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Centralisation

Original Editor - Angeliki Chorti

Top Contributors - Angeliki Chorti  

Introduction

Centralisation is a clinical marker commonly used in the assessment of patients with spinal pain. [1] Centralisation was originally noticed by Robin McKenzie in 1956, in the treatment of a patient with low back pain extending to the knee whose symptoms originating from the spine abolished and/or regressed as a result of an accidental therapeutic (prone) position. [2] In 1981, Robin included his observations in a treatment system [3] and since then, it has been one of the key features of the McKenzie method [4] as well as other classification systems in the management of neck, thoracic and low back pain. [5] [6] [7] The reverse of centralisation, peripheralisation, has also been described, as the phenomenon of pain (originating from the spine) spreading distally into the limb. [4]

Watch this video [8] on centralisation and peripheralisation:

[8]

Role of Physiotherapy

Centralisation is a clinically induced symptom response. This implies that centralisation is a phenomenon which reflects immediate changes in symptom status after a physical examination or therapeutic strategy using mechanical loading. Physiotherapists use a variety of tools i.e. positions, movement testing, manual tests to evoke this response; this is suggested to contribute to the assessment of the underlying acuity and nature of spinal symptoms, [9] the establishment of a diagnosis or prognosis, [7] [10] or the determination of a management strategy. [4] [11] [12]

Here's an example of centralisation being induced as a result of a physiotherapist's intervention:

[13]

Definition

Since the original report of centralisation as the abolition of peripheral symptoms as a result of movements or postures, there have been variations in the definition and the methods used to elicit this phenomenon across studies. [14] Fritz et al. [15] included changes in the neurological status, and others considered pain intensity reduction of peripheral symptoms. Because these differences make the comparison of study findings, and inferences about the best definition to use difficult, the use of standardised criteria for centralisation are commonly recommended. [14][16]

An international Delphi study was carried out to establish a uniform definition for centralisation and operational criteria for eliciting this symptom response . [17] A broader definition of centralisation was supported including "the progressive and stable reduction of the most distal pain towards the spinal midline in response to standardised repeated end-range movement or sustained loading testing procedures" with testing involving multiple strategies and/or alternative forces when appropriate, [17] indicating a mutual appreciation of the different but equally acceptable approaches when using this sign. This strategy reflects the clinical environment, where therapists may often combine approaches instead of exclusively following one system. [11]

Conceptual Model

The mechanism that is responsible for centralisation is not completely known; however, it was hypothesised that it involved the "reduction" of the painful and displaced part of the disc to a more central and less irritable position. [18] This view ignores various mechanisms that may be in play when treating patients and extend beyond anatomical explanations. For example, an investigation on such mechanisms occurring with the application of manual therapy has identified peripheral, segmental spinal, and supraspinal mechanisms, suggesting that treatment response is a complex and multisystem matter. [19]

Centralisation may even occur in ruptured discs shown in MRIs; [20] on the other hand, mechanisms that may lead to non-predictable displacements of the disc during mechanical loading are scarcely researched, but may include inflammatory processes within the disc, [21] or inadequate hydrostatic function of the disc. [22] To fill this gap, an international physiotherapy expert panel gathered and decided on the features of discogenic pain and in particular the specifics of non-reducible discogenic low back pain. [23]

Characteristics of discogenic low back pain included (% agreement among experts):

  1. Directional Preference (including centralisation and peripheralisation) - 88%
  2. Lateral tilt -81%
  3. Worsening of symptoms when sitting - 81%
  4. Positive discography (negative for epidural and facet joint injections) - 69%
  5. Pain shifting sides - 63%
  6. Worsening of symptoms when sneezing or coughing - 63%
  7. Posture Preference - 56%
  8. Worsening of symptoms with lumbar flexion - 56%
  9. Pain behaviour influenced by pain provocation and pain relief caused by postures / movements - 50%
  10. Flexion / Rotation / Compressive Force induces symptoms - 50%

Characteristics of non-reducible discogenic included (% agreement among experts):

  • No position / movement leads to a lasting pain reduction - 100%
  • Failure to achieve centralisation of symptoms with posture / movement - 94%
  • Peripheralisation of symptoms with mechanical loading - 75%
  • No change with mechanical loading - 69%
  • Constant pain - 63%
  • Symptom aggravation with mechanical loading - 63%
  • Difficulty controlling symptoms - 63%
  • Positive discography - 56%
  • Symptom aggravation with random provocative and inconsistent postures and movements - 50%

Prevalence

Centralisation has been reported to be present in approximately 40% of spinal pain cases. [24] Duration of symptoms determines its prevalence in patients, with acute populations reporting higher percentages (74%) than sub-acute and chronic patients (42%). [25]

