MDT and Centralization

Frequently Misunderstood and

Underappreciated
Brian McClenahan PT, MS, OCS, FAAOMPT, Dip.MDT
Bob Robinson PT, DPT, MS, FAAOMPT, Dip.MDT
 Outline

• Centralization as defined in literature

• Distinguishing Centralization vs. Directional
Preference
• MDT presence in 2012 guidelines
• Key literature to support Centralization
– Reliability
– Prevalence
– Prognosis/Outcomes
• Synopsis
 Defining Centralization
• “Abolition Centralization: The most distal pain was abolished and
pain was recorded more proximally on the second drawing than on
the first.”
• “Reductive Centralization: The pain was located at the same distal
location but with reduced intensity.”
• “Unstable Centralization: The pain was reduced or abolished during
the repeated movement testing or positioning but after resuming a
weight-bearing position for 1 minute, the pain intensity level returned
to the pre-testing intensity.”

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 Spine J 2011,21(4):630-636.
 Defining Centralization
• “Centralization is defined in the classification system of occurring
when a movement or position results in abolishment of pain or
paraesthesia or causes migration of symptoms from an area more
distal or lateral in the buttocks and/or lower extremity to a location
more proximal or closure to midline of the lumbar spine.”
• “Must have lower extremity pain.”

Fritz, J.; Cleland, J.; Child,s C. “Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach
to Physical Therapy”. JOSPT 2007; 37(6):296.
 Defining Centralization

• “Centralization is liberally defined as a movement, mobilization or

manipulation ‘technique’ targeted to pain radiating or referring from
the spine, which when applied, abolishes or reduces the pain distally
to proximally in a controlled predictable pattern.”

Cook, C. “Orthopedic Manual Therapy: An Evidenced Based Approach, 2nd Edition”. pp268; Article cited in text:
Aina, A.; May, S.; Clare, H. “The Centralization phenomenon of spinal symptoms: A Systematic Review”. Manual
Therapy 2004; 9:134-143.
Centralization Is Frequently
Misunderstood
The McKenzie Method of Mechanical Diagnosis
and Therapy (MDT) Definition of Centralization
Has Evolved:

• 1981 Lumbar Spine text

• “I would define this phenomenon as the situation in
which pain arising from the spine and felt laterally from
the midline or distally is reduced and transferred to a
more central or near midline position when certain
movements are performed.”

McKenzie, R. “The Lumbar Spine”. Spinal publications 1981; pp22.

The McKenzie Method of Mechanical Diagnosis
and Therapy (MDT) Definition of Centralization
Has Evolved:

• 2003 Lumbar Spine text

• “In response to therapeutic loading strategies, pain is
progressively abolished in a distal to proximal direction
with each progressive abolishing being retained over
time until all symptoms are abolished. If back pain only is
present, this moves from a widespread to a more central
location and then is abolished.”

McKenzie, R.; May S. “The Lumbar Spine: Mechanical Diagnosis and Therapy”. Spinal publications 2003; pp167.
The McKenzie Method of Mechanical Diagnosis
and Therapy (MDT) Definition of Centralization
Has Evolved:

• 2008 MDT research

• Centralization is characterized by spinal pain and
referred symptoms that are progressively abolished in a
distal to proximal direction in response to therapeutic
loading strategies.
• Very objective measures included to further remove
clinician bias.

Werneke, el al. “Centralization: Prevalence and Effect on Treatment Outcomes Using a Standardized Operational
Definition and Measurement Method”. JOSPT March 2008; 38(3):p116.
 Centralization:
Operational Definition

• Directed by precise application of movement and

positioning
• Proximal change in pain location only
• Remains better – lasting effect during treatment
• Midline pain abolishes
 Centralization:
Operational Definition
 Centralization:
Standardized Measurement

• Overlay Template
Donelson, et al. Spine 1991
Werneke, et al. Spine 1999
Delitto, et al. JOSPT 2012
 Centralization
vs.
Directional Preference

Directional
Preference

Centralization
 Symptomatic Responses

• The changes in the patient symptoms that

are elicited and recorded with the
application of assessment procedures,
treatment procedures or in response to
functional activities and positions.
 Mechanical Responses

• The measurable changes that occur in

movement loss, dural tension, neurologic
function, tolerance to functional activities
and positions or change in tested physical
abilities.
 Centralization

