Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials

Extracorporeal Shockwave Therapy for Greater Trochanteric Pain Syndrome: A Systematic Review with Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Greater trochanteric pain syndrome (GTPS) affects 17.6% of adults aged 50 to 79 years, particularly women. While exercise therapy and corticosteroid injections (CSIs) are common treatments, their limitations include inadequate pain control and potential tendon weakening. Extracorporeal shockwave therapy (ESWT) is an emerging alternative for GTPS. This systematic review assessed ESWT's efficacy in GTPS by evaluating pain and functional outcomes at different follow-up intervals.

METHODS

A literature search of PubMed, Embase, and Web of Science for randomized clinical trials (RCTs) was conducted comparing ESWT with other GTPS treatments up to March 1, 2024. Two reviewers independently extracted data, assessing study quality using the Cochrane risk-of-bias tool. A random-effects pairwise meta-analysis compared ESWT with other treatments.

RESULTS

Eight RCTs involving 754 patients (169 male, 585 female patients) were included. Seven RCTs were deemed high risk of bias, and 1 RCT had some concerns. Five RCTs investigated focused on focused ESWT, and 3 examined radial ESWT. ESWT provided significantly lower pain scores than other treatments at 2 to 4 months (standardized mean difference = -0.431; 95% confidence interval [CI], -0.82 to -0.039; I2 = 83%). Functional improvement (Lower Extremity Functional Scale) was significantly higher at 6 months (weighted mean difference = 6.68; 95% CI, 3.11-10.25; I2 = 0%) but did not exceed the minimal clinically important difference. Focused ESWT provided greater pain reduction than radial ESWT.

CONCLUSION

Three weekly ESWT sessions offer short-term pain relief at 2 to 4 months for patients with GTPS, especially with focused ESWT. Functional improvements at 6 months were notable but not clinically significant. These findings suggest ESWT may complement or serve as an alternative to CSIs and exercise. However, caution is needed when interpreting these results due to high risk of bias with the included RCTs and heterogeneity across the studies. Further high-quality trials are needed to confirm ESWT's long-term benefits over other treatments.

LEVEL OF EVIDENCE

Level II. See Instructions for Authors for a complete description of levels of evidence.

Does radiofrequency application improve function and reduce pain in patients with insertional Achilles tendinopathy? A retrospective study with a minimum 2-year follow-up

This case series study aimed to investigate patients with insertional Achilles tendinopathy (IAT) who underwent radiofrequency (RF), how much do their patient-reported outcomes scores improve and what percentage return to sport, and what patient-related factors are associated with improved scores and increased odds of return to sport, at a minimum of 2-year follow-up. Between 2012 and 2018, 41 patients were followed up. The median Victorian Institute of Sports Assessment-Achilles (VISA-A) score increased from 20 (range, 3-62) to 97 (range, 53-100), the median 11-point visual analogue scale (VAS) reduced from 8 (range, 1-10) to 0 (range, 0-3) and the median Tenger score increased from 1 (range, 0-1) to 3 (range, 2-8). Thirty-eight (92.7%) patients returned to sports with a mean time of 11 ± 4.8 months. In linear regression analysis, age was significantly associated with return-to-sports outcome (b = -0.07, 95% CI = -0.13 to -0.02, p = 0.02), while in logistic regression, symptoms duration revealed a significant impact on pain presence (OR = 1.07, 95% CI = 1.01 to 1.14, p = 0.02). In summary, RF for IAT had a 68.7 ± 14.5 VISA-A improvement at 5.4 years of follow-up regarding reliable functional restoration and pain reduction; however, the current evidence remains insufficient to support RF as an effective treatment for IAT.

The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Tendinopathy is a common condition that affects the body's tendon structures, causing discomfort, restricted movement, and reduced functionality. In this study, we looked at how extracorporeal shock wave therapy (ESWT) affected pain levels in individuals with various forms of tendinopathy around the world.

DESIGN

This study is a comprehensive review and meta-analysis of previously published randomized controlled trials. To gather relevant data, the researchers performed keyword searches in international databases, including PubMed (Medline), Scopus, Web of Sciences, Cochrane Central Register of Controlled Trials (CENTRAL), Research Registers of ongoing trials (ClinicalTrials.gov), as well as Embase. The search was conducted up until March 2023. The quality of the selected articles was assessed using the Cochrane risk-of-bias method for randomized trials (RoB2).

