. 2016 Jul 7;9:139–159. doi: 10.4137/CMAMD.S39160

Table 2.

Reviewed studies of dextrose prolotherapy in chronic musculoskeletal pain.

AUTHOR AND YEAR, COUNTRY, DESIGN, EVIDENCE SCORES	POPULATION AND SELECTION	TREATMENT AND EVALUATION	RESULTS
Tendinopathies
Topol, et al. (2011)⁵⁹ Argentina Double-blind RCT PEDro 10 Level 1	Osgood-Schlatter disease n = 54; athletes aged 9–17 years In clusion: • Anterior knee pain >3 mo. • Replication of pain severity and location to the tibial tuberosity during a single leg squat • Nonresponse to 2 mo. physiotherapy Exclusion: • Pain from patellofemoral crepitus or patellar origin	Active group: dextrose 12.5%, lidocaine 1% Injection control group: lidocaine 1% Noninjection control group: Usual care (supervised exercise) Injections given at 0, 1, and 2 months (double-blind) At 3 months, subjects not achieving NPPS = 0 were offered monthly dextrose injections as needed (open-label) 9 lidocaine and 8 usual care patients switched to dextrose at 3 months Outcome measure(s): Mean NPPS scores	6 month follow-up (double-blind): • Greater reduction in pain with dextrose than lidocaine (P = 0.004) and usual care (P < 0.0001) • Greater reduction with lidocaine than usual care (P = 0.024) 12 month follow-up (open-label): • NPPS <4 in 100% of dextrose, 92.3% of lidocaine, and 71.4% of usual care patients (dextrose vs. lidocaine, NS; dextrose vs. usual care, P = 0.008; lidocaine vs. usual care, NS) • NPPS of 0 in 84.2% of dextrose, 46.1% of lidocaine, and 14.2% of usual care patients (dextrose vs. lidocaine, P = 0.024; dextrose vs. usual care, P < 0.0001; lidocaine vs. usual care, P = 0.005)
Refai, et al. (2011)⁶⁰ Double-blind RCT Egypt PEDro: 8 Level 1	TMJ n = 12 Inclusion: • Confirmation of painful subluxation or dislocation of the TMJ • Absence of medical condition that could interfere with healing	Active group: dextrose 10%, mepivacaine 2% Control group: mepivacaine 2% 4 injections in each TMJ, spaced 6 weeks apart Outcome measure(s): • VAS pain score • MMO in cm. between the incisal edges of the upper and lower incisors • Frequency of clicking sound • Frequency of luxation	MMO in dextrose and control groups: • Baseline: 5.03 and 4.97 (NS) • 6 weeks: 4.72 and 4.93 (NS) • 18 weeks after first injection: 4.35 and 4.93 (P = 0.043) • 3 months after last injection: 4.33 and 4.97 (P = 0.039) Pain: Steady decrease in both groups, but NS Luxation frequency: NS Clicking frequency: NS
Zhou et al. (2014)⁶² Case series China Level 4	TMJ n = 45 Inclusion: • Non-neurogenic recurrent dislocation of the TMJ	Treatment: dextrose 50%, 0.1% lignocaine Outcome measure(s): • Absence of dislocation or subluxation for ≥6 months after treatment	At ≥ 6 months post treatment 41/45 (91%) no longer had dislocation or subluxation. Of the 41 rehabilitated patients • 26 (63%) required a single injection • 11 (27%) had 2 treatments • 4 (10%) needed a third injection.
Yelland et al. (2011)⁶³	Achilles tendinosis n = 43	Treatment: glucose 20%, lgnocaine 0.1%, ropivacain 0.1% Patients randomly selected for:	At 12 months, proportions achieving the minimum clinically important change for VISA-A • ELE - 73%
Double-blind RCT Austrailia Level 1 PEDro10		• Eccentric exercises only • Prolotherapy only • Eccentric and prolotherapy Outcome measure(s): • VISA-A	• Prolotherapy only - 79% • Combined treatment - 86% Mean (95%CI) increases in VISA-A scores at 12 months were: • ELE: 23.7 (15.6 to 31.9) • Prolotherapy only: 27.5 (12.8 to 42.2) • Combined treatment: 41.1 (29.3 to 52.9) At 6 weeks and 12 months - Increases were significantly less for ELE than for combined treatment. Compared with ELE, reductions in stiffness and limitation of activity occurred earlier with prolotherapy and reductions in pain, stiffness and limitation of activity occurred earlier with combined treatment.
