Course Material

Manual Therapy of the
Lumbar Spine, Pelvis,

and Hip
Amy McDevitt, PT, DPT, PhD, FAAOMPT
Not for reproduction or redistribution

Disclosures
• Financial
– Dr. Cook receives compensation from MedBridge for this
course. He is also a research consultant for the Hawkins
Foundation of the Carolinas and a consultant for a mobile
product for Zimmer. He has produced educational content for
Parker Education, Agence EBP (France), and TrustMe - Ed.
He is the director of the Duke Center of Excellence in Manual
and Manipulative Therapy. He receives book royalties from
Pearson Education, is an associate editor for JOSPT, and is
the PI for NIH U24 (ForceNET).
• Nonfinancial
– Dr. Cook is an associate editor with the BJSM and serves on
the editorial board of the JMMT.

This Course Is Part of a Certificate Program

Person-Centered Manual Therapy
Certificate Series
• Course 1: Introduction to Evidence-Based Manual Therapy
• Course 2: Evidence in Support of Manual Therapy
• Course 3: Identifying Candidates for Manual Therapy Care
• Course 4: The Patient Interview and Physical Examination
• Course 5: Manual Therapy of the Cervical Spine
• Course 6: Manual Therapy of the Thoracic Spine
• Course 7: Manual Therapy of the Shoulder, Elbow, Wrist, and Hand
• Course 8: Manual Therapy of the Lumbar Spine, Pelvis, and Hip
• Course 9: Manual Therapy of the Knee, Foot, and Ankle
• Course 10: Manual Therapy and Musculoskeletal Management:
Case-Based Examples

Background: Amy McDevitt
• Fairfield University, CT: BS in
biology in 1992
• University of St. Augustine, FL:
masters in physical therapy in
2000 and tDPT in 2004
• Completed fellowship training in
manual therapy in 2010
• Diverse background in clinical care
• University of Newcastle, Australia:
PhD in physiotherapy, 2023
• Associate professor at an R1
institution
• Research agenda: regional
interdependence, manual therapy, Include a personalized
clinical reasoning, shoulder photo
tendinopathy

Background: Chad Cook
• Graduated with a BS in physical
therapy in 1990
• Graduated with an MBA in 1999
• Graduated with a PhD in 2003
• Completed a certificate in pain
management in 2017
• Tenured professor
• >340 publications (2023)
• Over $11 million in funding
• ForceNET
• Duke Center of Excellence in
Manual and Manipulative Therapy
• Multi-award winner in teaching,
research, and service

Learning Objectives
• Examine considerations for approaching the management of
patients with low back, pelvis, or hip pain and/or disability
• Analyze current evidence for manual therapy in the lumbar
spine, pelvis, and hip regions
• Identify essential components of the lumbar spine, pelvis
and hip examination
• Distinguish between manual therapy assessment techniques
in the lumbar spine, pelvis, and hip regions
• Distinguish between manual therapy intervention techniques
• Apply knowledge of appropriate home exercises to augment
manual therapy–based techniques

Chapter 1
General Considerations With Lumbar Spine,
Pelvis, and Hip Management

Objectives of This Chapter
• Examine considerations for approaching the management
of patients with low back, pelvis, or hip pain and/or
disability
• Identify essential components of the lumbar spine, pelvis,
and hip examination

Relevant Anatomy and Physiology:
The Lumbar Spine
• Five lumbar vertebrae with intervertebral discs
• Large vertebral bodies, sturdy laminae, absence of costal
facets (no ribs)
• Allows mobility between the thorax and the pelvis
• Angle of the lumbar facet joints is oriented at almost 90
degrees on average
• Many ligaments, similar to other regions of the spine
• Iliolumbar ligament reinforces the lumbosacral junction
• Size of the vertebral bodies and curvature of articular facets
assists in stabilization and weight-bearing capacity
• Manual therapy is useful at the lumbar spine
1. Neumann, 2016 2. Waxenbaum et al., 2017
The Pelvic Girdle
• The pelvis consists of the sacrum, coccyx, ischium, ilium,
and pubis
• The pelvis supports the contents of the abdomen and
transfers weight to the lower extremities
• During gait, the pelvis attenuates forces from the ground and
lower extremities to the spine
• Joint articulations include
– Sacrum and coccyx
– Sacrum and ilium (right and left)
– Pubic bodies (pubic symphysis)
• The sacroiliac joint (SIJ) is only slightly moveable
• Manual therapy, in my opinion, is not necessary at the SIJ
Kiapour et al., 2020

The Hip
• Diarthrodial joint with stability provided by osseus

components/articulations
• Strong interrelationship of the spine-pelvis-hip complex
as a coordinated functional unit
• Primary function is to provide dynamic support for the
weight of the body/trunk and facilitate force and load
transmission from the spine to the lower extremities
• The joint is strong due to supporting ligaments and
musculature
• Manual therapy is useful at the hip
1. Neumann, 2010 2. Gold et al., 2017
Pain Generators in the Lumbar Spine
• Muscles • 80% of individuals will

have low back pain in their
• Ligaments life
• Dura mater • There are numerous pain
generators in the lumbar
• Nerve roots spine
• Zygapophyseal joints • Pathoanatomic findings
are common in
• Sacroiliac joint
asymptomatic individuals
• Annulus fibrosus • Remember, there is little
• Thoracolumbar fascia relationship between
physical pathology and
• Vertebrae pain/disability
1. Han et al., 2023 2. Freburger et al., 2009
Neurological Symptoms?
• Neurogenic claudication from lumbar spinal stenosis
– Narrowing of the spinal canal
– Narrowing of intervertebral foramen
– Thickening of ligamentum flavum
• Patient history and observation
– Bilateral neurologic symptoms
– Leg pain > back pain
– Pain with walking or standing
– Pain relief with sitting
– Age
• Over 48 years old
Cook et al., 2011
Chapter 1 Takeaways
• Each anatomical region is unique, but each also has to

work in concert to function
• One must consider the relationships of the lumbar
spine, pelvis, and hip in the context of weight-bearing
function
• Mechanism of injury matters, so make sure to take a
careful history to avoid missing ligament problems,
fractures, etc.

