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Waddell's signs

Discussion in 'PM&R' started by Diamox, Dec 21, 2008.

  1. Diamox

    10+ Year Member

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    There's been very little chat on this forum recently about anything involving the actual content of Physiatry. So I'll pose a question and see if we can generate some discussion.

    In the last few months I've been told by a few sources that G.Waddell has since began to refute his original hypothesis about the infamous 'signs' in LBP. Can any body corroborate this? I'll see if I can drag his original paper..

    cheers
     
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  3. PMR 4 MSK

    PMR 4 MSK Large Member
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    Last I heard he simply warned people about the over-use of the "signs." Basically saying these do not mean someone is malingering, moreso that one needs to look for alternative sources of pain and disability.

    I mostly avoid documenting them unless I feel strongly that there are serious secondary gain issues that overwhelm the injury, such as in some Work Comp pts.
     
  4. SSdoc33

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    this is how the story reads to me:

    1. waddell: ok, here are 5 signs to tell if people who say they have back pain are faking.

    2. overly politically correct medical community: hey, thats not fair, you are discriminating, people really do have pain yada yada yada.....

    3. waddell: here are five signs that may indicate non-organic back pain......


    personally, i think he was right the first time
     
  5. rehab_sports_dr

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    Waddel signs are one of the most misinterpreted findings in physiatry

    They were originally described to predict people who would have poor outcome from back surgery. Those who had 4 or more positive Waddell signs were less likely to have a good outcome

    There was NO implication of why they were having a bad outcome

    Waddell signs are useful as a predictor of poor outcome in spine surgery.

    They are not appropriate, however, it interpreting the intent of the patient- such as "non-organic" cause or malingering
     
  6. ampaphb

    ampaphb Interventional Spine
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    Rarely do I disagree with the esteemed rehab_sports_dr, however, Dr. Wadell's original article states:

    Nonorganic physical signs in low-back pain.

    Waddell G, McCulloch JA, Kummel E, Venner RM.
    Nonorganic physical signs in low-back pain are described and standardized in 350 North American and British patients. These nonorganic signs are distinguishable from the standard clinical signs of physical pathology and correlate with other psychological data. By helping to separate the physical from the nonorganic they clarify the assessment of purely physical pathologic conditions. It is suggested also that the nonorganic signs can be used as a simple clinical screen to help identify patients who require more detailed psychological assessment.

    Spine. 1980 Mar-Apr;5(2):117-25.
    PMID: 6446157
     
    #5 ampaphb, Dec 23, 2008
    Last edited: Dec 23, 2008
  7. rehab_sports_dr

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    I stand corrected. Thanks.
     
  8. SSdoc33

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    ahh, but that was what he said in 1980. getting back to the OP, i think he softened his stance a bit.
     
  9. Ludicolo

    Ludicolo Fib Hunter
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    Hard to believe Waddell’s original article is almost 30 years old. Thought you guys might like something a little more recent:

    A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs.

    Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS.

    STUDY DESIGN: This is a structured, evidence-based review of all available studies addressing the concept of nonorganic findings: Waddell signs (WSs).

    OBJECTIVES: To determine what evidence, if any, exists for the various interpretations for the presence of WSs on physical examination.

    SUMMARY OF BACKGROUND DATA: WSs are a group of eight physical findings divided into five categories, the presence of which has been alleged at times to have the following interpretations: Malingering/secondary gain, hysteria, psychological distress, magnified presentation, abnormal illness behavior, abnormal pain behavior, and somatic amplification. At the present time, there is, therefore, significant confusion as to what these findings mean.

    METHODS: A computer and manual literature search produced 61 studies and case series reports relating to WSs. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: 1) Reliability (test-retest); 2) Reliability (inter-rater); 3) Reliability (factor analysis); 4) Validity, psychological distress; 5) Validity, correlation Minnesota Multiphasic Pain Inventory (MMPI); 6) Validity, correlation abnormal illness behavior; 7) Validity, other behaviors; 8) Validity, as a nonorganic phenomenon; 9) Validity, correlation pain drawing; 10) Validity, functional performance; 11) Validity, treatment outcome; 12) Validity, predicting surgical treatment outcome; 13) Validity, return to work outcome; 14) Validity, secondary gain correlation; and 15) Validity, pain correlation. Each study in each topic area was classified according to the type of study it represented according to the type of evidence guidelines developed by the Agency for Health Care Policy and Research (AHCPR). In addition, a list of 14 study quality criteria was used to measure the quality of each study. Each study was categorized for each criterion as positive, (criterion filled), negative (criterion not filled), or not applicable independently by two of the authors. A percent quality score was obtained for each study by counting the total number of positives obtained, dividing by 14 minus the total number of not applicables, and multiplying by 100. Only studies having a quality score of 75% or greater were used to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies in each topic area (above) was then categorized according to the strength and consistency AHCPR guidelines. Conclusions of this review for each topic area are based on these results.

