Centralization In McKenzie Methodi f iA series of 10 patients

Charbel Rizk PT, MPT

Physical Therapy Department

McKenzie approachMcKenzie approach

• One of the most practiced and studied methods

• Self‐treatment with exercisesSelf treatment with exercises

• Repeated end‐range of motion tests to identify themovement direction which centralizes leg symptomsg y pinto the low back, which is the centralizationphenomenon

Literature reviewLiterature review

The modern approach to manage spine problemspp g p pinvolves reassurance and reactivation

M b k bl i l li dMost back problems are simple, uncomplicatedmechanical disorders (Waddell, 1998) the patientshould be reassured that the prognosis for speedyrecovery is excellent (Waddell, 1998; Deyo andWeinstein, 2001)

Self‐treatment with exercise is the proven “benchmark”and should be started immediately in order to preventdisability and treat chronic pain (Carey et al. 2000)

Literature reviewLiterature review

Exercise is superior to passive care when utilized in treatingfailed back surgery patients (Timm et al. 1994). Moreover,when comparing different types of exercise, studies showedh h l h i (i M K i d bili i ) ithat the low‐tech exercise (in McKenzie and stabilization) issuperior to high technology exercise (isotonics & Cybex)

The McKenzie method is as effective as the isotonicstrengthening programMcKenzie was superior during a 2 months follow‐up, but noMcKenzie was superior during a 2 months follow up, but nodifferences were noticed at 8 months follow‐up. (Petersen etal.2002)

McKenzie classifies paini din 3 syndromes 

PosturalPostural

Dysfunction

Derangement

Postural SyndromePostural Syndrome

The pain is produced when :p pNormal tissues in the back are 

under an end of range stress P l d itti itiProlonged sitting position Over a period of time Due to sustained positionp

Treatment principle:C hil d i hCorrect posture while doing the 

offending activity 

DysfunctionDysfunctionPain:

Occurs when abnormal tissuesare under end of range stresseslike bending forwardThis adaptive shortening of scarThis adaptive shortening of scartissue is related to previousunhealed injuryIntermittentIntermittent

Treatment principle :S h d d l hStretch and remodel theaffected tissues and correctposture

DerangementMost frequent syndrome 

Disc changes maybe caused by an injury

Pain:Pain:

in the  back and/or leg

Pain can be intermittent or constant 

Better or worse according to the movementsBetter or worse  according to the movements

Treatment principle 

Repetitive exercises according to the derangement directionp g g

Long term exercises

Education and prevention of injuries 

CENTRALIZATION IN MCKENZIECENTRALIZATION IN MCKENZIE METHOD 

The phenomenon of centralization was first recognizedby Robin McKenzie in the 1950s and further muchby Robin McKenzie in the 1950s and further muchexperimentation and verification were described in theliterature

Centralization is the process by which pain radiatingfrom the spine is consecutively abolished, from distal to

i l i t th ti itiproximal, in response to therapeutic positions ormovements and induces reduction and abolition ofspinal painp p

Centralization can occur in the lumbar, cervical, andthoracic spine

DefinitionDefinition

There was consensus around the core definition ofe e as co se sus a ou d t e co e de t o ocentralization:

The abolition of distal pain in response to the deliberateapplication of movements or postures. If pain is only inth b k thi i t li d d th b li h dthe back this is centralized and then abolished

To this definition, Fritz added that changes inneurological signs and symptoms also occur inneurological signs and symptoms also occur incentralization

Centralization and prognosisCentralization and prognosis

CENTRALIZATION A SERIES OF 10CENTRALIZATION A SERIES OF 10 PATIENTS 

ObjectiveObjective

This study examined the relationship between the painThis study examined the relationship between the pain scale and the centralization : 

10 patients 

Complaining of non‐specific low back pain 

Diagnosed with derangement syndrome

Treated by the McKenzie method

Inclusion criteriaInclusion criteria

Patients aged 20 – 75 yearsat e ts aged 0 5 yea s

Complaining of low back pain and associated withreferred pain to the leg

Referred pain was defined as reported pain distal tocentral on the Donelson modified body grid

Assessment: Donelson modified body gridAssessment: Donelson modified body grid

Assessment: lumbar spineAssessment: lumbar spine

Red and yellow flags

Assessment: lumbar spineAssessment: lumbar spine

InterventionIntervention

Education on proper body mechanics, correct postures,advice to stay active, coping strategyy , p g gy

