Last year, Dr. John W. Nelson, of Advanced Pain Management told Oklahoma legislators that workers’ compensation should cover stem cell treatments for back pain. Similar pleas have been heard with respect to platelet rich plasma (PRP) injections and autologous blood injections. In other words, certain groups have advocated that workers’ comp should not wait for FDA approval, and should instead adopt these treatments now. As stem cell treatments, PRP injections and autologous injections continue to draw a lot of attention, we must ask the question, “What is the efficacy of these treatments?”
What Are Stem Cells, PRP and Autologous Blood Products?
Stem cells are unique cells that have the ability to develop into multiple types of cells, such as tendon, bone or muscle. Stem cells come from multiple areas in the body. They can be harvested from a donor’s peripheral blood, fat or bone marrow. They can also be harvested from umbilical cord blood. There is still much debate about which source is better, the quantity needed for each condition and the frequency of treatments needed. Obviously, the ability to develop into different types of cells provides the potential to restore damaged tissue from injury, disease or normal wear and tear. However, one of the primary concerns with stem cells is the potential for them to convert into cancerous cells.
What are PRP and autologous injections? These injections use blood products. PRP is obtained from a the patient’s blood and then spun out to separate the various components. The goal of PRP injections is to get a high concentration of plasma that contains the healing growth properties. There are many systems to obtain the plasma, which has been the cause of great variability in the quality of the plasma that is obtained. Variability in the quality of PRP makes the studies difficult to compare and properly determine the efficacy of PRP. Autologous blood injections are simpler. Here, the provider takes blood from the patient’s arm – similar to a routine blood draw – and then mixes it with a local anesthetic. The mixture is then injected into the damaged area, such as a damaged tendon. The idea is that the procedure will reduce pain and provide healing properties at or near the injected site.
What Are the Costs of These Treatments?
Autologous blood injections are the least expensive because no special equipment is required. The provider just needs the equipment and manpower to draw the blood, and possibly a local anesthetic.
PRP costs more than autologous blood injections because one must 1) centrifuge the blood, and 2) use a special kit for obtaining the plasma. The cost of PRP injections varies widely and averages between $500 and $1,500 per injection. Some of these injections are done in the operating room, further increasing the cost. Although payers reimburse for the injection procedure, they often do not pay for the equipment needed to obtain the specimen.
Stem cell injections are the most costly. Harvesting stem cells from such areas as bone marrow or fat can often require surgery. The cost of a stem cell injection treatment can cost upwards of $3000 per injection.
Do Evidence Based Guidelines Support these Injections?
ODG and ACOEM have some support for the use of autologous blood injections for the elbow, medial and lateral epicondylitis. But MTUS Guideline, ACOEM, Chapter 10 notes that autologous blood injections are not recommended in the management of lateral epicondylalgia.
PRP injection studies have been conflicting – about half of them support PRP injections and half do not. Although PRP is being used for many conditions, including outpatient musculoskeletal ailments and as adjunct to surgery, currently ODG and ACOEM only support their use for conditions of the elbow, medial and lateral epicondylitis. ODG also supports its use in the knee for refractory patellar tendinosis.
Stem cell injections are still under investigation with only limited studies available. Although there is the potential for beneficial effects, the results are inconclusive. Some providers are recommending combining PRP and stem cells. There is no evidence-based medicine to support this. The FDA has not approved any stem cell based product except cord blood derived hematopoetic progenitor cells for certain conditions (such as blood cancers). Treatment with stem cells is still considered investigational. As more research studies are completed, opinions may change. For now, the consensus across evidence-based guidelines in the workers’ compensation industry does not support these injections.
In summary, while stem cell therapy, PRP and autologous injections may have the potential to improve healing in a number of injury types, questions remain regarding the efficacy and which specific injury types are likely to benefit from the treatment. Until more research becomes available about the benefits and side effects of these injections, we need to tread cautiously and ensure we are following evidence-based guidelines.