Aina A, May S, Clare H, The centralization phenomenon of spinal symptoms - a systematic review, Man Ther, Aug;9(3):134-143, 2004

Systematic review of 14 studies into centralisation. Prevalence 70% in 731 sub-acute back pain patients and 52% in 325 chronic back pain patients. Centralisation was reliably assessed (kappa values 0.51 to 1.0). Centralisation was consistently associated with good outcomes, and failure to centralise with poor outcomes. Association was confirmed by high quality studies.

Al-Obaidi SM, Al-Sayegh NA, Nakhi HB, Skaria N., Effectiveness of McKenzie intervention in chronic low back pain: a comparison based on the centralization phenomenon utilizing selected bio-behavioral and physical measures, Int J Phys Med & Rehab, 1:4, 2013

Comparison of outcomes in 2 groups of patients with chronic low back pain who demonstrate complete (N =62) or partial centralization (N=43), and followed-up over 10 weeks with treatment with MDT. The groups were significantly different at baseline in terms of fear-avoidance and Roland-Morris Back Disability questionnaire. Over time both groups had highly significant changes in all outcomes relating to pain perception, fear beliefs, disability beliefs and physical performance tests, but were better in the full centralization group.

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, 21(4):630-6, 2012

Secondary analysis of previous RCT; 176 patients with sciatica and pain below the knee given a mechanical assessment and classified: 85% reported centralization, 7% peripheralization, and 8% no effect in response to repeated movements. Leg pain was significantly better in the centralization and peripheralization groups at 3 and 12 months. Centralization occurred in all types of disc lesions reported on MRIs, from normal through to sequestrations.

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Bonnet F, Monnet S, Otero J, Short-term effects of a treatment according to the directional preference of low back pain patients: a randomized clinical trial., Kinesither Rev, 112.51-59, 2011

54 patients were randomly allocated to McKenzie method or guideline-based treatment, and final assessments were taken at the end of one week. There were significant differences in centralisation in the McKenzie group (62% versus 17%), but no difference in other outcomes (Oswestry and pain intensity)    (In French).

Broez D, Burkard S, Weller M, A prospective study of mechanical physiotherapy for lumbar disk prolapse: five year follow-up and final report., NeuroRehab, 26.155-158, 2010

Follow-up of previous study in which patients with lumbar herniations and demonstrating centralisation predicted good long-term outcome in the majority of patients.

Bybee F, Olsen D, Cantu-Boncser G, Condie Allen H, and Byars A, Centralization of symptoms and lumbar range of motion in patients with low back pain., Physio Theory Pract, 25:257-267, 2009

42 patients with back pain were classified as centralised (30), centralising (3), non-centralised (9); there were significant differences between initial and final extension range in first 2 groups, but not in the latter. Patients who showed centralisation on initial visit also showed an increase of ROM during initial visit.

Bybee R, Hipple L, McConnell R, Crossland P, The relationship between reported pain during movement and centralization of symptoms in low back pain patients., Manuelle Therapie, 9:122-127 (German), 2005

Occurrence of centralisation was correlated with occurrence of pain during movement in 33 patients with back pain. 22 (67%) reported centralisation, 8 (24%) centralising symptoms, and 3 (9%) reported no site change in symptoms; and 29 reported pain during movement. 97% of those who reported pain during movement reported centralisation/centralising; and 93% of those who reported centralisation/centralising reported pain during movement (p=0.001 for both).

Christiansen D, Larsen K, Jensen OK, Nielsen CV, Pain Responses in Repeated End-Range Spinal Movements and Psychological Factors in Sick-Listed Patients with Low Back Pain: is there an Association?, J Rehabil Med, 41.545-549, 2009

Cross sectional study looking at centralisation status and psychological factors in 331 patients with back pain. Centralisation occurred in 30% of their sample. There were significant associations between non-centralisation and mental distress and depression.

Christiansen D, Larsen K, Jensen OK, Nielsen CV., Pain response classification does not predict long-term outcome in sick listed low back pain patients., J Orthop Sports Phys Ther, 40:606-615, 2010

A cohort study running alongside a RCT of over 300 patients who were sick-listed for back pain and assessed for the presence of centralisation; with primary outcome being return to work. Following mechanical evaluation 30% were classified as centralisers, 8% as peripheralisers, and 62% as no response. All groups improved over the year, with no significant differences between pain response groups.

