Waddell's signs

Last updated
Waddell's signs
Differential diagnosis low back pain

Waddell's signs are a group of physical signs, first described in a 1980 article in Spine , and named for the article's principal author, Professor Gordon Waddell (19432017), a Scottish Orthopedic Surgeon. [1] [2] Waddell's signs may indicate non-organic or psychological component to chronic low back pain. Historically they have also been used to detect malingering in patients with back pain. While testing takes less than one minute, [2] it has been described as time-consuming and alternatives have been proposed. [3]

Spine is a biweekly peer-reviewed medical journal covering research in the field of orthopaedics, especially concerning the spine. It was established in 1976 and is published by Lippincott Williams & Wilkins. The current editor-in-chief is James N. Weinstein. Spine is considered the leading orthopaedic journal covering cutting-edge spine research. Spine is available in print, online, and on the iPad; there is an accompanying Spine blog. Spine is considered the most cited journal in orthopaedics.

Low back pain disorder involving muscles, nerves, bones of the back

Low back pain (LBP) is a common disorder involving the muscles, nerves, and bones of the back. Pain can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by duration as acute, sub-chronic, or chronic. The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people completely better by six weeks.

Malingering is the fabrication, intentional production, or significant exaggeration of physical or psychological symptoms or the intentional misattribution of genuine symptoms to an unrelated event or series of events designed to achieve a specific objective such as escaping duty or work; mitigating punishment; obtaining drugs; or receiving unwarranted recompense, such as disability compensation or personal damages award.


Use of Waddell's signs

Waddell, et al. (1980) described five categories of signs:

Straight leg raise

The straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test done during a physical examination to determine whether a patient with low back pain has an underlying herniated disc, often located at L5.

Any individual sign marks its category as positive. When three or more categories were positive, the finding was considered clinically significant. [2] However, assessing the patient on the basis of overreaction has raised concerns regarding observer bias and idiosyncrasies related to the patient's culture. Consequently, a practitioner may assess the patient on the remaining four categories, with two or more positive categories being considered clinically significant. [4]

In research, observer bias is a form of detection bias originating at a study's stage of observing or recording information. Different observers may assess subjective criteria differently, and cognitive biases can affect how a subject is assessed. For example, being aware of a subject's disease status may introduce a bias in how the outcome is assessed.

One or two Waddell's signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory. [5]

Hysteria colloquially means ungovernable emotional excess. Generally, modern medical professionals have abandoned using the term "hysteria" to denote a diagnostic category, replacing it with more precisely defined categories, such as somatization disorder. In 1980, the American Psychiatric Association officially changed the diagnosis of "hysterical neurosis, conversion type" to "conversion disorder".

The Minnesota Multiphasic Personality Inventory (MMPI) is a standardized psychometric test of adult personality and psychopathology. Psychologists and other mental health professionals use various versions of the MMPI to help develop treatment plans; assist with differential diagnosis; help answer legal questions ; screen job candidates during the personnel selection process; or as part of a therapeutic assessment procedure.


Although Waddell's signs can detect a non-organic component to pain, they do not exclude an organic cause. Clinically significant Waddell scores are considered indicative only of symptom magnification or pain behavior, and have been misused in medical and medico-legal contexts. Waddell's signs are not considered a de facto indicator of deception for the purpose of financial gain. [6]

In a 2003 review, Fishbain, et al. stated that Waddell's signs do not reliably distinguish organic from psychological pain but instead tend to underestimate the amount of pain that is actually experienced. [7] In a 2004 review, Fishbain, et al. concluded, "there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association". [8]

In 2010, a neuroanatomical basis of Waddell's signs has been proposed which argues that since the brain is organic, and even society is composed of a group of organic beings, the term "nonorganic" should be replaced by a term put forward by Chris Spanswick in 1997, "behavioral responses to physical examination." With the possible exception of cogwheel rigidity, these are best understood as neuroanatomical maladaptations to long-continued pain and, as Waddell and colleagues have stressed, do not indicate faking or malingering but rather that there are psychosocial issues that mitigate against successfully treating low back pain by lumbar discectomy, and which in themselves require other treatment. [9]

Related Research Articles

Back pain type of pain felt in the back

Back pain, also known as backache, is pain felt in the back. The back is divided into neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia based on the segment affected. The lumbar area is the most common area affected. Episodes of back pain may be acute, sub-acute, or chronic depending on the duration. The pain may be characterized as a dull ache, shooting or piercing pain, or a burning sensation. Discomfort can radiate into the arms and hands as well as the legs or feet, and may include numbness, or weakness in the legs and arms.

