Medical Policy


Subject:Prolotherapy for Joint and Ligamentous Conditions
Policy #:  MED.00007Current Effective Date:  07/15/2014
Status:ReviewedLast Review Date:  05/15/2014

Description/Scope

Prolotherapy, also referred to as joint sclerotherapy or reconstructive ligament therapy, has been used to treat chronic neck and back pain, musculoskeletal pain, and ligamentous instability.

This document addresses the use of prolotherapy for the treatment of musculoskeletal pain and ligament instability.

Position Statement

Investigational and Not Medically Necessary:

Prolotherapy, joint sclerotherapy and reconstructive ligament therapy with injections of sclerosing agents are considered investigational and not medically necessary for all conditions.

Rationale

Prolotherapy has been investigated as a treatment of various sources of musculoskeletal pain, including arthritis, degenerative disc disease, fibromyalgia, tendonitis and ligamentous instability. As with any therapy for pain, a placebo effect is anticipated and thus randomized placebo controlled trials are necessary to investigate the extent of the placebo effect and to determine whether any improvement with prolotherapy exceeds that associated with a placebo.

Chronic Neck and Back Pain and Osteoarthritis

Although there is extensive literature regarding the use of prolotherapy for joint pain, the earliest evidence in the peer-reviewed medical literature consists of small randomized, placebo-controlled trials. The treatment group in one trial for chronic low back pain included both spinal manipulation and prolotherapy. While positive results were reported in the treatment group, it is not possible to determine the independent effect of prolotherapy (Yelland, 2004a; 2004b; 2004c). In another trial, the treatment group was not effectively blinded from the placebo group (Wilkinson, 2005). In 2000, two randomized placebo-controlled trials were published that were effectively blinded and isolated the contribution of prolotherapy. One trial focused on osteoarthritis of the knees (Reeves, 2000a) while the other focused on osteoarthritis of the thumb and finger (Reeves, 2000b). Both studies included multiple outcomes and it is not possible to determine the clinical significance of the reported improvements. For example, in the study of the knees, there were improvements in the non-pain outcomes (swelling, buckling, etc) compared to the placebo effect, while there was no significant improvement in the pain outcomes. In the study of the thumb and finger, the treatment group reported improvements in flexion but not pain.

Other evidence in the peer-reviewed medical literature evaluating prolotherapy injections consists of case series and systematic reviews (Dagenais, 2005; Kim, 2004; Rabago, 2005; Watson, 2010). A systematic review by Dagenais and colleagues (2008) concluded "that despite its use for over 50 years, there is no evidence of efficacy for prolotherapy injections alone for chronic low back pain." A 2009 systematic review performed for the American Pain Society concluded that prolotherapy was found to be ineffective when used alone for chronic low back pain (Chou, 2009).

The use of prolotherapy was evaluated in a prospective, uncontrolled study of adults with at least three months of symptomatic moderate to severe knee osteoarthritis (Rabago, 2012a). The primary objective of the study was to determine whether prolotherapy improved pain, stiffness, and function when compared to baseline status with one-year follow-up. Participants received extra-articular injections of 15% dextrose and intra-articular prolotherapy injections of 25% dextrose at 1-, 5-, and 9 weeks, with "as-needed" treatments at weeks 13 and 17. The primary outcome measure was the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC). Secondary outcome measure was the validated Knee Pain Scale (KPS). Thirty-six participants received an average of 4.3 prolotherapy injection sessions over a 17-week treatment period and reported progressively improved scores during the 52-week study on WOMAC and KPS measures. Participants reported overall WOMAC score improvement four weeks after the first injection session (7.6 ± 2.4 points, 17.2%), and continued to improve through the 52-week follow-up (15.9 ± 2.5 points, p<0.001, 36.1%). KPS scores improved in both injected (p<0.001) and uninjected knees (p<0.05). Female gender, age 46-65 years old, and body mass index of 25 kg/m2 or less were associated with greater improvement on the WOMAC index. Limitations of this study include the lack of a randomized control group and the small number of study participants. Additional study with a larger randomized sample of participants is needed to determine the effectiveness of prolotherapy for knee osteoarthritis.

Rabago and colleagues (2013b) evaluated the efficacy of prolotherapy in adults with at least three months of painful knee osteoarthritis in a study supported by the National Center for Complementary and Alternative Medicine (NCCAM). Ninety participants were randomized to blinded injections (three to five treatments with dextrose prolotherapy or saline) or at-home exercise. The study measures were limited to subjective responses to treatment, pain, stiffness and functional limitations. All three groups showed improvements on the composite Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), with significantly greater improvement in the prolotherapy group (15.3 points) compared to saline and exercise groups (7.6, and 8.2 points, respectively). At 52 weeks, 50% of participants in the prolotherapy group achieved the minimum clinically important difference (MCID) of a 12-point change in WOMAC, compared to 30% of saline-treated participants and 24% of exercise participants. Knee pain scores also improved in the prolotherapy group. Limitations of this study include the relatively small sample size which resulted in an inability to detect uncommon adverse events such as intolerance to medication or rare-injection-related sequelae, lack of participants with very severe baseline WOMAC scores, and indirect assessment of participant satisfaction that was subject to bias.

