Overview of Waddell Sign
In 1980, Professor Gordon Waddell, an orthopedic surgeon, identified a set of eight physical signs, known as Waddell signs. He originally developed these signs as a way to determine which patients with lower back pain might not benefit from lower back surgery. Nowadays, doctors use these signs to identify psychological elements of lower back pain in patients. This has grown to include identifying patients who may be exaggerating their symptoms, for example, to create doubt about the validity of car accident insurance claims or to find psychological factors in other types of pain that’s not in the lower back.
In a 1998 article, Main and Waddell highlighted that these physical signs have often been misunderstood and misused, both in the clinic and in legal situations. They stressed the importance of considering back pain not only as a physical problem but also as something that can be influenced by a person’s psychological and social situation. They explained that a person’s behavior, such as showing Waddell signs, may be influenced by fear of further injury or developing long-term disability and does not necessarily indicate dishonesty. They concluded that patients showing Waddell signs may need treatment for both the physical and the psychological aspects of their condition.
Anatomy and Physiology of Waddell Sign
Waddell signs are simply tools created to help doctors assess people who are suffering from lower back pain.
Why do People Need Waddell Sign
If you’re experiencing lower back pain, your doctor may check for something called Waddell signs during your physical examination. Waddell signs are certain behavioral responses that could suggest your pain is influenced by psychological factors. However, there’s no set rule on when or how often to check for these signs.
Please remember that if your doctor sees signs of Waddell, it does not necessarily mean your pain is “all in your head”. Rather, it is an alert for the doctor that your mental state might be affecting your physical pain. In this case, they may recommend a more comprehensive mental health evaluation. This approach can provide useful information to give a more complete overview of what might be causing your back pain.
When a Person Should Avoid Waddell Sign
There are no official rules against doing certain physical tests known as Waddell signs. However, care should be taken when doing these tests, especially a few particular ones. These specific tests include the axial loading test, the acetabular rotation test, and the distracted straight leg test. For example, the axial loading test shouldn’t be done on people with serious injuries to the neck or upper spine. Similarly, the acetabular rotation test should be avoided if there’s damage in the hip joint, something like labral tears which are tears in the ring of cartilage that goes around the hip joint.
Equipment used for Waddell Sign
No specific medical tools are required for this procedure. It’s best if you, the patient, are either sitting upright in a chair or lying flat on your back in bed when your doctor tests for Wadell signs.
Who is needed to perform Waddell Sign?
It’s best to have a doctor who specializes in physical medicine and rehabilitation or pain management. These doctors have had extra training so they can better help people who are dealing with physical injuries or pain.
How is Waddell Sign performed
The Waddell signs are a group of physical tests that doctors use to understand if a patient might be experiencing pain more from their mind’s response to the injury rather than the injury itself. Here’s what the tests look like:
* Superficial tenderness: The doctor gently touches or pinches the skin over a wide area of the lower back. If this light touch causes pain, this is a positive sign.
* Non-anatomical tenderness: This test checks if the patient feels deep pain over a wide area that doesn’t match up with one specific structure and crosses areas that wouldn’t usually be connected in terms of pain reaction.
* Axial loading: The doctor puts a downward pressure on the top of the patient’s head. If this causes lower back pain, this is suggestive of a positive sign.
* Acetabular rotation: In this test, the doctor gently and simultaneously externally rotates the patient’s shoulder and pelvis together while the patient stands. If pain occurs within the first 30 degrees of rotation, it is considered a positive test.
Another unique test is the straight leg raise discrepancy. This test is done when the patient lies flat on their back (supine) and the doctor lifts the patient’s leg without bending the knee. If this causes pain, but the same movement doesn’t cause pain when the patient is seated, it suggests a positive sign. This test is designed to identify if the pain is a result of distraction or an actual physical concern.
Two other checks are done for regional sensory disturbance and regional weakness. In the first test, the doctor checks if the patient experiences decreased sensation like wearing a stocking rather than following the pattern of a specific nerve region. In the second test, the doctor observes if there is weakness, jerky movements or the giving way of many muscle groups that can’t be explained based on the anatomy and function of the nerves.
Lastly, the doctor looks for an overreaction. This means that the patient has a response to a painful stimulus that seems disproportionate or exaggerated and does not happen again when the same test is done later. This overreaction could be noted in the patient’s verbal expression, facial expression, muscle tension, or shaking.
What Else Should I Know About Waddell Sign?
Doctors use eight specific tests, grouped into five categories, to identify and understand a patient’s pain. These categories look at surface-level pain, pain in areas not usually associated with the examined body part, how your body responds to simulated joint movements, your body’s reaction when distracted, changes in skin senses and muscle strength, and excessive reactions or body movements.
If a patient shows three or more of these signs, it might suggest that they’re experiencing more pain than expected based on their physical symptoms. This could mean that psychological factors or behaviors are also affecting their pain. But it’s important to note that grouping these signs into categories may not provide a detailed understanding of the patient’s pain experience. So, it can be more helpful to consider every individual sign separately.
There’s a lot of ongoing research on what these signs could mean. One research review found that these signs don’t necessarily mean a patient is experiencing psychological distress or faking their symptoms. They also don’t clearly distinguish between physical and non-physical problems. Patients showing these signs often have worse outcomes from treatment and higher levels of pain, but it’s not always because they’re hoping to gain something, like money or attention.
Another article challenges the idea that these signs mean there’s no physical cause for a patient’s pain. It argues that our understanding of the brain and nerves could explain these signs as the body’s abnormal responses to pain. For example, the article suggests that pain on the skin’s surface could represent abnormal sensitivity caused by changes in nerve function. It also suggests that ‘overreacting’ might be due to the body’s harmful responses to nerve damage or changes in the patient’s personality before the discomfort started.
The signs can also be related to changes in how our nerve connections process pain. A painful event can cause new pain-related nerve connections to form in our spines, which can make us feel pain in different parts of our body. For these reasons, it’s recommended that doctors don’t label these signs as “non-physical”, as this can be misleading. Instead, they’re encouraged to see them as a patient’s “behavioral responses to a physical examination”.