Schmorls nodes

Schmorl's nodes are protrusions of the nucleus pulposus of the intervertebral disc through the vertebral body endplate and into the adjacent vertebra.

Lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

Coccydynia is a medical term meaning pain in the coccyx or tailbone area, often brought on by a fall onto the coccyx or by persistent irritation usually from sitting.

Back injury damage, wear, or trauma to the bones, muscles, or other tissues of the back

Back injuries result from damage, wear, or trauma to the bones, muscles, or other tissues of the back. Common back injuries include sprains and strains, herniated discs, and fractured vertebrae. The lumbar spine is often the site of back pain. The area is susceptible because of its flexibility and the amount of body weight it regularly bears. It is estimated that low-back pain may affect as much as 80 to 90 percent of the general population in the United States.

Sacroiliac joint Joint of the pelvis and spine

The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The joint is strong, supporting the entire weight of the upper body. It is a synovial plane joint with irregular elevations and depressions that produce interlocking of the two bones. The human body has two sacroiliac joints, one on the left and one on the right, that often match each other but are highly variable from person to person.

Arachnoiditis Human disease

Arachnoiditis is an inflammatory condition of the arachnoid mater or 'arachnoid', one of the membranes known as meninges that surround and protect the nerves of the central nervous system, including the brain and spinal cord. The arachnoid can become inflamed because of adverse reactions to chemicals, infection from bacteria or viruses, as the result of direct injury to the spine, chronic compression of spinal nerves, complications from spinal surgery or other invasive spinal procedures, or the accidental intrathecal injection of steroids intended for the epidural space. Inflammation can sometimes lead to the formation of scar tissue and adhesion that can make the spinal nerves "stick" together, a condition where such tissue develops in and between the leptomeninges. The condition is extremely painful, especially when progressing to adhesive arachnoiditis. Another form of the condition is arachnoiditis ossificans, in which the arachnoid becomes ossified, or turns to bone, and is thought to be a late-stage complication of the adhesive form of arachnoiditis.

Failure to thrive condition of children whose current weight or rate of weight gain is much lower than expected

Failure to thrive (FTT) indicates insufficient weight gain or inappropriate weight loss in pediatric patients unless the term is more precisely defined. In children, it is usually defined in terms of weight, and can be evaluated either by a low weight for the child's age, or by a low rate of increase in the weight.

Spinal manipulation adjustment and manipulation of the vertebral column

Spinal manipulation is an intervention performed on spinal articulations which are synovial joints, which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse and costovertebral joints. National guidelines come to different conclusions with respect to spinal manipulation with some not recommending it, and others recommending a short course in those who do not improve with other treatments.

Sacroiliitis is inflammation within the sacroiliac joint. It is a feature of spondyloarthropathies, such as axial spondyloarthritis, psoriatic arthritis, reactive arthritis or arthritis related to inflammatory bowel diseases, including ulcerative colitis or Crohn's disease. It is also the most common presentation of arthritis from brucellosis.

Spinal cord stimulator

A Spinal Cord Stimulator (SCS) or Dorsal Column Stimulator (DCS) is a type of implantable neuromodulation device that is used to send electrical signals to select areas of the spinal cord for the treatment of certain pain conditions. SCS is a consideration for people who have a pain condition that has not responded to more conservative therapy.

Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain following back surgeries. Many factors can contribute to the onset or development of FBS, including residual or recurrent spinal disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness, spinal muscular deconditioning and even Cutibacterium acnes infection. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease.

Spinal disc herniation disease

Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including posture.

Radiculopathy Human disease

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. This can result in pain, weakness, numbness, or difficulty controlling specific muscles.

