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What physical exam techniques are useful to detect malingering?
No examination technique objectively proves malingering (strength of recommendation [SOR]: C, expert opinion). Waddell’s signs are associated with poor treatment outcomes but cannot discriminate organic from nonorganic causes (SOR: B, systematic review of low-quality studies). Hoover’s and the Abductor sign indicate nonorganic paralysis (SOR: C, small, lower-quality case-control studies) (TABLE 1).
Meticulous examination and documentation will save time and trouble down the road
Tim Huber, MD
US Navy, Camp Pendleton, Calif
Warning flags for malingering include persistent noncompliance during prescribed evaluation or treatment, striking inconsistency between physical findings and stated symptoms, and an attorney or insurance company referring the patient to you. If monetary compensation is involved, malingering can potentially be prosecuted as fraud.
Meticulous examination and documentation will save you time and trouble down the road. If you find evidence of malingering, confronting the patient directly will likely result in animosity towards you from the patient and may result in litigation. The confrontation may escalate into violent behavior. Further complicating matters, specialist referral often reinforces the malingering behavior. A common option at approaching the potentially malingering patient is to allow him or her the opportunity to save face: “Well, Mr. Q, I am not finding the usual signs that go along with the complaints you are having….”
If you are in doubt of a diagnosis of malingering, it is generally safest to assume a person is not malingering until you specifically witness a contradictory event.
Evidence summary
The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines malingering as “the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.”1 Malingering is not considered a mental disorder because symptoms are intentionally produced for external incentives.
No physical exam maneuver can determine a patient's external incentives. Traditionally, a physician uses certain exam techniques to determine if symptoms are of functional, or nonorganic, origin. Both terms denote the absence of a structural or physiological source for the phenomena, and include malingering and mental disorders such as factitious disorder, conversion disorder, and somatoform disorders. Our literature search only found studies concerning the detection of nonorganic causes of back pain, paralysis, and sensory loss.
Several exam tests are commonly thought to detect nonorganic causes of low back pain. Gordon Waddell described 8 signs in 5 categories (TABLE 2) used to “identify [back pain] patients who require more detailed psychological assessment.”2 A systematic review critiqued 60 studies of Waddell’s signs published between 1980 and 2000.3 The authors performed a thorough database search, including hand searches of key pain journals, meeting abstracts, and textbooks. The majority of the reviewed studies were small and of lower quality. The review found little evidence on test-retest or interrater reliability. There was consistent evidence that Waddell’s signs are associated with poorer treatment outcomes and generally consistent evidence that they are not associated with secondary gain and cannot discriminate organic from nonorganic problems.
A small, diagnostic case-control study of Mankopf’s test, which is based on the theory that pain increases heart rate, investigated 20 chronic low back pain patients considered nonorganic vs 20 pain-free controls using mechanical pain stimulus applied to subjects’ fingers.4 There was no significant difference in heart rate response between groups, and no significant effect of pain on heart rate in either group. The authors did not define their criteria for determining patients’ back pain as non-organic, nor did they include patients with low back pain caused by an identifiable pathology. There was no mention of blinding. This literature search found no published studies of McBride’s test, where the patient’s refusal to stand on the unaffected leg and flex the affected leg to the chest determines a feigned radiculopathy.
A few tests attempt to detect nonorganic causes of paralysis. In Hoover’s test, a patient is asked to alternately press down with the paralyzed leg and raise the unaffected leg to resistance, while the hand of the examiner cups the heel of the affected leg.5 A small, diagnostic case-control study using a computer-assisted strain gauge to measure movement effort during Hoover’s test involved 7 women with true paresis, 9 with nonorganic paresis, and 10 controls.6 The investigators diagnosed nonorganic paresis by history, neurological exam, and lack of positive neuroradiologic findings. The authors calculated a maximal involuntary to voluntary ratio for each patient’s extremities. The calculation discriminated between all 9 nonorganic patients and both the normal controls and patients with true paresis. The authors did not mention blinding in the study. No attempt was made to compare the strain gauge measurements with a clinician-performed Hoover’s test.