Chapter 2
Review of the Evidence for OMT in
the Lumbar Spine, Pelvis, and Hip

and hip examination

Classification Systems for the
Management of Low Back Pain
• Mechanical diagnosis and therapy (B)
– Based on changes in low back pain in response to repeated movements
or postures
• Treatment-based classification (C)
– Based on an initial treatment approach and initial assessment findings
• Movement system impairment (C)
– Based on impaired trunk movements and postures
• Cognitive functional therapy (C)
– Integrated behavioral approach
• Prognostic risk stratification (B)
– Identifies patients at different levels of risk
• Pathoanatomic-based classification (B)
– Based on pathoanatomic findings
George et al., 2021

Clinical Practice Guidelines: 2021 Low
Back Pain
• Acute low back pain

– Physical therapists should use thrust or nonthrust joint
mobilization to reduce patient pain and disability (A)
– Physical therapists may use massage or soft-tissue
mobilization for short-term pain relief (B)
George et al., 2021

Clinical Practice Guidelines: 2021 Low
Back Pain (cont.)
• Chronic low back pain
– Physical therapists should use thrust or nonthrust joint
mobilization to reduce patient pain and disability (A)
– Physical therapists may use massage or soft-tissue
mobilization for short-term pain relief (B)
• Chronic low back pain with leg pain
– Physical therapists may use thrust or nonthrust joint
mobilization to reduce patient pain and disability (B)
– Physical therapists may use neural mobilization in
conjunction with other treatments to reduce short-term
pain and disability (B)
George et al., 2021

Treatment-Based Classification Update:
2016 Low Back Pain
Symptom Movement Functional

Modulation Control Optimization
Alrwaily et al., 2016

Triage
Triage by the first-contact healthcare provider
Determine the appropriate management approach
Medical management Rehabilitation management Self-care management
Triage by the rehabilitation provider
Determine the appropriate rehabilitation approach

Symptom modulation Movement control Functional optimization
Alrwaily et al., 2016

A Systematic Review of Clinical Practice
Guidelines: 2021 Managing Chronic Low Back Pain
• 10 clinical practice guidelines were included

• Diagnostic recommendations (strong)
– Conduct a focused history
– Assess red flags
– Assess prognostic factors (clinical, psychological, and
work-related factors)
– Do not obtain imaging
• Therapeutic recommendations (may do)
– Spinal mobilization
• In combination with exercise
Meroni et al., 2021
Cost-Effectiveness of Initiating Physical
Therapy Care Early
• Initiate early physical therapy to reduce downstream costs
associated with
– Advanced imaging and radiographs
– Spinal injections
– Opioid medication
– Physician visits
– Lumbar surgery
– Emergency department or urgent care visits
– Low-back-pain-related cost
• Initiating physical therapy for acute low back pain has the potential
to reduce health services utilization and improve healthcare
efficiency
• Early guideline-adherent physical therapy may decrease utilization
and healthcare costs
1. Arnold et al., 2019 2. Childs et al., 2015
Clinical Practice Guidelines: 2017 Hip Pain
and Mobility Deficits
• Manual therapy for mild to moderate hip osteoarthritis

and impairment of joint mobility
– Clinicians should use manual therapy, which may include
thrust, nonthrust, and soft-tissue mobilization
• As hip motion improves, therapists should add
exercises (strengthening and stretching) to augment
and maintain gains in range of motion, flexibility, and
strength
• Recommendation based on strong evidence
Cibulka et al., 2017

Clinical Practice Guidelines: 2020 Hip or
Knee Osteoarthritis
• Clinical practice guideline emphasis was on exercise

therapy
• Nonexercise therapeutic interventions are included only
in the term “passive mobilization”
• Manual therapy was not included as a search term
van Doormaal et al., 2020

Clinical Practice Guidelines: 2014
Nonarthritic Hip Joint Pain
• In the absence of contraindications, manual therapy

may be indicated when capsular restrictions are
suspected to impair the joint mobility
• Further, soft-tissue mobilization may be indicated when
soft tissues/fascia are suspected to impair hip mobility
• Recommendation based on expert opinion
Enseki et al., 2014

Harms and Adverse Events (AEs)
• A systematic review described AEs following spinal

manipulative therapy (SMT) to the lumbopelvic region
• 41 studies (77 cases) included in qualitative synthesis
• The anecdotal nature of the cases reported does not
allow for causal inferences between SMT and the
events reported in the review
• 2/3 cases had a favorable outcome
• SMT description, pre-SMT presentation, and adverse
event details were lacking
Hebert et al., 2015

Chapter 2 Takeaways
• As with the majority of other regions of the body,

evidence supports the use of manual therapy at the
lumbar spine, pelvis, and hip
• Evidence may be weakest with nonarthritic hip pain
• Cost-effectiveness research suggests the use of
physical therapy, which includes manual therapy, for
the management of acute low back pain

