Journal Riphah College of Rehabilitation Sciences

The Scientific Rationale of Manipulative Therapy in Rehabilitation Sciences

Asghar Khan — Mon, 23 Jun 2025 00:00:00 +0000

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.

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
Biomechanical and Mechanical Effects: Contrary to outdated concepts of bone “realignment,” current biomechanical evidence supports that manipulation affects joint function through subtle but meaningful mechanical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.
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.⁷Sustained 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.
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.
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.
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

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Effect of Repetitive Transcranial Magnetic Stimulation in Decreasing Muscle Tone of Spastic Cerebral Palsy Kids to Improve Motor Activity – A Systemic Review and Meta-Analysis

Mon, 23 Jun 2025 00:00:00 +0000

Background: Cerebral palsy (CP) is a neurodevelopmental disorder that predominantly affects the kids' motor activity. The mainstay of treatment for the motor deficit in CP is conventional physical therapy. Due to the advancement in medical technology, a non-invasive stimulation of brain parenchyma like repetitive transcranial magnetic stimulation (rTMS) is found to be an effective therapy for motor deficits in spastic CP kids

Objective: To assess the efficacy of repetitive transcranial magnetic stimulation in spastic CP kids.

Methodology: Data sources: PubMed and Google Scholar were systematically searched until June 2024. Study selection: The meta-analysis included all published Randomized controlled trials that investigated the efficacy of rTMS over conventional physical therapy in children up to 18 years of age. Data extraction was guided by a predetermined checklist.

Results: Data extraction was guided by a predetermined checklist using Revman 5 software. Mean and standard deviation were evaluated and analysed. A total of 8 articles were selected, of which 5 articles were assessed quantitatively and the remaining 3 articles were taken for qualitative assessment. The primary outcome (Modified Ashworth scale) favours the usage of rTMS in Spastic Cerebral palsy kids (Mean standard deviation = - 0.37, 95% CI -0.64, -0.09 P < 0.00001). The secondary outcome (Gross motor function measure) included 156 patients (Mean standard deviation = - 0.62, 95% CI -0.96, -0. 27 P < 0.00001). Both primary and secondary outcomes are in favour of rTMS or its combination with conventional therapy.

Conclusion: This systematic review and meta-analysis demonstrated that rTMS has a beneficial effect in reducing spasticity in CP kids compared to the control group under conventional therapy.

Keywords: Cerebral palsy, Spasticity, Conventional therapy, repetitive transcranial magnetic stimulation, Developmental delay.

Effects of Therapeutic Ultrasound with and without Trigger Point Release of Hamstring on Knee Pain, Range of Motion and Quality of Life in Patients with Hamstring Tightness - RCT

Saman Arshad, Akasha Ahmad, Taliah Bashir Sindhu, Tahreem Atta Mir — Mon, 23 Jun 2025 00:00:00 +0000

Background: Hamstring muscles defined as the three distinct components which collectively are situated in the rear of the knee regions make up the muscles known as the hamstrings.

Objective: To associate the special properties of therapeutic ultrasound with and without trigger point release of hamstring on knee pain, range of motion and quality of life in patients with Hamstring tightness.

Methodology: In the Physiotherapy Department of the University of Lahore Teaching Hospital, 36 patients were split into two equal groups for a randomized clinical trial. Group A received conventional physiotherapy whereas Group B received Therapeutic Ultrasonography along with conventional physiotherapy.. Data was gathered using a universal goniometer, timed up and go test, and visual analog scale at baseline, eight weeks, and twelve weeks utilizing non-probability sampling technique. SPSS version 24 was used for data analysis.

Result: Following eight and twelve weeks, an independent sample t-test revealed a significant difference among both teams, Group B which received Therapeutic Ultrasound with conventional therapy showed significant results.. Additionally, a significant difference between periods was shown by repeated measures ANOVA among every group receiving treatment.

Conclusion: The study concluded that Therapeutic Ultrasound with physiotherapy is more effective for improving knee pain, Range of Motion and Quality of Life as compared to conventional physiotherapy in subjects with Hamstring tightness.

