervical muscles, and myofascial referred pain from the neck muscles (2). People experiencing NP often show impairment of functional capacity and quality of life. It is often possible to observe postural alteration in the neck resulting from shortening and increased activation of muscles (3). The most common postural imbalance observed with NP is the forward head posture (FHP or poking chin posture). FHP is the protrusion of the head in the sagittal plane due to anterior translation of the head, lower cervical flexion and increased upper-cervical extension (4). FHP leads to an increase in the compressive forces on the cervical apophyseal joints and to changes in connective tissue, resulting in pain. Even though many therapeutic approaches can be used to cope with NP symptoms, it is difficult to decide which is the best treatment. Several systematic reviews have demonstrated the beneficial effect of physical exercise for chronic neck pain. Physical exercise showed to be effective in both the reduction of pain and the improvement of cervical range of motion and disability (5-6). Manual therapy is frequently used to treat mechanical neck disorders in clinical practice. Among treatments aiming to deal with symptoms that result from FHP, spinal joint mobilisation, such as Mulligan mobilisation, is known to be effective and currently represents a common clinical approach. Cervical sustained natural apophyseal glides (SNAGs) are mobilisation with movement techniques in which a sustained accessory facet glide is applied, together with active physiological movements (7). SNAGs have been shown to be effective for the treatment of NP; they seem to restore normal coupled motion and improve range of motion and neck posture (8). Moulson and Watson (2006) have suggested that Mulligan’s mobilisation techniques are an effective physiotherapeutic tool in the treatment of neuromuscular pain and dysfunction even though their underlying mechanism has not yet been clearly clarified. Otherwise, the best results in terms of outcome come from a multimodal approach combining mobilisations with exercise and an educational intervention (9). In literature, there is also evidence supporting the use of vibration to reduce NP symptoms. Vibrations produce mechanical barrage on the large myelinated fibres, Ia type fibres, reducing the perception of pain. The release of endorphins is largely stimulated by vibrations (10). After the use of vibrations, the pain threshold increases and an improvement in muscular parameters (elasticity, tone and stiffness) is recorded, as well as an increase in social activities(11). There have been a number of Cochrane reviews considering the evidence for the effectiveness of manipulations, mobilisations and exercise, and no reviews available which consider the beneficial effects of vibration therapy on neck pain (12). This suggests the need for further research to support the use of these commonly used interventions. This study was designed to compare the effects of combined therapies and home exercise alone in treating individuals with postural neck pain. Home exercises were used in conjunction with SNAGs or with Focused mechano-acoustic vibration (FMV).
MATERIALS AND METHODS
Participant selection
Recruitment of participants was in accordance with the latest revision of the Helsinki Declaration for Human Research and with European procedures concerning the privacy and protection of subjects participating in biomedical research, and in accordance with ISO 9001 standards for research and experimentation. A total of 76 participants, were initially recruited having been referred with NP. Finally, 16 subjects did not conclude the protocol, resulting in 60 participants being recruited and undertaking and completing the study. Following the consent of the participants, they were allocated to one of the three groups, using a random numbers table. Participants were selected according to the following criteria. Inclusion criteria: poking chin posture, localized pain symptoms in the neck region, reduced cervical rotation and flexion range of motion, adults over 18 years, gradual onset of symptoms. Exclusion criteria: neck trauma, peripheral signs and symptoms, paraesthesia, anaesthesia, altered reflexes or myotomes, dizziness or signs of vertebral artery insufficiency (Fig. 1).
Outcome measures and intervention
Before the intervention, baseline data was collected to evaluate: posture, functional disability, pain, cervical range of motion (ROM) and muscular tone, elasticity and stiffness (rheological parameters). The measurement of posture and the functional disability questionnaire were completed by each participant prior to data collection (T0) and following completion of the intervention period (T1). Posture was measured using RAROG software installed on a Kinect® system. Kinect® is largely used as a non-invasive, marker-free postural assessment tool. The RAROG software can reconstruct a 3D-avatar called “Skeletal View”, using frontal and sagittal parameters. Functional disability was evaluated using the Neck Disability Index (NDI). The NDI represents a validated and a reliable tool in evaluating functional disability in relation to NP (13-14). Pain intensity was measured using Numerical Rating Score (NRS) that has been demonstrated to be reliable. Pain was also evaluated using a pressure algometer, a valid instrument used to assess the tolerance to pressure. Algometer measurements were taken in the sub-occipital muscles (at the external occipital protuberance), the sternocleidomastoid (at the mastoid process) and the trapezius (targeting a selected point medial to the spine of scapula). Cervical range of flexion and rotation were assessed using Kinovea software, via a Body Analysis Kapture system. Kinovea is a software application suitable for recording and evaluating movements of the cervical spine, without the need to apply sensors to the participants. Myoton PRO was used to analyse any change in muscle tissue following treatment. The device is designed for the non-invasive measurement of any superficial skeletal muscle. Myoton PRO has been found to be reliable for assessing abnormalities of muscular rheological parameters. Three intervention groups were included in the study.
