title: Maximal versus feigned active cervical motion in healthy patients: the coefficient of variation as an indicator for sincerity of effort.
abstract: METHODS
  Maximal and submaximal (feigned) cervical motions in healthy patients were compared.
  
  
  OBJECTIVE
  To test the efficiency of the coefficient of variation in differentiating maximal (sincere) from submaximal (feigned) cervical motion in healthy patients.
  
  
  BACKGROUND
  Although limitation of cervical motion is a recognized impairment, no well-founded approach for verifying the degree to which a patient is maximizing his or her performance is available currently.
  
  
  METHODS
  A new ultrasound-based system for three-dimensional motion analysis of the head was used to test 25 healthy patients (22 women and 3 men) ages 26 to 48 years. During the first test, (Test 1), the patients were asked initially to move the head maximally at a self-determined velocity in all the primary directions: flexion, extension, right and left rotation, and right and left lateral flexion. They then were presented with a short vignette describing a fictitious accident and asked, using the same protocol, to perform the same types of cervical motions as if they had experienced an injury. No further instructions were provided. A retest (Test 2) in reverse order (feigned effort first) took place 1 to 16 weeks (mean, 3.3 weeks) later.
  
  
  RESULTS
  The range of motion and average velocity were significantly smaller (P = 0.0001) in the feigned than in the maximal performance in all directions and on both tests. Feigned range of motion and velocity also were significantly reduced in Test 2 (P = 0.006), as compared with those in Test 1 (P = 0.0001). The range of motion coefficient of variation in the feigned performance (CVf) remained stable on the retest, but was significantly larger on both tests (P < 0.001) than the corresponding CV derived from maximal performance (CVm). Furthermore, a case-by-case analysis showed that whereas the American Medical Association guidelines identified only 16% of the feigned cases, the use of CVf and CVm resulted in a corresponding rate of 87%. Tolerance intervals at 95% and 99% indicated total separation between the distributions of CVf and CVm, respectively. The average velocity-based CVf and CVm were not of a comparable differentiating power.
  
  
  CONCLUSIONS
  This study indicates that in healthy patients, feigned performance may be differentiated from maximal (sincere) performance effectively and reproducibly using the coefficient of variation.
authors.affiliation: Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel. zdvir@post.tau.ac.il
authors.forename: Z
authors.initials: Z
authors.lastname: Dvir
authors.forename: T
authors.initials: T
authors.lastname: Prushansky
authors.forename: C
authors.initials: C
authors.lastname: Peretz
mesh_terms: D000328:Adult; D004568:Electrodiagnosis / Q000295:instrumentation; D005080:Exercise Test / Q000706:statistics & numerical data; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000000981:diagnostic imaging / Q000502:physiology*; D005082:Physical Exertion / Q000502:physiology*; D016059:Range of Motion, Articular / Q000502:physiology*; D015203:Reproducibility of Results; D014463:Ultrasonography