RESULTS

Based on the results of the meta-analysis, which included 45 clinical studies, the use of ESWT was found to have a significant impact on reducing pain in various conditions. The standardized mean difference (SMD) in patients with plantar fasciitis (PF) was reduced by 1.63 (SMD: -1.63, 95% CI: -3.04, -0.21; I2: 77.36%; P heterogeneity: 0.0001). For lateral epicondylitis (LE), the SMD was 0.63 (SMD: -0.63, 95% CI: -1.11, -0.16; I2: 67.50%; P heterogeneity: 0.003). In the case of chronic Achilles tendinopathy, the SMD was 1.38 (SMD: -1.38, 95% CI: -1.66, -1.10; I2: 96.44%; P heterogeneity: 0.0001). Additionally, in individuals with rotator cuff tendinopathy, the SMD for pain reduction was 2.37 units (SMD: -2.37, 95% CI: -3.58, -1.15; I2: 98.46%; P heterogeneity: 0.0001).

CONCLUSION

This study suggests that ESWT can be a highly effective therapy option for relieving pain in people with tendinopathy. Nonetheless, it is encouraged to make additional recommendations based on high-quality clinical research and more accurate information in order to define the optimal therapeutic options for each type of tendinopathy.

The Efficacy of Extracorporeal Shock Wave Therapy as a Monotherapy for Achilles Tendinopathy: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review and meta-analysis was to determine the therapeutic efficacy of extracorporeal shock wave therapy (ESWT) for Achilles tendinopathy.

Methods

We searched PubMed, EBSCOHost, Ovid, and Embase for randomized controlled trials. Databases were searched from their inception until the last entry (July 16, 2022). The methodological quality of the randomized controlled trials was rated with the Physiotherapy Evidence Database scale. For continuous data, we presented the mean difference (D) and 95% confidence interval (CI). Heterogeneity was assessed with I2 statistics. The random effects model was applied for the pooled effect estimates. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool.

Results

The very-low-quality evidence suggested that ESWT was no more effective in decreasing pain than any other conservative treatment (D: -0.8; 95% CI: -3.15, 1.56; P > .5; I² = 85.62%). No significant differences were found between the ESWT and control groups on the pooled Victorian Institute of Sport Assessment-Achilles scores (D: 5.74; 95% CI: -15.02, 26.51; P = .58; I2  = 92.28%), but the quality of evidence was very low.

Conclusion

At present, the quality of the evidence is low; thus, the therapeutic efficacy of ESWT for Achilles tendinopathy is inconclusive.

Treatment of Jumper’s Knee with Extracorporeal Shockwave Therapy: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to determine the therapeutic efficacy of extracorporeal shockwave therapy (ESWT) for athletes with patellar tendinopathy. We searched PubMed, EBSCOHost and Ovid for randomized controlled trials (RCTs) which evaluated the therapeutic efficacy of ESWT in athletes with jumper’s knee. The methodological quality of RCTs was rated with the Physiotherapy Evidence Database scale. Data in the meta-analysis were expressed as standardized mean difference (SMDs) and 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Of 192 records identified, a total of seven articles met the inclusion criteria. The ESWT and control groups with any other conservative treatment did not differ significantly with respect to the Visual Analogue Scale (VAS) long-term scores obtained at ≥ 6 months of therapy completion (SMD: -0.33; 95% CI: -4.64 to 3.98; p = 0.87; I2= 98%). Furthermore, no significant differences were found between the ESWT and control groups regarding the pooled Victorian Institute of Sports Assessment for Patella (VISA-P) scores for long-term outcomes (SMD: 8.21; 95% CI: -39.3 to 55.73; p = 0.73; I2= 99%). The ESWT and control groups did not differ significantly on the VAS and VISA-P scores for long-term outcomes. In both cases, heterogeneity was considered to be high. Hence, no clear and generalized conclusions can be drawn regarding ESWT effectiveness in athletes with patellar tendinopathy.

Combined ultrasound guided peritendinous hyaluronic acid (500-730 Kda) injection with extracorporeal shock waves therapy vs. extracorporeal shock waves therapy-only in the treatment of shoulder pain due to rotator cuff tendinopathy. A randomized clinical trial

BACKGROUND

Rotator cuff tendinopathy (RCTe) is the most common cause of pain and shoulder dysfunction. Numerous clinical studies have demonstrated the therapeutic capacity of exogenous peritendinous hyaluronic acid (HA), and the effectiveness of extracorporeal shockwaves therapy (ESWT) in reducing pain. The aim of this study was to evaluate the added effects of HA treatment plus ESWT (E-g) or ESWT alone (SC-g), focusing on reduction of self-reported pain and disability of patients with RCTe.

