The effect of extracorporeal shock wave therapy on the treatment of moderate to severe knee osteoarthritis and cartilage lesion

Efficacy and safety of extracorporeal shock wave therapy combined with sodium hyaluronate in treatment of knee osteoarthritis: a systematic review and Meta-analysis

OBJECTIVE

To assess the efficacy and safety of extracorporeal shockwave therapy (ESWT) combined with sodium hyaluronate (HA) for the treatment of knee osteoarthritis (KOA).

METHODS

PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang database, China Science and Technology Journal Database, and SinoMed were searched from inception to July 2020. The quality of the randomized controlled trials was evaluated independently by two reviewers according to the criteria in the Cochrane Collaboration for Systematic Reviews. The identified articles were then screened individually using EndnoteX9 for eligibility in this Meta-analysis. The heterogeneity among the articles was evaluated using I2.

RESULTS

A total of 17 studies, comprising 2000 individuals, were included in this Meta-analysis. The results showed that a significant improvement was observed in knee pain and function based on the clinical efficacy of ESWT combined with HA. Statistical analysis of clinical efficacy showed that [relative risk (RR) = 1.21, 95% confidence interval (CI) (1.12, 1.30), P < 0.01]. Statistical analysis of visual analog scale showed that [standardized mean difference (SMD) = －2.84, 95%CI (－4.01, －1.66), P < 0.01]. Western Ontario and McMaster University osteoarthritis index statistical analysis showed that [SMD = －1.57, 95% CI (－2.52, －0.61), P < 0.01]. Lysholm score statistical analysis showed that [SMD = 1.71, 95% CI (0.98, 2.44), P < 0.01]. In addition, only minor side effects, such as redness and swelling of the skin, were observed.

CONCLUSIONS

Medium to low quality evidence showed that ESWT combined with HA offers an inexpensive, well-tolerated, safe, and effective method to improve pain and functionality in patients with KOA. However, tightly controlled, randomized, large multicenter trials are warranted to validate the current findings.

A randomized trial of treatment for anterior cruciate ligament reconstruction by radial extracorporeal shock wave therapy

OBJECTIVE

The aim of this study was to explore the effects of radial extracorporeal shock wave therapy (rESWT) in patients with anterior cruciate ligament(ACL) reconstruction(ACLR).

METHODS

We conducted a randomized, controlled trial involving 72 eligible patients with ACL reconstruction in which we compared two strategies: the experimental group was standard rehabilitation plus rESWT and the control group was standard rehabilitation plus sham rESWT. The outcome was the change from baseline to 24 weeks in the average score on Lysholm knee joint score (LKS), range of motion (ROM), visual analogue scale (VAS) and International Knee Literature Committee (IKDC).

RESULTS

Of 36 subjects assigned to rehabilitation plus rESWT, 4 lost to follow up. Of 36 assigned to rehabilitation plus sham rESWT, 5 lost to follow up. The LKS, ROM and IKDC scores of the experimental group were markedly increased at 3 and 6 weeks after treatment (P < 0.001), and the VAS was notably decreased (P < 0.001). However, there were no significant differences in the LKS, ROM, IKDC and VAS between the groups at 24 weeks after treatment (P > 0.05).

CONCLUSION

The strategy of rehabilitation plus rESWT had better functional outcomes after ACL reconstruction. As such, our study demonstrates that rESWT is essential for patients with ACL reconstruction. Early use of rESWT can improve joint function, pain relief and ability of daily living. rESWT has a positive effect on the overall rehabilitation of patients.

Extracorporeal Shock Wave Therapy as Regenerative Medicine in Knee Osteoarthritis: Pre-Experiment for Matrix Metalloproteinase-3 Evaluation

BACKGROUND

Knee osteoarthritis (KOA) is currently treated by regenerative therapies that aim to inhibit arthritic degeneration. Extracorporeal shock wave therapy (ESWT) is one of the physical regenerative approaches used for KOA management. However, little is known regarding the impact of shock wave treatment on matrix metalloproteinase-3 (MMP-3), which is one of the enzymes mediating cartilage degradation.

OBJECTIVES

To evaluate the effect of ESWT on MMP-3 levels and pain intensity in patients with KOA.

