They are obtained from the history and deal with certain occupational variables that can be seen summarized in Table 1.8–10 They have been cited in the literature as “yellow” or “red flags” of simulation.

All are part of the so-called bio-psycho-social model.11,12 In it, the biological factors (lesions) interact with other psychological (e.g. misconceptions about the spine, fear of pain, fear of job loss),13,14 social and labor aspects (education, family factors, type of work, career, etc.).

One characteristic of a style of distorted response is the need to highlight the sick role. Thus, the analysis of the patient's companions can be a key factor.

Frequently, they highlight the magnitude of the conditions (“enhancer”). Other times, the attitude is derogatory. Thus, the “liberated husband” of Rotes Querol15 tends to downplay or reinterpret the sufferings of the sick. Comments like “ignore him/her doctor,” “he/she is exaggerating” or “what he/she means is that it hurts there,” are common.

Other companions are “instructed or aware” and “coercive.” They boast an extensive knowledge of the disease or exhibit hostility or mistrust that appears to lead directly to the medical intervention, “Maybe something was wrong with the operation?”. In general, it is useful to explore the extent of knowledge about the disease showed by the companion. The concept of metasimulation regards monitoring by the subject of the guidelines or the script of a case similar to theirs and, not infrequently, the real patient is his or her companion.

Sometimes the patient appears “in need of support.” In this sense, it is not usually very reasonable for adult and autonomous patients to attend, visit after visit, constantly accompanied by their parents.

The presence in the clinic of an inordinate number of escorts can also be expressive of the desire or need for reinforcement company in the visit.

They are clinical manifestations lacking entity. Obtained through interrogation.

Examples are the following (Table 2):

3.1 A tendency to exaggeration. It can affect any aspect of the symptoms: number, intensity, quality, magnitude, etc. Total pain (“panalgia” or “totalgia”) is inconsistent.

3.2 Flashy symptoms.6 Constituted by those who a lay person would consider typical of the disease or disability. Examples: lameness, motor weakness, anesthesia of a region, loss of vision or hearing. These symptoms are greatly increased in frequency in the SADR.

3.3 Subtle symptoms.6 Constituted by those that are considered common or ‘normal’ in life (getting tired on Monday, ending the day tired, dulling headache in closed spaces or dizziness in a vehicle). Are more numerous and they come to the foreground in SADR.

3.4 Defensive symptoms. The patient denies symptoms of having symptoms in the past that are common in the population (sore throat, headache, morning fatigue, stomach pain, etc.). For example, in more than one case, there is a marked reluctance to acknowledge any problems before the accident.

3.5 Symptomatic hyperprecision and detail. For example, pain that began on a certain day and at a certain hour and reappear in a fixed interval, or at the same time. Writing down all diseases (“Maladie des petits papiers” Rotes Querol).15 In this same line we find the contribution, sometimes obsessively, of all kinds of tests or reports made before the current visit.

3.6 Use of specific adjectives. In SADR, the patient uses a particular language.16 Expressions as follow abound: “as if” (“It's as if I was wounded inside”). The use of profanity to refer to pain is also very typical.

3.7 Account of events rather than symptoms. Patients with SADR like to recreate or recount the events (accident, medical visits, fighting with insurers, etc.) more than the condition that was the reason for the visit.

These are impossible physical signs. They appear under examination. Some examples are listed in Table 2. The most relevant are mentioned below.

4.1 Reversed answers. When exploring thermal sensitivity, the patient says cold instead of hot, and vice versa. Clearly, this sign indicates NCRS or RS.

4.2 Exploration of resisted movement.7 Patient who believes that resisted movement must be painful, when in fact, this is unusual. Patients with RS or NCRS will tell us that spinal pain on resisted flexion–extension increases significantly. Normally, the point of fatigue is achieved gradually and is seen as the resistance gradually weakens. In SADR, the extremity relaxes abruptly (phenomenon of abrupt relaxation), sometimes with a snort at the end of the scan. Resisted movement can also be seen as disharmonic or faltering, with a touch reminiscent of a gear, as the patient acts voluntarily contracting and relaxing agonists and antagonists, indicating NCRS or RS.

4.3 Hoover maneuver.17 Performed with the patient supine and the heels out of the plane of the table, with the examiners hand on the healthy heel. The patient is asked to elevate the affected leg. If easily done, the test is considered negative. If the movement is difficult, the patient with no pathology will push the other leg against the examiners hand. Otherwise, it is an inconsistency. Similar maneuvers have been described, such as the abductor sign.18

4.4 McBride test.19 The patient is asked to hold on one leg while bending the other on the chest. As the knee is bent, no sciatic stretching occurs. In addition, the maneuver slightly flexes the spine, so facet pressure is relieved. Thus, this position should decrease back pain. An increase in pain is an incongruity.

