MALINGERING

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CHAPTER THIRTEEN MALINGERING

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.

ORTHOPEDIC GAMUT 13-1 COMMONLY USED PROCEDURES IN DETERMINING EXISTENCE OF COGNITIVE MALINGERING

• Victoria Symptom Validity Test (VSVT): The VSVT is a computer-administered and computer-scored test. It includes a total of 48 items, presented in three blocks of 16 items each. During the study trial, a single five-digit study number is presented for 5 seconds in the center of the computer screen. This presentation is followed by the retention interval and then by the recognition trial, in which the target and a five-digit distractor are displayed. The respondents are asked to choose the number they saw in the study trial. The retention interval is 5 seconds in the first block, 10 seconds in the second, and 15 seconds in the third.

• Test of memory malingering (TOMM): The TOMM is an instrument designed to provide an assessment whether an individual is falsifying symptoms of memory impairment. It consists of 50 pictures of common objects that the subject must remember. After the presentation of the 50 pictures, the individual has to recognize which one is the correct picture between two alternatives. The TOMM consists of two learning trials and an optional retention trial and has good face validity as a test of learning and memory.

• The b test: The b test is a measure to identify malingering requiring recognition of overlearned information. This test is a letter recognition and discrimination task that consists of a 15-page stimulus booklet. The examinee is asked to circle all instances of the letter b that appear on each page, working as quickly as possible.

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).

BOX 13-1 SYMPTOMS OF DEPRESSION

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.

1. Depressed mood or irritable mood

2. Markedly diminished interest or pleasure in activities

3. Significant weight loss or weight gain when not dieting

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation—observable by others

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt, which may be delusional

8. Diminished ability to think or concentrate; indecisiveness

9. Recurrent thoughts of death, recurrent suicidal ideation without a plan, a suicide attempt, or a specific plan for committing suicide

10. Lack of reactivity to usually pleasurable stimuli

11. Depression worse in the morning

12. Early morning awakening

ORTHOPEDIC GAMUT 13-2 DSM-IV ^* SYMPTOM SPECIFIC CATEGORIES IN EXCESSIVE COGNITIVE SYMPTOMS

A. Somatization disorder requires:

a. At least four pain symptoms

b. Two gastrointestinal symptoms

c. One sexual symptom

d. One pseudoneurologic symptom

B. Undifferentiated somatoform disorder requires one or more physical complaints, with no reference made to cognitive difficulties.

C. Conversion disorder requires one or more symptoms or deficits affecting voluntary motor or sensory function without mention of cognitive or memory difficulties.

D. Pain disorder requires only excessive pain symptoms.

E. Somatoform disorder NOS includes individuals with predominantly excessive cognitive symptoms.

F. Dissociative amnesia requires one specific type of cognitive problem, such as the inability to recall important personal information, usually of a traumatic or stressful nature.

G. Dissociative fugue requires one specific cognitive difficulty, such as the inability to recall some or all of one’s past. This difficulty must surface in the context of a sudden, unexpected travel away from home or one’s customary place of daily activities.

H. Dissociative identity disorder occurs in individuals with multiple personalities in which they exhibit an inability to recall important information about one or more personality states when they are in a different personality state.

I. Dissociative disorder NOS encompasses individuals with excessive cognitive complaints.

^* DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
NOS, Not otherwise specified.

ORTHOPEDIC GAMUT 13-3 PREDICTORS OF WORK INCAPACITY AND WORK LOSS BECAUSE OF DEPRESSION

1. Incoherent presentation of pain localization and stable symptoms

2. Inability to influence pain and function by movement or change of position

3. Relapse of a preexisting condition and lack of response in previous episodes

4. Work dissatisfaction

5. Problems of communicating realistic treatment goals

6. Poor self-perceived prognoses with unrealistically high perception of impairment

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

Anesthesia

Janet test

Midline tuning-fork test

Regional anesthesia testing

Blindness

Cuignet test

Marcus Gunn sign

Midline tuning-fork test

Snellen test

Cerebellar lesions

Coordination-disturbance testing

Position-sense testing

Romberg sign

Hemiplegic posturing

Simulated foot-drop testing

Consciousness

Limb-dropping test (upper extremities)

Stoicism indexing

Deafness

Gault test

Limb-dropping test (lower extremities)

Facial anesthesia

Facial anesthesia testing

Lombard test

Facial pain Seeligmuller sign General pain

Libman sign

Mannkopf sign

Marked part pain-suggestibility test

Related joint motion test

Lower back

Axial trunk-loading test

Trunk rotational test

Tripod test (bilateral leg-fluttering test)

Olfactory nerve Anosmia testing Paresis

Bilateral limb-dropping test (lower extremities)

Hemiplegic posturing

Hoover sign

Simulated foot-drop testing

Simulated forearm-and-wrist-weakness testing

Simulated grip-strength-loss testing

Sciatica

Flip sign

Plantar flexion test

Stoicism Stoicism indexing Trigeminal nerve Anosmia testing

ORTHOPEDIC GAMUT 13-4 THE FIVE Ds OF GLOBAL HEALTH STATUS

1. Death

2. Disability—upper or lower limb functional problems

3. Discomfort—physical or psychologic

4. Drug reactions—or other medical or surgical iatrogenic problems

5. Dollars—both direct and indirect costs

ORTHOPEDIC GAMUT 13-5 IMPORTANCE OF MALINGERING ASSESSMENT

Examiners should be concerned about whether treatment-seeking patients are malingering for several important reasons:

• Diagnosis and treatment planning

• Malingering needs to be ruled out before establishing a diagnosis.

• If the diagnosis is incorrect, the resulting treatment may be misguided.

• Threat to the therapeutic alliance with clinicians: Clinicians routinely working with traumatized populations that have high rates of suspected but undetected malingering often become suspicious of the motives of all patients.

• Economic impact

• In 1995, the total cost of insurance fraud in the United States was estimated to be .3 billion.

• Most of this cost was the result of health insurance fraud, including (but not limited to) the malingering of posttraumatic stress disorder.

• Threat to research databases: Researchers commonly recruit people studies from treatment-seeking populations.

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).

BOX 13-2 DISEASE IMPACT INDEX

From Carr AJ, Thompson PW: Towards a measure of patient-perceived handicap in rheumatoid arthritis, Br J Rheumatol 33:378, 1994.

