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ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 128-134  

Efficacy of sustained natural apophyseal glides mulligan technique on mobility and function in patients with cervical spondylosis: An experimental study


Department of PM and R, RMMC and H, Annamalai University, Chidambaram, Tamil Nadu, India

Date of Submission26-Sep-2019
Date of Decision08-Feb-2020
Date of Acceptance23-Mar-2020
Date of Web Publication22-Jul-2020

Correspondence Address:
S Arul Pragassame
Department of PM and R, RMMC and H, Annamalai University, Annamalai Nagar, Chidhambaram - 608 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_184_19

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   Abstract 


Background: Cervical spondylosis is a degenerative condition that affects the joints and discs of the cervical spine. Symptoms include pain associated with a positional fault in the joint with resultant subtle biomechanical changes, such as joint restriction and stiffness. Sustained natural apophyseal glides (SNAGS) Mulligan technique shows a direct effect on the facet joints, helping to correct the positional fault and correct the biomechanical changes. Objective: The objective of the study is to find the efficacy of SNAG Mulligan technique on pain, mobility, and functional disability in patients with cervical spondylosis. Materials and Methods: Forty subjects with cervical spondylosis were selected on the basis of selection criteria. The pain intensity was measured using the Numeric Pain Rating Scale (NPRS), the cervical range of motion (ROM) was measured using the universal goniometer, and the functional disability was measured using the neck Bournemouth Questionnaire (BQ). Patients were randomly assigned to two Groups A and B. Group A (n = 20) received SNAG Mulligan technique along with conventional treatment and Group B received transcutaneous electrical nerve stimulation and isometric neck exercises (conventional treatment) alone. Results: Group A had significant improvements in NPRS (Z = 25.754, P = 0.001), cervical ROM flexion (Z = 17.085, P = 0,001), extension (Z = 17.962, P = 0.001), side flexion (Rt) (Z = 16.520, P = 0.001), side flexion (Lt) (Z = 16.998, P = 0.001), right rotation (Z = 15.379, P = 0.001), left rotation (Z = 13.180, P = 0.001), and neck BQ (Z = 22.912, P = 0,001) compared to Group B. Conclusion: The study concludes that patients who received SNAG Mulligan technique showed better improvement in pain reduction, cervical ROM, and functional disability than the control group.

Keywords: Cervical spondylosis, isometric neck exercises, neck bournemouth questionnaire, sustained natural apophyseal glide, transcutaneous electrical nerve stimulation


How to cite this article:
Pragassame S A, Mohandas Kurup V K, Kour J. Efficacy of sustained natural apophyseal glides mulligan technique on mobility and function in patients with cervical spondylosis: An experimental study. J Nat Sc Biol Med 2020;11:128-34

How to cite this URL:
Pragassame S A, Mohandas Kurup V K, Kour J. Efficacy of sustained natural apophyseal glides mulligan technique on mobility and function in patients with cervical spondylosis: An experimental study. J Nat Sc Biol Med [serial online] 2020 [cited 2020 Oct 23];11:128-34. Available from: http://www.jnsbm.org/text.asp?2020/11/2/128/290483




   Introduction Top


Cervical spondylosis is a common and nonspecific term that refers to degenerative changes that develop gradually with age or secondarily due to trauma or other pathological conditions.[1] This chronic degenerative condition affects the vertebral bodies and the intervertebral discs of the neck in the form of spur formation and dick herniation, as well as the contents of the spinal canal, such as the spinal cord and nerve roots. These changes also affect the facet joints, longitudinal ligaments, and ligamentum flavum.[2]

The sign and symptoms include pain which may radiate or locate in the neck, limited movements in the neck, postural abnormalities, headache, paresthesia, and symptoms of vertebrobasilar insufficiency. These features may occur singly or in any combination.[3] Patients between the ages of 40 and 49 years show a maximum prevalence of a disease that is more prevalent in males than females. The Indian population study shows 78% radiological changes in levels C5–C6 and C6–C7.[4]

Various approaches to physical therapy are used to treat patients with cervical spondylosis. These include exercise therapy, massage, ergonomic advice, electrotherapy, and manual therapy (joint mobilization technique). Manual therapy is one of the fundamental treatment methods of the physical therapist in the management of cervical spondylosis and can be effective in alleviating pain, restoring motion, and helping to alter the biomechanics of a particular joint by equally distributing forces.[5]

There are various mobilization techniques for cervical neck pain, and Mulligan technique is one of them and sustained natural apophyseal glides (SNAGS) technique is used for our study purposes.

