Low Back Disability & Waddells

Inappropriate Symptoms
Questionnaire

Aaron Baker, Curtis Cox, Neil Esarte, Toby Mattson, Steve Meagher
 History of Low Back Disability
Historically, low back pain was not considered a
disabling condition. In fact the first recorded
case of compensation for a work injury was a
railroad worker related to the beginning of the
industrial revolution.
By 1920, the problem of low back disability
began to increase significantly.
In the last 45 years an interesting change has
occurred regarding our social attitudes towards
pain. It has shifted from being a symptom and
warning sign of disease, to a disease in itself
that demands a treatment and a cure.
 Prevalence
60-80% of people will have LBP sometime in their
lives.
30% are referred to Ortho; 3% admitted; 0.5%
operated.
90% LBP resolves in 6 weeks, 75% may experience
symptoms & disability one year after initial
consultation.
The prevalence of LBP has changed little over the
years, but the associated disability has increased
four fold.
In the US certified incapacity for LBP was 120
million days in 2004.
14 million consultations annually. Overall cost of
LBP was approximately 10 billion dollars.
 Why Take it Seriously?
Acute low back pain is often recurrent.
Predisposes to chronic pain and disability.
A warning of potential future trouble.
Impacts on the quality of life.
Lost days of productivity.
Huge cost of incapacity payouts.
Enormous burden on healthcare costs when
chronic.
 Types of Back Pain
Discogenic Back Pain
Annulus fibrosus when it is stretched with a
bulging disc.
Outer 1/3 has sensory innervations.
Radial fissuring is associated with painful
discs.
Radicular back pain
pain extending to the buttock and/or leg
disc herniation , spinal stenosis or intraspinal
pathology
 Types of Back Pain Cont
Iatrogenic back pain
Dural adhesions.
Post surgical scarring.
Psychogenic back pain
Must exclude organic pathology.
Waddell's inappropriate signs often present.
 Related Terms
Pain- an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage.
Chronic pain- long standing intractable pain of
longer than 6 month duration.
Chronic pain syndrome- pain which lasts longer
than 3 months without underlying cause and
interferes with major life activities such as work.
 Related Terms Cont
Symptom Magnification Syndrome- a conscious
or unconscious, self-destructive, socially
reinforced behavioral response pattern
consistent of reports or displays of symptoms
which function to control the life circumstances
of the sufferer (other similar terms are
malingering, Abnormal Illness Behavior,
symptom exaggeration).
Medical impairment- physically measurable
restriction determined by diagnostic measures.
Functional impairment- movement dysfunction
with respect to ROM, quality of motion, velocity
of motion, consistency of movement pattern,
strength, behavior, verbalization of pain and
disability, and distraction of evaluation.
 Oswestry Low Back Disability
Questionnaire

An extremely important tool that researchers and

disability evaluators use to measure a patient's
permanent functional disability.
The test has been around for 25 years and is
considered the "gold standard" of low back
functional outcome tools.
Purpose

10 item, self report checklist.

Has been shown to be valid in assessing
perceived disability.
Easy to complete for the client and easy for the
evaluator to score.
Administration

Provide client with the standard 10-item

checklist.
Have them answer the questions by choosing
the 'best answer' that describes their 'typical'
pain and/or limitations within the last week or
two.
They can only choose ONE answer.
If their limitations fall in-between two questions,
pick the higher point value question.
Scoring

Each section is scored from 0 to 5 points

depending on which statement they check.
If a section is not checked, potential score is
dropped by 5.
First statement in each sections score is 0.
Second scores 1, third scores 2, etc.
Scores for all answered sections are added
together and divided by the total potential score,
then multiplied by 100 to obtain a percentage.
Interpretation

Minimal Disability (0-20%)

The patient can cope with most living
activities.
Usually no treatment is indicated apart from
advice on lifting, sitting and exercise.
Ex: a secretary or truck driver.
Interpretation Cont

Moderate Disability (20-40%)

The patient experiences more pain and
difficulty with sitting, lifting and standing.
Travel and social life are more difficult and
they may be disabled from work.
Personal care, sexual activity and sleeping
are not grossly affected and the patient can
usually be managed by conservative means.
Interpretation Cont

Severe Disability (40-60%)

Pain remains the main problem in this group
but activities of daily living are affected.
These patients require a detailed
investigation.
Interpretation Cont

Crippled (60-80%)
Back pain impinges on all aspects of the
patient's life.
Positive intervention is required.
Extreme Cases (80-100%)
Either bed-bound or exaggerating symptoms.
Interpretation Cont

Simply add up your points for each section

and plug it in to the following formula in
order to calculate your level of disability:
Point total / 50 X 100 = % Disability
Clinical Applications

Workplace Safety and Insurance Board

(WSIB)
Ergonomics assessment for insurance
companies
 Waddells Inappropriate
Symptoms Questionnaire
In 1980 Dr. Waddell and his colleagues wanted
to distinguish and standardize "non-organic"
physical signs that sometimes accompany low
back pain.
Pain descriptions usually approximate
anatomical and pathological patterns of disease,
however, sometimes these descriptions do not
follow general clinical experience.
Inappropriate symptoms are usually attributed to
psychological features and are vague, not well
localized and lack the normal relationships to
time, activity and anatomy.
Purpose

This is a test to determine whether the clients

symptoms are appropriate or inappropriate with
respect to low back pain.
Should be noted that these symptoms may in
fact occur in other pathologies such as hip
pathology and therefore, the pathology should
be confirmed as emanating from the low back
before utilizing the test.
Administration

Provide the client with the questionnaire asking

5 simple questions requiring either a yes or a
no answer.
There are two additional questions which may
be utilized, they are gathered in the routine
history which doesnt appear on the patients
questionnaire.
A yes answer to either of these additional
questions constitutes an inappropriate response.
Instructions

Answer the 5 questions by circling either

Yes or No to each question.
1. Do you get pain at the tip of your tail bone?
2. Does your whole leg ever become painful?
3. Does your whole leg ever go numb?
4. Does your whole leg ever give way?
5. In the past year, have you had any spells
with very little pain?
Instructions Cont

Additional questions:
6. Do you have an intolerance of or reactions
to treatment?
7. Have you ever had emergency admission
to hospital with low back pain?
These are the added questions that can be
utilized in the routine history and they do not
appear on the clients questionnaire.
Scoring

A yes answer to questions 1 to 4 are

inappropriate.
A no answer to question 5 is inappropriate.
A total of 2 or more inappropriate scores is
indicative of inappropriate illness behavior.
Most symptom magnifiers usually score more
than 2 inappropriate answers in the first 5
questions and it is therefore unnecessary to
score questions 6 and 7.
Clinical Applications

Ergonomics assessment for insurance

companies.
Workers Compensations claims.
WSIB
 Placebo Tests
Waddells Light Pinch
Non-anatomical tenderness to light pinch.
Waddells Axial Vertical Loading
Vertical loading on a standing patients skull produces
low back pain.
Waddells Simulated Rotation
Passive rotation of shoulders and pelvis in the same
plane causes low back pain.
Distraction
Discrepancy between findings on sitting and supine
straight leg raising tests.
Overreaction
Disproportionate facial expression, verbalization or
tremor during examination.