METHODS

Fourteen patients diagnosed with Kellgren Lawrence, grades 2 and 3 KOA were recruited for the study. ESWT piezo shockwave was applied once a week for six weeks. MMP-3 levels in the blood were measured pre-test, mid-test (three weeks after therapy) and post-test (one week after the last session) by enzyme-linked immunosorbent assay (ELISA). The perceived pain was recorded at each session by the Wong Becker Face Scale.

RESULTS

The median pre-test, mid-test and post-test MMP-3 levels were 19.92 ng/mL, 15.89 ng/mL and 18.82 ng/mL, respectively, and there were significant differences between the pre-test and mid-test, and the pre-test and post-test values (p < 0.05). The pain scores also decreased significantly over the period of intervention.

CONCLUSION

MMP-3 levels decreased significantly in KOA patients after ESWT, and the decline was most obvious after 3 weeks of therapy. Therefore, EWST should be considered as a suitable treatment option for KOA.

The Efficacy of Microfracture Combined with Extracorporeal Shock Wave Therapy for Treating Osteochondral Lesion of the Talus and the Quality of Regenerated Cartilage: A Retrospective Cohort Study and MRI Assessment

BACKGROUND

osteochondral lesion of the talus (OLT) is a common disease in the physically active population, and extracorporeal shock wave therapy (ESWT) is a noninvasive treatment. We hypothesized that microfracture (MF) combined with ESWT may have great potential to become a novel combination treatment of OLT.

METHODS

the OLT patients who received MF + ESWT or MF + platelet-rich plasma (PRP) injection were retrospectively included, with a minimal follow up of 2y. The daily activating VAS, exercising VAS, and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS) were used to assess the efficacy and functional outcome, and ankle MRI T2 mapping was used to evaluate the quality of regenerated cartilage in the OLT patients.

RESULTS

only transient synovium-stimulated complications were found during the treatment sessions; the complication rate and daily activating VAS did not have differences between groups. MF + ESWT had a higher AOFAS and a lower T2 mapping value than MF + PRP at the 2y follow up.

CONCLUSIONS

the MF + ESWT had superior efficacy for treating OLT, which resulted in better ankle function and more hyaline-like regenerated cartilage, superior to the traditional MF + PRP.

Impact of soft tissue around the knee on the efficacy of extracorporeal shockwave therapy in knee osteoarthritis

Knee osteoarthritis (KOA) is the leading cause of knee pain in middle-aged and older individuals. Extracorporeal shockwave therapy (ESWT) has been applied to treat patients with KOA to reduce pain and improve function. Patients (n = 123) diagnosed with KOA who received ESWT were selected to participate in this study, and were grouped according to their body mass index (BMI). The treatment parameters were as follows: 8000 pulses, 2.0 bar, 0.25 mJ/mm2, and 6 Hz/s once per week for 8 weeks. The visual analog scale (VAS), Lequesne index, and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) were measured to assess knee pain and functional recovery according to BMI groups. Radiographs were used to measure the richness of the soft tissue around the knee joint. The correlation between the distribution of tissue, pain, and functional improvement was analyzed using the receiver operator characteristic curve. All the patients showed a reduction in pain after treatment compared to that before treatment (P < .01). As measured by the VAS, the Lequesne and WOMAC indexes, after the intervention, the pain and functional index of the overweight and above BMI group improved to a greater extent than that of the normal or below normal BMI group (P < .01). The area under the curve showed, with VAS as the demarcation criterion, when the tibial plateau soft tissue ratio, femoral intercondylar apex soft tissue ratio, and medial tibial soft tissue ratio exceeded 1.538, 1.534, and 1.296, respectively, the patient's pain relief was more pronounced the ESWT treatment was better. With pain in WOMAC as the demarcation criterion, the tibial plateau soft tissue ratio, femoral intercondylar apex soft tissue ratio, and medial tibial soft tissue ratio also are positively correlated with pain relief in patients. When the Lequesne and WOMAC scores were the demarcation criteria, the patients' function improved significantly when the patella apical soft tissue ratio exceeded 2.401 and 2.635, respectively. ESWT can effectively alleviate pain and improve knee function in patients with KOA, and the soft tissue around the knee joint should also be an important reference factor in KOA treatment.

