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So risky as to require very deft handling.

dodgy. (n.d.). The American Heritage® Dictionary of the English Language, Fourth Edition. Retrieved July 24, 2009, from Dictionary.com website: http://dictionary.reference.com/browse/dodgy

› Discuss types of non-organic barriers to recovery

› Learn how to identify potential barriers› Discuss strategies to

Help Workers’ Compensation patients recover in a timely manner

Appropriately utilize limited healthcare resources on challenging patients

Some patients in the Workers’ Compensation system over-consume resources

There are a variety of causes that do not always correlate with organic pathology› Psychosocial factors› Underlying personality traits› Secondary gain issues› Psychiatric disorders› Workplace problems

Depending on the practice, often cited as around 15% of total WC patients

These patients over-utilize finite medical resources› 80/20 Rule

Often drive clinicians (and probably many others in the system) to demoralization

Non-organic Source of Symptoms

Both

Primary gain› Internally motivated› Examples of “gain”: relief of guilt, internal

conflict, anxiety› Not recognized by the patient

Secondary gain› Can also be a component of any disease› External motivator› Examples of “gain”: miss work, gain

sympathy, monetary reward, drug-seeking› May or may not be recognized by the patient

Malingering Factitious disorder Münchausen syndrome Somatoform disorders

These disorders/problems are actually rare

We’ll focus most on more commonly encountered non-organic obstacles to recovery

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Intentional fabrication / exaggeration of symptoms for secondary gain

Separate from somatoform disorders and factitious disorders (in which primary gain is the goal)

Partial malingering (AKA functional overlay)› Malingering superimposed on a genuine organic

disease› Complicates diagnosis and treatment

More common in societies with› Regimented, enforced labor› Universal military service› Ability to sue for damages arising from accidents

More prevalent among› Women› Healthcare workers

Psychiatric disorder Patient deliberately produces, feigns, or

exaggerates symptoms DSM-IV-TR criteria

› Intentional production or feigning of signs or symptoms

› Motivation for the behavior is to assume the sick role (primary gain), and

› Absence of external incentives (secondary gain)

Signs and symptoms may be predominantly psychological, physical, or mixed

Subtype of factitious disorder – not technically a separate diagnosis

Usually more severe variety; may consume patient’s life

Illness intentionally produced through medically dangerous manipulations of the patient's body› Self-inflicted infection› Warfarin overdose

Patients willingly, if not eagerly, submit to invasive interventions/surgery

Psychiatric condition in which physical symptoms are due to mental factors

Not intentional / conscious Not the result of conscious malingering or

factitious disorder Physical causes must be ruled out, which can be

difficult/costly Example subtypes:

› Conversion disorder › Somatization disorder › Hypochondriasis › Body dysmorphic disorder › Pain disorder › Undifferentiated somatoform disorder

Usually more mundane

Personality disorders Symptom magnification Psychosocial stressors Secondary gain Underlying medical or psychiatric

disorders Litigation

› Increases WC costs 12-15%› In some cases 40% or more

› Sall RE. Strategies in Workers' Compensation. 62

› LaCaille R, et al. Obesity and litigation predict workers' compensation costs associated with interbody cage lumbar fusion. The Spine Journal, 7:3;266-272

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“Problem” employee› Attendance problems› Close to losing job› Low morale

Un-witnessed injury Distrustful, manipulative, demanding, noncompliant

patient Patient focuses more on distress symptoms and negative

concepts History of substance abuse Drug-seeking behavior

Angry or dissatisfied worker

Angry employer

flickr.com/photos/jemby/2476536595/

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Inconsistencies in› History› Record› Exam› Symptom character / severity / location

Improbable description› Multiple symptoms› Multiple locations› Unusually sudden onset› Extreme severity

Improbability that set of symptoms is medically plausible

Textbook descriptions, unusual grasp of medical terminology

Vague and inconsistent details

Dramatic / atypical presentation Theatrical or histrionic quality to

symptom presentation Demonstration of substantial

impairment inconsistent with the disorder

Easy acceptance of discomfort and risk of diagnostic procedures or surgery

Fluctuating clinical course Rapid development of complications if

initial findings prove negative Patient doesn’t improve as expected

medically

› Strange mechanism of injury › Delayed reporting› History of significant psychological

problems› History of prior contested WC claims› Altered gait not physiologic (and not

observed by staff once patient left clinic)

He had HNP and required surgery

Remember, patients can be injured AND dodgy

P.S. The case was litigated, costly.

Medical provider has to know typical presentation and recovery patterns for diseases/conditions in order to detect when something isn’t making sense.

Cannot equate the presence of non-organic signs as proof of malingering

Responsible to investigate all reasonable, potential organic sources of pathology.

Don’t let it get you down Don’t take it personally Trust your clinical skills Do your best Always have a professional

attitude, treat people with respect and dignity

Focus treatment on patient assuming responsibility for his/her own health and rehab

Accept that not everyone is going to get better; not everyone wants to

Understand the way the system works

Understand that everyone in the system is just doing their job

Know when to cease treatment

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Tests for non-organic contributors to pain complaints

Other non-physiologic findings

First described in a 1980 article in Spine

Named for the article's principal author, Gordon Waddell

Helpful in identifying nonstructural problems

http://www.keele.ac.uk/research/pchs/pcmrc/flags/photos/waddell.jpg

Gordon Waddell

Tenderness › Superficial: light pressure/pinching causing pain› Non-anatomic: deep tenderness over a wide area

Simulation › Axial loading: downward pressure on the head causing low back

pain› Rotation: Examiner holds shoulders and hips in same plane and

rotates patient causing pain Distraction

› Straight leg raise causes pain when formally tested, but straightening the leg with hip flexed ninety degrees while patient is distracted (e.g. during Babinski test) does not

