MY CASE JUST GOT WADDELLED!, OR DID IT?

Your mind shifts to what the jury will get out of "non-organic" and then the hammer hits.

"In other words, if you have so many Waddell signs, you have to, it leads you to the conclusion that the patient is faking the response to your test, or some kind of psychological implications, or that they have some kind of functional overlay."

Some of this the jury may not get but it surely will understand the word faking. The adverse then goes for the death blow.

"Dr. Waddell was an orthopedist that won an award of the year for his research, the research that he did, and the establishment of these signs. And it is generally known, Waddell signs are often stated that if someone has three out of five positive Waddell signs, they are faking. An example would be a 16-year old who was to take a test at school on Friday, and he should have been studying for it on Thursday night, so he gets up in the morning and tells his mom on Friday, I can't go to school because my tummy hurts. And if this patient was examined, he probably would demonstrate that, if you touch his tummy, that would hurt and that would be a Waddell sign. And so, they are having their symptoms for secondary gain. He has not prepared for the test and so his reason for not going to take the test is that he has a stomach ache and he doesn't have to go to school. That is a simplistic example or explanation of what this Waddell's and functional overlay problem is."

You have heard enough so you hit the defense with a battery of objections which include lack of foundation, relevancy, non-responsive, and undisclosed opinion. Hopefully, by the time the objection is argued, you will be able to strengthen these objections further. Thanks to some direction that I received at a recent CLE2, there is a lot more that can be done to take care of this opinion.

THE WADDELL SIGNS

In 1980, Dr. Gordon Waddell and group of colleagues did a study concerning the prospective results of twenty clinical signs in 350 patients. They focused on eight signs which identified non-structural problems in patients with low back pain3. As time has progressed, they have identified additional potential signs and also other factors that need to be looked at. Physicians who initially looked at these results came to the conclusion that three positive signs could be read to indicate the person was malingering and suffering no physical or "organic" problems.

In 1993, Hayes et al., concluded that patients receiving compensation show greater signs of behavioral inconsistency than those not receiving compensation4. This was followed in 1999 with the work of Dr. P. Douglas Kiester and Alexandra D. Duke, "Is it malingering or is it real?"5 Dr. William Gaines and Kurt Hegmann studied if the findings of positive Waddell signs took people off work and concluded that even one positive Waddell's non-organic sign could suggest that a person would be off work up to 4 times longer than a person who had no positive signs.6 The magic test had been found to see if people had a "real" injury. Many adverses stopped reading.

IT'S NOT THAT SIMPLE

From the start, the test was only intended for people with low back pain, the test was not recommended for older patients and never for the elderly, the possibility did exist for behavioral signs to exist even where there were organic problems, and that isolated behavioral signs should not be considered clinically significant.

As Dr. Waddell continued his work, he found that with the "acute injury" illness behavior was usually proportionate to the physical findings but "chronic pain, chronic disability, and chronic illness behavior", in contrast became dissociated from the physical problem, and there may be very little evidence of any remaining tissue damage. Instead, chronic pain and disability became increasingly associated with emotional distress, depression, disease, and illness behavior.7He concluded that with psychologic disturbances or even exaggeration "a more detailed test is then required of the patient's whole pattern of behavior." Later in 1991, Dr. Waddell added that with his low back studies there is a relationship between pain, anxiety and perceived control in improvement noting that psychological work up was required to deal with individual's pain beliefs and coping strategies.8

In the 1990's, different groups of physicians began comparing the Waddell signs to other lumbar testing methods:

In 1991, Gabriel Hirsch et al., compared the relationship of Waddell scores to lumbar dynamometry and concluded that further research needed to be done with psychological testing.9

Carl Chan et al., compared the Waddell signs to individual's use of pain drawings concluding that those patients with positive signs "could benefit from a full psychologic assessment as part of the treatment program."10

Dr. Mark Werneke compared the signs they used in a work/physical rehabilitation program and concluded "the tool is not a diagnosis for a psychiatric disorder and does not rule out anatomic problem. It simply shows the health care provider AIB (abnormal illness behavior) may be present as a coping strategy and that other learned cognitive and behavioral patterns and psychological instances may need to be addressed to improve treatment outcome."11

Dr. Michael R. Menard et al., compared the test to the performance of the worker's in comprehensive motor performance evaluations concluding "even if a psychometric test predicted with a high level of sensitivity and specificity a clinically important event, such a future occurrence of an episode of low back pain, it still would not be adequate in a screening setting, and should not be decisive in a legal setting, because of the substantial false/positive and false/negative rates."12

Dr. Toshihiko Maruta et al. looked at Waddell's and the Minnesota Multiphasic Personality Profiles (MMPI) and found that there may be different results in the way males react vs. females and concluded that caution must be taken in the "inclusion of Waddell's scores in planning treatment and in determining psycho social aspects of patients with low back pain is indicated, particularly with female patients."13

Dr. Alexander Vendrig et al. suggested in evaluating back pain in comparison to analysis of the MMPI-2.14 One potential reason for this association between complaints and pain behavior in men is a possibility of denying body signals and being "tough" (traditional masculine characteristic) actually producing the opposite effect in the long run. There is even experimental evidence showing the under-prediction of pain to be followed by an exaggerated fear of pain, subsequent over-prediction, and possible avoidance behavior.