Diffuse idiopathic skeletal hyperostosis calcinosis that is the calcification or a bony hardening of ligaments in areas where they attach to your spine

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by abnormal calcification/bone formation ("hyperostosis") of the soft tissues surrounding the joints of the spine, and also the peripheral or appendicular skeleton. In the spine, there is bone formation along the anterior longitudinal ligament and sometimes the posterior longitudinal ligament, which may lead to partial or complete fusion of adjacent spinal levels. The facet and sacroiliac joints tend to be uninvolved. The thoracic spine is the most common level involved. In the peripheral skeleton, DISH manifests as a calcific enthesopathy, with pathologic bone formation at sites where ligaments and tendons attach to bone.

McKenzie method

The McKenzie method is a comprehensive method of care primarily used in physical therapy.

Sacroiliac joint dysfunction

Sacroiliac joint dysfunction generally refers to pain in the sacroiliac joint region that is caused by abnormal motion in the sacroiliac joint, either too much motion or too little motion. It typically results in inflammation of the sacroiliac joint, and can be debilitating.

Rheumatoid disease of the spine

Rheumatoid disease of the spine is a morbid consequence of untreated longstanding severe cervical spinal rheumatoid arthritis (RA)–an inflammatory autoimmune disease that attacks the ligaments, joints, and bones of the neck. Although the anterior subluxation of the atlantoaxial joint is the most common manifestation of the disorder, subluxation can also occur with posterior or vertical movement, and subaxial joints can also be involved.


  1. "Waddell, Gordon (Short academic biography with selected publications)". mh-hannover.de. Archived from the original on May 2, 2014. Retrieved June 23, 2015.
  2. 1 2 3 Waddell, Gordon; John McCulloch; Ed Kummel; Robert Venner (March–April 1980). "Nonorganic Physical Signs in Low-Back Pain". Spine . 5 (2): 117–125. doi:10.1097/00007632-198003000-00005. ISSN   0362-2436. OCLC   2589719. PMID   6446157.
  3. Blom, Ashley; Adrian Taylor; Sarah Whitehouse; Bill Orr; Evert Smith (September 2002). "A new sign of inappropriate lower back pain" (pdf). Annals of the Royal College of Surgeons of England . Royal College of Surgeons of England. 84 (5): 342–343. doi:10.1308/003588402760452682. ISSN   0035-8843. OCLC   2832178. PMC   2504150 . PMID   12398129.
  4. Kurt Hegmann, ed. (2007). "Low Back Disorders (revised)". Occupational Medicine Practice Guidelines (2 ed.). American College of Occupational and Environmental Medicine. pp. 43–44.
  5. Maruta T, Goldman S, Chan CW, Ilstrup DM, Kunselman AR, Colligan RC. (1997). "Waddell's nonorganic signs and Minnesota Multiphasic Personality Inventory profiles in patients with chronic low back pain". Spine. 22 (1): 72–5. doi:10.1097/00007632-199701010-00012. PMID   9122786.CS1 maint: multiple names: authors list (link)
  6. Main, Chris; Gordon Waddell (November 1998). "Behavioral Responses to Examination: A Reappraisal of the Interpretation of 'Nonorganic Signs'". Spine . 23 (21): 2367–2371. doi:10.1097/00007632-199811010-00025. ISSN   0362-2436. OCLC   2589719. PMID   9820920.
  7. Fishbain, David; Brandly Cole; R. B. Cutler; John Lewis; H. L. Rosomoff; R. Steele Rosomoff (5 June 2003). "A Structured Evidence-Based Review on the Meaning of Nonorganic Physical Signs: Waddell Signs". Pain Medicine . American Academy of Pain Medicine. 4 (2): 141–181. doi:10.1046/j.1526-4637.2003.03015.x. ISSN   1526-2375. OCLC   42267277. PMID   12911018.
  8. Fishbain, David; R. B. Cutler; H. L. Rosomoff; R. Steele Rosomoff (November–December 2004). "Is There a Relationship Between Nonorganic Physical Findings (Waddell Signs) and Secondary Gain/Malingering?". Clinical Journal of Pain . American Academy of Pain Medicine. 20 (6): 399–408. doi:10.1097/00002508-200411000-00004. ISSN   0749-8047. OCLC   11198567. PMID   15502683.
  9. Ranney, DA. A Proposed Neuroanatomical Basis of Waddell's Nonorganic Signs, Am J Phys Med Rehabil 2010;89: 1036-1042.