Diagnostic Value

A systematic review of 41 moderate quality studies was undertaken to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. 28 investigated the disc, 8 the facet joint and 7 the SIJ. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4-5.3).[26] Although centralisation is suggested to indicate alterations in pain originating from the intervertebral disc, it has not been associated with the disc lesion type in patients with sciatica. [10]

Another important feature of any clinical test is its reliability i.e. its ability to produce consistent and reproducible results among clinicians. [27] Centralisation has produced variable reliability results and has yet to demonstrate adequate reliability across studies, [1] but the influence of patient and clinician characteristics on these reliability outcomes needs further clarification. [17]

Prognostic Value

Centralisation has been cited and acknowledged as an important favourable prognostic indicator that should be routinely considered in this patients with spinal pain. [1] [17] Its presence has been common and associated with activity limitation and leg pain improvements in outcome measures of patients with sciatica, constituting an argument against a surgical option. [14][10] Nevertheless, these associations refer to short and medium term favourable outcomes [28][12][29][30][31][32][33][34] and there is limited evidence for areas other than the lumbar spine. [1][35][36]

Therapeutic Value

Consistent evidence to imply that centralisation is an important treatment indicator is still lacking. [1] However, the nature of most study designs incorporating it have not determined its presence at baseline, nor randomised patients accordingly. [1]

Clinical Bottom Line

Diagnosis in physical therapy is a complex and multifaceted process that ideally uses clinical assessment tools that lead to clinical management strategies. [37]

Traditionally, health professionals (e.g. physiotherapists, chiropractors, osteopaths) have relied heavily in pathoanatomic explanations for subgroups of spinal pain (i.e. low back pain), focused more on pain and physical impairments and supported that reducible discs are common in primary musculoskeletal care. [38][39] This trend has changed over the years since clinical practice guidelines argue that the source of back pain is not well known in favour of the biopsychosocial model in pain management.

