Letters to the Editors.

Sincerity of Effort

To the Editor:

"Detecting Sincerity of Effort: A Summary of Methods and Approaches" by Lechner and colleagues (August 1998) addressed a very important and controversial topic. The authors handled the discussion well, forcing the reader to rethink what all these "symptom magnification" tests really mean. I agree with their conclusions that it is not the clinician's role to detect sincerity of effort. However, I think an important distinction needs to be made here to avoid misinterpretation of this article. If we avoid addressing consistency of effort, we are underreporting what I believe is an important bit of information. "Consistency" does not mean "sincerity." To say someone is consistent is to report an observation. To say someone is sincere is to judge that person, using our own personal value system.

Here is the distinction: we can and should report the results of tests such as Waddell's signs,[1] and our observations on consistency or inconsistency of the patient's behavior, in a way that is factual and nonjudgmental. Then, we should independently report the results of functional tests as being maximum or submaximum, based on what Isernhagen and others call the "kinesiophysical method of testing."[2-6] With the kinesiophysical method, the therapist stops the patient when adverse changes in body mechanics, accessory muscle use, heart rate, or other physical signs are seen. If the patient "self-limits" in the absence of these kinesiophysical signs, the therapist determines that the patient is not performing at his or her maximum safe ability. No attempt to judge the reason or motivation of the self-limitation is made.

As the authors suggested, there is a problem with the way some people use the results of the various "symptom magnification" tests available. When the patient passes these tests, I have heard clinicians refer to the pain behaviors as "believable," "consistent," and so forth, using this judgment to justify and support a self-limitation in a functional test. For example, one patient was requested to stop a floor lift at 20 lb, but the therapist did not see kinesiophysical signs that, in the therapist's opinion, would indicate the patient was nearing or exceeding a safe lifting limit. But because the patient was "believable," 20 lb was reported as the maximum amount the patient could or should lift. In fact, 20 lb was the maximum amount the patient was willing to lift. This willingness may or may not have been reasonable, and by attempting to interpret its reasonableness, we are simply inflicting our personal values on a measure that should be determined in a more objective fashion.

I have seen other examples in which the patient's behaviors have been judged "excessive," "inconsistent," and so on, and the clinician concluded that there was no basis for any work restriction. In other words, because we cannot believe the patient, he or she must be capable of unlimited powers! "Return to work without restrictions" is the recommendation.

An evaluation method that focuses on weeding out the "truth tellers" from the "liars" works only if we assume that liars always self-limit and truth-tellers always perform maximally. This is not true. When using a kinesiophysical method to determine a safe functional limit, we find that individuals who test positively on symptom magnification tests do not always self-limit. Conversely, individuals who pass the barrage of symptom magnification tests sometimes self-limit in the absence of kinesiophysical changes.

If we stick to our scope of practice, there are only 2 real conclusions that we need to choose between: either the patient described above demonstrated abilities that were based on a kinesiophysical limit, or the patient did not. Our specialty is not psychology, job placement, or social reform-it is physical measurement! On the other hand, it is important to report symptom complaints and observations of consistency, so that other, more appropriate parties can decide what treatment, settlement, or job placement options should be considered. I cannot believe that the authors of this article meant to imply that we should not report such relevant observations.

Here is an example of the way we reported functional results when the patient self-limited and inconsistencies were observed: "The abilities detailed in this report represent the patient's willingness to exert. Kinesiophysical signs of maximum effort such as [list] ... were not observed, so it is probable that the patient could perform at higher levels of effort safely. The actual kinesiophysical limit is unknown. Reasons given for the patient's self-limitation were pain complaints and fear of reinjury. The patient recorded 3/5 of Waddell's signs of nonorganic source of symptoms, and several inconsistencies in his presentation were observed. Inconsistencies observed included...."

This method of documentation allows us to stick to our area of expertise, without ignoring or underreporting important issues of symptom complaints and consistency of effort.

Robin Saunders, PT 4250 Norex Dr Chaska, MN 55318

References

[1] Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125.

[2] Isernhagen SJ. Functional capacity evaluation. In: Isernhagen SJ, ed. Work Injury: Management and Prevention. Gaithersburg, Md: Aspen Publishers Inc; 1988:139-174.

[3] Isernhagen SJ. Functional capacity evaluation: rational procedure, utility of the kinesio-physical approach. Journal of Occupational Rehabilitation. 1992;2:157-168.

[4] Isernhagen SJ. Functional capacity evaluation and work hardening perspectives. In: Mayer T, Mooney V, Gatchel R, eds. Contemporary Care for Painful Spinal Disorders. Malvern, Pa: Lea & Febiger; 1991:328-345.

[5] Isernhagen SJ. Return to work testing: functional capacity and work capacity evaluation. Orthopedic Physical Therapy Clinics. 1992;1(1):83-98.

[6] Smith RL. Therapists' ability to identify safe maximum lifting in low back pain patients during functional capacity evaluation. J Orthop Sports Phys Ther. 1994;19:277-281.

Author's Response:

It seems that the reader may have missed several salient points of the article. First, the methods discussed were not methods that are used to detect symptom magnification. Instead, the methods we reviewed are being used to detect motivation or sincerity of effort. The distinction between these two concepts is an important one. To miss this point is to miss one of the major issues of the article.

Although I support the notion that gross inconsistencies of effort should be reported, I also know that care must be taken in reporting these inconsistencies for 2 reasons. First, from my research and experience in testing motivated people, I know that even gross inconsistencies may occur due to fatigue, "warm-up," fear of pain or reinjury, misunderstanding of task instructions, lack of familiarity with the task being tested, and so on. Second, if these inconsistencies are reported, even in an objective manner, they will be interpreted (by those Ms Saunders characterizes as "more appropriate parties") as evidence of a lack of sincerity of effort. This misinterpretation will occur regardless of the way we think these tests should be interpreted.

