Cervical nonorganic signs: A new clinical tool to assess abnormal illness behavior in neck pain patients: A pilot study

Review by: Alec Meleger, M.D.
Fellow, UC Davis

Jerry B. Sobel, M.D., Patti Sollenberger, P.T., Richard Robinson, Peter B. Polatin, M.D., Robert J. Gatchel, Ph.D., Archives of Physical Medicine and Rehabilitation, Vol 81, February, 2000

Medical literature of the early twentieth century ascribed nonorganic symptoms and signs as an indication of malingering. With advancement of medical thought it has become apparent that these signs and symptoms were more closely correlated with psychological distress and abnormal illness behavior rather than malingering. Waddell and colleagues were the first to develop, standardize and demonstrate the reliability of a group of lumbar nonorganic physical signs. To date, there has not been such a description of cervical nonorganic signs.

The purpose of this study was to develop a set of cervical nonorganic physical signs, and to test their inter-examiner reliability.

Twenty-six consecutive patients with chronic neck pain (20 men and 6 women) who were referred to a functional restoration program were selected for the study. The average age of the subjects was 42.08+/-9.98years(range 28-61), and their average length of disability was 9.17+/-5.67 months (range, 0.4 to 25). In addition to the standard physical exam, each patient was evaluated for the presence of eight cervical nonorganic signs: exaggerated superficial tenderness, nonanatomic tenderness, en bloc rotation of head/shoulders/trunk/pelvis while standing and sitting, cervical range of motion, regional nondermatomal sensory loss, regional nonmyotomal motor loss or giveaway weakness, overreaction by exhibiting exaggerated pain behaviors. After the physician evaluation, either a physical therapist or occupational therapist reevaluated each subject for the presence of these specific physical signs. A standardized scoring criterion was used. Total and individual scores were then compared between physicians and therapists for reliability of these nonorganic signs.

The percent agreement ranged from a high of 100% for regional sensory loss, to a low of 68% for the en bloc rotation of the head, shoulders, and torso in the sitting position. The kappa coefficients ranged from a high of 1.00 to a low of .08. The average percent agreement between raters across all of the nonorganic test signs was 84.6%. Inter-rater analysis was also made separately for patients presenting with one or more signs, two or more signs, and so forth. For subjects presenting with two or more signs or greater, the agreement was high ranging from 84.6% to 92.3%. For subjects presenting with 3 or more signs or greater, the kappa coefficient ranged from .76 to .84.

To our knowledge this is the first published study that developed, standardized and determined the inter-rater reliability of a group of cervical nonorganic signs. Overall inter-rater reliability was moderately strong for the majority of the signs and was comparable to Waddell's findings on nonorganic lumbar signs. Previous studies have shown that patients with a higher number of Waddell signs tended to have significant psychological distress and to be suboptimal responders to surgical as well as rehabilitative interventions. The findings of this study suggest that these newly tested cervical nonorganic signs can be used in the same fashion in patients with cervical symptoms as the widely utilized Waddell signs have been used in patients with spinal lumbosacral symptomatology. Further independent studies are needed to duplicate these findings and to correlate them to patients' psychological health as well as to the response level to surgical as well as rehabilitative interventions.