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 Is it malingering, or is it 'real'?

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PostSubject: Is it malingering, or is it 'real'?   Thu Sep 20, 2007 10:20 pm

Is it malingering, or is it 'real'?

Eight signs that point to nonorganic back pain


Distinguishing behavioral from organic problems is a frequent challenge
for primary care physicians. Having techniques for deciphering the
often bewildering clinical picture produced by nonorganic causes of
musculoskeletal pain is invaluable. A systematic approach to evaluation
allows patients to receive the best treatment for their true condition,
avoids unnecessary testing and treatment, and helps maintain the
integrity of our profession.



Nonorganic causes of pain

Some patients who present with musculoskeletal complaints have
underlying nonorganic or behavioral problems that may not be
immediately apparent (table 1). These nonorganic causes of pain may be
a deliberate deception or a process unknown to the patient and include
malingering motivated by secondary gain, Munchausen's syndrome, and
psychosomatic disorders.



Table 1. Underlying causes of nonorganic back pain


Malingering

Feigning illness or disability to obtain secondary gain (eg, to escape work or elicit sympathy)

Munchausen's syndrome

Intentionally producing clinically convincing physical and laboratory
signs of disease in order to obtain medical treatment (the treatment
itself is the secondary gain)



Psychosomatic disorders

Manifestations of psychological conflicts (often unconscious) with somatic complaints





--------------------------------------------------------------------------------







Malingering is defined as feigning illness or disability to derive
benefit, or secondary gain. Examples of secondary gain are to escape
work, elicit sympathy, gain compensation, obtain medications, avoid
prosecution or get better jail conditions, and avoid military service.



In Munchausen's syndrome, the secondary gain is receiving the medical
treatment itself (1). Affected patients go to extreme lengths to
produce clinically convincing physical and laboratory signs of disease.
Occasionally, patients with Munchausen's syndrome inject their knees to
produce swelling, ingest agents to distort their laboratory findings,
rub irritants on their skin to produce rashes, or wear splints or
braces unnecessarily. Over time, their medical records show extensive
workups for convincing signs and symptoms, which change as the
originally suspected disorder is on the verge of being ruled out.



Pain due to a psychosomatic disorder is generally a more complex
process. Often patients with these disorders are unaware that their
pain does not have a physical cause. Such patients are a heterogeneous
group who have no genuine physical or organic disorder but manifest
psychological conflicts with somatic complaints that are real to them
(2).



Waddell signs

The back is a common site of nonorganic musculoskeletal complaints.
Because of the complex and hidden anatomy of the back, differentiating
between physical and behavioral causes of pain is especially
challenging. In 1980, Waddell and colleagues (3) reported the results
of their prospective study of 26 clinical signs in 350 patient
evaluations. They identified eight signs (referred to as behavioral
signs) that are consistently reliable and reproducible for identifying
nonstructural problems in patients with back pain (table 2).







It is important to note that some patients with physical back problems
may have one or two Waddell signs. Anxiety, fear, and the desire to
please the physician can cause patients to exhibit one or more of these
signs. Therefore, the predictive value of the Waddell signs is greatly
improved if three or more positive signs are present (4).



Superficial tenderness

Physical back pain does not make the skin tender to light touch. Pain
(the subjective complaint) and tenderness (discomfort on palpation)
should not have sharp demarcations at the body's midline. Therefore,
superficial tenderness is a positive behavioral sign. It is almost
always present in patients motivated by financial secondary gain and
almost never in patients with well-demonstrated physical pathologic
conditions that improve appropriately.



Nonanatomic tenderness

Physical pain usually localizes to a specific skeletal or neuromuscular
structure. Tenderness that crosses multiple somatic boundaries (eg,
thoracic back pain that extends out over the scapula, trapezial pain
involving the clavicle) rarely has a physical cause. Any pain or
tenderness that crosses anatomic lines without a reasonable explanation
is considered a positive Waddell sign.



Magnuson's test is defined as
nonreproducible localization of tenderness in the neck or low back. If
pain moves to various sites during the examination, it is nonanatomic
pain.



Axial loading

Axial loading involves pressing down on the top of the head of a
standing patient. This maneuver should not produce low back pain. If
pain is reported, it is a behavioral sign. Waddell and associates (3)
suggested disregarding any reported neck pain, because a few patients
with physiologic pain do have neck pain with axial loading.



Simulated rotation

Simulated rotation is a simple test performed in a standing patient.
When the shoulders and pelvis are rotated in unison, the structures in
the back are not stressed. If the patient reports back pain with this
rotation, the test is considered positive for a nonorganic source of
the patient's complaints.



Distracted straight-leg raise

In the standard straight-leg raise test, the patient is recumbent and
aware of the test being performed. In contrast, a distracted
straight-leg raise test is performed anytime the hip is flexed with the
knee straight. This position occurs naturally during lumbar
range-of-motion testing when the patient is bent forward. The
distracted straight-leg raise test also can be done by examining the
foot with the patient seated with one knee extended (ie, during
Babinski or reflex testing, inspection of the sole of the foot, sensory
testing, motor strength testing, and checking for pulses). Patients
with organic pain have the same results on both the standard
straight-leg raise and the distracted straight-leg raise test.