- Mulligan SNAG mobilisations treatment and home exercises.
- Focused mechano-acoustic vibration (FMV) and home exercises.
- Home exercise, as control group.
GROUP A: SNAGS and home exercise: six intervention sessions were administered. Mulligan’s SNAGs were applied with the participants sitting on a chair and the therapist behind them. After the identification of the symptomatic level in the cervical spine, the technique was applied to one joint above and to one joint below this level. The clinician applied an anterosuperior accessory glide through the superior spinous process with a postero-anterior pressure at 45° upwards inclination. The therapist asked the participant to turn their head to the right, facilitating the movement of cervical rotation, with the SNAG ensuring the absence of pain. At the end of the active movement, the patient was asked to provide an overpressure with a free hand, for 1-2 seconds. With the pressure being sustained by the therapist, the participant was instructed to return to the starting position. Ten SNAGs were performed to the right and then the left, for both the identified joint levels. Each participant was taught cervical exercises to be undertaken three times daily, consisting of 10 movements to the right and 10 movements to the left, with 1-2 seconds of overpressure.
GROUP B: FMV and home exercise: six intervention sessions were applied. Vibration Sound System® (Vissman s.r.l., Roma, Italy) was used which consists of a 32,000-revolution turbine and a flow modulator able to generate mechano-acoustic waves. FMV was applied to participants, using a hand-held applicator that was set to vibrate consequently at 120 Hz and at 200 Hz. The applicator was applied through its 2.5 cm head in the triangle formed by the Upper Trapezius muscle. In the first part of the treatment, 120 Hz frequency was used for twelve minutes with the head vibration being applied by progressively approaching the most painful points of the muscle. In the second part of the treatment, the frequency was set at 200 Hz and used for 8 minutes. Each participant was taught cervical rotation exercises to be undertaken three times daily, consisting of 10 movements to the right and 10 movements to the left, with 1-2 seconds of overpressure. GROUP C: home exercise program. Each participant was taught cervical rotation exercises to be undertaken three times daily (morning, afternoon and evening), consisting of 10 movements to the right and 10 movements to the left, with 1-2 seconds of overpressure.
Statistical analysis
Statistical analysis was performed using statistical software NCSS Data 12 using the Wilcoxon Signed-Rank Test. The Wilcoxon Signed-Rank Test (paired sample) is a non-parametric test, used when it is not possible to assume a given form for the distribution of the population and/or in the small sample size (n < 25). A p value < 0,05 was considered significant. Data were collected prior to and following the six attendances and before and after each attendance.
RESULTS
Neck Disability Index
Statistically significant effects were found for all three groups, with group A and B showing a better improvement compared to group C (Table I).
Pain – NRS
An overall reduction in pain perception was recorded, with statistically significant results in all three groups (Table II).
Pain – Algometer
All three groups recorded improvements in the algometer parameters. Only group A showed significant results at the external occipital protuberance and, with group C, the mastoid process. Both groups A and B and the control group showed better scores at the medial border of the scapula parameter. While group C obtained a smaller improvement on both sides compared to the experimental groups (Table III).
ROM – Flexion
A significant improvement in flexion, was recorded, with groups A and B scoring better results (Table IV).
ROM – Right rotation
Statistically significant improvement was observed in all groups: group A had the best results with a mean difference; group B reported a mean difference, while the control group scored the lowest results, mean difference (Table V).
ROM – Left rotation
Also for left rotation, group A had the best results (mean difference 13.8; SD 6.7), like group B and with group C showing lower mean difference (Table V).
MYOTON
At the data analyses, the muscular stiffness showed a statistically significant improvement only on the left side in group B. The value of elasticity was found to be statistically significant only in group B on the right and left side (Table VI).
