INTRODUCTION

In a framework for disability, the examining physician needs to understand the interaction between the disability and the factors affecting a return to work. In this model of interaction, a pathologic condition is the disturbance of normal bodily processes at the cellular level. Impairment is a specific loss of function. Functional limitation is the lack of ability to perform an action or activity. Disability is the inability to perform socially defined activities. Quality of life refers to the patient’s concept of total well-being. Risk or cofactors include biologic, environmental, lifestyle, and behavioral characteristics that are associated with musculoskeletal conditions. Whether people with specific physical limitations are disabled depends on their expectations, resources, and the demands of their physical environment.

Feigned illness, or malingering, is a sensitive medicolegal issue. Illness or injury that cannot be supported by medical fact confounds the physician’s diagnostic procedures and health care delivery; it also serves as an element of fraud in the third-party payer system. Patients participating in this behavior are a bane.

Not all patients who feign an illness are completely aware of their actions. Some patients embellish symptoms and physical signs as learned responses or traits, whereas others describe physical problems with hysterical emotional overlays. The latter group is influenced mostly by fear of the unknown. Depression bears a significant relationship to pain (Box 13-1).

Two major categories of hysterical disorders are identified: patients with a fictitious illness, such as in malingering, and patients with Munchausen syndrome. Both types of patients are those with signs and symptoms that have no organic basis but who are not deliberately attempting to mislead the examiner.

Trivial physical trauma or disease is often at the root of a portrayed illness or injury. In many instances, by the time symptom embellishment is clinically recognized, the complaints are of such a magnitude that they are completely incongruous with the original illness or injury. A patient who originally experienced a minor, clinically documented upper respiratory infection now describes symptoms and subjective complaints that resemble those for histoplasmosis or black lung disease. Yet another patient may complain of total leg disability after a minor thigh contusion. Both patients have in common the total lack of clinical findings to support the complaints, and some type of secondary gain serves as a driving force behind the medical charade.

Individuals may feign physical symptoms to continue in a less-strenuous job at work, or they may do so to receive a parking space closer to their place of employment. These individuals may also fake symptoms to gain control over family members or fellow workers. The injured party may also allow others to do work the patient would ordinarily do.

The diagnosis of hysteria should be established based only on positive evidence. Even if the patient has an obvious hysterical disorder, a serious organic illness may still be present.

Conversion symptoms have a physiologic or pathologic substrate. A conversion disorder denotes a process in which a patient’s emotions become transformed into physical (motor or sensory) manifestations. These patients are asking for help but in an inappropriate way. Conversion symptoms often occur in mentally defective individuals or in adolescents as a way of coping (albeit inadequately) with the environment. Common presentations include blindness, deafness, paresis, sensory disturbances, ataxia, seizures, and unconsciousness.

Malingering is the conscious misrepresentation of thoughts, feelings, and facts, and it is a condition in which symptoms and signs associated with pain or dysfunction are either partially or entirely feigned for secondary gain. Most commonly, malingering occurs in the setting of the workplace, where workers’ compensation is an issue.

Labeling patients as hysterics, frauds, or malingerers is difficult. This task is rarely accomplished without reaping the wrath of the patient or substantial legal repercussions.

The actual percentage of patients who are malingerers is undetermined. However, estimates suggest that 2% of all patients seeking health care are malingering. Obviously, the ascertainment of the inaccuracy of a patient’s report of pain and disability is a difficult process, but the possibility of malingering should be raised in the mind of the treating physician when major discrepancies or inconsistencies appear in the patient’s medical situation. In this effort, outcome measures for the assessment of work capacity, work tolerance, dependable ability, and task demand are useful tools (Table 13-3).

TABLE 13-3 DISTINCTIONS AMONG WORK CAPACITY, WORK TOLERANCE, DEPENDABLE ABILITY, AND TASK DEMAND

From Demeter SL, Andersson GBJ, Smith GM: Disability evaluation, St Louis, 1996, Mosby.

