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A few tests to toss…Waddell Signs

When was the last time you have questioned a patient due to the non-anatomical features related to their work-related injury?  When was the last time you utilized Waddell signs to screen for  malingering?   I want to propose the argument that, in the light of recent developments in our understanding of pain neurophysiology, we should be very reserved in questioning our patient’s complaints.  In addition, I believe it is time that we drop the Waddell signs in the screening  for potential malingering/secondary gain due to lack of validity in the face of research on central sensitization. 

Definition:

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition has defined malingering as, “the intentional production of false or grossly exaggerated physical or psychologic symptoms motivated by external incentives, such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” Incentives, which are motivation for malingering, are known as secondary gains

What are the Waddell Signs?

In 1987, a physician by the name of Gordon Waddell published a paper entitled, “A New Clinical Model for the Treatment of Low-Back Pain”.  This paper was well-received and won the 1987 Volvo Award in Clinical Sciences.  The paper was revolutionary and provided a new theoretical framework for medical management of low back pain (due to Waddell’s increasing concern about medical mismanagement and patient disability).   In this paper, Waddell proposed the notion that the biopsychosocial concept can be used as an operational model that explains many of our patient’s clinical presentations.  He proposed that bed rest is harmful, and that there is no evidence to support that movement and activity is harmful.   He understood that management of this condition must change .  Unfortunately, this pivotal piece is lesser known for some of the concepts/ideas which are relevant even in today’s debates, and instead for a list of signs which he categorized as identifying magnified or inappropriate illness behavior.

  Below is a copy of this chart:

  Physical disease/normal illness behavior Magnified or inappropriate illness behavior
Pain Drawing
  • Localized, Neuroanatomic/Proportional
  • Non-anatomic, Regional, Magnified
Pain Adjectives
  • Sensory
  • Emotional
Symptoms
  • Localized pain, numbness in dermatomal patterns
  • Weakness in myotomal patterns
  • Time for recovery varies response to treatment varies

 

  • Whole leg pain, Tailbone pain, Whole leg numbness
  • Whole leg giving way
  • Never free of pain
  • Intolerance of treatments
  • Emergency admissions to hospital
Signs
  • Localized Tenderness
  • No lumbar pain with axial loading
  • No lumbar pain with simulated rotation
  • Limited straight leg raising on distraction
  • Sensory signs in dermatomal pattern
  • Motor signs in myotomal pattern
  • Appropriate pain responses
  •  Superficial, Widespread, Non-anatomic tenderness
  • Lumbar pain with axial loading
  • Lumbar pain with simulated rotation
  • Straight leg praise pain improves with distraction
  • Sensory signs in regional patterns
  • Motor signs in regional patterns
  • Overreaction responses

This chart, known in the paper as Table 7, is described in very short detail on page 638.  He recognizes that with the current understanding of low back pain, the responses in the right hand column do not make sense.  But to his credit, this is not his fault.  Melzack’s proposal of the neuromatrix was still more than a decade away.  But despite the lack of Melzack’s model, he discusses the biopsychosocial model and states, “the interaction between physical and psychologic factors determine the outcome of treatment.  Work loss and return to work are determined more by social fators than physical disease.  All these analysis confirm that the biopsychosocial concept of illness can be used as an operational clinical model which explains many of the observations on the natural history of low back pain and disability”.  This quote is quite ahead of its time and I would like to go on a limb to propose that Waddell pulled a “Nostradamus” and saw the future of medicine.  There were some concepts which showed a biomedical mindset such as, “we must develop methods of localizing the exact source of pain…” but overall he was quite revolutionary.

Waddell Signs and Central Sensitization

I have written a couple of times on the Mechanism-Based Classification of Pain.  When looking at the right hand column in Table 7 (above), one cannot ignore the extreme similarities between the proposed signs and symptoms and Central Sensitization.  Below is a review of the diagnostic criteria for central sensitization:

Central Sensitization:

  • Pain is disproportionate to the nature or extent of injury/pathology
  • Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to aggravating/easing factors
  • Strong association with maladaptive psychological factors
  • Diffuse/non-anatomic areas of pain/tenderness to palpation

So with our understanding of Central Sensitization, do you suspect the Waddell signs tell us a malingerer OR someone with a sensitized nervous system?  Can these tests be dumped from our infamous bag of tricks?  I think so….

