Centralization, although first described by McKenzie14, has been replicated in multiple research studies15,16,17.
Centralization is the movement of symptoms from an area distal to the spine to a more proximal segment14,18.
Peripherilization is the movement of symptoms, originating from the spine, from a more proximal and central location to a more distal location14.
The centralization phenomenon, when produced in patients, correlates with good outcome9,10,18,19.
Patients presenting as non-centralizers are six times more likely to require surgical intervention19.
Centralization is shown to highly correlate with a discogenic lesion20.
- Spinal Stenosis= reduction of the surface area of the spinal canal or foramen
–No clinical feature or diagnostic test can confirm that stenosis is the cause of symptoms
–A literature review determined that “all studies favored decompressive surgery for improvement of pain, function and quality of life, as well as in terms of patient satisfaction” compared to conservative care24
- The advantage of surgery was noted within 3-6 months and remained constant for up to 4 years.
- Surgery is more cost-effective for this group of patients
- Appropriate for patients that have not improved with 12 weeks of conservative care.
EPIDURAL STEROID INJECTIONS
There are multiple systematic reviews demonstrating that ESI’s can be effective in the short term and long term for managing back pain for both discogenic pain and stenotic pain21,22
Following an ESI, about 45% of patients then demonstrate centralization and report 90% satisfaction of results after 1 year23
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2.Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with the current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.
3.Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Manual Therapy 2009;14:314-320.
4.Fritz JM, Cleland JA, Speckman M, et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine 2008;33(16):1800-1805.
5.Shin G, Mirka G. An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues. Clin Biomech 2007;22:965-971.
6.Kelsey JL, Githens PB, White AA, et al. An Epidemiologic Study of Lifting and Twisting on the Job and Risk for Acute Prolapsed Lumbar Intervertebral disc. J Orthop Research 1984;2:61-66.
7.Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine 1994;19(2):156-158.
8.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J orthopedic surg 2001;9(1):1-7.
9.Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004. 29(23):2593-2602.
10.Long A, May S, Fung T. Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008;60:307-317.
- Kovacs FM, Urrutia G, Alarcon JD. Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials. Spine 2011;36(20):1334-1351.
- Urquhart DM, Bell R, Cicuttini FM, et al. Low back pain and disability in community-based women: prevalence and associated factors. Menopause 2009;16(1):24-29.
- Konstantinou K, Dunn K. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine 2008;33(22):2464-2472.
- McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publication Ltd;2003.
15.Delitto A, Cibulka MT, Erhard RE, et al. Evidence for an extension-mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther 1993;73:216-228.
16.Donelson R, Silva G, Murphy K. The centralizaiotn phenomenon: Its usefulness in evaluationg and treating referred pain. Spine 1990;15:211-215.
17.Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: A multi-centered, prospective randomized trial. Spine 1991;16:S206-212.
- Werneke MW, Hart DL, Cutrone G, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. JOSPT 2011;41(1): 22-31.
- Skytte L, May S, Peterson P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005;30(11):293-299
- Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.
- Manchikanti L, Kaye AD, Manchikanti K, et al. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5(1):e23139.
- ManchikantiL, Buenaventura RM, Manchikanti K, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245.
- van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014;15(7):1100-1108.