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Directional Preference

June 5, 2014

Directional preference


Many patients suffering from back or neck pain, with or without referred pain, will clearly exhibit a “direction preference” when repeated movement and/or static positioning are applied to the spine. This means there will be a particular movement or position which will cause the symptoms to shift to a more central (proximal) location.


The Centralisation Sign was discovered by Robin McKenzie. Recently published scientific papers have established that the presence of this sign is a strong indicator of discogenic pathology and a highly accurate and reliable predictor of treatment outcome. Movement activities and postures that cause the symptoms to centralise indicate the self-treatment strategy. Simultaneously, the Physiotherapist must teach the patient how to avoid those positions, activities and movements that case the symptoms to move peripherally.


A common example seen in the clinical practice occurs when the patients sits with relaxed, slouched posture and experiences symptoms in the neck, head or arm. When the patient is asked to sit and restore lumbar and cervical lordosis, the patient reports that the symptoms are less or abolished in the arm or head and are much more pronounces in the neck region. Similarly, with the patient who has low back and leg symptoms, the symptoms reduces or abolished in the leg and become more prominent in the low back area.


The absence of the Centralisation Sign is equally significant and introduces a different range of specific tests, other mechanical diagnosis and treatment options. One option may be that the patient is not suitable for mechanical therapy. This can be determined in one or two visits.


These assessment and treatment methods developed by Robin McKenzie are now used by physiotherapists, doctors and spine surgeons worldwide.



Donelson R (1997): A prospective study of centralisation of lumbar and referred pain. Spine Vol. 222 No 10 pp1115-1122

Waddell et al (1996): Low back pain evidence review. London: Royal College of General Practitioners

Nwuga et al (1985): Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. Physiotherapy Practice 1: 99-105