Do you want to have back surgery? A therapist highly trained in treating back pain can tell you the odds that you will end up on a surgical table. This is a great study for patients that are debating surgical intervention. If you are already scheduled for surgery, ask your physician for a second opinion from a specially trained PT. What do you have to lose? Not all PT’s are trained the same and if your PT didn’t do a thorough assessment, go see a PT certified or Diplomaed in Mechanical Diagnosis and Therapy. I would be able to give you an honest assessment of whether therapy will be able to help you. Seek out someone trained in MDT.
MORAL OF THE STORY:
With patients that present to the clinic sub-acutely, with complaints of lower extremity pain referred from the spine, a MDT evaluation in order to assess for CP would be beneficial to predict non-response to conservative care. Patients that do not demonstrate the CP are greater than six times more likely to require surgery than patients that demonstrate CP.
A Critical Appraisal of Centralization and its Ability to Predict Surgical Outcome
P: For patients with back and leg pain
I: can patients that do not demonstrate the centralization phenomenon (CP)
C: as compared to patients that demonstrate the CP
O: be utilized to predict a surgical outcome
Reviewer:
Vincent Gutierrez, PT, MPT, cert. MDT
Search:
Ovidsp with keyword terms “centralization and prognosis”. The results were limited to full text. 58 citations were found with no limit to year published.
Date of Search: February 2,2014
Re-evaluation date: February 9, 2014
Citation:
Skytte L, May S, Petersen P. Centralization: Its Prognostic Value in Patients with Referred Symptoms and Sciatica. Spine 2005;30(11):E293-E299.
Summary:
The purpose of this study is to evaluate the CP prognostic value in determining conservative or surgical treatment. This is a prospective cohort study of patients with unremitting back and leg pain, between 18 and 60 years of age. One hundred fourteen consecutive patients meeting these criteria were initially entered in the study and 54 patients were excluded based on the exclusion criteria. The exclusion criteria consisted of the following: previous lumbar spinal operation, pregnancy, serious spinal pathology, other serious pathology, Danish not the patient’s first language, symptoms present greater than 14 weeks and lack of consent.
Baseline data including the Nottingham Health Profile (NHP), Low Back Pain Rating Scale (LBPRS), demographic data and the Quebec Task Force (QTF) category of symptom referral. The examining therapist was blinded to the baseline data and performed a Mechanical Diagnosis and Therapy (MDT) evaluation in order to classify the subject as “centralizer” (CG), indicating that the most distal symptom was abolished and remained abolished upon returning to a neutral position, or “noncentralizer” (NCG), indicating no change during the MDT evaluation or the symptoms changed to a more distal location. Twenty-five patients were allocated to the CG and 35 patients to the NCG.
The treatment was the same for both the CG and NCG, consisting of “watchful waiting”. This included bed rest for those with neurological deficit and “light mobilization” for those without neurological deficit. Follow-up data was obtained at 1,2,3,6, and 12 months. Three patients from the CG and 16 from the NCG underwent surgery by the one-year follow-up. All patients were accounted for in the results.
Appraisal:
The authors satisfied six of the nine questions regarding the Quality Appraisal Checklist. A follow-up study, to establish the reliability of the results was not performed, and patients entered the study with varying acuity of symptoms. The examiner was blinded from the data collection, and the treating therapists were blinded from the examiner’s assessment.
Assessing the CP can predict conservative compared to surgical treatment requirements with 84% specificity and 54% specificity. The odds ratio (OR) for surgery in the NCG was calculated to be 6.17, with a 95% confidence interval (CI).
Very interesting!
Thank you for your time, with regards to reading the article. An excellent book to follow-up with these thoughts is “Rapidly Reversible Back Pain” by Ron Donelson MD (an orthopedic surgeon). The concept of classifying patients is not new, but unfortunately there are not enough therapists trained to classify patients in this matter. The reasoning behind this could be as benign as they just don’t have the education or as sinister as they are not incentivized to help patients in fewer visits, as it would reduce the fee-for-service portion of therapy reimbursement. There are many articles that cover the concept of directional preference and centralization, but Long’s article is by far the most eye catching. She did a follow-up to this study, in which she had to give those in the other two groups the directional preference based exercises and the results were again dramatic. The second article is more enlightening that the first. When I get time, I will try to summarize it on the site.