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Low back pain – time we sang from the same song sheet



The 2024 Global Year will examine what is known about sex and gender differences in pain perception and modulation and address sex-and gender-related disparities in both the research and treatment of pain.

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Is it possible that a lack of centralisation reflects a predominance of centralisation?  Well, the undisputed wrestling champion of physical therapy is wrestling with this very topic, having been motivated by an intruiging paper.  Fortunately for BiM, John kindly agreed to write a post on it. Here it is:

Here is a riddle for you. What word by its absence probably means its presence? I do not know how to stop you here to think about the riddle before you read on. Hint- LBP.

In re-reading a great article on low back pain (LBP), Werneke and Hart, 2005, the riddle hit me.  What they did was investigate the relationship of centralization/non-centralization and behavioral signs in a group of acute non-specific low back pain patients. Each patient took a battery of psychometric and pain behavior tests and had repeated end range motion testing performed by a certified McKenzie therapist. The results are interesting. They found that there was no association between the scores on the tests and the finding of centralization. There was, however, a significant correlation between the behavioral scores and the finding of non-centralization.  Those who did not centralize were 8 time more likely to demonstrate non organic signs, 13 times more likely to demonstrate overt pain behaviors, 2 times more likely to demonstrate somatization, and 3 times more likely to demonstrate a fear of work than the centralizers.  Interestingly, the scores for depression, physical fear, disability, and pain intensity were not that different between the two groups.

The study demonstrates that the centralization/non-centralization marker is an important indicator discriminating between LBP that has a mechanical, nociceptive trigger and LBP that has a more central nervous system loci. Does this mean that when the pain hasn’t centralized, in reality, it has???  Could the language of LBP management be more confusing? Wouldn’t it be helpful to clarify our language so that we all know which centralization we are treating?  Language aside (they did not use the neuropathic centralization in the article), their study demonstrates how the two centralizations can be delineated by the absence of one.  That’s helpful. As a clinician, I need all the help I can get.

About John

John Barb and HersheyJohn Barbis is a physical therapist at Main Line Health. He has BS in biology from Haverford College and Masters in PT from Stanford. He has been practicing since 1978, a McKenzie certified therapist since 1991. He has taught at Temple and Jefferson and has held posh posts on the APTA, McKenzie Institute and Greater Philadelphia Pain Society. Enough said? John knows as much about patients and about treating them in the real world as anyone.  Add to that an enthusiastic and it seems daily assault on the literature, he is a formidable clinical thinker.  If you disagree with this, or with him, we advise you to not choose physical violence to settle it because John is a dead set bonafide dynamo on the squared circle.  Clearly he did not write this bio.



Werneke, M., & Hart, D. (2005). Centralization: Association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain Journal of Rehabilitation Medicine, 37 (5), 286-290 DOI: 10.1080/16501970510032901

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