MDT and Centralization Frequently Misunderstood and Underappreciated Brian McClenahan PT, MS, OCS,...

MDT and CentralizationMDT and CentralizationFrequently Misunderstood and Frequently Misunderstood and

UnderappreciatedUnderappreciated

Brian McClenahan PT, MS, OCS, FAAOMPT, Dip.MDTBrian McClenahan PT, MS, OCS, FAAOMPT, Dip.MDTBob Robinson PT, DPT, MS, FAAOMPT, Dip.MDTBob Robinson PT, DPT, MS, FAAOMPT, Dip.MDT

Outline

• Centralization as defined in literature• Distinguishing Centralization vs. Directional

Preference• MDT presence in 2012 guidelines• Key literature to support Centralization

– Reliability– Prevalence– Prognosis/Outcomes

• Synopsis

Defining Centralization

• “Abolition Centralization: The most distal pain was abolished and pain was recorded more proximally on the second drawing than on the first.”

• “Reductive Centralization: The pain was located at the same distal location but with reduced intensity.”

• “Unstable Centralization: The pain was reduced or abolished during the repeated movement testing or positioning but after resuming a weight-bearing position for 1 minute, the pain intensity level returned to the pre-testing intensity.”

Albert, H.; Hauge, E.; Manniche, C. “Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?” Eur Spine J 2011,21(4):630-636.


• “Centralization is defined in the classification system of occurring when a movement or position results in abolishment of pain or paraesthesia or causes migration of symptoms from an area more distal or lateral in the buttocks and/or lower extremity to a location more proximal or closure to midline of the lumbar spine.”

• “Must have lower extremity pain.”

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


• “Centralization is liberally defined as a movement, mobilization or manipulation ‘technique’ targeted to pain radiating or referring from the spine, which when applied, abolishes or reduces the pain distally to proximally in a controlled predictable pattern.”

Cook, C. “Orthopedic Manual Therapy: An Evidenced Based Approach, 2nd Edition”. pp268; Article cited in text: Aina, A.; May, S.; Clare, H. “The Centralization phenomenon of spinal symptoms: A Systematic Review”. Manual Therapy 2004; 9:134-143.

Centralization Is Frequently Misunderstood

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

Has Evolved:

• 1981 Lumbar Spine text• “I would define this phenomenon as the situation in

which pain arising from the spine and felt laterally from the midline or distally is reduced and transferred to a more central or near midline position when certain movements are performed.”

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


Has Evolved:

• 2003 Lumbar Spine text• “In response to therapeutic loading strategies, pain is

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

McKenzie, R.; May S. “The Lumbar Spine: Mechanical Diagnosis and Therapy”. Spinal publications 2003; pp167.


Has Evolved:

• 2008 MDT research• Centralization is characterized by spinal pain and

referred symptoms that are progressively abolished in a distal to proximal direction in response to therapeutic loading strategies.

• Very objective measures included to further remove clinician bias.

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

Centralization: Operational Definition

• Directed by precise application of movement and positioning

• Proximal change in pain location only• Remains better – lasting effect during treatment• Midline pain abolishes

Centralization: Standardized Measurement

• Overlay TemplateDonelson, et al. Spine 1991

Werneke, et al. Spine 1999

Delitto, et al. JOSPT 2012

Centralizationvs.

Directional Preference


Centralization

Derangement

Improves mechanicsRepeated

movements

Commonly with extensionAcute or

chronicLess with lateral

or flexSustained

Symptomatic Responses

• The changes in the patient symptoms that are elicited and recorded with the application of assessment procedures, treatment procedures or in response to functional activities and positions.

Mechanical Responses

• The measurable changes that occur in movement loss, dural tension, neurologic function, tolerance to functional activities and positions or change in tested physical abilities.

Centralization

• Describes the phenomenon by which limb pain emanating from the spine is progressively abolished in a distal to proximal direction in response to therapeutic loading strategies, with each progressive abolition being retained over time (lasting change).

