Natural Apophyseal Glides(NAGS)

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Introduction

Natural apophyseal Glides (NAGS) is the name Brian R. Mulligan given to small amplitude, multiple, rhythmic mid to end range gentle oscillatory glides which can be applied to the facet joints between cervical 2 and 7 vertebrae. They are mid to end-range facet joint mobilizations that are applied Antero- cranially along the treatment planes of the joints selected.

They are graded according to the tolerance of the patient. They should always be pain-free for the patients. If these are painful despite applying correctly, then all other means would be painful. The patient is always seated which is the most convenient starting position. This is much more acceptable than prone lying especially with kyphotic patients. They should be combined with a little manual traction to render them more comfortable.

Indications

• NAGS are used to increase spinal movement in the cervical region and decrease the pain associated with it.

• They are very useful in elderly patients having severe spondylotic changes when applied with 'tender loving care'.

• To relieve post-manipulative soreness
• NAGS is also used to check for irritability of the cervical spine.
• The patient with a grossly restricted cervical range of motion, is a godsend, assuming that the loss of movement is not due to serious structural injury or other contraindicated pathology.

Patient and Therapist Position

Patient position

The patient is seated in an upright position comfortably at the edge of the stool or chair without an armrest. To accommodate different sizes of patients, it would help if the seat was height adjustable. The head of the patient should be held in a neutral position (the neck may be kept in a slightly flexed position to have better palpation if pain frees).

Therapist Position

As a therapist (if right-handed) stand at the right side of the patient so that your lower trunk is in contact with the anterolateral surface of the patient's right shoulder. This is to stabilize the trunk of the patient when the mobilization is carried out.

The patient's head is cradled against your upper abdomen and chest, comfortably held there with the right forearm diagonally positioned across the patient's left temporal-mandibular joint. In positioning the head, rotation and side flexion should be avoided. As the patient's head makes some contact with the lower chest, Mulligan suggested that a female therapist may wish to place a soft pad between her chest and the patient's head. This is not only for hygienic reasons but also not to capture the cosmetics worn by some.

Application Guidelines

Hand placement

The middle phalanx of the therapist's right little finger is placed (hooked) under the spinous process of the vertebra on top of the joint to be mobilized. The other fingers of that hand are wrapped around the occiput, stabilizing the head. The lateral border of the thenar eminence of the left hand partially covers the little finger of the therapist’s right hand. The therapist typically needs to take up the slack in the soft tissue to come into contact with the vertebrae to be moved.

Mobilization

To mobilize the Cervical 5/6 joint your phalanx would be under the spinous process. Mid to end-range glides are performed along the cervical spine facet plane via the fifth digit of the right hand by pushing up and forwards with the therapist’s left hand (motive hand) towards the patient’s eyes ball.

• Before mobilization, the therapist takes up the skin slack to ensure good bone contact.
• Mobilization is applied to the spinous process for bilateral or central pain, or unilaterally on the side of pain.
• Ensure the fifth digit is relaxed, so it is being moved only by the therapist’s motive hand during the oscillations.
• Keep the head stationary during the mobilization.
• Mobilization is symptom-free. If symptoms are provoked, try applying traction with the mobilization. In the step/walk-stance position, the therapist shifts their weight to their rear leg, which induces a gentle distraction to the cervical spine.
• Mobilize at all vertebral levels causing symptoms.
• Glides are rhythmical and at a rate of one–Two per second.
• Mobilizations should be repeated 6–10 times (Such that; oscillate for 5–10 seconds) at each level, working from superior to inferior vertebral levels.
• Repeat the mobilization 3–5 times per vertebral level, if reassessment indicates a positive response.

Variations and Precaution

Variation

• A gentle glide should be trialed in acute pain and a stronger glide for more chronic stiffness-related disorders. If pain is elicited, try a more gentle glide, cushioning with a foam pad, or applying traction combined with mobilization.
• A foam pad also helps to avoid excessive sliding on the skin.

Precaution

While applying NAGS, they are precautions to be taken and those include the following:

• Use of the pillow or towel during NAGS
• Don't block the airway of the patient.
• Any rotation or side flexion of the neck should be avoided.
• The female therapist is advised to use a pillow or a thick towel between the patient's head and her breast.
• Therapists should use brachioradialis for giving a glide and not the pronators of the mobilizing forearm.

Contraindications

Some contraindications in the application of NAGs as one of the manual therapy techniques may include:

1. Spinal fractures: Any recent vertebral fracture or other spinal injuries may require special caution when it comes to applying manipulative therapy techniques like NAGs.
2. Spinal infections: Any infection may be contraindicated for manual therapy as it may potentially spread the infection or cause further damage.[1]
3. Osteoporosis: This medical condition may make bones fragile and susceptible to fractures. Thus, the application of NAGs may require careful modification or may be contraindicated entirely for people with this condition.
4. Severe nerve compression or radiculopathy: Extreme nerve compression can cause long-lasting damage to the spinal cord or nerve roots. Triggering pain or nerve symptoms during joint mobilization by a therapist may mean that the therapist should avoid using NAGs or other forms of manual therapy.