Pelvis course manual extract

The material presented in this course challenges current examination and treatment methods for pelvic girdle pain (PGP) and dysfunction. Two weeks before the course, participants are provided with the course manual and a reading list to become familiar with the premise and the evidence underpinning it. The manual is more than 100 pages and includes detailed explanations of examination and treatment techniques. This page contains extracts from the course manual to help understand the approach. 

Pelvic Girdle Pain and Pain Provocation Tests

Pelvic girdle pain is often grouped with either LBP (Kamper et al 2015) or described as a specific form of LBP (Vleeming et al 2008). Continued use of terms such as "non-specific LBP", "non-specific PGP disorders" (O'Sullivan & Beales 2007) and the latest iteration, "non-specific SIJ related pain" (Palsson et al 2019), arguably cause more confusion than clarity. "The very use of the term LBP as a 'quasi diagnosis' - when pain is a symptom, not a disease reflects a general lack of knowledge" (Cusi 2010). 

Most validated pelvic girdle tests are pain provocation procedures (Vleeming et al 2008) that, if used in combination, are predictive of intra-articular SIJ pathology (Laslett 2013, June 3, Laslett, 2008, Laslett et al 2005a, Laslett et al 2005b, Laslett and Williams, 1994, Laslett et al 2003). The original intention of these studies was to assist clinicians in differentiating the sacroiliac joint (SIJ) from the lumbar spine as the source of pain. However, the sacroiliac joint pain-provocation tests (PPTs) evaluated in these studies have unknown diagnostic power for pain sources external to the SIJ space ( Vleeming et al 2008, Laslett 2013, June 3). Consequently, they have unknown validity for the ligamentous components of the SIJ or any pelvic structure external to the SIJ (Vleeming et al 2008). Even in the latest article reviewing the evidence for the clinical detection and diagnosis of pain in the “SIJ area” (Palsson et al 2019), this point is not clearly explained. As a result, clinicians using these tests may be misinterpreting the results. 

That being said, PPTs that identify the site of pain using direct palpation can be valuable. A good example is a local pain elicited by direct palpation of the long dorsal ligament (LDL) in many patients with failed pelvis force closure (Vleeming et al 2008, Vleeming et al 2012).

Pelvic Dysfunction

Dysfunction is defined as abnormal or impaired functioning (Berube et al 2008). Sacroiliac PPTs are not intended to identify pelvic dysfunction (Laslett 2013, June 3). Identifying the anatomical source of pain does not automatically explain why a particular structure is painful (Cusi 2010). 

The SIJ has a unique role in ameliorating ground reaction contact stress during ambulation (Lovejoy 1988, 2007). Efficient form and force closure of the SIJ protects other body parts against injury (Vleeming et al 2012, Vleeming, 2016). Consequently, ineffective pelvic form and force closure (dysfunction) may cause abnormal distribution of stress and strain throughout the body, potentially contributing to injury and pain in areas remote from the pelvis. The biotensegrity conceptual model provides plausible explanations for how this may occur (Dischiavi 2018, Levin 2017, Levin 2007). 

Laslett (2013, June 3) described research into SIJ dysfunction as problematic because manual tests of mobility or position of the sacrum or innominate lack reliability, and there is no way to determine the existence or relevance of SIJ dysfunction. 

That pelvic dysfunction and PGP are simply linked to changes in the small amount of intra-pelvic motion at the SIJ or "abnormal" relative positions of bones is an outdated view but still gets unwarranted attention in peer-reviewed literature and on social media. A paper by Palsson et al (2019) reviewed the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction and questioned the continued use of assessing movement dysfunction and subsequent treatment paradigms based on such diagnoses. A recent systematic review of sacroiliac mobility tests performed on adult patients with non-specific LBP, PGP and SIJ pain confirmed poor reliability and validity for SIJ mobility tests. It concluded that using SIJ mobility tests in clinical practice is problematic (Pekarić-Klerx et al 2020).

Pelvic dysfunction is most likely a failure of the pelvis via many complex mechanisms to effectively transmit loads and forces during normal physical activity. 

Functional Tests

The active straight leg raise (ASLR) test is the only functional test recommended in the "European guidelines for the diagnosis and treatment of pelvic girdle pain" (Vleeming et al 2008). According to Mens et al (2001), the ASLR can be used to test the integrity of load transfer function between the lumbosacral spine and lower limbs. If pelvic control is adequate, the leg should rise effortlessly, and the pelvis should not move relative to the thorax and lower extremity (Lee 2011). The test is regarded as positive if the subject has difficulty lifting the leg or a maladaptive movement pattern is used (Mens et al 2001, Mens et al 2002, Beales, 2009a & b, Beales et al 2010, Lee 2011). 

Applying specific passive or active forces to the pelvis when performing the ASLR test can improve or normalize compensatory neuromuscular strategies (Beales, 2009a & b, Beales et al 2010, Mens, Vleeming, 1999, O'Sullivan et al 2002a, Pool-Goudzwaard et al 1998). This addition to the original ASLR is commonly used to detect pelvic dysfunction (Cook and Hegedus, 2012, Lee and Lee, 2011, Lee and Vleeming, 2007) and is termed the augmented ALSR (AASLR) by the course presenter. 

