Waddell’s signs: developed in 1980 as a simple clinical screen to identify patients who require a more detailed psychological assessment (Waddell et al. 1980). These tests were not specifically developed for malingering, or to prove patients are ‘faking’ their symptoms, but are a measure of illness behaviour.

The signs consist of 5 types of physical signs:

Tenderness: Tenderness is usually localized to a particular skeletal or neuromuscular structure. Nonorganic tenderness is related to the following.

  • Non-anatomic: Deep tenderness felt over a wide area, not localized to one structure, often extending to the thoracic spine, sacrum or pelvis.
  • Superficial: Skin is tender to a light pinch over a wide area of lumbar skin. Be aware of areas relating to nerve impingement.

Simulation: Gives the patient the impression that a certain test is being carried out when it is not. If pain is reported, a nonorganic influence is suggested.

  • Axial loading: Low back pain is reported on vertical loading over the standing patient’s skull by the examiner’s hands. Neck pain is common and should be discounted.
  • Rotation: Back pain is reported when shoulders and pelvis are passively rotated in the same plane as the patient stands relaxed with the feet together. In the presence of nerve root irritation, leg pain may be reproduced and should be discounted.

Distraction: A positive physical finding is demonstrated in the routine manner, then performed with the patient’s attention distracted. The distraction should be non-painful, non-emotional and non-surprising. Findings present only at formal examination and disappear at other times may be non-organic.

  • Straight leg raising: Patients with non-organic components will show marked improvement on straight leg raising with distraction compared with formal testing. There are several variations based on sitting, known as the ‘flip test’.

Regional: Involve a widespread region of neighbouring parts such as the leg below the knee, the entire leg, or a quarter or half of the body. It does not correspond with accepted neuroanatomy.

  • Weakness: Demonstrated in formal testing by a cogwheel ‘giving way’ of muscle groups that cannot be explained on a localized neurological basis.
  • Sensory: Disturbances including diminished sensation to light touch, pinprick, and sometimes other modalities fitting a ‘stocking’ rather than dermatological pattern. ‘Giving way’ and sensory changes often occur in the same area with possible associated non-anatomic tenderness.

Overreaction: During examination overreaction shows in the form of exaggerated verbalization, facial expression, muscle tension or tremor, sweating, or collapsing. Any individual sign counts as a positive sign for that type, a finding of three or more of the five types is clinically significant. Isolated positive signs are ignored (Waddell et al. 1980).