The standard straight-leg raise test works because the sciatic nerve
runs behind the axis of rotation of the hip. When the hip is flexed,
the nerve must "stretch." Up to 1.5 in. of nerve root slides in and out
of the exit foramina of the spine during this maneuver. When the knee
is flexed, the nerve remains lax, and no stretching or sliding of the
nerve root occurs. The test is considered positive when pain is
produced along a dermatome (ie, L4-medial calf, L5-lateral calf,
S1-lateral foot) below the knee. Pain in the low back is not a feature
of a positive test. Posterior thigh pain also is not a classic positive
sign but may be seen in patients with mild sciatica.



During a standard straight-leg raise, applying dorsiflexion to the foot
(flip test) further stretches the nerve and heightens the pain. A
reverse flip test involving plantar flexion of the foot should lessen
the pain. When it does not, the test is considered positive for a
behavioral source of pain.



In patients with organic pain, continuing to raise the leg after the
pain first starts is extremely painful. In behaviorally motivated
patients, however, further stretching is often easy and does not
significantly increase their distress. When questioned, some patients
motivated by secondary gain may report that the pain lessens with
further raising of the leg. Another incongruous finding is severe pain
at 10 flexion in patients who have no difficulty with other simple
movements, such as removing their socks.



Regional sensory change

Any widespread numbness that involves an entire extremity or side of
the body and does not follow expected neurologic patterns is suspect.
Innervations are relatively specific, and few spinal conditions other
than paralysis simultaneously involve more than one or two roots or
dermatomal distributions. A global or "stocking" (ie, the area covered
by a sock) distribution of numbness involves the entire extremity and
rarely has a traumatic cause. A knowledge of basic neuroanatomy of the
extremities is helpful for interpreting numbness patterns (5).



Reproducibility is another important feature of this sign. Results of
sensory testing on the right and the left are compared, then areas in
which pain is reported are retested medially and laterally. In patients
with neurologic injury, the sensory findings remain consistent. Most
noninjured patients do not understand whether an injured area should be
more or less sensitive, which explains why their results on comparison
testing are often inconsistent.



Regional weakness

Regional muscle weakness also follows established neurologic patterns,
and muscle testing can help detect inconsistent signs. Motor strength
is graded on a five-point scale, with 5 for normal, 3 for barely
resists gravity, and 1 for a flicker of movement. If any muscle group
tests 5/5 at any time during the examination, that muscle group is
considered normal. In patients with normal strength, the sudden letting
go of a muscle may be described as "cogwheeling," "giving way,"
"breakaway" weakness, or "dithering." In patients with physical
weakness, however, the muscle is smoothly overpowered with no jerking,
and the response throughout a resisted range-of-motion maneuver remains
smooth and constant. This smooth weakness is nearly impossible for a
patient with nonorganic weakness to duplicate.
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PostSubject: Re: Is it malingering, or is it 'real'?   Thu Sep 20, 2007 10:21 pm

Overreaction

A patient may be hypersensitive to light touch at one point during
examination but later give no response to touching of the same area.
This is a positive sign of overreaction, as evidenced by a
disproportionate grimace, tremor, exaggerated verbalizations, sweating,
or collapse. Other behavioral signs include inappropriate sighing,
guarding, bracing, and rubbing; insistence on standing or changing
position; and questionable use of walking aids or equipment.



Other useful signs

In addition to Waddell signs, close observation and a few simple
physical tests may reveal other useful signs that point to nonorganic
pain.



Observation

If the patient limps into the examination room, check his or her shoes
for signs of uneven wear. Asymmetry of wear should be apparent if the
limp has a physical cause and has been present for some time. Canes,
neck braces, and lumbar supports with no signs of wear are also
telltale signs of a behavioral problem.



In patients employed as manual laborers who claim that they have been
unable to work for 6 months, examine their hands for calluses (which
disappear within 3 weeks of inactivity), periungual dirt, and
lacerations. Also, as any exercise fanatic knows, muscle mass
disappears rapidly during periods of inactivity. Therefore, maintenance
of upper body muscle tone is unlikely in reportedly inactive patients.



Patients who put on a show by collapsing or fainting usually take care
not to injure themselves. Thus, such patients will collapse in front of
an attendant and fall onto a bed rather than directly onto a hard piece
of furniture. Likewise, patients who feign coma resist being injured.
For example, if you raise the hand of a comatose patient above the face
and drop it, the hand will hit the face. However, patients who are not
truly comatose will not allow their hand to strike their face. In
addition, patients who are in a coma do not resist attempts by an
examiner to open their eyelids (6).