The technique was introduced by Mulligan in 1999 and is performed by applying an accessory glide along the axis of the affected level facet joint while the patient is actively moved from the place of the weight bearing. The therapist applies the pressure over the spinous process in a cephalad direction. SNAG is the best technique as it improves the range of motion (ROM) of the patient by correcting the biomechanics of the joint, unlocking a jammed facet, and releasing the entrapped meniscoid between the joints if any. The pain reduction occurs due to various factors such as mobilization induced movements, which provide nutrition to the facet of the joint and disc, and may also stimulate mechanoreceptors and proprioceptors in and around the joint which releases muscle around the joint and thus reduce pain.[6]

Since there was relatively limited literature available in the past, the aim of the study is to find the efficacy of SNAG Mulligan technique on pain, mobility, and functional disability in patients with cervical spondylosis.


   Materials and Methods Top


Study procedure

The study was approved by the Departmental Research Committee (PMR/DRC-8/2019) on the conduct of human subjects with respect to ethical consent. During the specified period (January–July), the sample size was selected using the convenient sampling method. The selection criteria were (1) 40 patients with diagnosed cervical spondylosis, (2) both males and females, (3) age group between 40 and 60 years, (4) patients who can understand instructions and are willing to participate in the study, and (5) patients otherwise healthy. The informed consent was obtained from the patients prior to the procedure and the procedure was explained in detail. Demographic data were collected. The initial evaluation of pain intensity was performed using the Numeric Pain Rating Scale (NPRS). Active ROM of cervical flexion, extension, side flexion (Rt/Lt), and rotation (Rt/Lt) was measured by goniometer and the functional disability was measured using the Neck Bournemouth Questionnaire (BQ).

The participants were randomly assigned to two groups. Group A (n = 20) received Mulligan SNAG technique with transcutaneous electrical nerve stimulation (TENS) and isometric neck exercise and Group B (n = 20) received TENS and isometric neck exercises for 10 sessions. The evaluation was carried out by an experienced third person (physiotherapist) who was blind to the study groups.

Outcome measures

Numerical pain rating scale

The NPRS is used to measure the intensity of pain in the patient. The patient sat on a chair and was requested to mark the severity of resting pain ranging from 0 as “no pain” to 10 as “severe pain” on a 10 cm line.[7]

Cervical active range of motion

Goniometer measurement


   Cervical Flexion Top


The patient is asked to sit down and flex the neck to move the chin to the chest. The fulcrum is positioned over the angle of the jaw and the fixed arm along the ear in the upward direction and the movable arm with the base of the nares. The number of degrees of motion is estimated.


   Cervical Extension Top


The patient is seated and asked to extend his neck as if he/she was looking at the ceiling, so that the back of the head is approaching the thoracic spine. The fulcrum is over the jaw, the fixed arm along the ear, and the moving arm with the base of the nares. The degree is measured as the patient extends the neck to the ceiling.


   Cervical Side Flexion (Rt/lt) Top


The patient is made to sit and flex the neck laterally without rotation, moving the ear toward the shoulder. The fulcrum is over the spinous process of the seventh cervical vertebrae, the fixed arm over the shoulder parallel to the floor, and the movable arm aligned with external occipital protuberance. Measure the degree between the mastoid process and the acromion process. Repeat on both right and left.


   Cervical Rotation (Rt/lt) Top


The patient is sitting and asked to rotate his head to the right and to the left without rotating his spine. The fulcrum is over the vertex of the head, the fixed arm is parallel to the floor or the acromion process, and the moving arm is aligned with the tip of the nose. The degree of movement on both sides is measured.[8]

Neck bournemouth questionnaire

The Neck BQ described by Jennifer Bolton and Alan Breen is based on Any Qualified Provider system. It is a multidimensional core outcome tool for assessing patient outcomes and for measuring seven different items, including neck pain, daily activities, recreation social activities, anxiety, depression, work, and control on own. BQ contains seven questions, each with a rating scale of 0–10. The total score for each measure is added and can range from a minimum score of 0 to a maximum score of 70. The higher the score reflects the degree of impact on the life of the patient.[9]

Treatment procedure

The total duration of treatment was 10 sessions, with a frequency of one session per day. Both groups received TENS (15 min) following the Mulligan SNAG technique and the patients were taught isometric neck exercises (perform all exercises 10 s hold and 10 repetitions) at the end of the technique.

