Musculoskelet Sci Pract. 2018 (Dec); 38: 53–62 ~ FULL TEXT
Stephen May, Nils Runge, Alessandro Aina
Sheffield Hallam University,
BACKGROUND: Centralization and directional preference are common management and prognostic factors in spinal symptoms.
OBJECTIVE: To update the previous systematic review.
DESIGN: Systematic review to synthesis multiple aspects of centralization and directional preference.
METHOD: Contemporary search was made of multiple databases using relevant search terms. Abstracts and titles were filtered by two authors; relevant articles were independently reviewed by two authors for content, data extraction, and quality.
RESULTS: Forty-three additional relevant articles were found. The quality of the studies, using PEDro for randomized controlled trials, was moderate or high in six out of ten RCTs; moderate or high in six out of 12 cohort studies. Prevalence of centralization was 40%, the same as the previous review. Directional preference without Centralization was 26%; thus Centralization and directional preference combined was 66%, which was very similar to the previous review. Neither clinical response was recorded in about a third of patients. Centralization and directional preference were confirmed as key positive prognostic factors, certainly in patients with low back pain, but limited evidence for patients with neck pain. There was no evidence that these might be important treatment effect modifiers. One study evaluated reliability, and found generally poor levels, despite training.
CONCLUSIONS: Centralization and directional preference are worthwhile indicators of prognosis, and should be routinely examined for even in patients with chronic low back pain. But they do not occur in all patients with spinal problems, and there was no evidence that they were treatment effect modifiers.
From the FULL TEXT Article:
Centralization is defined as the abolition of distal and spinal pain in response to
repeated movements or sustained postures [McKenzie and May, 2003].
Directional preference is defined as the repeated movement that produces
centralization, or an abolition or decrease in symptoms, or an increase in
restricted range of movement [McKenzie and May, 2003]. Centralization and
directional preference are thus important clinical phenomena, as they occur in
response to therapeutic loading strategies and thus are clinically induced, and
also as they describe a lasting change. They have been commonly referenced
[May and Aina, 2012], in fact centralization is probably the most commonly
spoken of clinically induced symptom response in the literature. Furthermore
they are potentially useful prognostic and management indicators [May and
Aina, 2012]. For instance, the presence of centralization has been associated
with better pain, function, return to work, and non-surgical outcomes both
short and long-term [Long, 1995; Werneke and Hart, 2001; Skytte et al., 2005].
Whilst directional preference has been a useful indicator of appropriate
exercises, compared to other treatments in the short-term [Delitto et al., 1993;
Long et al., 2004, 2009]. There is the suggestion that centralization and
directional preference maybe helpful in determining the most effective
management strategy [Long et al., 2004]; thus being a so-called treatment
effect modifier [May and Aina, 2012].
Centralization has been the subject of several systematic reviews [Aina et al.,
2004; Chorti et al., 2009; May and Aina, 2012]. All these are reasonably dated;
even the most recent is over five years old now [May and Aina, 2012].
Although now somewhat dated that last review included 54 studies relevant to
centralization and eight studies relevant to directional preference. Since the
inclusion date of that last review a number of additional studies have been
published [for instance, Albert et al., 2011; Petersen et al., 2011; Edmond et
al., 2014; Apeldoorn et al., 2016]. Furthermore, a recent systematic review of
49 articles of relevant prognostic factors, concluded that there was
inconsistent evidence for the usefulness of most clinical findings, centralization
and non-organic signs being the exceptions [Hartvigsen et al. 2015]. Thus there
are very limited tools for the clinician to determine if a patient might recover
or not, and thus is an important area for further study.
In terms of updating systematic reviews, it has been suggested that the median
survival time of a systematic review is 5.5 years with 23% being outdated
within two years of publication [Shojania et al., 2007]. A recent consensus
statement and check list focussed on the question of whether, when and how
to update a previous systematic review [Garner et al., 2016]. It did not
stipulate how the results from the previous review(s) should be included;
whether to summarise the conclusions of the previous review only, or whether
to amalgamate the earlier individual studies with the new ones.
