In this article, we have summarised the most common ‘tests’ an IME doctor will perform on a physically injured worker in an attempt to demonstrate the injured worker is malingering or exaggerating a work injury. These include the so-called Waddell test.
Injured worker fraud is negligible
It has been suggested that the actual prevalence of workers’ compensation fraud committed by injured workers is actually quite tiny. Some research (eg. American Journal of Industrial Medicine in 2012) describe workcover fraud as a myth perpetrated by employers and workcover insurance companies. The collective ambition of these bedfellows is seemingly to decrease the benefits provided to those who are injured at work.
Workcover authorities in NSW, VIC and WA and others have also confirmed that the number of prosecuted fraud is just as small – so negligible, in fact, it’s an almost incalculable fraction of the overall number of workcover claims.
Yet while the anti-workers’ compensation rhetoric continues to be louder than the reality, the consequence ends up being injured workers’ stigmatisation. Injured workers are treated like fraudsters – until proven innocent (and still…) by workcover insurance companies and their bedfellows, which includes many so-called independent medical doctors.
Workcover IME doctors may check for signs of malingering
Having suffered a workplace injury can be devastating. Dealing with workcover insurers and their bedfellows can be downright humiliating and insulting. Most injured workers will be sent to independent medical examinations and on a ‘regular’ basis. Armed with a misleading cover letter from the requesting workcover case manager, and a list of questions, many IME doctors – in particular octogenarians – will be of the belief that injured workers are malingerers or worse, fraudsters. Over the years IME doctors have come up with intricate lists of ‘techniques’ to identify malingering, exaggeration or fraud ( Google ‘Waddell IME’ and you will see!).
In this article, we have summarised the most common ‘tests’ an IME doctor will perform on a physically injured worker in an attempt to demonstrate the injured worker is not as injured as s/he claims to be. Whether these tests are reliable ways of identifying non-physiological causes of physical injuries remains very ambiguous to us.
Malingering tests frequently performed by IME doctors on physically injured workers
Some injured workers who present with musculoskeletal complaints are often alleged (by the workcover insurer or workcover case manager) to have underlying non-organic or behavioural problems.
These may include the allegation of “deliberate deception” or malingering, psychological or psychosomatic disorders.
The following tests and/or behavioural signs are frequently used by workcover IME doctors as ways to identify non-structural (non-organic) problems in physically injured workers.
Waddell signs can be used by workcover IME doctors when there seems any reason to suspect the injured worker’s problem is “all in the mind”.
The Waddell signs are:
- Superficial tenderness: skin discomfort on palpation – feeling/ touching/pressing
- Non-anatomic tenderness: tenderness that crosses several somatic boundaries, in other words, pain that is away from a body part or area where it is expected to be
- Axial loading: injured worker reports low back pain – eliciting pain when pressing down on the top of the injured worker’s head or rotating the shoulders and pelvis together should not be painful
- Simulated rotation: injured workers reports back pain
- Distracted straight-leg raise: the injured worker reports of pain in the low back or posterior (back of) thigh; decreasing of pain with continued leg raising. If an injured worker complains of pain on straight leg raise, but not if the IME examiner extends the knee with the injured worker seated at another time during the initial evaluation
- Regional sensory change: “stocking” or global distribution of numbness – sensory loss in an entire extremity or side of the body or weakness that is not consistent and jerky, ie “cogwheeling”
- Regional weakness: sudden, uneven weakness such as “cogwheeling” or “dithering” in the injured worker with normal strength on muscle testing
- Overreaction: exaggerated, non-reproducible response to stimulus, including injured workers stating their pain is 10 of 10.
|Tenderness tests||Widespread superficial and diffuse tenderness to light pinch (also known as ground-glass back)
Deep tenderness in a non-anatomic distribution
|Simulation tests||Based on movements which produce pain, without actually stressing anatomical structures, such as:
Lumbar pain with axial loading from the head
Pain on simulated rotation (keeping the arms straight by the patient’s side while turning from side to side)
|Distraction tests||Rechecking of positive tests when the patient’s attention is distracted (e.g. a straight leg raise might cause pain when lying down but a much greater range of pain-free movement may be possible with the same test when sitting)|
|Regional disturbances||Lower extremity weakness or sensory changes not corresponding to accepted neuroanatomy (e.g. nerve root distribution)|
|Overreaction||Subjective signs such as grimacing, pleading to stop and tremor that seem out of proportion to the actual examination|
Three or more of such ‘positive’ signs are alleged proof that the injured worker is malingering!