Sustained natural apophyseal glides

The patent sits upright on the chair. The therapist stands behind the patient in a stride stance position. The SNAG technique is performed by the therapist by giving glide under the spinous process by pushing it towards the eyeball. The patient is asked to perform a painful or restricted movement and the therapist moves his/her hand along with the movement of the spine to sustain the glide, as shown in [Figure 1]. The total duration of treatment is 10 sessions.[6]
Figure 1: The sequence of the sustained natural apophyseal glides Mulligan technique (a) cervical flexion (b) extension (c and d) Lt/Rt side flexion and (e and f) Rt/Lt rotation

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Statitical analysis

Significant changes in pre- and post-measurements were studied using the Wilcoxon signed-rank test for NPRS, cervical ROM, and neck BQ. The comparison of improvement between groups was analyzed by the independent sample t-test for the outcome variables. The entire statistical procedure was carried out by the Statistical Packages for the Social Sciences-18.


   Results Top


The mean pre-NPRS for the experimental group was 7.85 ± 1.35 and was reduced to 3.05 ± 1.00 after treatment. The reduction was statistically significant (Z = 25.754, P = 0.001). The mean pre-NPRS for the control group was 6.65 ± 1.50 and the mean reduction after treatment was 3.80 ± 1.64. The reduction was statistically significant again (Z = 11.699, P = 0.001). The mean difference of improvement in the experimental group was 4.80 ± 0.83 and was relatively higher than the control group (2.85 ± 1.09). The difference was statistically significant (Z = 6.622, P = 0.001). The reduction in NPRS (improvement) was therefore significantly higher in the experimental group [Table 1].
Table 1: Comparison of numerical pain rating scale for experimental and control group in pre- and posttreatment

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The mean difference of improvement in the experimental group was 19.50 ± 5.10 and was comparatively higher than control group (11.00 ± 3.08). The difference was statistically significant (Z = 5.667, P = 0.001). Therefore, the increase in cervical flexion ROM in the experimental group was significantely higher, as shown in [Figure 2].
Figure 2: Comparison of cervical flexion range of motion for experimental and control group in pre- and post-treatment. Data are represented as mean ± standard deviation

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The mean difference of improvement in the experimental group was 20.50 ± 5.10 and was comparatively higher than the control group (11.50 ± 3.66). The difference was statistically significant (Z = 7.285, P = 0.001). Therefore, the improvement in cervical extension ROM in the experimental group [Figure 3] was significantly higher.
Figure 3: Comparison of cervical extension range of motion for experimental and control group in pre- and post-treatment. Data are represented as mean ± standard deviation

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The mean difference of improvement in the experimental group was 18.25 ± 4.94 and was comparatively higher than the control group (8.50 ± 6.71). The difference was statistically significant (Z = 4.717, P = 0.001). Therefore, the improvement in cervical right side flexion ROM was significantly higher in the experimental group [Figure 4].
Figure 4: Comparison of cervical (Rt) side flexion range of motion for experimental and control group in pre- and post-treatment. Data are represented as mean ± standard deviation.

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The mean difference of improvement in the experimental group was 21.00 ± 5.52 which was comparatively higher than the control group (11.00 ± 9.68). The difference was statistically significant (Z = 4.156, P = 0.001). Therefore, the improvement in cervical left side flexion ROM was significantly higher in the experimental group [Figure 5].
Figure 5: Comparison of cervical (Lt) side flexion range of motion for experimental and control group in pre- and post-treatment. Data are represented as mean ± standard deviation

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The mean difference of improvement in the experimental group was 19.00 ± 5.52 which was comparatively higher than the control group (9.00 ± 9.12). The difference was statistically significant (Z = 4.595, P = 0.001). Therefore, the improvement in cervical right rotation ROM was significantly higher in the experimental group [Figure 6].
Figure 6: Comparison of cervical (Rt) rotation range of motion for experimental and control group in pre- and post-treatment. Data are represented as mean ± standard deviation

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The mean difference of improvement in the experimental group was 16.75 ± 5.68 which was comparatively higher than the control group (7.00 ± 8.01). The difference was statistically significant (Z = 4.717, P = 0.001). Therefore, the improvement in cervical left rotation ROM was significantly higher in the experimental group [Figure 7].
Figure 7: Comparison of cervical (Lt) rotation range of motion for experimental and control group in pre- and post-treatment. Data are represented as mean ± standard deviation