Patients report severity of problems on a 0-to-10 scale in six dimensions:

• Functional activities

• Social activities

• Relationships

• Emotions

• Socioeconomic factors

• Body image

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

	Physical Disease/Normal Illness Behavior	Abnormal Illness Behavior
Symptoms
Pain	Anatomic distribution	Whole leg pain Tailbone pain

Numbness Dermatomal Whole leg numbness Weakness Myotomal Whole leg giving way Time pattern Varies with time and activity Never free of pain Response to treatment Variable benefit

Intolerance of treatments

Emergency admissions to hospital

Signs Tenderness Anatomic distribution

Superficial

Widespread nonanatomic

Axial loading No lumbar pain Lumbar pain Simulated rotation No lumbar pain Lumbar pain Straight-leg-raising Limited on distraction Improves with distraction Sensory Dermatomal Regional Motor Myotomal Regional, jerky, giving way

From Waddell G, et al: Symptoms and signs: physical disease or illness behavior? Br Med J 289:739, 1984, British Medical Association.

CLINICAL PEARL

Standardized instruments are often used in survey research. Many of these instruments are devised in clinic settings where trained health care professionals complete health assessments. However, prohibitive cost and relative ease make participant-assessed outcome measures a more feasible approach to obtain constructs describing functional and mental health outcomes. With these more-convenient measures of health increasingly used as primary outcomes in epidemiologic studies, selecting an appropriate assessment tool involves careful review of the many standard survey instruments available. The Millennium Cohort, the largest cohort study ever undertaken by the U.S. Department of Defense, was launched in 2001 to gather health outcome information along with occupational and environmental exposures employing a longitudinal approach. In the first panel of enrollment, more than 77,000 participants joined the 22-year-long study, filling out either a mailed survey or an identical Web-based survey.

GENERAL PROCEDURES

General Patient Observation

Consensus has been reached among physicians that malingering is readily detected with appropriate medical and psychologic tests. Most patients who have remained conscious during an injury can give an adequate description of what happened. A malingerer is vague and on guard while describing the incidents of an injury or accident. However, some patients who also remain conscious at the time of injury are not as observant as others are, and these patients will be somewhat vague.

A malingerer often appears quarrelsome, nervous, and ill at ease. General observation of the patient before and after the physical examination may reveal that the patient is fully capable of movements or activities that were claimed to be impossible in the physical examination. The examiner should note how the patient enters and behaves in the reception room. It is helpful if a nonprofessional staff person takes the patient’s history and engages the claimant in conversation.

Detailed History

Occasionally, the physician is asked to distinguish fraud or exaggeration from organic injury. As should be apparent by now, this task is not an easy one. An examination, when deception or exaggeration is suspected, should be completed with a strictly impartial attitude on the part of the examiner. The patient must be accorded all the tact and courtesy that is ordinarily extended to any other patient. If the physician-patient rapport is compromised, confidence is destroyed, and questions and tests, which are constructed to evoke sincerity on the part of the patient, become unreliable.

In many instances, the patient grudgingly gives the history. The malingering patient may remark, “I’ve told this to the last doctor, and I don’t see any reason to repeat it.”

The patient may also deny permission to review previous X-ray findings or case histories, stating that only the attorney can grant such permission. The genuine patient will not usually hesitate to furnish all patient information or permissions in this regard.

Malingerers will give an involved and long history, most of which is often discovered to be false. When the patient’s history, actions, and examination findings suggest that symptoms are exaggerated, one of the duties of the physician to make the examination so complete that no question will remain as to the actual extent of any organic disease or injury.

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

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

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.

AXIAL TRUNK-LOADING TEST

Assessment for Lumbar Spine Malingering

Comment

In the valid patient, any antalgic position can be taken as a sign that pain can be alleviated or abolished. The Quebec Task Force Classification System for categorizing spinal disorders lends in the differentiation of spinal pain validity (Table 13-6).

TABLE 13-6 THE QUEBEC CLASSIFICATION SYSTEM

PROCEDURE

• The examiner presses the patient’s cranium in a downward direction (Fig. 13-4).

• The existing antalgic positioning must not be disturbed during the axial loading.

• The axial loading may elicit pain in the neck, but it should not elicit pain in the lower back.

• Malingering should be suspected if the patient indicates that pain is felt in the lower back.

FIG. 13-4

CLINICAL PEARL

People with back pain express a fear that the reality of their pain is being questioned. Many of these individuals strive and frequently fail to achieve clinical and social characteristics that make up appropriate sickness behavior. A lack of proof that they are sick, including a lack of medical diagnosis, appropriate health care treatment, and visible disabilities, often leads to accusations, both felt and enacted, of malingering, hypochondria, mental illness, or any combination.

BURNS BENCH TEST

PROCEDURE

• The patient is instructed to kneel on a stool and bend the trunk forward far enough to allow touching of the floor with fingertips or hands (Fig. 13-5).

• Patients who may be expected to perform this test successfully include those afflicted with sciatica, sacralization, spondylolisthesis, compression fractures of vertebra, and so on.

• A malingerer will fail to perform the maneuver and usually states, “I can’t do it,” or words to that effect, even before attempting the move.

FIG. 13-5

CLINICAL PEARL

Patients with lumbar disc degeneration can cause back pain without associated radiculopathy or neurologic dysfunction in the lower extremities and represent a much greater challenge in terms of presentation, clinical imaging, and management than the other three diagnoses.

FLEXED-HIP TEST

Assessment for Lumbar Spine Malingering

PROCEDURE

• The examiner places one hand under the patient’s lumbar spine and the other hand under the patient’s knee.

• The examiner lifts the knee while flexing the hip (Fig. 13-6).

• If the patient indicates that lower back, or if leg pain is felt in the lower back before the lumbar spine moves, malingering should be suspected.

FIG. 13-6

CLINICAL PEARL

The causes of lower back pain in most people are unclear. Serious structural lesions such as tumors, infection, fractures, and severe deformities are frequently painful and are diagnosed with modern imaging studies. Such patients with serious structural problems are uncommon in outpatient clinical settings. Much more often, people have back pain episodes of varying degrees and either do not seek care or are treated symptomatically without a diagnosis.

FLIP SIGN

Assessment for Feigned Low Back Pain

PROCEDURE

• While the patient is lying in a supine position on the examining table, the examiner raises the patient’s affected leg, keeping the patient’s knee straight.

