Manual Therapy 17 (2012) 497e506

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Manual Therapy
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Review article

Centralization and directional preference: A systematic review

Stephen May a, *, Alessandro Aina b
a
b

Faculty of Health and Wellbeing, Collegiate Cresent Campus, Shefeld Hallam University, Shefeld S10 2BP, UK
Studio di Riabilitazione MDTC, Milano, Italy

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 13 February 2012
Received in revised form
25 April 2012
Accepted 1 May 2012

Centralization is a symptom response to repeated movements that can be used to classify patients into
sub-groups, determine appropriate management strategies, and prognosis. The aim of this study was to
systematically review the literature relating to centralization and directional preference, and specically
report on prevalence, prognostic validity, reliability, loading strategies, and diagnostic implications.
Search was conducted to June 2011; multiple study designs were considered. 62 studies were included in
the review; 54 related to centralization and 8 to directional preference. The prevalence of centralization
was 44.4% (range 11%e89%) in 4745 patients with back and neck pain in 29 studies; it was more
prevalent in acute (74%) than sub-acute or chronic (42%) symptoms. The prevalence of directional
preference was 70% (range 60%e78%) in 2368 patients with back or neck pain in 5 studies. Twenty-one of
23 studies supported the prognostic validity of centralization, including 3 high quality studies and 4 of
moderate quality; whereas 2 moderate quality studies showed evidence that did not support the
prognostic validity of centralization. Data on the prognostic validity of directional preference was limited
to one study. Centralization and directional preference appear to be useful treatment effect modiers in 7
out of 8 studies. Levels of reliability were very variable (kappa 0.15e0.9) in 5 studies. Findings of
centralization or directional preference at baseline would appear to be useful indicators of
management strategies and prognosis, and therefore warrant further investigation.
2012 Elsevier Ltd. All rights reserved.

Keywords:
Centralization
Directional preference
McKenzie assessment
Back pain

1. Introduction
The treatment of back and neck pain remains controversial.
Recent research has highlighted the value of reliable examination
ndings that can be used to predict response to different treatments (Long et al., 2004; Childs et al., 2004; Hicks et al., 2005; Long
et al., 2008). Clinically induced symptom responses have been used
to determine treatment; with spinal loads being used to induce
lasting changes in the site or intensity of symptoms to determine
prognosis and management. Such responses are intrinsic to
a number of spinal classication or management systems (Fritz
et al., 2003; McKenzie and May, 2003; Petersen et al., 2003;
Murphy and Hurwitz, 2007; Tuttle, 2009). Probably the most
researched clinically induced symptom response is centralization,
which has been dened as the abolition of distal and spinal pain in
response to repeated movements or sustained postures (McKenzie
and May, 2003). Centralization has been the subject of 2 systematic
reviews within the last decade, both of which were positive about
its usefulness as a prognostic indicator (Aina et al., 2004; Chorti

* Corresponding author. Tel.: 44 0114 225 2370.

E-mail address: s.may@shu.ac.uk (S. May).
1356-689X/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2012.05.003

et al., 2009). The rst of these reviews is no longer contemporary,

and the second was on the prognostic value of symptom responses
in general; only half of the 18 studies dealt specically with
centralization.
An associated, but separate phenomenon is that of directional
preference, which has been dened as the repeated movement
which induces centralization or abolition of symptoms, but also
a decrease in symptom severity, and/or a positive mechanical
response, such as an increase in range of movement (McKenzie and
May, 2003). Movements in the opposite direction may cause these
symptoms and signs to worsen. A nding of directional preference
at baseline has been shown to predict a signicantly better
response to directional preference exercises than non-specic
exercises (Long et al., 2004, 2008). A number of classication
systems use this phenomenon, though not always termed as such,
as a part of their assessment and management process (Fritz et al.,
2003; McKenzie and May, 2003; Petersen et al., 2003; Van Dillen
et al., 2003; Murphy and Hurwitz, 2007; Tuttle, 2009; Hall et al.,
2009).
Thus given the apparent usefulness of the centralization
phenomenon in predicting outcomes, and the value of directional
preference in directing management strategy, it seemed appropriate to conduct a new systematic review. The aim of the present

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S. May, A. Aina / Manual Therapy 17 (2012) 497e506

study was to systematically review the literature relating to all

aspects of centralization and directional preference.

partially or fully meeting all criteria; moderate evidence partially

fullling most criteria; weaker evidence when studies failed to full
multiple criteria. Any disagreements were resolved with discussion. Assessing methodological quality in the other studies or
conducting a meta-analysis was not possible due to the range of
study designs that were retrieved.

2. Methods
2.1. Study selection
Any full-text study that reported some aspect of centralization
or directional preference, in adults reporting spinal pain (low back
or neck pain) with or without radiating symptoms. As we knew
different types of study design were to be included we restricted
qualitative evaluation of study methods to the prognostic studies,
for which clear cut quality criteria exist (Hudak et al., 1996). To the
authors knowledge the rst paper on centralization was published
in 1990.

3. Results
3.1. Study selection and characteristics of studies
1416 titles and abstracts were screened, 131 full articles were
reviewed, and 62 articles were nally included (see Fig. 1). The
majority of studies related to centralization; only 8 related to
directional preference (Delitto et al., 1993; Erhard et al., 1994;
Snook et al., 1998; Fritz et al., 2003; Long et al., 2004; May, 2006;
Hefford, 2008; Long et al., 2008; Werneke et al., 2011). The majority
involved patients with back pain, only 5 involved patients with
neck pain (Tuttle, 2005; Tuttle et al., 2006; Dionne et al., 2006; Piva
et al., 2006; Fritz and Brennan, 2007), or a mixed population
(Werneke et al., 1999; May, 2006; May et al., 2008; Hefford, 2008;
Werneke et al., 2008). Nine studies involved patients with disc
herniation or sciatica (Mitchell et al., 2001; Lisi, 2001; Broetz et al.,
2003; Skytte et al., 2005; Abdulwahab and Beatti, 2006; Rapala
et al., 2006; Broetz et al., 2008; Murphy et al., 2009b; Broetz
et al., 2010) or pregnancy-related back pain (Murphy et al.,
2009a), the rest being non-specic acute to chronic spine pain
with or without referred symptoms (see Table 1 for study details).
There were 23 cohort studies, and 7 secondary analysis of cohort
studies. The cohort studies looked at the prognostic validity of
centralization, at associations between centralization and other
variables, or were simply observational studies. There were 9
randomised controlled trials (RCT) and 7 secondary analyses of
RCTs. There were 7 criterion validity studies against discography, or
MRI investigations. There were 6 reliability studies, 2 surveys, and
one mini case series.

