jrcrs-2025130201

Editorial: JRCRS. 2025; 13(2): 67-68

1- The Scientific Rationale of Manipulative Therapy in Rehabilitation Sciences

Prof Dr Asghar Khan

Chief Editor JRCRS
Dean / Professor, Faculty of Rehabilitation & Allied Health Sciences, Riphah International University, Islamabad, Pakistan.

Correspondence: Asghar Khan
[email protected]

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Introduction:

Manipulative therapy has emerged as a vital intervention in musculoskeletal rehabilitation, supported by a strong foundation of scientific research. This editorial highlight the neurophysiological, biomechanical, mechanotransducive, and clinical principles that underpin manipulative therapy and emphasizes its evidence-based application, particularly within Pakistan’s growing physiotherapy landscape. A formal recommendation is also proposed for recognizing manipulative therapy as a super-specialty in physical therapy training and policy.

Manipulative therapy, historically rooted in osteopathic and chiropractic practice, is now a scientifically validated tool in modern physiotherapy. Defined as a precisely directed manual force applied to body structures, manipulative therapy aims to relieve musculoskeletal (MSK) pain, restore mobility, and improve function. As musculoskeletal disorders rise in prevalence, particularly in low- and middle-income countries, the relevance of manipulative therapy within evidence-based rehabilitation grows stronger. This editorial outline its key mechanisms and calls for its strategic advancement in Pakistan.

1. Neurophysiological Basis: Spinal and peripheral joint manipulation induces both local and central nervous system responses. It stimulates joint mechanoreceptors, alters afferent sensory input, and modulates spinal reflexes. This leads to reduced pain perception, improved proprioception, and enhanced motor control. Functional imaging and electromyography studies confirm changes in cortical activity following manipulation, suggesting a broader neuroplastic impact.¹
2. Biomechanical and Mechanical Effects: Contrary to outdated concepts of bone “realignment,” current biomechanical evidence supports that manipulation affects joint function through subtle but meaningful mechanical actions. High-velocity, low-amplitude (HVLA) thrusts can transiently gap facet joints, stretch periarticular tissues, and break down adhesions. These effects improve joint kinematics and contribute to soft tissue remodeling.⁴ Mechanical loading also enhances viscoelastic properties of connective tissues, facilitating smoother and pain-free movement.
3. Mechanotransduction in Manipulative Therapy: Mechanotransduction, the conversion of mechanical stimuli into cellular and biochemical responses is a key scientific rationale supporting manipulative therapy. Mechanical forces activate integrins, ion channels, and the cytoskeleton, initiating intracellular cascades like MAPK and ERK pathways. These pathways regulate gene expression, protein synthesis, fibroblast activity, and collagen remodeling.⁷ Sustained mechanical stretching (typically 60–90 seconds or more) has been shown to activate integrin-based signaling, promoting anti-inflammatory effects and tissue repair.⁸ In the fascial system, Mechanotransduction also affects fluid dynamics and proprioceptive signalling, contributing to long-term neuromuscular and structural recovery.⁶ This cellular-level understanding elevates manipulative therapy from a manual skill to a mechanobiological intervention.
4. Pain Modulation Mechanisms: Pain modulation is one of the most clinically impactful outcomes of manipulative therapy. Non-nociceptive input from manual techniques activates inhibitory pathways within the spinal cord, consistent with the gate control theory. Supraspinal mechanisms also contribute, with studies reporting increased levels of endorphins and reduced pro-inflammatory cytokines post-manipulation.^{1, 3} these effects offer not only immediate analgesia but also potential for long-term pain control.
5. Clinical Effectiveness: Clinical trials and systematic reviews validate the effectiveness of manipulative therapy for various conditions including mechanical low back pain, cervicogenic headaches, thoracic spine dysfunction, and shoulder impingement. When integrated with therapeutic exercise and patient education, outcomes are significantly enhanced.² Evidence from international clinical guidelines supports the use of manipulation as a first-line treatment in appropriately screened patients.
6. Safety and Professional Training: When practiced by properly trained professionals, manipulative therapy is both safe and effective. The incidence of serious adverse events is extremely low, especially with appropriate clinical screening and adherence to contraindication protocols. Thus, inclusion of manipulative therapy in core DPT curricula is essential, and postgraduate training in advanced manual techniques must be encouraged.⁵

CONCLUSION

Manipulative therapy is not merely a legacy technique— it is a scientifically supported, mechanobiological intervention grounded in neurophysiology, biomechanics, and clinical research. Its integration into routine physiotherapy practice provides a non-invasive, cost-effective solution to MSK dysfunctions and enhances patient quality of life.

In light of the evidence presented, it is strongly recommended that the Allied Health Professional Council (AHPC) of Pakistan formally recognize manipulative therapy as a super-specialty within physical therapy education and clinical credentialing. Additionally, academic institutions are encouraged to explore the role of Mechanotransduction in manipulative therapy within regenerative rehabilitation medicine, potentially opening new avenues for cellular-level recovery in orthopaedic and neuro-rehabilitation patients.

REFERENCES

1. WHO. https://www.who.int/news-room/factsheets/detail/musculoskeletal-conditions (accessed February 10, 2025)
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3. Adesida Y, Papi E, McGregor AH. Exploring the Role of Wearable Technology in Sport Kinematics and Kinetics: A Systematic Review. Sensors. 2019; 19(7):1597. doi: 10.3390/s19071597
4. Mason R, Pearson LT, Barry G, Young F, Lennon O, Godfrey A, Stuart S. Wearables for Running Gait Analysis: A Systematic Review. Sports Med. 2023;53(1):241-268. doi: 10.1007/s40279-022-01760- 6.
5. Prisco G, Pirozzi MA, Santone A, Esposito F, Cesarelli M, Amato F, Donisi L. Validity of Wearable Inertial Sensors for Gait Analysis: A Systematic Review. Diagnostics. 2024;15(1):36. doi: 10.3390/diagnostics15010036.
6. Zadeh SM, MacDermid J, Johnson J, Birmingham TB, Shafiee E. Applications of wearable sensors in upper extremity MSK conditions: a scoping review. J Neuroeng Rehabil. 2023; 20(1):158. doi: 10.1186/s12984-023-01274-w.