Chapter 3
The Movement Examination

and hip examination
• Distinguish between manual therapy assessment
techniques in the lumbar spine, pelvis, and hip regions

Key Examination Features
• From the second course in this series

• Describe manual therapy (what it is and why it’s used)
• Describe the mechanisms of it (what happens)
• Describe what it likely does
• Make sure to blend it with the patient’s expectations for
care
• Discuss potential risks and harms
• Give other alternatives to care

Key Examination Features
• Define dominant pain mechanism
– Nociceptive pain
• Pain that arises from actual or threatened damage to
nonneural tissue and is due to the activation of nociceptors
– Nociplastic pain
• Pain that arises from altered nociception despite no clear
evidence of actual or threatened tissue damage causing the
activation of peripheral nociceptors or evidence for disease or
lesion of the somatosensory system causing the pain
– Neuropathic pain
• Pain caused by a lesion or disease of the somatosensory
nervous system
– Mixed pain
• A combination of any of the three above
IASP Terminology Working Group, n.d.
Unique Examination Features
• A manual therapy examination is looking at the

relationships between movement, positioning, and pain
• To complete a full orthopedic examination, consider
screening tests, movement, active and passive
physiological movement, passive accessory movement,
impairment-based tests, and special tests

Concordant/Comparable/Familiar Sign
• The concordant/comparable (familiar sign) is the pain
or other symptom that is identified on a pain drawing
and verified by the patient as being the complaint that
has prompted them to seek diagnosis and treatment
• The discordant sign is a painful movement that is not
the pain or other symptom identified on a pain drawing
and verified by the patient as being the complaint that
prompted them to seek treatment
• This drives our examination because it allows the
patient to see the relationship between movement and
pain

Patient Examination: Key Features
• Initial observation
• Patient interview and review of systems
• Systems review
• Initial hypothesis
• Movement
• Tests and measures
• Evaluation/clinical impression
• Intervention
• Outcomes

Patient Examination: Key Features (cont.)
Active Passive
Movement
Movement Movement
Passive
Impairment-
Special Tests Accessory
Based Tests
Movements

Movement
• Patients with lumbar, pelvis, or hip pain should perform

a movement or functional task that causes familiar
symptoms
• Movements that reproduce symptoms can be assessed
qualitatively and can serve as the comparable sign for
the examination and intervention
• Bending forward, single-leg standing, twisting, pulling,
pushing, sit-to-stand, rolling, squatting, and stair
negotiation are helpful movements to observe in this
region

Active Physiological Movements
• The purpose of active physiological movements is to

identify the concordant sign
– The concordant sign is the movement or position that
reproduces the patient’s pain
• Positive findings may be used as treatment for
nociceptive pain
• Overpressures may be used to rule out joints
• With so many joints in this examination, it’s okay to
refine the examination to specific movements
Maitland et al., 2001

Application
• First
– Allow active movements: it’s okay to guide movement
• Second
– Assess whether painful and whether the pain is
concordant
• Third
– Have the patient repeat movements into pain
(“touching” pain)
• Fourth
– Provide overpressure if there is no pain with the
movement, to clear that movement

Active Physiological Assessment of the
Lumbar Spine
• Lumbar flexion
• Lumbar extension
• Lumbar side flexion (right and left)
• Lumbar rotation (right and left)
– Standing
– Sitting
• Combined movements

Active Physiological Assessment of the Pelvis
• Forward bend
• Sit-to-stand
• Lunge (anterior rotation)
• Step-up (posterior rotation)
• Single knee to chest

Active Physiological Assessment of the Hip
• Hip flexion (supine)

• Hip extension (prone)
• Hip abduction
• Hip adduction
• Hip internal rotation (sitting)
• Hip external rotation (sitting)

Laboratory
• Active physiological assessment of the lumbar spine

• Active physiological assessment of the pelvis
• Active physiological assessment of the hip

Passive Physiological Movements
• The purpose of passive physiological movements is to

• Positive findings may be used as treatment

Application
• First
– Move the patient physiologically through range
• Second
– Assess if painful and if the pain is concordant
• Third
– Repeat the passive movements into pain (“touching”
pain)
• Fourth
– Modify pressure, speed, angle, etc., to see if pain
subsides

Passive Physiological Assessment of the
Lumbar Spine and Pelvis
• Lumbar flexion • Posterior rotation of the

• Lumbar extension innominate (sidelying)
• Lumbar side flexion • Anterior rotation of the
(right) innominate (sidelying)
• Lumbar side flexion
(left)
• Lumbar rotation (right)
• Lumbar rotation (left)

Passive Physiological Assessment of the Hip
• Hip flexion • Hip combined

• Hip abduction movement flexion/
• Hip adduction adduction/internal
rotation
• Hip internal rotation
• Hip combined
• Hip external rotation
movement flexion/
abduction/external
rotation
• Hip extension

Laboratory
• Passive physiological assessment of the lumbar spine

and pelvis
• Passive physiological assessment of the hip

Passive Accessory Movements
• The purpose of passive accessory movements is to

• Positive findings may be used as treatment

Application
• First
– Apply pressure until you feel resistance pushing back
(push lightly)
• Second
– Assess if painful and if the pain is concordant
• Third
– Repeat the passive accessory movement into pain
(“touching” pain)
• Fourth
– Modify pressure, speed, angle, etc., to see if pain
subsides