2.2. Data sources and searches

A search was made of Medline, Cinahl and AMed from 1990 to
June 2011. We also used the website www.mckenziemdt.org which
has a repository of references, which includes a section on
centralization. The reference lists of all included articles were also
searched. Search terms were as follows: centralization, directional
preference, spine pain, back pain, neck pain; which were used
individually and then in combinations. Titles and abstracts were
reviewed by one reviewer (SM) to see if they appeared relevant; all
potential articles were reviewed by both reviewers to determine
their nal relevance, with any disagreements resolved by
discussion.
2.3. Data extraction and quality assessment
Data was independently extracted and the prognostic studies
were scored against existing quality criteria (Hudak et al., 1996). If
studies came near to these set criteria half a point was given. Hudak
et al. (1996) also provided levels of evidence: strong evidence

Records identified through

database searching
(N = 1442)

Additional records through hand

searching reference list and
mckenziemdt.org website (N = 24)

Duplicates removed (N = 50)

Records screened (N = 1416)

Full-text articles assessed for

eligibility (N = 131)

Studies included in qualitative

synthesis (N = 62)
Fig. 1. Flow diagram of selection process of studies.

Records excluded
(N = 1285 )

Full-text articles excluded:

52 symptom response was
not to do with centralization
or DP; 9 related to
extremity problems; 4 were
technical papers; 4 related
to central nervous system
changes

Table 1
Description of studies into centralization (N 62).
Author

Purpose/Study design

Participants

Outcomes

Results

Abdulwahab and Beatti, 2006

28 patients with DH & 28 controls

H-reex, pain severity & distribution

Broetz et al., 2003

Evaluate effect of prone lying & IFT/

Observational
Evaluate effect of MDT/Observational

50 patients with DH & Cen in 5 sessions

Broetz et al., 2008

Evaluate effect of MDT/Observational

11 patients with DH

Broetz et al., 2010

Evaluate long-term effect of MDT/

Observational
Cen in response to extension repeated
movements used as inclusion criteria for
RCT
Relation between Cen & pain during
movement (PDM)/Association
Relation between Cen & ROM/Association

40/50 from 2003 study, 6 of rest had disc

surgery
48 patients with LBP with referral below
buttocks randomised to 1) extension or
2) strengthening
33 patients with LBP

Pain, neurology & satisfaction at 6 weeks/1

year
Pain, neurology & pain distribution at 50
days
Pain, neurology & satisfaction at1/5 years

No change in H-reex change in severity &

distribution (p < 0.001)
Pain in only 29%/11%, satisfaction 81%/93%
at 6 weeks/1 year
10/11 centralized

42 with LBP with referred symptoms

ROM inclinometer at up to 3 weeks

Christiansen et al., 2009

Relation between Cen & psychological

factors/Association

331 sick-listed patients with LBP /

referral

Correlation between Cen/non-Cen and

psychological factors in cross-section
analysis

Christiansen et al., 2010

Association between Cen & RTW/Prognosis

Return to work at 1 year

Cleland et al., 2006

Cen used as outcome measure in RCT

Delitto et al., 1993

DP in response to Ext as criteria for trial/RCT

Dionne et al., 2006

Reliability study of McKenzie assessment

Donelson et al., 1990

Prevalence & prognostic value of Cen

351 sick-listed patients with LBP /

referral
30 patients with positive slump test &
negative
SLR randomised to mobs, exercise or mobs,
exercise & slump stretching
24 patients with ALBP randomised to Ext or
Flexion
54 therapists viewed videos of 20 patients
with neck pain
87 patients acute to chronic LBP

Donelson et al., 1991

Loading strategy to induce Cen/Association

145 patients acute to chronic LBP

Donelson et al., 1997

Criterion validity against positive

discography/Validity

63 patients with CLBP

Edmond et al., 2010

2nd analysis of previous cohort study to

compare predictive value on Cen &
depression/somatisation/Association
DP in response to Ext for trial/RCT

231 patients with LBP

Function, pain & work status at discharge &

6 & 12 months
Oswestry at 5 days

Interrater reliability of judgements about

Cen
Comparison of CBT, including DP, versus
guideline-based treatment/RCT

27 patients randomised to manipulation or

Ext
40 physical therapists & 40 student PTs
viewed videotape of 12 exams
78 patients with acute LBP randomised to 1)
CBT or 2) guidelines

Fritz et al., 2006

Interrater reliability of classication system

that included Cen

60 patients with stable LBP between 2

exams

Fritz and Brennan, 2007

TBC system in patients with neck pain (NP)/

Observational
2ndary analysis from previous trial of Cen &
FAB to predict outcomes/Prognosis

274 patients with NP classied according to

TBC groups
28 patients classied with specic exercise

Browder et al., 2007

Bybee et al., 2005

Bybee et al., 2009

Fritz et al., 2000

Fritz et al., 2003

George et al., 2005

Relationship between Cen & PDM

Oswestry, pain, Cen

1) V 2) function better all time points

(p 0.01, 0.004 & 0.005); pain better 1
week (p 0.007); Cen 1& 4 weeks
PDM associated with Cen p 0.038
Cen group 33; more extension ROM
p < 0.001
Cen group 30%. Regression analysis
conrmed non-Cen group correlated with
mental distress and depression (p 0.013
and 0.044)
Cen 30%; periph 8%; no response 62%
No differences in RTW, pain or disability
Slump group better Oswestry (p 0.001),
pain (p 0.001), & Cen (p < 0.01)