The Abductor sign, based on a similar theory that thigh abductors work in concert, was developed and studied by one individual.7 In this diagnostic case-control study, the single author tested 33 patients from his practice, 17 with organic paresis, and 16 with nonorganic paresis. The author differentiated organic from nonorganic paresis by history, physical exam, and various imaging studies with no independent assessment. He reported his test as 100% accurate. We did not find any published studies of the Arm Drop test, where feigned paralysis of an upper extremity is tested by holding the arm over the face of the supine patient and letting go.
The Midline Split test attempts to detect nonorganic causes of sensory loss. The fact that cutaneous nerves cross the midline is the basis for the idea that a sharp midline split denotes nonorganic sensory loss. In 1 diagnostic cohort study of 100 people presenting to a neurology department with complaints of decreased sensation on one side of the face, 80 patients were determined to have organic deficits such as multiple sclerosis or stroke. The author did not describe how these diseases were diagnosed. Of those with organic deficits, 7.5% showed midline splitting of sensory loss, falsely suggesting a nonorganic process. Only 20% of the patients with nonorganic sensory loss showed the expected midline split.8 The author apparently performed the sensory exam without blinding or independent confirmation.
TABLE 1
Summary of tests for the detection of malingering
| TEST | SYMPTOMS | DESCRIPTION | EVIDENCE/OUTCOMES | SOR |
|---|---|---|---|---|
| McBride’s | Back pain with radicular symptoms | Stand on one leg. Flex symptomatic leg and raise to chest. Refusal or pain = nonorganic | No published studies | C (expert opinion) |
| Mankopf’s | Back pain | 1700 g pressure applied to the middle phalanx of the second finger of the nondominant hand. True pain should increase heart rate. | Did not correlate with organic pain | C (small inconclusive diagnostic case-control study) |
| Waddell’s | Back pain | Positive signs from 3 or more categories (TABLE 2) | Cannot discriminate organic from nonorganic | C (from SR) |
| Associated with poorer treatment outcomes | C (from SR) | |||
| Not associated with secondary gain | B (from SR) | |||
| Hoover’s | Leg paresis | Cup heels and have patient press down with paretic limb. Then have patient raise opposite limb. True paresis if no difference in downward pressure at heels | Indicates nonorganic paresis | C (extrapolated from small diagnostic case-control study using strain gauge) |
| Abductor | Leg paresis | Ask patient to abduct paretic leg to resistance. In true paresis, opposite leg should abduct. | Indicates nonorganic causes | C (small, lower-quality case-control study) |
| Arm Drop | Arm paresis | Hold paretic hand above face and drop it. If hand misses face, paresis is nonorganic | No published studies | C (expert opinion) |
| Midline Split | Sensory loss | Test facial sensation to pinprick. Nonorganic loss of sensation is delineated by the midline. | Very weakly indicates nonorganic cause | C (small diagnostic case-control study) |
| SOR, strength of recommendation (see page 722); SR, systematic review. | ||||
TABLE 2
Waddell’s signs
| CATEGORY | SIGNS |
|---|---|
| Tenderness | Superficial: light pinching causing pain = positive Nonanatomic: deep tenderness over a wide area = positive |
| Simulation | Axial loading: downward pressure on the head causing low back pain = positive Rotation: Examiner holds shoulders and hips in same plane and rotates patient. Pain = positive |
| Distraction | Straight leg raise causes pain when formally tested, but straightening the leg with hip flexed ninety degrees to check Babinski does not |
| Regional | Weakness: multiple muscles not enervated by the same root Sensation: glove and stocking loss of sensation. |
| Overreaction | Excessive show of emotion |
Recommendations from others
The DSM-IV recommends suspicion of malingering for patients who present with 2 or more of the following: medicolegal issues, disagreement between objective and subjective stress or disability, noncompliance with evaluation or treatment, or antisocial personality disorder.1
The American Medical Association published the Guides to the Evaluation of Permanent Impairment, which states, “Confirmation of malingering is extremely difficult and generally depends on intentional or inadvertent surveillance.”9
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine 1980;5:117-125.
3. Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS. A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Med 2003;4:141-181.
4. Peters ML, Schmidt AJM. Psychophysiological responses to repeated acute pain stimulation in chronic low back pain patients. J Psychosom Res 1991;35:59-74.
5. Hoover CF. A new sign for the detection of malingering and functional paresis of the lower extremities. J Am Med Assoc 1908;51:746-747.
6. Ziv I, Djaldetti R, Zoldan Y, Avraham M, Melamed E. Diagnosis of “nonorganic” limb paresis by a novel objective motor assessment: the quantitative Hoover’s test. J Neurol 1998;245:797-802.
7. Sonoo M. Abductor sign: a reliable new sign to detect non-organic paresis of the lower limb. J Neurol Neurosurg Psychiatry 2004;75:121-125.
8. Rolak LA. Psychogenic sensory loss. J Nerv Ment Dis 1988;176:686-687.
9. Cocchiarella L, Andersson G. Guides to the Evaluation of Permanent Impairment. 5th ed. Chicago: AMA Press, 2001.
No examination technique objectively proves malingering (strength of recommendation [SOR]: C, expert opinion). Waddell’s signs are associated with poor treatment outcomes but cannot discriminate organic from nonorganic causes (SOR: B, systematic review of low-quality studies). Hoover’s and the Abductor sign indicate nonorganic paralysis (SOR: C, small, lower-quality case-control studies) (TABLE 1).
Meticulous examination and documentation will save time and trouble down the road
Tim Huber, MD
US Navy, Camp Pendleton, Calif
Warning flags for malingering include persistent noncompliance during prescribed evaluation or treatment, striking inconsistency between physical findings and stated symptoms, and an attorney or insurance company referring the patient to you. If monetary compensation is involved, malingering can potentially be prosecuted as fraud.
Meticulous examination and documentation will save you time and trouble down the road. If you find evidence of malingering, confronting the patient directly will likely result in animosity towards you from the patient and may result in litigation. The confrontation may escalate into violent behavior. Further complicating matters, specialist referral often reinforces the malingering behavior. A common option at approaching the potentially malingering patient is to allow him or her the opportunity to save face: “Well, Mr. Q, I am not finding the usual signs that go along with the complaints you are having….”
If you are in doubt of a diagnosis of malingering, it is generally safest to assume a person is not malingering until you specifically witness a contradictory event.
Evidence summary
The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines malingering as “the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.”1 Malingering is not considered a mental disorder because symptoms are intentionally produced for external incentives.
No physical exam maneuver can determine a patient's external incentives. Traditionally, a physician uses certain exam techniques to determine if symptoms are of functional, or nonorganic, origin. Both terms denote the absence of a structural or physiological source for the phenomena, and include malingering and mental disorders such as factitious disorder, conversion disorder, and somatoform disorders. Our literature search only found studies concerning the detection of nonorganic causes of back pain, paralysis, and sensory loss.
Several exam tests are commonly thought to detect nonorganic causes of low back pain. Gordon Waddell described 8 signs in 5 categories (TABLE 2) used to “identify [back pain] patients who require more detailed psychological assessment.”2 A systematic review critiqued 60 studies of Waddell’s signs published between 1980 and 2000.3 The authors performed a thorough database search, including hand searches of key pain journals, meeting abstracts, and textbooks. The majority of the reviewed studies were small and of lower quality. The review found little evidence on test-retest or interrater reliability. There was consistent evidence that Waddell’s signs are associated with poorer treatment outcomes and generally consistent evidence that they are not associated with secondary gain and cannot discriminate organic from nonorganic problems.
