Paging Doper doctors: Q re back pain

[VunderBob]

QtM, USC_Diver, and the rest: I had a problem patient I took to the hospital Friday night, and it was the second time in 2-3 months that I’ve taken him for ostensibly the same complaint. I’m not asking for a diagnosis per se, but spotting characteristics for drug seekers and fakers in general.

The patient had the same story both times: he has broken vertebrae and associated back pain. He’s supposed to be having surgery ‘Wednesday’ (yes, both times).

He’s extremely uncooperative, and refuses to get on the stretcher in a timely manner, and refuses assitance. He’s in constant motion, balling up and hitting himself because of his ‘back spasms’.

I can’t do anything except take a BP or pulse ox, because he won’t stay still. During transport, he got off the stretcher and stood in a moving ambulance, doing his pain dance. These antics continued into the ER, and he was threatened with arrest on several occasions within 10 minutes of arrival. The ER staff knew him well as a frequent flyer, drug seeker, and overall problem patient.

My questions:

1. My impression, whether a true fracture or pinched nerve, is that a person with HTG back pain will stay as still as possible in whatever position hurts the least, and not jump around like an epileptic kangaroo. Is this a correct assumption?

2. Do you have any giveaway behaviors for the problem patients that scream to you “FAKER!”? Right now, the giveaway for this guy is the ‘surgery on Wednesday’ claim.

When this frequent flyer calls me the third time, I intend to do a full spinal packaging on the jerk, just so he doesn’t get off my stretcher.

[aruvqan]

I am not a doctor, but I have had a pinched nerve … and yes you do try to not move anything. Hell, if I could have stopped breathing I would have. The suggestion that they cut my throat and shove a tube down to breath for me would have cheerfully been accepted, as would removing my back from the rest of me.

I have had back pain that had me moving constantly, but it was from a pulled muscle that was in just the wrong place to sit, stand or lie comfortably, so it was a case of moving to try and find any position that was less than agonizing. Oddly enough, pressure on the spot helped as it isolated part of the muscle from moving, maybe that is what he is emulating[if he had seen it before on a legit patient?]

[Qadgop_the_Mercotan]

Waddell’s signs: Waddell's signs - wikidoc

Waddell’s signs are a group of physical signs, first described by Waddell et al in 1980, that may indicate non-organic or psychological component to chronic low back pain. Historically they have been used to detect “malingering” patients with back pain.

Use of Waddell’s Signs
One or two Waddell’s signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory.

Waddell’s signs are:
1.Superficial tenderness – skin discomfort on light palpation.
2.Nonanatomic tenderness – tenderness crossing multiple anatomic boundaries.
3.Axial loading – eliciting pain when pressing down on the top of the patient’s head.
4.Pain on simulated rotation - rotating the shoulders and pelvis together should not be painful as it does not stretch the structures of the back.
5.Distracted straight leg raise - if a patient complains of pain on straight leg raise, but not if the examiner extends the knee with the patient seated (e.g. when checking the Babinski’s reflex).
6.Regional sensory change - Stocking sensory loss, or sensory loss in an entire extremity or side of the body.
7.Regional weakness - Weakness that is jerky, with intermittent resistance (such as cogwheeling, or catching). Organic weakness can be overpowered smoothly.
8.Overreaction - Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.
Although Waddell’s signs can detect a non-organic component to pain, they do not exclude an organic cause. A high Waddell score (>3) is indicative only of symptom magnification or possible illness behavior. Often the test has been misused. It does not signify malingering.

Not diagnostic in and of themselves, but helpful in putting together a better picture of what’s going on.