Oswestry at 5 days

DP 61%; Ext responded better

% agreement, kappa, p-value for accuracy

DP 70% agreement, (p < 0.05),

kappa 0.46
Cen 87%; Cen & excellent/good outcome
(p < 0.001); non-Cen & fair/poor outcome
(p < 0.001)
Cen 47%; 40% extension; 7% exion

Outcome based on complete recovery/

improvement, RTW & satisfaction/pain
relief only/no change
Which sagittal plane movement induced
Cen
Correlation between Cen status &
discography ndings

Reliability of judgements about Cen status

during repeated movements
Pain, function, SF-36 depression, fearavoidance, work status at 4 weeks, 6
months, 1 year
Reliability of judgements about Cen status
during repeated exion, extension &
sustained extension
Prevalence rates, reliability, and value of
matching treatment to group
Disability and pain at 6 months

Cen 49%; Cen/Periph positive discography

(p < 0.007); Cen 21/23 competent AF
(p < 0.001)
Presence of Cen confounds association
between depression & somatisation on
chronic pain & disability
DP 55%; better response to manipulation

S. May, A. Aina / Manual Therapy 17 (2012) 497e506

Erhard et al., 1994

Cen, pain & function at 1, 4 weeks & 6

months

Pain 11%/23%, satisfaction 93%/82%

Overall kappa 0.79, PTs 0.82,

students 0.76
At 4 weeks 1 > 2 Oswestry p 0.02, SF-36
p 0.03, work status p 0.02. 1 year NSD
Kappa 0.46, 0.15 & 0.28

Cen group largest 35%; received matched

treatment better pain & function outcomes
No Cen/high FAB work predicted disability
(p 0.003/0.027); no Cen predicted pain
(p 0.031)
499

(continued on next page)

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Table 1 (continued )
Purpose/Study design

Participants

Outcomes

Results

Hefford, 2008

Survey of 34 therapists reporting 10

patients classication & DP/Observational
Prospective study prevalence & prognosis

321 patients with LBP (187), NP (111), &

thoracic pain (23)
126 patients acute to chronic LBP

MDT classication & DP

Reliability study into a McKenzie

algorithm
Reliability study of MDT assessment

% agreement & kappa values

78% derangement; DP extension (180),

exion (16), lateral (54)
Cen 73%; better RTW (p 0.038); low
Waddell better (p 0.006)
Cen 90% agreement, kappa 0.51

Kappa values

Cen 0.7; DP 0.9

Pain & disability 3, 6 months & 1 year

MDT & OMT some signicant differences V

advice especially at 6 months; MDT V OMT
leg pain at 3 months (p 0.011), function
(p 0.028)
After treatment LBP & disability better in
Cen (p 0.033 & 0.001); 6 months LBP
better in Cen (p 0.041)
Sensitivity 40%, specicity 94%,
PLR 6.9; values were less in presence of
severe disability or distress
Any 2 of Cen, CLBP, loss of extension,
vulnerability in early exion 37%, 100%,
6.7, 0.73
Absence of Cen 100%, 14%, 1.2, 0.0

Karas et al., 1997

Kilby et al., 1990

Return to work

Kilpikoski et al., 2009

2ndary analysis of previous trial in Cen

group

41 patients with LBP were examined by 2

physiotherapists
39 patients with LBP examined by 2
physiotherapists
119 patients with LBP & Cen randomised to
MDT, OMT, advice

Kilpikoski et al., 2010

2ndary analysis of previous trial between

Cen/non-Cen groups

119 patients with LBP Cen; 15 non-Cen

randomised to MDT, OMT, advice

Pain & disability 3, 6 months & 1 year

Laslett et al., 2005

Cen as predictor of tive provocation

discography
& inuence of disability & distress/Validity
Using Cen & other variables to see which
best predict positive discography/Validity

69 patients with CLBP who tolerated full

exam & discography

Sensitivity, specicity & positive likelihood

ratios (PLR) for Cen

117 patients with CLBP who received

discography

Sensitivity, specicity & positive & negative

likelihood ratios for variables

120 patients with CLBP who received ZJ

blocks
3 patients with LBP & sciatica treated with
manual therapy
223 patients with CLBP

Sensitivity, specicity & positive & negative

likelihood ratios for
Patient reported outcomes & surgery

Long, 1995

Cen & other variables as predictors of

response to lumbar ZJ blocks/Validity
3 case studies: 2 with Cen at baseline, one
non-Cen
Prognostic value of Cen in CLBP

Long et al., 2004

RCT of patients with DP at baseline

230 of 312 patients with LBP randomised to

DP, opposite to DP, or general exercises

Pain, function, tablets, depression, selfrated improvement at 2 weeks

Long et al., 2008

Case series of non-responders to non-DP

changing to DP exercises

Pain, disability, medication, depression

interference after further 2 weeks

Long et al., 2009

2ndary analysis of RCT comparing

prognostic value of
Cen against other baseline measures
Survey of 57 therapists on 578 patients/
Observational
2ndary analysis of RCT to determine factors
associated with good outcome in McKenzie
arm
Prospective RCT comparing distraction to
control group

96 patients with LBP who were no better

after 2 weeks of non-DP exercise & consent
to more treatment
241 patients with LBP with complete data:
84 met good outcome criteria
578 patients with spine pain

MDT classication

315 patients with LBP & NP randomised to

1) McKenzie, 2) Solution-Finding Approach

Identifying characteristics of patients who

improved (50% reduction in disability) in
McKenzie
Pain intensity & location & SLR pre & post
test

Kilpikoski et al., 2002

Laslett et al., 2006a

Laslett et al., 2006b

Lisi, 2001

May, 2006
May et al., 2008

Mitchell et al., 2001

Murphy et al., 2009a

30 patients with LBP & neurological signs

Prospective cohort study using a decision

rule that included Cen
Prospective cohort study using a decision
rule that included Cen