Passive Accessory Movements of the
Lumbar Spine
• Central posterior to anterior (prone)

• Unilateral posterior to anterior (prone)
• Transverse glide

Passive Accessory Movements of the
Pelvis
• Bilateral anterior to • Bilateral posterior to

posterior innominate anterior innominate
(supine) (prone)
• Unilateral anterior to • Unilateral posterior to
posterior innominate anterior innominate
(supine) (prone)

Passive Accessory Movements of the Hip
• Anterior-to-posterior • Posterior-to-anterior
glide (supine) glide (prone)
• Caudal glide (supine) • Posterior-to-anterior
• Distraction-direct glide, figure four (prone)
(supine)
• Long-axis distraction
(supine)

Laboratory
• Passive accessory movements of the lumbar spine

• Passive accessory movements of the pelvis
• Passive accessory movements of the hip

Chapter 3 Takeaways
• Make sure to communicate and get consent from the

patient before performing a manual therapy
examination
• A manual therapy examination has three general
movements
– Each of the three is useful in determining potential
response to care and whether MT is appropriate
• A meaningful manual therapy examination looks at the
relationships between movement, positioning, and pain

Chapter 4
Decision-Making and Clinical Reasoning

and hip examination
• Distinguish between manual therapy assessment

First, Safety (Indications and
Contraindications)
• Do you have concerns about a nonmechanical disorder

or visceral disease creating an episode of low back
pain?
• Do you have concerns about a fracture?
• Do you have concerns about cauda equina?
• Do you have concerns about instability or a
ligamentous disorder of the lumbar spine?
• Do you have concerns about a connective tissue
disorder?

Serious Specific Low Back Disease
Category Specific Disorders Examples of Disorders
Non- Neoplasia Metastasis, lymphoid tumor, spinal cord tumor
mechanical
disorders Infection Infective spondylitis, epidural abscess,
endocarditis, herpes zoster, Lyme disease
Seronegative Ankylosing spondylitis (AS), psoriatic arthritis,
spondyloarthritides reactive arthritis, Reiter’s syndrome,
inflammatory bowel disease (IBS)
Visceral Pelvic Prostatitis, endometriosis, pelvic inflammatory
disease disease
Renal Nephrolithiasis, pyelonephritis, renal papillary
necrosis
Aortic aneurysm Aortic aneurysm
Gastrointestinal Pancreatitis, cholecystitis, peptic ulcer disease
Miscellaneous Paget’s disease Paget’s disease
Parathyroid disease Parathyroid disease
Hemoglobinopathies Hemoglobinopathies
Lurie, 2005
Contraindications
• Bony • Neurological
– Tumor: metastases – Cervical myelopathy
– Infection: tuberculosis, – Cord compression
osteomyelitis – Cauda equina syndrome
– Metabolic: osteomalacia, – Nerve root compression with
osteoporosis increasing neurological deficit
– Congenital: dysplasia • Vascular
– Iatrogenic: long-term – Diagnosed vertebrobasilar
corticosteroid use insufficiency
– Inflammatory: severe – Aortic aneurysm
rheumatoid arthritis
– Bleeding diatheses, hemophilia
– Traumatic: fracture
– Lack of mechanical findings
– Lack of patient consent
Puentedura, 2016
Red Flags and Precautions
• Red flags
– Cauda equina
– Spinal fracture
– Malignancy
– Spinal infection
Puentedura, 2016
62
Red Flags and Precautions (cont.)
• Precautions
– Adverse reaction to prior manual therapy
– Disc herniation or prolapse
– Spondylolisthesis
– Psychological dependence on manipulative techniques
– Ligamentous laxity
Puentedura, 2016
SINSS
Variable Description
Severity Intensity of the patient’s pain; impact of the pain on activities of daily
living (ADLs); amount and type of pain medication taken to control
the pain; and presence or absence of night pain
Irritability Ratio of the magnitude of aggravating factors to easing factors;
amount and type of activity to aggravate symptoms; and amount and
type of activity to ease symptoms
Nature Broad, conceptual term that includes not only the specific diagnosis
or condition the patient is experiencing but the nature of the pain
itself
Stage Clinician’s assessment of the time frame in which a condition is
presenting (acute, subacute, and chronic)
Stability Progression of the patient’s symptoms over time; may relate to
current episode or all episodes over time (worse, better, or same)
Petersen et al., 2021

Stage/Duration
• Acute • Subacute/chronic: not

– Reassurance improving
– Promotion of activity, – Mobilization,
especially walking manipulation
– Promotion of gentle – Exercise
mobility exercises – Aerobic activity
– Deterrence from
invasive procedures

Ask yourself:
Is there a movement disorder,
and will movement be useful?

Key Considerations of the Movement
Examination
• Were you able to reproduce the concordant pain?

• Was there a notable range-of-motion limitation?
• Was there a relationship between movement and
concordant pain?
• Did movement modulate the pain?
• Did selected positioning or postures modulate the pain?
• Did the pain worsen with movements?