The Institute of Physical Medicine and Rehabilitation, Hospital das Clínicas University of São Paulo School of Medicine comprehensive rehabilitation program for elderly people with knee osteoarthritis

Background

Knee osteoarthritis (OA) is a leading cause of disability in the elderly population. Chronic disabling pain is associated with maladaptive neuroplastic changes in brain networks, commonly associated with central sensitization. The main clinical features of nociplastic pain conditions include combined peripheral and central sensitization, and it is crucial to recognize this type of pain, as it responds to different therapies than nociceptive and neuropathic pain.

Objective

To report the effect of the Institute of Physical Medicine and Rehabilitation (IMREA) comprehensive rehabilitation program to reduce pain and to improve functioning in elderly people with knee OA, under the DEFINE cohort.

Methods

This is a retrospective observational cohort of 96 patients with knee OA, recruited from October 2018 to December 2019. All patients were evaluated by a trained multidisciplinary team using the Kellgren Lawrence classification, bilateral knee ultrasonography, the visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, rigidity and difficulty scores, the Timed Up and Go Test (TUG), 10-m and 6-min walking test (10 and 6 MWT), Berg Balance Scale, isokinetic dynamometry for knee extension and flexion strength, and pain pressure thresholds. The rehabilitation program included paraspinous lidocaine blocks, focal extracorporeal shockwaves combined with radial pressure waves and functional electrical stimulation according to individual needs. The baseline was compred with the treatment results with a paired t-test.

Results

The study sample is composed of 96 participants, mostly females (n = 81, 84.38%), with bilateral osteoarthritis (n = 91, 94.79%), and a mean age of 68.89 (SD 9.73) years. Functional improvement was observed in TUG (p = 0.019), 6-mwt (p = 0.033), right knee flexion strength (p &lt; 0.0001), WOMAC rigidity and difficulty domains (p &lt; 0.0001). Pain was reduced from baseline as measured by WOMAC pain domain (p &lt; 0.0001), VAS for both knees (p &lt; 0.0001), and SF-36 pain domain (p &lt; 0.0001). Pressure pain threshold was modified above the patella (p = 0.005 and p = 0.002 for right and left knees, respectively), at the patellar tendons (p = 0.015 and p = 0.010 for right and left patellar tendons, respectively), left S2 dermatome (p = 0.017), and L1-L2 (p = 0.008).

Conclusions

The IMREA comprehensive rehabilitation program improved functioning and reduced disabling pain in elderly people with knee OA. We highlight the relevance and discuss the implementation of our intervention protocol. Although this is an open cohort study, it is important to note the significant improvement with this clinical protocol.

The Application of Focused Medium-Energy Extracorporeal Shockwave Therapy in Hemophilic A Arthropathy

Hemophilic arthropathy causes the damage of synovium, cartilage, and subchondral bone. The present study evaluated the safety and the effect of extracorporeal shockwave therapy (ESWT), a safe treatment widely used in musculoskeletal conditions in patients with hemophilic arthropathy. Between 1 August 2019 and 31 July 2020, seven hemophilia A patients were enrolled and treated with medium-energy ESWT on the knee joint in the first two months after prophylactic coagulation factor administration. At the beginning of the study and at 1-, 2-, 3-, and 6-month follow-ups, the Hemophilia Joint Health Score (HJHS), visual analog scale score (VAS), and Hemophilia Early Arthropathy Detection with Ultrasound score (HEAD-US) were evaluated for therapeutic effectiveness and safety, while serum bone morphogenetic protein 2 (BMP-2) and von Willebrand factor (vWF) levels were analyzed for assessing chondroprotection and bone healing. Magnetic resonance imaging (MRI) of the knee was performed at the beginning of the study and the 6-month follow-ups. As a result, a non-significant decrease in VAS scores (p = 0.151) but not HJHS after treatment was noticed. At the 3-month follow-up, there was a non-significant increase in BMP2 levels (p = 0.171) but not vWF. Ultrasonography showed no disease activity score elevation in five patients and no further disease damage in all patients. Repeated MRI examinations in three patients showed no structural progression during the 6-month follow-up. As to adverse events, redness, local heat, and mild swelling were noted in five patients without breakthrough bleeding. We concluded that medium-energy ESWT might be safe for hemophilic arthropathy once prophylactic coagulation factors are administered.