Regional › Weakness: multiple muscles not innervated by the same root › Sensation: glove and stocking loss of sensation, sensation in entire

limb or side of body Overreaction

› Excessive show of emotion› Exaggerated painful response to a stimulus that is not reproduced

when the same stimulus is given later

3 or more positives strongly correlated with› Nonorganic / psychological contribution to

symptoms› Illness behavior› Poor outcomes› Depression, hysteria, hypochondriasis

Does not necessarily prove malingering, secondary gain, or non-organic pain

Does not exclude organic disorder Patients with physical LBP may have 1

or 2 positive Waddell signs

ManKopf’s Test› Palpation of painful areas should increase pulse rate by

5% or more O’Donoghues Maneuver

› If passive ROM is not greater than active ROM, as would be expected in patients with true physiologic pain

Hoover’s Test› Supine. Hold heels off table. Lift one leg. If patient

reports inability to lift leg, but there is no downward pressure on the other heel

Burn’s Test› Forward flexion with knees bend should

be less painful Parking lot test

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Observation is most important!› Notice inconsistencies› Wear pattern on shoes› Wear pattern on braces and equipment› Calluses disappear with 3 weeks› Dirt under nails› Leading on/off table› Removing shirt (e.g. with shoulder pain)› Palpation/distraction

Emotional reactions to symptoms, such as reporting severe distress while appearing comfortable

Clinician must have strategies to deal with these issues. Remember dodgy patients require deft handling.

In general Be aware, smart and savvy Avoid being contentious Treat the person with dignity and respect Remember that difficult patients can be injured and

difficult

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Doctor-Patient relationship

Establish and reinforce expectations

Exclude organic/physical disease

Communication Give the patient a

ladder Know when/how to

cease treatment and close case

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If appropriate, insurance can deny claim

Surveillance

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http://www.longislandinvestigations.com/

Very important to have a trusting doctor-patient relationship, if possible

Doctor develop rapport with patient, if possible› This is not the same as being manipulated by a patient› Firm but trusting. Requires people skills.

Establishing rapport, in many cases, can help a great deal in appropriately utilizing resources

Understand patient's current personal, social and occupational situation

Frequent follow up Recognize patient’s problems are important to

them Keep them at work

Physician as educator Explain typical disease process Explain typical recovery, express positive expectations

› e.g: Initial low back pain› e.g: Pain cycle/chronic pain

When appropriate, give them “permission” to have pain.

RTW goals and time-lines incorporated from onset› Keep patients at work, if at all possible› RTW time can vary up to 1/3 as direct function of education

and recovery expectations in the initial treatment session

Solely a disease-oriented approach will likely fail in such cases

Judicious use of specialist consults› Confirm diagnosis or lack of serious pathology› Can give case more power to close

Testing/hasten the workup (“prove” a negative) Judicious use of psych testing

Assess the likelihood of a serious problem, weigh risks and benefits, etc.

This is not withholding appropriate care.

Differentiating between physical/organic and behavioral or non-organic causes is especially challenging

Document well Aggressively address causation early-on Promptly “confront” patient with inconsistencies in history Communicate with all parties involved

› Expect communication to occur with physician therapists specialists employer insurance case manager etc.

› Regarding treatment testing functional impact of the condition return to work alternate duty options etc.

Don’t try to solve management and industrial issues through clinical management.

Workers may very selectively describe workplace issues and over report negative experiences

Mannerisms› Offering reassurance “good news”› Puzzled looks› Firm confidence› If worker resistive, could be a red

flag

Be straightforward and truthful with everyone involved

Work together! Do not foster adversarial approach toward employer or case manager.

Between patient and employer› Poor communication increases likelihood of poorer outcomes› Supervisory support—you can be firm but still

professional/kind

Can be especially useful after testing has ruled out serious pathology

Gives the patient an opportunity to “save face”

Reassure that the presence of pain is not indicative of tissue damage.

Explain ways to improve daily activities and replace illness behavior

Gives the patient a “ladder” to climb out of the situation

Sometimes more effective to use this strategy before abruptly confronting

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Importance of language in reports MMI

› End of healing/plateau› What happens next

Impairment Restrictions

› FCE vs. no FCE

Sometimes, the clinician has to confront the patient How to handle when there is a disagreement or

difference of opinion› “The Chat”› Give them something to do

They usually already will know that they are entitled to pursue redress (legal counsel) for perceived injustice.› Industrial Commission› This should not postpone efforts to resume normal

functioning.› Typically, once a case gets to this point, closure of the

case is in everyone’s best interest. Allow the system to proceed.

If “dodgy” patients—those who have non-organic contributors to their pain complaints—are handled deftly, they are more likely to appropriately utilize healthcare resources, recover in a timely manner, and their cases will be less costly and painful

Dodgy does not mean “bad person,” it means that the person and his/her case needs to be handled “deftly,” with skill

Remember the most common non-organic obstacles to recovery

Non-organic does not always (or even typically) mean “faking it”

Red Flags & Clues Exam and Evaluation Management Strategies

› Doctor-Patient relationship› Establish and reinforce expectations› Exclude organic/physical disease› Communication› Give the patient a ladder› Know when/how to cease treatment and

close case

Cody Heiner, MD, MPHSt. Luke’s Occupational HealthBoise, ID

Brian A. Johns, MD, MPHSt. Luke’s Magic Valley Occupational HealthTwin Falls, ID

Cleaning lady with histrionic personality disorder› extensive workup› sad partings

“malingering”› psych evaluation

“Electrocuted” patient w/ personality disorder› Agree to disagree

30 year old mill worker. Metal machine at work

malfunctioned, striking his hand.