How reliable are Waddell’s signs?
Our Answer:
As most of you know Waddell’s signs (WS) are often used to negate or diminish the credibility of your clients. In the past month we have been asked by two attorneys from different firms about the real value of Waddell’s signs. We have all seen reports from physicians who treat positive Waddell’s signs as the be all and end all of objectively concerning non-organic factors in low back pain.
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 a 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 a quick way for physicians to determine if non-organic issues are at play in injured clients
The five markers are:
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 raise 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
If a client is positive for 3 or more of these tests, the maneuver is considered positive for non-organic issues in low back pain.
Reviewing the medical literature written over the last 10-20 years reveals some rather interesting findings. The preponderance of medical journal articles report that Waddell’s signs offer little objective confirmation that there are non-organic issues at play for low back pain sufferers and in traumatic low back pain injuries there is little or no reliability or validity of the testing.
Certainly that is not to say that some researchers find Waddell’s signs to be highly valid and reliable. Proponents of using Waddell’s signs for diagnostic purposes can find and quote medical journal articles that opine Waddell’s signs are useful tools. It is important to note that medical journal articles of this nature are a distinct minority.
In a 2004 review article in the Clinical Journal of Pain Fishbain, et al. concluded, “there was inconsistent evidence that Waddell signs were not associated with worker's compensation and medicolegal status; there was consistent evidence that Waddell signs improved with treatment; there was consistent evidence that Waddell signs were not associated with invalid paper-pencil test; and there was inconsistent evidence that Waddell signs were not associated with physician perception of effort exaggeration. Overall, 75% of these reports reported no association between Waddell signs and the 4 possible methods of identifying patients with secondary gain and/or malingering. Based on the above results, it was concluded that 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 a 2003 article in Pain Management the authors conclude “1) WSs do not correlate with psychological distress; 2) WSs do not discriminate organic from nonorganic problems; 3) WSs may represent an organic phenomenon; 4) WSs are associated with poorer treatment outcome; 5) WSs are associated with greater pain levels; 6) WSs are not associated with secondary gain; and 7) As a group, WS studies demonstrate some methodological problems.”
In fact in a 1998 article in Archives of Physical Medicine and Rehabilitation Novy et al, conclude “Taken together, multiple Waddell signs and some of their correlates present various factors that might interfere with optimal response to treatment.”
In summary, the preponderance of scientific medical journal articles looking at reliability and validity of Waddell’s signs did not find the procedure to produce valid results and Waddell’s signs do not have scientific reliability.
If you would like to further discuss Waddell’s signs with us, please contact us at davidgrundymd@gmail.com.
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