Waddell signs

From Neurosigns
Jump to: navigation, search
Waddell (touch-me-not) signs are a set of tests for nonorganicity in low back pain (Video).(1-3) The Waddell signs include a discrepancy between the positivity of straight leg raising between the supine and seated position; pain in the back on pressing down on top of the head; widespread and excessive tenderness (the “touch-me-not” sign); general overreaction during testing; pain during simulated spinal rotation, pinning the patients hands to the sides while rotating the hips (no spine rotation occurs as shoulders and hips remain in a constant relationship); and nondermatomal/nonmyotomal neurologic signs.

In the skin roll test, the loose skin over the lower back or neck is gently rolled. Pain produced by skin rolling in the patient with low back pain or headache suggests an exaggerated pain response and is analogous to the Waddell "touch-me-not" sign. An evidence based review of 61 studies challenged the orthodoxy regarding Waddell signs.(4) The study concluded that the Waddell signs are associated with decreased functional performance, poorer treatment outcomes, and greater levels of pain but no evidence of an association with psychological distress, abnormal illness behavior, or secondary gain and no evidence they can discriminate organic from nonorganic disease. A 2021 study of epidural steroid and sacroiliac joint injections and facet interventions for LBP found a significant relationship between the number of Waddell signs and treatment failure.(5)

Video legend. Waddell signs mini-lecture.


1. Waddell, G, McCulloch, JA, Kummel, E, et al. Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976);1980;5:117-125.

2. Campbell WW. Clinical signs in neurology: a compendium. Philadelphia: Wolters Kluwer Health, 2016.

3. D'Souza RS, Dowling TJ, Law L. Waddell Sign. 2021 Jul 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30137776.

4. Fishbain DA, Cole B, Cutler RB, et al. A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Med. 2003;4:141-81.

5. Cohen SP, Doshi TL, Kurihara C, et al. Waddell (nonorganic) signs and their association with interventional treatment outcomes for low back pain. Anesth Analg. 2021;132:639-651.