TABLE 13-1 MALINGERING CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

TABLE 13-2 MALINGERING, HYSTERIA, AND EMBELLISHMENT CROSS-REFERENCE TABLE BY SUSPECTED SYNDROME OR TISSUE

OUTCOMES ASSESSMENTS

The health assessment questionnaire (HAQ) is a self-administered instrument that assesses discomfort and disability. It is used to measure outcome in many different neuromusculoskeletal diseases. Disease-specific instruments have been produced to help follow outcomes in several other neuromusculoskeletal diseases. This area includes a fibromyalgia impact questionnaire. The activity of inflammatory neuromusculoskeletal diseases can be assessed through serologic measures. Separate measures of both tender and swollen joints can be charted on a homunculus. A generic measure of anxiety and depression, such as the hospital anxiety and depression (HAD) scale, allows psychologic variables to be assessed independently from orthopedic disease-related outcomes. The EuroQuol® thermometer is one of the instruments that uses a simple visual technique to allow people to assess their own health status; the disease repercussion profile is another such resource (Box 13-2).

Armed with Borg pain scales, Oswestry disability indices, symptom magnification indexing, Dallas Pain Questionnaire, Waddell indexing (Table 13-4), and neuroorthopedic malingering tests, the physician is able to substantiate or refute the existence of malingering in any given case. These tests and indices are usually used in combination with the more traditional neuroorthopedic physical examinations. A singular positive finding or test does not indicate that the patient is magnifying or faking symptoms. Rather, the malingering diagnosis is based on the preponderance of positive malingering test findings and the absence of findings from traditional neuroorthopedic tests. Any positive findings must be further correlated with the medical history of the patient. The constellation of positive malingering tests, normal findings in traditional tests, and medical history discrepancies form the malingering diagnosis. Malingering and psychogenic rheumatism patients complain primarily of pain, sensory losses, or paralysis in any combination.

TABLE 13-4 NONORGANIC PHYSICAL SIGNS INDICATING ILLNESS BEHAVIOR

GENERAL PROCEDURES

Psychogenic Rheumatism Profile

Patients with psychiatric disorders may develop pain as part of the symptoms associated with mental illness. Patients with pain may also develop psychiatric disorders as part of the symptoms associated with the physical illness. Pain associated with neurosis is more common than pain associated with schizophrenia or endogenous depression.

ORTHOPEDIC GAMUT 13-6 REASONS FOR PSYCHOLOGIC ILLNESS THAT CAUSE THE APPEARANCE OR EXACERBATION OF PAIN

1. Anxiety

2. Psychiatric hallucination

3. Increased tension in the muscles, with associated inadequate circulation and the accumulation of metabolic byproducts (lactic acid)

4. Hysteria with conversion reactions

ORTHOPEDIC GAMUT 13-7 PSYCHOGENIC RHEUMATISM^*

Symptoms and signs of psychogenic rheumatism are:

1. Dramatic urgency for an appointment that is not justified by the severity of the disease

2. A list (in writing) of complaints so long and detailed that no fact is left out

3. Multiple test results, including electrocardiogram, electromyelogram, electroencephalogram, barium enema, upper gastrointestinal series, computed tomography scans, myelograms, and magnetic resonance imaging, with no positive findings

4. Patient demands to review the laboratory data first to determine the cause of the symptoms; patient highlights any minor abnormalities

5. Preoccupation with future disability from minor physical changes

6. Persons who accompany the patient may be entirely separated from the patient’s condition or intensely supportive; the companion may be highlighting every abnormality, often using the pronoun we during the description of tests or treatments

7. Inability of the patient to relax during the examination (Boxes 13-3 and 13-4)

8. Marked theatrical responses to questions concerning pain

9. The patient often holds onto the physician during the examination, as a gesture of seeking support

BOX 13-3 CLINICAL SYMPTOMS OF ANXIETY

From White AH, Schofferman JA: Spine care, vol 1-2, St Louis, 1995, Mosby.

Motor tension

• Trembling, twitching, or feeling shaky

• Muscle tension, aches, or soreness

• Restlessness

• Easy fatigability

Autonomic hyperactivity

• Shortness of breath or smothering sensation

• Palpitations or accelerated heart rate

• Sweating or cold clammy hands

• Dry mouth

• Dizziness or light-headedness

• Nausea, diarrhea, or other abdominal distress

• Flushes (hot flashes) or chills

• Frequent urination

• Trouble swallowing or lump in throat

Vigilance and scanning

• Feeling keyed up or on edge

• Exaggerated startle response

• Difficulty concentrating or mind going blank because of anxiety

• Trouble falling or staying asleep

• Irritability

BOX 13-4 DSM-III-R^* CRITERION FOR ANXIETY

Data from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, ed 3, revised, Washington DC, 1987, American Psychiatric Association. In White AH, Schofferman JA: Spine care, vol. 1-2, St. Louis, 1995, Mosby.