78 patients with pregnancy-related LBP

Niemisto et al., 2004

Cen one of numerous predictive variables

considered in 2nd analysis of RCT

Piva et al., 2006

Reliability study of passive & active

movements & affect

204 patients with CLBP randomised to:

SMT, exercise & consultation or
consultation only
30 subjects with NP

Murphy et al., 2009b

49 patients with DH with mean 14 months

follow-up

Pain, Oswestry, return to work

17 baseline prognostic variables were

entered in regression analysis

Changes in pain & disability, mean 11

months follow-up
Changes in pain & disability

Pain & disability at 1 year

Symptom response: no effect, increase,

decrease, centralization, peripheralization

2 Cen patients resolved with treatment; 1

non-Cen failed & came to surgery
Cen better pain (p < 0.05), Oswestry (NS),
return to work (p 0.034)
DP better: LBP (p < 0.001), leg pain
(p < 0.003), function (p < 0.01), depression
(p 0.009), self-rated improvement
(p < 0.005)
All outcomes much better (p < 0.001)

Leg bothersomeness & treatment group

effect (p < 0.001) only in multivariate
analysis
78% derangement
Multiple logistic analysis Cen p 0.08;
LBP p 0.04; chronic p < 0.001
Treatment group less pain p 0.001; more
centralization p 0.006; better SLR
p 0.005
% with Cen not given
Cen 61%, periph 8%, NE 31%; Cen
associated with better disability after
treatment/long-term (p 0.068/0.022)
Non-Cen, pain & distress predicted poor
outcome in SMT group (model 69%)
Kappa 0.25, 0.28, 0.65, 0.69, 0.74, 0.75,
0.76, 0.87 for different movements

S. May, A. Aina / Manual Therapy 17 (2012) 497e506

Author

Correlation between Cen and MRI ndings/

Association

98 patients with DH

Schmidt et al., 2008

Skikic and Suad, 2003

Prognosis between Cen/non-lasting Cen/

Per/NE
Prospective study of use of MDT/Prognosis

793 patients with neck or LBP & radiating

symptoms
43 patients with LBP

Skytte et al., 2005

Prognostic value of Cen

60 patients with sciatica

Snook et al., 1998

Control of early morning exion activities/

RCT

Sufka et al., 1998

Prognostic value of Cen

85 patients with chronic LBP baseline

monitor for 6 months, randomised to
treatment or control for 6 months, then
control got treatment
36 patients with acute to chronic LBP

Tuttle, 2005

29 patients with NP who received manual

therapy

Likelihood & odds ratios for predictive value

Werneke et al., 1999

Cen, pain and ROM single session correlated

with between
session changes/Prognosis
Cen, pain and ROM single session correlated
overall change/Prognosis
Prognostic value of Cen, partial Cen

29 patients with NP who received manual

therapy
289 patients with acute LBP or NP

Correlation between change in measures &

nal outcome
Pain, function, N visits at end of treatment

Werneke and Hart, 2001

Prognostic value of Cen

223 patients with LBP

1-year follow-up previous cohort

multivariate analysis of 22 variables

Werneke and Hart, 2003

2ndary analysis of cohort to determine Cen

at initial
& multiple visits
2ndary analysis of cohort to determine
most useful
prognostic factor (Cen or leg pain)
2ndary analysis of cohort to determine if
Cen correlated
with behavioural signs/Association
Cohort study of Cen and correlation with
age and chronicity;
and prognosis/Association
2ndary analysis of previous cohort to
determine association
between Cen & fear-avoidance beliefs
Cohort to determine prevalence rate of Cen
status & criteria
for CPR/Observational
Cohort to determine prevalence of Cen & DP
and prognostic validity

287 patients with LBP

Change in Cen classication over time

171 patients with LBP with/without referral

& workers compensation

Predicting pain, disability & work status at

intake & 1 year

177 patients with LBP & workers

compensation

Non-organic signs, pain behaviours, fear of

activity & somatisation

418 patients with LBP or NP (76% LBP, 53%

chronic, mean age 58)

Pain, disability, N of visits

238 patients with LBP

Pain & disability

628 patients with LBP

Classication

584 consecutive patients with LBP; 481

with intake & discharge data

Classications & pain and functional status

at discharge

RCT of loading strategy associated with Cen

& peripheralization
To identify clinical exam ndings associated
with IVD, ZJ, SIJ
identied by injection/Validity

207 patients with LBP randomised to

lordosis or kyphosis when sitting over 24 h
81 patients with CLBP

% Cen & Per

Tuttle et al., 2006

Werneke and Hart, 2004

Werneke and Hart, 2005

Werneke et al., 2008

Werneke et al., 2009

Werneke et al., 2010

Werneke et al., 2011

Williams et al., 1991

Young et al., 2003

Status of DH: 1 DH but AF intact;

2 extrusion/sequestration; 3 no
pressure on nerve root
Outcomes at 1-year back & leg pain,
disability, RTW
Pain severity, location & ROM after
treatment
Pain, disability & surgery up to 1 year

