Author: Richard H. Adler

In 1980, Gordon Waddell, M.D. drew attention to non-organic signs or beavioral signs in back pain patients and attempted to integrate them into modern concepts of pain and illness behavior. His paper, published in 1980, described five types of non-organic physical exam signs that may suggest psychological factors are playing a role in a patient's pain response. These signs have been dubbed "Waddell signs" and were designed specifically for patients with low back pain. Following the widespread use of Waddell's testing in insurance medical-legal examinations, most particularly with respect to automobile collision PIP benefits and personal injury claims, Dr. Waddell has recently come forward to clarify and criticize the use and interpretation of the "Waddell signs" in both clinical and medical-legal assessments.

Eighteen years after his original study was published, Dr. Waddell co-authored Behavioral Responses to Examination: A Reappraisal of the Interpretation of "Non-Organic Signs." This article was again published in Spine. In the new article Dr. Waddell states:

"Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both in clinical context and in medical-legal assessment. The purpose of this article is to offer a reconsideration of their use and interpretation."

The original five types of Waddell signs included the following:

A. Tenderness: Organic causes of low back pain will elicit tenderness (pain upon palpation) that is localized to the painful structure. Two subtypes of non-organic tenderness were noted to include:

Superficial tenderness: Refers to a pain response over a wide area throughout the lower back region when touched lightly;

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

B. Simulation: If under the impression that they are undergoing a painful maneuver, patients may give a pain response. In actuality, the maneuver may not be painful. Two subtypes are described:

Cervical Axial loading: Refers to pressing lightly straight down on the patient's head. This should not aggravate lower back pain;

Simulated rotation: A pain response when the examiner turns the patient as one piece without one part of the back twisting on another. Since the lumbar spine itself is not twisted, this maneuver should not cause lower back pain.

C. Distraction: This refers to retesting a painful physical exam sign while the patient is distracted and unaware that a retest is occurring. For example:

Observing a patient in a straight leg position which should aggravate his/her sciatica - similar to the official straight leg raising test - at the same time distracting the patient from this task. The examiner achieves this by asking the sitting patient to extend his or her knee to insure good knee range of motion. In actuality, this is a sitting straight leg test and should cause leg pain similar to the straight leg raising test done in the supine position. However, if the patient does not develop similar pain from this distracted seated straight leg raise test, the examiner could consider it a positive Waddell sign.

D. Regional disturbance: This refers to a "non-organic" distribution of findings that cannot be explained based upon our knowledge of neurology and anatomy. Two subtypes were described:

Weakness: Refers to a weakness in the 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;

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 pin prick sensation is impaired throughout the entire leg, not just in the region of skin supplied by the fifth lumbar nerve root.

E. Overreaction: Refers to behaviors which are 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 original article in 1980, Dr. Waddell suggested the presence of several signs could mean that the patient did not have a straightforward physical problem. As pointed out in the 1998 article, there were three specific caveats in the original study that had to be considered before determining the patient had "pain behavior" or "positive Waddell signs":

1. An increase in behavioral signs was associated with older patients and the test was not recommended for use with elderly patients;
   
   
2. It was emphasized that behavioral signs can and do occur with clear organic findings. The presence of signs, therefore, does not contradict organic findings; and
   
   
3. It was stressed that isolated behavioral signs should not be considered clinically significant. A patient needs to have at least three behavioral signs to be considered having "pain behaviors."

Even when a patient has exhibited at least 3 of 5 behavioral signs, it does not mean the patient's actions should be labeled as inorganic or pain behavior. Other important points made by Dr. Waddell in the 1998 Spine article include:

1. Conscious deception by a patient undergoing an examination is thought to be extremely rare.
2. Positive Waddell signs can result from fear by the patient of the doctor or facility and from chronic or long-term decreased function.
3. "The behavioral sign tests were designed specifically to identify behavioral responses in patients with low back pain. ...it should be recognized, however, that the patients with low back pain may have other problems. Neck pain or fibromyalgia, for example, may need to be considered as alternative explanations for behaviors elicited in the context of an assessment of low back pain." (See page 2369)
4. Behavioral signs testing "could be carried out consistently by different examiner. Inevitably, however, a degree of judgement is required. ...Consistent differences among assessors in the number of behavioral signs found may illustrate inconsistencies in the manner in which the signs are elicited, unwitting bias, or even prejudice." (See page 2369)
5. "Over-interpretation of individual signs is common. The original article clearly stated that the test is designed to identify a pattern of responses to physical examination." (See page 2369)
6. Dr. Waddell indicates that even where there is "clear evidence of behavioral responses to an examination", it must not be used to deny adequate and appropriate treatment for the underlying physical condition. "In such cases, pain management as well as surgery may be necessary." (See page 2370)
7. "Failure to recover from an injury should not necessarily be viewed with suspicion. An important and significant minority of patients become chronically incapacitated after injury, regardless of whether litigation is involved." See page 2370.

Other misuse or misinterpretation of the Waddell signs in the medical-legal context of traumatic personal injury occurs when the interpreter indicates the signs as deliberate or intentional faking. Dr. Waddell speaks clearly and forcefully when he states:

Perhaps the most serious misuse and misinterpretation of behavioral signs has occurred in medico-legal context. The signs frequently are used as an indication of faking or simulated capacity. It is certainly true that all sorts of behavior can be faked, and responses to examination are not exempt from this charge. As stated above, however, behavioral signs may be learned responses to pain that have developed since the original injury and of which the patient is largely unaware... it cannot be assumed de facto that the signs are evidence of simulation for the purpose of financial gain. ...they are not a reason to deny appropriate physical treatment. Some patients may require both physical management and their physical pathology and more careful management of the psycho-social and behavioral aspects of their illness. The signs should be used to decide not whether to offer treatment, but the type of treatment to offer. ...The behavioral signs are not on their own a test of credibility or veracity. Interpretation of the signs is only possible within the context of a broader clinical and psycho-social assessment. (See page 2370)

This paper provides a much needed refresher course in the proper use and framework of "Waddell" testing, especially in the context of insurance personal injury claims. It is significant that despite clear caveats by the author in the original 1980 study about the interpretation of the signs, they have been misinterpreted and misused both clinically and in the medical-legal and IME arenas to the extent Dr. Waddle felt the need to speak out through the second journal article.

Healthcare providers involved with insurance medical examinations are urged to read this article in its original form to ensure they are not among the doctors Dr. Waddell was addressing when he indicated the "Waddell signs" have become widely misinterpreted and misused especially in the medical-legal context. Healthcare practitioners and clinicians providing treatment also need to review and understand Dr. Waddell's article since they may be called upon to respond to or rebut reports written by insurance examiners. Knowledge by care providers and personal injury attorneys of the limitations and/or misuses of pain behavior testing is an important element in preventing insurance companies from wrongfully terminating a patient's access to health care.

The experienced personal injury attorneys at Adler Giersch, PS stand ready to assist you and your patients through our offices in Seattle, Bellevue, Everett and Kent.

¹ Waddell G, McCullough JA, Kummel E, Venner RM. "Nonorganic Physical Signs in Low Back Pain." Spine 1980; 5: 117-125

² Main CJ, Waddell G. "Behavioral Responses to Examination: A Reappraisal of the Interpretation of 'Nonorganic Signs'." Spine 1998; 23 2367-2371

³ Main CJ, Waddell G. Behavioral Responses to Examination: A Reappraisal of the Interpretation of "Organic Signs." Spine 1998; 23: 2367-71