Gordon WaddellBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2938 (Published 23 June 2017) Cite this as: BMJ 2017;357:j2938
As an orthopaedic surgeon in the 1970s Gordon Waddell realised that the current model for treating back pain was not working. He identified three main problems: the standard advice of bed rest was incorrect, there was an over-reliance on surgery as a treatment, and the message that anything that causes pain must be avoided was wrong—“hurt does not mean harm” was his mantra.
Tackling back pain
Waddell was running a clinic in Glasgow and wondered why some patients were far more disabled by back pain than others. In what was a highly unusual move at the time, he formed a partnership with a young clinical psychology researcher, Chris Main, and together they investigated why some patients could barely walk while others were moving reasonably well, despite looking the same on physical examination.
Waddell was a conscientious data collector and, through careful observation and consideration of the evidence, he and Main realised that much of the medical assessment of back pain was unreliable. Waddell asked three doctors to examine the same patient and found that they came up with differing diagnoses. He also found that psychological factors were just as important as physical factors in terms of a patient’s disability: what a patient believed or had been told had an influence on how he or she responded to treatment.
Red flags and yellow flags
Together they came up with a new approach to clinical assessment and developed red flags (which indicated that urgent consideration of surgery was needed) and what later became known as yellow flags (which indicated that how the person was reacting to back pain needed to be tackled as an important aspect of management). This research led to a reappraisal of surgical interventions for lower back pain and a reduction in the number of operations being performed.
Unsurprisingly, some orthopaedic surgeons were unhappy at his findings, and Waddell was not always warmly received at meetings. Even he was initially uncomfortable about his findings: in an autobiography for his family he wrote: “Unfortunately, if I was honest, I had to face up to the fact that surgery was not the answer to back pain.”
Some also believed that his discussion of some of the psychological aspects of back pain—or the non-organic signs, as Waddell called them—meant that patients were malingering.1 Waddell and Main later said: “Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medicolegally.”2
Waddell’s interest in research led him to abandon surgery, and he set about tackling the problem of back pain at a society level, becoming a key member of the Clinical Standards Advisory Group on back pain set up by UK health ministers. He also advised a back pain committee in the US and developed clinical guidelines for the Royal College of General Practitioners.
Too much medicine
Much of his work culminated in The Back Pain Revolution, a medical textbook whose central message was that back pain had become overmedicalised.3 He enjoyed writing and communicating his ideas and was also co-author of a series of self help booklets for patients. The most successful of these was The Back Book, which was translated into 25 languages and sold two million copies.
Waddell grew up in Bishopbriggs, on the outskirts of Glasgow, to parents who were teachers. As a boy he was a keen Scout and he met his wife, Sandra, at a Scouts and Guides dance when they were both 15. Scouting gave him a lifelong love of the outdoors and he was a keen hill walker, bagging all 282 Munros—Scottish hills higher than 3000 feet—and later tackling the Corbetts, hills of 2500 to 3000 feet.
Waddell attended Allan Glen’s Secondary School, where he eventually became dux, before studying medicine at Glasgow University. His earliest ambition was to become a trauma surgeon, and he spent a year in Birmingham at what was one of the UK’s first trauma centres. However, he decided that elective orthopaedics offered more of an intellectual challenge and spent a formative year in Toronto, Canada, as a spinal fellow, where he got his introduction to the major challenges of back pain.
In his later career, Waddell became interested in the world of work and health, contributing to the development of occupational health guidelines on back pain, published in 2000 by the Faculty of Occupational Medicine. He also became an adviser to the Department of Work and Pensions, and it was at this time that his message on disability and work became muddied. A major policy review by Waddell and Kim Burton concluded that work was good for health, but some misconstrued his message, believing that the focus was to force disabled people into work.4 In fact, the review found that good work was good for health—not just any work—and that good work can be therapeutic. He was awarded a CBE in 2003 for services to social policy and disability assessment.
After he retired at the age of 67, Waddell wrote a history of a glen in Perthshire, where he owned a 17th century cottage. The book was Highland Roots: the Real Story of a Highland Cottage, whose cover was illustrated by Sandra, a keen painter. He spent many happy times with his family in the cottage, writing of the pleasures of enjoying a good meal and a glass of wine after a day’s walking in the hills.
He leaves Sandra and three daughters.
Gordon Alex Bryce Waddell, professor of orthopaedic surgery (b 1942; q Glasgow University Medical School 1967), died from mesothelioma on 20 April 2017