| Signs suggestive of
nonorganic back pain |
 | In 1980, Waddell and colleagues reported the results
of their prospective study of 26 clinical signs in 350 patient
evaluations. |
| They identified eight behavioral signs that are
consistently reliable and reproducible for identifying nonstructural
problems in patients with back pain |
|
| Sign |
Description |
Result |
| Superficial tenderness |
| Skin discomfort on light palpation. |
| Physical back pain does not make the skin tender to
light touch. |
|
|
| Nonanatomic tenderness |
| Tenderness that crosses multiple somatic boundaries |
| Any pain or tenderness that crosses anatomic lines
without a reasonable explanation is considered positive. |
|
|
| Axial loading |
| Pressing down on the top of the head of a standing
patient. |
| This maneuver should not produce low back pain. |
|
|
| Simulated rotation |
| In a standing position, when the shoulders and pelvis
are rotated in unison, the structures in the back are not stressed. |
|
|
| Distracted straight-leg raise |
| Patient may complain of pain or limitation in range
in a supine straight leg raising test. |
| Lack of pain when examiner extends the
knee with the patient seated, and looking at the foot for
pulses, Babinski or reflex testing. |
|
|
| Regional sensory change |
| "Stocking" or global distribution of
numbness |
| Any widespread numbness that involves an entire
extremity or side of the body. |
|
|
| Regional weakness |
| In patients with normal strength, the sudden letting
go of a muscle may be described as "cogwheeling,"
"giving way," "breakaway" weakness, or
"dithering." |
| In patients with physical weakness, the muscle is
smoothly overpowered with no jerking, and the response throughout a
resisted range-of-motion maneuver remains smooth and constant. |
| This smooth weakness is nearly impossible for a
patient with nonorganic weakness to duplicate. |
|
|
| Overreaction |
| Exaggerated, nonreproducible response to stimulus |
| A patient may be hypersensitive to light touch at one
point during examination but later give no response to touching of the
same area. |
| A disproportionate grimace, tremor, exaggerated
verbalizations, sweating, or collapse. |
|
|
| The predictive value is greatly improved when three
or more positive signs are present. |
| some patients with physical back problems may have
one or two Waddell signs. Anxiety, fear, and the desire to please the
physician can cause patients to exhibit one or more of these signs. |
|
|
| Other useful tests |
| Mankopf's test |
| Pain raises the pulse rate. |
| Palpation of a painful area should increase the pulse
rate by 5% or more. |
|
|
| O'Donoghue's maneuver |
| In patients with true physiologic pain, passive range
of motion is greater than active range. |
| If the patient's active range of motion is greater,
it is a positive behavioral sign. |
|
|
| McBride's test |
| Ask the patient to stand on one leg while raising the
opposite knee to the chest. |
| Because the knee is bent, no sciatic stretch occurs
and the spine is flexed, thereby removing pressure from the facets.
Thus, this position should lessen low back pain. |
| A reported increase in pain, or a refusal to do the
test, is a positive behavioral sign. |
|
|
| Hoover's test |
| Performed in a supine patient. |
| Hold the patient's heels off the table, and ask
patient to raise one leg.
 | Negative: If the leg is raised easily |
| Positive if patient reports inability to raise
one leg but there is no downward pressure on the
contralateral leg. |
|
|
|
| Burn's test
|
| Ask the patient to kneel on a chair and touch the
floor. |
| Since the knees are bent, patients with true back
pain or sciatica should be able to do the test without much difficulty |
| Those with nonorganic back pain usually cannot. |
|
|