RAROG
The data analyses showed a statistically significant value only in the measurement of the alignment of the iliac crests in group B.
DISCUSSION
Previous studies have investigated the effects of exercise and Mulligan mobilisations on neck pain symptoms. There is a developing trend in clinical practice to treat patients with exercises in conjunction with other therapies, however, to date, there are no reviews available which consider the beneficial effects of vibration therapy on neck pain. For this reason, our research focuses on the use of home exercise in conjunction with SNAGs and with FMV. Following the completion of the interventions, we recorded a reduction in pain, both in terms of subjective perception measured by the NRS and in the objective pain perception in muscles assessed with the algometer. This reduction was more meaningful in groups A and B than group C, suggesting a higher impact of combined therapies compared to home exercise alone. The small degree of improvement in the control group is supported by the research of Tunwattanapong (2015) and Gross (2015) that found some beneficial effect of neck exercises (12-15). We found a pain reduction both in NRS and algometer scores in group A. This can be explained by the effects of SNAGs over the re-alignment of the articulation and the lowering of proprioceptive stimuli. Therefore, the improvement in the load over muscles and the associated muscle tone normalisation produce the reduction in pain on muscles painful areas recorded by the algometer. Similar results were scored by group B at the NRS evaluation. This trend confirms the mechanical barrage effect of vibrations over perception of pain, explained by the effect of the FMV vibrating hand piece inducing muscle relaxation in combination with the analgesic effect on nociceptors. Moreover, the effect of SNAGs and FMV was strengthened by the known benefits of a home exercise program on neck pain recovery. Significant results for the ROM were scored in all three groups, but the experimental groups, especially group A, achieved better results compared to the control group. SNAGs facilitate pain-free movement and, guiding the zygoapophyseal joints, the glide and the overall range of motion are improved. On the other hand, the good results obtained in group B are probably due to vibration-linked effect reducing muscular tension: a muscle tissue of normal length and tension is better able to perform its function. Therefore, SNAGs and FMV combined with the beneficial effects of exercises on articulation mobility and muscular tension proved to be a better alternative in the recovery of ROM restriction caused by neck pain. The achievements at the NDI support the direct correlation between neck pain and disability. Therefore, our results indicate that improving pain and restoring a better articular movement, positively influence the quality of life. In addition, the results show that all three groups obtained an improvement at the NDI but doing home exercise alone is not as effective as in combination with SNAGs or FMV. The better scores of group A and B at the NDI follow those of pain and ROM, indicating that working both in the treatment session and at home is more effective in reducing disability. The study failed to show substantial improvements for the three rheological parameters of muscular tone, stiffness and elasticity, even if Myoton results show some positive changing. In particular, group B recorded an improvement in muscular stiffness and elasticity. The lower scores of stiffness and higher elasticity are likely to be linked to an improved range of motion and a pain reduction. Further studies are needed to understand exactly how the changes in the muscular parameters are influenced by therapeutic interventions. In conclusion, interventions such as Mulligan joint mobilisation or focused mechano-acoustic vibrations in combination with a program of home exercises could represent an effective approach to deal with individuals suffering from neck pain. The combined therapies are more beneficial compared to home exercise alone in reducing the discomfort, improving pain, neck mobility and quality of life. Furthermore, home exercise could increase the effectiveness of the therapy and consequently the results of the manual or vibration treatment.