Tendinopathies of the Upper and Lower Limbs

A 2009 systematic review evaluating injection therapies for lateral epicondylosis (tennis elbow) included two randomized controlled trials and one prospective case series on prolotherapy (Rabago, 2009). One of the randomized trials was referenced as a report from a 2006 conference on complementary and alternative medicine; no authors are listed in the reference and the study does not appear to be available in the peer-reviewed medical literature. The second randomized double-blind placebo-controlled trial involved 20 individuals who had elbow pain for at least six months and failure of conservative therapy (rest, physical therapy, nonsteroidal anti-inflammatory drugs, and two corticosteroid injections) to three treatments (over eight weeks) of prolotherapy or saline injection. Compared to the control group, prolotherapy subjects reported improved pain scores but there was no difference in grip strength between the two groups. The authors reported that clinical improvement in prolotherapy group subjects was maintained at 52 weeks, however, additional research with a larger study population is needed (Scarpone, 2008).

Rabago and colleagues (2013a) conducted a three-arm randomized controlled trial of 26 adults (32 elbows) with chronic lateral epicondylosis for three months or longer who were randomized to ultrasound-guided prolotherapy with dextrose solution, ultrasound-guided prolotherapy with dextrose-morrhuate sodium solution, or watchful waiting. The primary outcome was the Patient-Rated Tennis Elbow Evaluation (100 points) at 4-, 8-, and 16 weeks (all groups) and at 32 weeks (prolotherapy groups). The participants receiving prolotherapy with dextrose and prolotherapy with dextrose-morrhuate reported improved Patient-Rated Tennis Elbow Evaluation composite and subscale scores at 4-, 8-, and/or 16 weeks compared with those in the wait-and-see group (p<0.05). At 16 weeks, when compared with baseline, the prolotherapy with dextrose and prolotherapy with dextrose-morrhuate groups reported improved composite Patient-Rated Tennis Elbow Evaluation scores by a mean of 18.7 (9.6; 41.1%) and 17.5 (11.6; 53.5%) points, respectively. The grip strength of the participants receiving prolotherapy with dextrose exceeded that of the prolotherapy with dextrose-morrhuate and the watchful waiting group at 8 and 16 weeks (p<0.05). Limitations in drawing conclusions from this pilot study include the small number of participants and the lack of blinding.

Krogh and colleagues (2012) performed a systematic review and meta-analysis of the available randomized trials, concluding there was "a paucity of evidence from unbiased trials on which to base treatment recommendations regarding injection therapies for the treatment of lateral epicondylitis."

Yelland and colleagues (2011) reported a multicenter randomized trial of prolotherapy or exercises for Achilles tendonitis in 43 individuals. The percentage of individuals achieving full recovery was 53% for exercise alone, 71% for prolotherapy alone, and 64% for the combined treatment group, but these differences were not significant. Although the authors concluded that prolotherapy may be a cost-effective method to speed recovery in individuals with Achilles tendonitis, this study is limited by the combination of a small number of subjects per group, unequal duration of pain in the treatment groups at baseline, and minimal differences in the number of individuals showing recovery. Additional randomized trials are needed to replicate and extend these findings.

Gross and colleagues (2013) conducted a systematic review of clinical outcomes following injectable therapy of noninsertional Achilles tendinosis. The nine clinical studies that met the inclusion criteria at the final follow-up consisted of randomized controlled trials and cohort studies with a comparative control group (n=312 Achilles tendons). Interventions included platelet-rich plasma (n=54), autologous blood injection (n=40), sclerosing agents (n=72), protease inhibitors (n=26), hemodialysate (n=60), corticosteroids (n=52), and prolotherapy (n=20). Yelland and colleagues (2011) was the only prolotherapy study included in the review. The authors concluded that the available literature evaluating injectable treatments for noninsertional Achilles tendinosis has variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of their effects on chronically degenerated tendons.

Musculoskeletal and Other Pain-Related Conditions

Reeves and Hassanein (2003) reported on a study of dextrose prolotherapy for anterior cruciate ligament (ACL) laxity. Of 16 evaluable individuals, statistically significant improvements were found at six, twelve, and 36 months in ACL laxity, pain, swelling, and range of motion. However, this small, non-randomized trial, without placebo-control, is limited in determining if the extent of the improvements with prolotherapy exceeds those associated with a placebo.

