ARTICLE IN PRESS

Manual Therapy 13 (2008) 357366

www.elsevier.com/locate/math

Original article

Sustained natural apophyseal glides (SNAGs) are an effective

treatment for cervicogenic dizziness
Susan A. Reid, Darren A. Rivett, Michael G. Katekar, Robin Callister
School of Biomedical Sciences, Faculty of Health, The University of Newcastle, Callaghan, NSW 2308, Australia
Received 2 June 2006; received in revised form 2 February 2007; accepted 11 March 2007

Abstract
Cervicogenic dizziness is dizziness described as imbalance occurring together with cervical pain or headache. This study aimed to
determine the efcacy of sustained natural apophyseal glides (SNAGs) in the treatment of this condition. A double-blind
randomised controlled clinical trial was undertaken. Thirty-four participants with cervicogenic dizziness were randomised to receive
four to six treatments of SNAGs (n 17) or a placebo of detuned laser (n 17). Participants were assessed by a blinded assistant
before treatment, after the nal treatment and at 6- and 12-week follow-ups. The primary outcome measures were severity of
dizziness, disability, frequency of dizziness, severity of cervical pain, and global perceived effect; balance and cervical range of
motion were secondary measures. At post-treatment, 6- and 12-week follow-ups compared to pre-treatment, the SNAG group had
less (Po0.05) dizziness, lower (Po0.05) scores on the Dizziness Handicap Inventory (DHI), decreased (Po0.05) frequency of
dizziness, and less (Po0.05) cervical pain. The placebo group had signicant (Po0.05) changes only at the 12-week follow-up in
three outcome measures: severity of dizziness, DHI, and severity of cervical pain. Compared to the placebo group at post-treatment
and 6-week follow-up, the SNAG group had less (Po0.05) dizziness, lower (Pp0.05) scores on DHI, and less (Po0.05) cervical
pain. Balance with the neck in extension improved (Pp0.05) and extension range of motion increased (Po0.05) in the SNAG
group. No improvements in balance or range of motion were observed in the placebo group. The SNAG treatment had an
immediate clinically and statistically signicant sustained effect in reducing dizziness, cervical pain and disability caused by cervical
dysfunction.
r 2007 Elsevier Ltd. All rights reserved.
Keywords: Dizziness; SNAG; Manual therapy; Randomised controlled trial; Cervical spine

1. Introduction
Dizziness is a common presenting problem in clinical
practice (Luxon, 1984; Kroenke and Mangelsdorff, 1989;
Shumway-Cook and Horak, 1989; Kroenke et al., 1992;
Colledge et al., 1996; Furman and Whitney, 2000) and is
particularly prevalent in the elderly (Luxon, 1984; Colledge
et al., 1996). Dizziness has substantial physical, social and
emotional effects as well as nancial consequences on
individuals and the community (Yardley et al., 1992). The
physical problems include postural instability, unsteadiCorresponding author. Tel.: +61 2 49813111; fax: +61 2 49812111.

E-mail address: suereidphysio@bigpond.com (S.A. Reid).

1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2007.03.006

ness and falls. Yardley et al. (1992) found dizziness often

leads to increased dependence on family members, anxiety
about public exposure, withdrawal from work, travel and
social activities, and depression.
Dizziness is a term used to describe a wide range of
symptoms, which have been loosely grouped into four
main types: faintness, imbalance, vertigo, and disorientation (Drachman and Hart, 1972; Froehling et al., 1994;
Enloe and Shields, 1997). One specic type of dizziness is
cervicogenic dizziness, which is thought to be caused by
dysfunction in the upper cervical spine. It is characterised
by symptoms of dizziness described as imbalance or
disequilibrium, commonly associated with neck pain,
stiffness or headache (Wrisley et al., 2000), and is

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S.A. Reid et al. / Manual Therapy 13 (2008) 357366