In fact, studies have shown that a person’s back has a “complex and hidden anatomy” which makes it particularly difficult to differentiate between physical and behavioural causes of pain.
Waddell’s signs have been controversial. They have been interpreted by many doctors as signs of “malingering”.
Doctors, including workcover IME doctors, should avoid attributing any subjective overlay as the faking of symptoms.
2. Close observation of injured worker can allegedly detect fraudsters
For example, if an injured worker limps into the IME examination room, their shoes may be checked by the IME for uneven wear, which should be obvious if the limp has a long-standing physical cause. (So, please when attending a workcover IME put your old regular shoes or thongs on and do not wear new shoes or shoes you normally do not wear, as you may be accused of malingering!)
If a labourer or a manual worker claims to have been unable to work for 6 months or so, the IME doctor may well check the hands of the injured worker for calluses, which are supposed to vanish within 3 weeks of inactivity.
An injured worker who claims not to have been able to work or undertake physical activities will be checked over by the IME doctor for upper body muscle and muscle tone. Apparently injured workers who are inactive should not be able to maintain their upper body tone.
It has been alleged that some injured workers will ‘ put on a show of collapsing’ or even ‘fainting’ and in doing so they will NOT injure themselves (so if the injured worker malingers, s/he will take great care not to hurt her/himself when collapsing or fainting).
3. Further simple physical tests can allegedly show signs of injured worker’s exaggeration or malingering
- Mankopf’s test: palpation/feeling of a painful area is supposed to increase the heart rate by at least 5% and absence of this finding is supposed to be a positive behavioural sign of malingering, exaggeration etc. (While it does make sense that when we have severe pain our heart rate goes up, however, in order to accurately test it the IME doctor would have to cause considerable pain and have the injured worker hooked up to heart rate machine.)
- O’Donoghue’s manoeuvre: Injured workers with true underlying physiological pain are supposed to have a greater passive range of motion than an active range of motion, again, it is a positive behavioural sign of malingering if the injured worker’s active range of motion is greater.
- McBride’s test: In this test, the IME doctor will ask the injured worker to stand on one leg while raising the opposite knee to the chest. This should decrease any low back pain. A reported increase in pain, or a refusal to do the test, is supposedly a positive behavioural sign of malingering.
- Hoover’s test: In this test, the IME doctor will hold the injured worker’s (who is lying down on the examination table) heels off the table and ask the injured worker to raise one leg. If this is easy, the test is negative, if this is difficult, the injured worker will push the opposite leg towards the table to assist in raising the leg. A lack of downward pressure from the opposite leg is alleged to be a positive sign of malingering.
- Burn’s test: In this test, the IME doctor will ask the injured worker to kneel on a chair and touch the floor – those injured workers with genuine back pain or sciatica are supposed to be able to do this but those with non-organic back pain are usually unable to do this.
While there may be some merit in some of the above ‘malingering’ tests, the fact remains that injured workers fraud is negligible. In addition, many genuine pathological conditions are hidden under some ‘ illness behaviours’. Just dealing with workcover can make any injured worker so depressed, so insulted, so angry and so frustrated. Having to constantly prove over and over again that an injured worker actually suffers from a genuine injury does not help either. It also does not help that workcover insurers only write one diagnosis in their file, and generally, this is something along the lines of ‘bruised shoulder’; whereas the injured worker may have had 10 reconstructions to that shoulder, osteomyelitis and countless other complications. In the editor’s own case, her current correspondence with the workcover insurer still shows ‘ bruised shoulder’ as the ‘diagnosis’ – which is sent to various IME doctors – notwithstanding that she has a broken (fractured) total reverse shoulder prosthetic which is infected and is currently facing a complete disarticulation (amputation).
In addition, many doctors have discovered that they were wrong in not first believing that a patient’s complaints were genuine and truly organic. Sometimes, they fail to prescribe better tests (eg. MRI as opposed to CT) assuming a patient simply suffers from a ‘strain’ or whatever.
Again, good luck with your workcover independent medical examinations 😉