• If this movement is limited by pain or muscle resistance, the examiner then directs the patient to sit up, making sure the legs are kept flat on the table.

• If the patient can sit in this manner without pain, the test is positive.

• Sitting with the legs straight out reproduces the same maneuver as a straight-leg-raising test (Fig. 13-7).

FIG. 13-7 In a modification of this test, the patient is directed to sit up, with the legs extended and flat on the examination table. If the patient can sit up in this manner, the test is positive (A); in a final move, the examiner performs a leg lift of the affected part. If this can be accomplished without pain, the test is positive (B).

LIBMAN SIGN

Assessment for Hypersensitivity of Mastoid Process

PROCEDURE

• The examiner applies finger pressure to the mastoid process (Fig. 13-8).

• The pressure is gradually increased until the patient states that it is becoming noticeably uncomfortable.

• This point is an indication of that patient’s pain threshold, which varies from patient to patient.

• The threshold gives the examiner an idea if this patient has a low, high, or moderate pain threshold.

• The threshold is not to be used specifically as a criterion for malingering.

• Identifying a patient’s pain threshold will quantify discomfort in this patient and applies to this patient only.

• This testing procedure will be useful during interpretation of palpation findings or subjective statements concerning pain or discomfort.

FIG. 13-8

CLINICAL PEARL

Chronic pain patients are typically more impaired on more complex attention-demanding tasks; however, tasks that require fewer attentional resources are unaffected even when pain levels were high. However, the relationship between pain and cognitive impairment is complex.

MAGNUSON TEST

Assessment for Feigned Low Back Pain

PROCEDURE

• The patient with lower back pain is directed to point to the site of the pain.

• The examiner marks the site.

• The examiner then distracts the patient by performing an examination away from the marked site of pain and later resumes the examination of the lower back.

• The test is positive with any change in the location of the pain of greater than 1 to 2 cm (Fig. 13-9).

• The test is significant as evidence of simulated pain, hysteria, or malingering.

FIG. 13-9

MANNKOPF SIGN

Assessment for Simulated Pain

PROCEDURE

• The examiner establishes the patient’s resting pulse rate, and the patient is made as comfortable as possible.

• Then, without changing the patient’s position, the examiner applies mechanical pressure or electrical stimulation over the painful area while monitoring the pulse rate (Fig. 13-10).

• An increase in pulse rate of 10 or more beats per minute constitutes a positive sign.

• The sign is absent in simulated pain.

FIG. 13-10

MARKED PART PAIN-SUGGESTIBILITY TEST

Assessment for Pain Exaggeration

PROCEDURE

• The examiner applies pressure to the described painful point and marks it.

• The patient is distracted by examination of some other part of the body and pressing on new, tender areas.

• The examiner returns to the area of original complaint and asks the patient to close the eyes and then locate the tender points.

• If the patient cannot place the points of pain or tenderness closer than 2 in from the marked area, exaggeration is suspected (Fig. 13-11).

FIG. 13-11

CLINICAL PEARL

Human babesiosis was first recognized in Europe in 1957. In 1999, the southern-most range of human babesiosis on America’s Atlantic coast was reported to be northwestern New Jersey. Other agents such as Borrelia burgdorferi, the Lyme disease spirochete, the rickettsiae of ehrlichiosis, and bacterial rods of Bartonella spp. within tick saliva often accompany Babesia spp.; increasingly, patients are coinfected with Lyme disease and babesiosis. If the disease is misdiagnosed as influenza, for example, and therefore goes untreated, infected humans tend to decompensate, often mislabeled as depressed or hypochondriacal, among others, rarely receiving optimal treatment for smoldering but active babesiosis—a sometimes fatal disease, especially if the patient is older or becomes immunocompromised.

PLANTAR FLEXION TEST

Assessment for Feigned Low Back Pain

ORTHOPEDIC GAMUT 13-16 ACTIVE PLANTAR FLEXION

Active plantar flexion stresses the calf muscles similarly to the treadmill test but with less effect on the cardiovascular system. The procedure is as follows:

• Both feet are placed in an adjustable brace, stabilizing and isolating the lower limbs.

• The patient pushes with both feet against pedals simultaneously until the pedals stop and holds the position for two seconds.

• The patient releases the pedals gently over 2 seconds.

• The patient presses the pedals in time to an audible signal set at 30 beats per minute; one signal to push is followed by a signal to release the pedals.

• The time in which the patient feels pain in the calf muscles is recorded (pain-free exercise time).

• The time at which the patient claims to reach their limit of exercise is recorded (maximal exercise time).

• The patient is allowed to stop for other symptoms; as in the treadmill test, symptoms, as well as blood pressure and heart rate before and after exercise, are recorded.

RELATED JOINT MOTION TEST

Assessment for Feigned Pain

PROCEDURE

• The painful part is either actively or passively moved.

• This move is performed with isometric resistance of a muscle group that is nearby but is in no way associated with the pain.

• If the patient complains of pain, the examiner moves the muscle group or related joint later, judging the inaccuracy of the statements and the correlated reactions (Fig. 13-13).

• This assessment is accomplished by using a flexor group where an extensor group may produce pain in the joint.

• In cases in which the same muscle serves more than one movement, all movements should be tested.

FIG. 13-13

SEELIGMULLER SIGN

Assessment for Hysterical Face Pain

PROCEDURE

• Mydriasis (dilated pupil) is present on the side of the face that is afflicted with neuralgia.

• The sign is present as long as pain is present.

• The sign is absent in cases of hysteria and malingering (Fig. 13-14).

FIG. 13-14

SENSORY DEFICIT QUALIFICATION AND QUANTIFICATION

Overview

The nervous system does not perceive external events directly. Instead, the brain receives an abstract picture that is a composite of nerve impulses that originate at the periphery. The transformation of external stimuli into conductible impulses is called transduction. Sensibility is the reception or encoding of external stimuli and the transmission of impulses along nerve fibers.

ORTHOPEDIC GAMUT 13-18 SPECIFIC ASPECTS OF POSTINJURY NEUROPATHIC PAIN SYNDROMES

1. Mechanoallodynia and thermal allodynia

a. Allodynia refers to pain provoked by an innocuous mechanical or thermal stimulus.

b. Dynamic mechanoallodynia and hyperalgesia refers to a gentle moving stimulus over the skin surface that elicits pain, whereas static mechanoallodynia and hyperalgesia is pain produced by a stationary pressure stimulus.