• Symptomatic Response

Peripheralization

• Describes the phenomenon by which pain emanating from the spine spreads distally into or further into the limb as a result of loading strategies (lasting change).

• Symptomatic Response


• Phenomenon of preference for postures/movements that decrease, abolish or centralize symptoms and often improve a limitation of movement (lasting change).

• Symptomatic and/or Mechanical Response

Pain Response Subgroups

PAIN RESPONSE

Non-CEN

2. DP/Non-CEN 3. No-DP/non-CEN

1. CEN/DP

Linking Centralization’s Importance to APTA’s

Perspective on LBP Care

Important?

• Mechanical Diagnosis and Therapy (MDT)– Discovered by Robin McKenzie in the 1950s and published in

1981– Key finding of assessment when elicited

• Clinical Practice Guidelines (CPG) – Centralization and Directional Preference exercises 'considered'

Important Interventions• Level 1 evidence• Grade A recommendation

• Treatment Based Classification (TBC)– Step 1 of Algorithm

Clinical Practice Guidelines

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

CPG

• Risk factors• Clinical course• Diagnosis/Classification• Differential diagnosis• Examination outcome measures• Examination impairment/functional • Interventions

Concepts of MDT throughout CPG

• A3. Centralization/Directional Preference• A3. Patient education and counseling• A12. Argument against pathoanatomical• A12. Mechanical assessment vs. imaging• A12. Clinical course: rate of re-occurrence


• A13. Importance of classification– ICF vs. MDT

• A17. Biopsychosocial (Werneke 2006)• A17-18. Red flags


• Establishing existence of Centralization key to the assessment.

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


• A34-36. (Interventions)– Centralization and Directional Preference exercises and

procedures

• A36. (Interventions)– First mention of repeated movements

Clinical Practice Guidelines

• Treatment-based classification

• Primary influence on CPG

Key Research to Discuss Centralization

Reliability

Kilby, J.; Stignant, M.; Robert, A. “The reliability of back pain assessment by physiotherapists using a McKenzie Algorithm”. Physiotherapy 1990;76(9):579-583.

•Video observation (Question: Do any repeated movements decrease, abolish or centralize pain•Examination of inter-examiner agreement•Two examiners trained in C and D (Not credentialed)•Kappa value of centralization identification = 0.51%

Kilpilkoski, et al. “Inter-examiner reliability of low back pain assessment using the McKenzie Method”. Spine 2002;27(8).

•Agreement on Centralization Phenomenon 95%; Kappa = 0.7•Inter-examiner agreement “high” using those credentialed in MDT

Reliability

Fritz, J., et al. “Inter-rater reliability of Centralization judgments of the Centralization Phenomenon and status change during movement testing in patients with low back pain”. Arch Phys Med Rehab 2000;81: 57-61.

•High reliability between examiners in determining presence or absence of Centralization pain response.

Reliability

• Low back pain practice guidelines

• P24: Judgments of Centralization during movement testing

• Kappa 0.7 to 0.9 for novice and experienced physical therapists

Reliability

ReliabilityStandardized Operational Definition

Standardized Measurement

Werneke, M.; Hart, D.L.; Cook, D. “A descriptive study of the centralization phenomenon: A prospective analysis”. Spine 1999;24:676-83

•Body diagrams/measurement template•Almost perfect•Kappa = 0.96 - 1.0


• Directed by precise application of movement and positioning

• Proximal change in pain location only• Remains better – lasting effect during treatment• Midline pain abolishes

Centralization: Standardized Measurement

• Overlay TemplateDonelson, et al. Spine 1991

Werneke, et al. Spine 1999

Delitto, et al. JOSPT 2012

Prevalence

Reliability demonstrated to be high, yet different prevalence rates?•Werneke, M.; Hart, D.L. “Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomical pain patterns”. Spine 2003; 28(2), 161-166.•George, S.; Bialosky, J; Donald, D. “The Centralization Phenomenon and Fear-Avoidance Beliefs as Prognostic Factors for Acute Low Back Pain: A Preliminary Investigation Involving Patients Classified for Specific Exercise”. JOSPT 2005; 35(9), 580-588.