Thus it would appear to be appropriate to update the previous systematic
reviews. The aims of the present paper were to summarise previous findings
and to systematically review recent literature since June 2011 relating to all
aspects of centralization and directional preference.
data were synthesised from the previous review [May and
Study selection and reporting
Any full-text study that reported some aspect of centralization or directional
preference, in adults reporting low back or neck pain, with or without radiating
symptoms was included. PRISMA guidelines for reporting systematic reviews
were followed [Harms, 2009]. For data prior to the present search (June 2011
to December 2017]
Data sources and searches
A search was made of Medline, Cinahl and AMed from June 2011, the date of
the last search, until December 2017. The website www.mckenziemdt.org,
which lists references relevant to the McKenzie method, and includes a section
on centralization, was also used. The reference lists of all included articles
were also searched. Search terms used were as follows: centralization, OR
directional preference; OR phenomenon; AND spine pain, OR back pain, OR
neck pain, OR cervical, OR lumbar; used individually and in combination. Titles
and abstract were reviewed initially by one author (AA) to see if they might be
relevant and duplications removed. All potential articles were reviewed by two
authors (AA, SM) to determine their final relevance, with any disagreements
resolved by referral to the third author.
Data extraction and quality assessment
Data extraction was done independently and blinded to each other by two
authors (SM, NR); any disagreements were resolved by consensus. Likewise
quality assessment was done independently and blinded to each other by two
authors (SM, NR); any disagreements were resolved by consensus. In both
instances there was the option, not used, to refer to the third author if a
consensus was not reached.
There is not full agreement on the best methods to assess quality either in
randomized controlled trials (RCTs), or in cohort studies. There are many tools
to choose from for such tasks [Sanderson et al., 2007; Olivio et al., 2008], but
the different criteria share may commonalities. The Physiotherapy Evidence
Database (PEDro) scale was used to assess internal and external validity of the
RCTs. The PEDro scale is comprised of 11 criteria (only 10 of which are scored),
has been shown to be valid and reliable, and was used in a recent systematic
review, with a score of 7 or above considered high, 5 or 6 moderate, and 4 or
below poor quality [Young et al., 2018]. To assess the quality of cohort and
observation studies a tool for prognostic studies was used that had been
adopted from earlier work by Hayden et al. , and was used in a recent
systematic review [Hartvigsen et al., 2015]. The quality criteria consist of five
domains, with 15 items, which was scored as yes, OR no / unsure / not stated,
so that we had a dichotomous outcome; and led to an overall scoring of low,
moderate or high risk of bias; this decision being reached by consensus.
Besides the dichotomous outcome, other minor amendments were made to
the criteria for clarification: criterion 3: 'population of interest' was changed to
'source population'; criteria 4 and 5: completeness of follow-up was defined as
one-year and 85% of the inception cohort; criterion 14: we made to include the
ability 'to account for other prognostic factors', as in a multivariate analysis.
Assessing methodological quality in the other studies was not possible due to
the range of study designs that were retrieved.
Data synthesis / analysis
Studies were grouped according to study design and purpose, such as case
studies, effectiveness studies, prognostic, prevalence and cross-sectional
studies; and summarised and tabulated accordingly. A narrative summary was
used mostly, except regarding prevalence, for which a meta-analysis was
conducted, pooling individual studies for totals regarding Centralization,
Directional Preference, and no Directional Preference.
Study selection and characteristics of studies
2,86 titles and abstracts were initially screened, 101 full texts were reviewed
for eligibility, and 43 articles were finally included (see Figure 1). The 43
additional studies since the last review [May and Aina 2012] were: randomized
controlled trials or controlled trials (10), or their secondary analyses (4), cohort
studies (15), or case studies (10), and four cross-sectional studies (see Table 1
for full details). Seven papers related to patients with neck pain; the rest to
patients with low back pain. Most studies involved patients with non-specific
neck or back pain; but studies also included specific pain syndromes, including:
sciatica or cervical radiculopathy (3), discogenic pain (2), candidates for lumbar
disc surgery (2), potential red flags (1), and spinal stenosis (1). Although
centralization and DP were originally concepts related to the McKenzie
approach of MDT, other classification systems were also referred to, which all
involved some element of these clinical responses. Specifically these were the
Treatment-Based classification system [Heinz and Hegedus, 2008; Stanton et
al., 2011], the diagnosis-based clinical decision guide [Murphy and Hurwitz,
20111, 2], the Hall classification system [Gregg et al., 2014], a combined
McKenzie and patho-anatomical assessment [Flavell et al., 2016], and a
discogenic sub-group from a wider classification system [Surkitt et al., 2016].