Healthcare and Scientific Treatment of Knee Osteoarthritis

Knee osteoarthritis is a chronic degenerative disease companied with chronic knee pain and dysfunction. However, the etiology and pathogenesis of knee osteoarthritis were unclear. Currently, age, diet, trauma, obesity, and inheritance are the main risk factors. The major pathological hallmarks of knee osteoarthritis included subchondral bone sclerosis, articular cartilage degeneration, arthrosynovitis, and osteophyte. With the acceleration of the aging process in China, the treatment of knee arthritis and the methods to improve the quality of life have become the focus of medical staff. Currently, therapies in clinical practice include surgery and nonoperative treatment; however, the clinical effects of different individuals at different stages will still be very different. This article reviews the recent advances in the treatment of knee osteoarthritis from three aspects: nonsurgical treatment, surgical treatment, and modern new medical means.

Comparison of Extracorporeal Shockwave Therapy with Non-Steroid Anti-Inflammatory Drugs and Intra-Articular Hyaluronic Acid Injection for Early Osteoarthritis of the Knees

Conservative treatments for early osteoarthritis (OA) of the knee included the use of non-steroid anti-inflammatory drugs (NSAIDs) and intra-articular hyaluronic acid (HA) injection. Recently, several animal studies reported that extracorporeal shockwave therapy (ESWT) demonstrated chondroprotective effects on knee OA. The present study compared the efficacy of oral NSAIDs, HA injection, and noninvasive ESWT for early OA of the knee. Forty-five patients with early knee OA were randomized into three groups. NSAIDs group received celecoxib 200 mg daily for 3 weeks. HA group received intra-articular injection of HA once a week for 3 weeks. ESWT group received ESWT for 3 sessions at bi-weekly interval. All patients were followed up for one year. Evaluations included the visual analogue scale (VAS) score, serum enzyme-linked immunosorbent assay (ELISA), plain radiography, dual-energy X-ray absorptiometry (DEXA), and magnetic resonance imaging (MRI). In addition, the functional scores were performed including, WOMAC (Western Ontario and McMaster Universities Arthritis Index) score, KOOS (knee injury and osteoarthritis outcome) score, and IKDC (International Knee Documentation Committee) score. All three groups showed significant improvement in VAS and functional scores as well as in the collected one-year follow-up data after treatments. ESWT group had better pain relief than NSAIDs and HA groups. ESWT group had better therapeutic effects in the functional scores than NSAIDs and HA groups. The bone mineral density (BMD) of proximal tibia is significantly increased after ESWT than others. In the serum ELISA, ESWT inhibited the expression of COMP in knee OA patients as compared with NSAIDs and HA groups. The parameters of MRI showed no significant differences between three groups after treatments. ESWT and intra-articular HA injection showed comparable results than NSAIDs. ESWT was superior in pain relief than HA and NSAIDs. The results demonstrated that ESWT was an effective and alternative therapy than HA and NSAIDs for early osteoarthritis of the knees.

Biophysical Stimulation in Athletes' Joint Degeneration: A Narrative Review

Osteoarthritis (OA) is the most prevalent degenerative joint disease and the main cause of pain and disability in elderly people. OA currently represents a significant social health problem, since it affects 250 million individuals worldwide, mainly adults aged over 65. Although OA is a multifactorial disease, depending on both genetic and environmental factors, it is reported that joint degeneration has a higher prevalence in former athletes. Repetitive impact and loading, joint overuse and recurrent injuries followed by a rapid return to the sport might explain athletes' predisposition to joint articular degeneration. In recent years, however, big efforts have been made to improve the prevention and management of sports injuries and to speed up the athletes' return-to-sport. Biophysics is the study of biological processes and systems using physics-based methods or based on physical principles. Clinical biophysics has recently evolved as a medical branch that investigates the relationship between the human body and non-ionizing physical energy. A physical stimulus triggers a biological response by regulating specific intracellular pathways, thus acting as a drug. Preclinical and clinical trials have shown positive effects of biophysical stimulation on articular cartilage, subchondral bone and synovia. This review aims to assess the role of pulsed electromagnetic fields (PEMFs) and extracorporeal shockwave therapy (ESWT) in the prevention and treatment of joint degeneration in athletes.