Repetitive extension principle in lying, 15 repetitions, 3times per day

Repetitive extension principle in standing, 15 repetitions, every 2 hours

InterventionIntervention 

Repetitive extension principle in standing, 15 p p p g,repetitions, every 2 hours

InterventionIntervention 

Th t l li d h i itThe same protocol was applied on each visit

Subjects were followed for a maximum of 9 visits over a maximum period of 6 weeksa maximum period of 6 weeks 

Study ResultsStudy Results 

Subject’s responses to the treatment  were divided into Subject s espo ses to t e t eat e t e e d ded to2 groups:

Centralized and abolished (group 1)

Symptoms centralization (group 2)

Group 1 : Centralized and abolishedGroup 1  : Centralized and abolished

The group consisted of 4 subjects:e g oup co s sted o subjects

with LBP whose initial distal 

0

symptoms were located on the area marked “zero” and moved 

i ll d th b li h dproximally and then abolished

Group 2 : symptoms centralizationGroup 2 : symptoms centralization

The centralizing group consisted of 6 subjects:

Initial distal symptoms were located outsideh k d ‘‘Z ’’ d h fthe area marked ‘‘Zero’’ and thereaftermoved to a more proximal location, butnever abolished nor reached area ‘‘Zero’’ onnever abolished nor reached area Zero onthe Donelson modified body grid

Data analysis:Data analysis:

Data analysis was applied on Excel programata a a ys s as app ed o ce p og a

Two variables were used for comparison

Visual Analogue Scale (VAS)

Donelson modified body grid

Pre-treatment Post-treatment

Male Female Total Male Female TotalMale Female Total Male Female Total

Number of Patients 5 5 10 5 5 10

Age

Mean 46.6 39.6 43.1 46.6 39.6 43.1

Range of age (20-75) (24-61) (20-61) (20-75) (24-61) (20-61)

Previous episodes

Mean 2.4 3 2.7 2.4 3 2.7

Range of Number of episodes (0-4) (1-7) (0-7) (0-4) (1-7) (0-7)

Pain (VAS)

Mean 4.8 5.4 5.1 1.4 1.8 1.6

Range of intensity of pain (3-7) (4-8) (3-8) (0-3) (1-3) (0-3)Donelson modified body

idgrid

Mean 2.6 2 2.3 0.2 0.8 0.5

Range of score (1-5) (1-3) (1-5) (0-1) (0-1) (0-1)

Results : Pain improvementResults : Pain improvement

5

6

5.4

4.8

3

4

Pain

Inte

nsity

1

2

P

1.8

1.4

0Pre-treatment Post-treatment

Male Female

Results: centralizationResults: centralization

2.5

3

Grid

2.6

1.5

2

fied

Don

elso

n B

ody

2

0.5

1Mod

i

0.8

0 20

Pre-treatment Post-treatmentMale Female

0.2

DiscussionDiscussionCentralization provides physiotherapists with a clinical toolto differentiate groups with different outcomes and it is ag pmanagement tool to identify appropriate specific exercisesor postures

The pre alence of the centrali ation is a green light for bothThe prevalence of the centralization is a green light for boththe patient and the physical therapist

Centralization is an important prognostic indicator and itp p gshould be monitored routinely in order to guide thetreatment management

Th t li ti i i t t di t fThe non‐centralization is an important predictor of pooroutcomes

DiscussionDiscussion

The presence of centralization in theexamination/treatment process has been a predictor ofexamination/treatment process has been a predictor ofgood patient outcomes with both acute and chronicspine pain (Donelson, Sukva, and Murphy, 1990; Long,1995 S fk t l 1998)1995; Sufka et al, 1998)Sufka et al (1998), and Werneke, Hart, and Cook (1999)demonstrated that practitioners have shown high levelsp gof agreement on the existence of centralization andthat for low back pain patients, McKenzie therapyresults in a greater decrease in pain in the short termresults in a greater decrease in pain in the short termthan do other standard therapies

LimitationsLimitations

Limited number of patients 10p

Correlations between ROM, pain and symptoms centralization will be good to elaborate

ConclusionConclusion

The difference between initial and final assessments ofThe difference between initial and final assessments ofcentralization upon the Donelson modified body gridseems to indicate a positive relation between thepprocess of centralization and decreasing of pain

THANK YOUTHANK YOU