How to Identify a Symptom Magnifier

PREVIEW: 
Distinguishing behavior from organic problems is a frequent challenge for physicians. 

Listed below are eight signs that were developed by Waddell and colleagues. 

Using this approach for 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.

1. 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.

2. Nonanatomic Tenderness:
   Physical pain usually localizes to a specific skeletal or neuromuscular structure.  Tenderness that crosses multiple somatic boundaries (eg, thoracic 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 reasonable explanation is considered a positive Waddell sign.

3. 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.

4. 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.

5. 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 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 foot 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 test.

6. 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.

7. Regional Weakness:
   Regional muscle weakness does not follows established neurologic patterns, and muscle testing can help detect inconsistent signs.

8. 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.

In addition to the eight Waddell signs, Dr. Dennis has incorporated some of his own signs based on his experiences:

1. Simple instructions are not easily understood (apparent confusion). “Raise your toes against me” causes the reverse.

2. Observation of simple activities, like taking off a jacket or shirt demonstrates excellent range of motion of shoulders and neck while testing of these areas are individually demonstrating a dramatic limitation of the specific areas.

3. Observation of the Examinee entering the office and exam room compared to the Examinee being asked to perform the same activities under direct observation; Stand, walk, sit, etc.).

4. Maintaining eye contact during introductory conversation.  The doctor notes the ease of use of the neck when he purposely speaks to the Examinee from his right and then his left.

5. Hoover Test:  muscle spasms or their absence.  Other classic tests.

6. The opposite of an antalgic gait.  Where more time is spent on the defective leg then less, during Gait Analysis.

7. “ Everything hurts”:  Even to light touch.

8. Distribution or radiation of subjective pain, follows No known neurologic path.

9. Jerky motions when asked to contract a muscle group against resistance.  As if  The Examinee can’t decide how strong he should be. 

NO ONE TECHNIQUE IS 100%. ONE MUST BE CAUTIONED AGAINST OVER DEPENDENCE ON THESE SIGNS.  BUT IT IS IMPORTANT FOR A PHYSICIAN (WHETHER A TREATING PHYSICIAN OR AN EXAMINING PHYSICIAN) TO BE AWARE AND SENSITIZED TO PATIENTS WHO PRESENT WITH  MALINGERING OR MAGNIFYING OF THEIR SYMPTONS FOR PURPOSES OF SECONDARY GAIN. 

MOST PHYSICIANS RESENT BEING LIED TO , ABUSED OR INVOLUNTARILY USED AS PART OF A CONSPIRACY.  THE APPLICATION OF THIS KNOWLEDGE SERVES TO PROTECT NOT ONLY THE PHYSICIAN BUT ALSO ALL PARTIES CONCERNED.