Patient Expectations/Contextual Elements
• Does the patient exhibit significant fear or low

expectations about manual therapy?
• Did they seem to understand the context behind the
movement examination?
• Have they had prior experience with manual therapy?
• Did they consent to treatment?
Bishop et al., 2011

Chapter 4 Takeaways
• SINSS (Severity, Irritability, Nature, Stage, and Stability)

is useful in framing where a person is in their recovery
process
• The movement examination should help you
understand not only the role of movement in a person’s
pain but what potential pain mechanism you are
dealing with
• Patient expectations are a key consideration in the
management of low back, pelvis, and hip pain

Chapter 5
Manual Therapy Application

and hip examination
• Distinguish between manual therapy intervention

Application Disclaimer
• We use diagnostic conditions purely to help frame the

approach
– The movement examination should drive your treatment
selection
• Laboratory practice is essential
– Please don’t practice on your patients
• These applications are not plug-and-play
– Nuances of your own patients may dictate different
approaches

Most Common Problems for a Manual
Therapy Intervention
• Lumbar spine
– Mobility deficits (facet pain, degenerative joint disease)
– Movement coordination (hypermobility, musculotendinous or
ligamentous injury)
– Referred/related pain (disc herniation)
– Radiating pain (lumbar/sacral nerve root, disc herniation)
– Generalized pain (chronic)
• Pelvis
– Sacroiliac joint pain (sacroiliac ligament, trauma, pregnancy)
• Hip
– Hip osteoarthritis
– Nonarthritic hip pain
– Lateral hip pain
– Piriformis syndrome

Condition: Low Back Pain/Mobility Deficits
• Facet pain, degenerative joint disease

• Dominant nociceptive pain (long-term, it may have
some nociplastic elements)
• May report movement deficit at end ranges and/or pain
at end ranges
• Restricted segmental mobility
• Often will see improvements of range versus pain
George et al., 2021

Sidelying Lumbar Rotation:
Nonthrust Manipulation Grades I–II
• Sidelying with knees bent
and legs stacked; painful
segment up
• Therapist stands behind
the patient
• Patient’s fist is in contact
with the table
• Therapist produces
oscillations through the
femur (grade I)
• Patient’s fist is removed to
produce higher grade
(grade II)

Nonthrust Manipulation Grades III–IV
• Sidelying with knees bent and legs
stacked; painful segment up
• Therapist stands in front of patient
• Therapist flexes the patient’s hips
while the cephalad hand monitors for
movement in the target segment
(spinous process)
• Therapist holds the patient’s humerus
and rotates until the caudal hand
perceives movement at the target
segment (spinous process)
• Patient holds their wrists while the
therapist weaves under the patient’s
armpit with their cephalad arm
• Therapist produces a rotational force
at the targeted segment using their
body and arms
• Used to restore mobility

Thrust and Nonthrust Manipulation
• Sidelying; painful segment up • Therapist provides a thrust into
• Therapist flexes the patient’s hips slight rotation (posterior thorax and
while the cephalad hand monitors anterior at the pelvis) and toward
for movement in the target segment the floor
(spinous process) • Techniques can be delivered as a
• Therapist holds the patient’s thrust or nonthrust technique
humerus and rotates until the
caudal hand perceives movement
at the target segment (spinous
process)
• Patient holds their wrists while the
therapist weaves under the
patient’s armpit with their cephalad
arm
• Therapist rotates away from the
patient’s head to take the patient to
end range

Laboratory
• Sidelying lumbar rotation: nonthrust manipulation

grades I–II
• Sidelying lumbar rotation: nonthrust manipulation
grades III–IV
• Sidelying lumbar rotation: thrust and nonthrust
manipulation

Condition: Low Back Pain/Movement
Coordination Deficits
• Lumbar segmental hypermobility
• History of recurrence/episodic low back pain
• Dominant nociceptive (long-term, will have some
nociplastic components)
• Observation of faulty movement patterns, including
transitional movements
• Pain at rest or with midrange movements
• May include report of referred lower extremity pain
• Pain may be provoked with segmental provocation
• Decreased muscle strength and endurance
George et al., 2021
Prone Lumbar Central Posterior-to-Anterior
Nonthrust Manipulation
• Prone
• Therapist stands at the side
of the table
• Therapist identifies the stiff
or painful segment
• Therapist uses their hand
(just distal to the pisiform) to
contact the patient’s spinous
process; supports with the
other hand
• Therapist applies P/A
pressure at desired
therapeutic grade
Cook, 2012
Condition: Low Back Pain/
Related (Referred) Pain
• Low back pain with lower extremity pain
• Dominant neuropathic (long-term, will have some
• Pain with sustained postures (such as standing or
sitting) or repeated movements (such as flexion or
extension)
• May observe a lateral trunk shift
• Symptoms centralize or peripheralize with repeated
movements
• Neurological screening is typically negative
George et al., 2021

Prone Lumbar Unilateral Posterior-to-Anterior
• Prone
• Therapist stands at the
Medbridge
side of the table Photo
• Therapist identifies the
stiff or painful segment
• Therapist uses thumb
over thumb to mobilize
the facet joint posterior
to anterior at desired
therapeutic grade
Cook, 2012
Nonthrust Manipulation With Prone Press-Up
• Prone
• Therapist stands at side of table
• Therapist identifies painful segment
Medbridge
• Therapist uses their hand (just distal Photo
to the pisiform) to contact the
patient’s spinous process; supports
with the other hand
• Therapist applies P/A pressure at
desired therapeutic grade
• Used for a patient who responds to
repeated extension to centralize
symptoms
• Can be used in prone side bending or
combined extension and prone side
bending
Cook, 2012
Nonthrust Manipulation With Flexion
• Prone over pillows
• Therapist stands at side of table
• Therapist identifies painful
segment Medbridge
• Therapist uses their hand (just Photo
distal to the pisiform) to contact
the patient’s spinous process;
supports with the other hand
• Therapist applies P/A pressure at
desired therapeutic grade
• Used for a patient who responds to
repeated flexion to centralize
symptoms
• Can be used in prone side bending
or combined extension and prone
side bending
Cook, 2012
Laboratory
• Prone lumbar unilateral posterior-to-anterior nonthrust

manipulation
• Prone lumbar central posterior-to-anterior nonthrust
manipulation with prone press-up
• Prone lumbar central posterior-to-anterior nonthrust
manipulation with flexion