2. Mechanohyperalgesia and thermal hyperalgesia—hyperalgesia signifies a lowered threshold to a normally painful stimulus and enhanced pain perception.

3. Hyperpathia—hyperpathia is a reflection of disordered central pain processing in which the pain threshold is increased but once exceeded pain reaches maximal intensity too rapidly, is more severe than expected, and is not stimulus bound.

ORTHOPEDIC GAMUT 13-19 NEURAL SENSIBILITY

Neural sensibility encompasses:

5. Temperature change

6. Pain

7. Touch-pressure

8. Movement or change in position

ORTHOPEDIC GAMUT 13-20 SENSATION

Sensation is divided into three groups:

1. Superficial

2. Deep

3. Combined

ORTHOPEDIC GAMUT 13-21 TWO GROUPS OF CUTANEOUS SENSIBILITY

1. Epicritic

2. Protopathic

CLINICAL PEARL (SENSORY DEFICIT ASSESSMENT)

In the evaluation of what appears to be psychogenic changes in sensation, the examiner must remember that some variation in the nerve supply exists in normal individuals. Furthermore, hysterical or malingered changes may be superimposed on organic anesthesia in peripheral nerve lesions and other neurologic disorders. An ipsilateral decrease or loss of the senses of vision, hearing, smell, and taste may occasionally accompany hysterical (or malingered) hemianesthesia, which almost invariably occurs on the left side.

PROCEDURE

• With complaints involving the loss of the sense of smell, the patient is directed to index various odors by smelling aromatics such as peppermint, clove, vanilla, coffee grounds (uncooked), and then, finally, spirit of ammonia (Fig. 13-16).

• An individual with psychogenic loss of smell often claims the inability to smell any of these substances.

• Ammonia is extremely pungent and actually irritates the trigeminal nerve endings in the nose, rather than being smelled by the olfactory nerve proper.

• Hence, a damaged olfactory nerve does not impair a patient’s ability to notice (smell) the pungent ammonia fumes.

FIG. 13-16

CLINICAL PEARL

One challenge to the implementation of the olfactory event-related potential in a clinical setting is the need for measurement of habituation-free brain potentials. The neuronal recovery time for the olfactory system is significantly longer than that of both the auditory and the visual systems. Specifically, the presentation of two olfactory stimuli 45 seconds apart results in habituation to the second presentation, which does not completely recover even after 90 seconds. This phenomenon is the result, in part, of adaptation of olfactory receptor cells and, in part, of habituation to the original presentation of the stimulus.

COORDINATION-DISTURBANCE TESTING

Assessment for Nonorganic Loss of Coordination

ORTHOPEDIC GAMUT 13-24 PRINCIPLES OF ESSENTIAL TREMOR

• Essential tremor (ET) is the most common tremor disorder and ranks among the most common neurologic movement disorders.

• Because the tremor persists, the prevalence of ET in older adults is much higher, estimated at 4% to 37% in people older than 40 to 55 years, many of whom are never formally diagnosed.

• The principal criterion for diagnosing ET is the clinical observation of postural or kinetic tremor involving the hands and forearms that is visible and persistent; additional or isolated tremor of the head may also be present.

• Tremor in the voice, jaw, or lower extremities may also be present.

• In addition, other common causes of tremor (e.g., enhanced physiologic tremor, altered thyroid function, Parkinson disease, dystonia, other neurologic disorders) must be ruled out.

PROCEDURE

• The patient with coordination disturbances is instructed to touch the tip of the nose while the eyes are open.

• The patient is then instructed to close the eyes and again touch the tip of the nose.

• With organic cerebellar lesions, an intention crescendo tremor is demonstrated as the finger approaches the nose.

• The malingerer will move the finger in a guided but devious course toward the nose without exhibiting the intention tremor (Fig. 13-17).

FIG. 13-17

CUIGNET TEST

Assessment for Simulated Blindness

ORTHOPEDIC GAMUT 13-25 SUMMARY OF CLINICAL TESTS FOR FUNCTIONAL VISUAL LOSS

Adapted from Chen CS et al: Practical clinical approaches to functional visual loss, J Clin Neurosci 14(1):1-7, 2007.

Clinical tests	Principle
Total Binocular Blindness
Observation	Clue to true or simulated difficulties in visual tasks
Finger tip test	Proprioceptive tasks and does not require
Signature test	vision
Mirror test	Convergence, miosis and accommodation reflex
Optokinetic test	Optokinetic reflex of smooth pursuit
Pupil response	Detection of afferent and efferent pathway
Menace reflex	Shock value
Tearing reflex	Tearing with bright light
Monocular Blindness
Pupil response	Direct afferent visual pathway light testing
Fogging test	Elicit better vision than claimed
Stereopsis testing	Require binocular vision
Prism shift test	Demonstrates binocular vision
Reduced Visual Acuity
Fogging test and stereoacuity	As above
Reduced Visual Field
Visual field to confrontation, kinetic and static perimetry	Physiological visual field characteristics

PROCEDURE

• The examination starts from the moment the patient walks into the consulting room; much information can be gained by careful observation. A truly blind patient will move cautiously and bump into objects naturally. A functionally blind patient will deliberately bump into objects or exaggerate movements. The examiner observes hand shaking. Furthermore, the examiner observes the accompanying person and their behavior toward the patient. It provides a very strong clue to the overall picture.

• Without a positive Marcus Gunn phenomenon but with continued complaint of unilateral blindness, the examiner places a refractive lens over the good eye, ostensibly to test it.

• The lens actually deprives the eye of any effective vision.

• The malingering patient is directed to read a Snellen chart (Fig. 13-18).

• This task is accomplished perfectly with the blind eye.

FIG. 13-18

FACIAL ANESTHESIA TESTING

Assessment for Hysterical or Simulated Face Anesthesia

ORTHOPEDIC GAMUT 13-26 LESIONS INVOLVING THE TRIGEMINAL COMPLEX

Adapted from Valls-Sole J: Neurophysiological assessment of trigeminal nerve reflexes in disorders of central and peripheral nervous system, Clin Neurophysiol 116(10):2255-2265, 2005.