Pain, interference with activity, medication

Oswestry, SFS in 14 days

Variables associated with positive injection

1 49; 2 46; 3 3. 90% Cen protrusions

& extrusions; 35% Per Sequestrations & SS
All groups improved. NS between groups.
18% Cen
61.5% Cen (40% acute, 57.5% sub-acute,
80% chronic). SD in pain & ROM (p < 0.01)
42% Cen. SD leg pain/disability at 2
months (p < 0.001); disability at 1 year
(p 0.029); surgery (p 0.01)
Treatment group decrease pain intensity
p < 0.01, days in pain p < 0.05, & medication
p < 0.05; SD for control with treatment
69% Cen; better SFS scores (p 0.015),
Oswestry (NS)
Odds ratios: Cen 9.2, pain 4.5, limited ex/
ext 8.0, limited rotation 21.3
Changes in measures only predicted change
in that measure
31% Cen; 46% partial Cen; Cen fewer
visits (p < 0.001); Cen & partial Cen Better
pain & function (p < 0.001)
Only Cen status predicted pain, RTW,
function, health care use p < 0.004, & leg
pain at baseline sick leave p 0.004
45% Cen initial visit, 97% remained Cen;
55% non-Cen initial visit, 60% Cen at
multiple visits
Both predicted at initial visit; only Cen at
discharge & 1 year p < 0.001
46% Cen; non-Cen OR for non-organic
signs, pain behaviours, somatisation, fear of
work 9, 13, 2, 3
16% Cen (acute > chronic,
younger > older). Non-Cen associated with
worse outcomes & more visits
18% Cen; Cen present fear beliefs did not
impact on outcomes. Non-Cen fear beliefs
should be addressed
43% Cen, 39% non-Cen,
18% NC 18%; 67% Der 13% MCPR,
7% SCPR
60% DP; 41% Cen; rates decreased with
age & chronicity. Cen, not DP predicted
function; Cen & DP predicted pain
Lordosis: 56% Cen, 6% Per; kyphosis:
10% Cen, 24% Per
IVD pain: Cen p 0.025, pain rising from
sitting p 0.017, sensitivity 47%,
specicity 100%

S. May, A. Aina / Manual Therapy 17 (2012) 497e506

Rapala et al., 2006

AF annulus brosus; ALBP acute low back pain; CBT cognitive behavioural therapy; Cen centralization; CLBP chronic low back pain; CPR clinical prediction rules; DH disc herniation; DP directional preference;
ext extension; FAB fear-avoidance beliefs; IFT interferential therapy; IVD intervertebral disc; LBP low back pain; MCPR manipulation clinical prediction rule; MDT mechanical diagnosis and therapy;
MRI magnetic resonance imaging; NE no effect; NP neck pain; Per peripheralization; PDM pain during movement; OMT orthopaedic manual therapy; OR odds ratio; RCt randomised controlled trial;
ROM range of movement; RTW return to work; SD signicant difference; SFS performance assessment and capacity testing spinal function sort; SCPR stabilisation clinical prediction rule; SIJ sacro-iliac joint;
SLR straight leg raise; SS spinal stenosis; TBC treatment-based classication; ZJ zygapophyseal joint.
501

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S. May, A. Aina / Manual Therapy 17 (2012) 497e506

Some studies offered little additional material, and so have not

been included in further discussion though these are listed in
Table 1. These included a mini case series (Lisi, 2001), a pilot study
of slump stretching that used centralization as one of its outcome
measures (Cleland et al., 2006), and a study that used centralization
as part of a treatment algorithm, but did not give prevalence gures
(Murphy et al., 2009a). One study looked at the effect of prone lying
and the addition of interferential therapy on patients with lumbar
radiculopathy, but the study design could not distinguish between
the effect of prone lying and the addition of the modality
(Abdulwahab and Beatti, 2006). One study involving patients with
neck pain referred to centralization in the abstract and methods,
but did not specically report on this in the results (Piva et al.,
2006). In addition three studies did not clearly use repeated
movements in determining centralization, which is a key component of inducing this symptom response, so these results have been
discounted (Cleland et al., 2006; Piva et al., 2006; Fritz and Brennan,
2007). The latter reported use of active range of movement
(retraction exercises) or use of traction (at least 50% of sessions).
3.2. Denitions of centralization
Most studies were consistent in the operational denition they
used for centralization, which was the abolition of the most distal
symptoms in response to repeated movements or sustained
posture. If back pain only was present then this was centralized and
abolished. This is mostly in line with McKenzies original description. Fritz et al. (2000) included a change in neurological signs and
symptoms as well; and some studies included a reduction in
intensity of symptoms in the denition (Delitto et al., 1993; Erhard
et al., 1994; Karas et al., 1997; Laslett et al., 2006a). Werneke et al.
(1999) applied a stricter denition in which centralization
occurred only in the clinic, progressed sequentially on each clinic
visit, until complete abolition of all symptoms. They also described
a partial centralization group, in which changes occurred, but less
completely and not on each visit. An overlay body template was
used to measure the occurrence of centralization (Werneke et al.,
1999). Tuttle (2005; Tuttle et al., 2006) monitored centralization,
but in response to manual therapy rather than repeated movements, but we have included this study in the results.
3.3. Prevalence of centralization and directional preference

Table 2
Prevalence e centralization.
Reference

Duration

Symptoms

Broetz et al., 2003

Broetz et al., 2008
Browder et al., 2007
Bybee et al., 2009
Christiansen et al.,
2009, 2010
Delitto et al., 1993
Donelson et al., 1990
Donelson et al., 1991
Donelson et al., 1997
Erhard et al., 1994
George et al., 2005
Karas et al., 1997
Kilpikoski et al., 2002
Kilpikoski et al., 2010
Laslett et al., 2005
Laslett et al., 2006a
Long, 1995
Mitchell et al., 2001
Murphy et al., 2009a
Rapala et al., 2006
Schmidt et al., 2008
Skikic and Suad, 2003
Skytte et al., 2005
Sufka et al., 1998
Werneke et al., 1999
Werneke et al., 2008
Werneke et al., 2010
Werneke et al., 2011
Young et al., 2003

Mixed
Mixed
Mixed
Not stated
Mixed

Disc herniation
Disc herniation
Distal to buttock
Referred symptoms
37% nerve root

50/86 (58%)
8/11 (73%)
63/300 (21%)
33/42(79%)
100/331 (30%)

Sub-acute
Mixed
Mixed
Chronic
Sub-acute
Acute
Mixed
Chronic
Mixed
Chronic
Chronic
Chronic
Mixed
Mixed
Not stated
Mixed
Mixed
Sub-acute
Mixed
Acute
Mixed
Mixed
Mixed
Chronic

Back pain
Referred symptoms
Referred symptoms
Back pain /
Back pain
Back pain
Back pain /
Back pain /
Back pain /
Back pain
Back pain
Back pain
Back pain & sciatica
Disc herniation
Disc herniation
Back & referred pain
Back Pain
Sciatica
Back pain
Back/neck pain
Back/neck pain
Back pain
Back pain
LBP

