Behavioral responses to examination. A reappraisal of the interpretation of "nonorganic signs"

Spine (Phila Pa 1976). 1998 Nov 1;23(21):2367-71. doi: 10.1097/00007632-199811010-00025.


Waddell et al in 1980 developed a standardized assessment of behavioral responses to examination. The signs were associated with other clinical measures of illness behavior and distress, and are not simply a feature of medicolegal presentations. Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medicolegally. Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding. Isolated signs should not be overinterpreted. Multiple signs suggest that the patient does not have a straightforward physical problem, but that psychological factors also need to be considered. Some patients may require both physical management of their physical pathology and more careful management of the psychosocial and behavioral aspects of their illness. Behavioral signs should be understood as response affected by fear in the context of recovery from injury and the development of chronic incapacity. They offer only a psychological "yellow-flag" and not a complete psychological assessment. Behavioral signs are not on their own a test of credibility or faking.

MeSH terms

  • Disability Evaluation*
  • Humans
  • Low Back Pain / psychology*
  • Malingering
  • Physical Examination / psychology*
  • Sick Role*