METHODS

Monocentric, randomized open-label clinical trial. Patients' selection, enrollment and interventions were conducted at the Chiparo Physical Medicine and Rehabilitation outpatient facility (Lecce, Italy). Patients with a diagnosis of RCTe, were randomly allocated to the E-g or to the SC-g. Participants were assessed for self-perceived pain, and for disability, at baseline, after 30 and 60 days.

RESULTS

Forty adults (mean age 50.8±6.3; 23 woman, 17 men) were enrolled in the study, twenty for each group. During the study, both groups improved their perceived level of disability of the arm (-25.01±2.79; P<0.001), and for pain (-3.13±0.50; P<0.001). A multiplicative effect was demonstrated in the time × treatment interaction for disability (beta±SE beta: 7.40±1.77; P<0.001), and pain (beta±SE beta: 0.95±0.32; P<0.001). Moreover, more patients in the E-g reached the MCID in the outcomes-score compared to SC-g. Lastly, number needed to treat were calculated, for disability: NNT=2 (95% CI: 1-3), and for pain-score: NNT=1 (95% CI: 1-2).

CONCLUSIONS

This study provides preliminary evidence that, compared to ESWT alone, the combining ESWT and peritendinous HA-injections, revert disability and reduces shoulder pain faster in patients with RCTe.

Relative Effect of Extracorporeal Shockwave Therapy Alone or in Combination with Noninjective Treatments on Pain and Physical Function in Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

Extracorporeal shockwave therapy (ESWT) has been recommended for managing pain in patients with knee osteoarthritis (KOA). The difference in therapeutic effects between radial shockwave characteristics (RaSW) and focused shockwave characteristics (FoSW) with different energy levels for KOA remains controversial. The purpose of this network meta-analysis (NMA) was to identify the effects relative to the different ESWT regime and combination treatments on pain and functional outcomes in individuals with KOA. The randomized controlled trials (RCTs) which investigated the efficacy of RaSW, FoSW, and combination treatments in patients with KOA were identified by searches of electronic databases. The included RCTs were analyzed through NMA and risk-of-bias assessment. We analyzed 69 RCTs with a total of 21 treatment arms in the NMA. Medium-energy FoSW plus physical therapy, medium-energy acupoint RaSW plus Chinese medicine, and high-energy FoSW alone were the most effective treatments for reducing pain [standard mean difference (SMD) = -4.51], restoring function (SMD = 4.97), and decreasing joint inflammation (SMD = -5.01). Population area and study quality influenced the treatment outcomes, particularly pain. Our findings indicate that medium-energy ESWT combined with physical therapy or Chinese medicine is beneficial for treating pain and increasing function in adults with KOA.

Functional Gains Using Radial and Combined Shockwave Therapy in the Management of Achilles Tendinopathy

Achilles tendinopathy is a common condition and many patients have functional limitations after initial conservative treatment. Shockwave therapy has been shown to improve function within patients; however, comparative outcomes for different forms of shockwave are poorly described. In this retrospective cohort study, we describe findings from a quality improvement initiative evaluating safety and functional outcomes after treatment with radial shockwave therapy (n = 58) or combined radial and focused shockwave therapy (n = 29) for patients with Achilles tendinopathy refractory to exercise therapy. All patients were prescribed an eccentric exercise program. We hypothesized both groups would see improvements in function quantified using the Victorian Institute of Sports Assessment-Achilles with similar safety outcomes. Overall, the minimal clinically important difference (defined at 7 for insertional and 12 for noninsertional Achilles tendinopathy) was met in a greater proportion of patients treated with combined shockwave compared to radial shockwave (26 [89.7%] vs 37 [63.8%], p = .022). The change in Victorian Institute of Sports Assessment-Achilles from baseline to final treatment was not different between combined and radial-only groups (23.3 ± 12.6 vs 19.9 ± 18.7, p = .2). Within group differences from baseline to final follow-up measures (mean duration 17.9 ± 14.8 weeks) demonstrated overall functional improvement for both groups (both p < .0001). No serious adverse effects were observed. Our findings suggest combined radial and focused shockwave therapy may provide more predictable functional gains for treatment of Achilles tendinopathy compared to radial shockwave therapy.