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Fig. 1. Flow chart of interventions
Table 1. Neck Disability Index. (Score: /50)
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group A – T0 | 20 | 18,75 (9,4) | 14,35 | 23,14 | |||
| Group A – T1 | 20 | 6,25 (2,6) | 12,5 (8,7) | 5,03 | 7,46 | 0,0001 | |
| Group B – T0 | 20 | 20,9 (6,2) | 17,99 | 23,8 | |||
| Group B – T1 | 20 | 8,2 (3,7) | 12,7 (4,9) | 6,46 | 9,93 | 0,0001 | |
| Group C – T0 | 20 | 19,4 (7,5) | 15,89 | 22,91 | |||
| Group C – T1 | 20 | 16,35 (6,8) | 3,05 (1,3) | 13,18 | 19,52 | 0,0001 | |
Group A: Mulligan SNAGs and home exercise;
Group B: Focused mechano-acoustic vibration (FMV) and home exercise;
Group C: home exercise
* p value shows the differences between T0-T1 of the experimental groups (Wilkoxon matched-pairs signed rank test)
Table 2. Pain – NRS
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group A – T0 | 20 | 6,15 (1,5) | 5,47 | 6,83 | |||
| Group A – T1 | 20 | 2 (1,4) | 4,15 (1,9) | 1,35 | 2,64 | 0,0001 | |
| Group B – T0 | 20 | 6,5 (1,4) | 5,86 | 7,13 | |||
| Group B – T1 | 20 | 1,8 (1,6) | 4,7 (1,9) | 1,03 | 2,57 | 0,0001 | |
| Group C –T0 | 20 | 6,15 (1,2) | 5,58 | 6,72 | |||
| Group C – T1 | 20 | 4,9 (0,8) | 1,25 (1,0) | 4,53 | 5,27 | 0,0002 | |
NRS: Numerical Rating Score
Group A: Mulligan SNAGs and home exercise;
Group B: Focused mechano-acoustic vibration (FMV) and home exercise;
Group C: home exercise
* p value shows the differences between T0-T1 of the experimental groups (Wilkoxon matched-pairs signed rank test)
Table 3. Pain – Algometer (1=0.2Kg)
| External Occipital Protuberance | ||||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | ||
| Group A. Right side – T0 | 20 | 5 (3,6) |
|
3,33 | 6,67 | |||
| Group A. Right side – T1 | 20 | 6,9 (3,7) | 1,9 (2,8) | 5,14 | 8,65 | 0,014 | ||
| Group A. Left side – T0 | 20 | 4,8 (3,1) | 3,34 | 6,26 | ||||
| Group A. Left side – T1 | 20 | 7,3 (2,7) | 2,5 (3,0) | 6,06 | 8,54 | 0,003 | ||
| Mastoid process | ||||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | ||
| Group A. Right side – T0 | 20 | 3,05 (2,0) | 2,13 | 3,97 | ||||
| Group A. Right side – T1 | 20 | 4,8 (2,3) | 1,75 (1,6) | 3,74 | 5,86 | 0,0006 | ||
| Group A. Left side – T0 | 20 | 3,5 (1,8) | 2,65 | 4,35 | ||||
| Group A. Left side – T1 | 20 | 5,35 (3,1) | 1,85 (3,0) | 3,88 | 6,82 | 0,012 | ||
| Group C. Left side – T0 | 20 | 5,4 (1,7) | 4,6 | 6,19 | ||||
| Group C. Left side – T1 | 20 | 6,75 (1,3) | 1,35 (1,6) | 6,14 | 7,35 | 0,002 | ||
| Medial border Spine of the Scapula | ||||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | ||
| Group A. Right side – T0 | 20 | 9,35 (4,6) | 7,21 | 11,49 | ||||
| Group A. Right side – T1 | 20 | 13,45 (4,4) | 4,1 (4,0) | 11,38 | 15,52 | 0,0007 | ||
| Group A. Left side – T0 | 20 | 9,1 (3,8) | 7,34 | 10,86 | ||||
| Group A. Left side – T1 | 20 | 13,6 (4,4) | 4,5 (2,7) | 11,52 | 15,68 | 0,0001 | ||
| Group B. Right side – T0 | 20 | 8,1 (6,5) | 5,03 | 11,16 | ||||
| Group B. Right side – T1 | 20 | 11,4 (6,0) | 3,3 (4,1) | 8,6 | 14,2 | 0,003 | ||
| Group B. Left side – T0 | 20 | 7,7 (5,0) | 5,38 | 10,02 | ||||
| Group B. Left side – T1 | 20 | 12,5 (6,4) | 4,8 (5,0) | 9,51 | 15,48 | 0,0008 | ||
| Group C. Right side – T0 | 20 | 10,5 (4,4) | 8,45 | 12,55 | ||||
| Group C. Right side – T1 | 20 | 11,9 (4,4) | 1,4 (2,3) | 9,83 | 13,96 | 0,02 | ||