Choi and colleagues (2011) evaluated the most current evidence in a systematic review of treatment options for athletes with osteitis pubis and osteomyelitis pubis, attempting to determine which options provide optimal pain relief with rapid return to sport and prevention of symptom reoccurrence. Treatment options included either conservative measures/physical therapy, local injection with corticosteroids and/or local anesthetic, dextrose prolotherapy, surgery or antibiotic therapy. There were no randomized controlled trials available for review. Only one case series described the use of dextrose prolotherapy as a treatment modality. The authors concluded that the evidence was weak in all case reports/case series and suggested further study is necessary to compare the different treatment options and determine which modality provides the fastest return to sport.

In a small randomized controlled trial (n=48), Kim and colleagues (2010) evaluated the efficacy and long-term effectiveness of intra-articular prolotherapy compared with intra-articular steroid injection in relieving sacroiliac joint pain. Participants experienced sacroiliac joint pain (confirmed by greater than or equal to 50% improvement in response to local anesthetic block) lasting three months or longer and failed medical treatment. The treatment involved intra-articular dextrose water prolotherapy or triamcinolone acetonide injection using fluoroscopic guidance, with a biweekly schedule and maximum of three injections. Pain and disability scores were assessed at baseline, in two weeks, and monthly after completion of treatment. The pain and disability scores were significantly improved from baseline in both groups at the two-week follow-up, with no significant difference between them. The cumulative incidence of greater than or equal to 50% pain relief at 15 months was 58.7% (95% confidence interval [CI]: 37.9%-79.5%) in the prolotherapy group and 10.2% (95% CI: 6.7%-27.1%) in the steroid group, as determined by Kaplan-Meier analysis; there was a statistically significant difference between the groups (log-rank p<0.005). The authors concluded that intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections. However, further studies are needed to confirm the safety of the procedure and to validate an appropriate injection protocol.

Summary

A California Technology Assessment Forum (CTAF) (Feldman, 2004) has concluded that prolotherapy does not meet CTAF's assessment criteria as:

…only one early study (Ongley, 1987) was able to demonstrate conclusively that prolotherapy was significantly superior to placebo for treatment of chronic low back pain. Subsequent research has not been able to replicate this finding. It is therefore not possible to conclude from the published literature that prolotherapy is superior to placebo injection for the treatment of chronic low back pain.

At this time the scientific evidence does not permit conclusions concerning the effect of prolotherapy on net health outcomes for chronic neck or back pain, tendinopathies of the upper or lower limbs, osteoarthritic pain, or other musculoskeletal pain and related conditions. Prolotherapy injections have not been proven to be more effective than placebo injections. Additionally, treatment was frequently combined with other therapeutic modalities including exercise, spinal manipulation and various pharmaceutical solutions. Heterogeneity among studies, small populations, short-term outcomes, lack of control groups, poor study design, and the use of other treatment modalities leads to weak or inconsistent conclusions regarding improvement in health outcomes as a result of prolotherapy injections.

Background/Overview

Prolotherapy, also known as joint sclerotherapy or reconstructive ligament therapy, has been used to treat chronic neck and back pain, musculoskeletal pain, and ligamentous instability. The procedure consists of a series of injections to stimulate tissue repair or growth by prompting release of growth factors, such as cytokines, or increasing the effectiveness of existing circulating growth factors. Proliferative or sclerosing agents used with prolotherapy have included dextrose as a single agent or combinations of dextrose, glycerine and phenol, hypertonic glucose, psyllium seed oil, sodium morrhuate (a cod liver oil derivative), or zinc sulfate. These agents are generally injected into facet joint capsule, fascia, ligament, or a combination of these sites. Prolotherapy may involve a single injection or a series of injections, often diluted with local anesthetic agents such as lidocaine or Marcaine™ (Hospira, Inc., Lake Forest, IL). Sarapin® (High Chemical Company, Levittown, PA), another agent thought to have anesthetic properties, is a derivative of the Sarraceniaceae plant and has been used in combination with sclerosing agents in prolotherapy.

Definitions

Ligament: A band of fibrous tissue connecting bones or cartilages, serving to support and strengthen joints.

Prolotherapy: A procedure proposed to strengthen lax ligaments or to relieve pain by injecting chemical agents directly into torn or stretched ligaments.