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The mean pre-BQ for the experimental group was 38.25 ± 11.02 and it was reduced to 24.80 ± 9.56 after treatment. The reduction was statistically significant (Z = 22.912, P = 0.001). The mean pre-BQ for the control group was 30.65 ± 11.03 and the mean reduction after treatment was 25.85 ± 11.24. The reduction was again statistically significant (Z = 3.929, P = 0.001). The mean difference of improvement in the experimental group was 13.45 ± 2.62 and was relatively higher than the control group (4.80 ± 5.46). The difference was statistically significant (Z = 7.492, P = 0.001). Therefore, the reduction in BQ was significantly higher in the experimental group, as shown in [Table 2].
Table 2: Comparison of Bournemouth questionnaire for experimental and control group in pre- and posttreatment

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   Discussion Top


Cervical spondylosis usually results in pain, limited ROM, and difficulty in performing activities of daily living in the patients. The main focus of the treatment is on controlling pain, improving ROM, and preventing recurrence of the condition. TENS, isometric neck exercises, cervical traction, and mobilization exercises are the treatment protocols usually followed in patients with cervical spondylosis.

Interpretation of improvement in sustained natural apophyseal glides

The physiological effects of SNAG'S Mulligan technique are that it helps to stretch the structures on the convex side of the offending movement and opens the intervertebral foramen on the convex side, which helps to unlock the jammed facet. This might also correct the positional fault between the affected facets due to the cranial glide of the inferior facet of the superior vertebrae on the superior facet of the inferior vertebrae, thus correcting the biomechanics of the joints and if present might also release entrapped meniscoid between the facet joints. The neurophysiological effects are that it stimulates mechanoreceptors and proprioceptors in and around the joints, thus helps to release the muscles around the joints. Mobilization-induced movements contribute to the nutrition of the facet joints and disc.[6]

Interpretation of improvement in transcutaneous electrical nerve stimulation

The pain reduction in TENS is due to the analgesic effects it produces and is due to the pain gate theory. According to this theory, TENS may stimulate the large diameter of afferent fibers, which may reduce pain signal transmission through the small nociceptive afferent fibers and thus prevent pain discrimination and perception. Analgesia may be caused by the modulation of the nociceptive input of large sensory afferent nerves into the spinal cord through peripheral electrical stimulation. Endorphin and encephaline can be released by electrical stimulation of certain receptor sites in the dorsal horn of the spinal cord.[10],[11]

Interpretation of improvement in isometric neck exercises

The postural muscles work in an isometric fashion and provide a strengthening base for a dynamic exercise. Isometric neck exercises assist to increase muscle strength and as they are done in one position, improve strength in one particular position. They help to improve stability due to the fact that the muscles contract isometrically. These exercises help to improve muscle imbalance, which also leads to adequate alignment. All of these variables help to improve the posture of the patient. This strength training helps in pain reduction and improves physical function.[12]

Comparison of improvement of sustained natural apophyseal glides technique and conventional therapy group-wise analysis

For NPRS, the mean difference of improvement in Group A was comparatively higher than in Group B. As a result, the NPRS (improvement) was significantly higher in Group A. The statistical results of both groups were significant, while the SNAG'S showed an additional pain improvement. SNAG Mulligan technique can reduce the H-reflex, evoking as an inhibitory reaction in the central nervous system and increasing the firing threshold of the individual alpha motor neurons resulting in relaxation of the spinal muscles.

For cervical ROM, the mean difference of improvement is comparatively higher in Group A than in Group B. The reason is probably that the sustained gliding force could unlock the jammed facet, open the intervertebral foramen, help to stretch the posterior structures and help to nourish the facet joint and disc.[6]

The BQ in our study was found to be highly effective in assessing the pain, disability, affective, and cognitive aspects of the patient. The questionnaire shows high sensitivity, good validity, and reliability in patients with neck pain. The overall score was seen to be lower in the experimental group compared to the control group, with a mean difference of 13.45 ± 2.62 for the experimental group.

Interpretation of results

Our study supports the previous study done by Buyukturan et al., 2018,[13] in which they studied the effect of SNAG Mulligan technique on older adults with neck pain, and the findings of the study concluded that it had positive effects on pain, ROM, functional level, fear of movement, and quality of life.

The findings of this study, consistent with Ali et al. 2014,[14] indicated that patients with nonspecific neck pain when treated with SNAG Mulligan technique and followed by isometric neck exercises had a more effective reduction in pain and improved function.

Another study that supports our current study was done by El-Sayed et al. 2017[15] which observed the effect of SNAG Mulligan Technique on chronic cervical radiculopathy in 50 patients with cervical radiculopathy and concluded that SNAG Mulligan technique provides additional objective and measurable, effective in the treatment of chronic cervical radiculopathy patients.