Maxwell (2007)⁶⁴ Canada Case series Level 4	Achilles tendinosis n = 32, mean duration 28.6 months Inclusion: • Failure of conservative therapy • Pain >3 months Exclusion: • Acute tendinitis • Symptoms due to acute trauma, surgery or interventional procedures in past 3 months	Treatment: dextrose 25% Patients injected every 6 weeks until symptoms resolved or no improvement was shown; mean injections were 4 Outcome measure(s): • VAS pain score • US evaluation	Mean reduction in pain scores from baseline at 12 months: • At rest: 88.2% (P < 0.0001) • ADL: 84.0% (P < 0.0001) • Physical activity: 78.1% (P < 0.0001) Mean decrease in tendon thickness: 11.7 to 11.1 mm (P < 0.007) at 12 months Tendon neovascularity decreased in 55%
Ryan et al. (2010)⁶⁵ Case series Canada Level 4	Achilles tendinosis n = 99 (108 tendons), median duration 21 months Inclusion: • Pain at Achilles tendon insertion or midportion >6 months • Pain directly at posterior border of the calcaneus or along midportion of the tendon 2–6 cm proximal to its insertion • Documented non-response to conservative treatment Tendon locations of tendonosis: • 86 midportion • 22 insertion	Treatment: dextrose 25% Injection guidance by GS or color Doppler US into abnormal hypoechoic areas and anechoic clefts or foci in the thickened portion of the Achilles tendon 1–3 sites injected per treatment session Patients received a median 5 sessions spaced a mean 5.6 weeks apart Outcome measure(s): • VAS pain score • US evaluation Measurements at baseline, post-test and 28.6 mo. follow-up	Mean baseline, post-test, and follow-up VAS: Midportion tendonosis (pain improved): • At rest: 34.1, 12.6 (P < 0.001), 3.3 (P < 0.001) • ADL: 50.2, 21.8 (P < 0.001), 9.5 (P < 0.001) • Physical activity: 70.7, 36.7 (P < 0.001), 16.7 (P < 0.001) Insertional tendonosis (pain improved): • At rest: 33.0, 18.0 (NS), 2.7 (P < 0.001) • ADL: 51.3, 29.6 (P < 0.05), 10.0 (P < 0.001) • Physical activity: 69.6, 39.8 (P < 0.01), 17.7 (P < 0.001) Baseline and post-test US findings: • Midportion tendiosis: Size of hypoechoic region (mm²) 81.60 and 52.1 (P < 0.01) • Insertional tendiosis: Intratendinous tear size (mm) 5.3 and 1.6 (P < 0.01) Greater reduction in grades 2 and 3 echotexture and neovascularization severity in midportion vs. insertional patients
Lyftogt et al. (2005)⁶⁶ Case series New Zealand Level 4	Achilles tendinopathy n = 16, mean duration 14 months Inclusion: x-ray confirmation	Treatment: dextrose 20% Outcome measure(s): • VAS pain score	At 18-week follow-up: • 11/16 pain VAS score of 0 • 14/16 satisfied with therapy
Scarpone et al. (2008)⁶⁷ United States Double-blind RCT Level 1 PEDro10	Lateral epicondylitis of the elbow n = 24 Inclusion: ≥6 months duration refractory lateral epicondylosis	Active group: 50% dextrose/5% sodium morrhuate/4% lidocaine/0.5% sensorcaine/saline Control group: 0.9% saline Three 0.5 mL injections at the supracondylar ridge, lateral epicondyle and annular ligament at baseline, 4 and 8 weeks. Outcome measure(s): • Resting elbow pain (0–10 Likert scale) • Extension and grip strength Each was performed at baseline, 8 and 16 weeks. One-year follow-up included pain assessment and effect of pain on activities of daily living	Active group vs. Contols: Improved pain scores (4.5 ± 1.7, 3.6 ± 1.2 and 3.5 ± 1.5 versus 5.1 ± 0.8, 3.3 ± 0.9 and 0.5 ± 0.4 at baseline, 8 and 16 weeks, respectively); At 16 weeks, differences were significant compared to baseline scores within and between groups (P<.001). Active group improved extension strength compared to Controls (P < 0.01) and grip strength compared to baseline (P < 0.05) Clinical improvement in Active group maintained at 52 wks.
