Saying No to Drugs
Gabriel Williams MD
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Address key concepts in interaction,
decision making and documentation:
History
Physical
Ways to document this information
Documenting decision making
Outline
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Basics of Pain history:
◦ where, when, how
Equipment: current and prior use, do they
have it and is it functional?
 Chronos
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History
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Weakness, numbness, changes in
bowel/bladder, unintentional weight loss,
history of cancer, progress decrease in
function, fever, systemic symptoms.
Red Flags
Work history: ask about how many years,
what and workman’s comp.
 Task specific: anything they cannot do?
 Home exercise program: If you suspect
they are misrepresenting functional
status, ask when was last time they did
push ups, dips, back arms, burpies,
lunges, water bags…
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Functional History
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Sports: last did…
Activities
Fall History
Reports prepared by custody
Asking custody officers of patient
activities.
Functional History
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Sleep History
◦ Insomnia
◦ Daytime Somnulence
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Substance Abuse History
◦ Prescription, ivdu, alcohol
◦ Duration
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Family History of alcohol, drug or sexual
abuse.
Psychiatric Disorders
◦ Severity
◦ Date last treated
Other Important History
Treatment History
and Compliance
PT
 HEP: provided written, verbal
HEP
 Procedures / Operations
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OSA not on CPAP
 COPD
 Intolerance to Opioids
 Medical noncompliance
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Pertinent ROS
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Observation – starts from the
moment you can see patient
Cane
Glasses
Attire - cervical collar,
additional bracing/wraps/built
up
Muscle Bulk. Ask for them to
remove their shirts.
Examination
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When patients ask you to repeat questions
the increased time allow them to think of an
answer.
If patient is not answering your question:
Rephrase the question to a simple yes or no
or body part answer and ask it again.
Repeat asking the same question until
answered. Remark how many times you
needed to ask the question to get a simple
answer. Request they are more forthcoming
next time.
Behavioral Cues, Evasive History
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Long pause together with left gaze often
imply a creative answer, and an intense
adversarial gaze can stand for a
premeditated nonfactual answer.
Disclaimers of “to tell you the truth,” or
“honestly” should either negate the sentence
or consider adding in a negative to make it
factually correct.
Count how many times they mention/ask for
a specific medication or pain
medications.
Behavioral cues, Evasive History
Waddell‘s Superficial Tenderness
Not related to a particular skeletal or neuromuscular
structure; may be either superficial or nonanatomic:
 Superficial - The skin in the lumbar region is tender
to light pinch over a wide area not associated with the
distribution of a posterior primary ramus.
 Nonanatornic - Deep tenderness, which is not
localized to one structure, is felt over a wide area and
often extends to the thoracic spine, sacrum, or pelvis.
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Waddell’s Simulation
Simulation tests – These tests give the patient the
impression that a particular examination is being carried out
when in fact it is not.
 Axial loading - Low back pain is reported when the examiner
presses down on the top of the patient‘s head; neck pain is
common and should not be considered indicative of a
nonorganic sign.
 Rotation - Back pain is reported when the shoulders and
pelvis are passively rotated in the same plane as the patient
stands relaxed with the feet together; in the presence of root
irritation, leg pain may be produced and should not be
considered indicative of a nonorganic sign.
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Waddell’s Distraction
Distraction tests A positive physical finding is
demonstrated in the routine manner, and this finding is
then checked while the patient's attention is distracted; a
nonorganic component may be present if the finding
disappears when the patient is distracted.
 Straight leg raising
 The examiner lifts the patient's foot as when testing the
plantar reflex in the sitting position; a nonorganic
component may be present if the leg is lifted higher than
when tested in the supine position.
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Waddell’s Regionalization
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Dysfunction involving a widespread region of
body parts in a manner that cannot be
explained based on anatomy; care must be taken
to distinguish from multiple nerve root
involvement.
Motor - Demonstrated on testing by a partial
cogwheel "giving way" of many muscle
groups that cannot be explained on a localized
neurologic basis.