frequently related to a neck injury such as whiplash or to

spinal degeneration. It is a diagnosis of exclusion; other
causes of dizziness must be excluded based on history,
physical examination and vestibular function tests
(Wrisley et al., 2000; Heikkila, 2004). There is evidence
that cervicogenic dizziness is a result of perturbation in the
information from sensory afferents in the cervical spine
(de Jong et al., 1977; Brandt and Bronstein, 2001).
Balance problems can be the result of abnormal afferent
input to the vestibular nuclei from altered cervical
articular proprioceptors (Terrahe, 1979; Wyke, 1979).
Cervicogenic dizziness should be distinguished from the
most common type of dizziness, vertigo, which is a
spinning sensation and usually due to a problem with the
vestibular system (Brandt, 1991; Heikkila, 2004).
To date there is limited evidence to support the use of
manual therapy in treating cervicogenic dizziness. A
systematic review of the literature on this topic conducted
by Reid and Rivett (2005) found that randomised
controlled trials of all manual therapy treatments for
cervicogenic dizziness were scarce and generally of poor
methodological quality. Despite this limited evidence,
manual therapy is advocated to treat cervicogenic dizziness
in the clinical setting (Karlberg et al., 1996b; Galm et al.,
1998; Zhou et al., 1999; Bracher et al., 2000). Brian
Mulligan, a New Zealand physiotherapist, described a
manual therapy treatment for this condition in 1991 entitled
sustained natural apophyseal glides (SNAGs) (Mulligan,
1991). A SNAG is a sustained passive accessory glide in the
plane of the zygapophyseal joint performed by the therapist
while the patient actively moves their neck physiologically in
the symptomatic direction (Mulligan, 1991). The accessory
glide provides immediate pain/symptom relief when moving
in the provocative direction (Mulligan, 1991). Since 1991 its
use clinically has spread among physiotherapists despite not
having been evaluated in any clinical trials (Exelby, 1995;
Wilson, 1996; Mulligan, 1999).
Thus, the aim of the present study was to determine
the efcacy of SNAGs in the treatment of the signs and
symptoms of patients with cervicogenic dizziness. If
effective, SNAGs would provide an option for patients,
manual therapists and medical practitioners who previously had no evidence-based treatment for this
disabling problem. In addition, if manual therapy to
the cervical spine is shown to be an effective treatment
for cervicogenic dizziness, it would provide indirect
evidence of the existence and origins of this disorder, a
topic of some controversy in the literature (Karlberg
et al., 1996a; Brandt and Bronstein, 2001).
2. Methods
2.1. Research design
This study was a double-blind randomised controlled
clinical trial, conducted at the University of Newcastle,

Australia. Participants were randomly assigned to either

a SNAGs manual therapy treatment group (SNAG
group) or a sham laser placebo group. A research
assistant blinded to group allocation performed all the
evaluation measurements. The study was approved by
the University of Newcastle Human Research Ethics
Committee. All participants provided written informed
consent prior to participation.
2.2. Sample size
Calculations to determine the required group sample
sizes (n 17 for each group) were based on the
differences in the DHI and VAS for dizziness scores
that would be needed for a statistically signicant effect
of a treatment based on a change in the DHI of 15 units
and a change in the VAS for dizziness of 2 units, with
power set at 80% and the signicance level at 0.05. The
magnitude of these differences in scores was determined
from previous studies (Koes et al., 1992a, b; Newman
and Jacobsen, 1993; Enloe and Shields, 1997; Storper
et al., 1998; OReilly et al., 2000) using these evaluation
tools to indicate clinically meaningful differences. The
calculations were performed by a statistician using the
PS Power and Sample Size Calculation computer
program available online from the Vanderbilt Medical
Centre (www.mc.vanderbilt.edu).
2.3. Subjects
The inclusion and exclusion criteria for the participants in the study are provided in Table 1. Participants
had to meet all the inclusion criteria to enter the study,
but were excluded if they met any of the exclusion
criteria.
2.4. Recruitment and screening
Participants with suspected cervicogenic dizziness
were recruited from a press release by the Universitys
media unit (378 respondents), and respondents were
screened by telephone interview by a manipulative
physiotherapist. After questioning, 83 respondents with
dizziness described as imbalance or unsteadiness combined with a stiff or painful neck or headache were
considered potential participants. Nine other participants were directly referred to the study by neurologists
in the local region. All potential participants were
invited to undergo comprehensive assessment by a
neurologist (Table 2) in which other causes of dizziness
(Table 1) were excluded. Following neurological assessment of 59 people, 25 people were excluded because they
were diagnosed with other causes of dizziness and 34
entered the trial (Fig. 1).