Physical tests

The following tests, although not often used, further demonstrate the principles identified by Waddell and colleagues.



Mankopf's test: This test is based on
the fact that pain raises the pulse rate. Palpation of a painful area
should increase the pulse rate by 5% or more. Absence of this finding
is a positive behavioral sign.



O'Donoghue's maneuver: In patients with
true physiologic pain, passive range of motion is greater than active
range. If the patient's active range of motion is greater, it is a
positive behavioral sign.



McBride's test: Ask the patient to
stand on one leg while raising the opposite knee to the chest. Because
the knee is bent, no sciatic stretch occurs and the spine is flexed,
thereby removing pressure from the facets. Thus, this position should
lessen low back pain. A reported increase in pain, or a refusal to do
the test, is a positive behavioral sign.



Hoover's test: This test is performed
in a supine patient. Hold the patient's heels off the table, and ask
him or her to raise one leg. If the leg is raised easily, the test is
negative. However, if this movement is difficult, the patient will push
the contralateral leg toward the table for assistance in raising the
leg. Therefore, lack of downward pressure from the contralateral leg is
a positive sign of malingering (7).



Burn's test: Ask the patient to kneel
on a chair and touch the floor. Because the knees are bent, patients
with true back pain or sciatica should be able to do the test without
much difficulty, but those with nonorganic back pain usually cannot.



Treatment approach to nonorganic pain

Directly confronting patients who are psychologically invested in their
pain is generally unwise. You may never see them again, thus losing the
opportunity to help them, or they may despise you and seek revenge.



Recognize that the patients' problems are important to them. Do not
dismiss their complaints out of hand, or they may believe you have not
listened to them. Often other factors not initially apparent have
contributed to their condition. For example, after an automobile
accident, a patient may have been told by a lawyer, another physician,
family members, or coworkers just how hurt he or she should be. The
patient's perception of being injured may produce Waddell signs.



Give patients a ladder to climb out of their symptoms, rather than push
them down. First, explain that they do not have a serious physical
problem, and reassure them that no significant deterioration in their
condition is expected. Tell them that although exercise may hurt, it
will not negatively affect their condition. Then explore with them ways
to improve their daily activities to overcome and replace their illness
behaviors. You may have to tell patients who overtly exhibit
malingering that you cannot help them. Patients who are psychologically
disturbed should be referred to a psychotherapist.



Be aware that true physical pathologic conditions are occasionally
hidden under a mountain of illness behaviors. All physicians have had
the experience of not believing that a patient's complaints are organic
and later discovering that they were wrong. Reexamine the patient at
every visit, focusing on the reportedly painful areas, and perform a
more complete examination if the findings change significantly over
time.



Conclusion

Being aware of signs indicative of nonorganic pain is an indispensable
tool for anyone who has direct patient contact. Waddell signs and other
tests for behavioral disorders provide physicians with tools to assist
in the evaluation of challenging patients. Proper diagnosis is crucial
to helping patients receive the care they need as well as avoiding
wasted time and effort.



References

Lande RG. Factitious disorders and the 'professional patient.' J Am Osteopath Assoc 1996;96(Cool:468-72

Righter EL, Sansone RA. Managing somatic preoccupation. Am Fam Physician 1999;59(11):3113-20

Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine 1980;5(2):117-25

Main CJ, Waddell G. Behavioral responses to examination: a reappraisal
of the interpretation of "nonorganic signs." Spine 1998;23(21):2367-71

Wipf JE, Deyo RA. Low back pain. Med Clin North Am 1995;79(2):232-46

Hawkes CH. Diagnosis of functional neurological disease. Br J Hosp Med 1997;57(Cool:373-7

Cozen L. Tests for chronic back pain. Contemp Orthopaedics 1992;24(4):405-10

Dr Kiester is associate clinical professor, department of orthopedic
surgery, and Dr Duke is assistant clinical professor, department of
family medicine, University of California, Irvine, College of Medicine.
Correspondence: P. Douglas Kiester, MD, Department of Orthopedic
Surgery, UCI Medical Center, Rte 81, 101 The City Dr S, Orange, CA
92868-3298. E-mail: pkiester@uci.edu.







--------------------------------------------------------------------------------



Symposium Index

COMMON MUSCULOSKELETAL PROBLEMS IN PRIMARY CARE: Introduction to a
three-article symposium by Joseph E. Scherger, MD, MPH, Harry B.
Skinner, MD, PhD

THE PAINFUL SHOULDER: Zeroing in on the most common causes by Patrick J. McMahon, MD, Robert E. Sallis, MD

IDENTIFYING STRUCTURAL HIP AND KNEE PROBLEMS: Patient age, history, and
limited examination may be all that's needed by Harry B. Skinner, MD,
PhD, Joseph E. Scherger, MD, MPH

IS IT MALINGERING, OR IS IT 'REAL'?: Eight signs that point to
nonorganic back pain by P. Douglas Kiester, MD, Alexandra D. Duke, DO
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