Shin et al. (2002)⁶⁸ South Korea Case series Level 4	Lateral epicondylitis of the elbow n = 84 Inclusion: US confirmation	Treatment: dextrose 15% Patients received 3 injections spaced 2 months apart Outcome measure(s): VAS pain score	Mean pain scores at baseline and 6 mo. were 6.79 and 2.95 (P < 0.01) 9 mo. follow-up (n = 71) pain scores same/improved in 80.2%, increased in 19.7% Greater pain reduction in patients without (7.08 to 2.16) vs. with partial tendinous tear (6.9 to 3.67; P < 0.01)
Park et al. (2003)⁶⁹ Case series South Korea Level 4	Lateral Epicondylitis of the elbow n = 11 Inclusion: • Partial (n = 11) tear or full thickness but incomplete width tear (n = 1) of common extensor tendons	Treatment: dextrose 15% Patients received 2–6 injections Outcome measure(s): Change in: • Echogenicity (GS US) • Tendon fibrillar pattern (GS US) • Vascularity (color Doppler US) • Pain (VAS)	At mean 5.8 month follow-up: VAS decreased a mean 4.5 points 1 tendon–a few echogenic lines in initially anechoic lesion 3 tendons–most of anechoic lesion filled with fibrillar echogenicity except for a small anechogenic focus 2 tendons–initial anechoic lesion became same sized hypoechoic lesion with diffuse fibrillar pattern 6 tendons–initial anechoic lesion smaller, with diffuse fibrillar pattern Hypervascularity in 6 of 11 tendons
Ryan et al. (2011)⁷⁰ Case series Canada Level 4	Overuse patellar tendonopathy n = 47, mean duration 21.8 months Inclusion: • Failure of standard-of-care therapy • Confirmation by palpation and US	Treatment: dextrose 25% Under US guidance, injections given into abnormal hypoechoic areas and anechoic clefts/foci in the thickened portion of the patellar tendon Patients received a median 4 injections 6.4 weeks (mean) apart Outcome measure(s): • VAS pain score • US evaluation	Mean pain scores at baseline and 45 weeks: • At rest, 38.4 and 18.7 (P < 0.01) • ALD: 51.1 and 25.8 (P < 0.01) • Sports activity: 78.1 and 38.8 (P < 0.01) Change in pain scores during rest, ADL and sport activity correlated with change in echotexture severity (r values 0.306, 0.379 and 0.428, respectively; P < 0.05) General improvement in echotexture and neovascularity severity was found
Topol et al. (2008)⁷² Case series	Chronic groin pain n = 72 athletes, mean duration	Treatment: dextrose 12.5% Patients received a mean 2.7	Mean scores at baseline and 26 month follow-up (mean):
Argentina Level 4	11 months Inclusion: • Chronic groin pain from osteitis pubis and/or adductor tendinopathy • nonresponse to conservative therapies	treatments. Outcome measure(s): • VAS pain score • NPPS assessment of pain-related athletic avoidance	VAS, 6.47 and 1.18 (P < 0.001) NPPS, 5.13 and 1.06 (P < 0.001) At follow-up, 66/72 (91.6%) had fully resumed sport activities; all but 2 of these were pain-free
Topol et al. (2005)⁷³ Case series Argentina Level 4	Chronic groin pain n = 24, mean duration 15.5 months Inclusion: • Chronic groin pain from osteitis pubis and adductor tendinopathy	Treatment: dextrose 12.5% Patients received a mean 2.8 treatments. Outcome measure(s): • VAS pain score • NPPS assessment of pain-related athletic avoidance	Mean scores at baseline and 17 month follow-up (mean): • VAS, 6.3 and 1.0 (P < 0.001) • NPPS, 5.3 and 0.8 (P < 0.001) 20 of 24 reported an absence of pain at follow-up