Extracorporeal Shock Wave Therapy Promotes Osteogenic Differentiation in a Rabbit Osteoporosis Model

Extracorporeal shock wave therapy (ESWT) has been identified to accelerate bone formation. However, detailed mechanism has not been fully explained. In this study, we found that ESWT promoted osteoblast formation in vitro. Local ESW treatment of femur increased bone formation in vivo. Furthermore, changing the density or frequency of energy, there was no statistical difference in osteogenic differentiation. Therapeutically, local ESW therapy relieved bone loss and increased the number of bone trabecular in a rabbit osteoporosis model and promoted endogenous levels of SMAD2 protein expression. Thus, ESWT may be a potential therapy by promoting osteoblast maturation through TGF-β/SMAD2 pathway.

Unicompartmental knee replacement and high tibial osteotomy for medial unicompartmental knee osteoarthritis: A comparative study protocol

BACKGROUND

Many clinical studies have been published in the literature to compare the outcomes of unicompartmental knee replacement (UKR) and high tibial osteotomy (HTO), but reached different conclusions. Therefore, the relative merits and demerits of these 2 procedures remain under debate. The purpose of the present protocol was to design a retrospective comparative study to further investigate the clinical effectiveness of HTO compared to UKR in the medial unicompartmental osteoarthritis of knee patients.

METHODS

This is an observational retrospective research, which prospectively collected the data from several surgeons in our center and utilized the above 2 methods to treat the unicompartmental osteoarthritis of knee. In our single hospital, we reviewed unicompartmental knee osteoarthritis patients treated using UKR or HTO from June 2016 to February 2018. For the HTO, its criteria included:For the UKR, its inclusion criteria containedIn our cohorts, the clinical investigations of the knee were composed of the objective parameters, which were recorded and then documented through utilizing the Function Score and Orthopedic American Knee Society Knee Score. The extra clinical findings evaluated involved operative time, postoperative requirements of blood transfusion, possible postoperative complications, as well as the range of motion.

CONCLUSION AND DISCUSSION

The results of this study will provide clinical evidence on appropriate surgical treatment for patients with medial unicompartmental knee osteoarthritis.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6152).

Retrospective Study of Rehabilitation Exercise Combined with Extracorporeal Shock Wave Therapy for Knee Osteoarthritis

Background

The aim of this study was to investigate the effect of rehabilitation exercise combined with extracorporeal shock wave therapy (ESWT) on knee osteoarthritis (KOA).

Material/Methods

The clinical data of 217 patients with KOA who underwent ESWT in our hospital from December 2017 to January 2020 were retrospectively analyzed. The patients were divided into a rehabilitation exercise (RE) group and a non-rehabilitation exercise (NRE) group according to whether they were given RE. The treatment course of the 2 groups was 5 weeks. Pain Visual Analog Scale (VSA), Western Ontario and McMaster Universities knee osteoarthritis index visualized scale (WOMAC), Lequesne index scores, Range of motion (ROM) score, and Japanese Orthopaedic Association (JOA) scores were used to evaluate the treatment effect of the 2 groups of patients.

Results

After 5 weeks of treatment, the VSA scores (p<0.001), WOMAC scores (P<0.001) and Lequesne index scores (P<0.001) of the RE group and NRE group were significantly lower than those before treatment, while ROM score (P<0.001) and JOA score (p=0.006) were significantly increased. Compared with the NRE group, the VAS score (3.14±0.64 vs. 4.78±0.85, P=0.002), WOMAC score (20.37±4.06 vs. 27.82±4.57, P<0.001) and Lequesne index score (6.13±1.83 vs. 7.35±2.21, P=0.019) in the RE group were significantly lower than those in the NHE group; however, the ROM score (89.13±9.83 vs. 79.15±6.25, P=0.021) and JOA score (79.53±7.59 vs. 67.85±8.27, P=0.016) were significantly higher than those in the NRE group.

Conclusions

RE combined with ESWT has a positive effect on KOA, which may more significantly relieve the patient’s clinical symptoms and improve joint function and quality of life.

Analgesic effect of extracorporeal shock-wave therapy for frozen shoulder: A randomized controlled trial protocol

BACKGROUND

Till date only a few studies have reported the efficacy and clinical improvements obtained by extracorporeal shock-wave therapy (ESWT) on frozen shoulder. Limited by small number of studies and insufficient outcomes, it is important and necessary to conduct a new randomized controlled trial. The purpose of the present study is to determine whether ESWT could be more effective than oral steroid in treatment of frozen shoulder.

