Testing for Non-organic Physical Signs
Psychological factors may markably affect the way people experience and express their pain.
This being the case, distinguishing between organic or a true anatomical lesion
and functional or a non-anatomical cause for pain
is necessary to fully understand the patient's painful experience,
and to assess the patient both clinically and psychologically.
It's prudent to evaluate the patient with regards to functional difficulties
in order to understand what social or psychological factors, if any, exist
so as to make case management decisions regarding psychological referral.
It's important for the clinician to understand
that physical and psychological difficulties are not mutually exclusive.
In patients with chronic pain, these two factors overlap one another.
The extent of the psychological overlay
is often very informative
in making future treatment recommendations
and assessing the patient's overall progress or response to treatment.
There are numerous psychological assessment tools which are helpful in this regard.
These include the Dallas Pain Questionnaire,
McGill Pain Questionnaire,
Minnesota Multiphasic Personality Inventory,
Oswestry Low Back Pain Questionnaire,
Hendler Pain Questionnaire,
Roland Morris Pain Questionnaire,
and a slew of others.
Discussion and utilization of these pain questionnaires is outside the scope of this video lecture.
However, Waddell has developed a clinician-friendly tool which is easily utilized
in evaluating the patient for non-organic physical signs, predominately, in the low back.
There are five categories evaluated in Waddell signs.
No.1 Tenderness to superficial palpation,
which produces inordinate widespread sensitivity to light touch
or otherwise known as the jumping jack syndrome.
No. 2 Simulation, which is tested by axial loading and rotational lumbar spine.
No. 3 Distraction, which is comparing sitting straight leg raise with straight leg raise.
No. 4 Regional, by evaluating for collapsing weakness or non-derma thermal deficits,
diffused motor weakness or bizarre sensory deficits,
which cannot be explained by neuroanatomy principles.
And No. 5 Over-reaction.
That is inappropriate response as an excessive or inappropriate grimacing, groaning or collapsing
during a simple request.
If three or more of these categories are positive,
the patient is felt to have non-organic physical signs.
The clinician may choose to refer the patient for psychological evaluation
to determine the extent to which these psychological factors are playing on the overall condition.
Let's go through how he would evaluate a patient for Waddell's signs.
As we're palpating the patient, we're looking for light palpation and we're looking for trigger points.
Now, if I've got an abnormal, inappropriate response to palpation, this is something we might see.
Deb: Ouch! Ouch! Ouch!
A lot of contraction to muscle, a lot of verbal response.
That's inappropriate response to palpation.
Next, we're going to do simulation
or we're going to check for pain in the low back with axial loading and rotation.
So I'm going to put axial pressure light on the top of the head.
Deb: Ouch! That hurts my back.
Dr. Conwell: That hurts your back?
Let's do it one more time.
Deb: Ouch! Ouch!
Now that should not cause the patient much pain, if any.
If they respond like that, it's an inappropriate response.
The second part of simulation is to rotate the trunk.
So we have the patient's hands to their side.
And we tell them to rotate to the right.
Deb: Ouch! Ouch!
Dr. Conwell: We can't do that?
Deb: No, that hurts.
Dr. Conwell: It hurts what?
Deb: It hurts when you move me like that.
Dr. Conwell: Okay, let's do this.
Deb: That hurts.
That's inappropriate response to simulation.
If the patient responds like Deb did,
we're looking at a patient that's got some psychological overlay.
The next category of Waddell's signs is distraction.
And we do that by comparing sitting straight leg versus straight leg.
So will you sit down for me, please?
Now, we're going to do sitting straight leg.
And we're going to raise it up, no problem.
Up, no problem there. Let's raise this one up.
It doesn't seem to be any problem there.
Now, go face up for me, please, on your back.
Now, I'm going to raise your leg gently.
You tell me if you have any problems.
Deb: Ouch! Ouch! Don't raise it anymore.
Dr. Conwell: What's the problem there?
Deb: That hurts when you raise it. Don't raise it anymore.
Okay. Now. these two should be the same.
I went to 90 degrees without pain.
And I went to somewhere in 30 degrees with pain,
which shows us that we've got some psychological overlay with straight leg raise
versus sitting straight leg raise.
Now I'm going to have you sit up for me.
Come on, sit up please. And just go ahead and get up.
Dr. Conwell: It just bothered you at all?
Deb: It hurts to move.
Dr. Conwell: What hurts?
Deb: It just hurts when I try to move from one place on the neck.
Dr. Conwell: It hurts, huh?
Okay?
All right?
Now, I'm going to check for muscle weakness or abnormal sensation.
Will you put your hands up like so?
Hold wrist strong for me.
Oh, see how they give?
That's inappropriate muscle response.
They should lock or they should give smoothly.
Let's do this.
Raise your leg up here.
Go and raise it up, no problem. Raise it up, no problem.
Raise it up. Now hold your foot out like that.
Hold it out, hold it out. Hold your foot out.
Now, just hold it out. See how it just goes?
Come on. Hold it out. Can't you hold that out?
Deb: No.
The patient should be able to have some contraction on that muscle.
The patient walked in to the office using these muscles.
There should be some strength.
The patient is giving us some signs of psychological overlay with abnormal muscle weakness.
Let's check for symptoms of sensation.
I'm going to poke this patient with a pin.
And you tell me if you feel this, okay?
Deb: [Shouts] Ouch!
Oops! You see, that's inappropriate response to pin prick.
Those are signs that we have a patient with some psychological overlay.
And last is what we saw when the patient was getting up from the sitting position, which is overreaction.
That's the patient showing over-hysterical signs from doing the simplest of a physical activity
such as going from a lying to sitting or sitting to standing position.
Let's see that one more time.
Dr. Conwell: Deb, would you please stand up for me?
Deb: Oh! Oh!
Dr. Conwell: Does that bother you?
Deb: It hurts to stand up.
Dr. Conwell: It hurts to stand up.
Then go ahead and sit back down.
That's fine.
Now relax for me.
Deb just did a beautiful job of showing that the patient has positive Waddell's signs in all five categories.
There was abnormal response to light touch.
There was inappropriate comparison of straight leg raise versus sitting straight leg raise.
There was over pain with axial compression and rotation, which we should not have in a patient
with low back pain, because we're not stressing those tissues with those provocative tests.
She showed inappropriate muscle weakness and inappropriate response to a sensation examination.
And she certainly showed difficulty with going from a sitting to a standing and a sitting to a lying position.
All of these show the patient has some psychological overlay.
It does not mean that they don't have a true physiological condition,
but there is some psychological problem going on here, which would suggest a psychological evaluation.
If we don't treat the psychological condition and only treat the physical condition,
the patient's not going to respond maximally to treatment.