24/39(61.5%)
76/87 (87%)
68/145 (47%)
31/63 (49%)
13/24 (55%)
14/28 (50%)
92/126 (73%)
34/39 (87%)
119/134 (89%)
22/69 (32%)
26/92 (28%)
105/223 (47%)
13/15 (87%)
30/49 (61%)
55/98 (56%)
307a/793 (39%)
21/34 (61.5%)
25/60 (42%)
25/36 (69%)
222b/289 (77%)
57/342 (17%)
270/628 (43%)
197/481 (41%)
9/81 (11%)

Mixed/not stated duration

Acutec
Sub-acute
Chronic
Neck pain
TOTAL

1584/3738
236/317
62/123
227/567
62/168
2109/4745

Prevalence e directional preference/derangement classication

Hefford, 2008
Mixed
Back/neck/thoracic
250/340 Der
Long et al., 2004
Mixed
Back pain /
230/312 DP
May, 2006
Mixed
Spine pain
473/607 Der
Werneke et al., 2010 Mixed
Back pain
421/628 Der
Werneke et al., 2011 Mixed
Back pain
287/481 DP
TOTAL
1661/2368
a
b
c

The occurrence of centralization as a proportion of the total

study population could be calculated in 29 studies (Table 2). Among
4745 patients centralization occurred in 2109 (44.4%); ranging from
11% to 89%. This included 168 patients with neck pain of whom 62
(36.9%) demonstrated centralization.
Centralization occurred in 74%, 50%, and 40% of 317 acute, 123
sub-acute, and 567 chronic spine problems. In 3738 patients with
mixed duration pain or not stated duration centralization occurred
in 1584 (42%). Among 2368 patients in 5 studies (Table 2) directional preference or derangement was reported by 1661 (70%); with
a much smaller range 60%e78%. The studies that included
mechanical classication of derangement (May, 2006; Hefford,
2008) were included in this summation, as directional preference
is one of the main characteristics of derangement (McKenzie & May,
2003).
Centralization has been documented as being more common in
those with acute, rather than chronic problems; and in those who
are younger, rather than older (Werneke et al., 2008, 2011). For
instance in acute and chronic back pain 54% and 35%, and in those
aged 18e44 years 61% compared to 15% in those aged over 65 years
(Werneke et al., 2011). Classication with centralization (43%) or
derangement (67%) was far more common than patients who met

Centralization

(42.4%)
(76.8%)
(50.4%)
(40%)
(36.9%)
(44.4%)

(78%)
(74%)
(78%)
(67%)
(60%)
(70%)

Centralization and non-lasting centralization.

Centralization and partial reduction groups.
Includes patients with neck pain.

the manipulation (13%) or stabilisation (7%) clinical prediction rules

(Werneke et al., 2010).
3.4. Prognosis of centralization
Twenty-three studies considered the prognostic value of
centralization; 4 of these (Werneke and Hart, 2003, 2004; Tuttle
et al., 2006; Broetz et al., 2010) were long-term follow-ups or
secondary analyses of earlier studies so are not included in the
quality review table (Table 3). Two other studies were also
secondary analyses (George et al., 2005; May et al., 2008), but the
original studies were not included in this review. The mean quality
score was 3.4. Three studies showed strong evidence for the prognostic validity of centralization (Long, 1995; Werneke and Hart,
2001; Skytte et al., 2005); 2 studies showed moderate evidence
(Werneke et al., 1999; Tuttle, 2005; May et al., 2008), and one
showed moderate evidence for non-centralization as a negative
prognostic factor (Niemisto et al., 2004). Two studies showed
moderate evidence unsupportive of centralization (Schmidt et al.,

S. May, A. Aina / Manual Therapy 17 (2012) 497e506

Table 3
Method score for centralization and prognosis.
Reference

Total

Broetz et al., 2003

Christiansen et al., 2010
Donelson et al., 1990
George et al., 2005
Karas et al., 1997
Kilpikoski et al., 2010
Long, 1995
Long et al., 2009
May et al., 2008
Murphy et al., 2009b
Niemisto et al., 2004
Schmidt et al., 2008
Skikic and Suad, 2003
Skytte et al., 2005
Sufka et al., 1998
Tuttle, 2005
Werneke et al., 1999
Werneke and Hart, 2001
Werneke et al., 2011
Total
Mean

0
1
1
0
0
1
0.5
1
1
1
1
1
1
1
0.5
1
1
1
1
15

0
0
0
1
0
0
1
0
0
0
0
0
0
1
0
0
1
1
0
5

1
1
0
0
0
1
1
0
1
1
1
1
0
1
0
0
0
1
0
10

1
0
0
0
0.5
0
0.5
0
0
0
1
0
1
1
0.5
1
0.5
0.5
0
7.5

0
1
1
1
1
0
1
0
1
1
0
1
0
1
0
1
1
1
1
13

0
1
0
1
1
1
1
1
1
0
1
1
0
1
0.5
1
0
1
1
13.5

2
4
2
3
2.5
3
5
2
4
3
4
4
2
6
1.5
4
3.5
5.5
3
3.4

A. Was the sample representative of the underlying population? B. Were they at

a well-dened point in the natural history? C. Was the follow-up of sufcient
lengthd1 year? D. Was there follow-up of >85% of the sample? E. Was there
blinded assessment of outcome? F. Were other prognostic factors equal or
accounted for in analysis?

