• Insurance adjusters and defense attorneys often seek to undermine the credibility of individuals injured as the result of another person’s negligence in order to deny or reduce the amount paid on a claim.  One common approach is to imply that the injured person is exaggerating his or her symptoms, simply to maximize the possibility of compensation, or for some other improper, personal gain.  This insurance industry strategy is very common and is referred to as “litigation neurosis” or “compensation neurosis.”   The assumption that litigants do not respond as well to treatment as non-litigants became popular following a 1961 study by Dr. Henry Miller, a prominent British neurologist, who concluded that settlement of a legal claim enabled patients to recover from their injuries and return to work.[1]  Dr. Miller’s conclusion has been critiqued and challenged over the years from many medical researchers.[2]

    A recent study followed chronic spine pain patients who treated with dextrose prolotherapy and found no difference in treatment outcomes between patients involved in litigation and non-litigant patients.[3]  The study, designed to determine whether patients involved in a legal claim could be included in future randomized control trials (RCTs) on the efficacy of spine prolotherapy, prospectively measured outcomes on disability scales and retrospective global impressions of change questionnaires.[4]

    The study comprised a prospective case series on 147 patients (71 litigants and 76 non-litigants) referred by manual therapists for prolotherapy for chronic cervical, thoracic or lumbar pain of six months or more in duration, who had not responded to conservative care (manipulation, exercise, and dry needling of trigger points).  During the course of prolotherapy, participants were prohibited from taking NSAID’s for 4 weeks after each treatment.  All study subjects received co-interventions, such as manipulation, exercise, and dry needling.

    Participants completed the Neck Disability Index (NDI), Patient Specific Functional Scale (PSFS) and Roland-Morris Disability Questionnaire (RMDQ), depending on the nature of their chronic spine pain.  Patients completed the questionnaires prior to starting treatment and again approximately one year post-treatment.

    26 participants (23 litigants and 3 non-litigants) provided data for cervical spine disability.  Statistical comparison between the two groups was limited by the low number of non-litigants.  However, litigants and non-litigant groups reported significant improvement with prolotherapy treatment and two-thirds of the litigant group reported improvement of greater than 50% on NDI.

    70 patients (50 litigants, 20 non-litigants) provided thoracic disability data.  Both groups reported significant improvement on PSFS, with litigants reporting significantly greater improvement than their counterparts, and more patients with improvement greater than 50%.

    97 participants (35 litigants and 62 non-litigants) provided lumbar disability data.  Both groups reported improvement after treatment with no difference in the degree of improvement between the groups.

    Findings from Study

    1.  Both litigant and non-litigant patient groups showed significant improvement on all disability scales with treatment.
    2. Litigant patients demonstrated improvement in outcomes equal to or greater than the non-litigants, despite higher initial disability scores and more treatment areas.
    3. There was essentially no difference in the percentage of litigants v. non-litigants who reported decreased symptoms, improved function and ability to work, willingness to repeat treatment, ability to decrease medication use, and decreased need for other treatment modalities:

    The following chart provides the breakdown for patients into litigants to non-litigants groups.



    Symptom Improvement






    Improved ability to work



    Willingness to repeat treatment



    Decreased medication use



    Decreased need for other treatment modalities




    This study is the first of its kind to document the outcomes of prolotherapy in a consecutive case series of litigants versus non-litigants.  There are several implications from this study’s results:

    • Prolotherapy may be an effective treatment for patients with chronic spine pain;
    • Inclusion of litigants in future studies on the efficacy of prolotherapy is unlikely to affect the mean outcomes of the cohort as a whole;
    • The theory that patients involved in a injury claims process do not respond as well as their non-litigant counterparts is without merit in this study.

    Also, the study’s findings correspond with multiple studies (see footnote 2) and by renowned researchers, Susan Lord, MD, and Nicolai Bogduk, MD, on neck pain patients who treated with radiofrequency neurotomy, concluding that sustaining symptom improvement is independent of whether or not the patient was involved in litigation.[5], [6]

    Please do not hesitate to contact our office if you or someone you know has been injured by the negligence of another person.  The attorneys at Adler ♦ Giersch ps are available to answer your questions and explain the claims process to you, your patients, colleagues, family and friends.  Simply give us a call.  Consultations are without charge and complimentary.


    [1] Miller H.  “Accident Neurosis,” Br Med J 1961;1: 919-25.

    [2] A. F. dePalma, D. K. Subin, “Study of the Cervical Syndrome,” Clin Orthop, 1965, Vol. 38, pp. 135-142;  C. H. Schutt, F. C. Dohan, “Neck Injury to Women in Auto Accidents,” JAMA, 1968, Vol. 206, No. 12, pp. 2689-2692; M. Hohl, “Soft Tissue Injuries of the Neck in Automobile Accidents: Factors Influencing Prognosis,” J Bone Joint Surg, 1974, Vol. 56-A, No. 8, pp. 1675-1682; C. Maimaris, M. R. Barnes, M. J. Allen, “Whiplash Injuries of the Neck: A Retrospective Study,” Injury, 1988, Vol. 19, No. 5, pp. 393-396; S. P. Hodgson, M. Grundy, “Whiplash Injuries: Their Long-Term Prognosis and its Relation to Compensation,” Neurol Orthop, 1989, Vol. 7, pp. 88-91; A. Watkinson, M. G. Gargan, G. C. Bannister, “Prognostic Factors in Soft Tissue Injuries of the Cervical Spine,” Injury, 1991, Vol. 22, No. 4., pp. 307-309; B. Pennie, L. Agambar, “Patterns of Injury and Recovery in Whiplash,” Injury, 1991, Vol. 22, pp. 57-59; H. V. Parmar, R. Raymakers, “Neck Injuries from Rear Impact Road Traffic Accidents: Prognosis in Persons Seeking Compensation,” Injury, 1993, Vol. 24, pp. 75-78; D. D. Robinson, V. N. Cassar-Pullicino, “Acute Neck Sprain After Road Traffic Accident: A Long-Term Clinical and Radiological Review,” Injury, 1993, Vol. 24, No. 2, pp. 79-82.

    [3] Hooper RA, et al., “Prospective case series of litigants and non-litigants with chronic spine pain treated with dextrose prolotherapy,” International Musculoskeletal Medicine 2011;33(1):15-20.

    [4] Prolotherapy is an injection technique to treat pain due to ligamentous laxity which has been in use for over 70 years.  It involves repeated injections of tender ligaments with an irritant solution to produce inflammation in order to create collagen fibers, which improve ligament strength.

    [5] McDonald GJ, Lord SM, Bogduk N. “Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain,” Neurosurgery 1999;45(1): 61-7.

    [6] Sapir DA, Group JM. “Radiofrequency medial branch neurotomy in litigant and nonlitigant patients with cervical whiplash: a prospective study,” Spine 2001;26(12): E268-73.


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