• Trigeminal nerve branches

• Isolated idiopathic trigeminal neuropathy

• Vasculitis

• Traumatism

• Lymphoma, bone tumors, metastasis

• Trigeminal tumors

• Trigeminal ganglion

• Herpes zoster

• Immunological aggressions to Gasserian ganglia neurons

• Trigeminal neuralgia surgery

• Trigeminal nerve roots

• Meningioma, acoustic neurinoma, trigeminal neurinoma

• Aneurysms, vascular malformations

• Polyradiculoneuritis

• Vascular compression

• Trigeminal nuclei

• Infarcts, other vascular lesions in the brainstem

• Encephalitis and intraaxial tumors

• Demyelinating diseases of the central nervous system

• Syringobulbia

• Changes in excitability in trigeminal nerve mediated reflexes

• Parkinson disease and other parkinsonisms

• Cranial and cervical dystonia

• Huntington disease

• Various movement disorders (tics, head tremor; hemifacial spasm)

ORTHOPEDIC GAMUT 13-27 CLINICALLY APPLICABLE BRAINSTEM REFLEXES MEDIATED BY THE TRIGEMINAL NERVE

• Blink reflex

• Corneal reflex

• Masseteric inhibitory reflex

• Mandibular reflex

PROCEDURE

• In a patient with symptoms of facial anesthesia, the examiner applies a vibrating tuning fork to the numb side of the patient’s forehead near the midline (Fig. 13-19).

• The malingerer or hysteric will state that no sensation is felt.

• When the examiner moves the application of the tuning fork just across the midline, the patient now reports sensing the vibrations immediately.

• The lack of vibration sense on the numb side is impossible because the bone tissue conducts the vibration that is applied to the area of claimed anesthesia to the normal side.

• This test is valid even for a pathologic bone condition or an organic bone disease.

FIG. 13-19

GAULT TEST

Assessment for Simulated Deafness

ORTHOPEDIC GAMUT 13-28 CAUSES OF IMPAIRED HEARING

1. Involvement of the auditory structures in infectious diseases such as meningitis, syphilis, typhoid, mumps, measles, and hemolytic streptococcal infection

2. Tumors of the cerebellopontine angle, temporal lobe, eighth nerve, or cochlea

3. Trauma, such as from skull fracture

4. Injury by such toxic substances as quinine, arsenic, alcohol, salicylates, mercury, or aminoglycoside antibiotics (kanamycin)

5. Psychogenic disturbances

6. Physiologic dysfunction that may occur in senility and from excessive noise

ORTHOPEDIC GAMUT 13-29 COMPONENTS OF REFLEX BLINKING

• The inhibition of the basal tonic levator palpebrae superioris muscles, which keeps the eyes open

• The concurrent activation of the orbicularis oculi muscles

ORTHOPEDIC GAMUT 13-30 CONSIDERATIONS IN BLINKING

• Levator palpebrae superioris inhibition precedes and outlasts the orbicularis oculi activation

• This normal configuration is impaired in parkinsonism and blepharospasm

• Spontaneous blinking demonstrates a highly interindividual rate variation (among 10 to 20 per minute in adults)

• Abnormal blink rates occur in neurologic diseases related to dopaminergic transmission impairments

JANET TEST

Assessment for Simulated Anesthesia

PROCEDURE

• If anesthesia is the complaint, the patient is instructed to close the eyes.

• The patient is then directed to answer yes if a pinprick is felt on the skin or no if not (Fig. 13-21).

• Obviously, the only appropriate answer is silence when the supposedly anesthetic area is touched.

FIG. 13-21

LIMB-DROPPING TEST (UPPER EXTREMITIES)

Assessment for Feigned Unconsciousness

ORTHOPEDIC GAMUT 13-31 THREE COMPONENTS OF THE GLASGOW COMA SCALE

• Motor response: The ease with which motor responses can be elicited in the limbs, together with the wide range of different patterns that can occur, makes motor activity a suitable guide to the functioning state of the central nervous system.

• Verbal response: Probably the commonest definition of the end of a coma, or the recovery of consciousness, is the patient’s first understandable utterance.

• Eye opening: Spontaneous eye opening indicates that the arousal mechanisms in the brainstem are active.

ORTHOPEDIC GAMUT 13-32 GLASGOW COMA SCALE

Eye Opening
Spontaneous	4
To speech	3
To pain	2
None	1
Best Verbal Response
Oriented	5
Confused conversation	4
Inappropriate words	3
Incomprehensible sounds	2
None	1
Best Motor Response
Obeys commands	6
Localizes pain	5
Withdrawal (normal flexion)	4
Abnormal flexion (decorticate)	3
Extension (decerebrate)	2
None	1

ORTHOPEDIC GAMUT 13-33 LEVEL OF CONSCIOUSNESS

Diseases producing disturbances of the level of consciousness fall into the following four main categories:

1. Supratentorial mass lesions that secondarily compress deep midline structures

2. Infratentorial lesions that directly damage the central brainstem core

3. Metabolic disorders that widely depress or interrupt cortical function

4. Psychiatric disorders resembling coma

ORTHOPEDIC GAMUT 13-34 GLASGOW-LIEGE SCALE

The five brainstem reflexes selected disappear in descending order during rostral-caudal deterioration. The disappearance of the last, the oculocardiac, coincides with brain death.

Brainstem Reflex	Points
Frontoorbicular	5
Vertical oculovestibular	4
Pupillary light	3
Horizontal oculovestibular	2
Oculocardiac	1
No response	0

PROCEDURE

• In many instances, when the examiner holds up the hand of a patient who is feigning reduced consciousness and lets the hand drop over the patient’s face, the arms will consciously swerve to keep the hand from striking the face.

• A patient with an organically reduced level of consciousness will not make this movement of avoidance and will usually have pupillary abnormalities and other positive neurologic signs (Fig. 13-22).

FIG. 13-22

LOMBARD TEST

Assessment for Simulated Deafness

MARCUS GUNN SIGN

Assessment for Normal Optic Neural Function

PROCEDURE

• If an organic basis for unilateral blindness is found, the lesion must be situated anteriorly to the optic chiasm, and the pupillary reaction is usually abnormal.

• Marcus Gunn sign is especially useful for evaluating the existence of unilateral blindness.

• To elicit the Marcus Gunn sign, the patient’s eyes are fixed at a distant point and a strong light shone on the intact eye.

• A crisp, bilateral contraction of the pupils is noted.

• When the light is moved to the affected eye, both pupils dilate for a brief period.