A small, diagnostic case-control study of Mankopf’s test, which is based on the theory that pain increases heart rate, investigated 20 chronic low back pain patients considered nonorganic vs 20 pain-free controls using mechanical pain stimulus applied to subjects’ fingers.4 There was no significant difference in heart rate response between groups, and no significant effect of pain on heart rate in either group. The authors did not define their criteria for determining patients’ back pain as non-organic, nor did they include patients with low back pain caused by an identifiable pathology. There was no mention of blinding. This literature search found no published studies of McBride’s test, where the patient’s refusal to stand on the unaffected leg and flex the affected leg to the chest determines a feigned radiculopathy.
A few tests attempt to detect nonorganic causes of paralysis. In Hoover’s test, a patient is asked to alternately press down with the paralyzed leg and raise the unaffected leg to resistance, while the hand of the examiner cups the heel of the affected leg.5 A small, diagnostic case-control study using a computer-assisted strain gauge to measure movement effort during Hoover’s test involved 7 women with true paresis, 9 with nonorganic paresis, and 10 controls.6 The investigators diagnosed nonorganic paresis by history, neurological exam, and lack of positive neuroradiologic findings. The authors calculated a maximal involuntary to voluntary ratio for each patient’s extremities. The calculation discriminated between all 9 nonorganic patients and both the normal controls and patients with true paresis. The authors did not mention blinding in the study. No attempt was made to compare the strain gauge measurements with a clinician-performed Hoover’s test.
The Abductor sign, based on a similar theory that thigh abductors work in concert, was developed and studied by one individual.7 In this diagnostic case-control study, the single author tested 33 patients from his practice, 17 with organic paresis, and 16 with nonorganic paresis. The author differentiated organic from nonorganic paresis by history, physical exam, and various imaging studies with no independent assessment. He reported his test as 100% accurate. We did not find any published studies of the Arm Drop test, where feigned paralysis of an upper extremity is tested by holding the arm over the face of the supine patient and letting go.
The Midline Split test attempts to detect nonorganic causes of sensory loss. The fact that cutaneous nerves cross the midline is the basis for the idea that a sharp midline split denotes nonorganic sensory loss. In 1 diagnostic cohort study of 100 people presenting to a neurology department with complaints of decreased sensation on one side of the face, 80 patients were determined to have organic deficits such as multiple sclerosis or stroke. The author did not describe how these diseases were diagnosed. Of those with organic deficits, 7.5% showed midline splitting of sensory loss, falsely suggesting a nonorganic process. Only 20% of the patients with nonorganic sensory loss showed the expected midline split.8 The author apparently performed the sensory exam without blinding or independent confirmation.
TABLE 1
Summary of tests for the detection of malingering
| TEST | SYMPTOMS | DESCRIPTION | EVIDENCE/OUTCOMES | SOR |
|---|---|---|---|---|
| McBride’s | Back pain with radicular symptoms | Stand on one leg. Flex symptomatic leg and raise to chest. Refusal or pain = nonorganic | No published studies | C (expert opinion) |
| Mankopf’s | Back pain | 1700 g pressure applied to the middle phalanx of the second finger of the nondominant hand. True pain should increase heart rate. | Did not correlate with organic pain | C (small inconclusive diagnostic case-control study) |
| Waddell’s | Back pain | Positive signs from 3 or more categories (TABLE 2) | Cannot discriminate organic from nonorganic | C (from SR) |
| Associated with poorer treatment outcomes | C (from SR) | |||
| Not associated with secondary gain | B (from SR) | |||
| Hoover’s | Leg paresis | Cup heels and have patient press down with paretic limb. Then have patient raise opposite limb. True paresis if no difference in downward pressure at heels | Indicates nonorganic paresis | C (extrapolated from small diagnostic case-control study using strain gauge) |
| Abductor | Leg paresis | Ask patient to abduct paretic leg to resistance. In true paresis, opposite leg should abduct. | Indicates nonorganic causes | C (small, lower-quality case-control study) |
| Arm Drop | Arm paresis | Hold paretic hand above face and drop it. If hand misses face, paresis is nonorganic | No published studies | C (expert opinion) |
