Symptom Magnification and

Malingering in Occupational Health

and Workers Compensation

Matthew Barber, M.D.

Symptom Magnification and Malingering

Difficulties of the subject

Definitions
Possible ways to detect (exam,etc.)
Testing (in a specialty setting)
Improving Recovery Time and Return To Work
Q&A
* Perspective of orthopaedic surgeon

Training
Treating health providers often do not consider malingering, even
in cases of delayed recovery involving work injuries or other
personal injuries, where there may be a significant incentive to
feign or embellish symptoms or delay recovery (Aronoff et al,
2007).
The term malingering, as a description of behavior or as a
diagnosis, usually is considered highly pejorative and
controversial. Clinicians may be reluctant to address this behavior
directly, even if there is strong evidence, because they are afraid
of the consequences (e.g., mislabeling someone, being
threatened, or being sued) [Binder & Iverson, 2000].

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

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

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

Non-organic Physical Signs

(Waddells signs)
Non-anatomic weakness or sensory loss
Non-anatomic superficial tenderness
Simulation tests with axial loading and en
bloc rotation producing pain
Distraction test or flip test in which pt has no
pain with full extension of knee while seated,
but the supine SLR is markedly positive
Over-reaction verbally or exaggerated body
language
Waddell, et al. Spine 5(2):117125, 1980.

Tests / Waddells Signs

Waddells Light Pinch
Non-anatomical tenderness to light pinch.

Waddells Axial Vertical Loading

Vertical loading on a standing patients skull produces
low back pain.

Waddells Simulated Rotation

Passive rotation of shoulders and pelvis in the same
plane causes low back pain.

Distraction
Discrepancy between findings on sitting and supine
straight leg raising tests.

Overreaction
Disproportionate facial expression, verbalization or
tremor during examination.

Waddells Light Pinch

Detection
Non-anatomic
weakness or sensory
loss

Bowlus and Currier Test

Waddells Axial Vertical Loading

Waddells Simulated Rotation

Distraction

Overreaction

Hoover Test

Helps to determine whether pt is malingering

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

Hip Adductor Test

Observation
Gait
Movements
Particularly when not being examined

Window Test

Surveillance

Resource-intensive
Not practical in every
case

FCE

Inconsistencies
Excess of self-limiting
behaviors

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

Diagnostic Testing
Sometimes early
Sometimes late
Careful interpretation

Improving Recovery Time and

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

Thank You

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

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

Administration
Provide the client with the questionnaire asking
5 simple questions requiring either a yes or a
no answer.
There are two additional questions which may
be utilized, they are gathered in the routine
history which doesnt appear on the patients
questionnaire.
A yes answer to either of these additional
questions constitutes an inappropriate response.

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

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

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

Non-organic Physical Signs

(Waddells signs)
Non-anatomic weakness or sensory loss
Non-anatomic superficial tenderness
Simulation tests with axial loading and en
bloc rotation producing pain
Distraction test or flip test in which pt has no
pain with full extension of knee while seated,
but the supine SLR is markedly positive
Over-reaction verbally or exaggerated body
language
Waddell, et al. Spine 5(2):117125, 1980.