2008; Christiansen et al., 2010). The remaining 15 studies, representing weaker evidence, supported the prognostic validity of
centralization.
Non-centralization was generally a negative predictor of
outcome and also more likely to be associated with psychosocial
issues. Specically non-centralization had odds ratio of 9, 13, 2, and
3 for non-organic signs, pain behaviours, somatisation, and fear of
work respectively (Werneke and Hart, 2005). When centralization
was present fear beliefs did not need to be addressed, whereas if
non-centralization was present fear beliefs should be addressed
(Werneke et al., 2009). The presence of centralization also
confounded the association between depression and somatisation
and had an impact on chronic pain and disability (Edmond et al.,
2010). Centralization was a more signicant predictor than fearavoidance (George et al., 2005), bothersomeness and depression
(Long et al., 2008), work satisfaction, Waddell signs, pain behaviours, depression, somatisation, and fear-avoidance (Werneke et al.,
1999), and referral of symptoms (Werneke and Hart, 2004).
Patients with sciatica who centralized at baseline had signicant
improvements in pain and disability both short and long-term
(Broetz et al., 2003; Skytte et al., 2005; Murphy et al., 2009b;
Broetz et al., 2010); and were signicantly less likely to undergo
surgery in the following year e odds ratio for surgery in the noncentralization group was 6.2 (Skytte et al., 2005). Centralization
detected over several treatment sessions was more likely to predict
pain and function outcomes than centralization at the rst session
(Werneke and Hart, 2003). Relative precision to discriminate
changes in pain intensity and function were respectively 5.5 and 6.6
(Werneke and Hart, 2003).
Patients with neck pain who demonstrated centralization in one
session were more likely to show overall improvement across
sessions (Tuttle, 2005). Odds ratio for improvement were 9.2,
compared to 21.3 for a change in rotation movement, and 4.5 for
a change in pain intensity. However a re-analysis found that
centralization in one session, and other changes, only predicted
overall change in that particular outcome, and not in other
impairments (Tuttle et al., 2006).
Two studies showed a lack of association between centralization
and outcomes, which included return to work, back and leg pain,

503

disability, and back surgery (Schmidt et al., 2008; Christiansen

et al., 2010). Higher Waddell scores were a better predictor of
return to work in another study (Karas et al., 1997). Back pain,
rather than neck pain, and chronic rather than acute symptoms
were stronger predictors of improvement in the secondary analysis
of a RCT (moderate evidence) (May et al., 2008).
3.5. Prognosis of directional preference
Whereas directional preference accompanied by centralization
predicted a good outcome in terms of pain and function, directional
preference by itself was not a useful predictor of function (Werneke
et al., 2011).
3.6. Using centralization as a treatment effect modier
In 2 studies patients with centralization responded signicantly
better to treatment when randomised to appropriate centralizing
exercises than other treatments (Browder et al., 2007; Kilpikoski
et al., 2009). However differences were not dramatically better
than treatment with orthopaedic manual therapy (Kilpikoski et al.,
2009).
3.7. Using directional preference as a treatment effect modier
In 3 studies patients with a directional preference responded
signicantly better to treatment when randomised to appropriate
directional preference exercises than other treatments (Delitto
et al., 1993; Long et al., 2004, 2008), but not in another study
(Erhard et al., 1994). These were all trials with very short follow-up.
In a trial of classication-based treatment, which included directional preference exercises, versus guideline-based treatment,
there were signicantly better outcomes in the former group at 4
weeks (Fritz et al., 2003). Snook et al. (1998) found that restricting
early morning exion, which would apply with a directional preference for extension, resulted in signicant differences in pain
severity and days in pain and levels of medication compared to
a control group. When the control group then received the same
intervention they also had signicant improvements in these
outcomes.
3.8. Reliability of assessment for centralization
For judgements about centralization in the assessment of
patients with neck pain kappa was 0.46 (Dionne et al., 2006). For
judgements about centralization in patients with back pain kappa
values were 0.79 (Fritz et al., 2000); 0.15 during exion, 0.28 during
extension, 0.46 during sustained extension (Fritz et al., 2006); 0.51
(Kilby et al., 1990); 0.7 (Kilpikoski et al., 2002); and judgements
about DP had a kappa value of 0.9 (Kilpikoski et al., 2002). Studies
used video recordings of patient assessment, and direct observation
by 2 therapists to collect data on agreement.
3.9. Variables associated with centralization
A number of variables were associated with the presence of
centralization, or non-centralization. Centralization has been
shown to have a signicant association with pain during movement, more improvement in extension range of movement over
time, and confound the association between depression, somatisation and fear-avoidance beliefs and chronic disability (Bybee
et al., 2005, 2009; Werneke et al., 2009; Edmond et al., 2010).
Non-centralization has been shown to have a signicant association with mental distress and depression (Christiansen et al., 2009),

504

S. May, A. Aina / Manual Therapy 17 (2012) 497e506

and non-organic signs, pain behaviours, somatisation and fear of

work (Werneke and Hart, 2005).
3.10. Loading strategies associated with centralization
Only a few studies reported the loading strategy that was
associated with centralization or directional preference. Just using
sagittal plane repeated movements Donelson et al. (1991) found
that 40% centralized with extension, and 7% centralized with
exion. Hefford (2008) listed treatment principles for derangement
syndromes and described loading strategies associated with
directional preference. These were as follows for lumbar, cervical,
and thoracic spine: extension: 70%, 72%, 85%; exion: 6%, 9%, 0%;
and lateral movement: 24%, 19%, 15% respectively. Of 30 of 49
patients with back pain who centralized this was with extension
77%, exion 3%, and with lateral movements 20% (Murphy et al.,
2009b). Williams et al. (1991) found different sitting postures
assumed over a 24-h period associated with very different
symptom responses. Of those encouraged to main a lordotic sitting
posture 56% experienced centralization and 4% experienced
peripheralization; whereas those encouraged to maintain
a kyphotic sitting posture 10% experienced centralization and 24%
experienced peripheralization.
3.11. Diagnostic implications of centralization
A number of studies have linked centralization to discogenic
problems, or non-centralization to non-discogenic problems
(Donelson et al., 1997; Young et al., 2003; Laslett et al., 2005, 2006a,
2006b). These studies compared response to discography to
symptomatic responses. Donelson et al. (1997) found a sensitivity
and specicity of 92% and 52% to discogenic pain (Bogduk and Lord,
1997); whereas others found a sensitivity and specicity of 40% and
94% (Laslett et al., 2005). However diagnostic implications are
affected by the presence of disability and distress, especially
regarding specicity, which was 80% and 89% in those with severe
distress, but 100% in those with moderate, minimal or no distress
(Laslett et al., 2005). Centralization is not associated at all with
positive responses to lumbar zygapophyseal joint blocks (Laslett
et al., 2006b), but is associated with discogenic pain and pain
when rising from sitting (Young et al., 2003).
There was a signicant association between a positive discography and the occurrence of centralization (p < 0.007) or peripheralization (<0.004), and centralization was signicantly associated
with an intact annulus (p < 0.001), whereas peripheralization was
not (Donelson et al., 1997). If there were no symptom changes there
was highly unlikely to be a positive discography (p < 0.001).
However in studies comparing MRI or CT ndings to pain response,
centralization commonly occurred in patients with extrusions and
sequestrations (Broetz et al., 2003; Rapala et al., 2006; Broetz et al.,
2008).
4. Discussion
This is the largest review to date on centralization, and the rst
to attempt to review data on directional preference. The literature
on centralization has expanded considerably since the rst review
(Aina et al., 2004). This current review found that the occurrence of
centralization was less than reported previously, but still represented a substantial proportion of the neck and back pain populations that were included. There was an indication that
centralization was more common in acute spine problems and
patients under 44-years old. Centralization was associated with
a good prognosis in 21 of 23 studies; and non-centralization was
associated with a poor prognosis, but also greater psychosocial

