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The 8 Waddell Signs For Low Back Pain Evauation

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The 8 Waddell Signs for Low Back Pain Evauation

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Waddell Signs or Waddell Nonorganic Signs are group of eight clinical physical signs to detect psychogenic, or “non-organic,” low back pain in patients.

Waddell Signs were first described by Professor Gordon Waddell in 1980. Waddell initially developed these signs as a method to identify patients with low back pain who were likely to experience a poor surgical outcome from lower back surgery.

What are the 8 Waddell Signs?

The 8 Waddell Nonorganic Signs include the following:

Superficial Tenderness

Tenderness is not related to a particular structure. It may be superficial over a wide area of the lumbar skin to light touch or pinch.

Nonanatomic Tenderness

The patient experiences deep tenderness over a wide area that is not localized to one structure and crosses over non-anatomical boundaries.

Acetabular rotation

Lumbar pain is elicited while the provider passively and simultaneously externally rotates the patient’s shoulder and pelvis together in the same plane as the patient stands. It is considered a positive test if pain occurs within the first 30 degrees of rotation.

Simulation tests (axial loading in rotation)

These tests give the client the impression that diagnostic tests are being performed. Slight pressure (axial loading) applied to the top of the head or passive rotation of the shoulders & pelvis in the same direction produces complaints of LBP.

Distraction tests (SLR)

A positive clinical test (straight leg raise) is confirmed by testing the structures in another position. By appearing to test the plantar reflex in sitting, the examiner may actually lift the leg higher than that of the supine SLR.

See Also: Straight Leg Raise Test

Regional sensory disturbances

The patient experiences decreased sensation fitting a stocking-like distribution rather than a dermatomal pattern.

Regional weakness

Weakness, cogwheeling, or the giving way of many muscle groups that are not explained on a neuroanatomical basis.


Disproportionate responses via verbalization, facial expressions, muscle tremors, sweating, collapsing, rubbing affected area, or emotional reactions.

Any positive test in 3 or more categories results in an overall Waddell Score.


In 1998, Main and Waddell stated that these physical signs have been misinterpreted and misused both clinically and medico-legally. In their article, they emphasize the importance of viewing back pain within a psychosocial context. They state that behavioral signs may be a response affected by fear from injury and development of chronic incapacity and are not a test of credibility. They conclude that patients displaying Waddell signs may require both physical management of their physical pathology as well as careful therapy for the psychosocial and behavioral aspects of their illness.

See Also: Neck Disability Index

Somatosensory Amplification Rating Scale (SARS)

The Somatosensory Amplification Rating Scale (SARS) is a version of the Waddell’s signs, which has been modified to allow for a more accurate appraisal of the patient with exaggerated illness behavior.

It is important to remember that the Waddell and the SARS assessment tools are designed not to detect whether patients are malingering, but only to indicate whether they have symptoms of a nonorganic origin.

SARS scores of 5 or greater are indicative of inappropriate illness behavior. The higher the score, the greater the exaggerated behavior.

Somatosensory Amplification Rating Scale (SARS)
Somatosensory Amplification Rating Scale (SARS)


  1. D’Souza RS, Dowling TJ, Law L. Waddell Sign. 2022 Apr 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30137776.
  2. Waddell G, McCullochJA, Kummel E, et al: Nonorganic physical signs in low-back pain. Spine 5:117–125, 1980.
  3. Barsky AJ, Goodson JD, Lane RS, et al.: The amplification of somatic symptoms. Psychosom Med 50:510–519, 1988.
  4. WernekeMW,Harris DE, Lichter RL: Clinical effectiveness of behavioral signs for screening low-back pain patients in a work oriented physical rehabilitation program. Spine 18:2412, 1993.
  5. Kenna O, Murtagh A: The physical examination of the back. Aust Fam Physician 14:1244–1256, 1985.
  6. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
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