Symptom Magnification and Malingering in Occupational Health and Workers' Compensation - Matthew Barber, M.D.

Symptom Magnification and
Malingering in Occupational Health
  and Workers’ Compensation

       Matthew Barber, M.D.

Symptom Magnification and Malingering

•   Difficulties of the subject
•   Definitions
•   Possible ways to detect (exam,etc.)
•   Testing (in a specialty setting)
•   Improving Recovery Time and Return To Work
•   Q&A

    * Perspective of orthopaedic surgeon

Training
“Treating health providers often do not consider malingering, even
 in cases of delayed recovery involving work injuries or other
 personal injuries, where there may be a significant incentive to
 feign or embellish symptoms or delay recovery” (Aronoff et al,
 2007).

“The term malingering, as a description of behavior or as a
diagnosis, usually is considered highly pejorative and
controversial. Clinicians may be reluctant to address this behavior
directly, even if there is strong evidence, because they are afraid
of the consequences (e.g., mislabeling someone, being
threatened, or being sued) [Binder & Iverson, 2000].

Symptom Magnification
• Symptom Magnification refers to the conscious or
  sub-conscious tendency of an individual to under-rate his or her
  abilities and/or over-state his or her limitations. Symptom
  magnification is measured through assessment of observed
  functional performance, as compared to a subjective reports of the
  limitations caused by his or her symptoms. It does not imply intent.

Malingering
• Malingering is a medical term that refers to fabricating or
  exaggerating the symptoms of mental or physical disorders for a
  variety of "secondary gain" motives, which may include financial
  compensation (often tied to fraud); avoiding school, work or military
  service; obtaining drugs; getting lighter criminal sentences; or simply
  to attract attention or sympathy.

Detection of Malingering

• Complaints grossly in excess of clinical findings
• Bizarre, absurd, inconsistent symptoms
• Atypical fluctuation in symptoms in response to external
  incentives
• Unusual response to treatment that cannot be otherwise
  explained (e.g., paradoxical response to medication)
• Markedly discrepant capacity for work vs. recreation
• Substantial noncompliance with evaluation or treatment
• Compliance only with passive versus active treatment
• Refusal to undergo invasive testing or treatment,
  regardless of potential benefit
• Special Signs/Tests

Non-organic Physical Signs
          (“Waddell’s signs”)
• Non-anatomic weakness or sensory loss
• Non-anatomic superficial tenderness
• Simulation tests with axial loading and en
  bloc rotation producing pain
• Distraction test or flip test in which pt has no
  pain with full extension of knee while seated,
  but the supine SLR is markedly positive
• Over-reaction verbally or exaggerated body
  language

                 Waddell, et al. Spine 5(2):117-
                          125, 1980.

Tests / Waddell’s Signs
• Waddell’s Light Pinch
  – Non-anatomical tenderness to light pinch.
• Waddell’s Axial Vertical Loading
  – Vertical loading on a standing patients skull produces
    low back pain.
• Waddell’s Simulated Rotation
  – Passive rotation of shoulders and pelvis in the same
    plane causes low back pain.
• Distraction
  – Discrepancy between findings on sitting and supine
    straight leg raising tests.
• Overreaction
  – Disproportionate facial expression, verbalization or
    tremor during examination.

Waddell’s Light Pinch

Detection
• Non-anatomic
  weakness or sensory
  loss

Bowlus and Currier Test

Waddell’s Axial Vertical Loading

Waddell’s Simulated Rotation

Distraction

Overreaction

Hoover Test

• Helps to determine whether pt is malingering
• Should be performed in conjunction with SLR
• When pt is genuinely attempting to raise leg, he
  exerts pressure on opposite heel to gain leverage

Hip Adductor Test

Observation
• Gait
• Movements
• Particularly when not being “examined”

Window Test

Surveillance

          • Resource-intensive
          • Not practical in every
            case

FCE

• Inconsistencies
• Excess of “self-limiting”
  behaviors

Index of Suspicion
• Must be on the lookout
• Variation from clinical experience
• Other information sources

Diagnostic Testing
• Sometimes early
• Sometimes late
• Careful interpretation

Improving Recovery Time and
          Return To Work
• Acknowledge that this can be an issue (M.D.)
• Be alert to signs
• Set expectations with the patient
   – Active participant
   – You WILL get well
• Use exam and diagnostic tests
• Confirm ( FCE ?, Second Opinion ?)

Thank You

Waddell’s Inappropriate
     Symptoms Questionnaire
• In 1980 Dr. Waddell and his colleagues wanted
  to distinguish and standardize "non-organic"
  physical signs that sometimes accompany low
  back pain.
• Pain descriptions usually approximate
  anatomical and pathological patterns of disease,
  however, sometimes these descriptions do not
  follow general clinical experience.
• Inappropriate symptoms are usually attributed to
  psychological features and are vague, not well
  localized and lack the normal relationships to
  time, activity and anatomy.

Purpose

• This is a test to determine whether the clients
  symptoms are appropriate or inappropriate with
  respect to low back pain.
• Should be noted that these symptoms may in
  fact occur in other pathologies such as hip
  pathology and therefore, the pathology should
  be confirmed as emanating from the low back
  before utilizing the test.

Administration

• Provide the client with the questionnaire asking
  5 simple questions requiring either a “yes” or a
  “no” answer.
• There are two additional questions which may
  be utilized, they are gathered in the routine
  history which doesn’t appear on the patients
  questionnaire.
• A “yes” answer to either of these additional
  questions constitutes an inappropriate response.

Instructions

• Answer the 5 questions by circling either
  “Yes” or “No” to each question.
  – 1. Do you get pain at the tip of your tail bone?
  – 2. Does your whole leg ever become painful?
  – 3. Does your whole leg ever go numb?
  – 4. Does your whole leg ever give way?
  – 5. In the past year, have you had any spells
    with very little pain?

Instructions Con’t

• Additional questions:
  – 6. Do you have an intolerance of or reactions
    to treatment?
  – 7. Have you ever had emergency admission
    to hospital with low back pain?
  – These are the added questions that can be
    utilized in the routine history and they do not
    appear on the clients questionnaire.

Scoring

• A “yes” answer to questions 1 to 4 are
  inappropriate.
• A “no” answer to question 5 is inappropriate.
• A total of 2 or more inappropriate scores is
  indicative of inappropriate illness behavior.
• Most symptom magnifiers usually score more
  than 2 inappropriate answers in the first 5
  questions and it is therefore unnecessary to
  score questions 6 and 7.

Non-organic Physical Signs
          (“Waddell’s signs”)
• Non-anatomic weakness or sensory loss
• Non-anatomic superficial tenderness
• Simulation tests with axial loading and en
  bloc rotation producing pain
• Distraction test or flip test in which pt has no
  pain with full extension of knee while seated,
  but the supine SLR is markedly positive
• Over-reaction verbally or exaggerated body
  language

                 Waddell, et al. Spine 5(2):117-
                          125, 1980.