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Waddells Nonorganic Signs

Screening for Psychological Factors in Patients With Low Back Problems: Waddell's Nonorganic Signs

Adapted from: Scalzitti DA. Screening for psychological factors in patients with low back problems: Waddell's nonorganic signs. Phys Ther. 1997;77:306-312.

For the majority of patients with low back pain (LBP), the cause of their pain is unknown. 1 Psychological factors, which may include behavioral, cognitive, or somatoform components, can be just as important as the diagnosis of pathology affecting the low back in a patient's recovery from a low back problem. 2-5 A recent US Agency for Health Care Policy and Research clinical practice guideline recommends exploration of psychological factors when an individual with an acute low back problem is having difficulty regaining his or her tolerance to activity. 4

Feuerstein and Beattie 5 discussed several biobehavioral instruments that can be used to identify psychological factors in individuals with LBP. If factors are identified that are potential contributors to the low back problem, the physical therapist can then refer the patient to the appropriate professional. Routine application of these instruments, however, may be impractical during physical therapy examinations because of the time required for administration and scoring as well as the expertise needed to interpret the results. Thus, there is a need for a brief screening tool to help identify patients who may require more detailed psychological testing. A review of the description and diagnosis of psychological disorders that may relate to LBP is beyond the scope of this update. For further information on these areas, the reader is referred elsewhere. 5-7

Signs of organic problems are findings from the physical examination that indicate the presence of pathology or disease. Paresthesia over the lateral border of the foot, for example, is a sign for S-1 nerve root involvement. Signs of nonorganic problems, in contrast, are findings that deviate from the usual presentation of disease. 8 Both organic and nonorganic signs may be present in a patient with LBP. Therefore, the presence of nonorganic signs should not be equated with malingering or the presence of a psychological problem, but only with the need for further investigation.

Waddell et al 8 described a group of signs that indicate the presence of nonorganic problems for patients with LBP. Waddell has also referred to these signs as "behavioral signs" or "inappropriate signs." 2,9 Testing for these signs is performed as part of the physical examination and takes less than 1 minute. 8 Nonorganic signs have been used to describe different characteristics of patients with LBP. The purpose of this update is to describe the use of Waddell's nonorganic signs as a screening tool for psychological factors in patients with LBP. Additionally, the relationship between the nonorganic signs and physical impairments, disability, and treatment outcomes will be discussed.

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