• Describes the phenomenon by which limb pain

emanating from the spine is progressively abolished in a
distal to proximal direction in response to therapeutic
loading strategies, with each progressive abolition being
retained over time (lasting change).
• Symptomatic Response
 Peripheralization
• Describes the phenomenon by which pain emanating
from the spine spreads distally into or further into the
limb as a result of loading strategies (lasting change).
• Symptomatic Response
 Directional Preference
• Phenomenon of preference for postures/movements that
decrease, abolish or centralize symptoms and often
improve a limitation of movement (lasting change).
• Symptomatic and/or Mechanical Response
Pain Response Subgroups

PAIN RESPONSE

Non-CEN 1. CEN/DP

2. DP/Non-CEN 3. No-DP/non-CEN
Linking Centralization’s
Importance to APTA’s
Perspective on LBP Care
 Important?
• Mechanical Diagnosis and Therapy (MDT)
– Discovered by Robin McKenzie in the 1950s and published in
1981
– Key finding of assessment when elicited
• Clinical Practice Guidelines (CPG)
– Centralization and Directional Preference exercises 'considered'
Important Interventions
• Level 1 evidence
• Grade A recommendation

• Treatment Based Classification (TBC)

– Step 1 of Algorithm
 Clinical Practice Guidelines

• “Clinical Guidelines Linked to International

Classification of Functioning, Disability and
Health”, from the Orthopedic Section of the
American Physical Therapy Association. JOSPT
2012;42(4):A1-A57.Doi:10.2519/jospt.0301
 CPG

• Risk factors
• Clinical course
• Diagnosis/Classification
• Differential diagnosis
• Examination outcome measures
• Examination impairment/functional
• Interventions
 Concepts of MDT throughout CPG

• A3. Centralization/Directional Preference

• A3. Patient education and counseling
• A12. Argument against pathoanatomical
• A12. Mechanical assessment vs. imaging
• A12. Clinical course: rate of re-occurrence
 Concepts of MDT throughout CPG

• A13. Importance of classification

– ICF vs. MDT
• A17. Biopsychosocial (Werneke 2006)
• A17-18. Red flags
 Concepts of MDT throughout CPG

• Establishing existence of Centralization key to the

assessment.
• A24. Instrument variation: “Techniques to improve
precision to the judgments have been described,
including strategies between Centralization and
Directional Preference responses”. (Werneke 2008)
 Concepts of MDT throughout CPG

• A34-36. (Interventions)
– Centralization and Directional Preference exercises and
procedures
• A36. (Interventions)
– First mention of repeated movements
 Clinical Practice Guidelines

• Treatment-based classification
• Primary influence on CPG
 Key Research
to Discuss Centralization
 Reliability

Kilby, J.; Stignant, M.; Robert, A. “The reliability of back

pain assessment by physiotherapists using a McKenzie
Algorithm”. Physiotherapy 1990;76(9):579-583.
• Video observation (Question: Do any repeated
movements decrease, abolish or centralize pain
• Examination of inter-examiner agreement
• Two examiners trained in C and D (Not credentialed)
• Kappa value of centralization identification = 0.51%
 Reliability

Kilpilkoski, et al. “Inter-examiner reliability of low back pain

assessment using the McKenzie Method”. Spine
2002;27(8).
• Agreement on Centralization Phenomenon 95%; Kappa
= 0.7
• Inter-examiner agreement “high” using those
credentialed in MDT
 Reliability
Fritz, J., et al. “Inter-rater reliability of Centralization
judgments of the Centralization Phenomenon and status
change during movement testing in patients with low back
pain”. Arch Phys Med Rehab 2000;81: 57-61.
• High reliability between examiners in determining
presence or absence of Centralization pain response.
 Reliability

• Low back pain practice guidelines

• P24: Judgments of Centralization during
movement testing
• Kappa 0.7 to 0.9 for novice and experienced
physical therapists
 Reliability
Standardized Operational Definition
Standardized Measurement

Werneke, M.; Hart, D.L.; Cook, D. “A descriptive study of

the centralization phenomenon: A prospective analysis”.
Spine 1999;24:676-83
• Body diagrams/measurement template
• Almost perfect
• Kappa = 0.96 - 1.0
 Centralization:
Operational Definition
• Directed by precise application of movement and
positioning
• Proximal change in pain location only
• Remains better – lasting effect during treatment
• Midline pain abolishes
 Centralization:
Standardized Measurement