4.5 Goldthwait sign.19 With the patient supine, a hand is placed under the lumbar spine and the examiner raises the lower extremity with the other. If there is pain before moving the lumbar region (perceived by the hand), this indicates sacroiliac involvement. If it appears later, then it indicates pathology of the L5-S1 joint.

4.6 Mankopf test.19 Palpation of the painful area should increase the heart rate by 5% or more. If this response does not occur (Mankopf positive), it would be incongruous.

4.7 Other incongruities. They are Lasègue positivity with maneuvering of less than 10°; lumbosciatic onset of pain, rather than crural pain in the reverse Lasègue, etc.

These can be defined as the lack of agreement between 2 or more different elements of the clinical history. Discrepancies point more to a NCRS or RS than a SADR. There are different types (Table 2):

5.1 Clinical-interrogation. A permanent collarette does not allow a tanned neck. If it exists, this would be a discrepancy. Another example is patients who report disabling pains but live alone and unaided.

5.2 Clinical and exploratory. There are differences between the symptoms and examination (clinical or complementary).1 The patient reports loss of strength and yet the examiner appreciates increased passive resistance. The patient holds antigravity attitudes if the examiner suddenly drops the patient's hand and leaves the extremity in the air. The patient complains of decreased cervical mobility, but flexes the neck to look at his watch, or makes a perfect cervical extension if asked to calculate the height of the room. The patient complains of lack of movement of the limb for weeks, but no atrophy is evident. Hand calluses usually go away after 3 weeks of inactivity. Their presence in a “fixed” extremity may be another discrepancy. If a collarette (or other orthotics) is worn it shows signs of wearing, stains or tarnish, this should be considered a discrepancy. Using canes should produce callused hands. A person with cervical or lumbar disk herniations (and no motor deficit) appearing in a wheelchair is a discrepancy. The chair-bound patient usually gains weight and, in the areas of contact, develops dermatitis, signs of chafing, eczema and skin discoloration.

Nerve stretching maneuvers are used to detect inconsistencies. Thus Lasègue maneuver can be performed in various ways (Fig. 1) and can be assessed for discrepancies between them. If the patient has a positive Lasègue sign, for example at 30°, and feels no pain when performing the indirect Lasègue maneuver, the examiner is faced with a discrepancy.

Fig. 1.

Illustration showing different ways to perform nerve root stretching maneuvers. Its purpose is to detect exploratory discrepancies.

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Another way is to ask the prone patient to relax the painful extremity, dropping by the side of the examiners bed to the floor (Barraquer-Ferré sign). Lasègue maneuver on the patients’ side is also helpful. Neri I and II maneuvers, stretching neural roots in different positions, allow the examiner to detect discrepancies.

The Bench test involves the patient kneeling on a low stool (20cm in height approximately) and told to lean forward to touch the ground. This can usually be made without low back pain because it only involves the hip joint. The test is considered positive when the patient says it cannot be performed because of back pain.19

Lower back pain upon rotation of the hip in both supine and prone positions can also be considered a discrepancy.

If it is seen that passive range of joint mobility is greater than active, the clinician could be facing a discrepancy (O’Donoghue maneuver).19

5.3 Clinical-behavioral. Between symptoms and behavior. These must be documented. Detective investigation is of widespread use as of lately and could document a discrepancy, although it is not clear as to it proving the existence of SADR or RS, although it is associated with RS.

5.4 Discrepancies regarding causality. Between the traumatic event and clinical outcome (lack of proportionality between cause and effect).

Opposition between verbal, graphic, documentary or other related disease productions.

May occur in a single visit or on successive visits or interviews. In SADR it is usual to find difficulty in maintaining the constant subterfuge. Many times, the version that was previously mentioned is not remembered. Therefore, it is necessary to document the manifestations and physical findings. It is also recommended to increase the frequency of visits.

In 1980, Waddell et al.,20 reported 8 signs that, according to the authors, identified LBP patients with no structural problems. In our opinion, the Waddell signs are actually inconsistencies, incongruities or discrepancies, as can be seen in Table 3.

These allow for the detection of discrepancies. Thus, for a lumbar disk herniation on an MRI that does not correspond to the clinical evidence, there would be a clinical-radiologic discrepancy.21,22

Its foundations are different. Some are based on the analysis of variability in23 successive scans. Thus, in patients with NCRS/RS it is difficult to accurately reproduce the symptoms in the same way or in the same range of motion.