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S.A. Reid et al. / Manual Therapy 13 (2008) 357366
Table 1
Inclusion and exclusion criteria
Inclusion criteria
 Dizziness described as imbalance or unsteadiness (not rotatory
vertigo)
 Dizziness related to either movements or positions of the cervical
spine, or occurring with a stiff or painful neck
 Symptoms 43 months
 1890 years of age
Exclusion criteria
By neurologist
 Vestibular disorders (e.g. Benign Paroxysmal Positional Vertigo,
Menieres disease, peripheral vestibulopathy)
 CNS disorder (e.g.cerebellar ataxia, stroke, demyelination)
 Mal de debarquement syndrome
 Migraine associated vertigo
 Psychogenic dizziness
 Cardiovascular disorders
A history of
 Vestibular disorder
 Active inammatory joint disease
 Spinal cord pathology
 Cervical spine cancer or infection
 Bony disease or marked osteoporosis
 Marked cervical spine disc protrusion
 Acute cervical nerve root symptoms (severe pain, weakness, pins
and needles or numbness in the arm or hand for less than six weeks)
 Recent (in the previous three months) fracture or dislocation of the
neck
 Previous surgery to the upper cervical spine
 Physiotherapy or any manual therapy treatment to the neck in the
previous month
 Pregnancy
 Inability to read English

2.5. Randomisation
Participants were randomly allocated to either the
SNAG group (n 17) or the placebo group (n 17) by
choosing an opaque envelope with a computer generated
random number inside. This number was then checked
against a list (prepared by a biostatistician) that
allocated the participant to either the placebo group or
the SNAG group. The participants were unaware that
the laser procedure was a sham treatment, so were blind
to whether they were in the treatment or placebo group.
The success of the blinding was evaluated by the Global
Perceived Effect (GPE) Questionnaire (Koes et al.,
1992a, b).
2.6. Interventions
Both groups of participants received their interventions 46 times over 4 weeks. Most participants (15
participants in each group) received it four times. At the
discretion of the treating manipulative physiotherapist,

359

Table 2
Clinical examination process used by the neurologist for determining
the presence of cervicogenic dizziness
1. Presence of symptoms and signs of musculoskeletal pain and
stiffness in the neck.
2. Current history of positionally aggravated dizziness, unsteadiness
or imbalance; or a persisting disequilibrium. Volunteers with true
rotatory vertigo were considered to have other disorders.
3. Exclusion of alternative causes of dizziness. These included, but
were not limited to Benign Paroxysmal Positional Vertigo,
peripheral vestibulopathy, Menieres disease, stroke, demyelination
and other CNS disorders, and migraine associated vertigo. This
was based on the history, standard neurological and neuro
otological examination including:
 Hallpike test
 Examination for positional, gaze evoked or head shaking
nystagmus
 Head thrust vestibulo-ocular reexes
 Ocular smooth pursuit and saccades testing
 Romberg and Unterberger tests
 Tandem gait and blind gait testing.
4. Following clinical examination, caloric testing was performed in
the neurologists laboratory by a trained technician to exclude
other vestibular causes of dizziness.

two extra sessions were given to two participants in the

SNAG group for whom it was felt it would be benecial
to receive six treatments in 4 weeks. This was matched in
the placebo group with two participants also receiving
six sessions. All participants were asked to avoid new
co-interventions throughout their participation in the
trial, and as far as can be ascertained, all participants
complied with this request.
2.6.1. SNAGS intervention
One group of participants received the SNAG
treatment as described by Brian Mulligan (Mulligan,
1999). From the participants history, the offending
active cervical movement (i.e. the movement that
predominantly caused their dizziness) was ascertained
and used to determine the treatment direction. Mulligan
suggests the most common active movement to bring on
dizziness is cervical extension, though it can be
provoked by rotation or exion (Mulligan, 1999). Active
movement did not elicit reproducible symptoms (dizziness or cervical pain) in all participants at the time of
treatment. In these cases, the provocative active cervical
movement for dizziness, as determined by the history,
was used in the SNAG treatment.
With the participant in an upright (weight-bearing)
sitting position, a manipulative physiotherapist of 18
years clinical experience applied a sustained passive
accessory movement (glide) while the participant moved
actively through their available physiological range in
the direction that produced their symptoms. This was
repeated six times. The participant was asked to report

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S.A. Reid et al. / Manual Therapy 13 (2008) 357366

Assessed for eligibility

(n = 59)
n = 50 from press release
n=9 from neurologists
Enrollment

Excluded by exclusion criteria

(n = 25)

Randomized
(n = 34)

Allocated to placebo group

(n = 17)
Received allocated intervention
(n = 17)

Allocated to SNAG group

(n = 17)
Allocation

Received allocated intervention

(n = 16)
One participant left study due to
previous bad experience with manual
therapy

