Prolotherapy for Musculoskeletal Disorders
DESCRIPTION
Prolotherapy involves injecting proliferating agents/sclerosing solutions directly into torn or stretched ligaments or into a joint or adjacent structure to create scar tissue in an effort to stabilize a joint. It has been investigated as a treatment used to strengthen lax ligaments. Agents that have been used with prolotherapy include zinc sulfate, psyllium seed oil, combinations of dextrose, glycerine, and phenol, or dextrose alone. Proliferatives act to promote tissue repair or growth by prompting release of growth factors, such as cytokines, or increasing the effectiveness of existing circulating growth factors. Prolotherapy may involve a single injection or a series of injections, often diluted with a local anesthetic.
POLICY
Prolotherapy for the treatment of musculoskeletal disorders is considered investigational.
See also: Platelet Rich Plasma as a Treatment for Wound Healing or Other Conditions
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Prolotherapy has been investigated as a treatment option of various types of pain. Although there is extensive literature regarding prolotherapy, additional studies with larger control and experimental groups must be conducted to evaluate the efficacy of this treatment.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2010). Prolotherapy (2.01.26). Retrieved August 15, 2011 from BlueWeb. (18 articles and/or guidelines reviewed)
Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for an American Pain Society clinical practice guideline. Spine, 34 (10), 1078-1093.
Complete Guide to Medicare Coverage Issues [Computer software]. (2011, April). Prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents (NCD 150.7, p. 2-74). Ingenix.
Dagenais, S., Mayer, J., Haldeman, S., & Borg-Stein. (2008). Evidence-informed management of chronic low back pain with prolotherapy. The Spine Journal, 8 (1), 203-212.
Grote, W., Delucia, R., Waxman, R., Zgierska, A., Wilson, J., & Rabago, D. (2009). Repair of a complete anterior cruciate tear using prolotherapy: A case report. International Musculoskeletal Medicine, 31 (4), 159-165.
National Guideline Clearinghouse. (2011, May). Pain (chronic). Retrieved August 15, 2011 from http://www.guidelines.gov.
Rabago, D., Slattengren, A., & Zgierska, A. (2010). Prolotherapy in primary care practice. Primary Care, 37 (1), 65-80.
Scarpone, M., Rabago, D. P., Zgierska, A., Arbogest, J., & Snell, E. (2008). The efficacy of prolotherapy for lateral epicondylosis: A pilot study. Clinical Journal of Sport Medicine, 18 (3), 248-254. (Level 2 Evidence - Independent study)
Winifred S. Hayes, Inc. Medical Technology Directory. (2008, August; last update search July 2011). Prolotherapy for treatment of joint and ligamentous conditions. Retrieved August 15, 2011 from www.Hayesinc.com/subscribers. (20 articles and/or guidelines reviewed)
Yelland, M. J., Sweeting, K. R., Lyftogt, J. A., Ng, S. K., Scuffham, P. A., & Evans, K. A. (2011). Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: A randomised trial. British Journal of Sports Medicine, 45 (5), 421-428. (Level 2 Evidence - Independent study)
ORIGINAL EFFECTIVE DATE: 6/1/2000
MOST RECENT REVIEW DATE: 9/22/2011
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