| Midline Split | Sensory loss | Test facial sensation to pinprick. Nonorganic loss of sensation is delineated by the midline. | Very weakly indicates nonorganic cause | C (small diagnostic case-control study) |
| SOR, strength of recommendation (see page 722); SR, systematic review. | ||||
TABLE 2
Waddell’s signs
| CATEGORY | SIGNS |
|---|---|
| Tenderness | Superficial: light pinching causing pain = positive Nonanatomic: deep tenderness over a wide area = positive |
| Simulation | Axial loading: downward pressure on the head causing low back pain = positive Rotation: Examiner holds shoulders and hips in same plane and rotates patient. Pain = positive |
| Distraction | Straight leg raise causes pain when formally tested, but straightening the leg with hip flexed ninety degrees to check Babinski does not |
| Regional | Weakness: multiple muscles not enervated by the same root Sensation: glove and stocking loss of sensation. |
| Overreaction | Excessive show of emotion |
Recommendations from others
The DSM-IV recommends suspicion of malingering for patients who present with 2 or more of the following: medicolegal issues, disagreement between objective and subjective stress or disability, noncompliance with evaluation or treatment, or antisocial personality disorder.1
The American Medical Association published the Guides to the Evaluation of Permanent Impairment, which states, “Confirmation of malingering is extremely difficult and generally depends on intentional or inadvertent surveillance.”9
No examination technique objectively proves malingering (strength of recommendation [SOR]: C, expert opinion). Waddell’s signs are associated with poor treatment outcomes but cannot discriminate organic from nonorganic causes (SOR: B, systematic review of low-quality studies). Hoover’s and the Abductor sign indicate nonorganic paralysis (SOR: C, small, lower-quality case-control studies) (TABLE 1).
Meticulous examination and documentation will save time and trouble down the road
Tim Huber, MD
US Navy, Camp Pendleton, Calif
Warning flags for malingering include persistent noncompliance during prescribed evaluation or treatment, striking inconsistency between physical findings and stated symptoms, and an attorney or insurance company referring the patient to you. If monetary compensation is involved, malingering can potentially be prosecuted as fraud.
Meticulous examination and documentation will save you time and trouble down the road. If you find evidence of malingering, confronting the patient directly will likely result in animosity towards you from the patient and may result in litigation. The confrontation may escalate into violent behavior. Further complicating matters, specialist referral often reinforces the malingering behavior. A common option at approaching the potentially malingering patient is to allow him or her the opportunity to save face: “Well, Mr. Q, I am not finding the usual signs that go along with the complaints you are having….”
If you are in doubt of a diagnosis of malingering, it is generally safest to assume a person is not malingering until you specifically witness a contradictory event.
Evidence summary
The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines malingering as “the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.”1 Malingering is not considered a mental disorder because symptoms are intentionally produced for external incentives.
No physical exam maneuver can determine a patient's external incentives. Traditionally, a physician uses certain exam techniques to determine if symptoms are of functional, or nonorganic, origin. Both terms denote the absence of a structural or physiological source for the phenomena, and include malingering and mental disorders such as factitious disorder, conversion disorder, and somatoform disorders. Our literature search only found studies concerning the detection of nonorganic causes of back pain, paralysis, and sensory loss.
Several exam tests are commonly thought to detect nonorganic causes of low back pain. Gordon Waddell described 8 signs in 5 categories (TABLE 2) used to “identify [back pain] patients who require more detailed psychological assessment.”2 A systematic review critiqued 60 studies of Waddell’s signs published between 1980 and 2000.3 The authors performed a thorough database search, including hand searches of key pain journals, meeting abstracts, and textbooks. The majority of the reviewed studies were small and of lower quality. The review found little evidence on test-retest or interrater reliability. There was consistent evidence that Waddell’s signs are associated with poorer treatment outcomes and generally consistent evidence that they are not associated with secondary gain and cannot discriminate organic from nonorganic problems.