300.02 Generalized anxiety disorder—unrealistic or excessive anxiety and worry more days than not

Other anxiety disorders

Panic disorder

300.21 with agoraphobia or

300.01 without agoraphobia

300.22 Agoraphobia without history of panic disorder

300.23 Social phobia

300.29 Obsessive compulsive disorder

300.89 Posttraumatic stress disorder

300.00 Anxiety disorder not otherwise specified

^* DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, third edition, revised.

ORTHOPEDIC GAMUT 13-8 COMBINED EMORY AND ELLARD INCONSISTENCY PROFILES^*

Data from Ellard J: Psychological reaction to compensable injury, Med J Australia 2:349-55, 1970; and Brena SF, Chapman SL: Pain and Iitigation: textbook of pain, London, 1984, Churchill Livingstone.

1. Discrepancies become apparent between a patient’s complaints of terrible pain and an attitude of calmness and well-being.

2. A complete work-up for organic disease by two or more physicians is negative.

3. The patient makes dramatized complaints that are vague or have global implications. “It just hurts,” or “I hurt bad.” This statement may be further attested by malingering hand signals.

4. The patient exaggerates a trivial pathologic condition (e.g., a mild strain, muscular cramp, contusion) and embellishes it with medical terms learned from previous contact with physicians. “My back spasms paralyze my legs.”

5. The patient overemphasizes gait or posture abnormalities that develop suddenly, persist, and cannot be substantiated objectively. For example, the patient complains of a limp that is not confirmed by a specific pattern of wear on old shoes; or the patient reports daily use of a cane or back brace, but these items show little wear.

6. The patient resists evaluation or rehabilitation when the stated goal of therapy is a return to gainful employment.

7. The patient exhibits a lack of motivation to learn new coping skills, despite verbal reports of compliance with treatment. For instance, the patient will show no increase in back motion despite claims of completing range-of-motion exercise daily.

8. The patient misses appointments for objective studies that measure function, motion, or vocational capabilities.

9. The patient has an unconventional response to treatment, such as reports of increased symptoms after therapy that follows no anatomic or physiologic pattern. For example, the patient may respond to tranquilizers as if they are stimulants and vice versa.

10. The patient shows resistance to treatment procedures, especially in the presence of intense complaints of pain.

11. Psychologic or emotional disturbances are absent (Box 13-5).

12. Psychologic tests are inconsistent and without clinical presentations. For example, the Minnesota Multiphasic Personality Index profile indicates a psychotic disorder, but no clinical signs of psychosis are present (Box 13-6).

13. Discrepancies arise between reports by the patient and spouse or other close relatives.

14. Personal and occupational history appears unstable.

15. The patient’s personal history reflects a character disorder that might include drug or alcohol abuse, criminal or compulsive behavior, erratic personal relationships, and violence.

BOX 13-5 MOOD DISORDERS—DSM-III-R^* CLASSIFICATIONS

Data from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, ed 3, revised, Washington DC, 1987, American Psychiatric Association. In White AH, Schofferman JA: Spine care, vol. 1-2, St. Louis, 1995, Mosby.

Bipolar Disorders

296.6x Mixed—both manic and depressed features

296.4x Manic

296.5x Depressed

301.13 Cyclothymia

296.70 Bipolar disorder not otherwise specified

Depressive Disorders—Major Depression

296.6x Single episode

296.3x Recurrent

300.40 Dysthymia

^* DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, third edition, revised.
Fifth digit (x) allows coding of current state of disorder: 1 = mild; 2 = moderate; 3 = severe, without psychotic features; 4 = with psychotic features; 5 = in partial remission; 6 = in full remission; 0 = unspecified

BOX 13-6 DESCRIPTION OF MMPI-2^*

From White AH, Schofferman JA: Spine care, vol 1-2, St Louis, 1995, Mosby.

L, F, and K are validity scales.

L is called the lie scale and measures willingness to admit minor social faults. It gives information about social conformity, self-image and self-insight, and denial.

F refers to infrequency and consists of items that are socially unacceptable or have disturbing content. Persons scoring on the low end of this scale are usually conventional and unassuming. Those with elevations are admitting to severe emotional distress or psychopathologic condition or both. Very high scores suggest an invalid profile.

K refers to correction, and the items measure personal resources required to cope with life. Low scores suggest exaggeration of problems or severe emotional distress. Higher scores can result when patients are very confident and in charge or when they are being defensive in their efforts to present themselves as adequate and in control when in fact their lives are in disarray.

