In reviewing numerous medical records, including orthopedic and physical therapy reports, it is common to find mention of "The Waddell Test" and extensive reporting of examination findings featuring the results of its component maneuvers. These comments, will review the testing as it was originally described in its proper clinical application. Finally, some insights that can be used in formulating cross examination of expert witnesses who feature the Waddell test in their testimony will be discussed.
In permanent disability from workplace injury, physical and mental factors must be considered. It was the intent of Dr. Gordon Waddell(1) and his colleagues to distinguish and standardize "nonorganic" physical signs that sometimes accompany low back pain. Their larger goal was to help identify patients "who require more detailed psychological assessment". Presumably, patients with back pain that exhibit various nonorganic physical signs are individuals that would likely benefit from psychotherapy and psychotropic medication treatment primarily. These same individuals can likely avoid risky surgery.
The authors rejected the notion that their testing identifies malingerers or exaggerators. Among patients with more nonorganic signs were patients with conservative treatment failure, which sometimes resulted in multiple surgeries. Furthermore, nonorganic signs were equally common among litigants and non-litigants. In one group of ten patients with spinal infection or tumors, two had nonorganic signs. The authors caution: "It is safer to assume that all patients complaining of back pain have a physical source of pain in their back. Equally, all patients with pain show some emotional and behavioral reaction." Moreover, they assert, "Nonorganic signs, in the absence of other nonorganic symptoms, history, and behavior, must not prevent the physical assessment and investigation of such patients."
The presence of three or more of the following "nonorganic" signs is considered to be clinically significant:
1.Tenderness (excess or widespread reaction)
- Superficial
- Nonanatomic
1.Simulation (pain reported with sham maneuvers)
- Axial loading
- Rotation
1.Distraction (less pain when attention is diverted)
- Straight leg raising
1.Regional (widespread give-way or dysesthesia)
- Weakness
- Sensory
1.Overreaction ("disproportionate" psychomotor responses)
These signs are only valid if the examiner is "non-obtrusive". Attempts were made to correlate nonorganic clinical signs with radiographs, but CT scan and EMG is not mentioned; MRI was not yet available. The authors correlated the finding of multiple nonorgainc signs with "neurotic" behavior. (In today's parlance, the term "mood disorder" would be considered appropriate.)
The authors recognize the fact that a finding of "overreaction" may be biased by the observer. Furthermore, they realize that, even with a "proven and treatable physical lesion", persons with multiple nonorganic signs may need psychological assessment. Finally, the authors caution that these signs do not substitute for a standard psychological evaluation.
Unfortunately, various court cases resulting in denial of Workers' Compensation benefits contained unchallenged expert testimony that a positive result on Waddell testing demonstrated "symptom magnification",(2) "negative findings",(3) and "exaggerating".(4)
In keeping with the authors' original intent, here are some areas to consider for cross examination:
Q. Your examination elicited some nonorganic signs. What are nonorganic signs?
Q. Does the presence of nonorganic signs exclude all pathology in the low back?
Q. Can persons with serious low back pathology exhibit nonorganic signs?
Q. Please define "excess" reaction to palpation?
Q. How are you certain the patient was distracted when you were testing for nonorganic signs?
Q. How much reaction is "overreaction"?
Q. Are you certain that your examination technique did not influence any of the findings?
Q. Are you aware of any studies reporting treatment outcomes in persons with or without nonorganic signs?
Q. Are you aware that the "simulation" items of axial loading and rotation were proven to have poor interrater reliability? (5)
Q. Are you aware that "overreaction" was proven to have low interrater reliability? (6)
Q. Did you take a psychological or psychiatric history? Why not?
Q. You made a finding of multiple nonorganic signs. Did you refer the patient for psychological testing? Why not? When is it appropriate to make such a referral?
Q. Are you aware of any DSM-IV diagnosis whose criteria requires the presence of nonorganic signs?
Q. To your knowledge, are any psychiatric diagnoses made solely on the basis of physical findings?
Q. Are you aware of the adoption of nonorganic signs as diagnostic criteria by any medical organization?
Q. Does the presence of nonorganic signs mean there is no disability?
Endnotes:
1.Waddell G, McCulloch JA, Kummel E, Venner, RM: Nonorganic Physical Signs in Low-Back Pain. Spine 5:117-125, 1980. Dr. Waddell was a Scottish physician
who conducted a study in the late 1970's evaluating a patients' subjective complaints in relationship to objective findings.
2.Pierce v. Louisiana Maintenance Service, Inc., 668 So.2d 1232 (La.App. 5 Cir. 1996).
3.Danzy v. Evergreen Presbyterian Ministries, 657 So.2d 491 (La.App. 3 Cir. 1995)
4.Tharpe v. Henry I.Siegel Company, et al., No. 02S01-9405-CV-00021, 1995 WL 866422 (Tenn. Jan. 3, 1995), Cooper v. Insurance Company of North America, 884 S.W.2d 446 (Tenn. 1994).
5.Korbon GA, DeGood DE, Schroeder ME, Schwartz, DP and Shutty MS: The development of a somatic amplification rating scale for low-back pain. Spine, 12:787-791, 1987.
6.Id.