Shehri et al., 2018,[16] conducted a comparative study of Mulligan SNAG and Maitland mobilization in neck pain. The patients were given these two therapies along with conventional therapy that is isometric exercises and moist hot packs and the patients were assessed for pain using NPRS, ROM using universal goniometer, and neck function using the neck disability index. They concluded that both mobilization techniques are significant in reducing the symptoms of the patient, but Maitland mobilization is statistically significant compared to Mulligan SNAG mobilization, which is differs from our present study outcomes.

Limitation and future suggestions

The studied sample size is considerably smaller. To further validate this effective therapeutic technique for cervical spondylosis, it may be necessary to increase the number of participants.

This study did not focus on follow-up, and further studies could focus on patient follow-up.


   Conclusion Top


The study concludes that SNAG Mulligan technique and conventional treatment are effective in reducing pain and improving cervical ROM and functional disability in patients with cervical spondylosis. However, the patients who received the SNAG Mulligan technique showed better improvement in pain reduction, cervical ROM, and functional disability than the control group.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Voorhies RM. Cervical spondylosis: Recognition, differential diagnosis, and management. Ochsner J 2001;3:78-84.  Back to cited text no. 1
    
2.
Hassan Al-Shatoury HA. Cervical Spondylosis. Physical Medicine and Rehabilitation; 2017. Available from: http//emedicine.medscape.com/article. [updated 2018 Mar 30 ].  Back to cited text no. 2
    
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Harsulkar SG, Khatri SM, Rao K, Iyer C. Effectiveness of Gong's mobilization in cervical spondylosis: A prospective comparative study. Int J Community Med Public Health 2015;2:38-44.  Back to cited text no. 3
    
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Rose Bist PK, Peethambaran AK, Peethambar GA. Cervical spondylosis: Analysis of clinical and radiological correlation. Int Surg J 2018;5:491-5.  Back to cited text no. 4
    
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Peng B, Pang X, Li D, Yang H. Cervical spondylosis and hypertension: A clinical study of 2 cases. Medicine (Baltimore) 2015;94:e618.  Back to cited text no. 5
    
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Kumar D. Manual mulligan concept: International Edition (Paperback), Capri Institute of Manual Therapy. 2nd ed, New Delhi: India; 2015. p. 19-20.  Back to cited text no. 6
    
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Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods. Pain 1986;27:117-26.  Back to cited text no. 7
    
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Pedretti LW. Mary Beth Early, Practice Skills for Physical Dysfunction. 5th ed. London, United Kingdom, Mosby; 1986.  Back to cited text no. 8
    
9.
Fawkes C. The Neck Bournemouth Questionnaire. National Council for Osteopathic Research. NCOR Research Development Officer; 2012.  Back to cited text no. 9
    
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Johnson M. Transcutaneous Electrical Nerve Stimulation: Mechanisms, Clinical Application and Evidence. Rev Pain 2007;1:7-11.  Back to cited text no. 10
    
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Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: The state of the evidence. Pain Manag 2014;4:197-209.  Back to cited text no. 11
    
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Laskowski ER. Are Isometric Exercises a Good Way to Build Strength? The New York (Internet). Available from: http://www.mayoclinic.org/. [Last accessed on 2018 Apr 26].  Back to cited text no. 12
    
13.
Buyukturan O, Buyukturan B, Sas S, Karartı C, Ceylan İ. The effect of mulligan mobilization technique in older adults with neck pain: A randomized controlled, double-blind study. Pain Res Manag. May 15; 2018. doi.org/10.1155/2018/2856375.  Back to cited text no. 13
    
14.
Ali A, Shakil-Ur-Rehman S, Sibtain F. The efficacy of sustained natural apophyseal glides with and without isometric exercise training in non-specific neck pain. Pak J Med Sci 2014;30:872-4.  Back to cited text no. 14
    
15.
El-Sayed WH, Mohamed AF, El-Monem GA, Ahmed HH. Effect of SNAGS mulligan technique on chronic cervical radiculopathy: A randomized clinical trial. Med J Cairon Univ 2017;85:787-93.  Back to cited text no. 15
    
16.
Shehri AA, Khan S, Shamsi S, Almureef SS. Comparative study of mulligan (SNAGS) and Maitland mobilization in neck pain. Eur J Physical Educ Sport Sci 2018;5:19-29.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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    Abstract
   Introduction
    Materials and Me...
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   Cervical Extension
    Cervical Side Fl...
    Cervical Rotatio...
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