Sclerosis: A thickening or hardening of a body part from excessive formation of fibrous tissue.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the code listed below for all indications, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary:

HCPCS 
M0076Prolotherapy
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
References

Peer Reviewed Publications:

  1. Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. 2011; 45(1):57-64.
  2. Dagenais S, Haldeman S, Wooley JR.  Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature. Spine J. 2005; 5(3):310-328.
  3. Dagenais S, Mayer J, Haldeman S, et al. Evidence-informed management of chronic low back pain with prolotherapy. Spine J. 2008; 8(1):203-212.
  4. Dechow E, Davies RK, Carr AJ, Thompson PW. A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain. Rheumatology (Oxford). 1999; 38(12):1255-1259.
  5. Gross CE, Hsu AR, Chahal J, Holmes GB Jr. Injectable treatments for noninsertional Achilles tendinosis: a systematic review. Foot Ankle Int. 2013; 34(5):619-628.
  6. Kim SR, Stitik TP, Foye PM, et al. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil. 2004; 83(5):379-389.
  7. Kim WM, Lee HG, Jeong CW, et al. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010; 16(12):1285-1290.
  8. Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013; 41(6):1435-1446.
  9. Rabago D, Best TM, Beamsley M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med. 2005; 15(5):376-380.
  10. Rabago D, Best TM, Zgierska A, et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. Br J Sports Med. 2009; 43(7):471-481.
  11. Rabago D, Lee KS, Ryan M, et al. Hypertonic dextrose and morrhuate sodium injections (prolotherapy) for lateral epicondylosis (tennis elbow): results of a single-blind, pilot-level, randomized controlled trial. Am J Phys Med Rehabil. 2013a; 92(7):587-596.
  12. Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013b; 11(3):229-237.
  13. Rabago D, Zgierska A, Fortney L, et al. Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: results of a single-arm uncontrolled study with 1-year follow-up. J Altern Complement Med. 2012; 18(4):408-414.
  14. Reeves KD, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med. 2003; 9(3):58-62.
  15. Reeves KD, Hassanein KM. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med. 2000a; 6(2):68-74, 77-80.
  16. Reeves KD, Hassanein KM. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy. J Altern Complement Med. 2000b; 6(4):311-320.
  17. Scarpone M, Rabago DP, Zgierska A, et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008; 18(3):248-254.
  18. Watson JD, Shay BL. Treatment of chronic low-back pain: a 1-year or greater follow-up. J Altern Complement Med. 2010; 16(9):951-958.
  19. Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the "failed back syndrome": a single blinded, randomized and cross-over study. Pain Physician. 2005; 8(2):167-173.
  20. Yelland MJ, Del Mar C, Pirozzo S, Schoene ML. Prolotherapy injections for chronic low back pain: a systematic review. Spine. 2004a; 29(19):2126-2133.
  21. Yelland MJ, Glasziou PP, Bogduk N, et al. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine. 2004b; 29(1):9-16; discussion 16.
  22. Yelland MJ, Sweeting KR, Lyftogt JA, et al. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011; 45(5):421-428.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Prolotherapy, joint sclerotherapy, and ligamentous injections with sclerosing agent. NCD #150.7. Effective September 27, 1999. Available at: http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on February 6, 2014..
  2. Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine 2009 (Phila Pa 1976); 34(10):1078-1093.
  3. Feldman M. California Technology Assessment Forum (CTAF). Prolotherapy for the treatment of chronic low back pain. Technology Assessment. San Francisco, CA: CTAF. June 9, 2004. Available at: http://www.ctaf.org/assessments/prolotherapy-treatment-chronic-low-back-pain. Accessed on February 6, 2014..
  4. National Institutes of Health (NIH). Clinical trials: prolotherapy. Available at: http://www.clinicaltrials.gov/ct2/results?term=prolotherapy. Accessed on February 6, 2014..
  5. Yelland MJ, Mar C, Pirozzo S, et al. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev. 2004c; (2):CD004059.
Index

Sclerotherapy

Document History
StatusDateAction
Reviewed05/15/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Rationale and Reference sections.
Reviewed05/09/2013MPTAC review. Updated Description, Rationale, Background, Definitions, References, and Index.
Reviewed05/10/2012MPTAC review. Updated Rationale and References.
Reviewed05/19/2011MPTAC review. Updated Description, Rationale and References.
Reviewed05/13/2010MPTAC review. Revised document title to Prolotherapy for Joint and Ligamentous Conditions. Clarified Position Statement. Updated Description, Rationale, Background, and References.
Reviewed05/21/2009MPTAC review. References updated.
Reviewed05/15/2008MPTAC review. Sarapin® moved from Description to Background. Rationale and References updated.
 02/21/2008The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed05/17/2007MPTAC review. Rationale and References updated. 
 01/23/2007Added Sarapin® to the Description.
Reviewed06/08/2006MPTAC review. References updated. 
 11/21/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised07/14/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review
Date
Document 
Number
Title

Anthem, Inc.

 

09/19/2003MED.00007Prolotherapy/Sclerotherapy for Joint and Ligamentous Injections
WellPoint Health Networks, Inc.12/02/20042.07.06Prolotherapy