6-week follow-up
(n = 17)
12-week follow-up
(n = 17) for self-report
(n = 15) for physical assessments
(2 unable to attend)

Follow-Up

Analyzed
(n = 17) for self-report
(n = 15) for physical assessments

6-week follow-up
(n = 16)
12-week follow-up
(n = 16)

Analysis

Analyzed
(n= 16)

Fig. 1. Flow chart of progression of participants through the study.

any dizziness or other symptoms during the application

of the procedure to ensure the treatment was symptomfree. If the participant reported some dizziness or
cervical pain then either the range of active movement
was decreased, the angle of the glide was slightly altered
or the point of application was changed to ensure the
treatment was symptom-free in all participants.
Consistent with the recommendations of Mulligan
(1999), if cervical spine extension or exion was
symptomatic then the glide was applied ventrally to
the C2 spinous process while the participant slowly,
actively extended or exed their neck. If left rotation
was symptomatic then the anterior glide was applied to
the left C1 transverse process while the participant
rotated their neck slowly to the left. If dizziness
persisted, the glide was then applied to the contralateral
right transverse process of C1, while the participant still

performed active left rotation. The comparable approach was used for symptomatic right rotation.
To progress the treatment at subsequent sessions, the
number of repetitions of the SNAG was increased from
six to 10. If the participant reported in their history that
a sustained cervical position such as prolonged extension (e.g. changing a light bulb) or exion (e.g. reading)
produced their dizziness, the end-range physiological
position was maintained for up to 10 s at the discretion
of the treating manipulative physiotherapist. A second
active movement was added if symptoms persisted in
that direction, again at the discretion of the treating
physiotherapist.
2.6.2. Placebo procedure
The second group of participants received a placebo
consisting of sham treatment with a detuned laser and

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carried out by the same therapist. The laser device used in

the study (Omni Laser Micro 301, Serial No. 1875,
manufactured by Laserdyne P/L, 17 Production Ave,
Ernest, Queensland, Australia) had been deactivated by
the manufacturer to produce no effective emission. The
laser appeared to operate normally, emitting a light signal
and a beeping sound. The detuned laser, which has been
shown to have a very strong placebo effect (Irnich et al.,
2001), was used for six applications of 20 s to various sites
on the upper cervical spine, at a distance of 0.51 cm
from the skin. Sham laser was chosen as it does not
activate somatosensory receptors (Irnich et al., 2001).

benet, 4 a lot of benet, 5 great benet,

6 maximal benet) as used in other studies (Koes,
1991; Koes et al., 1992a, b).
Secondary outcome measures were assessed as follows
at pre-treatment, post-treatment and at the 12-week
follow-up.

2.7. Outcome measures

Outcome measurements were obtained pre-treatment,
following the nal treatment, and at 6 and 12 weeks
after the nal treatment (1618 weeks after randomisation). The primary outcomes were the following selfreport measures:

Severity of dizziness (an average level over the

previous few days) was measured with a 10 cm visual
analogue scale (VAS). The VAS has been used to
measure dizziness in other studies (Gill-Body et al.,
1994; Cohen, 1999; Heikkila et al., 2000; Boismier
and Disher, 2001).
Disability caused by dizziness was measured with the
Dizziness Handicap Inventory (DHI). The DHI
assesses the impact of dizziness on the functional,
emotional and physical aspects of everyday life
(Jacobsen and Newman, 1990). The highest possible
score is 100, indicating maximum self-perceived
handicap. The DHI has been shown to be a highly
reliable and responsive tool (Newman and Jacobsen,
1993; Enloe and Shields, 1997). Signicant correlations between DHI scores and specic objective
measures of balance and gait have been demonstrated
(Whitney et al., 2004; Treleaven, 2006).
Frequency of dizziness was measured on a six-point
rating scale (0 no dizziness, 1 dizziness less than
once per month, 2 14 episodes of dizziness per
month, 3 14 episodes of dizziness per week,
4 dizziness once daily, 5 dizziness more than
once a day or constant). This scale was used by
Karlberg et al. (1996b) and Gill-Body et al. (1994) to
measure change in frequency of dizziness after
manual therapy.
Severity of cervical pain and headache (an average
level over the previous few days) was assessed with a
10 cm VAS. There is much evidence supporting the
validity of the VAS for measuring pain intensity (Scott
and Huskisson, 1976; Turk and Melzack, 1992;
Murphy et al., 1998; Maher et al., 2000; Scudds, 2001).
GPE was measured by self-assessment on a six-point
scale (1 no benet, 2 minimal benet, 3 some