Condition: Low Back Pain/Radiating Pain
• Low back pain with radiating leg pain
• Dominant neuropathic (long-term, will have some
• Patient reports pain with sustained sitting or
standing/walking
• Patient reports paranesthesia and/or numbness, lower
extremity weakness
• Positive straight leg raise and/or crossed straight leg
raise and/or slump test
• May have mobility deficits
George et al., 2021

Supine Hook-Lying Lumbar Traction
• Supine; hook lying
• Therapist kneels at the
bottom of the table Medbridge
• Therapist places their hands Photo
underneath the patient’s
knees and leans back
• A strap/belt can be used to
sustain the hold time
• Used to produce a traction
force
• Amount of force and hold
time can vary based on
patient’s symptom report
Cook, 2012
Supine Hook-Lying Lumbar Traction:
Leg Pull
• Supine; skin on the table
• Therapist stands at the bottom of the table and lifts the
patient’s leg 1 to 2 feet from the table
• Therapist crosses their hands on the patient’s anterior
ankle and leans back
• A strap/belt (crossed over the patient’s anterior ankle)
can be used to sustain the hold time
• Used to produce a traction force
• Amount of force and hold time can vary based on
patient’s symptom report
Cook, 2012
Laboratory
• Supine hook-lying lumbar traction

• Supine hook-lying lumbar traction: leg pull

Condition: Sacroiliac Joint Pain
• May have a history of trauma, pregnancy

• Dominant nociceptive
• Reports pain is worse with weight-bearing and/or
transitional movements
• May present with restricted innominate mobility
• May present with positive thigh thrust test followed by
sacroiliac joint test cluster
Laslett et al., 2005

Supine Lumbopelvic Thrust Manipulation
• Supine; targeted side is away from
therapist
• Therapist side bends the patient
away from therapist
• Patient crosses their arms behind
their head; therapist rotates the
patient’s thorax toward the therapist
• Therapist maintains hold on the
patient’s scapula to maintain
rotation
• Therapist rolls patient toward them
until the contralateral ilium raises
slightly
• Therapist’s hand is placed just
medial to the anterior superior iliac
spine
• Thrust is in a posterolateral direction

Supine Muscle Energy for Anterior or
Posterior Rotation
• Supine
• Therapist flexes the patient’s leg to
move the innominate into posterior
rotation
• Therapist extends patient’s leg on
the contralateral side off the table
to move the innominate into
anterior rotation
• Therapist stabilizes the
nonsymptomatic side
• Patient is instructed to push into
therapist’s hand on the
symptomatic side (into either hip
flexion or extension)
• This is repeated for 3–5
repetitions of 3 seconds

Laboratory
• Supine lumbopelvic thrust manipulation

• Supine muscle energy for anterior or posterior rotation

Condition: Hip Pain/Mobility Deficits
• Hip osteoarthritis
– Moderate lateral or anterior hip pain during weight-bearing
– Over the age of 50
– Morning stiffness less than 1 hour
– Limited hip IR and flexion by more than 15 degrees
• Reports lateral hip pain or groin pain
• Observation of faulty movement patterns
• Pain with transitional movements (sit-to-stand)
• Motion limitations, especially at end ranges
• Dominant nociceptive (long-term, will have some
Cibulka et al., 2017

Supine Anterior-to-Posterior Nonthrust
Manipulation
• Supine; involved leg bent with
contralateral leg straight
• Therapist crosses patient’s involved
leg over the contralateral leg
• Therapist stands on the side of the
contralateral leg
• Therapist places their hands over the
patient’s knee and braces the knee
against their stomach
• Therapist produces an
anterior-to-posterior force through
the femur toward the hip
• A towel roll can be placed in patient’s
inguinal crease if patient reports pain
from impingement
• Therapist produces a nonthrust
mobilization at the desired
therapeutic grade

Prone Posterior-to-Anterior Nonthrust
Manipulation
• Prone; involved leg straight or
bent into knee flexion (keeping
two joint hip flexors on slack)
• Therapist stands on the side of
the involved hip
• Therapist places one hand under
the patient’s knee and raises the
leg to the perceived barrier
• Therapist places other hand just
inferior to the gluteal fold
• Therapist produces a
posterior-to-anterior nonthrust
therapeutic grade

Prone Posterior-to-Anterior Nonthrust
Manipulation (cont.)
• Prone; involved leg bent into flexion
abduction and external rotation
• If patient is limited in available
range of movement, the leg can be
placed on a stool
• Therapist stands on the side of the
involved hip
• Therapist’s hands are in a C-grip
position; therapist creates a skin
lock into internal rotation with their
hands
• Therapist produces a
posterior-to-anterior force; the force
vector may vary depending on the
patient’s position
• Therapist produces a nonthrust
therapeutic grade