Method of Assessing for Centralization:Influences Prevalence

Werneke, M.W.; Hart, D.; Oliver, D.; McGill, T.; Grigsby, D.; Ward, J.; Weinberg, J.; Oswald, W.; Cutrone, G. “Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation and stabilization clinical prediction rules”. J Man Manip Ther 2010;18:197-210.

•Data collected on 628 patients from 8 different clinics by therapists with training in MDT•Centralization (43%), Non-Centralization (39%) and not classified (18%)•Positive to Manipulation (13%) and Stabilization (7%) clinical prediction rules

• Prevalence rates of Centralization in:– Patients (+) for Manipulation CPR = 0.68– Patients (+) for Stabilization CPR = 0.8

• Prevalence rates for Derangement (DP/CEN) in:– Patients (+) for Manipulation CPR = 0.8– Patients (+) for Stabilization CPR = 0.83

Werneke, M.W.; Hart, D.; Oliver, D.; McGill, T.; Grigsby D.; Ward, J.; Weinberg, J.; Oswald W.; Cutrone, G. “Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation

and stabilization clinical prediction rules”. J Man Manip Ther 2010; 18:197-210.

I Thought Manipulation and Stabilization Prevalence Rates Were Higher?

Brennan, G.P.; Fritz, J.M.; Hunter, S.J.; Thackeray A.; Delitto, A.; Erhard, R.E. “Identifying subgroups of patients with acute/subacute ‘non-specific’ low back pain: results of a randomized clinical trial”. Spine 2006;31:623-31

• 48% fit Manipulation CPR and 24% fit Stabilization CPR• % of 123 subjects who consented from 268 eligible from 1,052

potential patients referred for treatment to all participating clinics; military facilities

• Recalculation based on all potential patients• 6% Manipulation CPR and 3% Stabilization CPR

Brennan Study vs. Werneke Study

• MDT training unknown

• Military facility

• 123 subjects of a possible 1,052

• Eliminated ~75% of participants

• Randomized controlled trial

• Not generalizable

• MDT-certified clinicians

• Diverse medical facilities

• 692 subjects of a possible 725

• No exclusions; 95% participation

• Practice-based evidence

• Very generalizable

How Did They Define Centralization When Eliciting High Prevalence?

• Using the most strict definitions in available literature• Items used to judge Centralization in Werneke/FOTO

studies:– Change in pain location only– Pain diagram and template to judge for patients with pain to

gluteal fold– Pain diagram and overlay template (Delitto, et al. LBP

Guidelines JOSPT 2012)– Track change in pain location over time (Werneke, et al. JOSPT

2008; Werneke, et al. Spine 1999; Werneke, et al. PTJ 2004)

Method to Assess for Directional Preference

• Recognized as distinct from Centralization• Items used to judge Directional Preference in

Werneke/FOTO studies:– Centralization– Pain intensity (2/10 or more change in pain report from most

distal pain location)– Increase trunk AROM (single inclinometer)– Patient’s report: improved ability to bend forward/back and

perform task– Before/After RMT: LE Break Test; Aberrant Trunk Motion; Neural

Tension Sign

What Does This Say about Prevalence and Testing Methods?

Centralization can be elicited with a very high prevalence in a very general population even when differentiated from Directional Preference and using strict definitions that will “decrease” rates compared to studies that use more general definitions ... if ...

Proper Mechanical Testing to

Exhaust Loading Strategies Is Utilized.

Prognosis / Outcomes

CentralizationPredicts Pain at 6 Months

• George, S.Z.; Bialosky, J.E.; Donald, D.A. “The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise”. J Orthop Sports Phys Ther 2005; 35:580-588.