    RESULTS OF DATA SYNTHESIS: Of the 61 studies, four had quality scores below 75% and were not used to generate the results of this review. According to the AHCPR guidelines for strength and consistency of the reviewed data, the following results were obtained: 1) There was consistent evidence for WSs being associated with decreased functional performance, poor nonsurgical treatment outcome, and greater levels of pain; 2) There was generally consistent evidence for WSs not being associated with psychological distress, abnormal illness behavior, or secondary gain; 3) There was also generally consistent evidence that WSs are an organic phenomenon and that they cannot be used to discriminate organic from nonorganic problems; 4) There was inconsistent evidence that WSs do demonstrate inter-rater reliability, do not correlate with the neurotic triad of the MMPI, are associated with poorer surgical treatment outcome, and are associated with nonreturn to work; 5) There was little or no evidence that WSs demonstrate test-retest reliability, or reliable factors, and are associated with self-esteem problems, catastrophizing, or the nonorganic pain drawing.

    CONCLUSIONS: Based on the above results, the following conclusions were made: 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.

    Pain Med. 2003 Jun;4(2):141-81.
    PMID: 12911018
     
  10. drusso

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    Waddell's "signs" are not "signs" in the sense that McMurphy's sign or Apprehension sign actually reflect underlying pathology, but they can be hypothesis generating when assessed appropriately...
     
  11. Diamox

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    Well put SSDoc33.


    Poor test-retest reliability, greater pain, poorer surgical outcome, and organic disease. It sounds like these signs may be validating patients with central sensitization +/- psychosocial overlay. Any thoughts?

    Certainly I agree with Drusso in that they can be used to get a gestalt of what's going on.
     
  12. ampaphb

    ampaphb Interventional Spine
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    Behavioral responses to examination. A reappraisal of the interpretation of "nonorganic signs".

    Main CJ, Waddell G.
    Waddell et al in 1980 developed a standardized assessment of behavioral responses to examination. The signs were associated with other clinical measures of illness behavior and distress, and are not simply a feature of medicolegal presentations. Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medicolegally. Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding. Isolated signs should not be overinterpreted. Multiple signs suggest that the patient does not have a straightforward physical problem, but that psychological factors also need to be considered. Some patients may require both physical management of their physical pathology and more careful management of the psychosocial and behavioral aspects of their illness. Behavioral signs should be understood as response affected by fear in the context of recovery from injury and the development of chronic incapacity. They offer only a psychological "yellow-flag" and not a complete psychological assessment. Behavioral signs are not on their own a test of credibility or faking.

    Spine. 1998 Nov 1;23(21):2367-71.PMID: 9820920
     
  13. ampaphb

    ampaphb Interventional Spine
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    Dr. Fishbain is bit of a nihilist, believing the only way to tell anything about pain patients is through extensive psychoanalysis (any surprise that he is a psychiatrist?). For "the rest of the story," however -


    Effectiveness of Waddell's nonorganic signs in predicting a delayed return to regular work in patients experiencing acute occupational low back pain.


    Gaines WG Jr, Hegmann KT.
    Department of Occupational and Environmental Medicine, Scott and White Clinic, Texas A & M Health Sciences Center, Texas A & M University, USA. [email protected]

    STUDY DESIGN: Consecutive case series. OBJECTIVE: To determine whether the presence of Waddell's nonorganic signs in occupational, acute low back pain patients predicts a longer time before return to unrestricted regular work.

    SUMMARY OF BACKGROUND DATA: Waddell's nonorganic signs identify patients with chronic low back pain with a poor prognosis; however, they have not been used as an outcome predictor in patients with occupational, acute low back pain.

    METHODS: Standardized histories and physical examinations, including Waddell's signs were recorded at the first clinic visit (n = 143) by a single physician who was not blinded to the study's goals or methods. Those with chronic low back pain or complicating medical conditions (n = 88) were excluded. Data from patients exhibiting the nonorganic signs were compared with those from patients without the signs for time to return to regular work without restrictions and medical resource use.

    RESULTS: Fifty-five patients with acute work-related low back pain were included. One or more of the nonorganic signs were seen in 14 patients (25.5%) at the first appointment. The most common signs were simulated axial loading (78.6%) and simulated rotation (71.4%). Those with any nonorganic sign required a median 58.5 days to return to regular work compared with 15.0 days for those without (P < 0.0001). Patients exhibiting any nonorganic sign compared with those without used more physical therapy (50.0% vs. 12.2%; P < 0.01) and lumbar computed axial tomography (21.4% vs. 0.0%; P = 0.01).

    CONCLUSIONS: Patients with acute, occupational low back pain exhibiting Waddell's nonorganic signs had a four times lengthier time for return to unrestricted, regular work and a greater use of physical therapy and lumbar computed tomographic scans.

    Spine. 1999 Feb 15;24(4):396-400; discussion 401.PMID: 10065525
     
    #12 ampaphb, Dec 25, 2008
    Last edited: Dec 25, 2008
  14. ampaphb

    ampaphb Interventional Spine
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    I also thought this was interesting - I know we all think through some of them iontuitively, but does anyone do as a formal test in addition to Waddell's?

