Malingering, or somatization of symptoms may be present in patients with a-specific low back pain. Psychological and psychosocial aspects play important roles in the setting and perpetuation of symptoms. Cultural differences and how people experience their symptoms also plays a role. Mood and anxiety disorders, secondary gains such as early retirement and financial compensations should be acknowledged by the physician as possible contributors to symptoms (Oliveira, 2000). Waddell’s signs were developed in 1980 to differentiate between organic and nonorganic signs as a screening tool for psychological factors in the examination of patients with low back problems. The signs showed an 80% interrater reliability and an 85% intrarater reliability (Lechner et al. 1998) and was found to have satisfactory cross-sectional construct validity (Apeldoorn et al. 2012). A systematic review by Fishbain et al. (2003) using 77 studies concluded the following:

  • Waddell signs (WSs) do not correlate with psychological distress
  • WSs do not discriminate organic from nonorganic problems
  • WSs may represent an organic phenomenon
  • WSs are associated with poorer treatment outcome
  • WSs are associated with greater pain levels
  • WSs are not associated with secondary gain
  • As a group, WS studies demonstrate some methodological problems

The presence of nonorganic signs should alert the physical therapist to the need for additional psychological tests and should not necessarily be considered an indicator of malingering (Scalzitti, 1997). One must also be aware that nonorganic signs may coexist with organic findings. Having two or more of Waddell’s signs are thought to be associated with psychological distress, disability, and poor treatment outcomes, and appear to have promise as a quick indicator of treatment complexity and outcome (Carleton et al. 2009).