Waddell G. A new clinical model for the treatment of low-back pain. Spine 1987; 12: 632-44.

Fishbain DA, Cutler RB, et al. Is there a relationship between nonorganic physical findings (Waddell Signs) and Secondary Gain/Malingering? Clin J Pain 2004; 20: 399-408.

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8 replies »

  1. Take a look at Waddell’s The Back Pain Revolution for his response to the misuse of the so-called “Waddell signs”. He never intended they be used to “detect” malingering (you can’t!) but instead intended they be an indication for further assessment of psychosocial factors influencing the person’s responses. Waddell was strongly influenced by his long friendship with Prof Chris Main, a clinical psychologist, and has been a longtime advocate for the biopsychosocial model, as were so many of the original IASP founders.

  2. I found what you had to say very interesting. Being a dinosaur I used those “Waddell Signs” when doing FCE’s to identify “symptom Magnifers”. As I recall those signs were very often positive in Comp Patients who just seemed off the chart in their behavior – for example – rating their pain as a 10 and laughing about it or rating the pain as very high yet continuing to perform box lifts where under normal circumstances that person should have been almost incapacitated with the high pain levels they were reporting. I don’t believe the test was ever designed to find malingers but symptom Magnifiers – there is a crucial difference between the 2. Anyway I think your idea is certaining an interesting one and I look forward to following the responses.

  3. Tim it is interesting that you bring up the ‘symptom magnifier terminology’ used with FCE’s. I used to do the Blankenship FCE many years ago and remember the terminology well. As I have started to understand central and peripheral sensitization from the many great pain scientist that have been shedding new light on to our understanding of pain over the past 10-15 years, I know see all of those patients I labeled as symptom magnifiers from back then as probably being central and/or peripheral sensitization patients. Before seeing them through strict biomedical model eyes, I now see them from a biopsychosocial model changes my view dramatically.

  4. As a patient I find the Waddell testing a little misleading and overused or in my case misused. My Doctor recently had me go through an FCE for Right SI Joint injury. I fell onto my back side. My pain is so severe I cannot sit or walk without crutches. The specialist performing the FCE was surprised that I was even there because of the shape I was in. I didn’t even complete most of the test, and I tried. I cried through the whole process. At one point they even had me lay down because the pain was getting so severe. I can’t lift my leg up in order to get into the bed so they even had to help with that and laid me on my left side. When I received the results from the Dr. he said I was 5/5 on the Waddell, 2/3 bell curve and said I was self limiting. Based on these results he said I was able to do Limited Work capacity, even though I can’t sit or walk without crutches. Even with crutches I have difficulty. As far as I can remember they didn’t do any Waddell testing on me at all. Please explain…I’m a little confused. Didn’t Mr. Waddell say not to use the tests for Malingering?

  5. As a former Workers Comp judge and a Federal judge now, I see Waddell’s routinely used as a lie detector. Surprisingly, few challenge this premise with the zealousness I would expect out of advocates (a.k.a. lawyers). My question to the medical profession is how can any doctor, knowing what we know about (1) the Waddell’s test; (2) the subjectively unmeasurable biopsychosocial aspect to pain; and (3) the DSM 5’s treatment of psychological malingering versus somatoform disorders, etc., continue to ethically use the test at all?

    • Thank you so much for these comments! I am in full agreement with you. Continued usage leads to a “post hoc ergo propter hoc” logical fallacy, especially in the absence of validation.

      It will take a while before Waddell Signs are dropped because many practitioners have yet to understand the science of pain (ironic, since we spend more money in the US on the management of pain, compared to any other sign, symptom or condition). As a judge, are you able to question the ethics of an expert presenting information that has questionable validity?

  6. Should the signs be dropped, or should the interpretation of them just be adjusted? I agree that they can’t show malingering definitively (and were not proposed by Dr. Waddell to do so), but misinterpretation of the results does not make them worthless tools. I still think that they are worthwhile in helping a doctor or PT understand how a patient experiences pain and can point to a need for treatment that incorporates behavioral and movement approaches.

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