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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 …