361

Balance was measured with the Chattecx Balance

Dynamic System (Serial No. 1001, Chattecx Corporation, the Chattanooga Group, Tennessee) for
10 s during quiet standing with eyes open, with eyes
closed, and in cervical extension. The sway index (SI)
obtained is a computer-generated single number that
expresses the extent of sway in each direction over
four footplates.
Cervical range of motion was measured with the
cervical range of motion instrument (CROM; Performance Attainment Associates, St Paul, MN) by
the research assistant, who had been trained in the
use of the CROM. Single measurements of cervical
exion, extension, left rotation, right rotation, left
lateral exion and right lateral exion were obtained.
Moderate to high reliability of CROM measurements
has been demonstrated independent of the investigator performing the measurements (Dhimitri et al.,
1998). Also, CROM values have been shown to be
highly correlated (0.97) with the radiographic method
for measuring cervical exion and extension, strongly
supporting its validity (Tousignant et al., 2000).

2.8. Statistical analysis

An intention-to-treat analysis was performed on the
study cohort. The baseline characteristics of the two
groups were compared using univariate analyses. T-tests
were used for continuous measures and w2 tests for
categorical data. An alpha level of 0.05 was chosen
to indicate a signicant difference between groups
(Altman, 1996). The effects of the interventions were
determined by two-way repeated measures analyses of
variance with group (treatment) as the between factor
and time as the repeated factor. Subsequent analyses
depended on the presence of interactions or main effects,
and included repeated measures analysis of each group
independently and group comparisons at each time
point. Also, the difference between the assessment scores
at each time point and the baseline scores was calculated
for each outcome measure. These differences were also
calculated as percentage change.
2.9. Clinical significance
A change of 15 units in DHI scores was considered
clinically relevant (Newman and Jacobsen, 1993; Enloe

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362

and Shields, 1997; Storper et al., 1998; OReilly et al.,

2000). A change of 2 points in VAS scores for the main
complaint (in this case dizziness and pain) was
considered clinically signicant (Koes et al., 1992a, b).

3. Results
3.1. Participants
The characteristics of the participants prior to
treatment are shown in Table 3. The groups were
similar for age, gender and all outcome measures, except
posturography.
One participant in the SNAG group withdrew from
the study after the second treatment as she had
previously (prior to the study) had an adverse experience
with manual therapy (Fig. 1). No participants experienced any adverse effects from the interventions received
in the study.
3.2. Severity of dizziness responses to interventions
In the SNAG group dizziness was signicantly less
severe post-treatment (P 0.001), at 6 weeks (Po0.001)
and at 12 weeks (Po0.001) compared to pre-treatment
Table 3
Characteristics of participants with cervicogenic dizziness prior to
treatment
Characteristic

Placebo group
(n 17)

SNAG group
(n 17)

Gender no. (%)a

Age (years)
VAS dizziness
DHI
Frequency of dizziness
VAS pain
Posturography
Quiet standing/eyes
open
Eyes closed
Cervical extension/eyes
open
CROM (deg)
Cervical exion
Cervical extension
Left rotation
Right rotation
Left lateral exion

F:10
63.6
5.6
43.9
3.4
4.7

F:11(65)
63.4 (13.1)
5.6 (2.2)
44.4 (18)
3.3 (1.4)
4.7 (2.5)

0.12b
0.97
1.00
0.94
0.82
1.00

3.6 (1.4)

5.2 (2.2)

0.02

6.6 (2.6)
7.7 (4.5)

10.7 (10.1)
10.3 (8.0)

0.12
0.26

(59)
(13.7)
(2.9)
(18.4)
(1.1)
(2.2)