METHODS

This randomized, single-blind, superiority clinical trial was approved by the institutional review board in The Third People's Hospital of Linyi. The inclusion criteria were patients aged >18 years with shoulder pain and restriction in range of motion. A symptom duration >3 months was required, with no radiographic findings on anteroposterior shoulder plain radiographs except for osteoporosis. Group 1 patients were given 30 mg of oral prednisolone daily for 2 weeks as a single morning dose and then 15 mg daily for another 2 weeks. Group 2 patients received 3 sessions of ESWT on the first, 14th, and 28th days. The primary outcome measure was shoulder pain score. The secondary outcomes included Disabilities of the Arm, Shoulder, and Hand score, range of motion, satisfaction rate, and complications.

RESULTS

It was hypothesized that there would be a significant difference between ESWT and control groups in improving shoulder pain and functions in frozen shoulder.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5736).

Comparison of the effects between low- versus medium-energy radial extracorporeal shock wave therapy on knee osteoarthritis: A randomised controlled trial

Objective

This study aimed to compare the effects between low- versus medium-energy radial extracorporeal shock wave therapy on knee osteoarthritis (KOA).

Method

Forty-five patients (26 women and 19 men) aged 45–55 years with grade 2 KOA were randomly assigned into the following three groups (all n = 15): Group A received low-energy radial shock wave therapy (2000 shock/session [10 Hz], energy flux density [EFD] 0.02 mJ/mm²) with strengthening exercises once per week for 4 weeks; Group B received medium-energy radial shock wave therapy (2000 shock/session [10 Hz], EFD 0.178 mJ/mm²) with strengthening exercises once per week for 4 weeks; and Group C (control group) received sham shock wave therapy with strengthening exercises once per week for 4 weeks. Severity of pain was determined using the visual analogue scale, and knee physical function was assessed using the Arabic version of the knee injury and osteoarthritis outcome score physical function short form. Knee proprioception was measured before and after the treatment programme using an isokinetic dynamometer.

Results

The within-group analysis showed significant differences in severity of pain, knee physical function, and knee proprioception in Groups A and B before and after the treatment programme (p < 0.05). The between-group analysis showed significant differences in all variables after treatment, with more significant differences observed in Group B than in Groups A and C (p < 0.05).

Conclusion

Low- and medium-energy radial shock wave therapies are effective modalities for the treatment of KOA, with medium-energy radial shock wave therapy being superior to low-energy radial shock wave therapy.

The efficacy and safety of extracorporeal shockwave therapy in knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

Extracorporeal shockwave therapy (ESWT) has been widely applied for pain control in musculoskeletal disorders. Whether ESWT can improve pain relief and joint function for knee osteoarthritis remains controversial. Therefore, we designed a meta-analysis based on relevant studies to comprehensively analyze and determine the efficacy and safety of ESWT for knee osteoarthritis.

METHODS

We identified relevant studies by an electronic search consisting of five English language databases: MEDLINE (1966 to July 2019), the Cochrane Central Register of Controlled Trials (2019 Issue 2), EMBASE (1980 to July 2019), and PubMed (1946 to July 2019). The methodological quality of randomized controlled trials (RCTs) was independently evaluated by two reviewers according to the criteria in the Cochrane Collaboration for Systematic Reviews. The quality of cohort and case-control studies was assessed by the Newcastlee-Ottawa scale (NOS). We performed statistical analysis by the Stata software, version 15.

RESULTS

Three RCTs and three cohort studies involving 589 patients were included. The present meta-analysis indicated that ESWT was associated a significant reduction of pain score at 4 weeks (WMD = -0.436; 95% CI = -0.604 to -0.269), 8 weeks (WMD = -0.234; 95% CI = -0.447 to -0.022) and 12 weeks (WMD = -0.239; 95% CI = -0.436 to -0.043). There were significant differences between the two groups in terms of the Western Ontario and McMaster Universities Osteoarthritis Index at 4 weeks (WMD = -3.107; 95% CI = -5.073 to -1.142), 8 weeks (WMD = -3.617; 95% CI = -5.760 to -1.475) and 12 weeks (WMD = -2.271; 95% CI = -3.875 to -0.667).

CONCLUSION

The ESWT was efficacious and safe for reducing pain and improving knee function in patients with knee osteoarthritis, without increasing the risk of adverse effects.