issues. Centralization appeared to be a positive prognostic indicator

for non-specic low back pain and for sciatica; whereas there was
less evidence for centralization as a treatment effect modier.
Directional preference had limited evidence as a prognostic indicator, but there was some evidence for it as a treatment effect
modier.
Although some good levels of reliability were reported for
centralization and directional preference, some studies also reported poor levels of reliability between clinicians. This degree of
uncertainty about whether clinicians can agree or not about the
existence of centralization is clearly a limitation to centralization.
More training in the McKenzie approach appeared to be associated
with better levels of reliability. Centralization and directional
preference appear to be most commonly associated with extension
repeated movements in all spinal areas (70e80%), a minority with
lateral movements (about 20%), and a minority with exion
movements (<10%).
There appears to be some relationship between centralization
and discogenic pathology, but it is somewhat unclear at this time
what this relationship is. Differing levels of sensitivity and specicity have been recorded, and also that disability and distress can
be a confounding factor. Exactly what type of discogenic pathology
this might represent is also unclear; whereas one study has clearly
linked the response to an intact annular wall; other studies have
suggested that centralization can occur with extrusions and
sequestrations.
There have been two previous systematic reviews that considered centralization (Aina et al., 2004; Chorti et al., 2009). The rst of
these considered various aspects of centralization as this review
has done; it included 14 studies and made positive conclusions
about the high prevalence, reliability of assessment, and prognostic
validity of centralization (Aina et al., 2004). Chorti et al. (2009)
considered the prognostic value of symptom responses in
general, and concluded that only changes in pain location/centralization and/or intensity with repeated spinal movements could be
considered as useful responses to inform management. This current
review does not seriously challenge these conclusions, but it does
draw attention to the fact that the prevalence rate, the reliability,
and the prognostic validity may be less than previously reported or
contradictory between studies.
This review also included data about directional preference,
which no previous review has done. There was some evidence that
it may be a possible treatment effect modier, but possibly less
important as a prognostic indicator. However data is very limited
on the differential prognostic validity of these 2 variables and the
prognostic validity of centralization is much more clearly
established.
One of the strengths of the review is that our search strategy
allowed us to access substantially more data than any previous
review. However a weakness has to be noted that we did not gain
this comprehensiveness from the initial search, but depended
substantially on searches of the reference lists of included articles
and the mckenziemdt.org website. We did not need to restrict our
search to English language only. Because of the heterogeneity of
study design it was clearly inappropriate to attempt to summarise
all data, and also not possible to make any overall summary of study
quality. In deed as we make clear in the results, and is clear from
Table 1 there is a large degree of heterogeneity across studies. The
sample sizes range from very small to substantial, there is variety in
the outcomes, and variety in study designs. This could be deemed
a major aw, and certainly would in most standard systematic
reviews. However we have attempted to summarise all the literature on this topic, rather than address a single research question,
such as what is the prognostic value on centralization? This review
did however relate the prognostic validity of centralization to

S. May, A. Aina / Manual Therapy 17 (2012) 497e506

a denite quality review criteria, and found that high and weak
quality studies provided strong evidence in favour of the prognostic
validity of centralization; whereas moderate quality evidence was
contradictory.
Although the evidence does not appear to be as overwhelming
as in the rst review of centralization (Aina et al., 2004); the
majority of the evidence is still supportive of this clinical symptom
response as being common, mostly reliably assessed, and generally
associated with a good prognosis. Thus the clinical implications still
remain about the importance of assessing with the use of repeated
movements for the presence of directional preference or
centralization.
Clearly more research is needed, especially given the contradictory or limited nature of some of the evidence reviewed. There is
the suggestion, especially from more recent literature that the
prognostic value of centralization declines with increasing chronicity of symptoms, and with older patients, and also that
centralization is a more useful prognostic indicator than directional
preference. There is limited evidence relating to the topic in
patients with neck pain, and there is an urgent need for a long-term
cohort study to determine the prognostic value of these
phenomena in these patients. More evidence is needed about their
role as treatment effect modiers.
5. Conclusion
Centralization and directional preference appear to be well
accepted concepts commonly encountered by clinicians examining
patients with back and neck pain, of a specic or non-specic
nature, and have been reported in at least 62 studies, most of
which deal with centralization. This review attempted to summarise the data from these studies. Centralization is generally, but not
universally associated with a good prognosis, but this effect
declines in certain sub-groups. The evidence for directional preference and prognosis is more limited, though it is better for
directional preference as a treatment effect modier. Studies into
the reliability of determination of centralization and directional
preference have been contradictory. The review also summarised
evidence about the relevant loading strategies, and the diagnostic
implication of centralization.
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