If inconsistencies are noted, it seems only fair that they should be discussed with the patient at the time of testing and prior to report writing. Such discussions allow patients to explain why they think that the inconsistencies occurred. I have found that often there are interesting and unusual biomechanical, physical, or physiological reasons for the inconsistencies. These underlying causes never would have become apparent if this discussion did not occur. Minor inconsistencies are even more likely to occur for reasons other than lack of motivation. I have read functional capacity evaluation (FCE) reports in which the patient demonstrated maximal effort on all tasks but displayed one minor inconsistency. The documentation of this one minor discrepancy diminished the patient's credibility and his case settlement. I submit that such reporting is grossly unjust.

As mentioned in the article, Waddell never intended his nonorganic signs to be used to detect sincerity of effort.[1] In today's environment, however, that is how they are being interpreted. Again, if we report that Waddell's nonorganic signs are positive, they will be interpreted negatively regardless of whether they are reported independently from the results of functional tests. As mentioned in the article, 3 out of the 8 signs have been found to be unreliable.[2] If we insist on using tests that have been shown to be unreliable, what have we accomplished? One cannot have validity (accuracy) without reliability. For what purpose should unreliable tests be used?

Although I agree that therapists can determine whether patients have reached a maximum effort by comparing visual observations of movement patterns to patients' willingness to perform, I hesitate to use the term "kinesiophysical." Therapists have been observing movement patterns, biomechanics, and use of accessory muscles and basing clinical decisions on these observations long before this terminology was coined. In fact, biomechanics, kinematics, and kinetics are essential components of the scientific underpinnings of our profession. They have been utilized by therapists in assessment long before FCEs, as they are known today, came into existence. To use terms to describe this assessment process that are not universally defined, understood, and accepted by the medical community weakens our credibility as a profession.

The issues then become: (1) How reliable and valid are our observations? (2) How much do we allow therapist observations to drive the end point of functional tests? and (3) How much do we allow patient perceptions to determine that end point? In my view, there must be a careful integration of therapist observation/scoring and patient perception/willingness to perform. The process should be based on mutual respect between therapist and patient. The ultimate control over whether to continue or discontinue testing should lie with the patient. However, the patient's perception should not drive the scoring system. The therapist's observations should be systematically applied through clinical decision-making algorithms, and these algorithms, in turn, should be studied for reliability and validity with results published in the peer-reviewed literature. Until this is done, the labels that we put on our approaches are meaningless. Only after this is done will FCEs comply with the Standards for Tests and Measurements in Physical Therapy Practice.[3]

When a patient self-limits, how does Ms Saunders know that it is "probable that the patient could perform at a higher level?" Earlier in her letter, she criticizes others for making such predictions. Perhaps the next repetition would be a maximum effort. In such an example, the return to work level would be the same whether the patient self-limited or not. I question how Ms Saunders measures "muscle recruitment patterns and spine stabilization." My suspicion is that those 2 variables cannot be measured reliably or accurately with visual observation. Have those concepts even been adequately defined? We need to be careful how we use terminology if we wish to maintain credibility as a profession.

I agree that judgment of the underlying cause of self-limiting behavior should not be made and that therapists should avoid trying to discern who is "believable." I too have frequently found that patients who test positively on sincerity-of-effort "tests" do not exhibit self-limiting behavior during functional testing. This fact is one of the primary reasons that I began to examine the literature addressing the reliability and validity of these measures.

As the article explains, we do not have adequate evidence to use the results of these tests for the purpose of detecting sincerity of effort. For this reason I ask: What relevance do such tests have? I would cite U34.4.1 of the Standards for Tests and Measurements in Physical Therapy Practice[3]: "Test users who misrepresent their clinical opinions as being based on test results when evidence for such opinions is not found in the research literature violate the rights of persons taking tests." I see no problem with refusing to conduct or report biased, unreliable, and invalid information. To the contrary, I feel that not refusing to do so is damaging to the patient and to our profession.

Deborah E Lechner, PT

Associate Professor
Division of Physical Therapy
The University of Alabama at Birmingham
Bishop 102
900 19th St S
Birmingham, AL 35284

References

[1] Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125.

[2] Korbon GA, DeGood DE, Schroeder ME, et al. The development of a Somatic Amplification Rating Scale for low-back pain. Spine. 1987;12:787-791.

[3] Task Force on Standards for Measurement in Physical Therapy. Standards for tests and measurements in physical therapy practice. Phys Ther. 1991;71:589-622.

RELATED ARTICLE: Letters to the Editor

Letters to the Editor provide a forum for discussion of all matters that are important to the physical therapy profession. Letters responding to articles should be received on a timely basis to ensure meaningful dialogue. Due to space constraints, we ask that letters be less than 600 words. All letters should be signed.

Receipt of Letters to the Editor is not acknowledged; however, correspondents will be notified if the letter has been accepted for publication. The Journal reserves the right to copyedit letters. Unless extensive copyediting is required, correspondents will not be sent a copy of the edited version to review. Letters regarding a specific article will be printed with an author response whenever possible.

Submission by mail or fax: Letter should be typed, double-spaced. Send two copies to the Editor, Physical Therapy, American Physical Therapy Association, 1111 North Fairfax Street, Alexandria, VA 22314-1488; fax, 703/706-3169. Submission via e-mail: Letters should include the correspondent's mailing address. Send to [e-mail].