|Subject:||Prolotherapy for Joint and Ligamentous Conditions|
|Policy #:||MED.00007||Current Effective Date:||06/28/2016|
|Status:||Reviewed||Last Review Date:||05/05/2016|
This document addresses the use of prolotherapy for the treatment of musculoskeletal pain and ligament instability.
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.
Prolotherapy, also referred to as joint sclerotherapy or reconstructive ligament therapy, has been investigated as a treatment of various sources of musculoskeletal pain, including arthritis, chronic neck and back pain, degenerative disc disease, fibromyalgia, tendonitis and ligamentous instability.
Chronic Neck and Back Pain
Although there is extensive literature regarding the use of prolotherapy for joint pain, the earliest evidence in the peer-reviewed medical literature for back pain 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).
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).
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 osteoarthritis of the knees, there were improvements in the non-pain outcomes (such as, swelling, buckling) compared to the placebo effect, while there was no significant improvement in the pain outcomes. In the study of osteoarthritis of the thumb and finger, the treatment group reported improvements in flexion but not pain.
The use of prolotherapy was evaluated in a prospective, uncontrolled study of adults with at least 3 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 1-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). A total of 36 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 4 weeks after the first injection session (17.2%, 7.6 ± 2.4 points), and continued to improve through the 52-week follow-up (36.1%, 15.9 ± 2.5 points; p<0.001). 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 3 months of painful knee osteoarthritis in a study supported by the National Center for Complementary and Alternative Medicine (NCCAM). A total of 90 participants were randomized to blinded injections (3 to 5 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 3 groups showed improvements on the composite 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.
Rabago and colleagues (2015) reported the long-term results of prolotherapy-treated individuals with knee osteoarthritis who participated in a randomized controlled trial (Rabago, 2013b) and two uncontrolled open-label follow-up studies. The prolotherapy-treated study groups were comparable, having undergone similar treatment courses and showing similar improvements in WOMAC score at 52 weeks (15.3, 12.4, 15.9 points, respectively). At the 2.5-year follow-up (range, 1.5-3.5 years), 65 participants who agreed to telephonic evaluation of outcomes reported a mean 20.9-point improvement in the WOMAC score. Limitations of this study include a risk of bias due to the open-label design and the relatively high proportion (10%) of prolotherapy-treated participants who declined to participate in the follow-up telephonic interviews.
Jahangiri and colleagues (2014) reported results of a double-blind randomized trial that compared prolotherapy to local injection of corticosteroid for the treatment of osteoarthritis in the first carpometacarpal joint. A total of 60 participants (60 hands) were randomized to 3 monthly prolotherapy injections or 2 monthly saline injections plus a corticosteroid injection in the third month. The groups were comparable at baseline, with a VAS score for pain on pressure of 6.7 in the prolotherapy group and 6.4 in the corticosteroid group. At the 6-month follow-up, pain had decreased more in the prolotherapy group compared with the corticosteroid-treated group (p<0.001). Pain on movement and hand function also improved to a greater extent in the prolotherapy group. Additional study is required to evaluate the long-term efficacy and adverse effects of repeat prolotherapy injections for the treatment of first carpometacarpal joint osteoarthritis.
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 is not 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 6 months and failure of conservative therapy (that is, rest, physical therapy, nonsteroidal anti-inflammatory drugs, and 2 corticosteroid injections) to 3 treatments (over 8 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 2 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 3-arm randomized controlled trial of 26 adults (32 elbows) with chronic lateral epicondylosis for 3 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." A systematic review by Sims and colleagues (2014) confirmed this conclusion, stating that lateral epicondylitis is a condition that is usually self-limited, and resolves over a 12- to 18-month period without treatment.
Rotator Cuff Tendinopathy
Bertrand and colleagues (2016) compared the effect of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy. In this blinded, randomized controlled trial, 72 participants who received 3 monthly injections of 0.1% lidocaine with dextrose prolotherapy (entheses dextrose [Enth-Dex group]) or 1 of 2 control injections (entheses saline injection without dextrose [Enth-Saline group] or superficial saline injection [Superfic-Saline group]) were included in the 9-month follow-up data. All participants received concurrent physical therapy. The primary outcome measure was achieving an improvement in maximal current shoulder pain ≥ 2.8 (twice the minimal clinically important difference for visual analog scale (VAS) pain score). At 9 months, the Enth-Dex group maintained a 2.9-point improvement in pain in comparison with 1.8 points for the Enth-Saline group and 1.3 points for the Superfic-Saline group. The percentage of participants reaching and maintaining a clinically significant improvement of ≥ 2.8 in pain was significantly different between groups (p=0.046). The use of prolotherapy in the Enth-Dex group reported a significant improvement compared to the Superfic-Saline group (16 [59%] vs. 7 [27%]; p=0.017); however, the difference between the Enth-Dex group and the Enth-Saline group did not reach clinical significance (16 [59%] vs 7 [37%]; p=0.088). The Ultrasound Shoulder Pathology Rating Scale was not different between the groups (p=0.734). Limitations of this study include the concurrent use of active physical therapy which may have accounted for much of the treatment benefit at short-term follow-up and lack of data to confirm improvement in physical function.