Bertrand et al. (2016)⁷⁴ Canada Double-blind RCT Level 1 PEDro10	Chronic shoulder pain n = 73 Inclusion: • Examination findings of rotator cuff tendinopathy • US conformation of supraspinatus tendinosis/tear	Enthesis-Dex group: 25% dextrose, 0.1% lidocaine/saline Entheis-Saline group: 0.1% lidocaine/saline Superficial-Saline group: injection 0.5- to 1-cm depth with 0.1% lidocaine/saline All participants received 3 monthly injections to painful entheses at and concurrent programmed physical therapy. Outcome measure(s): improvement in maximal current shoulder pain ≥2.8 (twice the minimal clinically important difference for VAS pain); USPRS; 0-to-10 satisfaction score (10, completely satisfied)	At 9-month follow-up the Enthesis-Dextros Group: Maintained greater improvement in pain 59% ≥2.8 VAS compared with Enthesis-Saline (37%; P = .088) and Superficial-Saline (27%; P = .017). Had greater satisfaction: 6.7 ± 3.2 compared with Enthesis-Saline (4.7 ± 4.1; P = .079) and Superficial-Saline (3.9 ± 3.1; P = .003). USPRS findings were not different between groups (P = .734).
Lee et al. (2015)⁷⁵ South Korea Retrospective case controlled series Level 3	Chronic shoulder pain n = 151 Inclusion: • Non-traumatic refractory rotator cuff disease • Unresponsive to 3 months of aggressive conservative treatment	Active group: dextrose 16.5%. Control group: conservative treatment Outcome measure(s): • VAS score of shoulder pain level for the past 1 week; • SPADI score • Isometric strength of the shoulder abductor • AROM of shoulder • Maximal tear size on ultrasonography • Number of analgesic ingestions per day	Compared with the control group, the active group showed significant improvement at 1-year follow-up in: • VAS score • SPADI score • Isometric strength of shoulder abductor • Shoulder AROM of flexion, abduction, and external rotation
Ryan et al. (2009)⁷⁶ Canada Case series Level 4	Plantar fasciitis n = 20, median 21 months duration Inclusion: • Symptoms >6 months • Non-response to conservative treatment Exclusion: acute plantar foot pain, surgery or interventional procedures in last 6 months	Treatment: dextrose 25% Injections into plantar fascia Injections were given at 6 week intervals; median of 3 treatments per patient Outcome measure(s): VAS pain score	Mean pain scores at baseline and 18 week follow-up: • At rest, 3.7 and 1.0 (P < 0.001) • With walking, 7.5 and 2.5 (P < 0.001) • With running, 9.2 and 3.9 (P < 0.001) No change in mean pain score from 18 week to 11.8 month (mean) follow-up
Osteoarthritis and Degenerative Conditions
Rabago et al. (2011)⁷⁷ United States 3-way double-blind RCT PEDro 9 Level 1	Knee osteoarthritis n = 89 Inclusion: • ARA criteria moderate-severe knee osteoarthritis • >3 months duration	Active group: dextrose 15% and dextrose 25% Injection control group: saline Noninjection control group: exercise instruction Injections at 1, 5, and 9 weeks, and weeks 13 and 17 as needed. Extra-articular injections at periarticular tendon and ligament insertions (dextrose 15%), with 1 intra-articular injection (dextrose 25%) through an infero-medial approach. Patients received a mean 4.3 