(Fig. 2). The placebo group had no change posttreatment or at 6 weeks, although there was a signicant decrease by 12 weeks (P 0.02) (Fig. 2).
Dizziness was signicantly less severe in the SNAG
group compared to the placebo group post-treatment
(P 0.03) and at 6 weeks (P 0.03) but no longer
different at the 12-week follow-up (P 0.09). Using the
criteria for clinical signicance of a 2-unit change in
scores, the SNAG group had a clinically signicant
reduction in dizziness severity post-treatment (mean
change 3.1 units) that was maintained at the 12-week
follow-up (mean change 3.3 units). The changes in the
placebo group were not clinically signicant (mean
changes of 1.0 post-treatment and 1.9 units at 12-weeks
follow-up.
3.3. DHI responses to interventions
In both the SNAG and placebo groups pre-treatment,
30% of participants reported mild handicap from their
dizziness (scoring 030 on DHI), 53% moderate (score
3160) and 17% severe handicap (score 61100). Posttreatment in the SNAG group 68% of participants
reported mild handicap, 32% moderate and none severe.
Post-treatment in the placebo group 22% reported mild,
66% moderate and 12% severe handicap. The SNAG
group had signicantly lower scores on DHI at all
reassessment times compared to pre-treatment (P
0.001 post-treatment, Po0.001 at 6 weeks, Po0.001 at
12 weeks), while the placebo group had a signicant
change only at the 12-week follow-up (P 0.01)
(Fig. 3). The SNAG group had lower scores on DHI
compared to the placebo group post-treatment
(P 0.02) and at the 6-week follow-up (P 0.05), but
this difference was not statistically signicant at the
12-week follow-up (P 0.06).

10

46.2
42.7
28.9
29.1
47.2

(13.7)
(12.5)
(11.0)
(10.4)
(11.1)

40
43.4
30.6
29
44.9

(15.1)
(13.2)
(8.1)
(10.1)
(12.2)

0.23
0.88
0.61
0.98
0.57

Values are mean (SD) unless stated otherwise.

Note: SNAG sustained natural apophyseal glide; M males;
F females; DHI dizziness handicap inventory; VAS visual
analogue scale; CROM cervical range of motion.
 Signicant at Pp0.05.
a
For gender, the number and percentage of participants are
reported.
b 2
X.

VAS Dizziness Scores

Placebo Gp

SNAGs Gp

8
6

4
2

Pre
Treatment

Post
Treatment

6-Weeks
Follow-up

12-Weeks
Follow-up

Fig. 2. Effect of interventions on Visual Analogue Scale for dizziness

scores for Placebo group (n 17) and SNAG group (n 16) over
time. Data are mean7SE. *Signicantly different (Po0.05) to pretreatment score.

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S.A. Reid et al. / Manual Therapy 13 (2008) 357366

100

DHI Scores

80
60

40
20

Pre
Treatment

Post
Treatment

6-Weeks
Follow-up

12-Weeks
Follow-up

Fig. 3. Effect of interventions on Dizziness Handicap Inventory scores

for Placebo group (n 17) and SNAG group (n 16) over time. Data
are mean7SE. *Signicantly different (Po0.05) to pre-treatment
score.

For the SNAG group the change in score (18.1 posttreatment and 19.7 at 12-week follow-up) exceeded the
15 points required for a clinically signicant true change
that is attributable to the treatment. The small decrease
observed in DHI for the placebo group (2.2 posttreatment and 6.5 at 12-week follow-up) did not reach
this level and therefore, could be due to variability in the
measuring tool (Newman and Jacobsen, 1993).
3.4. Frequency of dizziness responses to interventions
At initial assessment 48% of participants reported
dizziness at least once daily. The SNAG group had
signicantly decreased frequency of dizziness posttreatment (P 0.02), at 6 weeks (P 0.02) and at 12
weeks (P 0.03) compared to pre-treatment (Fig. 4).
For the placebo group there was no signicant change at
any time point (Fig. 4). There was no signicant
difference in the frequency of dizziness episodes between
the SNAG and placebo groups at any of the assessment
times.

Frequency of Dizziness

SNAGs Gp

Placebo Gp

SNAGs Gp

4
3
2

6-Weeks
Follow-up

12-Weeks
Follow-up

Pre
Treatment

Post
Treatment

Fig. 4. Effect of interventions on frequency of dizziness scores for

Placebo group (n 17) and SNAG group (n 16) over time. Data are
mean 7 SE. *Signicantly different (Po0.05) to pre-treatment score.

10
8
VAS Pain Scores

Placebo Gp

363

Placebo Gp

SNAGs Gp

4
2

Pre
Treatment

Post
Treatment

6-Weeks
Follow-up

12-Weeks
Follow-up

Fig. 5. Effect of interventions on Visual Analogue Scale for pain

scores for Placebo group (n 17) and SNAG group (n 16) over
time. Data are mean7SE. *Signicantly different (Po0.05) to pretreatment score.

achieved clinical signicance at 12-weeks follow-up with

a 32% decrease in pain.