    Cervical nonorganic signs: a new clinical tool to assess abnormal illness behavior in neck pain patients: a pilot study.

    Sobel JB, Sollenberger P, Robinson R, Polatin PB, Gatchel RJ.
    OBJECTIVE: To develop and assess the reliability of a group of cervical nonorganic physical signs to be used as a simple screening tool for identifying patients with low neck pain who exhibit abnormal illness behavior.

    DESIGN: Survey, consecutive sample. DATA SET: Double masked.

    SETTING: Functional restoration program.

    PATIENTS: Twenty-six consecutive patients with complaints of chronic neck pain (greater than 4 months duration). Each patient was evaluated by a physician and then again by either a physical or occupational therapist, for the presence of specific cervical nonorganic signs. Both of the evaluations occurred on the same day.

    MAIN OUTCOME MEASURES: Five categories consisting of eight tests were appraised: (1) tenderness, (2) simulation, (3) range of motion, (4) regional disturbance, and (5) overreaction.

    RESULTS: The percent agreement between raters ranged from a high of 100% for regional sensory disturbance, to a low of 68% for one of the simulation tests. The average agreement between raters across all of the nonorganic test signs was 84.6%. Likewise, kappa coefficients ranged from 1.00 to .16, reflecting differences in strength of agreement.

    CONCLUSION: For many years, the lumbar nonorganic signs (developed by Waddell and colleagues) have been a useful screening tool in the assessment of abnormal illness behavior in the low back pain population. For the first time, a group of cervical nonorganic signs have been developed, standardized, and proven reliable.

    Arch Phys Med Rehabil. 2000 Feb;81(2):170-5.PMID: 10668770



    Methods:

    Examination Technique
    A standardized set of eight physical examination signs, classified into five categories, was developed for this study. As a starting point, some of Waddell’s lumbar nonorganic signs were extrapolated to the cervical spine, and an additional three signs were specifically developed for this project. The eight signs and five categories are as follows:

    Tenderness. Superficial.
    Examiner palpates the cervical spine region, comprised of the posterior aspect of the cervical and upper thoracic spine.

    Nonanatomic.
    The areas of the cervical, thoracic, lumbar, and brachial regions are deeply palpated. If the patient also had concomitant low back pain, then pain on deep palpation of the low back was discounted and the region of the arm was added to the criteria

    Simulation.
    When a simulation test is performed, the patient is under the assumption that the painful area is being tested when. in reality, it is not. A test is considered positive if the subject reports pain with the physical exam maneuver.

    Head/shoulder/trunk rotation in the sitting position.
    With the patient sitting on the examination table, facing the examiner, the clinician rotates the patient’s trunk to the right and left using the patient’s shoulders. Care must be taken to observe that the patient is rotating his or her head in the same plane as the shoulders.

    Head/shoulder/trunk/pelvis rotation while standing.
    Similar to the sitting test, the examiner rotates the patient’s shoulders, trunk, and pelvis to the tight and left as one unit. Care must be taken to observe that the patient is rotating his or her head in the same plane as the shoulders/trunk/pelvis

    Range of motion. Cervical rotation.
    The examiner asks the seated patient to rotate his or her head as far as possible to the right and then left This test was devised based on the fact that the majority of cervical rotation occurs in the upper cervical spine, and the majority of cervical spine lesions are in the mid to lower cervical spine.

    Regional disturbance.
    For motor or sensory changes to be classified under this category, the deficit has to fall out of what is considered normal neuroanatomy. For example, a patient who reports loss of sensation involving half of the body or an entire upper extremity would be considered to fall into this category
    as long as multiple nerve root or peripheral nerve injury has been ruled out. It must be emphasized that care must be taken to rule out multiple nerve root or peripheral nerve injuries before considering that either or both of the regional disturbance subcategories are positive.

    Sensory loss.
    For this test to be considered positive, the patient must report diminished sensation to either light touch or pinprick in a pattern that does not correspond to a specific dermatome of a nerve root(s) or peripheral nerve(s). Frequently, patients will report loss of sensation of the entire upper extremity, or below the elbow.

    Motor loss.
    On formal manual muscle testing, weakness is detected in a nonanatomic pattern. The hallmark of this test is “giveaway weakness.” In addition, a test would also be considered positive if, on observation, the patient demonstrates normal muscle strength. but on formal testing exhibits weakness. As an example, the patient uses his or her elbow extensors to get up onto the examination table, but is then noted to have less than antigravity strength on manual muscle testing of the elbow extensors.

    Overreaction.
    In this study, this category was considered positive if the examiner felt that the patient was “overreacting” during the examination. See table 1 for examples of overreaction. For the clinician, this is a very subjective category, and therefore, care must be taken not to let one’s own emotional feelings about the patient interfere with the assessment of whether or not the patient is overreacting to the examination. In addition, the examiner must take into account that there can be a considerable degree of cultural variation in the response to painful maneuvers.
     

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