Centralisation is a clinical marker commonly used by physiotherapists in the assessment of patients with spinal pain. Its is more present in patients acute symptoms than sub-acute and chronic populations. Variations in the definition and the methods used to elicit centralisation across studies have been noticed, and these differences make the comparison of and definite conclusions about study findings, as well as inferences about the best definition to use difficult. Nevertheless, centralisation has been cited and acknowledged as an important favourable prognostic indicator; especially for short and medium term outcomes. To date, consistent evidence to imply that centralisation on its own is an important treatment indicator is still lacking.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 May S, Runge N, Aina A. Centralization and directional preference: an updated systematic review with synthesis of previous evidence. Musculoskelet Sci Pract 2018; 38:53-62.
  2. ↑ Donelson R. Rapidly reversible low back pain: an evidence-based pathway to widespread recoveries and savings. Hanover, NH: Self Care First, LLC, 2006.
  3. ↑ McKenzie RA. The lumbar spine. Mechanical diagnosis and therapy. Waikanae: Spinal Publications; 1981.
  4. ↑ 4.0 4.1 4.2 McKenzie R, May S. The lumbar Spine. Mechanical Diagnosis & Therapy. Volume One. Waikanae New Zealand: Spinal Publications, 2003
  5. ↑ Delitto A, Erhard R, Bowling R. A treatment-based classification approach to low back pain syndrome: identidying and staging patients for conservative treatment. Phys Ther 1995; 75:47-=485.
  6. ↑ Fritz J, Brennan G. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther 2007; 87:513-524.
  7. ↑ 7.0 7.1 Murphy D, Hurwitz E. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord 2007;8:75.
  8. ↑ 8.0 8.1 Tauzell R. Centralization and Peripheralization. Available from: https://youtu.be/mTX2ZU7XghA (accessed 22/4/2022)
  9. ↑ Kuhnow A, Kuhnow J, Ham D, Rosedale R. The McKenzie method and its association with psychosocial outcomes in low back pain: a systematic review. Physiother Theory Pract 2021; 37:1283-1297.
  10. ↑ 10.0 10.1 10.2 Albert H, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur J Spine 2012; 21: 630-636.
  11. ↑ 11.0 11.1 Pinto D, Cleland J, Palmer J, Eberhart S. Management of low back pain: a case series illustrating the pragmatic combination of treatment - and mechanism - based classification systems. J Man Manip Ther 2007; 15: 111-122.
  12. ↑ 12.0 12.1 Al-Obaidi S, Nakhi H-B, Skaria N. Effectiveness of McKenzie intervention in chronic low back pain: a comparison based on the centralization phenomenon utilizing selected bio-behavioural and physical measures. Int J Phys Med Rehabil 2013; 1:1-8.
  13. ↑ Physical Therapy Nation. Explaining centralization. Available from: https://www.youtube.com/watch?v=mNoYEZltG8o(accessed 25/4/2022)
  14. ↑ 14.0 14.1 14.2 Berthelot J-M, Delecrin J, Maugars Y, Passuti N. Contribution of centralization phenomenon to the diagnosis, prognosis, and treatment of diskogenic low back pain. Joint Bone Spine 2007; 74:319-323.
  15. ↑ Fritz JM, Delitto A, Vignovic M, Busse RG. Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil. 2000 Jan;81(1):57-61.
  16. ↑ Werneke M, Hart D, Resnik L, Stratford P, Reyes A. Centralization:prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther 2008; 38:116-125.
  17. ↑ 17.0 17.1 17.2 17.3 Chorti A. Towards a uniform definition for the centralisation phenomenon. PhD thesis. Coventry: University of Warwick, 2009.
  18. ↑ Wetzel FT, Donelson R. The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. Spine J. 2003 Mar-Apr;3(2):146-54.
  19. ↑ Keter DL, Bialosky JE, Brochetti K, Courtney CA, Funabashi M, Karas S, Learman K, Cook CE. The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews. PLoS One. 2025 Mar 18;20(3):e0319586.
  20. ↑ Albert HB, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J. 2012 Apr;21(4):630-6.
  21. ↑ Adams MA, Stefanakis M, Dolan P. Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain. Clin Biomech (Bristol). 2010 Dec;25(10):961-71.
  22. ↑ Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine (Phila Pa 1976). 1997 May 15;22(10):1115-22.
  23. ↑ Chan AY, Ford JJ, McMeeken JM, Wilde VE. Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique. Physiotherapy. 2013 Sep;99(3):212-20.
  24. ↑ Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms--a systematic review. Man Ther. 2004 Aug;9(3):134-43.
  25. ↑ May S, Aina A. Centralization and directional preference: a systematic review. Man Ther 2012; 17:497-506.
  26. ↑ Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 Oct;16(10):1539-50.
  27. ↑ Sim J, Wright C. Research in healthcare:concepts, designs and methods. Cheltenham, Nelson Thornes, 2000.
  28. ↑ Werneke M, Hart D, Cutrone G, Oliver D, McGill M-T, Weiberg J, et al. Association between directional preference and centralization in patients with low back pain. JOSPT 2011; 41:22-31.
  29. ↑ Edmond S, Cutrone G, Werneke M, Ward J, Grisby D, Weinberg J, et al. Association between centralization and directional preference and functional and pain outcomes in patients with neck pain. JOSPT 2014; 44:68-75.
  30. ↑ Gregg C, McIntosh G, Hall H, Hoffman C. Prognostic factors associated with low back pain outcomes. J Prim Health Care 2014; 6:23-30.
  31. ↑ Rose T, Butler J, Salinas N, Stolfus R, Wheatley T, Schenk R. Measurement of outcomes for patients with centralising versus non-centralising neck pain. J Man Manip Ther 2016; 24:264-268.
  32. ↑ Surkitt L, Ford J, Chan A, Slater S, Pizzari T, Hahne A. Effects of individualised directional preference management versus advice for reducible discogenic pain: a pre-planned secondary analysis of a randomised controlled trial. Musculoskel Sci Pract 2016; 25:69-80.
  33. ↑ Werneke M, Edmond S, Young M, Grigsby D, McClehanan B, McGill T. Directional preference and functional outcomes among subjects classified at high psychosocial risk using STarT. Phys Res Int 2018; 23:e1711.
  34. ↑ Yarznbowicz R, Tao M, Owens A, Wlodarsky M, Dolutan J. Pain pattern classification and directional preference are associated with clinical outcomes for patients with low back pain. J Man Manip Ther 2018; 26:18-24.
  35. ↑ Runge N, Aina A, May S. Are within/and/or between session improvements in pain and function prognostic of medium and long-term improvements in musculoskeletal problems? A systematic review. Musculoskelet Sci Pract 2020; 45:
  36. ↑ Chorti A, Chortis A, Strimpakos N, McCarthy C, Lamb S. The prognostic value of symptom responses in the conservative management of spinal pain: a systematic review. Spine 2009; 34:2686-2689.
  37. ↑ Spoto MM, Collins J. Physiotherapy diagnosis in clinical practice: a survey of orthopaedic certified specialists in the USA. Physiother Res Int. 2008 Mar;13(1):31-41.
  38. ↑ Kent P, Keating JL. Classification in nonspecific low back pain: what methods do primary care clinicians currently use? Spine (Phila Pa 1976). 2005 Jun 15;30(12):1433-40.
  39. ↑ Kent PM, Keating JL, Taylor NF. Primary care clinicians use variable methods to assess acute nonspecific low back pain and usually focus on impairments. Man Ther. 2009 Feb;14(1):88-100.
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