By Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT
When a patient presents with lower back pain, we expect to see some amount of an antalgic lean. It is understood that this lean is both a conscious and reflexive protective mechanism of the body to reduce the pain and prevent more irritation in the back.
Antalgia is a natural protective posturing of the lower back – but it is also a sign that the body recognizes that there is a way the pain can be controlled and minimized. Careful review of the antalgic posture can give a lot of information about what is going on with the patient.
What needs to be discussed is how to further evaluate the lower back beyond the antalgic posture. This is an important thing to understand for acupuncturists who see patients with lower back pain. It has been noted several times that lower back pain is the No. 1 cause of disability worldwide. Not everyone who presents with lower back complaints has a legitimate problem – unfortunately, some people have motives of secondary gain.
It is doubtful you will be able to help them no matter how good your technique or your care. It becomes very important to be able to accurately evaluate a patient and determine what their complaints truly are. When a patient presents with a complaint of lower back pain – and often antalgic posturing – further assessment must be performed to determine the exact root of the problem.
When a person presents with true antalgia, they are assuming a position of least discomfort. Both the abdominal and spinal extensor muscles must be under tension to hold this pose. A quick and simple test is the Axial Trunk-Loading test. In this test the examiner will press downward on the patient's head while they are still standing in their antalgic posture. The patient may report neck pain, but should not have back pain. It can become very easy to confuse this test with Y-axis cervical compression maneuvers – Foraminal Compression, Jackson's or Spurling's – but the Axial Trunk-Loading test must be performed with the patient standing so that the back muscles are engaged in the position of compensation. If a patient reports lower back pain with this maneuver, it indicates that there is a lack of organic basis for the lower back problem.
Please remember that just one test finding is not grounds to determine malingering, but it can certainly give insight into the nature of the patient's complaints. Malingering is certainly an option, but hysteria, confusion and poor pain tolerance must also be considered. "Symptom magnification" is fairly common. Symptom magnification is defined as the patient exaggerating or magnifying their actual complaints in order to "sell" the doctor on the truth of their claims. Symptom magnification should not be confused with the term "malingering," which is defined as the deliberate and fraudulent feigning of symptoms. Actual malingering is rare, while symptom magnification is expected among the majority of patients. A positive finding would dictate the additional testing and evaluation is necessary. A standard spinal evaluation including palpation and goading, orthopedic testing including the Straight Leg Raise test and Soto-Hall and diagnostic imaging would all be reasonable.
If you truly believe your patient is feigning symptoms, then you must pursue testing to document that suspicion. Remember to watch for the "jump sign" - such a finding should be reproducible. Orthopedic maneuvers such as Magnuson's (the distraction test), Mannkopf's and the marked pain-suggestibility test can confirm your suspicions. As always, you must thoroughly document your findings. Reviewing Waddell's Signs is another great was to assess the psychosocial component of a patient's complaints.
If you reach a point where you are truly unable to justify your patient's complaints, then you must be able to tell them in a way that is not going to put you in an antagonistic situation. Too often, patients are confronted with their "lies" when the examiner has simply exhausted his abilities.
In the legal realm, you can state that you are not able to justify the patient's complaints by objective measures, but you must then give recommendations for further evaluation or treatment. To evaluate a patient is to assume a measure of responsibility for their health care. You cannot just brush them off as a faker. If you confront a patient, you must explain what your findings are and what you are going to recommend and why you recommend that course of treatment. If you refer that patient to another practice or specialist, you must explain your reasons and document the discussion.
No patient situation is the same. Some patients are just difficult: It might be their personality, they might have another agenda, they may just be having a bad day. It is impossible for any one practitioner to be able to treat every complaint of every patient. Pain can be a very complex condition to treat. There is no blood test to measure a "serum pain level" so good consultation and examination are crucial to all patient care. If you can help them, then you are obligated to do your best to care for that person. If not, you are obligated to give them reasonable options for further treatment. As always, document your findings and your treatment plan.
Evans, R.C. Illustrated Essentials in Orthopedic Physical Assessment. St. Louis, Missouri: Mosby, 1994.
Hoppenfeld, S. Physical Examination of the Spine and Extremities. San Mateo, CA: Appleton & Lange, 1976.
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