Waddell's Signs

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Hi all,

Most of us have come across Waddell's sign, typically used in the course of an adverse exam of our patient. I don't think that there is a very good understanding of what comprises a positive Waddell's, generally, and I know that it is frequently misused by an examiner who tries to use it to disprove the presence of injury. Main PhD ans Gordon Waddell MD published a revisitation of the test in Spine in 1998. For anyone who is interested, I have pasted the reference and my review of the paper that was published in "Litigating Minor Impact Soft Tissue Injuries" Vol 2, Forensic Medicine, Kohler and Freeman, from West Group publishers, below.

Regards,

D Freeman Mailing address: 2480 Liberty Street NE Suite 180Salem, Oregon 97303phone 503 763-3528fax 503 763-3530cell 503-871-0715

Main CJ, Waddell G. Behavioral Responses to Examination. A Reappraisal of the Interpretation of “Nonorganic Signs”. Spine 1998;23:2367-71.

Discussion: Understanding this paper is of importance when evaluating the findings of a defense medical examiner (DME). Main and Waddell write concerning an orthopedic test called Waddell’s sign that is most frequently encountered in the context of a defense medical exam and is often used to disparage the legitimacy of injury claims by plaintiffs. Waddell’s sign was first described by Gordon Waddell, a British consulting orthopedist, in a paper in Spine in 1980.[1] In the original paper, Waddell described five types of physical signs that may indicate a nonorganic basis of a patient’s complaints, possibly indicating psychological factors underlying the patient’s symptoms. The purpose of the original paper was to help in the identification of patients that may not be good candidates for low back surgery because of psychological overlay. The signs are summarized as follows:[2]

1. Tenderness: For organic causes of low back pain, tenderness (pain upon palpation) should localize to the painful structures. The authors described two subtypes of “nonorganic” tenderness:

A. Superficial tenderness: Refers to a pain response from the patient when touched lightly over a wide area throughout the lower back region.

B. Non-anatomic tenderness: Refers to tenderness that is felt as “deep,” is not localized to a single area, and may extend into the thoracic and pelvic regions.

2. Simulation: If under the impression that they are undergoing a painful maneuver, patients may give a pain response. In actuality, the maneuver performed may not be painful. Two sub-types are described:

A. Axial loading: Refers to pressing lightly straight down on the patient’s head. Since the lumbar spine should not be appreciably compressed beyond the patient’s upper body weight with this gentle test this should not aggravate lower back pain.

B. Simulated rotation: Refers to a pain response when the examiner turns the patient as one piece (en bloc from the shoulder to the pelvis), without one part of the back twisting on the other. Since the lumbar spine itself is not twisted, this maneuver should generally not cause lower back pain.

3. Distraction: This refers to double-checking a painful (“positive”) physical sign exam while the patient is distracted. The classic example is:

Straight leg raising: Refers to observing the patient in a leg position which should aggravate his/her sciatic pain – similar to the official straight leg raise test – at the same time distracting the patient from this task. The examiner may achieve this by asking the sitting patient to extend his/her knee to insure “good knee range of motion”. In actuality, this is a “sitting” straight leg raise test, and should cause leg pain similar to the straight leg raise test done with the patient lying down. However, if the patient does not develop similar pain from this “distracted” straight leg raise test, this would be considered a positive Waddell’s sign.

4. Regional disturbance: This refers to a “nonorganic” distribution of findings that cannot be explained based upon our knowledge of neuroanatomy. Two sub-types were described.

A. Weakness: Refers to weakness in a region that cannot be explained on an anatomic basis. For example, a patient with a fifth lumbar nerve root injury from a lower lumbar disc herniation may exhibit severe weakness of all the leg muscles, not just muscles which receive a fifth lumbar nerve root supply.

B. Sensory: Refers to sensory changes that also cannot be understood on an anatomic basis alone. For example, the patient with the “L5 lumbar radiculopathy” may also state that their pinprick sensation is impaired throughout the leg, not just in the region of skin supplied by the fifth lumbar nerve root.

5. Overreaction: Refers to behaviors which appear too dramatic to be explained by the injury in question. Such behaviors may involve sighing, grimacing, and walking with a marked limp when no weakness is noted.

In the newest paper, Main and Waddell make it clear that only three or more positive signs of the five types of Waddell’s signs should be considered meaningful, since many patients with legitimate and no nonorganic signs (signs of psychological overlay) may exhibit one or two positive types of Waddell’s signs. The authors emphasize that multiple positive signs does not indicate deliberate faking of an injury, even though the signs are frequently used for this purpose by the defense medical examiner. They indicate that positive Waddell’s signs can result from fear and from chronic decreased function resulting from real injury. The authors state that they feel that deliberate faking is extremely rare. They also point out the fact that three or more positive Waddell’s signs are not an indication of psychological abnormality and cannot be used as a substitute for psychological evaluation. They may, however, point to a need for further psychological evaluation. Another important point brought out by the authors is the fact that some signs that may appear to be positive Waddell’s signs, non-anatomic tenderness in particular, may be caused by other problems that the patient may have, such as fibromyalgia syndrome, that can result in generalized tenderness.

Personal note: in my experience of evaluating more than 1,000 defense medical examination reports, I have yet to see a positive Waddell’s sign that was performed correctly.

[1] Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic Physical Signs in Low-Back Pain. Spine. 1980;5:117-25.

[2] Eisinger D. Doctors Main and Waddell Revisit the Correct Use of Waddell’s Signs. Injury Forum 2000;2(2):pages 13-17.