A small, diagnostic case-control study of Mankopf’s test, which is based on the theory that pain increases heart rate, investigated 20 chronic low back pain patients considered nonorganic vs 20 pain-free controls using mechanical pain stimulus applied to subjects’ fingers.4 There was no significant difference in heart rate response between groups, and no significant effect of pain on heart rate in either group. The authors did not define their criteria for determining patients’ back pain as non-organic, nor did they include patients with low back pain caused by an identifiable pathology. There was no mention of blinding. This literature search found no published studies of McBride’s test, where the patient’s refusal to stand on the unaffected leg and flex the affected leg to the chest determines a feigned radiculopathy.
A few tests attempt to detect nonorganic causes of paralysis. In Hoover’s test, a patient is asked to alternately press down with the paralyzed leg and raise the unaffected leg to resistance, while the hand of the examiner cups the heel of the affected leg.5 A small, diagnostic case-control study using a computer-assisted strain gauge to measure movement effort during Hoover’s test involved 7 women with true paresis, 9 with nonorganic paresis, and 10 controls.6 The investigators diagnosed nonorganic paresis by history, neurological exam, and lack of positive neuroradiologic findings. The authors calculated a maximal involuntary to voluntary ratio for each patient’s extremities. The calculation discriminated between all 9 nonorganic patients and both the normal controls and patients with true paresis. The authors did not mention blinding in the study. No attempt was made to compare the strain gauge measurements with a clinician-performed Hoover’s test.
The Abductor sign, based on a similar theory that thigh abductors work in concert, was developed and studied by one individual.7 In this diagnostic case-control study, the single author tested 33 patients from his practice, 17 with organic paresis, and 16 with nonorganic paresis. The author differentiated organic from nonorganic paresis by history, physical exam, and various imaging studies with no independent assessment. He reported his test as 100% accurate. We did not find any published studies of the Arm Drop test, where feigned paralysis of an upper extremity is tested by holding the arm over the face of the supine patient and letting go.
The Midline Split test attempts to detect nonorganic causes of sensory loss. The fact that cutaneous nerves cross the midline is the basis for the idea that a sharp midline split denotes nonorganic sensory loss. In 1 diagnostic cohort study of 100 people presenting to a neurology department with complaints of decreased sensation on one side of the face, 80 patients were determined to have organic deficits such as multiple sclerosis or stroke. The author did not describe how these diseases were diagnosed. Of those with organic deficits, 7.5% showed midline splitting of sensory loss, falsely suggesting a nonorganic process. Only 20% of the patients with nonorganic sensory loss showed the expected midline split.8 The author apparently performed the sensory exam without blinding or independent confirmation.
