Centralization of Low Back Pain

Centralization of Low Back Pain

 Centralization describes the phenomenon by which distal limb pain, coming from the spine, although not necessarily felt there, is immediately or eventually abolished in response to loading strategies. (McKenzie 2003)

During centralization, the response to therapeutic loading strategies is assessed.  Pain is progressively abolished in a distal to proximal direction with each progressive movement until all symptoms are abolished.  In back pain only, the pain moves from a widespread to a more central location and then abolishes.

This phenomenon only occurs in derangement syndrome (McKenzie 1981, 1990).  Reduction describes the process by which the derangement is progressively lessened.  During the process, symptomatic and mechanical baselines improve.  Thus, centralization is occurring and movement is restored.  Centralization has been proved to be a good indicator of a positive outcome in low back patients.

Studies carried out independently in several countries inEuropeand in the United Stated showed that centralization (movement of the pain the in a more central location) mechanically determined directional preference.  Movement in the direction    that stops, reduces or centralizes pain provides the most important guidelines for exercise prescription.

A historical study (Long et al 2004) on how mechanical determines directional preference was carried out by trained McKenzie clinicians in several countries and involved 200 patients.  Patients were examined by McKenzie therapists who determined which exercise centralized, reduced or abolished their symptoms.  exercises were either flexion (bending forward) or extension (bending backwards) as developed and described in “The Lumbar Spine; Mechanical Diagnosis and Therapy” (McKenzie 1981, 2003).

One third of the patients were given the correct exercise based on directional preference.  One third was given the opposite exercise and another third were told to keep generally active.  After two weeks, over 90% using directional preference exercises were better or resolved compared to 24% with the opposite exercise and 43% with general activity.  Many of these who did the opposite exercise experienced a worsening of symptoms and dropped out of the study.  This clearly indicates that people with back pain respond best to specific exercises bases on directional preference.

            Another study (Aina A et al 2004) did a systemic review of centralization studies.  Fourteen studies of centralization were examined.  Prevalence 70% in 731 sub-acute back pain patients and 52% in 325 chronic back pain patients.  Centralization was reliably assessed (Kappa values 0.51 to 1.0).  Centralization was consistently associated with good outcomes and failure to centralize with poor outcomes.  Association was confirmed by high quality studies.


Craig Zettergren, PT, MS, MBA is a fellowship trained physical therapist in Mechanical Diagnosis and Therapy for the spine and extremities with the McKenzie Institute.  He has two offices servicing Central Connecticut,  Physical Therapy of Bristol and Physical Therapy Southington.  The Bristol office is located at72 Pine Street, (860) 585- 5800 and the Southington office is located at 1090 Meriden-Waterbury Tpke., (203) 272-8490

Personal, Professional, Physical Therapy






  1. Aina A, May S., Claire H. (2004)  The Centralization Phenomenon of Spinal Symptoms- A systemic Review.

Manual Therapy 9.134-143

  1. Long A, Donelson R, Fung T (2004) Does it matter which exercise?  A randomized control trial of exercise for low back pain, Spine 29; 2593-2602
  2. McKenzie R, (1981) The Lumbar Spine: Mechanical Diagnosis and Therapy, Spinal Publications New Zealand Ltd
  3. McKenzie R, (1990) The Cervical and Thorasic Spine Mechanical Diagnosis and Therapy, Spinal Publications New Zealand Ltd
  4. McKenzie R, May S (2003) The Lumbar Spine Mechanical Diagnosis and Theraoy, Spinal Publications New Zealand Ltd
  5. McKenzie R, (2006) Treat Your Own Back Spinal Publications New Zealand Ltd


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