Keywords: Therapeutic Ultrasound, Joint range of motion, Trigger points, Hamstring muscles

Effects of knee muscles strengthening with and without core stability exercises after platelet rich plasma therapy in knee osteoarthritis

Zaibun Nisa, Bazal Bukhari — Mon, 23 Jun 2025 00:00:00 +0000

Background: For the management of early knee OA, after platelet rich plasma therapy, proximal stability and lower limb strengthening is essential in improving the symptoms in knee osteoarthritic patients.

Objective: To compare the effects of knee muscles strengthening exercises with and without core stability exercises after PRP therapy on pain, functional mobility, range of motion, and balance in knee osteoarthritic patients.

Methodology: From March 2023 to September 2023, this randomized controlled trial was in operation, included 72 patients, aged 45 to 60, of both sexes, randomly assigned in two groups included group A which received knee exercises after PRP therapy and group B received knee as well as core stability exercises after PRP therapy and were assessed at baseline and week 6 using the Numeric Pain Rating Scale, the WOMAC scoring, the Berg Balance Scoring and TUG scoring, and goniometry.

Results: the results showed there was significant difference in between both groups when mean of variables were compared, included VAS, WOMAC, balance berg scale, time up and go test, knee ROM, taken at baseline and at 6^th week and calculated as p<0.05, after intervention except WOMAC stiffness and WOMAC physical activity. It indicated improvement in pain, functional activity, balance and range of motion after intervention more in group B.

Conclusions: In summary, core stabilization exercises with knee exercises after platelet-rich plasma treatment are beneficial for pain reduction, functional activity level, knee mobility, and maintenance of balance.

Impact of Prolonged Computer Use on Upper Extremity Pain and Disability among Medical Coders in Twin Cities of Pakistan

Ayesha Kifayat, Hina Javed, Afifa Ittefaq, Muhammad Umair Khan , Aimen Shouket — Mon, 23 Jun 2025 00:00:00 +0000

Background: With the increasing reliance on computers, prolonged usage has become a common occupational factor associated with musculoskeletal symptoms, especially among medical coders. Studies have shown that static postures and repetitive upper limb movements contribute to upper extremity (UE) pain and disability. However, there is limited research focusing on this professional group in Pakistan.

Objective: This study aimed to assess the frequency of upper extremity symptoms and investigate associated demographic and occupational factors among medical coders in Islamabad and Rawalpindi.

Methodology: A cross-sectional, questionnaire-based survey was conducted with 191 medical coders (age 20-35 years; 56.5% males, 43.5% females) using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) outcome measure and Visual Analog Scale (VAS) for pain. Participants provided demographic information, and data were analyzed using descriptive statistics and linear regression.

Results: Among participants, 50% reported mild to severe UE disability, while 59.7% reported varying levels of pain, as indicated by Quick DASH and VAS scores. Factors such as age, gender, working hours, shift type, and experience were positively associated with increased UE pain and disability. Evening shift workers and those with longer working hours reported higher symptom severity.

Conclusion: Upper extremity pain and disability are prevalent among medical coders, with occupational factors significantly affecting their daily activities and quality of life. These findings underscore the need for ergonomic interventions and workload management to mitigate symptoms and enhance the well-being of medical coders.

Keywords: Quick DASH questionnaire, VAS scale, upper limb disability, upper extremity symptoms, medical coders, computer users

Awareness of Modifiable Risk Factors Associated with Cardiovascular Diseases among Post-Menopausal Females and Role of Physical Therapist in preventive Strategies

Uzba Bilal, Somia Faisal — Mon, 23 Jun 2025 00:00:00 +0000

Background: Menopause significantly increases the risk of cardiovascular diseases (CVD) due to modifiable risk factors such as visceral obesity, dyslipidemia, impaired glucose regulation, non-alcoholic fatty liver disease, and hypertension, all influenced by hormonal changes. Physical therapists play a crucial role in managing these risk factors through structured physical activity, lifestyle modifications, and rehabilitation strategies.