Scales 1 through 10 are the basic clinical scales of the MMPI-2. The information is presented using T scores. A T score of 50 is average; T scores over 65 are in the abnormal range.

Scale 1 is also known as the Hypochondriasis (HS) scale. This scale consists of items that concern bodily functioning. Many of the items are vague in their content. Persons scoring low on this scale do not have or are denying that they have any physical complaints. Those whose scores are elevated have many physical complaints and concerns. If scores are above 65, physical complaints are often the major focus of the person’s life.

Scale 2 is known as the Depression (D) scale. It consists of items that measure subjective depression, psychomotor slowing and immobilization, physical complaints, mental dullness, and brooding. High scores indicate the presence of depression, and low scores indicate persons whose affective functioning is within normal limits.

Scale 3 is known as Hysteria (Hy). It consists of items that indicate whether the individual tends to avoid emotional and social unpleasantness. Those that do may then experience their emotions and stress as somatic complaints. High scorers will often deny psychologic problems and look for concrete solutions to their problems.

Scale 4 is known as psychopathic deviate (Pd). Eight items refer to authority conflicts, and the rest of the items deal with family conflicts, denial of social and dependency needs, social alienation, and self-integration. High scorers are often angry, impulsive, in conflict with authority figures in their lives, and are feeling isolated and despondent. High scorers who are not psychopathic are often undergoing stressful transitions in their lives.

Scale 5 is known as Masculinity-Femininity (Mf). Scores on this reflect traditional versus nontraditional masculine or feminine interests and beliefs, conflicts about sexuality, and interests in aesthetics. Low scores for women suggest feelings of helplessness and dependency, whereas low scores for men suggest an action-oriented macho approach to life. High-scoring men often hold interests in activities usually considered as feminine and may be experiencing insecurity, helplessness, and conflicts of sexuality. High-scoring women report interest in traditional male patterns and are often seen as unfriendly, dominating, and aggressive.

Scale 6 is known as Paranoia (Pa). In addition to paranoia and externalization of blame, this scale contains items related to hypersensitivity, subjectivity, naiveté, righteousness, and denial of hostility and distrust. Very high scorers are outright paranoid and may have a thought disorder, whereas low scorers may be insensitive to others and unaware of others’ motives. They may also be denying the presence of paranoid thoughts.

Scale 7 is known as Psychasthenia (Pt). Items center on the presence of worries, brooding, and rumination. High scorers are seen as anxious and insecure, and may be indecisive. If scores are very high, the individual may be compulsive and agitated with feelings of guilt and fear disrupting everyday functioning.

Scale 8 is known as Schizophrenia (Sc). High scorers are having difficulty with their thinking and feelings. They often feel out of control and unable to take positive action in their own behalf. Extremely high scores are suggestive of severe situational stress. More moderate elevations are seen in those with thought disorders with difficulties in logic concentration and judgment common.

Scale 9 is known as Hypomania (Ma). This scale provides information about motivation, physical and emotional activity levels, confidence in social situations, and feelings of self-importance. High scorers are restless, agitated, emotionally labile and may have racing thoughts. They may also have difficulty delaying gratification and can be impulsive. Manic features appear as scores elevate.

Scale 10 is known as Social Introversion (Si). This scale provides information about social interests, interpersonal skills, self-consciousness, and feelings of alienation from self or others. High scorers are often depressed. They withdraw from social interactions and feel shy and insecure. Low scorers are usually socially extroverted and outgoing.

^* MMPI-2, Minnesota Multiphasic Personality Inventory, second edition.

CLINICAL PEARL

In distinguishing psychogenic rheumatism from primary fibromyalgia, the patients with primary fibromyalgia are usually women, 25 to 40 years of age, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas, and numbness. Physical examination reveals the presence of multiple tender points at specific sites and the absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day (worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism have little fluctuation, if any, and are modulated by emotional rather than physical factors. Psychogenic rheumatism produces diffuse tenderness rather than tender points at specific sites.

Special Hand Signals by the Patient

How a patient uses the hands to describe the area of pain is useful in determining the validity of the complaints. At first, malingering patients take care not to touch the area they claim experiences pain. Because the complaint is a sham, touching of the part abets the lie. The examiner often inadvertently aids this process by physically touching the area of complaint before the patient has. The patient now only has to agree with the frustrated examiner concerning the exact location of the pain (Fig. 13-1).