TABLE 1
Summary of tests for the detection of malingering
| TEST | SYMPTOMS | DESCRIPTION | EVIDENCE/OUTCOMES | SOR |
|---|---|---|---|---|
| McBride’s | Back pain with radicular symptoms | Stand on one leg. Flex symptomatic leg and raise to chest. Refusal or pain = nonorganic | No published studies | C (expert opinion) |
| Mankopf’s | Back pain | 1700 g pressure applied to the middle phalanx of the second finger of the nondominant hand. True pain should increase heart rate. | Did not correlate with organic pain | C (small inconclusive diagnostic case-control study) |
| Waddell’s | Back pain | Positive signs from 3 or more categories (TABLE 2) | Cannot discriminate organic from nonorganic | C (from SR) |
| Associated with poorer treatment outcomes | C (from SR) | |||
| Not associated with secondary gain | B (from SR) | |||
| Hoover’s | Leg paresis | Cup heels and have patient press down with paretic limb. Then have patient raise opposite limb. True paresis if no difference in downward pressure at heels | Indicates nonorganic paresis | C (extrapolated from small diagnostic case-control study using strain gauge) |
| Abductor | Leg paresis | Ask patient to abduct paretic leg to resistance. In true paresis, opposite leg should abduct. | Indicates nonorganic causes | C (small, lower-quality case-control study) |
| Arm Drop | Arm paresis | Hold paretic hand above face and drop it. If hand misses face, paresis is nonorganic | No published studies | C (expert opinion) |
| Midline Split | Sensory loss | Test facial sensation to pinprick. Nonorganic loss of sensation is delineated by the midline. | Very weakly indicates nonorganic cause | C (small diagnostic case-control study) |
| SOR, strength of recommendation (see page 722); SR, systematic review. | ||||
TABLE 2
Waddell’s signs
| CATEGORY | SIGNS |
|---|---|
| Tenderness | Superficial: light pinching causing pain = positive Nonanatomic: deep tenderness over a wide area = positive |
| Simulation | Axial loading: downward pressure on the head causing low back pain = positive Rotation: Examiner holds shoulders and hips in same plane and rotates patient. Pain = positive |
| Distraction | Straight leg raise causes pain when formally tested, but straightening the leg with hip flexed ninety degrees to check Babinski does not |
| Regional | Weakness: multiple muscles not enervated by the same root Sensation: glove and stocking loss of sensation. |
| Overreaction | Excessive show of emotion |
Recommendations from others
The DSM-IV recommends suspicion of malingering for patients who present with 2 or more of the following: medicolegal issues, disagreement between objective and subjective stress or disability, noncompliance with evaluation or treatment, or antisocial personality disorder.1
The American Medical Association published the Guides to the Evaluation of Permanent Impairment, which states, “Confirmation of malingering is extremely difficult and generally depends on intentional or inadvertent surveillance.”9
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine 1980;5:117-125.
3. Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS. A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Med 2003;4:141-181.
4. Peters ML, Schmidt AJM. Psychophysiological responses to repeated acute pain stimulation in chronic low back pain patients. J Psychosom Res 1991;35:59-74.
5. Hoover CF. A new sign for the detection of malingering and functional paresis of the lower extremities. J Am Med Assoc 1908;51:746-747.
6. Ziv I, Djaldetti R, Zoldan Y, Avraham M, Melamed E. Diagnosis of “nonorganic” limb paresis by a novel objective motor assessment: the quantitative Hoover’s test. J Neurol 1998;245:797-802.
7. Sonoo M. Abductor sign: a reliable new sign to detect non-organic paresis of the lower limb. J Neurol Neurosurg Psychiatry 2004;75:121-125.
8. Rolak LA. Psychogenic sensory loss. J Nerv Ment Dis 1988;176:686-687.
9. Cocchiarella L, Andersson G. Guides to the Evaluation of Permanent Impairment. 5th ed. Chicago: AMA Press, 2001.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine 1980;5:117-125.
3. Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS. A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Med 2003;4:141-181.
4. Peters ML, Schmidt AJM. Psychophysiological responses to repeated acute pain stimulation in chronic low back pain patients. J Psychosom Res 1991;35:59-74.
5. Hoover CF. A new sign for the detection of malingering and functional paresis of the lower extremities. J Am Med Assoc 1908;51:746-747.
6. Ziv I, Djaldetti R, Zoldan Y, Avraham M, Melamed E. Diagnosis of “nonorganic” limb paresis by a novel objective motor assessment: the quantitative Hoover’s test. J Neurol 1998;245:797-802.
7. Sonoo M. Abductor sign: a reliable new sign to detect non-organic paresis of the lower limb. J Neurol Neurosurg Psychiatry 2004;75:121-125.
8. Rolak LA. Psychogenic sensory loss. J Nerv Ment Dis 1988;176:686-687.
9. Cocchiarella L, Andersson G. Guides to the Evaluation of Permanent Impairment. 5th ed. Chicago: AMA Press, 2001.
Evidence-based answers from the Family Physicians Inquiries Network