• Overlay Template
Donelson, et al. Spine 1991
Werneke, et al. Spine 1999
Delitto, et al. JOSPT 2012
 Prevalence
Reliability demonstrated to be high, yet different
prevalence rates?
• Werneke, M.; Hart, D.L. “Discriminant validity and
relative precision for classifying patients with non-
specific neck and back pain by anatomical pain
patterns”. Spine 2003; 28(2), 161-166.
• George, S.; Bialosky, J; Donald, D. “The Centralization
Phenomenon and Fear-Avoidance Beliefs as Prognostic
Factors for Acute Low Back Pain: A Preliminary
Investigation Involving Patients Classified for Specific
Exercise”. JOSPT 2005; 35(9), 580-588.
 Method of Assessing for Centralization:
Influences Prevalence
Werneke, M.W.; Hart, D.; Oliver, D.; McGill, T.; Grigsby, D.; Ward, J.;
Weinberg, J.; Oswald, W.; Cutrone, G. “Prevalence of classification
methods for patients with lumbar impairments using the McKenzie
syndromes, pain pattern, manipulation and stabilization clinical
prediction rules”. J Man Manip Ther 2010;18:197-210.

• Data collected on 628 patients from 8 different clinics by

therapists with training in MDT
• Centralization (43%), Non-Centralization (39%) and not
classified (18%)
• Positive to Manipulation (13%) and Stabilization (7%)
clinical prediction rules
Werneke, M.W.; Hart, D.; Oliver, D.; McGill, T.; Grigsby D.; Ward, J.; Weinberg, J.;
Oswald W.; Cutrone, G. “Prevalence of classification methods for patients with
lumbar impairments using the McKenzie syndromes, pain pattern, manipulation
and stabilization clinical prediction rules”.
J Man Manip Ther 2010; 18:197-210.

• Prevalence rates of Centralization in:

– Patients (+) for Manipulation CPR = 0.68
– Patients (+) for Stabilization CPR = 0.8

• Prevalence rates for Derangement (DP/CEN) in:

– Patients (+) for Manipulation CPR = 0.8
– Patients (+) for Stabilization CPR = 0.83
I Thought Manipulation and Stabilization
Prevalence Rates Were Higher?

Brennan, G.P.; Fritz, J.M.; Hunter, S.J.; Thackeray A.;

Delitto, A.; Erhard, R.E. “Identifying subgroups of patients
with acute/subacute ‘non-specific’ low back pain: results of
a randomized clinical trial”. Spine 2006;31:623-31
• 48% fit Manipulation CPR and 24% fit Stabilization CPR
• % of 123 subjects who consented from 268 eligible from 1,052
potential patients referred for treatment to all participating clinics;
military facilities
• Recalculation based on all potential patients
• 6% Manipulation CPR and 3% Stabilization CPR
Brennan Study vs. Werneke Study

• MDT training unknown • MDT-certified clinicians

• Military facility • Diverse medical facilities
• 123 subjects of a possible • 692 subjects of a possible
1,052 725
• Eliminated ~75% of • No exclusions; 95%
participants participation
• Randomized controlled • Practice-based evidence
trial
• Not generalizable • Very generalizable
 How Did They Define Centralization
When Eliciting High Prevalence?

• Using the most strict definitions in available literature

• Items used to judge Centralization in Werneke/FOTO
studies:
– Change in pain location only
– Pain diagram and template to judge for patients with pain to
gluteal fold
– Pain diagram and overlay template (Delitto, et al. LBP
Guidelines JOSPT 2012)
– Track change in pain location over time (Werneke, et al. JOSPT
2008; Werneke, et al. Spine 1999; Werneke, et al. PTJ 2004)
 Method to Assess for Directional
Preference

• Recognized as distinct from Centralization

• Items used to judge Directional Preference in
Werneke/FOTO studies:
– Centralization
– Pain intensity (2/10 or more change in pain report from most
distal pain location)
– Increase trunk AROM (single inclinometer)
– Patient’s report: improved ability to bend forward/back and
perform task
– Before/After RMT: LE Break Test; Aberrant Trunk Motion; Neural
Tension Sign
 What Does This Say about Prevalence
and Testing Methods?