• When the light is returned to the intact eye, both pupils contract promptly and remain contracted (Fig. 13-24).

• This response indicates damage to the optic nerve on the affected side.

FIG. 13-24 On return of the light to the intact eye, both pupils contract promptly and remain contracted. This response indicates damage to the optic nerve on the affected side. The absence of Marcus Gunn sign in unilateral blindness indicates a nonorganic basis for the complaint.

MIDLINE TUNING-FORK TEST

Assessment for Simulated Anesthesia

PROCEDURE

• Patients with organic sensory disturbances are able to perceive a vibrating tuning fork placed on either side of the head or on either side of the sternum because the conduction vibrates through the bone (Fig. 13-25).

• In a conversion reaction, the sternum or head is split.

• For example, vibration is perceived on one side of the midline of the forehead or sternum but not on the other.

FIG. 13-25

OPTOKINETIC NYSTAGMUS TEST

Assessment for Feigned Blindness

PROCEDURE

• With faked blindness, the patient will often avoid personal injury when walking and will blink to unexpected physical threats.

• Pupillary reactions are normal, and optokinetic nystagmus is normal.

• To demonstrate optokinetic nystagmus, the examiner instructs the patient to keep the eyes open.

• The examiner holds a ruler or a tape measure 10 inches in front of the patient’s face, ostensibly to measure pupillary distances.

• As the pupils constrict, which demonstrates attempted focusing, the ruler is moved from left to right across the patient’s field of vision (Fig. 13-26).

• A patient who can see the ruler will fix the vision on the vertical markings and develop an involuntary eye movement called optokinetic nystagmus.

• This phenomenon is a similar to the one a person exhibits while riding in a vehicle and looking out the window watching telephone poles go by.

• This test is used when routine eye examination reveals a normal fundus and intact pupillary reactions to light.

• With organic blindness, pupillary reflexes are abnormal, and optokinetic nystagmus is absent.

• Hysterical field defects, when plotted out on a tangent screen, will not change with the varying distance between the patient and the screen.

FIG. 13-26

POSITION-SENSE TESTING

Assessment for Feigned Loss of Position Sense

PROCEDURE

• If a patient claims that the position of a body part cannot be differentiated, the patient is directed to close the eyes, and the examiner bends the patient’s fingers or toes up or down.

• The patient is instructed to state what direction the examiner is bending the digit.

• A patient may report contrary findings by saying up when the examiner is bringing the digit down, and vice versa (Fig. 13-27).

• With organic sensory loss, the patient has a 50% chance of correctly guessing the digit position.

• The malingerer’s reporting average is always contrary to the actual digit position and therefore incorrect a majority of the time.

FIG. 13-27

PROCEDURE

• To define a regional complaint of numbness, the examiner uses a straight pin or a Wartenberg pinwheel and delineates the areas where the claimed numbness ceases.

• The usual organic cause of anesthesia or paresthesia is peripheral neuritis.

• With peripheral neuritis, the upper border of the anesthesia is blurry and usually different for each different sensation tested, such as pain, touch, heat, and vibration.

• In the hysterical or malingering patient, the border of anesthesia is extremely abrupt, stopping at a wrist crease or some other external anatomic area that is unrelated to the dermatome pattern (Fig. 13-28).

• This numbness landmark may even vary from examination to examination.

• Most malingerers claim a simultaneous loss of all forms of sensation, including touch, pain, temperature, and vibratory sensation.

• All losses are identical as to extent and accurate neural distribution or dermatome patterns are not present.

FIG. 13-28

ROMBERG SIGN

ALSO KNOWN AS STATION TEST

Assessment for Nonorganic Ataxia

PROCEDURE

• With this disorder of balance loss, the patient is instructed to stand with the feet together, first with the eyes open, then with the eyes closed.

• With organic sensory ataxia, the patient will sway the body from the ankles.

• Swaying from the hips toward a wall to catch one’s self in the nick of time suggests malingering (Fig. 13-29).

FIG. 13-29

SNELLEN TEST

Assessment for Feigned Color Blindness

ORTHOPEDIC GAMUT 13-36 COLOR BLINDNESS

Color blindness may be hereditary or acquired. Hereditary types are transmitted as recessive characteristics, sometimes X-linked. These characteristics include the following:

1. Achromatopsia (total color blindness)

2. Monochromatism (partial color blindness, with ability to recognize one of the three basic colors remaining)

3. Dichromatism (ability to recognize two of the three basic colors)

In normal (trichromatic) vision, the eye can perceive three light primaries (red, blue, and green) and can mix these in suitable portions. Thus white or any color of the spectrum can be matched. Color blindness can result from a lessened capacity to match three primary colors. It can be dichromatic vision, in which only one pair of the primary colors is perceived, the two colors being complementary to each other. Most dichromats are red-green blind and confuse red, yellow, and green (Table 13-7).

TABLE 13-7 COMPARISON OF ACQUIRED AND CONGENITAL COLOR VISION DEFICIENCIES

Acquired Color Vision Defect	Congenital Color Vision Defect
Onset after birth	Onset at birth
Monocular differences in the type and severity of the defect occur frequently	Both eyes are equally affected
Color alterations are frequently associated with other visual problems such as low acuity and reductions in the useful visual (except in rod monochromatism) or visual field	The visual problems are specific to color perception; there are no problems with acuity field
The type and severity of the deficiency fluctuate throughout life	The type and severity of the defect are the same
The type of defect might not be easy to classify; combined or nonspecific defects occur frequently	The type of defect can be classified precisely
Predominantly either protan or deutan	Predominantly tritan
Higher incidence in men	Same incidence in both sexes

Adapted from Lillo JA, Moreira H, Charles S: Color blindness. In Encyclopedia of applied psychology, New York, 2004, Elsevier.

PROCEDURE

• For pretended color blindness in one eye, the patient is requested to look at alternate red and green letters.

• The admittedly good eye is covered with a red glass (Fig. 13-30).

• If the green letters are read, evidence of fraud is present.

FIG. 13-30

STOICISM INDEXING

Assessment for Congenital Insensitivity to Pain

PROCEDURE

• The interval between eye blinks in the average patient is 25 to 30 seconds.

• A 60-second lapse between blinks while staring straight ahead indicates a patient who is stoic (Fig. 13-31).

• A stoic patient can be described as impassive and calm in the face of pain and discomfort.

