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Background: Initial or between session improvements in pain and/or function are often considered to be predictive of ultimate outcomes in musculoskeletal problems., Objective: To determine the long-term prognostic value of within and between session improvements to pain and function., Design: Systematic review of relevant literature., Method: A search was made of multiple databases (Pubmed/Medline, Cochrane, Cinahl, and AMed) using relevant search terms. Titles, abstracts, and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction, and quality assessment, using GRADE, were done independently by two authors. Disagreements were resolved by consensus., Results: Only 13 articles met the criteria for inclusion. For the effect of pain location or pain intensity changes in the first treatment session on medium or long-term pain, disability, return-to-work, or global outcomes nine outcomes were available. Findings were mostly inconclusive (5) or negative (3). There was only one study evaluating between session improvements with ambiguous results. There were no studies evaluating the prognostic value of early improvements in function., Conclusions: There is no conclusive evidence to support the concept that early changes in pain location or pain intensity offer a good longer-term prognosis on a variety of outcomes; and no evidence relating to early improvements in function. The idea that patients who appear to improve in the first treatment session will do well longer term is not supported by the literature., Competing Interests: Declaration of competing interest None declared., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Centralization and directional preference are common management and prognostic factors in spinal symptoms., Objective: To update the previous systematic review., Design: Systematic review to synthesis multiple aspects of centralization and directional preference., Method: Contemporary search was made of multiple databases using relevant search terms. Abstracts and titles were filtered by two authors; relevant articles were independently reviewed by two authors for content, data extraction, and quality., Results: Forty-three additional relevant articles were found. The quality of the studies, using PEDro for randomized controlled trials, was moderate or high in six out of ten RCTs; moderate or high in six out of 12 cohort studies. Prevalence of centralization was 40%, the same as the previous review. Directional preference without Centralization was 26%; thus Centralization and directional preference combined was 66%, which was very similar to the previous review. Neither clinical response was recorded in about a third of patients. Centralization and directional preference were confirmed as key positive prognostic factors, certainly in patients with low back pain, but limited evidence for patients with neck pain. There was no evidence that these might be important treatment effect modifiers. One study evaluated reliability, and found generally poor levels, despite training., Conclusions: Centralization and directional preference are worthwhile indicators of prognosis, and should be routinely examined for even in patients with chronic low back pain. But they do not occur in all patients with spinal problems, and there was no evidence that they were treatment effect modifiers., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Centralization is a symptom response to repeated movements that can be used to classify patients into sub-groups, determine appropriate management strategies, and prognosis. The aim of this study was to systematically review the literature relating to centralization and directional preference, and specifically report on prevalence, prognostic validity, reliability, loading strategies, and diagnostic implications. Search was conducted to June 2011; multiple study designs were considered. 62 studies were included in the review; 54 related to centralization and 8 to directional preference. The prevalence of centralization was 44.4% (range 11%-89%) in 4745 patients with back and neck pain in 29 studies; it was more prevalent in acute (74%) than sub-acute or chronic (42%) symptoms. The prevalence of directional preference was 70% (range 60%-78%) in 2368 patients with back or neck pain in 5 studies. Twenty-one of 23 studies supported the prognostic validity of centralization, including 3 high quality studies and 4 of moderate quality; whereas 2 moderate quality studies showed evidence that did not support the prognostic validity of centralization. Data on the prognostic validity of directional preference was limited to one study. Centralization and directional preference appear to be useful treatment effect modifiers in 7 out of 8 studies. Levels of reliability were very variable (kappa 0.15-0.9) in 5 studies. Findings of centralization or directional preference at baseline would appear to be useful indicators of management strategies and prognosis, and therefore warrant further investigation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The centralization phenomenon was first described 20 years ago. It refers to the abolition of distal pain emanating from the spine in response to therapeutic exercises. Since then a number of papers on the subject have been published. A review of current knowledge is appropriate. Selection criteria were established prior to a computer-aided search for published papers. Two reviewers independently extracted data and checked quality; a third reviewer resolved any disagreements. A narrative review was conducted based on the findings. The review primarily considered prevalence, reliability of assessment, and prognostic significance. These have been most commonly reported, and are important to establish the clinical worth of this symptom response. Fourteen studies were identified. Quality of studies varied; prognostic studies were given a mean score of 3.3 out of 6 by using established quality criteria. The prevalence rate of pure or partial centralization was 70% in 731 sub-acute back patients, and 52% in 325 chronic back patients. It is a symptom response that can be reliably assessed during examination (kappa values 0.51-1.0). Centralization was consistently associated with a range of good outcomes, and failure to centralize with a poor outcome. Centralization appears to identify a substantial sub-group of spinal patients; it is a clinical phenomenon that can be reliably detected, and is associated with a good prognosis. Centralization should be monitored in the examination of spinal patients.