These studies will be discussed relative to their study designs and purpose in
the results section (Table 1).
Case study designs
Surprisingly, given the length of time that the concepts of centralization and
directional preference have been extant, ten studies were of a case study
design or case series, which is generally considered the weakest of study
designs [Muir Gray, 1997]. One case study [Desai et al., 2012], and two cohort
studies [Van Helvoirt et al., 2014; 2016] described the effect of transforaminal
epidural steroid injections at reversing cervical or lumbar disc herniations with
radiculopathy from likely surgical candidates into potentially responding to
conservative interventions and demonstrating centralization or directional
preference. Other case studies demonstrated unusual presentations, such as
patients with spinal fractures, use of the treatment-based classification system,
spinal stenosis, disc displacement, a positive cranio-cervical flexion test, a
lateral component, or a patient with lower urinary tract symptoms. These
patients generally responded with centralization or directional preference,
reversed these pathologies, and showed improvement over time [Heintz and
Hegedus, 2008; Takasaki et al., 2010; Padmanabhan et al., 2011; Williams et
al., 2011; Ojha et al., 2013; Elenburg et al., 2016; Robinson, 2016; Takasaki and
Herbowy, 2016; Wu and Rosedale, 2018].
Effectiveness of exercises based on centralization or directional preference
Some of the RCTs and trials of MDT utilising centralization and directional
preference (DP) demonstrated significant improvements in Global Perceived
Effect and disability at two-three months, and one year [Petersen et al., 2011;
Albert and Manniche, 2012; Halliday et al., 2016; Franz et al., 2017; ], and
disability at one month [Garcia et al. 2013] compared to a range of controls.
But there were no significant differences in other trials [Bonnet et al., 2011;
Hosseinifar et al., 2013; Hagovska et al., 2014; Lopez-Diaz 2015; Moncelon
2015]. In a retrospective analysis centralization or DP produced significantly
better function, but not pain in patients with neck pain compared to noncentralizers
[Edmond et al., 2014]. Likewise in a small retrospective cohort of
patients with neck pain centralizers had better disability than non-centralizers
[Rose et al., 2016]. In RCTs disability, but not pain, was significantly better
short-term (1m) compared to back school [Garcia et al., 2013]; and also shortterm
(8w) in Global Perceived Effect, but not other outcomes, compared to
motor control exercises [Halliday et al., 2016]; whereas motor control exercises
had a better outcome short-term in another trial [Hosseinifar et al., 2013].
Centralization and directional preference as treatment effect modifiers
Because of the nature of all study designs it was not possible to determine if
either symptom response was a useful treatment effect modifier; no trial had
determined their presence at baseline, and then randomized patients to
management based on those concepts versus another management strategy.
Prognosis of centralization and directional preference and other prognostic factors
Centralization or peripheralization was not associated with any particular type
of disc lesion, but both improved more than the no pain response group
[Albert et al., 2012]. Other secondary analyses looked at factors that improved
outcomes. Older age was associated with better outcomes in a MDT group
compared to a back school group [Garcia et al., 2016]. Age, severity of leg pain,
pain distribution, nerve root involvement and centralization were not found to
be treatment effect modifiers favouring MDT over manipulation; however
nerve root involvement and peripheralization together did make the chance of
success greater especially for the MDT group [Petersen et al., 2015].