| Group C. Left side – T0 | 20 | 9,65 (2,8) | 8,31 | 10,98 | ||||
| Group C. Left side – T1 | 20 | 11,45 (2,8) | 1,8 (2,4) | 10,14 | 12,75 | 0,008 | ||
Group A: Mulligan SNAGs and home exercise;
Group B: Focused mechano-acoustic vibration and home exercise;
Group C: home exercise
* p value shows the differences between T0-T1 of the experimental groups (Wilkoxon matched-pairs signed rank test)
Table 4. Range of motion – Flexion. (Degrees)
| Variable | Count | Mean (SD) | Mean difference (SD)
|
95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group A – T0 | 20 | 25,55 (7,3) | 22,14 | 28,96 | |||
| Group A – T1 | 20 | 39,95 (8,5) | 14,4 (7,7) | 35,95 | 43,94 | 0,0001 | |
| Group B – T0 | 20 | 25,95 (8,6) | 21,92 | 29,98 | |||
| Group B – T1 | 20 | 40,32 (5,2) | 14,37 (7,7) | 37,88 | 42,77 | 0,0001 | |
| Group C – T0 | 20 | 26,2 (6,4) | 23,19 | 29,21 | |||
| Group C – T1 | 20 | 31,15 (6,3) | 4,95 (3,4) | 28,17 | 34,13 | 0,0001 | |
Group A: Mulligan SNAGs and home exercise;
Group B: Focused mechano-acoustic vibration and home exercise;
Group C: home exercise
* p value shows the differences between T0-T1 of the experimental groups (Wilkoxon matched-pairs signed rank test)
Table 5. Range of motion – Rotation (Degrees
| Right rotation | |||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group A – T0 | 20 | 53,7 (11,7) | 48,22 | 59,17 | |||
| Group A – T1 | 20 | 68,1 (12,2) | 14,4 (7,8) | 62,39 | 73,8 | 0,0001 | |
| Group B – T0 | 20 | 58,2 (13,7) | 51,79 | 64,6 | |||
| Group B – T1 | 20 | 68 (15,5) | 9,8 (6,8) | 60,74 | 75,26 | 0,0001 | |
| Group C – T0 | 20 | 57,1 (10,3) | 52,25 | 61,94 | |||
| Group C – T1 | 20 | 61,55 (7,9) | 4,45 (4,2) | 57,84 | 65,25 | 0,0005 | |
| Left rotation | |||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group A – T0 | 20 | 55,75 (11,4) | 50,41 | 61,08 | |||
| Group A – T1 | 20 | 69,55 (11,0) | 13,8 (6,7) | 64,41 | 74,69 | 0,0001 | |
| Group B – T0 | 20 | 57,75 (14,3) | 51,06 | 64.44 | |||
| Group B – T1 | 20 | 68,5 (17,4) | 10,75 (6,3) | 60,35 | 76,64 | 0,0001 | |
| Group C – T0 | 20 | 56,7 (11,3) | 51,4 | 62,0 | |||
| Group C – T1 | 20 | 60,8 (10,9) | 4,1 (2,9) | 55,71 | 65,88 | 0,0003 | |
Group A: Mulligan SNAGs and home exercise;
Group B: Focused mechano-acoustic vibration and home exercise;
Group C: home exercise
* p value shows the differences between T0-T1 of the experimental groups (Wilkoxon matched-pairs signed rank test)
Table 6. Myoton – Stiffness (N/m) and Elasticity
| Stiffness | |||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group B. Left side – T0 | 20 | 256,5 (44,9) | 235,48 | 277,5168 | |||
| Group B. Left side – T1 | 20 | 244,35 (44,6) | 12,15 (18,8) | 223,49 | 265,2109 | 0,01 | |
| Elasticity | |||||||
| Variable | Count | Mean (SD) | Mean difference (SD) | 95%LCL of Mean | 95%UCL of Mean | p value* | |
| Group B. Right side – T0 | 20 | 1,24 (0,4) | 1,04 | 1,44 | |||
| Group B. Right side – T1 | 20 | 1,47 (0,4) | 0,23 (0,3) | 1,26 | 1,68 | 0,02 | |
| Group B. Left side – T0 | 20 | 1,32 (0,4) | 1,13 | 1,52 | |||
| Group B. left side – T1 | 20 | 1,509 (0,5) | 0,18 (0,3) | 1,28 | 1,74 | 0,009 | |
Group A: Mulligan SNAGs and home exercise;
Group B: Focused mechano-acoustic vibration and home exercise;
Group C: home exercise
* p value shows the differences between T0-T1 of the experimental groups (Wilkoxon matched-pairs signed rank test)