injection sessions Outcome measure(s): • OA-related pain, function and stiffness (WOMAC) • Knee pain severity and frequency (KPS)	WOMAC composite score: no significant difference between groups WOMAC score, adjusted for gender, age and BMI: greater reduction in mean dextrose (15.32) than saline (7.68) (P < 0.05) and exercise (8.25) (P < 0.05) scores Mean KPS scores in dextrose subjects showed greater improvement per injected knee relative to baseline status (P < 0.001) and compared to both control groups (P < 0.05)
Reeves & Hassanein (2000)⁷⁹ United States Double-blind RCT PEDro 10 Level 1	Knee osteoarthritis with/without ACL laxity n = 77 Inclusion: • ≥ grade 2 joint narrowing or ≥ grade 2 osteophytic change in any knee compartment • pain duration ≥6 months	Active group: 10% dextrose, xylocaine 0.075% Control group: xylocaine 0.075% Tibiofemoral injections Patients received 3 bimonthly injections; dextrose-injected patients then received 3 further bimonthly injections under open-label conditions Outcome measure(s): • VAS pain and swelling scores • Goniometric measurement of joint flexion, • KT1000 measurement of ADD • US	6 month follow-up (dextrose vs. control): Greater improvement in dextrose vs. control group in pain, swelling, buckling episodes, and knee flexion range (P = 0.015 for all) 12 month follow-up (dextrose vs. baseline): Improvement found in lateral patellofemoral cartilage thickness (P = 0.019) and distal femur width in mm (P = 0.021). Knees w/joint laxity showed improved knee flexion range (+12.8 degrees, P = 0.005) and ADD (57%, P = 0.025). 8/13 dextrose-treated knees with ACL laxity at baseline no longer lax at 1 year
Reeves & Hassanein (2003)⁸⁰ United States Case series Level 4	ACL laxity in patients with knee osteoarthritis n = 18 Inclusion: • Laxity with ADD ≥2 mm measured by KT1000 arthrometer • Duration >6 months	Treatment: dextrose 10% and dextrose 25% Injections of dextrose 10% at months 0, 2, 4, 6, and 10, dextrose 25% at month 12, then dextrose 10% or 25% every 2–4 months through month 36 according to patient preference Outcome measure(s): • VAS pain and swelling scores • Goniometric measurement of joint flexion • KT1000 measurement of ADD	VAS at baseline and 12 months: • Pain during rest, 2.31 and 1.56 (NS) • With walking, 4.19 and 2.50 (P = 0.004) • With stair use, 5.88 and 4.06 (P = 0.022) • Swelling, 2.75 and 1.31 (NS) VAS at baseline and 36 months: • Pain at rest, 2.31 and 1.25 (NS) • With walking, 4.19 and 2.38 (P = 0.002) • With stair use, 5.88 and 3.82 (P = 0.007) • Swelling, 2.75 and 1.00 (P = 0.017) Biomechanical assessments: Flexion range: 111.88, 125.94 at 12 months (P = 0.001), 122.38 at 36 months (P = 0.002) ADD: 2.88, 1.32 at 12 months (P = 0.023), 0.82 at 36 months (P = 0.002) At 36 months, normal ADD in 10 of 14 knees
Dumais et al. (2012)⁸¹ Randomized Crossover Study	Chronic knee osteoarthritis n = 36 Inclusion: • Pain duration ≥6 months • Age ≥18 years	Treatment: dextrose 20%, lidocaine 0.5% Random assignment: Group A: exercise therapy for 32 weeks in combination with injections inside the	Group A: • 0–16 weeks - significant change in WOMAC indicating decrease in symptoms (mean ± standard deviation: −21.8 ± 12.5, P < 0.001).