Laboratory
• Supine anterior-to-posterior nonthrust manipulation

• Prone posterior-to-anterior nonthrust manipulation

Supine Hip Caudal Glide Nonthrust
Manipulation
• Supine
• Patient’s body is angled on the table, involved hip is flexed,
and patient’s knee is placed over therapist’s shoulder
• Therapist stands to the side and slightly inferior to the
involved leg
• Therapist places their interlaced hands at the patient’s joint
line
• Therapist produces a caudal/inferior force and nonthrust
mobilization at the desired therapeutic grade
• Multiple repetitions can be performed, followed by
reassessment

Supine Hip Distraction Nonthrust
Manipulation
• Supine
• Involved hip is flexed, and patient’s knee is placed over
therapist’s shoulder
• Therapist stands to the side and slightly inferior to the
involved leg
• Therapist places interlaced hands at the patient’s joint line
• Therapist produces a lateral/distraction force and produces
a nonthrust mobilization at the desired therapeutic grade
• Multiple repetitions can be performed, followed by
reassessment

Laboratory
• Supine hip caudal glide nonthrust manipulation

• Supine hip distraction nonthrust manipulation

Supine Long-Axis Distraction Thrust or
• Supine
• Therapist stands at end of table
• Therapist grasps the patient’s ankle and moves the leg
into 30 degrees of flexion/abduction and slight external
rotation
• Therapist leans back and provides a distraction force
• Therapist produces a nonthrust mobilization at the
desired therapeutic grade or a thrust manipulation
repeated 5 times prior to reassessment

Supine Nonthrust Mobilization With Active
Movement (Flexion)
• Supine; patient’s body is angled on
table; involved hip is flexed • Med bridge photo
• Therapist stands to side and slightly
inferior to the involved leg
• Therapist places a towel followed by a
mobilization belt at the patient’s joint
line and around the therapist’s gluteal
region
• Therapist produces a caudal/inferior
force or an inferior and lateral/
distraction force and produces a
nonthrust mobilization at the desired
therapeutic grade
• This can be followed by patient
initiating active hip flexion while
therapist maintains a caudal/inferior
or lateral/distraction force
• Multiple repetitions can be performed,
followed by reassessment

Supine Nonthrust Mobilization With Active
Movement (Internal Rotation)
• Supine; patient’s body angled on the
table; involved hip is flexed 90 degrees • Med bridge photo
at the knee and hip
• Therapist stands to side and slightly
inferior to involved leg
• Therapist places a towel, followed by a
mobilization belt, at the patient’s joint
line and around the therapist’s gluteal
region
• The therapist produces an inferior and
lateral/distraction force and produces a
nonthrust mobilization at the desired
therapeutic grade
• This can be followed by patient
initiating active hip internal rotation
while therapist maintains an inferior
and lateral/distraction force

Laboratory
• Supine nonthrust mobilization with active movement

(flexion)
• Supine nonthrust mobilization with active movement
(internal rotation)

Condition: Nonarthritic Hip Pain
• Hip pain, including anterior groin pain
• May have mechanical symptoms
• May have pain with deep squat, sitting, pivoting, running,
kicking
• Pain reproduced with FADIR (flexion, adduction, internal
rotation) test
• May have decreased flexion, adduction, internal rotation
• Treat impairments of accessory motion

Supine Soft-Tissue Mobilization: Iliopsoas
• Supine with involved leg in hip and
knee flexion
• Therapist stands to side of patient
• Therapist locates anterior superior
iliac spine and umbilicus and moves
fingers (hand over hand) one-third of
the way just lateral to the rectus
abdominis
• Therapist has patient flex hip slightly
to locate iliopsoas muscle
• Therapist moves perpendicular to
muscle fascicles in a medial and
lateral direction, or therapist holds
their position while patient moves hip
into adduction and abduction

Condition: Greater Trochanteric Pain
Syndrome
• Presence of lateral hip pain

• Worse with repetitive movements/activities
• Pain with palpation of lateral hip structures, including
musculature

Sidelying Soft-Tissue Mobilization:
Tensor Fascia Lata
• Sidelying with involved leg in hip
and knee flexion
• Therapist stands behind patient
• Therapist locates anterior superior
iliac spine and greater trochanter
• Therapist has patient flex slightly
and internally rotate hip to locate
tensor fascia lata
• Therapist moves perpendicular to
muscle fascicles in medial and
lateral direction or parallel to the
muscle fascicles in superior and
inferior direction
• Multiple repetitions of the
technique can be performed,

Condition: Piriformis Syndrome
• Presence of posterior hip pain
• Worse with sitting and driving
• Dominant nociceptive or neuropathic (if presence of
radiating pain)
• Familiar symptoms reproduced with FAIR test (flexion,
adduction, and internal rotation)
• Familiar symptoms may be reproduced with straight-leg
raise test
• Pain with palpation of piriformis muscle

Prone Soft-Tissue Mobilization: Piriformis
• Prone
• Therapist stands to side of
patient
• Therapist locates posterior
superior iliac spine and greater
trochanter
• Therapist locates piriformis
between the bony landmarks
• Therapist moves perpendicular
to muscle fascicles in a medial
and lateral direction
• Multiple repetitions of the
technique can be performed,

Chapter 5 Takeaways
• The movement examination is useful in driving the

treatment selection
• Remember the following elements during application
and after:
– Were you able to reproduce the concordant pain?
– Were you able to change the range-of-motion limitation?
– Were you able to reinforce the relationship between
movement and concordant pain?
– Did movement modulate the pain?
– Did the pain worsen with the movements?