In the other cohort studies or secondary analysis of RCTs centralization or
directional preference compared to their absence or to guideline-based advice,
was associated with better pain and functional outcomes, but mostly only in
the short to medium-term [Werneke et al., 2011; Al-Obaidi et al., 2013;
Edmond et al., 2014; Gregg et al. 2014; Rose et al., 2016; Surkitt et al., 2016;
Werneke et al., 2018; Yarnbowicz et al. 2018]; but did not add to predictive
factors in one study [Werneke et al., 2016]. (See table 1 for details)
Prevalence of centralization and directional preference
The occurrence of centralization and directional preference could be calculated
from 21 studies (Table 2, which also shows the summary data from the
previous review). Out of 5135 spinal patients centralization occurred in 2028
(39.5%), and directional preference in 1321 (26%); neither centralization nor
directional preference was reported in 1716 (33.5%), and only 70 patients with
LBP were not counted in one of these groups. The total included 720 patients
with neck pain in who the following was reported: centralization, 56%,
directional preference, 18%, and no directional preference, 26%. Centralization
was found in 44% of those with chronic low back pain in the 11 papers that
reported specifically on chronic, as opposed to mixed symptom duration, of
low back pain.
Five studies reported on the plane of movement of the directional preference;
which was predominantly extension (about 80%) in four of them; generally
smaller proportions with lateral movements (mostly 10-14%); and less than
10% for flexion (Table 2 for prevalence from previous and this review).
Only one recent study considered the reliability of therapists to identify
centralization, directional preference, and other aspects of the MDT
assessment process [Werneke et al. 2014]. Reliability was generally weak, with
15 kappa values (k) all below 0.44 ; the level of training in MDT that the
therapists had undertaken did not make any difference. Three judgements
were poor (k < 0.20), 10 fair(k = 0.21-0.40), and two moderate (k = 0.41-0.60)
according to Altman . Another study looked at the reliability and
prevalence levels of the treatment-based classification system, which included
directional preference [Stanton et al., 2011]. One study looked at the effect of
centralization and directional preference on tests for spinal control [Apeldoorn
et al., 2016]. Two studies examined the prevalence levels of different
classification systems including MDT responses [Flavell et al., 2016; Mazzone et
Quality of the studies
Two authors (SM, NR) independently rated the quality of the 10 RCTs against
the PEDro quality scale, and of 12 cohort studies against the quality scale
[Hartvigsen et al., 2015]. There was 97% and 84% agreement between raters
(85 / 88 agreements; 126 / 150 agreements) respectively. Kappa values
between the two authors were respectively 0.92 and 0.78, indicating excellent
to good levels of reliability in the two judgements [Altman, 1991].
Rated against the PEDro quality scale it was concluded that four RCTs were
low, three RCTs were moderate and three RCTs were high quality (Table 3). It
was concluded that the quality of the 12 cohort studies were as follows: six
were low, one was moderate and five were high quality (Table 4). Regarding
the effect of quality, in the RCTs four of the six moderate and high quality trials
had positive outcomes for the MDT groups. In the cohort studies two of the six
moderate and high quality analyses had positive outcomes for the MDT
groups; but in the others a clear dichotomous comparison was not possible.
The present and previous review [May and Aina, 2012] bring together over 100
pieces of evidence about centralization and directional preference. This
probably make them the most referenced clinical responses exposed during
routine physical examination of specific and non-specific spinal patients. The
focuses in the previous review were on the definitions used for centralization,
the prevalence of centralization and directional preference, and their role as
prognostic indicators. There was limited evidence for them as treatment effect
modifiers, variable evidence for the reliability of assessment of centralization,
evidence for extension movement as the most common directional preference,
and some evidence of a link between centralization and discogenic problems.
Some of the focuses in the present review were similar, but study designs were
different between the two reviews. The previous review contained 36 studies
(N = 7,113 patients) from which prevalence data could be extracted, whereas
this review contained 21 studies (N = 5,135 patients). Between reviews the
prevalence of centralization was very similar, about 40%, whereas there was a
marked decline in reporting of directional preference, from 70% down to 26%.
The previous review only reported directional preference in five studies,
compared to 13 in the present review; so it might be suggested that the
present estimate is more robust. In the present review there was also a much
clearer identification of the absence of centralization or directional preference,
with a lack of either symptom response occurring in about a third of all
patients. This has important clinical implications; the point of centralization
and directional preference is that they direct patient management. If these
symptom responses are missing in about a third of patients, then patient
management is seriously compromised. However centralization and directional
preference between them would appear to account for a sizeable proportion
(60-70%) of patients.