• Stoic patients may also be cool and indifferent to the sensations elicited in testing.

FIG. 13-31

PARALYSIS QUALIFICATION AND QUANTIFICATION

Overview

Motion is a fundamental property of most animal life. The lowest multicellular animals possess rudimentary neuromuscular mechanisms. In higher forms, motion is based on the transmission of impulses from a receptor through an afferent neuron and ganglion cell to muscle. This same principle is found in the reflex arc of higher animals, including humans, in whom the anterior spinal cord has developed into a central regulating mechanism. This central regulating mechanism is involved in initiating and integrating movements.

Motor disturbances include weakness and paralysis, which may result from lesions of the voluntary motor pathways or of the muscles themselves. Impaired motor functioning may result from involvement of muscle, myoneural junction, peripheral nerve, or the central nervous system.

The types of paralysis or paresis are based on the location. Hemiplegia is a spastic or flaccid paralysis of one side of the body and extremities, limited by the median line sagittally. Monoplegia is a paralysis of one extremity only. Diplegia is a paralysis of any two corresponding extremities, both of which are usually lower extremities, but may be upper extremities. Paraplegia is a symmetric paralysis of both lower extremities. Quadriplegia, or tetraplegia, is a paralysis of all four extremities. Hemiplegia alternans (crossed paralysis) is a paralysis of one or more ipsilateral cranial nerves and contralateral paralysis of the arm and leg.

ORTHOPEDIC GAMUT 13-37 MOVEMENT DISORDERS OF ORGANIC ORIGIN

Distractibility and variability are especially common in psychogenic tremor (80% of cases) and commonly coexist with entrainment and coactivation signs (Table 13-8).

TABLE 13-8 CLINICAL CHARACTERISTICS OF PSYCHOGENIC MOVEMENT DISORDERS

Mode of onset

• Abrupt

• Precipitating event

• Fast progression to maximal symptom severity and disability

Clinical signs

• Signs incongruent with organic disease

• Distractibility and variability

• Multiple abnormal movements

• Increased movement with attention to the affected body part

• Deliberate slowness of movement

• Entrainment, coactivation

• Association with false weakness, sensory loss, and pain

• Unresponsiveness to drugs for organic movement disorders, response to placebo drugs and suggestion

Adapted from Hinson VK, Haren WB: Psychogenic movement disorders, Lancet Neurol 5(8):695-700, 2006.

CLINICAL PEARL (PARALYSIS ASSESSMENT)

Abnormalities of the motor system, which may be manifestations of both hysteria and malingering, include disturbances of muscle strength and power, disorders of tone, dyskinesia, and abnormalities of coordination, station, and gait. Rarely do changes in volume or contour occur (except for wasting from disuse), and no abnormalities are found on electromyographic examination. These motor changes of psychic origin may resemble almost any type of motor disturbance that is brought about by organic disease of the nervous system.

In both hysterical and malingered paralyses, the patient makes little effort to contract the muscles necessary for executing the desired movement. The patient may remain calm and indifferent while demonstrating the lack of strength. The patient may also show little sign of alarm at the presence of complete paralysis and may smile cheerfully during the examination. Reliable evidence that the patient is not exerting all available power in an attempt to carry out a voluntary movement can be elicited by watching and palpating the contraction of the antagonists, as well as the agonists.

BILATERAL LIMB-DROPPING TEST (LOWER EXTREMITIES)

Assessment for Feigned Paresis of Lower Extremity

ORTHOPEDIC GAMUT 13-39 FUNCTIONAL AMBULATION CLASSIFICATION

Level 0: Nonambulation

Level 1: Nonfunctional or dependent ambulation

Level 2: Household ambulation

Level 3: Surroundings of the house ambulation (neighborhood)

Level 4: Community ambulation

Level 5: Normal ambulation

ORTHOPEDIC GAMUT 13-40 THE BARTHEL INDEX

Full credit is not given for an activity if the patient needs even minimal help/supervision. A score of 0 is given when the patient cannot meet the criteria as defined.

Patient Name: ___________________________

Rater Name: ___________________________

Date: ___________________________

Activity	Score
Feeding
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent	_______
Bathing
0 = dependent
5 = independent (or in shower)	_______
Grooming
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)	_______
Dressing
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)	_______
Bowels
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent	_______
Bladder
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent	_______
Toilet Use
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)	_______
Transfers (bed to chair and back)
0 = unable help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent	_________
Mobility (on level surfaces)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards	_________
Stairs
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent	_________
Total (0–100)	SCORE_______

1. The index should be used as a record of what a patient does, not as a record of what a patient could do.

2. The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason.

3. The need for supervision renders the patient not independent.

4. A patient’s performance should be established using the best available evidence. Asking the patient, friends or relatives, and nurses are the usual sources, but direct observation and common sense are also important. However direct testing is not needed.

5. Usually, the patient’s performance over the preceding 24 to 48 hours is important, but occasionally longer periods will be relevant.

6. Middle categories imply that the patient supplies over 50% of the effort.

7. Use of aids to be independent is allowed.

The advantage of the BI is its simplicity. It is useful in evaluating a patient’s state of independence before treatment, patient progress undergoing treatment, and patient status when reaching maximum benefit. The total score is not as significant or meaningful as the breakdown into individual items, because these indicate where the deficiencies are.

HEMIPLEGIC POSTURING

Assessment for Nonorganic Hemiplegia

ORTHOPEDIC GAMUT 13-41 HEMIPLEGIC MOVEMENT PATTERNS IN CHILDREN WITH CEREBRAL PALSY

Movement Patterns for the Task of Rising from a Supine Position to a Standing Position	Segmental Score
I. Upper Limb Categories
a. Push and reach to bilateral push	1
b. Push and reach to asymmetric push	2
c. Symmetric push	3
d. Symmetric reach	4
e. Push and reach followed by pushing on one leg	5
f. Push and reach to bilateral push followed by pushing on leg	6
II. Axial Categories
a. Full rotation with abdomen down	1
b. Full rotation with abdomen up	2
c. Partial rotation	3
d. Forward with rotation	4
e. Symmetric	5
III. Lower Limb Categories
a. Pike	1
b. Pike jump to squat	2
c. Kneel	3
d. Jump to squat	4
e. Half-kneel	5
f. Asymmetric wide based squat	6
g. Narrow based symmetric squat	7

PROCEDURE

• Paralysis is yet another symptom presentation from the repertoire of the hysteric, psychogenic, rheumatic, or malingering patient.