In the biomechanics laboratory of our hospital, the functional study of spinal pathology is performed using the following tests:

2.1 Dynamometry: It is designed to measure the range of motion of the cervical spine and the maximum isometric force in flexion-extension and lateral-flexion at 0°, 25° and 45° rotation. A normal finding when there are normal strength values (compared to a normality database), a flexor-extensor ratio between 1/1 and 5-1/2, more force in neutral position than at 25° rotation and when the coefficients of variation are all under 15°.

2.2 It can detect discrepancies between strength and mobility in the cervical physical examination, obtained with the dynamometer and range of motion in the laboratory. One can also find contradictions, if repeat testing is performed on 2 different days and got different results.

2.3 Kinetic studies (study of forces): These tests analyze kinetic and kinematic motion of the lumbar spine in simple activities. It provides data on lumbar mobility and forces by the person being tested under certain movements and mobilizing various loads. We can detect discrepancies between history and test results, for example, the patient refers limitation related to mobilizing loads and back pain when performing the test, handling loads of 5kg better than 0kg (Fig. 2). Likewise, we can find contradictions when retested on 2 different days and find different results.

Fig. 2.

It can be seen that the patient manipulates more easily weight of 5kg than 0kg. In general, with increasing load it is illogical to have lower execution time and higher speeds and accelerations (inconsistency).

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2.4 Kinematic studies (analysis of velocity and angular acceleration): These tests can detect discrepancies between the physical examination, medical history and test results, for example, the patient cannot flex his lumbar spine over 30° during the physical examination and yet, can do a complete bend to pick up a box off the floor (Fig. 3).

Fig. 3.

In this case, the patient performs, on the weight test (same patient as in Fig. 2), a lumbar flexion of 78% and 63% in the seat test (image). There is a lack of consistency in the assessment because very different results are obtained for the same variables (discrepancy).

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It has been noted that the normality of motor evoked and/or somato-sensory potentials points toward a conversion syndrome.24–28

It would occur here as with the other examinations. On the one side, the neurophysiologic indemnity can express a discrepancy in a patient who refers important symptoms.

Also, demonstrating neurophysiological chronicity clues the observer into a problem with a history that the patient may deny (through a defensive inconsistency, clinical-exploratory discrepancy).

Some techniques seem more specific of NCRS or RS, such as surface electromyography.29 In our hospital, we use it for the study of the lumbar spine, through the lumbar flexion-relaxation phenomenon. It guides us to a discrepancy if the patient complains of back pain and the flexion-relaxation phenomenon occurs, since this is related to the absence of LBP (Fig. 4).

Fig. 4.

Patient with back pain. In surface electromyography a phenomenon of flexion/relaxation is recorded, which is indicative of the absence of LBP (discrepancy).

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An interesting aspect of simulation is pain. In a review of the literature, one can find at least 22 different pain scales.30 They can be classified into 3 types: pain intensity, other aspects of pain and mixed scales that measure two items (intensity and affective components).

Among the former we find the visual analog scale31 or other numbered scores.32 They intend to gauge the intensity of pain and may be useful in demonstrating inconsistencies between different visits, inconsistencies (exaggeration) or discrepancies (very severe pain, normality tests, conduct, etc.).

Among the latter, there are those that measured the affective component of pain.33,34 Some tests are more specific for back pain.35 Others have turned to simulation in general pain.36–40 Others study somatization in chronic low back pain.41 To detect the possibility that a patient with chronic back pain may return to work, Kool et al.42 advocate employing 4 scores. Other tests measure different work, social and family variables, such as “mass psychogenic illness”.43 Finally, there are psychogenic test simulations, most notably the Minnesota Multiphasic Personality Inventory.44,45 Its role in low back pain has been noted.46 The Wechsler Adult Intelligence Scale has been used to build the so-called Simulation index.47 Using this test, some authors have shown the presence of cognitive impairments they attribute, in the absence of brain damage, to a manifestation of exaggeration.48 Projective tests (such as Rorschach)49 may also be used, geared more toward mental illness50,51 as well as others aimed at the detection of simulating physical disability, such as the Composite Index of Simulation of Disability.52

We have found utility in tests that include body drawing.39,53 Thus, the graphical representation of pain and its nuances can be used to check inconsistencies (exaggeration, neatness, hyperprecision), contradictions (between different drawings) or incongruences (non-metameric distribution of pain) (Fig. 5).

Fig. 5.

Discrepancy between MRI findings (L5-S1 disk disease) and body drawing in acute low back pain refractory to all treatment.

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There are tests to detect a low deliberate effort (“faking bad”), as in the so-called forced-choice tests.54-57 It has been said that they allow the examiner to prove untruthfulness in multiple neurological signs such as: touch hypoesthesia, graphesthesia, blindness, deafness and other functions.