Canada Level 1	• Able to execute exercises	knee joint on weeks 0, 4, 8, and 12 Group B: exercise therapy for 32 weeks in combination with injections inside the knee joint on weeks 24, 28, and 32 (Group B) Outcome measure(s): Change in WOMAC scores between weeks 0 and 16; and weeks 20 and 36	• 20–30 weeks - no significant change in WOMAC scores (−1.2 ± 10.7, P = 0.65). Group B: • 0–16 weeks - no significant change in WOMAC scores (−6.1 ± 13.9, P = 0.11). • 20–30 weeks - significant change in WOMAC indicating decrease in symptoms (−9.3 ± 11.4, P = 0.006). >36 weeks - W OMAC scores improved in both groups by 47.3% (A) and 36.2% (B). The improvement attributable to RIT alone corresponds to a 11.9-point (or 29.5%) decrease in WOMAC scores.
Eslamian & Amouzandeh (2015)⁸² Iran Case series Level 4	Moderate knee osteoarthritis n = 24 Inclusion: female	Treatment: dextrose 20% Injections given at baseline, 4 weeks, 8 weeks Patients were followed for 24 weeks. Outcome Measure(s): • VAS pain scale • AROM • WOMAC Measurements made at baseline, 4, 8, and 24 weeks later.	At baseline: • Mean AROM (105.41 ± 11.22°) • Mean VAS scale at rest (8.83 ± 1.37) • Mean VAS scale at activity (9.37 ± 1.31) Week 24: • Mean AROM increased by 8° • Mean VAS scale at rest decreased in 45.89% (P < 0.001) • Mean VAS scale at activity decreased in 44.23%, (P < 0.001) • Total WOMAC decreased by 30.5 ± 14.27 points (49.58%) (P < 0.001) Improvements of all parameters were considerable until week 8, and were maintained throughout the study period.
Hashemi et al. (2015)⁸³ Iran Double-blind RCT PEDro 9 Level 1	Mild to moderate knee osteoarthritis n = 80 Inclusion: Diagnosis of knee osteoarthritis (clinical examination and anteroposterior standing radiography)	Active Group 1: dextrose 12.5%, lidocaine 1% Active Group 2: 15 g/mL of ozone-oxygen mixture, lidocaine 1% Injections given 3 times at 7 to 10 day intervals. Outcome Measure(s): • VAS pain scale • WOMAC	Active Groups 1 and 2: • Mean VAS decreased (P < 0.001) • WOMAC increased (P < 0.001 • No significant difference between the two groups
Reeves & Hassanein (2000)⁸⁴ United States Double-blind RCT PEDro 10 Level 1	Osteoarthritic finger joints n = 27; average pain duration >4 years Inclusion: • Moderate osteophytosis • Moderate joint space narrowing • Mild osteophytosis plus mild joint space narrowing • Pain duration ≥6 months	Active group: dextrose 10%, xylocaine 0.075% Control group: xylocaine 0.075% Injections performed 0, 2, and 4 months after enrollment, data obtained 6 months after first injection After 6 months, patients in both groups offered bimonthly dextrose 10% injection Patient attrition: 4/13 active, 3/14 control group Outcome measure(s): • VAS pain scale • Goniometric measurement of joint flexion • X-ray imaging of joint repair	6 month follow-up: • Greater improvement in dextrose vs. control groups in pain with movement (P = 0.027); other comparisons NS • Greater improvement in flexion range in dextrose vs. control group (P = 0.003) 12 month follow-up: • Dextrose group showed difference from baseline in joint narrowing (P = 0.006) • All other comparisons NS
Jahangiri et al. (2014)⁸⁵ Iran Double-blind RCT PEDro 9 Level 1	Osteoarthritic finger joints n = 60 Inclusion: • >40 years of age • history of pain in first carpometacarpal joint >3 months • Pain intensity VAS >30 at baseline • radiographic evidence of OA	Active group: dextrose 20%, lidocaine 2% Control group: 40 mg methylprednisolone acetate (0.5 ml), lidocaine 2% Outcome measure(s): VAS pain score Hand function and strength of lateral pinch grip Measured at baseline, 2 and 6 months after the treatment	At 1 and 2 month follow-up results were more favorable among control group than active group participants. At 6 months outcome was more favorable for active group [mean difference (95% CI) in VAS = 1.1 (0.2, 2.0), P = 0.02]. After 6 months of treatment, both study and control groups increased functional level, but study group seemed to be more effective [mean difference (95% CI) in total function score = 1.0 (0.2, 1.8), P = 0.01]