• A patient with a feigned paralyzed leg and arm may incorrectly assume the existence of difficulty in turning the head toward the paralyzed side (Fig. 13-33).

• Pronation drift (the inability to hold the pronated arms still) is absent on station and gait.

FIG. 13-33

HOOVER SIGN

Assessment for Feigned Leg Paresis

Neurologic loss is usually described as a sensory or motor deficit. The sensory loss may produce hypoesthesia, paresthesia, or hyperesthesia and may produce pain or numbness over a specific area. The motor deficits may be described as a weakness, as stiffness, or, more commonly, as difficulty in walking far, running, or jumping. If outright paralysis is present, the onset may have been sudden or insidious (Table 13-9). The paralysis may be flaccid or spastic. Flaccidity is associated with lower motor neuron disorders and spasticity with upper motor neuron disorders. The examiner must determine whether the symptoms have increased or decreased and to what degree the patient is disabled. The examiner must also determine whether a loss of sphincter control of the bladder and rectum has occurred.

TABLE 13-9 COMMON CAUSES OF HYPOKALEMIC PARALYSIS

Potassium Deficit
Group 1
Hypochloremic metabolic alkalosis	Excessive vomiting Diuretics Licorice ingestion Mineralocorticoid syndromes Bartter or Gitelman syndrome Liddle syndrome

Group 2 Hyperchloremic metabolic acidosis and low NH₄⁺ excretion

Distal renal tubular acidosis (medullary-sponge kidney, Sjögren syndrome)

Proximal renal tubular acidosis, Fanconi syndrome

Group 3 Hyperchloremic metabolic acidosis and high NH₄⁺ excretion

Toluene abuse

Diarrheal state

Urethral diversion

Intracellular potassium shift Group 4 Normal acid–base balance

Thyrotoxic periodic paralysis

Familial periodic paralysis

Sporadic periodic paralysis

Hypernatremic hypokalemic paralysis

Barium poisoning

NH₄⁺ Ammonium.

From Pompeo A et al: Thyrotoxic hypokalemic periodic paralysis: an overlooked pathology in Western countries, Eur J Intern Med 18(5):380–390, 2007.

SIMULATED FOOT-DROP TESTING

Assessment for Feigned Steppage Gait or Foot Drop

SIMULATED FOREARM-AND-WRIST-WEAKNESS TESTING

Assessment for Simulated Weakness of Forearm and Wrist

ORTHOPEDIC GAMUT 13-42 LAMB BILATERAL HAND ACTIVITY INDEX OF ACTIVITIES PERFORMED WITH BOTH HANDS ACTING SIMULTANEOUSLY AND TOGETHER ^*

• Unscrew the top from a bottle.

• Fill a cup or glass and drink.

• Open a can with a manual can opener.

• Remove a match from a box or book and light it.

• Use a knife and fork for eating.

• Apply toothpaste to a toothbrush and clean teeth.

• Put on a jacket.

• Close buttons on clothing.

• Fasten a belt around the waist.

• Tie shoelaces.

• Sharpen a pencil in a manual sharpener.

• Write messages.

• Use a dial telephone.

• Staple papers together.

• Wrap string around a package.

• Use playing cards.

When progress is being measured, each of these items listed may be scored on a scale of 0 to 5, or 0 to 10, and added. A total score of 80 or 160, respectively, represents a return to normal bilateral hand functions.

^* Modified from McRae R: Clinical orthopaedic examination, ed 3, Edinburgh, 1990, Churchill Livingstone.

PROCEDURE

• If the complaint is persisting forearm or wrist weakness that is not associated with grip strength loss, the patient is directed to dorsiflex the wrist, usually by making a fist.

• If this task cannot be performed, the patient is then asked to squeeze a dynamometer while the examiner palpates the patient’s forearm (Fig. 13-37).

• In functional or feigned weakness, the examiner will feel the patient’s forearm extensors contract synergistically and will see the wrist extend when the patient squeezes.

FIG. 13-37

PROCEDURE

• When grip strength loss is the complaint, the patient is directed to squeeze the examiner’s fingers with the paralyzed hand as hard as possible.

• While the patient performs this task, the examiner suddenly tears the fingers away.

• If grip weakness is caused by organic disease, a sudden tug will break the grasp easily.

• If the weakness is being faked, strong resistance is likely to be encountered before the malingerer realizes the error or contradiction and releases the grip (Fig. 13-38).

FIG. 13-38

TRIPOD TEST (BILATERAL LEG-FLUTTERING TEST)

Assessment for Simulated Lumbar Pain

PROCEDURE

• A patient may attempt to fake a leg paralysis as the result of a further faked lumbar intervertebral disc syndrome.

• In this instance, the patient is instructed to sit on the examination table with the knees flexed at 90 degrees and the legs hanging dependent.

• The patient is directed to extend and relax, or flex, the legs rapidly and repeatedly.

• If lumbar disc involvement exists, the patient will need to lean back to perform this maneuver, if able to do it at all (Fig. 13-39).

• The patient feigning disc involvement can accomplish the maneuver without assuming such a tripod posture (Fig. 13-40).

FIG. 13-39

FIG. 13-40

TABLE 13-10 CAUSES OF UNILATERAL FOOT DROP AND BILATERAL FOOT DROP

II. Bilateral foot drop

a. Myopathies

b. Distal myopathies

c. Scapuloperoneal muscular dystrophy

d. Facioscapulohumeral muscular dystrophy

e. Myotonic dystrophy

f. Neuropathies

g. Multifocal motor neuropathy with conduction block

h. Chronic inflammatory demyelinating polyneuropathy

i. Bilateral peroneal neuropathies

j. Bilateral sciatic neuropathies

k. Bilateral lumbosacral plexopathies

l. Radiculopathies

m. Bilateral L5 radiculopathies

n. Conus medullaris lesion

o. Anterior horn cell disorders

p. Amyotrophic lateral sclerosis

q. Poliomyelitis and the postpoliomyelitis syndrome

r. Cerebral lesions

s. Bilateral cortical or subcortical parasagittal lesions

(Adapted from Katirji B, Michael JA, Robert BD: Causes of unilateral foot drop and bilateral foot drop. In: Encyclopedia of the neurological sciences, New York, 2003, Academic Press.)

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