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, May 15;22(10):1115-22, 1996

63 chronic patients received a mechanical evaluation and discography, with clinicians blind to the findings of the other assessment. Centralisation (74%) and peripheralisation (69%) were strongly associated with discogenic pain, compared to no change in symptoms (12%). Centralisation (91%) was strongly associated with a competent annulus compared to peripheralisation (54%).

Donelson R, Silva G, Murphy K., Centralization phenomenon. Its usefulness in evaluating and treating referred pain., Spine, Mar;15(3):211-3, 1989

The centralisation phenomenon is found to be a reliable predictor of good or excellent treatment outcome. In 87 patients centralisation occurred in 87% - with centralisation occurring in 100% of 59 patients with excellent outcomes.

Edmond SL, Cutrone G, Werneke M, Ward J, Grigsby D, Weinberg J, Oswald W, Oliver D, McGill T, Hart DL., Association between centralization and directional preference; and functional and pain outcomes in patients with neck pain, J Orth Sports Phys Ther, 44(2):68-75, 2014

304 patients with neck pain were included, and prevalence rates of 40% for centralization and 70% for directional prevalence were recorded. Neither were associated with pain outcomes, but directional preference and to a lesser extent, centralization, were associated with improvements in function. Younger subjects were more likely to centralize, and those with acute symptoms more likely to demonstrate directional preference.

Edmond SL, Werneke MW, Hart DL., Association between centralization, depression, somatization, and disability among patients with nonspecific low back pain., J Orthop Sports Phys Ther, 40:801-810, 2010

Secondary analysis of cohort study of 231 patients with back pain in which data was gathered about depression, somatization, and centralization at baseline, and measures of disability and pain at baseline and follow-up. Associations between depression and somatizisation and chronic disability were reduced in the presence of centralization.

George SZ, Bialosky JE, Donald DA, 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, 35:580-588, 2005

Secondary analysis of 28 patients who were classified as specific exercise category and observed for the effects of prognostic variables at baseline on outcomes at 6 months. Centralisation and fear-avoidance at work both independently and significantly predicted disability at 6 months. Only centralisation significantly predicted pain at 6 months.

Gregg CD, McIntosh G, Hall H, Hoffman CW, Prognostic factors associated low back pain outcomes, J Primary Healthcare, 6;23-30, 2014

Retrospective analysis of 1076 patients treated over 3 years with multivariate analysis to determine prognostic factors that were associated with outcome. Shorter duration of pain, lower baseline pain, intermittent pain, and a directional preference for extension were all associated with better outcomes.


Hagovska M, Takac P, Petrovicova J., Changes in the muscle tension of erector spinae after the application of the McKenzie method in patients with chronic low back pain., Phys Med Rehab Kuror, 24:133-140, 2014

Comparison of muscle activity in centralizers and healthy controls, with the latter showing significantly lower erector spinae activity. Following centralization pain, disability, and erector spinae were all reduced.

Karas, R.; McIntosh, G.; Hall, H.; Wilson, L.; Melles, T., The Relationship Between Nonorganic Signs and Centralization of Symptoms in the Prediction of Return to Work for Patients With Low Back Pain, Phys Ther, 77:354-360, 1996

Inability to centralize indicated a decreased probability of returning to work, regardless of the Waddell score. A high Waddell score predicted a poor chance of returning to work regardless of the patients ability to centralize symptoms. Waddell scores appear to be a better predictor of poor outcomes.

Kilpikoski S, Alen M, Paatelma M, Simonen R, Heinonen A, Videman T, Outcome comparison among working adults with centralizing low back pain: secondary analysis of a randomized controlled trial with 1-year follow-up., Advances in Physio, 11:210-217, 2009

Secondary analysis looking at outcomes in a group of patient with centralisation randomised to McKenzie, orthopaedic manual therapy (OMT) or advice to stay active. The McKenzie group had some significantly better outcomes after treatment and at 3 and 6 months than the advice group, but at one year there were no significant differences between the groups. There were few significant differences between the 2 active treatments (McKenzie group less leg pain at 3 months) or between OMT and the advice only group (OMT group less back and leg pain at 6 months).