Sensory - Include diminished sensation to light
touch, pinprick or other neurologic tests fitting a
“stocking" rather than a dermatomal pattern.
Waddell’s Overreaction
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May take the form of disproportionate
verbalization, facial expression, muscle
tension and tremor, collapsing, or
sweating; judgments should be made with
caution, minimizing the examiner's own
emotional reaction.
3 or more positive tests count, 2 or
less do not.
 Article relates to use of “up-to-date
roentgenograms” for diagnosis
 Predicted correlation results of
chemonucleolysis for prolapsed
intervertebral disc: less than 3 signs 74%
success, equal or more than 3 signs with
11% success
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Waddell’s Signs
Overreaction has been most contested in
the literature since “there are
considerable cultural variations, and it is
very easy to introduce observer bias.”
 False positive nonorganic signs do exist,
population identified most at risk is
elderly who cannot stand.
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Waddell’s Signs
Reliability 86% for two examiners.
Age, gender, occupation or compensation
did not influence results of nonorganic
signs.
 Correlations with hypochondriasis,
depression, and hysteria.
 Conflicting evidence regarding nonorganic
signs and return to work.
 Presence of Waddell’s signs should not
preclude work up.
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Waddell’s Signs
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Direct versus indirect examination
Specific ones that I look at: ADF direct
versus staying on heels versus gait
Seated Hip Flexion versus Supine assisted
hip flexion
Spine ROM during direct and indirect
exam
MMT: with suboptimal effort, always ask:
“are you doing the best you can?”
Exam
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The inverted ankles sign:
Not as simple as naming the painful
area...
 May want to defer a diagnosis because it
does not make sense - discrepancies
 misrepresentation of functional status history, noted during exam
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Should I make a diagnosis?
Patient with history of insomnia, claims
can only sleep 20 minutes at a time, for a
maximum of 2 hours total per 24 hours.
Has had this sleep problem for 14 months
since morphine was discontinued.
 On exam, is alert, talking in complete
sentences. Thought process goal
oriented.
 What do we want to ask next? What
should we review?
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Case
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Review medications, ask about recent
drug abuse, manic episodes, bipolar
disorder, psychiatric history. If all ROS is
negative, what next?
Case
Since it is impossible to have such a
profound sleep disorder and objective
findings on exam lacking drowsiness
and/or delirium, documentation should
include noncredible historian and
misrepresentation of functional status.
Case
Documentation of
Decision Making
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The risks of constipation, dizziness,
nausea, somnulence, respiratory
depression, sweating, vomiting, pruritis,
urinary retention, overdose, headache,
dry mouth, hyperalgesia, fatigue,
decreased neuroendocrine axis, triggering
addictive behavior outweigh possible
benefits of starting/continuing/increasing
… given that
Documentation of Decision Making
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there are no functional goals
there is limited evidence of significant
impairment
patient has history of abuse or significant
risk factors for drug abuse
History of opioid intolerance
History of noncompliance
History of poor relief with opioids
Current treatment for pain is …
and plans for pain management
include …
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Diagnostic studies,
Health care appliance
Accommodation
Activity modification / work restriction
Procedure
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Physical therapy
Modalities
Stress management
HEP management including
revision/restriction or advancement
Patient Education
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Psychiatric Patient
◦ Axis I
◦ Axis II
Overtly Manipulative Patient – “In order to
be my doctor, you have to prove yourself.”
 Angry patient –
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◦ Acknowledge frustration and redirect
◦ Rephrase, Repeat, Remark and Request
◦ May have to end encounter
Other Difficult Encounters
Any Questions?
Waddell G, McCulloch JA, Kummel E,
Venner RM. Nonorganic physical signs in
low-back pain. Spine. 1980;5:117-125.
 Scalzitti DA. Screening for psychological
factors in patients with low back
problems: Waddell’s nonorganic signs.
Physical Therapy. 1997;77:306-312.
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References: