A pain, an ache, a discomfort - these are the common complaints of those who seek the doctor's help. Pain issues a warning with timely intent. She calls to action, pointing the way, no delay. Unless the ancient cycle is served from pain to cause, to treatment to cure.
A video deposition in small town Minnesota a week before trial as the defense doctor goes on about the physical examination of your client:
"And when a patient has positive response to a straight leg raising in the normal way and then you bend the knee and they also complain of discomfort, that indicates an inconsistency in the patient's response, that he, that their, the patient is, is trying to overemphasize to you that he has something wrong with his back."
The doctor continues.
"And it feeds into what we call Waddell's signs. The Waddell's signs1 are signs of non-organic causes of pain."
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.
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.
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.
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:
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:
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:
By 1993, Dr. Waddell looked at how patients react to low back pain. At that time, he noted that:
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:
In 1996, Dr. Bertram Kummel suggested that there may be additional Waddell's tests that could be applied and came to the following conclusions:
In 1997, Dr. David Scalzitti looked at the use of Waddell's non-organic signs and noted:
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:
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:
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:
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.