Waddell's Signs

Last updated: Thu, Aug 1, 2024

Now for something somewhat different, Waddell's signs. The history of Waddell's signs is part of the broader history that leads through Freud and the various versions of the DSM concept of psychogenesis. Neurologists in the 19th century developed a group of neurological signs that, based on their understanding of the nervous system, couldn't be caused by organic illness and therefore must be signs of conversion ("hysteria") or malingering. Waddell and co-researchers (ca. 1980) developed a sub-set of these signs that could be used as an adjunct to the examination of patients who complained of low back pain. These signs were believed to be unrelated to low back pain, and therefore patients who showed the signs might be referred for psychological attention. The signs have since come to be known as "Waddell's signs." They include:

• pain at the tip of the tailbone
• whole-leg pain—stocking pain rather than pain that follows a dermatome
• whole-leg numbness—stocking numbness rather than numbness that follows a dermatome
• leg that gives way
• absence of periods without pain
• inability to tolerate treatments
• ER visits for pain
• disproportionate reaction to the examination (too much verbalizing, grimacing, and so forth)

Waddell's signs came to be used frequently by independent examiners in adversarial proceedings (workers comp or accident litigation) to suggest that petitioners were either dissembling or were victims of psychological disorders, particularly during the 1980s and 1990s. Waddell himself co-authored a paper in 1998 that criticised the use of these signs for that purpose.1

A 2003 review of 61 studies of Waddell's signs found that there was consistent evidence that those patients who exhibited the signs had lower functional abilities, poor outcomes from non-surgical treatment, and higher pain. The review also found that the signs were not associated with greater psychological distress, with abnormal illness behavior, nor with secondary gain. Finally, the review found consistent evidence that the signs are in fact an organic phenomenon and so can't discriminate between organic and inorganic problems.2

...it should be noted that most of the research on secondary gain and malingering has been funded by insurance carriers. This research has shone an unflattering light on injured workers and litigants....Virtually no systematic research has examined the frequency with which insurance adjusters, employers, or defense attorneys distort information to minimize their financial liability in contested claims. Research on the behavior of all participants in contested claims is needed before we can get an accurate grasp of the frequency with which these actors engage in deceptive behavior3

Which is to say that not only pain sufferers have an imperfect grasp on the truth.