1. Waddell’s Signs Clinical Use and Interpretation
Lealah Fremuth
Clinical Education II Inservice
June 25, 2015

2. Introduction
ORIGIN: first described in a 1980 article in Spine discussing potential behaviors of low back pain patients
PURPOSE: to identify psychogenic, or nonorganic, manifestations of pain in patients that may have heightened emotional effects on their conditions.
SIGNIFICANCE: >3/5 signs must be present to be significantly correlated w/ disability.

3. The Five Signs Tenderness (excess or widespread reaction) -Superficial
-Nonanatomic
Simulation (pain reported with sham maneuvers)
-Axial loading
-Rotation
Distraction (less pain when attention is diverted)
-Straight leg raising
Regional Symptoms (widespread give-way or dysesthesia)
-Weakness
-Sensory
Overreaction ("disproportionate" psychomotor responses)
If there are more than 3 of 5 present then there is high probability that patient has non-organic pain.
The modern use of nonorganic signs for patients with low back problems increased greatly after Waddell et grouped eight signs into five types in These five types, or categories of signs, are tenderness, simulation, distraction, regional disturbances, and overreaction. These signs were narrowed down from a list of 16 which included grip strength, lumbar sensory changes, and pretibial tenderness that were not part of the final list because of poor intertester and intratester reliability, overlap with other signs, and difficulty for the examiner to learn.

4. Tenderness Superficial: light pinching/palpation causing pain
Nonanatomic: deep tenderness over a wide area w/ nonanatomic boundaries
The patient has skin surface tenderness that is not related to a particular skeletal or neuromuscular structure, meaning it occurs over a wide area or extends across several unrelated structures.

6. Simulation
Axial loading: downward pressure on the head causing low back pain  
Rotation: Examiner holds shoulders and hips in same plane and rotates patient causing pain
The patient complains of pain in the lower back when the examiner presses down on top of the head or rotates the shoulders and pelvis together on the same plane, neither of which should produce this type of pain.

8. Distraction
Straight leg raise when formally tested in supine  pain, but
Straightening the leg in sitting to check Babinski reflex does not
The examiner does the same test twice, once while distracting the patient, and he/she only complains of pain in one test.

10. Regional Symptoms
Weakness: multiple muscles not innervated by the same root
Sensation: glove and stocking loss of sensation
Sensory loss often described as encompassing an entire extremity or side of the body. Weakness that is non consistent and jerky.
With either sensory deficits or weakness, the dysfunction is over a widespread area that cannot be explained based on anatomy or neurological patterns.

12. Overreaction
Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later
May include verbalization, facial expression, muscle tension and tremor.
Presence of guarding, bracing, rubbing, grimacing, and sighing during a physical examination may also indicate overreaction.

14. Do Waddell’s signs signify malingering?
Although Waddell's signs can detect a non-organic component to pain, they do not exclude an organic cause. A Waddell score of >3 is indicative only of symptom magnification. It does not signify malingering.
-Symptom Magnification: conscious or sub-conscious tendency of an individual to under-rate his or her abilities and/or over-state his or her limitations. It does not imply intent, but may rather indicate psychosocial issues that may add challenges towards recovery.
-Malingering: fabricating or exaggerating of symptoms for a variety of "secondary gain" motives, which may include financial compensation, avoiding school, work or military service; obtaining drugs; simply to attract attention or sympathy.

15. What do Waddell’s signs imply about return to work?
Conflicting evidence:
Bradish et al
LBP (N=120)
positive nonorganic signs test at initial assessment  No correlation with work status between 12 and 18 months after injury
Lancourt and Kettelhutin
LBP (N=134)
axial loading, simulated rotation, distraction, and a sensory regional disturbance  BETTER predictors
ankle and knee reflexes, motor loss, and sensory loss in a dermatomal pattern  LESS predictive
Bradish et al reported that a positive nonorganic signs test at initial assessment in a group of workers with a low back injury (N= 120) did not correlate with work status between 12 and 18 months after injury.
In contrast, Lancourt and Kettelhutin reported that in a study of 134 patients with LBP that the nonorganic signs of axial loading, simulated rotation, distraction, and a sensory regional disturbance were among the factors that were better predictors of return to work than were ankle and knee reflexes, motor loss, and sensory loss in a dermatomal pattern

16. PHYSICAL THERAPY MULTIDISCIPLINARY TEAM PSYCHOLOGICAL OCCUPATIONAL
Other factors, besides the presence of nonorganic signs, may influence an injured worker returning to previous job duties. Waddell et al found return to work after lumbar surgery was predicted by physical, psychological, and occupational factors. Physical therapists should consider the relationship of these factors in the treatment of injured workers. The referral to an appropriate professional or multidisciplinary team should be made for management of any confounding factors when a patient's work tolerance fails to improve from physical therapy.
PHYSICAL
THERAPY
MULTIDISCIPLINARY
TEAM

17. Considerations
Both organic and nonorganic signs may be present in a patient with LBP. Therefore, the presence of nonorganic signs should not be equated with malingering or the presence of a psychological problem, but only with the need for further investigation.
Waddell et al caution, however, that nonorganic signs should not be overinterpreted and used as substitutes for comprehensive psychological assessment. Instead, they should be used as part of an examination to identify patients who require more detailed testing.
If nonorganic signs are found, the therapist should take the psychological implications into account when communicating with and treating the patient.

18. Summary Waddell's signs = screening tool
nonorganic signs may coexist with organic findings in addition to physical impairments.
positive test = need for additional psychological assessment, NOT an indicator of malingering.
physical therapy management for these patients should focus on treatment of illness behavior and on combating disability
Help set the patient’s expectations and encourage them to be an active participant in their therapy
The role of Waddell's nonorganic signs test is that of a screening tool for psychological factors in the examination of patients with low back problems. Nonorganic signs may coexist with organic findings. The presence of nonorganic signs should alert the physical therapist to the need for additional psychological tests and should not necessarily be considered an indicator of malingering. Physical therapy management for these patients should focus on treatment of illness behavior and on combating disability.

19. References