Waddell Sign

Introduction

Waddell’s sign was first described by Professor Gordon Waddell to identify patients who are likely to have poor prognosis following low back pain surgery. But it has been misused and misinterpreted, clinically and medico-legally as a test of credibility and to detect malingering. Many assessors misuse the Waddell’s sign to disclaim motor vehicle accidents and imply that the patient is faking it.[1]

Waddell’s sign consist of 8 clinical physical signs that are labeled “non-organic signs”. The term non-organic implies that the pain is not real, which was not the intent of Professor Gordon Waddell. As he assures that back pain should be viewed within a psychosocial context and that Waddell’s sign should be used to guide clinicians to patients that need physical as well as psychosocial and behavioral management for low back pain.[1][2]

Waddell’s sign 8 clinical signs are divided into 5 broad categories that include[1]

  1. Superficial and non-anatomic tenderness
  2. Axial loading and acetabular rotation simulation
  3. Distraction,
  4. Regional sensory disturbance and weakness
  5. Overreaction

Examination Technique

Waddell signs include:

  • Superficial tenderness: Tenderness over a wide area of lumbar skin to light touch or pinch.
  • Non-anatomic tenderness: Deep tenderness over a wide area that crosses the over non-anatomic boundaries.
  • Axial loading: In axial loading patient stands and the examiner presses downwards vertically on the patient’s head, eliciting lumbar pain.
  • Acetabular rotation: The examiner rotates the shoulder and the pelvis passively in the same plane while the patient is standing. It is a positive sign if pain is elicited in the first 30 degrees of rotation.  
  • Distracted straight leg raise discrepancy:  In distraction test, the same positive physical finding is tested but while the patient is distracted, which can be achieved by testing a body part of the patient and observing another. Straight Leg Raising test can be used as a distraction test by using its variations. The test is positive when the patient reports pain on formal SLR examination such as on supine and the pain markedly decrease on performing the distracted SLR when the examiner extends the knee with the patient sitting.
  • Regional sensory disturbance: The patient’s reports pain that follows a stocking-like disturbance and doesn’t follow a dermatomal pattern.
  • Regional weakness: Weakness or cogwheel “giving away” that can’t be explained on neuroanatomical basis.
  • Overreaction: Which is exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.

A score of 3 or more out of the 5 categories is considered significant and the test is positive.[1][3]

Indications

Waddell’s sign should be done as a part of physical examination in lumbar back pain as it offers only an alert that the patient may need a psychological examination.[1]

Precautions

Rotation should be avoided in patients with hip pathologies, as acetabular tear.

Axial loading should not be performed in patients with severe neck or cervical spine injury.[1]

Evidence

A systematic review performed by Fishbain et al, concluded that Waddell signs do not identify psychogenic pain nor does it differentiate organic from non-organic problems.[1]

A cross sectional study by Adri T et al, assessing the validity of Waddell score  stated that Waddell score can’t be used as a psychological screener.[4]

However a study by Dustin B Wygant et al, found that Waddell signs are associated with somatic over reporting.[5]

The term “non-organic” pain is not accurate, as it indicates that the pain doesn’t have a physical origin. However, the study of neurobiology helps understand Waddell signs causes, so the more correct term that should be used is “behavioral responses to physical examination”.[6]

The pain could be due to a physical cause that is not understood due to poor knowledge of the neurobiology of pain. Attributing the pain to a psychological cause should not be a convenient reason to avoid exploring other physical causes of pain.[6]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 D'Souza RS, Law L. Waddell Sign. InStatPearls [Internet] 2019 Jul 28. StatPearls Publishing.
  2. Ranney D. A proposed neuroanatomical basis of Waddell's nonorganic signs. American journal of physical medicine & rehabilitation. 2010 Dec 1;89(12):1036-42.
  3. Waddell G, McCULLOCH JA, Kummel EG, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980 Mar 1;5(2):117-25.
  4. Apeldoorn AT, Ostelo RW, Fritz JM, van der Ploeg T, van Tulder MW, de Vet HC. The cross-sectional construct validity of the Waddell score. The Clinical journal of pain. 2012 May 1;28(4):309-17.
  5. Wygant DB, Arbisi PA, Bianchini KJ, Umlauf RL. Waddell non-organic signs: new evidence suggests somatic amplification among outpatient chronic pain patients. The Spine Journal. 2017 Apr 1;17(4):505-10.
  6. 6.0 6.1 Ranney D. A proposed neuroanatomical basis of Waddell's nonorganic signs. American journal of physical medicine & rehabilitation. 2010 Dec 1;89(12):1036-42.