Spinal and pelvic pain
Miller et al. (2006)⁸⁶ Case series Level 4	Discogenic leg pain n = 76, mean duration 39 months Inclusion: • Moderate to severe degenerative disc disease without herniation • Concordant pain reproduction with CT discography • Normal neurological exam • Nonresponse to 6 months of conservative treatment	Treatment: dextrose 25% Dextrose solution injected into disc space; patients received a mean 3.5 injections into a mean 1.7 discs Outcome measure(s): • Mean NRS pain rating	n = 37 non-responders (<20% pain reduction); n = 6 temporary (<2 months) responders Of 33 sustained responders, mean (SD) pain scores at baseline, 2 month, and 18-month follow-up: 8.9 (1.4), 2.5 (2.0), and 2.6 (2.2) Mean overall pain improvement: 71%
Khan et al. (2008)⁸⁷ India Case series Level 4	Coccygodynia n = 37 Inclusion: • Nonresponse to conservative therapy for >6 months Exclusion: Posttraumatic and post-delivery coccygodynia, sacro-coccygeal subluxation, coccygeal spicule, organic bony pathology on radiograph	Treatment: dextrose 25% 2 injections into sacro-coccygeal joint 15 days apart; those with VAS pain score >4 given 3rd injection 4 weeks later Outcome measure(s): VAS pain scores	Baseline pain score: 8.5* Pain score after 1st injection: 3.4 Pain score after 2nd injection: 2.5 n = 7 little-no improvement n = 30 good pain relief *patients w/previous steroid injection (n = 27) had baseline pain score 8.8
Kim WM, et al. (2010)⁸⁸ South Korea (in English) Double-blind RCT PEDro 9 Level 1	Sacroiliac joint pain n = 48 Inclusion: • Pain origin confirmed by pain reduction ≥50% to intraarticular SI joint block with levobupivacaine 0.25% • Following SI block response, non-response to 1 month of medical treatment Exclusion: Cancer, fractures, inflammatory arthritis, infection, fibromyalgia, active litigation	Active group: dextrose 25%, levobupivacaine 0.25% Control group: triamcinolone 40 mg, levobupivacaine 0.25% Biweekly intraarticular injections into intra-articular SI, up to 3 injections Outcome measure(s): NRS pain scores Oswestry (2 weeks only)	2-week follow-up: Significant improvement in both groups, no significant difference between active and control 15 month follow-up: Cumulative incidence of ≥50% pain reduction: Dextrose: 58.7% (95% CI 37.9%–79.5%) Steroid: 10.2% (95% CI 6.7%-27.1%) Between-groups difference P < 0.005
Kim HS, et al. (2007)⁸⁹ South Korea Double-blind RCT Level 2	Iliac crest pain syndrome n = 44	Active group: dextrose 20%, 1% lidocaine Control group: triamcinolone, lidocaine Weekly injection for 4 weeks Outcome measure(s): • Mean change from baseline in VAS pain • Oswestry • Pressure threshold (algometer, kg/cm²)	3 month follow-up: Both groups improved in pain, disability and pressure threshold scores (P < 0.05) No significant difference between groups on any measure at any follow-up interval
