MDT and Centralization: Frequently Misunderstood and Underappreciated
MDT and Centralization: Frequently Misunderstood and Underappreciated
MDT and Centralization: Frequently Misunderstood and Underappreciated
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
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:
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:
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
• 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
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
• Risk factors
• Clinical course
• Diagnosis/Classification
• Differential diagnosis
• Examination outcome measures
• Examination impairment/functional
• Interventions
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
• 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.
• Very generalizable
Does It Matter Which Exercise?
A RCT of Exercise for LBP
Great!