Detection of Malingering Flashcards
Def: Malingering
The deliberate misrepresentation of gross exaggeration of an injury to avoid work, gain financial benefits, or obtain other advantage
Prevalence of Malingering
- Probable malingering in 29% of personal injury cases
- 30% of disability claims
- 19% of criminal evaluations
- only 8% of medical cases unrelated to litigation or compensation
Less common without financial gain or criminal avoidance
Motivations for malingering
Patients may fake symptoms to avoid work, stay out of legal trouble, access medication or gain sympathy and attention
Impact of malingering on health care
fraud frustrates clinicians working to facilitate genuine healing and complicates the diagnostic process
Role of biomechanics in Malingering
Helps assess physical capabilities and detect inconsistencies in reported injuries
Issues for physicians with malingering
- Limited time with patient to make a thorough assessment
- Patients see several physicians
- Patients go online to find symptoms that are consistent with actual disease or injury
- Physicians trust their patients and rely on history taken to make the diagnosis
Hoover’s Test
- Used to detect malingering
- patient asked to raise their left led while the clinician observes the right foot’s response
- A lack of effort to push down with the right foot indicates malingering, as the patient is not genuinely trying to lift the leg
Covert Observation
- Malingerers often behave differently when they know they are being observed
- Legal surveillance is employed by investigators to capture inconsistencies in behaviour
- Biomechanist interprets video evidence by analyzing physical demands of observed tasks, comparing them to job requirements, medical reports, therapy assessments
- Reports include estimates of joint moments, posture comparisons, muscle group involvement, and expected behaviour for the claimed injury
- Absence of expected behaviours is noted to further identify inconsistencies
Detection: Tremor
- Assess isometric contractions by feeling for tremors during maximal effect
- Lack of tremor may indicate a faked effort
- transducer provides objective data on tremor presence during MVC
- Tremor between 5-10 Hz, submax makes smoother force patterns
Detection: Force Variability and Effort
- Test hand grip strength using dynamometer across 5 grips widths
- Faking group show flatter force curves compared to sincere groups
- Sincerer trials had a rapid increase in force and plateaued near peak levels
- Faking trials had rapid increase with initial spike in force (overshooting intended force)
Detection: Movement Variability
- Multiple max efforts with adequate rest should yield consistent results
- range of motion in cyclic tasks can highlight inconsistencies
- Normal patterns will be symmetrical and consistent ROM
- Faking variations in range on one side indicate deliberate exaggeration or reduced mobility
Detection: Endurance Time
- Max isometric contractions can only be maintained for a few seconds
- Endurance increases at lower effort
- 50% MVC: 1 min, 20% MVC 5 min
- Holding longer than expected suggests misrepresentation of max strength
- LIMITATIONS: patients can quit early to avoid detection, misrepresentation of maximum effort impacts endurance tests
Detection: EMG and Endurance time
- In submax effort EMG increases as muscle fatigues (CNS increases motor unit recruitment, raises firing rate to maintain force)
- Patient maintains 50% of max effort as long as possible and EMG should double by the end of the task if effort is sincere
- Expected increase not seen if ended premature or strength is misrepresented
Pain consideration
Pain can cause a patient to exert less force, leading to a false positive for malingering despite legitimate injury
Risk of false positives of Malingering
False positive (incorrectly identifying someone as malingering) is more detrimental than a false negative (missing malingering