The AASLR and pelvis MWM techniques have similarities. During the AASLR, the leg raise is comparable to the active movement component of the pelvis MWM, and the application of forces to the innominates in the AASLR is comparable to the "mobilization" component of a pelvis MWM. 

The original ASLR test described by Mens et al (2001) and the AASLR test rely on a combination of visual observations by the examiner and subjective reporting on the quality of movement by the patient but do not take into account the influence of pain. According to Palsson et al (2015), this is problematic as they have determined that pain alone significantly impacts the subjective and objective outcome of the ASLR test. They recommend that this be accounted for when using the test in research and clinical practice.  

There is a clear need to develop and validate functional tests to use in combination with the ASLR. With this in mind, new functional tests (that consider the influence of pain) have been developed. Some are existing functional tests that have been modified or repurposed. In addition, a cutting-edge pelvis MWM examination process is used. As for the ASLR, pelvis MWM tests employ visual and qualitative judgments but, most importantly, also consider the effect of pain. The clinician applies external forces to the pelvis that eliminate pain or maladaptive responses as movement occurs. The application points, directions, magnitudes, and combinations of forces depend entirely on real-time feedback from the patient. Pelvis MWM tests are deemed positive if the pain is mitigated (rather than provoked) and normal function is restored. The value of this approach is that the tests detect relevant dysfunction and provide clues to determine the appropriate treatment. The new tests are designed to be scrutinized and researched.

Pelvis MWM for treatment of PGP and dysfunction

Over the last thirty years, published research has greatly enhanced our understanding of PGP and pelvic function. Despite this, advances in clinical management have been slow to arise (Meijer wt al 2020). Significant research findings, particularly regarding the mechanisms of failed load transfer through the pelvis, appear to have been ignored or misunderstood. One example is persistence with the reductionist approach to active rehabilitation involving isolating individual muscles or muscle groups and isolated actions (Dischiavi et al 2018). Another is patients presenting with chronic pain related to an undetected and untreated pathoanatomical problem with no signs of central sensitization or psychosocial issues but managed with only pain management education, cognitive behavioral therapy, and other pain therapies as if they do (Taylor and Kerry 2017). 

Active exercise should be the favored treatment for most neuromusculoskeletal conditions, but sometimes exercise therapy does not work. Inappropriate exercise in the presence of unrecognized but clinically significant maladaptive movement patterns may be ineffective or even harmful. Pelvis MWM techniques are ideally used as "breakthrough" techniques when exercise produces pain or abnormal bracing and inhibition responses that interfere with movement. If necessary, a pelvis MWM can be performed as a self-treatment procedure and integrated into functional exercise training to help re-establish normal low load and high load movement strategies. 

Although MWM techniques often employ passive external forces, they are first and foremost active functional treatment techniques. In line with a significant volume of research, pelvis MWM examination procedures and MWM treatment techniques DO NOT: 

•    Require palpation of the relative position of bony landmarks or relative movement of bones 

•    Depend on passive manual tests of intra-pelvic motion (SIJ or PS range of movement) 

•    Rely on findings of pain provocation tests

•    Require belief in any theory of pelvic or SIJ dysfunction, including the "positional fault" hypothesis

•    Depend on establishing a diagnosis, identifying a specific pathology or "pain generator”.

The material presented in this workshop has been developed and refined over 30 years. Although based on sound clinical reasoning and reflecting the findings of a rapidly expanding body of scientific research, a conscious decision was made to delay researching the system until empirical clinical evaluation demonstrated that the approach was sound and that it could produce a worthwhile advance in the treatment of PGP and pelvic dysfunction. 

The most obvious difference when using the MWM principles outlined in this program, and the one most worth researching, is that the presenting problem reported by the patient can often be assessed and treated utilizing real-time responses. 

I hope that the long-term view we have adopted will eventually bear fruit for clinicians and those individuals who seek their care.

Self-reflection tool

For the duration of this course, please critically and logically consider the material presented in relation to your clinical practice and how it compares to peer-reviewed literature relating to the examination and treatment of PGP and pelvic dysfunction. Then consider:

1.    Why did you choose this course, and what need does it address for you? 

2.    How will the information from the course relate to your practice? 

3.    How will the information presented in this course change your behavior in the future?


Beales DJ, O'Sullivan PB, Briffa NK. Motor control patterns during an active straight leg raise in pain-free subjects. Spine 2009a;34:E1-8. 

Beales DJ, O'Sullivan PB, Briffa NK. Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects. Spine 2009b;34:861-70.

Beales DJ, O'Sullivan PB, Briffa NK. The effects of manual pelvic compression on trunk motor control during an active straight leg raise in chronic pelvic girdle pain subjects. Manual Therapy 2010;15:190-9.