Centralization can be elicited with a very high prevalence

in a very general population even when differentiated from
Directional Preference and using strict definitions that will
“decrease” rates compared to studies that use more
general definitions ... if ...
Proper Mechanical Testing to
Exhaust Loading Strategies Is Utilized.
Prognosis / Outcomes
 Centralization
Predicts Pain at 6 Months

• George, S.Z.; Bialosky, J.E.; Donald, D.A. “The

centralization phenomenon and fear-avoidance beliefs
as prognostic factors for acute low back pain: a
preliminary investigation involving patients classified for
specific exercise”. J Orthop Sports Phys Ther 2005;
35:580-588.
• Long, A. “The centralization phenomenon: its usefulness
as a predictor of outcome in conservative treatment of
chronic low back pain (a pilot study)”. Spine 1995;
20(23):2513-2521.
 Centralization
Greater Prognostic Indicator of Chronic Disability then
Psychosocial Variables

• Werneke, M.; Hart, D.L. “Centralization phenomenon as

a prognostic factor for chronic low back pain and
disability”. Spine 2001; Apr 1;26(7):758-65.
• Edmond S.L.; Werneke, M.W.; Hart, D.L. “Association
between Centralization, depression, somatiziation and
disability among patients with non-specific low back
pain”. J Orthop Sports Phys Ther 2010; 40:801-810.
Optimal Treatment Follows Centralization

Long, A.; Donelson, R.; Fung, T. “Does it matter which

exercise? A RCT of exercise for LBP”. Spine, 2004. 29 (23):
p 2593-2602.
• 230 subjects (acute, subacute, chronic; pain location and
neurological status were all very diverse); ~half LBP only; 34%
full leg pain (sciatica); and half of those mild neurological loss

• Very generalizable
 Does It Matter Which Exercise?
A RCT of Exercise for LBP

• Direction-specific group (matched care)

• Opposite direction (unmatched care)
• Evidence-based care (unmatched care)
– Assurance, advice, education to keep active, general
non-direction exercise program
 Does It Matter Which Exercise?
A RCT of Exercise for LBP

• Direction Specific Rx 2-5 times greater improvement in

all 7 outcomes compared to either unmatched group
– Low Back Pain
– Leg Pain
– Physical Function
– Medication Use
– Self Report of Degree of Recovery
– Activity Interference
– Depression
 Does It Matter Which Exercise?
A RCT of Exercise for LBP
• An intervention that directly influences the
pain-generating disorder improves an
individual’s:
– Functional abilities
– Medication intake
– Depression
 Does It Matter Which Exercise?
A RCT of Exercise for LBP

• Dir Spec Rx 95% reported better or fully recovered at 2

weeks vs. 42% of evidence-based group and 23% of opp dir
group
• A third of patients treated in unmatched exercise groups
withdrew from study due to being either worse or no better
• 15% of patients who were strongly predicted to do well
actually worsened by the care recommended by every LBP
clinical guideline vs. 0% in matched
• Is guideline-based treatment safe?
• 95% improvement agreed with 95% recovery reported in 1990
cohort study (Donelson)
 Does It Matter Which Exercise?
A RCT of Exercise for LBP

• Demonstrates how forms of exercise can produce a rapid and

significant alleviation of pain
• Demonstrates that it does matter what exercise is prescribed
for those with a DP who centralize
• Demonstrates that guideline-based care is inferior to exercise
matching the DP
• Only 23% of consecutive LBP patients presenting for care
were excluded
• Large Central/DP subgroup includes at least 50% of those
with sciatica and neurological loss (eliminated from TBC)
Prognosis / Outcomes?

Great!

... but ...

Only if you elicit it.

 Synopsis

• ADTO MODEL serves to support Centralization as:

– Reliable
– Valid
– Associated with strong outcomes
– Guides treatment
• Centralization does not equal Directional Preference
 Synopsis

• MDT principles are found throughout the CPG

• MDT is the first step of the TBC
• MDT assessment to search for Centralization allows one
to safely assess/treat individuals that are frequently
ineligible for many RCTs
 Synopsis

• CPG, TBC and MDT agree Centralization is important ...

so make sure you do not fail to elicit.
• Standardized definitions and measurement of
Centralization coupled with proper testing procedures
means optimal elicitation of results and ultimately optimal
outcomes for patients.
 Recommendations
• APTA to agree upon a common definition for
Centralization.
• Trained MDT Clinicians represented in the ICF
recommendations in regards to eliciting Centralization
and Direction Preference.
• Based on evidence and optimal results per literature.
Use Centralization definition established by Robin
McKenzie and refined by the work of Mark Werneke for
further studies and discussion.
• Future studies recommended that explore TBC with
more exhaustive RMT in order to find ideal responders
to stabilization/other categories.
 Special Thanks

• Mark Werneke, MS, PT, Dip.MDT

• Ron Donelson, MD
• Past and present members of Team FOTO
• The many individuals involved in testing MDT
principles to establish strength within an ADTO
Model
 Questions

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