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Non-Physical Interference - Spine limited patients commonly find themselves facing significant dilemmas resulting in an expression of fear, anger or survival behavior that we sometimes view as unpleasant or even dishonest. Some examples include altered views of self or others, or view from concentrating on a real or perceived "return to work contest" or fault. The threats of failure commonly lead to an embellishment of symptoms. The safest interpretation is that the patient has reason to question whether the clinician has his or her best interest in mind. Embellishment and anger are attempts to enlist an effort for help in what seems to the patient as the "return to work contest". More and more psychosocial issues are being found to be dynamic and reactive. Non-physical threats to self-esteem, livelihood, future or other loss, can significantly influence the patient's response to job, you and your care.   
Gaines et al.,'99 four times lengthier time for return to unrestricted, regular work and a greater use of physical therapy and lumbar computed tomographic scans in the presence of 3-5 Waddell Embellishments (see below). The Waddell tests and your personal impression are probably the best predictors of a slow recovery that is not limited to physical issues, e.g., affected by non-physical pressures like economic or social issues. Try not to judge but recognize that survival behavior is a common response though not always effective. In nature, animals use many means to survive as both prey and predator. Sometimes survival behavior is effective; other times it is not. Since there must be a winner and loser in a survival game, both sides use betrayal to gain an advantage over the adversary. Birds feign a broken wing to lure predators away from the nest, lizards and fish change color or fan out to appear larger, zebras bear stripes and lion have a camouflaged coat in high grass. The use of all these advantages is natural survival for these creatures. Embellishment of symptoms is but a more sophisticated expression of survival behavior that we should not take personally as being dishonest behavior but as feeling desperate or trapped, seeking help and understanding. (see Non-physical Factors
Waddell Embellishment Tests -  (For significance see Non-Physical Interference) 
1. Non-Physiologic -Tenderness: Subcutaneous (or less) pressure reproduces symptoms. 
2. Simulation: of symptoms 
  a)  Loading the spine with the weight of your hands on top of the patient's head  
  b)  Simulation of twisting the trunk when rotating the shoulders and hips in unison (can physiologically reproduce sciatica). 
3. Distraction = perform sciatic tension test with sitting knee extension while distracting patient with knee or foot examination while gently extending the knee.  If no discomfort during sitting knee extension, straight-leg raise should not be positive and, if positive, SLR is considered to be of questionable significance (See Fig. Sitting Knee Extension). 
4. Non-Anatomic = distribution of pain on pain drawing (total body or outside the body) or giving away on muscle testing (intermittent efforts) 
5. Over reaction = Grimacing, complaints or suffering displays inappropriate for situation or maneuver. 
A score of 0-2 is normal. Three to five positive responses warn the clinician that non-physical interference may render the history and physical examination somewhat confusing (identifying a need for a greater focus on objective measures).  The more positive Waddell tests, the greater chance that non-physical factors may alter the patient's response to your care and potentially lowers a clinician's expectations for an excellent outcome from both surgical and non-surgical efforts.  
     The potential reasons for slow recovery are usually too many to pinpoint.  No matter the reason for slowed or delayed recovery the approach is the same, help the patient de-emotionalize reactions to the unknown by gathering enough data about options to make more logical decisions (see Slow Recovery). 
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