Kilpikoski S, Alen M, Simonen R, Heinonen A, Videman T., Does centralizing pain on the initial visit predict outcomes among adults with low back pain?, Manuelle therapie, 14:136-141, 2010

Secondary analysis of previous RCT (Paatelma et al. 2008) in which baseline centralizers (N=119) were compared to baseline non-centralizers (N=15) during follow-up. Centralizers had a significantly greater reduction in pain and disability immediately after the treatment period; and at 6 months for pain only. (In German)

Laslett M, Oberg B, Aprill CN, McDonald B, Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power., Spine J, 5:370-380, 2005

83 patients with chronic low back pain underwent a full or partial mechanical examination and discography and the results were compared. The prevalence of positive discography was 75%, and of centralisation 32%. Sensitivity of centralisation to predict discogenic pain was weak (about 40%), but specificity was high and 100% in patients without severe distress or disability.

Lisi AJ., The centralization phenomenon in chiropractic spinal manipulation of discogenic low back pain and sciatica, J Manipulative Physiol Ther, Nov-Dec;24(9):596-602, 2000

3 case studies demonstrating value of centralisation. 2 patients displayed centralisation and responded to mobilisation / manipulation treatment. One patient only able to peripheralise came to surgery.

Long A, The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain (a pilot study), Spine, 20(23):2513-2521, 1995

A pilot study indicating that centralisation is useful as an outcome predictor in chronic patients. There was a superior outcome comparing centralisers to non-centralisers in an interdisciplinary work-hardening programme.

Long A, May S, Fung T, The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians?, J Manual Manip Thera, 16.248-254, 2008

Secondary analysis from a previous trial (Long et al 2004) of 312 patients who received a mechanical evaluation at baseline, 84 were deemed to have a good outcome (defined as at least 30% reduction in baseline Roland-Morris score). Factors that were predictive of a good outcome were analysed using multivariate analysis. Only leg bothersomeness rating and treatment assignment survived multivariate analysis. Subjects with directional preference who received matched directional treatment were 7.8 times more likely to have a good outcome, which was a stronger predictor than a range of other biopsychosocial factors.

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May S, Aina A, Centralization and directional preference: a systematic review., Manual Therapy, 17:497-506, 2012

The review included 54 studies relating to centralization and 8 relating to directional preference exercises. The prevalence on centralization was 44% in back and neck pain, with higher prevalence in acute (74%) than sub-acute or chronic symptoms (42%). Twenty-one of 23 studies supported the prognostic validity of centralization, whereas 2 did not. Centralization and directional preference appear to be useful treatment effect modifiers in 7 of 8 studies. Levels of reliability were very varied (kappa 0.15-0.9).

Murphy DR, Hurwitz EL, Application of a diagnosis-based clinical decision guide in patients with low back pain., Chiro Man Ther, 19:26, 2011

Assessment of 264 consecutive patients using previously described algorithm found that 2.7% had serious pathology and 41% showed centralization. According to definitions used 23% / 27% / 24% showed lumbar, sacroiliac segmental signs (pain provocation tests) and radicular signs respectively. In 63% and 40% dynamic instability and fear beliefs were respectively diagnosed.

Murphy DR, Hurwitz EL, Application of a diagnosis-based clinical decision guide in patients with neck pain., Chiro & Man Ther, 19:19, 2012

Data on 95 patients with neck pain on their classification according to the diagnosis-based clinical decision guideline previously published. Potential serious illness was found in 1%, centralization in 27%, segmental pain provocation signs in 69%, and radicular signs in 19%.

Murphy DR, Hurwitz EL, McGovern EE, Outcome of pregnancy-related lumbopelvic pain treated according to a diagnosis-based decision rule: a prospective observational cohort study., J Manip Physiol Ther, 32:616-624, 2010

Use of a classification system that included centralisation as initial part of algorithm, after exclusion of serious pathology, in a cohort with pregnancy related back pain, of which 58% was pelvic pain, 20% back pain and the rest a mixture. Proportion with each classification is not given.

Murphy DR, Hurwitz EL, McGovern EE., A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: a prospective observational cohort study with follow-up., J Manip Physiol Thera, 32.723-733, 2009

Report on consecutive cohort study of patients with lumbar radiculopathy of who 62% demonstrated centralisation with repeated movements, and 8% peripheralisation. Centralisation was associated with functional improvement, especially at long-term follow-up.

Murphy DR, Hurwitz EL., Application of a diagnosis-based clinical decision guide in patients with neck pain., Chiro & Manual Ther, 19:19, 2011

Application of a diagnosis-based classification system (not MDT) in 95 patients with neck pain; centralization was found in 27%. Larger proportions had segmental pain provocation signs, myofascial sign sand dynamic instability according to the study criteria. Classifications were not mutually exclusive.

Otero J, Bonnet F, Low back pain: prevalence of McKenzie's syndromes and directional preference., Kinesither Rev, 14:36-44, 2014

66 French certified McKenzie therapists each collected data on 10 consecutive patients, providing data on 349 patients with back pain. At baseline 92% were classified with Derangement, 2.3% with Dysfunction, 0.9% with Postural, and 4.9% with Other. Centralization was recorded in 70.5% at baseline, which increased to 73.5%, and Directional Preference remained at 73.5%. Between baseline and the fifth session the classification remained the same in 90.1%. Directional preference was as follows: extension 79.5%, lateral 12.6%, and flexion 4.3%.

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Rathore S, Use of McKenzie cervical protocol in the treatment of radicular neck pain in a machine operator., J Can Chiropr Assoc, 47:291-297, 2003

Case study of patient with cervical radicular pain, demonstrating centralisation in response to retraction and extension, categorised as derangement and treated with retraction and extension exercises.

Schmidt I, Rechter L, Hansen VK, Andreasen J, Overvad K, Prognosis of subacute low back pain patients according to pain response., Eur Spine J, 17:57-63, 2008

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Skikic EM, Suad T, The effects of McKenzie exercises for patient with low back pain, our experience., Bosnian J Basic Med Sci, III.70-75, 2003

Cohort study of 34 acute to chronic patients treated with McKenzie approach, with significant improvements in pain and range of movement: 61.5% demonstrated centralisation.

Skytte L, May S, Petersen P, Centralization: Its prognostic value in patients with referred symptoms and sciatica, Spine, 30:E293-E299, 2005

60 patients with referred symptoms and sciatica following a mechanical evaluation were classified as centralisers (25) or non-centralisers (35). Patients then followed a standardised management pathway that involved surgery if there was a failure to improve. Both short and long-term the centralisation group had significantly better outcomes for pain and disability. Non-centralisers were 6 times more likely to have surgery.

Tuttle N, Is it reasonable to use an individual patient's progress after treatment as a guide to ongoing clinical reasoning?, J Manip Physiol Ther, 32.396-403, 2009

Review and commentary about using patient responses as a guide to clinical reasoning. Changes in range of movement and centralisation of symptoms are better indicators of treatment effectiveness than changes in pain intensity or changes in joint position. Limited evidence to support the use of changes in segmental stiffness to guide management.

Werneke M, Hart DL, Cook D, A descriptive study of the centralization phenomenon. A prospective analysis., Spine, Apr 1;24(7):676-83, 1998

Of 289 patients with acute neck and back pain 31% centralised during repeated movement testing in the clinic and achieved abolition of symptoms on an average of 4 sessions; 46% showed some centralisation or reduction of symptoms on an average of 8 sessions (partial response); 23% showed no change in symptom site or intensity over an average of 8 sessions. The authors question whether in the partial response group changes were a product of the natural history or exercise programme. Both centralisers and partial responders showed significant improvement in pain intensity and function, whilst the non-response group did not. Assessment of initial pain location was reliably assessed.

Werneke M, Hart DL, Resnik L, Stratford PW, Reyes A, Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method., J Orthop Sports Phys Ther, 38:116-125, 2008

Report of over 350 spine patients; 76% lumbar, 53% chronic symptoms (> 3 months), mean age 58 years. Overall rate of centralization at intake as measured on a body chart template was 17%, with higher rates in more acute and younger patients. For instance rates were 29% and 24% for acute (< 3 weeks) lumbar and cervical patients, and 32% and 30% for lumbar and cervical patients aged between 18 and 44. Centralization was much less common in those with chronic symptoms and those over 64 for lumbar problems and over 44 for those with cervical problems. Outcomes were better amongst centralizers and outcomes were worse amongst non-centralizers.

Werneke M, Hart DL., Centralization phenomenon as a prognostic factor for chronic low back pain and disability., Spine, Apr 1;26(7):758-65, 2000

In 225 patients with acute back pain 24 psychosocial, somatic and demographic variables were recorded at initial assessment. Patient outcomes at one year were predicted by a range of independent variables. When all these variables were entered in a multivariate analysis only pain pattern classification (centralisation or partial centralisation v non-centralisation), and leg pain at intake were significant predictors of chronic pain and disability.

Werneke M, Hart DL., Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomical pain patterns, Spine, 28(2), 161-166, 2002

Re-analysis of data from earlier study comparing prognostic usefulness of classifying patients as centralisers on the first visit compared to during subsequent visits. At first visit 130 (45%) were classified as centralisers, only 4 became non-centralisers, but 43 became partial centralisers. At first visit 157 (55%) were classified as non-centralisers _x0013_ of these 95 (60%) became partial or full centralisers at later sessions.

Werneke MW, 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, 18:197-210, 2010

Data collected on 628 patients from 8 different clinics by therapists with training in MDT found prevalence of derangement (67%), dysfunction (5%), and posture syndrome (0%); centralisation (43%), non-centralisation (39%), and not classified (18%); and positive to manipulation (13%) and stabilisation (7%) clinical prediction rules. Derangement classification and centralisation prevalence was high in patients who fulfilled both clinical prediction rules.

Werneke MW, Hart DL, George SZ, Deutscher D, Stratford PW., Change in psychosocial distress associated with pain and functional status outcomes in patients with lumbar impairments referred to physical therapy services., J Orth Sports Phys Ther, 41:969-980, 2012

Re-analysis of data from 586 patients with back pain; patients who demonstrated non-centralization (37%) had significantly worse pain, functional disability and psychosocial distress outcomes compared to those who centralized (45%). No pain pattern classification was recorded in 18%.

Werneke MW, Hart DL, George SZ, Stratford PW, Matheson JW, Reyes A, Clinical outcomes for patients classified by fear-avoidance beliefs and centralization phenomenon, Arch Phys Med Rehab, 90:768-777, 2009

Secondary analysis looking at predictors of outcome in 238 patients with back pain: 18% centralisers, 52% non-centralisers, and 30% could not be classified; 56% had low fear avoidance, 44% had high fear avoidance. Treatments depended on classification according to these variables. Patients who demonstrated centralisation improved most whatever their levels of fear avoidance; those with high levels of fear avoidance improved least. Both centralisation and fear-avoidance levels impacted on outcomes.

Werneke MW, Hart DL., Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain., J Rehabil Med, Sep;37(5):286-90, 2005

Re-analysis of data from previous study to determine association between centralisation category and psychosocial variables. Non-centralisation patients were significantly more likely to have positive non-organic signs, overt pain behaviour, fear of work activities and somatisation, but no difference was found between centralisation category regarding depression, fear of physical activity, disability or pain intensity.

Werneke MW, Hart DL., Categorizing patients with occupational low back pain by use of the Quebec Task Force Classification system versus pain pattern classification procedures: discriminant and predictive validity, Phys Ther, Mar;84(3):243-54, 2004

Re-analysis of previously collected data comparing different methods of classifying back pain patients for their ability to predict outcome. QTF 3 or 4 predicted high levels of pain and disability at intake, but only centralisation / non-centralisation categories predicted pain and disability at discharge. Non-centralisation was stronger predictor of work status at 1 year than fear-avoidance. Predictive value of centralisation / non-centralisation stronger when followed through rehabilitation period, than just at intake.