Fishbain David A, Cole Brandly, Cutler R B, Lewis John, Rosomoff H L, Rosomoff R Steele
Department of Psychiatry, University of Miami School of Medicine, Miami, Florida, USA.
Pain Med. 2003 Jun;4(2):141-81. doi: 10.1046/j.1526-4637.2003.03015.x.
This is a structured, evidence-based review of all available studies addressing the concept of nonorganic findings: Waddell signs (WSs).
To determine what evidence, if any, exists for the various interpretations for the presence of WSs on physical examination.
WSs are a group of eight physical findings divided into five categories, the presence of which has been alleged at times to have the following interpretations: Malingering/secondary gain, hysteria, psychological distress, magnified presentation, abnormal illness behavior, abnormal pain behavior, and somatic amplification. At the present time, there is, therefore, significant confusion as to what these findings mean.
A computer and manual literature search produced 61 studies and case series reports relating to WSs. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: 1) Reliability (test-retest); 2) Reliability (inter-rater); 3) Reliability (factor analysis); 4) Validity, psychological distress; 5) Validity, correlation Minnesota Multiphasic Pain Inventory (MMPI); 6) Validity, correlation abnormal illness behavior; 7) Validity, other behaviors; 8) Validity, as a nonorganic phenomenon; 9) Validity, correlation pain drawing; 10) Validity, functional performance; 11) Validity, treatment outcome; 12) Validity, predicting surgical treatment outcome; 13) Validity, return to work outcome; 14) Validity, secondary gain correlation; and 15) Validity, pain correlation. Each study in each topic area was classified according to the type of study it represented according to the type of evidence guidelines developed by the Agency for Health Care Policy and Research (AHCPR). In addition, a list of 14 study quality criteria was used to measure the quality of each study. Each study was categorized for each criterion as positive, (criterion filled), negative (criterion not filled), or not applicable independently by two of the authors. A percent quality score was obtained for each study by counting the total number of positives obtained, dividing by 14 minus the total number of not applicables, and multiplying by 100. Only studies having a quality score of 75% or greater were used to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies in each topic area (above) was then categorized according to the strength and consistency AHCPR guidelines. Conclusions of this review for each topic area are based on these results.
Of the 61 studies, four had quality scores below 75% and were not used to generate the results of this review. According to the AHCPR guidelines for strength and consistency of the reviewed data, the following results were obtained: 1) There was consistent evidence for WSs being associated with decreased functional performance, poor nonsurgical treatment outcome, and greater levels of pain; 2) There was generally consistent evidence for WSs not being associated with psychological distress, abnormal illness behavior, or secondary gain; 3) There was also generally consistent evidence that WSs are an organic phenomenon and that they cannot be used to discriminate organic from nonorganic problems; 4) There was inconsistent evidence that WSs do demonstrate inter-rater reliability, do not correlate with the neurotic triad of the MMPI, are associated with poorer surgical treatment outcome, and are associated with nonreturn to work; 5) There was little or no evidence that WSs demonstrate test-retest reliability, or reliable factors, and are associated with self-esteem problems, catastrophizing, or the nonorganic pain drawing.
Based on the above results, the following conclusions were made: 1) WSs do not correlate with psychological distress; 2) WSs do not discriminate organic from nonorganic problems; 3) WSs may represent an organic phenomenon; 4) WSs are associated with poorer treatment outcome; 5) WSs are associated with greater pain levels; 6) WSs are not associated with secondary gain; and 7) As a group, WS studies demonstrate some methodological problems.
这是一项对所有涉及非器质性体征概念（即沃德尔征，WSs）的现有研究进行的结构化循证综述。
确定体格检查中出现沃德尔征（WSs）的各种解释是否存在证据。
沃德尔征（WSs）是一组八项体格检查结果，分为五类，其存在有时被认为有以下解释：诈病/继发获益、癔症、心理困扰、夸大表现、异常疾病行为、异常疼痛行为和躯体放大。因此，目前对于这些体征意味着什么存在很大的困惑。
通过计算机和人工文献检索，获得了61项与沃德尔征（WSs）相关的研究和病例系列报告。对这些参考文献进行了详细审查、分类，并根据以下主题领域整理成表格形式：1）信度（重测）；2）信度（评分者间）；3）信度（因子分析）；4）效度，心理困扰；5）效度，与明尼苏达多相疼痛问卷（MMPI）的相关性；6）效度，与异常疾病行为的相关性；7）效度，其他行为；8）效度，作为非器质性现象；9）效度，与疼痛图的相关性；10）效度，功能表现；11）效度，治疗结果；12）效度，预测手术治疗结果；13）效度，重返工作结果；14）效度，与继发获益的相关性；15）效度，与疼痛的相关性。每个主题领域的每项研究根据其代表的研究类型，按照卫生保健政策与研究机构（AHCPR）制定的证据指南类型进行分类。此外，使用一份包含14项研究质量标准的清单来衡量每项研究的质量。两位作者分别独立地将每项研究的每个标准分类为阳性（标准满足）、阴性（标准未满足）或不适用。通过计算获得的阳性总数，除以14减去不适用的总数，再乘以100，得到每项研究的质量得分百分比。只有质量得分达到75%或更高的研究才被用于形成本综述的结论。然后根据AHCPR指南的强度和一致性，对每个主题领域中其余研究（上述）所代表的证据的强度和一致性进行分类。本综述对每个主题领域的结论基于这些结果。
在61项研究中，有4项质量得分低于75%，未被用于生成本综述的结果。根据AHCPR指南对所审查数据的强度和一致性，得到以下结果：1）有一致的证据表明沃德尔征（WSs）与功能表现下降、非手术治疗效果不佳和更高水平的疼痛相关；2）有总体一致的证据表明沃德尔征（WSs）与心理困扰、异常疾病行为或继发获益无关；3）也有总体一致的证据表明沃德尔征（WSs）是一种器质性现象，不能用于区分器质性问题和非器质性问题；4）有不一致的证据表明沃德尔征（WSs）确实显示出评分者间信度，与MMPI的神经症三联征不相关，与较差的手术治疗结果相关，且与无法重返工作相关；5）几乎没有证据表明沃德尔征（WSs）显示出重测信度或可靠的因子，并且与自尊问题、灾难化思维或非器质性疼痛图相关。
基于上述结果，得出以下结论：1）沃德尔征（WSs）与心理困扰不相关；2）沃德尔征（WSs）不能区分器质性问题和非器质性问题；3）沃德尔征（WSs）可能代表一种器质性现象；4）沃德尔征（WSs）与较差的治疗结果相关；5）沃德尔征（WSs）与更高水平的疼痛相关；6）沃德尔征（WSs）与继发获益无关；7）作为一个整体，沃德尔征（WSs）的研究显示出一些方法学问题。