WADDELL'S OWN EXPANSION OF THE WORK

Contemporaneous with the number of the studies that have been done using the Waddell's test, Dr. Waddell has continued his own expansion of the work. Working in a contributing factor to Dr. Chris Maine et al. attempts were made to come up with a "simple patient classification."15 This study concluded that "ineffective or failed treatment makes people worse psychologically." Of note, this study also found that the individuals that were identified at risk, distressed, depressed, and distressed/somatic showed no signs that they were "distorting their self-report by defensiveness or faking."

In 1992, along with Dr. James Richardson, Dr. Waddell linked his test to those of the Keefe and Block systematic observations of specific overt pain behaviors from a psychological perspective on the taxonomy of pain. Individual pain behaviors of guarded movement, bracing, rubbing, grimacing and sighing were defined.16 In doing the comparison, problems were identified as:

• 1. Levels of reproducibility was not as high
• 2. Fundamental problems appeared to be needed for the examiner to carry out their series of physical maneuvers while simultaneously and continuously observing overt pain behavior during the whole period of examination.
• 3. The physician may consciously or unconsciously bias the findings by his technique in manner of examination.
• 4. Since all behavior observations have the potential for activity, the clinical examination can be affected by the way the examiner applies painful stimuli to the patient in pain.17

In 1992, Waddell et al. indicating that an ideal would be to combine the various elements of pain, the physical impairment attributed to it and disability alleged to derive from it into a single overall measurement of severity for clinical, legal and comprehensive compensation purposes. Searching for that ideal, the following items were noted:

• 1. Due to lack of reliability, four physical tests - pelvic tilt, sacral angle and separate measurements of lumbar and pelvic extension were thrown out as being unreliable.
• 2. Even the most sophisticated discriminating analysis based on mathematical computations of all the individual physical tasks failed to demonstrate any objective impairment in 70% of patients which may be interpreted as a high false negative rate.
• 3. It is never possible to separate clinical examination of pain entirely from cognitive and behavioral influences.
• 4. Finally, that there are implications that the most chronic low back pain can be helped with rehabilitation.18

In late 1992, Dr. Waddell produced the biopsychosocial analysis of low back pain which included a comprehensive history of low back pain and an extensive look at all the factors the previous studies had covered. Of significance, he points out:

• 1. Fear of pain and what we do about pain appears to be more disabling than pain itself.
• 2. That the Waddell's tests failed to include the cognitive dimension because there were limited clinical measures of illness behavior available at the time.19

By 1993, Dr. Waddell looked at how patients react to low back pain. At that time, he noted that:

• 1. While non-organic or behavioral signs could be found in medicolegal context, they were also commonly seen in the Problem Back Clinic in patients with no compensation claims.
• 2. Non-organic or behavioral signs must not be interpreted as faking and full evaluation is essential before drawing conclusions.
• 3. That beliefs can be aggravated by ill-considered medical information about discs and degeneration and standard medical advice to avoid physical activities, rest and stay at home.20

By late 1993, Dr. Waddell et al. looked at the Waddell signs as they applied to the Fear-Avoidance Beliefs Questionnaire. At that time, they noted:

• 1. Pain is one of the most powerful aversive drives in animals and humans and is closely allied to fear.
• 2. That chronic low back pain patients expectations of pain associated with certain physical activities correlates with their subsequent performance.
• 3. They hypothesize that physiological impairment gives rise to muscular skeletal nociception related to physical activity.21

OTHERS DISSECT THE WADDELL'S SIGNS

In 1996, Dr. Bertram Kummel suggested that there may be additional Waddell's tests that could be applied and came to the following conclusions:

• 1. At no time may the examiner suggest any connection between cervical or shoulder motion and low back pain. The affected individual should only be asked to point to the location of pain.
• 2. The examiner has to carefully follow all the testing criteria or personal bias may mare the results.
• 3. That the person being evaluated often comes in with a prejudice as to what is going to take place and about the physician. It is suggested that the neck and upper extremities be tested first to indicate to the low back patient that the doctor is "thorough and really interested."
• 4. He concludes that the significance of non-organic signs suggest only psychological follow up and that he has even used the early administration of anti-depressants but can not offer proof as to their value.22