FIG. 13-1 At first, the malingering patient takes care to avoid touching the area of claimed pain.

The psychogenic rheumatic patient uses the whole hand to paint the area of involvement with pain. Because this type of patient perceives the lesion abnormally, the distribution is painted to cover a whole body part. This pain crosses more than one dermatome boundary, and this patient’s discomfort is real. The discomfort may have origin in an organic lesion, but because of learned responses or fear, the patient rubs the whole part with the hand to indicate its extent. Careful questioning and guidance will help this patient better define the most focal trigger areas (Fig. 13-2).

FIG. 13-2 The hysteric patient, or the patient with psychogenic rheumatism, paints the area of complaint with the whole hand. The discomfort is real, but the borders of the complaint exceed the known anatomic distributions.

Patients with organic, pain-producing lesions are concerned that the source of the pain might be missed. When directed to point to the pain, this type of patient will touch the part with one or two fingers, which is representative of a more focal appreciation of the discomfort. In severe expression of the symptoms, this patient also may place the examiner’s hand on the exact location of the pain. These patients do not want to risk having the source missed and not treated (Fig. 13-3).

FIG. 13-3 Patients experiencing organic pain for the first time are concerned that the lesion will be missed. This patient will touch the part, precisely locating it with one or two fingers. The patient may also hold the examiner’s finger on the spot of worst complaint.

PAIN QUALIFICATION AND QUANTIFICATION

Overview

Pain disrupts the life of the individual in terms of relationships with others, self-esteem, ability to complete tasks of daily living and to work, and ability to function as a member of the community. Disability is strongly correlated with attitude to illness; these considerations underlie the importance of assessing patients’ beliefs regarding the nature and prognosis of their pain (Table 13-5).

TABLE 13-5 ACTIVITIES OF DAILY LIVING AND VISUAL ANALOG QUESTIONNAIRE

ORTHOPEDIC GAMUT 13-9 RELAY STATIONS

Three main relay stations for sensory stimuli from the periphery to the sensory cortex include:

1. The peripheral sensory nervous system, with its cell station in the spinal ganglia

2. The pathways and centers in the spinal cord and medulla

3. The sensory centers of the diencephalon, especially the thalamus

ORTHOPEDIC GAMUT 13-10 PAIN-RATING SCALES

ORTHOPEDIC GAMUT 13-11 CLINICAL FEATURES OF BURNING MOUTH SYNDROME

Adapted from Patton LL et al: Management of burning mouth syndrome: systematic review and management recommendations, Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 103(suppl 1):S39.e1-S39.e13, 2007.

Pain

Descriptors: burning

Intensity: variable, weak to intense

Pattern: continuous, not paroxysmal

Localization:

• Independent of a nervous pathway

• Often bilateral and symmetrical

Paroxysmal: not

Pain during sleep: infrequent

Associated signs and symptoms:

Dysgeusia

Xerostomia

Thirst

Sensory:

Chemosensory anomalies

Psychological changes

ORTHOPEDIC GAMUT 13-12 CATEGORIES OF PAIN

1. Pure nerve pain

2. Pain associated with nerve and vascular insufficiency

3. Pain related to numerous local alterations, such as inadequate skin coverage, fibrosis, bone pressure, tendon irritation, and collagen fibrosis

ORTHOPEDIC GAMUT 13-13 OSWESTRY-TYPE PAIN-DISABILITY QUESTIONNAIRE^*

This questionnaire has been designed to give the examiner information about pain and how it affects your ability to manage in everyday life. Please circle, in each section, only one statement that most closely applies to you.

SECTION 1: PAIN INTENSITY

1. I can tolerate the pain I have without having to use painkillers.

2. The pain is bad, but I manage without taking painkillers.

3. Painkillers give complete relief from pain.

4. Painkillers give moderate relief from pain.

5. Painkillers give very little relief from pain.

6. Painkillers have no affect on the pain, and I do not use them.

SECTION 2: PERSONAL CARE (E.G., WASHING, DRESSING)

1. I can look after myself normally without causing extra pain.

2. I can look after myself normally, but it causes extra pain.

3. Looking after myself is painful, and I am slow and careful.

4. I need some help, but I manage most of my personal care.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

PELVIS AND SACROILIAC JOINT THORACIC SPINE LOWER LEG, ANKLE, AND FOOT HIP CERVICAL SPINE LUMBAR SPINE

Stay updated, free articles. Join our Telegram channel

Join