Cook C, Hegedus E 2012 Orthopedic Physical Examination Tests: An Evidence-Based Approach 2nd Ed. Chapter 11. Prentice Hall, Upper Saddle River, New Jersey.

Cusi, M 2010 Paradigm for assessment and treatment of SIJ mechanical dysfunction. Journal of Bodywork & Movement Therapies. 2010;14:152-61. 

Dischiavi SL, Wright AA, Hegedus EJ, Bleakley CM. Biotensegrity and myofascial chains: A global approach to an integrated kinetic chain. Medical Hypothesis 2018;11:90-96.

Hing W, Hall T, Mulligan B. Introduction. In: Hing W, Hall T & Mulligan B, editors. The Mulligan Concept of Manual Therapy: textbook of techniques. Elsevier Publishing; 2020.p.1-19. 

Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. BMJ. 2015:doi:10.1002/14651858.

Kumah EA, McSherry R, Bettany-Saltikov J, Hamilton S, Hogg J and Whittaker V. Evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding and behaviour towards the application of evidence into practice. Campbell Systematic Reviews. 2019;15:e1015.

Laslett M, Williams W. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 1994;19:1243-9.

Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 2003;49:87-97.

Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy 2005a;10:207-18.

Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B. Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disorders 2005b. 6:28.

Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. The Journal of Manual and Manipulative Therapy 2008;16:142- 52.

Laslett M. What is the best test to assess innominate mobility? [blog post] Retrieved from  2013, June 3.

Lee DG, Vleeming A. An integrated therapeutic approach to the treatment of pelvic girdle pain. In: Vleeming A, Mooney V, Stoekart R, editors. Movement, Stability and Lumbopelvic Pain; Integration of Research and Therapy. Edinburgh: Churchill Livingstone; 2007.

Lee DG. The pelvic girdle. An integration of clinical expertise and research. 4th ed. Edinburgh: Churchill Livingston Elsevier; 2011.

Lee DG, Lee LH. Techniques and tools for assessing the lumbopelvic-hip complex In: Lee D, editor. The Pelvic Girdle: An integration of clinical expertise and research. London: Churchill Livingstone Elsevier; 2011. p. 173-254.

Levin SM. A suspensory system for the sacrum in pelvic mechanics: Biotensegrity. In: Vleeming A, Mooney V, Stoekart R, editors. Movement, Stability and Lumbopelvic Pain; Integration of Research and Therapy. Edinburgh: Churchill Livingstone; 2007 p.229-237.

Levin SM. The significance of closed kinematic chains to biological movement and stability. Journal of bodywork and movement therapies 2017;21:664-672. 

Lovejoy CO 1988 Evolution of human walking. Scientific American November p118-125.

Lovejoy CO 2007 Evolution of the human lumbopelvic region and its relationship to some clinical deficits of the spine and pelvis. In: Vleeming A, Mooney V, Stoekart R, editors. Movement, Stability and Lumbopelvic Pain; Integration of Research and Therapy. Edinburgh: Churchill Livingstone.

Mens JMA, Vleeming A, Snijders C, Stam HJ, Ginai AZ. The active straight leg raise test and mobility of the pelvic joints. European Spine 1999;8:468-74.

Mens JM, Vleeming A, Snijders C, Stam HJ, Ginai AZ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine 2001;26:1161-71.

Mens JM, Vleeming A, Snijders C, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain since pregnancy. Spine 2002a;27:196-200.

O'Sullivan PB, Beales, DJ, Beetham JA, Cripps J, Graf F, Lin IB, et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine 2002a;27:E1-8.

O'Sullivan PB, Beales DJ. Diagnosis and classification of pelvic girdle pain disorders - part 1: a mechanism based approach within a biopsychosocial framework. Manual Therapy 2007a;12:86-97.

Palsson TS, Hirata RP, Graven-Nielsen T. Experimental pelvic pain impairs the performance during the active straight leg raise test and causes excessive muscle stabilization. The Clinical Journal of Pain 2015;31:642-651.

Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G, Rabey M et al. Changing the narrative in diagnosis and management of pain in the sacroiliac joint area. Physical Therapy 2019;99:1511-1519.

Pool-Goudzwaard A, Vleeming A, Stoeckart R, Snijders CJ, Mens JM. Insufficient lumbo-pelvic stability: a clinical, anatomical and biomechanical approach to non-specific low back pain. Man Ther 1998;3:12-20.

Taylor A, Kerry R. When Chronic Pain Is Not "Chronic Pain": Lessons From 3 Decades of Pain. Journal of Orthopaedic and Sports Physical Therapy 2017;47:512-518. DOI:10.2519/jospt.2017.0606 

Vicenzino B, Hing W, Rivett D, Hall T, editors. Mobilisation with movement: the art and science. Australia: Elsevier Publishing; 2011. p. 2-8.

Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17:794-819.

Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of Anatomy 2012;221:537-67.

Vleeming A 2016 Understanding Lumbar & Pelvic Girdle Pain:  An Evidence Based Course on Clinical Anatomy, Biomechanics & Effective Rehabilitation. Auckland University of Technology, Auckland, New Zealand