Waddell's signs
Encyclopedia
Waddell's signs are a group of physical signs, first described in a 1980 article in Spine
, and named for the article's principal author, Gordon Waddell. Waddell's signs may indicate non-organic or psychological component to chronic low back pain
. Historically they have also been used to detect malingering
in patients with back pain. While testing takes less than one minute, it has been described as time-consuming and alternatives have been proposed.
Any individual sign marks its category as positive. When three or more categories were positive, the finding was considered clinically significant. However, assessing the patient on the basis of overreaction has raised concerns regarding observer bias
and idiosyncrasies related to the patient's culture. Consequently, a practitioner may assess the patient on the remaining four categories, with two or more positive categories being considered clinically significant.
One or two Waddell's signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression
, hysteria
and hypochondria
sis on the Minnesota Multiphasic Personality Inventory
.
In a 2003 review, Fishbain, et al. stated that Waddell's signs do not reliably distinguish organic from psychological pain but instead tend to underestimate the amount of pain that is actually experienced. In a 2004 review, Fishbain, et al. concluded, "there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association".
In 2010, a neuroanatomical basis of Wadell's signs has been proposed which argues that since the brain is organic, and even society is composed of a group of organic beings, the term "nonorganic" should be replaced by a term put forward by Chris Spanswick in 1997, "behavioral responses to physical examination." With the possible exception of cogwheel rigidity, these are best understood as neuroanatomical maladaptations to long-continued pain and, as Waddell and colleagues have stressed, do not indicate faking or malingering but rather that there are psychosocial issues that mitigate against successfully treating low back pain by lumbar discectomy, and which in themselves require other treatment.
Spine (journal)
Spine is an international bi-weekly peer-reviewed medical journal in the field of the spine.- Affiliated societies :The following societies are affiliated with Spine:* Argentine Society for the Study of Spine Pathology...
, and named for the article's principal author, Gordon Waddell. Waddell's signs may indicate non-organic or psychological component to chronic low back pain
Low back pain
Low back pain or lumbago is a common musculoskeletal disorder affecting 80% of people at some point in their lives. In the United States it is the most common cause of job-related disability, a leading contributor to missed work, and the second most common neurological ailment — only headache is...
. Historically they have also been used to detect malingering
Malingering
Malingering is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation ; avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences;...
in patients with back pain. While testing takes less than one minute, it has been described as time-consuming and alternatives have been proposed.
Use of Waddell's signs
Waddell, et al. (1980) described five categories of signs:- Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness
- Simulation tests: these are based on movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation
- Distraction tests: positive tests are rechecked when the patient's attention is distracted, such as a straight leg raiseStraight leg raiseThe Straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, mostly located at L5 , S1 or S2 .-Technique:With the patient...
test - Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomy
- Overreaction: subjective signs regarding the patient's demeanor and reaction to testing
Any individual sign marks its category as positive. When three or more categories were positive, the finding was considered clinically significant. However, assessing the patient on the basis of overreaction has raised concerns regarding observer bias
Observer-expectancy effect
The observer-expectancy effect is a form of reactivity, in which a researcher's cognitive bias causes them to unconsciously influence the participants of an experiment...
and idiosyncrasies related to the patient's culture. Consequently, a practitioner may assess the patient on the remaining four categories, with two or more positive categories being considered clinically significant.
One or two Waddell's signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
, hysteria
Hysteria
Hysteria, in its colloquial use, describes unmanageable emotional excesses. People who are "hysterical" often lose self-control due to an overwhelming fear that may be caused by multiple events in one's past that involved some sort of severe conflict; the fear can be centered on a body part, or,...
and hypochondria
Hypochondria
Hypochondriasis or hypochondria refers to excessive preoccupation or worry about having a serious illness. This debilitating condition is the result of an inaccurate perception of the body’s condition despite the absence of an actual medication condition...
sis on the Minnesota Multiphasic Personality Inventory
Minnesota Multiphasic Personality Inventory
The Minnesota Multiphasic Personality Inventory is one of the most frequently used personality tests in mental health. The test is used by trained professionals to assist in identifying personality structure and psychopathology....
.
Criticism
Although Waddell's signs can detect a non-organic component to pain, they do not exclude an organic cause. Clinically-significant Waddell scores are considered indicative only of symptom magnification or pain behavior, and have been misused in medical and medico-legal contexts. Waddell's signs are not considered a de facto indicator of deception for the purpose of financial gain.In a 2003 review, Fishbain, et al. stated that Waddell's signs do not reliably distinguish organic from psychological pain but instead tend to underestimate the amount of pain that is actually experienced. In a 2004 review, Fishbain, et al. concluded, "there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association".
In 2010, a neuroanatomical basis of Wadell's signs has been proposed which argues that since the brain is organic, and even society is composed of a group of organic beings, the term "nonorganic" should be replaced by a term put forward by Chris Spanswick in 1997, "behavioral responses to physical examination." With the possible exception of cogwheel rigidity, these are best understood as neuroanatomical maladaptations to long-continued pain and, as Waddell and colleagues have stressed, do not indicate faking or malingering but rather that there are psychosocial issues that mitigate against successfully treating low back pain by lumbar discectomy, and which in themselves require other treatment.