Chapter 6
The Use of Augmented Home Exercises

and hip examination

Home Exercise and Adherence
• From the clinicians

– Exercise should be performed routinely
– Patients should put effort into the activity
• From the patients
– Exercise should be pain modulatory
– Activity must mean something to the patient
Himler et al., 2023

Augmented Manual Therapy
(Home Exercise Program)
• A home exercise
program that mimics the
applications performed
in the clinic (through
movement and
consequence)
• For manual therapy, it’s
a self-applied technique
that matches the
intention of the clinical
treatment
Petersen et al., 2015
Augmented Lumbopelvic Tilts
• Supine; patient bends knees
with feet on floor
• Patient bends low back and
tilts pelvis backward into the
floor, then return tilts pelvis
forward; patient returns to
starting position and repeats
• Depending on presentation, the
therapist may choose to have
an emphasis on the posterior
component or the anterior
component of the movement
• Movement is repeated for
desired treatment effect

Augmented Lumbar Rotation
• Supine; patient lying on side with
top leg bent at 90-degree angle,
holding it in place with bottom
arm; other leg is straight
• Patient’s top arm should be
straight in front of them on the
floor
• Patient reaches top arm straight
overhead and directly backward
– Tries to place shoulders flat on
floor while keeping hips facing
forward

Augmented Lumbar Rotation (cont.)
• Sidelying; patient bends

knees with feet on floor
• Keeping back flat,
patient slowly rotates
knees down toward floor
until they feel a stretch
in the trunk
• Movement is repeated
for desired treatment
effect

Augmented Lumbar Flexion
• Supine; patient seated in
chair with knees spread
apart
• Patient bends forward,
letting their arms hang
toward the ground until
they feel a stretch in the
lower back
• Movement should be slow
and controlled

Augmented Lumbar Extension
• Prone; patient on
stomach, resting elbows
low to ground
• Patient pushes up on
elbows, bending their
back upward
• Hips stay in contact
with floor
effect

Augmented Lumbar Extension (cont.)
• Standing; patient in
upright position with
hands resting on hips
• Patient slowly arches
trunk backward and
returns to standing
• Patient should not bend
knees
effect

Augmented Anterior and Posterior
Innominate
• Supine with knees bent and
feet on floor
– Patient lifts one leg to a
90-degree angle and places
both hands just above knee
• Patient presses knee up
toward chest, resisting the
movement with their hands
(posterior innominate)
• At the same time, patient digs
opposite heel into ground
(anterior innominate)
• Patient holds for 3–6 seconds
Selkow et al., 2009
Augmented Hip Lateral Glide
• Standing; patient places

band at hip height and
puts leg through band to
the top of the thigh
• The patient squats with
band pulling thigh/hip
out directly to the side
effect

Augmented Hip Inferior Glide
• Standing
• Patient places band
around top of the hip at the
hip crease and stabilizes
band with other leg by
standing on top of band
• Patient places foot up
onto chair
• Patients rocks into the leg
on the chair to mobilize hip

Augmented Hip Inferior Glide With
Hip Flexion
• Supine
• Patient places band
around top of the hip at the
hip crease and stabilizes
band with other foot or
externally fixates
• Patient flexes hip to
mobilize hip

Chapter 6 Takeaways
• Manual therapy approaches have short-term effects

(we need something to assist in carrying over treatment
effects)
• The home exercise program should be pain modulatory
and must mean something to the patient
• An augmented home exercise program should reflect
the intervention they received in clinical practice
• The augmented approach should be something they
can perform on their own

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Manual Therapy of the

Lumbar Spine, Pelvis,

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Not for reproduction or redistribution

Not for reproduction or redistribution

Not for reproduction or redistribution

Not for reproduction or redistribution

Not for reproduction or redistribution

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Not for reproduction or redistribution

Not for reproduction or redistribution

Kiapour et al., 2020

• Diarthrodial joint with stability provided by osseus

• Muscles • 80% of individuals will

• Each anatomical region is unique, but each also has to

Not for reproduction or redistribution

Not for reproduction or redistribution

Not for reproduction or redistribution

George et al., 2021

• Acute low back pain

George et al., 2021

George et al., 2021

Symptom Movement Functional

Alrwaily et al., 2016

Triage by the first-contact healthcare provider

Determine the appropriate management approach

Medical management Rehabilitation management Self-care management

Triage by the rehabilitation provider

Determine the appropriate rehabilitation approach

Alrwaily et al., 2016

• 10 clinical practice guidelines were included

• Manual therapy for mild to moderate hip osteoarthritis

Cibulka et al., 2017

• Clinical practice guideline emphasis was on exercise

van Doormaal et al., 2020

• In the absence of contraindications, manual therapy

Enseki et al., 2014

• A systematic review described AEs following spinal

Hebert et al., 2015

• As with the majority of other regions of the body,

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Not for reproduction or redistribution

Not for reproduction or redistribution

• From the second course in this series

Not for reproduction or redistribution

• A manual therapy examination is looking at the

Not for reproduction or redistribution

Not for reproduction or redistribution

Not for reproduction or redistribution

Not for reproduction or redistribution

• Patients with lumbar, pelvis, or hip pain should perform

Not for reproduction or redistribution

• The purpose of active physiological movements is to

Maitland et al., 2001

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Not for reproduction or redistribution

Not for reproduction or redistribution

• Hip flexion (supine)

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• Active physiological assessment of the lumbar spine

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• The purpose of passive physiological movements is to

Maitland et al., 2001