Waddell's Nonorganic Signs in low back pain are being misused, particularly by personal injury defence counsel. Physical medicine specialists usually have no special expertise in the assessment and interpretation of illness behaviour. Waddell Signs do not predict a client's response to multidisciplinary management.
Waddell's Nonorganic Signs in low back pain are being misused, particularly by personal injury defence counsel. Nearly 20 years after Waddell first described his "simple methods for the assessment of distress and illness behavior in chronic low-back pain" 1, 2, the authors of a recent paper point out that Waddell Signs were not designed to test sincerity of effort 3.
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PRACTICE POINT Be prepared to examine non-psychiatric medical experts about their special training in psychosomatic medicine |
Other investigators, while finding a loose relationship between total Waddell Score and indicators of resistance to therapy, found no correlation with the validity scale of the Minnesota Multiple Personality Inventory (MMPI) 4. There remain no reliable and valid methods of determining genuineness of maximal exertion.
Physical medicine specialists usually have no special expertise in the assessment and interpretation of illness behaviour. Waddell's Signs were developed as convenient indicators which could be derived from routine clinical examination of low back pain. At most they signal a need for multidisciplinary diagnosis 5.
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PRACTICE POINT For the litigator, an expert medical report identifying Waddell Signs should be a reminder to obtain psychiatric expert opinion on Somatoform Disorder and Malingering |
Orthopedic surgeons, physiatrists and rheumatologists are not specially trained in the interpretation of illness behaviour, and personal injury counsel should object to witness examination that implies such special expertise.
General and family practitioners are better trained in psychosomatic medicine, the integration of psyche, the mind, with soma, the body. The true experts are medicolegal sub-specialists from psychiatry who, in contrast with psychologists, also have formal training in "physical" medicine.
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PRACTICE POINT For chronic pain, the appropriate management is multidisciplinary and the prognosis is determined by litigation status, and not by the presence of somatisation |
Waddell Signs do not predict a client's response to multidisciplinary management. Though they have prognostic value in the outcome of acute backache, the Signs have no power to predict outcome after multidisciplinary management of the chronic Low Back Pain that, of course, more commonly features in personal injury litigation 6. As the authors of this paper point out, consistency between the various therapists in their handling of symptoms prevents somatisation from becoming a barrier to recovery from disability.
A structured, evidence-based review7 of all the available studies addressing the concept of non-organic findings concluded:
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PRACTICE POINT Waddell Signs: 1 do not correlate with psychological distress 2 do not discriminate organic from non-organic problems 3 may represent an organic phenomenon 4 are associated with poorer treatment outcome 5 are associated with greater pain levels 6 are not associated with secondary gain |
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