Objective: To assess awareness of modifiable cardiovascular disease risk factors among postmenopausal women and highlight the role of physical therapy in preventive strategies

Methodology: A cross-sectional survey of 188 postmenopausal women (aged 45–60) from six Lahore hospitals was conducted using non-probability convenience sampling. Women with prior cardiovascular diseases or severe cognitive impairments were excluded. Awareness of modifiable CVD risk factors was assessed via the CARRF-KL questionnaire (Cronbach's alpha = 0.768). Data was analyzed using SPSS 21.

Results: The participants' mean age was 49.9 ± 3.48 years. Descriptive statistics of the CARRF-KL questionnaire showed scores ranging from 11 to 27, with a mean of 20.84 ± 3.77.

Conclusion: Postmenopausal women exhibited moderate awareness of modifiable CVD risk factors. While a general understanding was present, variability in scores highlights the need for targeted educational interventions. Given the role of physical therapy in promoting preventive strategies, integrating structured exercise and lifestyle counseling into healthcare programs can enhance cardiovascular health in this population.

Keywords: Cardiovascular disease, Risk factors, Postmenopausal

Upper Body Dynamic Balance and Power in Fast and Spin Cricket Bowlers

Yamna Mazher, Affan Ahmed, Mahrukh Asif, Hassan Shahid Dar, Muhammad Tariq Shafi — Mon, 23 Jun 2025 00:00:00 +0000

Background: Bowlers in cricket can be classified as fast or spin bowlers. A player must have excellent balance, strength, and speed to move quickly between the wickets and on the field. The determination of upper body dynamic balance and power will provide a greater insight on how these factors can affect the overall performance of different cricket bowlers especially during overhead throwing activities and those which require great balance.

Objective: To determine upper body power and dynamic balance in spin and fast cricket bowlers.

Methodology: Using non-probability convenient sampling techniques, a descriptive cross-sectional study was conducted in three sports clubs in Lahore, Pakistan. The study lasted for a total of six months, from June 2023 to December 2023. The sample included 80 spin and fast bowlers aged 18 to 25 years, who had at least one year of bowling experience. Players who complained of pain, exhaustion, or had undergone upper extremity surgery within the previous six months were excluded from participating in study. Y balance dynamic test of upper quadrant was used to asses upper extremity balance and medicine ball was used to assess the power. Data were analyzed using SPSS version 22, with descriptive statistics presented as frequencies, percentages, means, & standard deviations.

Results: The results of the study showed that the mean composite Score of Y balance test of dominant arm in fast bowlers was 87.98 ± 11.92 SD while for spin bowlers it was 98.83 ± 8.72 with P value of 0.03. Upper body power found using Backward Overhead Medicine Ball throw (BOMB) showed no statistical difference in power between the two groups, with mean SD of 40 ± 11.49 for fast bowlers and 40 ± 9.79 for spin bowlers with P value of 0.08.

Conclusion: There was no significant statistical variation in upper body power observed between fast and spin bowlers, based on the study's finding. However, results imply that there was statistically significant difference in balance of bowling arm with spin bowlers having greater balance compared to fast bowlers.

Keywords: Athletic performances, Biomechanics, Cricket sports, Physical fitness testing, Postural balance.

Translation and Validation of Prolapse-Quality of Life Questionnaire into Urdu Version

Mehwish Khalid , Amna Riaz, Hassan Bin Akram, Mahrukh Asif — Mon, 23 Jun 2025 00:00:00 +0000

Background: Pelvic organ prolapse (POP) causes the inner and outer layers of the vagina to descend which can influence female quality of life in physical, social, mental and sexual ways. The Prolapse Quality of Life Questionnaire is a reliable tool for assessing symptom severity and impact, guiding treatment decisions, and evaluating outcomes.

Objective: To translate and validate the Prolapse-Quality of Life Questionnaire into the Urdu version.