Lee and colleagues (2015) conducted a retrospective case study of individuals with nontraumatic refractory rotator cuff disease who were unresponsive to 3 months of aggressive conservative treatment. Participants in the prolotherapy treatment group (n=63) received an average number of 4.8 (± 1.3) injections of 16.5% dextrose 10-ml solution compared to no injections in the conservative treatment group (n=63). Outcome measurements analyzed over 1 year included the average shoulder pain level (VAS score) for the prior week, Shoulder Pain and Disability Index (SPADI) score, isometric strength of the shoulder abductor, active range of motion (AROM) of the shoulder, maximal tear size on ultrasonography, and number of analgesic ingestions per day. Compared to the control group, the prolotherapy treatment group showed significant improvement in all outcome measurements. No adverse events were reported. Limitations of this study include its retrospective design and lack of randomization to a sham treatment group. Prospective, double-blind randomized controlled trials are needed to confirm the clinical efficacy of prolotherapy treatment for individuals with refractory rotator cuff disease.
Yelland and colleagues (2011) reported a multicenter randomized trial of prolotherapy or exercises for Achilles tendonitis in 43 individuals. While the percentage of individuals achieving full recovery was 53% for exercise alone, 71% for prolotherapy alone, and 64% for the combined treatment group, 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 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.
Sanderson and Bryant (2015) conducted a systematic review of the literature to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. The analysis included prospective randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials published between January 1960 and September 2014 with results that reported the effectiveness of one or more prolotherapy injections for tendinopathy or fasciopathy at or below the superior aspect of the tibia/fibula. A total of 203 studies were identified, of which 8 studies met the inclusion criteria. Studies were then grouped according to tendinopathy or fasciopathy (that is, Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease). The methodological quality of the eight studies was identified as "generally poor" in regards to allocation concealment, intention-to-treat analysis and blinding procedures. No adverse events following prolotherapy injections were reported in any study. The analysis found limited evidence that prolotherapy injections are a safe and effective treatment for Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease. Larger, methodologically-sound randomised controlled trials are needed to determine if prolotherapy injections can improve health outcomes for individuals with lower limb tendinopathy and fasciopathy.
Other Musculoskeletal and 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 6, 12, 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 3 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 3 injections. Pain and disability scores were assessed at baseline, in 2 weeks, and monthly after completion of treatment. The pain and disability scores were significantly improved from baseline in both groups at the 2-week follow-up, with no significant difference between them. The cumulative incidence of ≥ 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.
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.
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.
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.
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:
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale, References and Websites for Additional Information sections. Removed ICD-9 codes from Coding section.|
|Reviewed||05/07/2015||MPTAC review. Updated Description, Rationale, References, and Websites for Additional Information sections.|
|Reviewed||05/15/2014||MPTAC review. Updated Description, Rationale and Reference sections.|
|Reviewed||05/09/2013||MPTAC review. Updated Description, Rationale, Background, Definitions, References, and Index.|
|Reviewed||05/10/2012||MPTAC review. Updated Rationale and References.|
|Reviewed||05/19/2011||MPTAC review. Updated Description, Rationale and References.|
|Reviewed||05/13/2010||MPTAC review. Revised document title to Prolotherapy for Joint and Ligamentous Conditions. Clarified Position Statement. Updated Description, Rationale, Background, and References.|
|Reviewed||05/21/2009||MPTAC review. References updated.|
|Reviewed||05/15/2008||MPTAC review. Sarapin® moved from Description to Background. Rationale and References updated.|
|02/21/2008||The 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.|
|Reviewed||05/17/2007||MPTAC review. Rationale and References updated.|
|01/23/2007||Added Sarapin® to the Description.|
|Reviewed||06/08/2006||MPTAC review. References updated.|
|11/21/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||07/14/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||09/19/2003||MED.00007||Prolotherapy/Sclerotherapy for Joint and Ligamentous Injections|
|WellPoint Health Networks, Inc.||12/02/2004||2.07.06||Prolotherapy|