3.5. Severity of pain responses to interventions

3.6. Global perceived effect responses to interventions
The SNAG group had signicantly less pain posttreatment (Po0.001), at 6 weeks (P 0.001) and at 12
weeks (P 0.01) compared to pre-treatment (Fig. 5).
There was no signicant change in the placebo group
post-treatment and at 6 weeks, although there was a
signicant change by 12 weeks (P 0.02) (Fig. 5). The
SNAG group had less pain than the placebo group posttreatment (P 0.001) and at 6-week follow-up
(P 0.048) but not at 12 weeks (P 0.32). In the
SNAG group, pain decreased 69% post-treatment and
54% at 12-weeks follow-up, easily meeting the criteria
for a clinically signicant change of 28%. The placebo
group was only 4% lower post-treatment but just

The GPE ratings of the SNAG group were signicantly higher than those of the placebo group posttreatment, and at the 6- and 12-week follow-ups
(all Po0.001) (Table 4). On average, participants in
the SNAG group rated the treatment as being a lot of
benet post-treatment and at 6-week follow-up and of
great benet at the 12-week follow-up. Participants
receiving the placebo intervention rated it as having
minimal benet to some benet at all assessment
points suggesting that, although it had much less effect
than SNAGs, they did not know it was a placebo, and
therefore blinding to group allocation was successful.

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364
Table 4
Scores for global perceived effect

Posttreatment
6-week
follow-up
12-week
follow-up

Placebo
group
(n 17)

SNAG
group
(n 16)

Mean difference
(95% CI of the
difference)

2.1 (1.2)

4.1 (1.2)

1.95 (2.87, 1.13)

o0.001

2.4 (1.1)

4.3 (1.3)

1.90 (2.75, 1.04)

o0.001

2.4 (1.1)

4.5 (1.2)

2.15 (2.97, 1.32)

o0.001

Values are mean (SD) with mean differences (95% condence intervals
[CI]).Note: SNAG sustained natural apophyseal glide.
 Signicant at 0.05.

3.7. Balance responses to interventions

There was no signicant change (P 0.29) in SI
during quiet standing in the SNAG group at any stage
following treatment, whereas the SI increased signicantly (P 0.01) (i.e. poorer balance) at the 12-week
follow-up for the placebo group. When the SI was
measured with the participants eyes closed, there was a
24% decrease in SI from pre- to post-treatment in the
SNAG group, although this was not statistically
signicant. During balance assessment with the cervical
spine in extension, the SI for the SNAG group was
lower (i.e. better balance) at the 12-week follow-up
(P 0.05) but there was no change in the placebo group
(P 0.23).
3.8. Cervical range of motion responses to interventions
There was a signicant increase (P 0.01) in cervical
extension range of motion in the SNAG group posttreatment with an increase in mean range of movement
from 441 to 501 with only minor regression at the
12-week follow-up (491). In the placebo group there was
no signicant change in extension range of movement.
In the SNAG group there was a trend for increased
cervical left rotation range of motion after treatment
(P 0.065) and an increase at the 12-week follow-up
(P 0.05). There was no signicant change in the
placebo group. There was no statistically signicant
difference between the two groups at any time, although
for cervical extension range of motion post-treatment
and at the 12-week follow-up there was a trend
(P 0.09) for the two groups to be different.

4. Discussion
This is the rst time the SNAG manual therapy
technique has been investigated in the treatment of
cervicogenic dizziness or any other cervical spine