Hooper et al. (2011)⁹⁰ Canada Case series Level 3	Chronic cervical, thoracic or lumbar pain n = 71 litigants (mean pain duration 2.1 years) n = 76 non-litigants (mean pain duration 6.3 years) Inclusion: • Demonstration of laxity on stress testing in spinal, iliolumbar, or sacroiliac ligaments • Pain >6 months • Nonresponse to conventional therapies	Active treatment: dextrose 20% Injections into the facet capsules of the cervical, thoracic, lumbar spine Patients received weekly injections for up to 3 weeks, and 1 month later if needed Outcome measure(s): • NDI • PSFS • RMDQ	At baseline, litigants compared to non- litigants: • Higher disability scores (P = 0.001) • More multiple regions affected • More cervical and thoracic regions affected (P < 0.0001) • Shorter mean symptom duration (P < 0.0001) 1-year follow-up: Both litigants and non-litigants improved in all disability scales (P < 0.001). Percentage of litigants vs. non-litigants reporting improvement: • Impression of change scales for symptoms (91/92%) and function (90/90%) • Improved ability to work (76/75%) • Willingness to repeat treatment (91/93%) • Ability to decrease medication (82/81%) • Decreased need for other treatment (80/84%) Litigants showed greater improvement in treatment of the thoracic spine (P < 0.05)
Centeno et al. (2005)⁹¹ United States Case series Level 4	Neck pain n = 6 Inclusion: • ≥50% pain reduction and >2.7 mm absolute cervical translation with 2-day cervical immobilization • Post-MVA cervical instability, neck pain and disability • Pain/disability >6 months • Failure to respond to conservative therapy Exclusion: previous neck injury, connective tissue disease, arthritis or diabetes I or II	Treatment: dextrose 12.5% Injections targeted instability sites including the spinous processes, lamina, and posterior elements Outcome measure(s): • Mean changes from baseline in VAS pain scores • Radiographic findings	Pain scores, baseline and 1 month: 5.75 and 3.83 (P = 0.04) Significant correlation between changes in pain scores and translation (rho = 0.88, P = 0.02), Significant correlation between changes in flexion and translation (rho = 0.94, P < 0.01)
Lee et al. (2009)⁹² South Korea Case series Level 4	Low back and pelvic pain n = 22, mean duration 39.8 months Inclusion: • Sacroiliac pain confirmed by ≤50% pain reduction with local anesthetic block	Treatment: Dextrose 25% Injections every other week for 3 weeks Outcome measure(s): • Mean changes from baseline in NRS pain scale • Oswestry	Mean (range) NRS scores: (P < 0.01) Baseline: 6 (4–8) 10 weeks: 1(0–3) Mean (SD) Oswestry scores (P < 0.01) Baseline: 34.1 (15.5) 10 weeks: 12.6 (9.8) Mean duration of pain reduction ≥50% was 12.2 months
Myofascial Pain Syndrome
Kim MY, et al. (1997)⁹³ South Korea Double-blind RCT Level 2 PEDro 8	Myofascial pain syndrome n = 64	Active group: dextrose 5% Control group: lidocaine 0.5% Control group: saline Outcome measure(s): • Mean changes from baseline at 7 days in VAS pain score • Pressure threshold (algometer, kg/cm²)	Change in VAS pain score: Dextrose: 6.87 and 2.39 (P < 0.01) Saline: 6.50 and 3.85 (NS) Lidocaine: 6.95 and 4.05 (NS) Pressure threshold tolerance: Dextrose: 1.79 and 2.49 (P < 0.05) Saline: 1.70 and 1.91 (NS) Lidocaine: 1.75 and 2.07 (NS)

Abbreviations: ACL, anterior cruciate ligament; ADD, anterior displacement difference; ADL, activities of daily living; AROM, active range of motion; BMI, body mass index; CI, confidence interval; CT, computerized tomography; GS, gray scale; KPS, Knee Pain Scale; MMO, maximum mouth opening; MVA, motor vehicle accident; NDI, Neck Disability Index; NPPS, Nirschl Pain Phase Scale; NRS, Numeric Rating Scale; NS, not significant; OA, osteoarthritis; Oswestry, Oswestry Disability Index; PEDro, Physiotherapy Evidence Database; PRS, Pain Rating Scale; PSFS, Patient Specific Functional Scale; RMDQ, Roland-Morris Disability Questionnaire; SD, standard deviation; SI, sacro-iliac; SPADI, Shoulder Pain and Disability Index; TMJ, temporomandibular joint; US, ultrasound; USPRS, Ultrasound Shoulder Pathology Rating Scale; VAS, Visual Analog Scale; VISA-A, Victorian Institute of Sports Assessment; WOMAC, Western Ontario Macmaster University Osteoarthritis Index.