In 1997, Dr. David Scalzitti looked at the use of Waddell's non-organic signs and noted:

• 1. That the presence of non-organic signs should not be associated with malingering or the presence of psychological problems, but only with further investigation.
• 2. That the Waddell's sign should not be over-interpreted or used as a substitute for comprehensive psychological assessment.
• 3. That the utility of Waddell's non-organic signs applies to low back and that as of yet, there are no tests for other muscular skeletal problems in common use.23

In 1997, Dr. Ronald Karas et al. did a research report to attempt to predict people's return to work based upon low back pain. As part of that study, they noted:

• 1. A high Waddell score is indicative only of symptom magnification or possible illness behavior. It does not signify malingering.24
• 2. In a conference to discuss the impact of Karas et al. study following the article, Dr. Richard Erhard25 answered the question "How are your colleagues using the Waddell signs? "I posed that question to Waddell himself a few years ago, and he expressed dismay at the way some people have used his test against the patient. In his original work, he described the signs as a screening tool...there is a lot of variability not only among physical therapists, but among insurers and employers, in how these types of measurements are used and interpreted."26

In 1998, Deborah Lechner PT, Sam Bradbury MOM and Lawrence Bradley PHD reviewed the methods and approaches for detecting sincerity of effort. As part of this study, they noted:

• 1. Waddell's non-organic signs were not developed for the purpose of detecting the sincerity of effort.
• 2. That the Waddell signs were not intended for use in detecting malingering.
• 3. That tenderness tests may contribute to a classification of patients as needing further psychological associated when their primary problems stems from organic sources or tissues other than nerve roots.
• 4. That in patients with poor trunk strength or lack of kinesthetic awareness acting with movement may cause resulting lumbar pain.
• 5. That the tests require the elimination of motion in the lumbar spine during the maneuver which may not be possible even with precise verbal instruction and careful hand placement.
• 6. The straight-leg raising test and knee extension may be affected by hamstring muscle tightness.
• 7. That the overreaction test is based upon an assumption that there is a standard, acceptable intensity for response to the experience of pain, against which reactions can be measured.
• 8. Techniques of test administration such as the amount of pressure exerted during the axial loading, hand placement during rotation, and pelvic control during the distraction test, are not standardized in Waddell's original description of non-organic signs and may introduce variables in testing and scoring the non-organic signs. (The individuals that took part in the initial Waddell study received considerable informal, non-standardized training from Waddell himself).
• 9. Finally, in noting the U.S. Supreme Court ruling of Daubert, they conclude that given the available literature, the reviewed approaches for documented sincerity of effort do not meet the criteria established under this ruling nor do they comply with American Physical Therapy Association Standards.

WADDELL DEALS WITH THE STUDY HIMSELF

In 1998, Dr. Waddell along with Dr. Chris Main provided a reappraisal of the interpretations of "non-organic signs." After looking at the original goals of the 1980 study, Dr. Waddell included the additional findings:

• 1. That it can not be assumed without further evidence that the behavioral signs are de facto to be viewed with suspicion.
• 2. Over-interpretation of individual signs is common.
• 3. Assessment of behavioral signs is not a complete psychological assessment.
• 4. Clear evidence of behavioral responses indicates that the patient does not have a straight forward physical problem, he or she may require an orthopedic intervention. In such cases, pain management as well as surgery may be necessary.
• 5. An important significant minority of patients become chronically incapacitated after injury, regardless of whether litigation is involved.
• 6. The most serious misuse and misinterpretation of behavioral signs has occurred in medicolegal context and that they do not represent a comprehensive psychological evaluation and formulations such as "functional overlay", should not be taken as definitive.
• 7. That the signs should only be described as "behavioral responses to examination" and should be understood as such.
• 8. That the signs are a form of communication between the patient and doctor and are therefore influenced by expectations (both by the patient and the doctor)
• 9. The signs are not a reason to deny appropriate physical treatment. Some patients may require both physical management and physical pathology and more careful management of psycho social behavioral aspects of their illness.
• 10. The behavioral signs are not on their own a test of credibility.27

CONCLUSION

Reviewing all the research and study that has been done since Waddell's original findings, there is solid support for many objections concerning the use of the Waddell's tests. Further, in looking into the topic, it is obvious that many of these tests are being used in day to day examinations. The question is what those findings mean as to the success of treatment and the comprehensive effect of the treatment. While Waddell's goal of the single comprehensive index may be here some day, until then, it is our job to make sure these findings do not continue to get misquoted, abused, and misused against our clients.