PT Classroom - A Review of Waddell’s Nonorganic Signs for Low Back Pain ׀ by Chai Rasavong, MPT, MBA


Data from the National Health Interview Survey of the U.S. population in 2006 suggests that 27.4% of the US population ages 18 and older experienced low back pain. Given this high percentage for individuals who experience low back pain, it is not surprising that low back pain is a common condition treated in physical therapy. When physical therapists evaluate patients with low back pain they not only perform a detailed examination and assessment to determine organic problems which indicate the presence of pathology or disease, but they also consider psychological factors which could be contributing to the pain as well (1). Often times when conducting an examination on a patient with low back pain, physical therapists may also come across nonorganic signs as well. These nonorganic signs are findings which differ from the common characteristics of a disease or condition (1, 2, 3).

One such tool utilized to screen patients with low back pain for nonorganic signs was developed by Waddell et al. (2). These researchers developed a standardized group of five types of physical signs to screen for nonorganic low back pain. These physical signs include: tenderness, simulation tests, distraction test, regional disturbances and overreaction. Any individual sign counts as a positive sign for that type; a finding of three or more of the five types is clinically significant for non-mechanical, pain-focused behavior. A single positive sign, however, is ignored. Below is a more detailed description of these signs:

1) Tenderness
(from table of Scalzitti DA (1) adapted from Waddell et al (2))
Tenderness not related to a particular skeletal or neuromuscular structure; may be either superficial or nonanatomic.
Superficial – The skin in the lumbar region is tender to light pinch over a wide area not associated with the distribution of the posterior primary ramus.
Nonanatomic – Deep tenderness, which is not localized to one structure, is felt over a wide area and often extends to the thoracic spine, sacrum or pelvis.

2) Simulation Tests
(from table of Scalzitti DA (1) adapted from Waddell et al (2))
These tests give the patient the impression that a particular examination is being carried out when in fact it is not.
Axial Loading – Low back pain is reported when the examiner presses down on the top of the patient’s head; neck pain is common and should not be indicative of a nonorganic sign.
Rotation – Back pain is reported when the shoulders an pelvis are passively rotated in the same plane as the patient stands relaxed with the feet together; in the presence of root irritation, leg pain may be reproduced and should not be indicative of a nonorganic sign.

3) Distraction Test
(from table of Scalzitti DA (1) adapted from Waddell et al (2))
A positive physical finding is demonstrated in the routine manner, and this finding is then checked while the patient’s attention is distracted; a nonorganic component may be present if the finding disappears when the patient is distracted.
Straight Leg Raising – The examiner lifts the patient’s foot as when testing the plantar reflex in the sitting position; a nonorganic component may be present if the leg is lifted higher than when tested in the supine position.

4) Regional Disturbances
(from table of Scalzitti DA (1) adapted from Waddell et al (2))
Dysfunction (eg, sensory, motor) involving a widespread region of body parts in a manner that cannot be explained based on anatomy; care must be taken to distinguish from multiple nerve root involvement.
Weakness – Demonstrated on testing by a partial cogwheel “giving way” of many muscle groups that cannot be explained on a localized neurological basis.
Sensory – Include diminished sensation to light touch, pinprick or other neurological tests fitting a “stocking” rather than a dermatomal pattern.

5) Overreaction
(from table of Scalzitti DA (1) adapted from Waddell et al (2))
May take the form of disproportional verbalization, facial expression, muscle tension and tremor, collapsing, or sweating; judgments should be made with caution, minimizing the examiner’s own emotional reaction.

One research study found that Waddell’s signs was a useful tool to be utilized in the physical therapy setting to predict return to work. In a study conducted by Karas et al. (3) they assessed the relationship between the nonorganic signs (Waddell scores) of patients with low back pain, their response to repetitive end range lumbar spine test movements (centralization of symptoms), and the rate of return to work at a 6 month follow up. In this study, their original sample size comprised of 171 consecutive patients with low back pain were assessed by experienced physical therapists for responses to repetitive test movements (centralization as described by McKenzie) and for nonorganic signs (Waddell scores). These therapists completed a data sheet that classified patients as either those who centralize their symptoms or those who do not centralize their symptoms and recorded their Waddell scores. The patients than all followed a structured Canadian Back Institute protocol for active exercise, regardless of centralization status or Waddell score. A six-month follow up was than conducted on these patients to determine return to work status. Seventeen patients from the original sample size were excluded from the results of this study as their jobs had been terminated or the patients were homemakers, students or retirees. From this final sample, the researchers obtained results which revealed that among the patients with low Waddell scores, those who centralized their symptoms had a higher return to work rate than those who did not centralize their symptoms. For those patients that had high Waddell scores, they had a lower return to work rate, regardless of the patients’ ability to centralize symptoms. Despite these findings in support of Waddell’s signs as a predictor for return to work, additional information such as specifics of patients who had positive Waddell’s signs (ie . patients who had pain for 14 days or 1 to 2 years, age, gender, type of occupation) and specifics for the results from the double straight leg raise they developed would have helped the reader understand the study better (4). Other shortcomings included the researchers limiting their approach to movement classification, having a broad definition of centralization, utilizing multiple therapists for the study, testing a sagittal plane movement only, and not having another group to compare results with (4).

However, another study by Bradish et al (5), utilizing Waddell’s Signs to correlate return to work for 120 worker’s compensation patients with onset of low back pain within six months displayed conflicting results compared to Karas et al (3). In this study the participants underwent a detailed history and physical examination, examination for nonorganic signs as described by Waddell et al (2) and a radiographical examination of the lumbosacral spine. The authors of this study reported treatment for these patients were symptomatic and at the discretion of the referring practitioners, with recommendations from the Board as indicated. Between 12-18 months following injury the patients were reviewed again. Analyzing the initial and review data they found no correlation between the presence of nonorganic signs at initial assessment and either return to activity or resolution of the patient’s symptoms. Despite the study finding no correlation, a few shortcomings of the study could have resulted in different outcomes. Some of these shortcomings include the use of multiple therapists, the allowance of varying treatment procedures and not setting a more specific time parameters to review the subjects.

Although Waddells’ Signs are a common method to assess the nonorganic or psychological component of low back pain, great care must be taken when interpreting results (2, 3, 4). The results should be viewed as one of many influencing factors, including other clinical findings and chronicity of the problem (4). Positive findings should, in fact, alert the therapist to the need for more detailed testing for the patient (1, 2).

Last revised: October 18, 2010
by Chai Rasavong, MPT, MBA


1) Scalzitti DA. Screening For Psycological Factors in Patients with Low Back Problems: Wadell’s Nonorganic Signs. Physical Therapy. 1997;77:306-312.
2) Waddell G, et al. Nonorganic Physical Signs in Low-Back Pain. Spine. 1980;5(2):117-125.
3) Karas R, et al. The Relationship Between Nonorganic Signs and Centralization of Symptoms in the Prediction of Return to Work for Patients with Low Back Pain. Physical Therapy. 1997;77(4):354-360.
4) Erhard R, Scalzitti D, Rothstein J. Conference. Physical Therapy. 1997;77(4):361-368.
5) Bradish C, et al. Do Nonorganic Signs Help to Predict the Return to Activity of Patients with Low-back Pain? Spine. 1988;13(5):557-560.

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