condition. The results provide evidence of the benets

of this manual therapy technique for cervicogenic
dizziness and pain, and support the cervicogenic origins
of this form of dizziness. Although there is some
evidence that multi-modal treatment may be effective
for cervicogenic dizziness (Karlberg et al., 1996b), this is
the rst time an isolated manual therapy technique,
which is more specic and less time consuming than
multi-modal treatment, has been shown to be effective
(Gross et al., 2002; Reid and Rivett, 2005) .
The key ndings of this study were that the SNAG
treatment of cervicogenic dizziness results in substantial
and clinically meaningful decreases in the severity of the
dizziness (measured with VAS), disability associated
with the condition (measured by the DHI), frequency of
dizziness (measured on a six-point scale) and the severity
of the cervical pain (measured with VAS). The
improvement in the SNAG treatment group was
immediate and maintained over the 12-week follow-up
period after the cessation of treatment. Improvements in
DHI and severity of dizziness and pain in the placebo
group were of lesser magnitude and followed a much
slower time course, reaching statistical but not necessarily clinical signicance at the 12-week follow-up. The
gradual improvement over time in the placebo group
could be due to the placebo intervention, or more likely,
to be a result of slow natural resolution over time. It is
reasonable to assume that most patients would prefer
greater and more immediate relief from these disabling
symptoms. Based on GPE ratings, the SNAG treatment
was perceived by the participants to be of greater benet
than the placebo intervention. Most participants receiving SNAGs were very satised with their treatment and
there were no adverse effects.
One of the clear benets of the SNAG treatment was
the shorter time frame over which it proved effective.
For the four primary outcome measures (severity of
dizziness, DHI, frequency of dizziness and severity of
pain) the effectiveness of the treatment was observed at
the end of the intervention period in the SNAG
treatment group. Importantly, this improvement was
maintained throughout the follow-up period.
Using the DHI, this study was able to demonstrate
that cervicogenic dizziness had a substantial negative
impact on the functional, emotional, and physical
aspects of everyday life. Prior to treatment, the
participants had a mean score on the DHI of 44.4,
and four participants had severe disability, scoring
between 76 and 78 out of a possible 100. After receiving
the SNAG treatment there was a signicant reduction in
the DHI score (mean 24.7) for that group. This
improvement indicates that the SNAG treatment had
a marked, positive effect on their quality of life and level
of disability associated with their dizziness.
It is possible that the SNAG treatment may normalise
input from Type IV nociceptors, as there was a decrease

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S.A. Reid et al. / Manual Therapy 13 (2008) 357366

in pain parallel to the decrease in dizziness in

participants treated with SNAGs. The rapid pain
relieving effect produced by SNAGs is similar to the
rapid pain relief reported in the treatment of lateral
epicondylalgia using another Mulligan technique, mobilisation with movement. This pain relief was shown to
be the result of activation of the non-opioid descending
noradrenergic system of analgesia (Paungmali et al.,
2003).
Extension was the movement that most commonly
reproduced the participants symptoms and was thus the
direction of movement used in the SNAG treatment in
59% of cases. Mulligan (1999) reported that cervical
extension is the most common movement linked to
cervicogenic dizziness. A signicant increase in cervical
extension range of motion was seen at post-treatment in
the SNAG group, and this was maintained at the
12-week follow-up. No improvement in cervical extension
was found in the placebo group. Since both dizziness
and extension range of motion improved there is
possibly a relationship between the two. Indeed, it has
been shown experimentally that loss of normal input
from Type I cervical articular mechanoreceptors leads to
dizziness and poor balance (Wyke, 1979). Previous
studies have shown the presence of mechanoreceptive
and nociceptive nerve endings in the cervical zygapophyseal joint capsules which implies that neural input
from these joints is important in proprioception and
pain sensation (Wyke, 1979; Hulse, 1983; Hinoki, 1985).
It has been proposed that joint hypomobility may
lead to pain and further reduction in movement
(Kaltenborn and Evjenth, 1989; Oostendorp et al.,
1993), and consequently a decrease in the number of
mechanoreceptors stimulated (Oostendorp et al., 1993).
Several clinical authors suggest that once normal joint
accessory movement is restored, symptom-free voluntary physiological movement is then encouraged, facilitating pain-free normal function (Maitland, 1986;
Kaltenborn and Evjenth, 1989; Mulligan, 1994). These
theories are supported by the present study that has
shown parallel improvements in range of motion, pain
and dizziness following manual therapy directed to the
cervical spine.
Because participants had a decrease in their dizziness
after manual therapy treatment to the upper cervical
spine, it can be inferred that dysfunction in the upper
cervical spine was the likely source of the problem. This
provides evidence in support of the existence of
cervicogenic dizziness, a topic still of some controversy
to date (Karlberg et al., 1996a; Oostendorp et al., 1999;
Brandt and Bronstein, 2001; Tjell, 2001).
One limitation of present the study is that the
manipulative physiotherapist providing both interventions was aware that the laser procedure was a sham
treatment. Even though the therapist attempted to treat
all participants equally, she may have unknowingly been

365

biased towards the SNAG treatment. Also, larger

sample sizes may be required when measures such as
posturography and cervical range of motion are used as
the magnitude of the changes observed are small but
may be functionally valuable.

5. Conclusion
The present study found that SNAGs are a safe and
effective manual therapy technique for the treatment of
cervicogenic dizziness and pain. SNAGs were shown to
have a clinically and statistically signicant immediate
and sustained effect in reducing dizziness, neck pain and
disability caused by cervical spine dysfunction. The
results of this study provide a new evidence-based
treatment option for patients suffering this disabling
condition.
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