Methodology: The P-QOL was translated and back-translated to and from Urdu, pretested and reviewed by a committee following the Guillemin criteria, and then cross-cultural linguistic validation study was conducted on 150 Urdu-speaking patients with pelvic organ prolapse. The months from June 2023 to December 2023 were the total study duration. Data entry and analysis were done using SPSS. Descriptive analysis was presented in the form of tables and graphs.

Results: The average participant was 47.9 years, with a SD of 7.67 years. All participants were between 35 and 60 years old. The Urdu form of the P-QOL questionnaire scored well for internal consistency, showing a Cronbach’s alpha of 0.96. The content validity was strong at 0.87. The high reliability was clear from the value for the intra-class correlation coefficient, ranging from 0.35 to 0.9.

Conclusion: The Urdu version of the Prolapse Quality of Life Questionnaire allows us to reliably assess symptoms, Severity of the condition and the quality of life of someone with pelvic organ prolapse. The consistency over time and between different assessments, as well as its content relatedness, is all acceptable.

Keywords: Translation, Validation, Reliability, Prolapse-Quality of life, and Pelvic Organ Prolapse

Level of physical Activity in Patients with Fatty Liver - A Cross Sectional study

Adnan Ahmed, Karamatullah, Nimra, Fayaz , Aishmal, Maheen — Mon, 23 Jun 2025 00:00:00 +0000

Background: Liver with fatty appearance illness is a common disorder that is caused by addition of extra fats in the liver. Fats make up 5% to 10% of the weight of the liver, it becomes an issue and it is termed as steatosis.

Objective: To determine the tendency of physical activity in fatty liver patients.

Methodology: 232 patients were selected through non-probability convenient sampling technique and were asked to fill the questionnaire (International physical activity questionnaire). The sample size was calculated by Rao soft. Chi square test was applied for checking association between physical activity and grades of Fatty liver patients

Results: A total n=100 participants with age of 47.82±10.79. Out of 100 participants 45(45%) were male and 55(55%) were female. Physical activity related to grades of fatty liver were categorized grade 1 the high physically active were 62.5%, moderate 72.9% and low physically active were 20%. In grade 2 high physically active were 37.5%, moderate 25.4% and low physically active were 48%. In grade 3 the high physically active were 3%, moderate 1.7% and low physically active were 32%, with significance difference of 0.05.

Conclusion: The outcomes of current project showed that the trend of physical activity is low in fatty liver patients. The patients with high level of physical activity have grade 1 fatty liver. It is concluded from present study that high physical activity showed significant effect on control of fatty liver.

Keywords: Hepatitis, Fatty Liver Disease, MET, Physical Activity, IPAQ.

Awareness of Physical Therapy in Managing Endometriosis among Obstetrician and Gynecologists

Zarnab Asif, Mehwish Khalid, Hassan Bin Akram — Mon, 23 Jun 2025 00:00:00 +0000

Background: Endometriosis, a chronic inflammatory condition where endometrial cells grow outside the uterus, affects approximately 10% of women of reproductive age. The prevalence is higher among women experiencing infertility or chronic pelvic pain. Research supports physical activity and physical therapy interventions such as manual therapy, pelvic floor strengthening, kinesiotherapy, and electrotherapy as effective in managing endometriosis symptoms.

Objective: To determine the awareness regarding the role of physical therapy in endometriosis among gynecologists.

Methodology: A descriptive cross-sectional study was conducted from June to December 2023 with 100 obstetricians and gynecologists in Lahore, including 34 PGRs, 13 MOs, 27 Senior Residents, and 26 Associate Professors. Sixty-two participants were from private hospitals, and 38 were from government hospitals. Data was collected using a pre-tested, 22-item self-administered questionnaire, with written consent obtained from participants. Non-probability convenient sampling was applied.

Results: The study showed that most participants (82.0%) agreed on the need for awareness of physical therapy’s effectiveness in managing endometriosis, with 31.0% strongly agreeing, 51.0% agreeing, 10.0% neutral, and a small percentage (8.0%) disagreeing.

Conclusion: Most respondents recognized the role and benefits of physical therapy as a complementary treatment. However, many gynecologists rarely refer patients to physical therapy or collaborate with physical therapists.