In the previous review symptom duration was a definite determinant of
centralization; with 77% prevalence in acute patients (N = 317), and about 40%
in patients with chronic and mixed duration symptoms (4305). In the present
review very few patients with acute / sub-acute LBP were included (250); all
the other studies reported mixed or chronic duration of symptoms. So it is not
possible to make any present judgement about the role of symptom duration
in the occurrence of these phenomena.
In the previous review centralization was generally associated with a good
prognosis, and non-centralization with a poor prognosis, whereas directional
preference had limited evidence. However, the latter had some evidence, and
centralization limited evidence as a treatment effect modifier. In the present
review there was some evidence that centralization and directional preference
were positive prognostic indicators in eight out of nine studies, although only
short to medium-term. Due to lack of appropriate study designs it was not
possible to comment on either as treatment effect modifiers. There was
conflicting evidence from recent RCTs that MDT-management based on these
concepts lead to more successful outcomes than control groups; with five out
of ten trials either way.
In the previous review reliability of the MDT assessment process had been
evaluated by six studies, and found to be very variable, mostly from moderate
to good [Altman, 1991]. In this review only one high quality study [Werneke et
al., 2014] had evaluated reliability of several components of the MDT
assessment process, including centralization and directional preference, and
overwhelmingly found it fair at best. So, despite training, it appears that
therapists are not reliable at classifying sub-groups that are purported to
In this review as in previous literature the movement of directional preference
and centralization has been pretty consistent. Most patients appear to respond
to extension forces, and far fewer proportions respond to flexion or lateral
There are some differences from the previous review. There were 30 cohort
studies or secondary reviews of such, 16 RCTs or secondary analysis of such,
seven criterion validity studies, six reliability, two surveys and one mini case
series - a total of 62 studies [May and Aina, 2012]. In the present review there
were 43 studies, of which there were 15 cohort studies, 14 RCTs or related
studies, four cross-sectional studies, and ten case studies. It seems very
surprising that at this distance from the foundation and development of the
McKenzie Method that virtually a quarter of the recent published articles are
simply case studies, which have so limited a role in the development of
evidence-based physiotherapy. Furthermore it is also disturbing that reliability
amongst practitioners is still so untrustworthy. If even trained therapists
cannot agree, then this is a major problem, as MDT is a practitioner-led
classification system that leads to management strategies.
In the previous review there were several studies that appeared to link
centralization with discogenic pain, although heterogeneous definitions of
Centralization produced different results, very high levels of specificity were
clearly linked to non-Centralization [Laslett et al. 2005]. In the present review
only one study attempted to explore this link, and found that type of disc
lesions, such as, whether contained or extruded, were not associated with
centralization or non-centralization responses, as might have been expected
[Albert et al., 2012]. However this study explored abnormal morphology,
whereas the earlier study used provocation discography [Laslett et al. 2005], a
much more direct way to establish a link between pathology and symptoms. In
addition there was one case series and two cohort studies that evaluated the
ability of transforaminal steroid injections to make disc herniations with
radiculopathy amenable to directional preference management [Desai et al.,
2012; van Helvoirt et al., 2014; 2016].
These studies that investigated the McKenzie intervention using centralization
or directional preference add further to the literature about the inconclusive
benefit of MDT. There is some indication for their therapeutic value, but no
further evidence that they might be treatment effect modifiers. However there
is still reasonably good evidence that both are a positive prognostic sign. In
other words the recognition of these clinical responses at baseline is a good
indicator of outcome, perhaps regardless of the applied management strategy.
Additionally in this review we evaluated the quality of studies that were
included; but unfortunately this provided limited further information,
suggesting possibly that MDT had some added value, but not with any clarity.
This review has synthesised literature from 62 previous studies, but also
evaluated 43 additional studies. The importance of centralization and
directional preference as prognostic factors is probably overwhelming;
whether they indicate a particular management pathway is not clear.
Centralization and directional preference are still very important clinical
indicators to monitor during the taking of patients' history and physical
examination. Although about a third of patients may demonstrate neither
clinical response, they are still common and important prognostic indicators.
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Young JL, Rhon DI, Cleland JA, Snodgrass SJ.
The influence of exercise dosing on outcomes in patients with knee disorders: a systematic review.
J Orth Sports Phys Ther 2018;48:146-161.
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