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

CentralizationGreater Prognostic Indicator of Chronic Disability then

Psychosocial Variables

• Werneke, M.; Hart, D.L. “Centralization phenomenon as a prognostic factor for chronic low back pain and disability”. Spine 2001; Apr 1;26(7):758-65.

• Edmond S.L.; Werneke, M.W.; Hart, D.L. “Association between Centralization, depression, somatiziation and disability among patients with non-specific low back pain”. J Orthop Sports Phys Ther 2010; 40:801-810.

Optimal Treatment Follows Centralization

Long, A.; Donelson, R.; Fung, T. “Does it matter which exercise? A RCT of exercise for LBP”. Spine, 2004. 29 (23): p 2593-2602.

• 230 subjects (acute, subacute, chronic; pain location and neurological status were all very diverse); ~half LBP only; 34% full leg pain (sciatica); and half of those mild neurological loss

• Very generalizable

Does It Matter Which Exercise? A RCT of Exercise for LBP

• Direction-specific group (matched care)• Opposite direction (unmatched care)• Evidence-based care (unmatched care)

– Assurance, advice, education to keep active, general non-direction exercise program

• Direction Specific Rx 2-5 times greater improvement in all 7 outcomes compared to either unmatched group– Low Back Pain– Leg Pain– Physical Function– Medication Use– Self Report of Degree of Recovery– Activity Interference– Depression


• An intervention that directly influences the pain-generating disorder improves an individual’s:– Functional abilities– Medication intake – Depression


• Dir Spec Rx 95% reported better or fully recovered at 2 weeks vs. 42% of evidence-based group and 23% of opp dir group

• A third of patients treated in unmatched exercise groups withdrew from study due to being either worse or no better

• 15% of patients who were strongly predicted to do well actually worsened by the care recommended by every LBP clinical guideline vs. 0% in matched

• Is guideline-based treatment safe?

• 95% improvement agreed with 95% recovery reported in 1990 cohort study (Donelson)


• Demonstrates how forms of exercise can produce a rapid and significant alleviation of pain

• Demonstrates that it does matter what exercise is prescribed for those with a DP who centralize

• Demonstrates that guideline-based care is inferior to exercise matching the DP

• Only 23% of consecutive LBP patients presenting for care were excluded

• Large Central/DP subgroup includes at least 50% of those with sciatica and neurological loss (eliminated from TBC)


Prognosis / Outcomes?

Great!

... but ...

Only if you elicit it.

Synopsis

• ADTO MODEL serves to support Centralization as:– Reliable– Valid – Associated with strong outcomes– Guides treatment

• Centralization does not equal Directional Preference

Synopsis

• MDT principles are found throughout the CPG• MDT is the first step of the TBC• MDT assessment to search for Centralization allows one

to safely assess/treat individuals that are frequently ineligible for many RCTs

• CPG, TBC and MDT agree Centralization is important ... so make sure you do not fail to elicit.

• Standardized definitions and measurement of Centralization coupled with proper testing procedures means optimal elicitation of results and ultimately optimal outcomes for patients.

Synopsis

• APTA to agree upon a common definition for Centralization.

• Trained MDT Clinicians represented in the ICF recommendations in regards to eliciting Centralization and Direction Preference.

• Based on evidence and optimal results per literature. Use Centralization definition established by Robin McKenzie and refined by the work of Mark Werneke for further studies and discussion.

• Future studies recommended that explore TBC with more exhaustive RMT in order to find ideal responders to stabilization/other categories.

Recommendations

Special Thanks

• Mark Werneke, MS, PT, Dip.MDT• Ron Donelson, MD• Past and present members of Team FOTO• The many individuals involved in testing MDT

principles to establish strength within an ADTO Model

Questions

This webinar will be available at:www.mckenzieinstituteusa.org

(Resource Center)

Connect with The McKenzie Institute/McKenzieInstituteUSA@McKenzieUSA

MDT and Centralization Frequently Misunderstood and Underappreciated Brian McClenahan PT, MS, OCS,...

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