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 Waddells 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 patients trunk to the right and left using the patients 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 patients 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 ones 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.
