Don’t Make Promises That You Can’t Keep
Predicting responders vs. non-responders for any given treatment can be difficult; and estimating recovery is even more burdensome. While there is no foolproof way of answering either question, there is a concept to help you make more informed treatment decisions for LBP. Many clinicians grade patient improvement by decreases in pain scores and mechanical sensitivity. However, some clinicians use Centralization of symptoms as more effective a metric of success.
Watch Dr. Steele describe the process of centralization and learn how to incorporate this concept into your patient education.
Recovery odds improve when you can influence symptoms in-office
Directional preference - repeated movement that produces centralization, or abolition or decrease in symptoms, or an increase in range of motion.
Centralization - the rapid abolition or retreat of distal symptoms in response to repeated end-range movements or sustained postures.
Peripheralization - the rapid increase or spread of distal symptoms in response to repeated end-range movements or sustained postures.
The purpose of an orthopedic exam is to reproduce a patient’s chief complaint and identify the tissue source of pain. Evidence-based chiropractors can also use positions or repetitive movements to define a patient’s “directional preference”. Patients who present with pain that can be centralized during exam demonstrate better outcomes than those with un-modifiable symptoms. Constant and un-changing symptoms are commonly the result of chemical mediated pain or significant structural change.
Centralization occurs during directional preference testing. Centralization and directional preference are important clinical phenomena, as they occur in response to therapeutic loading strategies. Both directional preference and centralization are the primary variable assessed through McKenzie classification. Although the principles are immediately applicable, the evaluation and treatment aspects of McKenzie directional therapy require proper training and certification. You can check out MDT class options here.
Directional preference and centralization phenomena should become primary predictors for your treatment success.
There is reasonably good evidence that directional preference and centralization phenomena are favorable prognosticators of patient success to treatment. Patients that experience pain that centralizes or a reduction in directional preference are likely improving with the care they are receiving. In other words, the recognition of clinical responses at baseline is a good indicator of outcome, perhaps regardless of the applied management strategy.
“Centralization and directional preference are useful indicators of prognosis and should be routinely evaluated in patients with chronic low back pain.” (1)
Clinical Utility
Let's consider a LBP patient with radicular pain and paresthesia extending to the posterior calf with these findings:
This patient experiences an increase in lower back and leg pain with ipsilateral SLR at 45 degrees.
Milgram’s Test reproduces sharp pain in the lower back.
Upon sustained prone extension (Sphinx Test), leg pain eases in severity and centralizes to the buttock.
Assuming no red flags, this minimal exam and history infer the patient is suffering from a disc lesion with nerve root impingement that will very likely be helped by repetitive extension exercises.
Most patients want to feel better, and they want to feel better NOW. Unfortunately, with a combination of a structural lesion and radicular symptoms, it is unlikely to resolve the pain in one visit. Instead, it becomes essential to diagnose patients and lay out a plan and prognosis to instill truthful confidence. Patients must understand that pain shooting into the calf is worse than localized back pain. Centralization of pain back toward the spine is a vital clinical sign - inferring improvement. The same goes for directional preference. In the beginning, pain centralizes with sustained prone extension. During your initial trial of care, this patient should experience less pain and centralization of symptoms without the need to extend their spine. In fact, during the last phase of care, they should even be able to go into flexion without exacerbating leg symptoms.
Centralization defines the retreat of symptoms toward the spine. Educating your patients on how this principle predicts successful treatment will ease concerns. Predicting future symptoms accurately instills trust. Patient compliance will improve when everyone is on the same page. Be sure to review ChiroUp.com for the most up-to-date information on the treatment and management of radiculopathy. If you want to start prescribing the best exercises and advice for radiculopathy and 95 other conditions, give ChiroUp.com a try today.
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May S et al. Centralization and directional preference: An updated systematic review with synthesis of previous evidence. Musculoskelet Sci Pract. 2018 Dec;38:53-62. doi: 10.1016/j.msksp.2018.09.006. Epub 2018 Sep 18.
