1. Symptom Magnification & Worker’s Compensation Gordon C. Manin, MD, MPH Medical Director

2. Outline  Background  Definitions  History and Physical  Diagnostic Tests  Psychological Tests  Functional Tests

3. The Players  Worker  Employer  Primary Physician  Specialist Physician  Chiropractor  Therapist  Attorney  Insurer  TPA  State Worker’s Compensation System

4. Worker’s Compensation Compromise  No Fault  Medical Treatment  Income Maintenance  Limits on Employer Liability  Right to Appeal  Mandatory Coverage

5. Incentives - Worker  To Recover from Injury or Illness  To Return to Full Duty Position  To Punish Employer  To Get Their “Due”  To “Win the Lottery”  To Obtain Attention and Consolement

6. Pain Defined  An Unpleasant Sensory and Emotional Experience Arising from Actual or Potential Tissue Damage (International Association for the Study of Pain)  An Unpleasant Sensation and Emotional Response to that Sensation (American Academy of Pain Medicine)  A Complex Experience Consisting of a Physiological (Bodily) Response to a Noxious Stimulus Followed by an Affective (Emotional) Response to that Event (Web Version of Encyclopedia Britannica)

7. Pain  Subjective/Emotional Response  Influenced by Biology, Psychology, Culture, and Social Situation  Limited Ability to Objectively Measure  Acute, Sub-Acute, Chronic

8. Symptom Magnification Defined  The Conscious or Subconscious tendency of an individual to under-state his/her Abilities and/or Over-State his/her Limitations. (Matheson 1997)

9. Malingering Defined  The willful, deliberate, and fraudulent feigning or exaggeration of the symptoms of illness or injury, done for the purpose of consciously desired end. Dorland’s Illustrated Medical Dictionary, Twenty-Sixth Edition, W.B. Saunders, 1985. Dorland’s Illustrated Medical Dictionary, Twenty-Sixth Edition, W.B. Saunders, 1985.

10. Somatization Defined  In Psychiatry, the Conversion of Mental Experiences or States to Bodily Symptoms. Dorland’s Illustrated Medical Dictionary, Twenty-Sixth Edition, W.B. Saunders, 1985. Dorland’s Illustrated Medical Dictionary, Twenty-Sixth Edition, W.B. Saunders, 1985.

11. One Clinicians View of Pain and Worker’s Compensation Motivated Worker Malingering Worker Somatic Worker

12. How Do I Know Who is Real?  Initially Very Hard to Determine  Compilation of History, Physical Findings, Objective Studies, Course of Injury/Illness, Observation, Observation, Observation  Court Decision

13. Meticulous History  Chief Complaints  Mechanism of Injury  Temporal Course of Symptom and Event  Contributory Medical Conditions  Prior Injury History and Related Studies  Medications  Prior Litigation History  Family History  Social History

14. Historical “Yellow Flags”  Story Changing from one Visit to the Next  Involvement of an Automobile  History of Chronic Pain Syndromes  History of Depression or Anxiety  Previous Work Comp Claims  Newly Hired  Poor Job Performance or Satisfaction  Mention of an Attorney

15. Detailed Physical Examination  Visual Observation  Auscultation  Palpation

16. Special Physical Examination Maneuvers  Orthopedic  Neurologic  Other –Mankopf’s Test –O’Donoghue’s Maneuver –Hoover’s Test –Ect.

17. Waddell Signs of Non-Organic Back Pain  Superficial Tenderness  Non-Anatomic Tenderness  Axial Loading  Simulated Rotation  Distracted Straight- Leg Raise  Regional Sensory Changes  Regional Weakness  Overreaction Three or More Waddell Signs Implies Non-Organic Back Pain

18. Physical “Yellow Flags”  Waddell Signs  Inconsistent Observations  Inconsistent Results from Tests that Measure the Same Anatomical Location  Abnormal Provocative Maneuvers

19. Other Tests  Plain Film Radiographs  CT  MRI  Bone Scan  Nerve Conductions Studies

20. Physical Therapy  Phase 1 – Pain Mitigation / Protection  Phase 2 – Maintain ROM  Phase 3 – Restorative  Phase 4 – Work Simulation

21. “Interventional” Tests  Discogram  Pain Management –Local Block –Central Block (Epidural) –Nerve Root Block –Autonomic Block  Surgery

22. Psychological Tests  Magill Pain Questionnaire  Ransford Drawing  Dallas Pain Questionnaire  Oswestry Disability Scale  Minnesota Multiphasic Personality Test

23. “Functional” Tests  Functional Capacity Test (FCE) –Blankenship –Isernhagen –Key –Hanoun  IME  Video Surveillance

24. Caveats  Must First Rule Out Serious Pathology  Must Avoid Observer Bias  Isolated Behavioral Signs and Symptoms Carry Little Weight  Symptom Magnification May be Conscious or Subconscious (Symptom Magnification ≠ Malingering)  Symptom Magnification does not Rule Out Real Injury or Illness  Symptom Magnification is not a Diagnosis

25. Bottom Line  In All but the most Extreme Cases, the Medical Provider Must go Through a Process  Process should be Measured  Process should be Timely  Process should be Performed with Respect for All “Players”  Communicate with Medical Providers