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries

ABSTRACT

Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

Bone Marrow Edema Syndrome of the Foot Treated with Extracorporeal Shock Wave Therapy: A Retrospective Case Series

To determine the validity and safety of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema syndrome (BMES) of the foot. Twenty patients diagnosed as foot BMES in our Center were followed and treated by ESWT for 1 to 2 courses. The target of the ESWT treatment was the most obvious foot tenderness, or the most obvious part of bone edema on magnetic resonance imaging (MRI). One course of ESWT was 1 time/week, 5 times in total, with the shock wave energy flow density 0.18 mJ/mm². The visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society (AOFAS) scores of the foot were recorded before treatment, at 3 months after treatment and the last follow-up; the areas of BME before treatment and at the last follow-up were measured by the fat suppression MRI. Complications during treatment were also recorded. Twenty follow-up patients were obtained. Compared with the pretreatment, the patients had significant improvement in various indicators at 3 months after treatment (p < 0.01). The sagittal MRI at the last follow-up showed that the BME area decreased significantly (p < 0.01). Two patients developed transient erythema on their skin after treatment and alleviated after 2 days of rest. No serious complications were found during treatment. Our findings show that for patients with foot BMES, the use of ESWT treatment can effectively relieve local pain, improve the motor function of the foot and ankle. Two courses of treatment may be required for some patients.

Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment

Objective

To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment.

Data sources

Medline from inception to June 2020.

Study eligibility

All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy.

Data extraction and synthesis

Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication.

Results

A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals (mean difference 26.4%±8.8%, p=0.004). The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs (mean difference 8.3%±13.7%, p=0.54). Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half (n=30; 50%) did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately.

Conclusions

In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs.

Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs).

METHODS

Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles.

RESULTS

40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I² = 1.9%, p = 0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27].

CONCLUSIONS

Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.

Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis

Background:

Achilles tendinopathy (AT) is a common cause of overuse injury in both athletes and nonactive individuals, especially at older ages. Due to the limited number of direct comparisons among interventions, determining the best treatment option can be difficult.

Purpose:

To evaluate the comparative efficacy and tolerability of nonsurgical therapies for midportion AT.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

PubMed, MEDLINE, EMBASE, and Google Scholar were searched from database inception through June 20, 2019. Randomized controlled trials investigating the effect of nonsurgical therapies for midportion AT using the Victorian Institute of Sports Assessment–Achilles (VISA-A) assessment were eligible for inclusion. Primary outcome was mean change in VISA-A score from baseline. Comparisons between interventions were made through use of random-effects network meta-analysis over the short term (≤3 months) and longer term (>3 to <12 months). A safety profile was defined for each intervention by rate of all-cause discontinuation (dropout) during follow-up. Relative ranking of therapies was assessed by the surface-under-the–cumulative ranking possibilities.

Results:

A total of 22 studies with 978 patients met the inclusion criteria. In short-term studies, high-volume injection with corticosteroid (HVI+C) along with eccentric exercise (ECC) significantly improved the change of VISA-A score compared with that of ECC alone (standardized mean difference [SMD], 1.08; 95% CI, 0.58-1.58). Compared with ECC, acupuncture showed benefits over both the short term (SMD, 1.57; 95% CI, 1.00-2.13) and longer term (SMD, 1.23; 95% CI, 0.69-1.76). In longer-term studies, the wait-and-see approach resulted in unfavorable outcomes compared with ECC (SMD, −1.51; 95% CI, −2.02 to −1.01). Improvement was higher when ECC was combined with HVI+C (SMD, 0.53; 95% CI, 0.05-1.02) and extracorporeal shockwave therapy (ESWT) (SMD, 0.99; 95% CI, 0.48-1.49). All interventions had a similar safety profile.

Conclusion:

From available high-level studies, HVI+C and ESWT may be possible interventions to add along with ECC to improve longer-term outcomes.

Radial extracorporeal shock wave therapy: a novel approach for the treatment of Dupuytren's contractures: A case report

INTRODUCTION

While the efficacy of focused Extracorporeal Shock Wave Therapy (ESWT) in the treatment of Dupuytren's disease (DD) is supported by one positive trial, the effects of radial ESWT is unclear.

PATIENT CONCERNS

A 79-year-old man with a 4-year history of impairment of left-hand function and pain due to DD with weakness and flexion deformities of middle and ring fingers. He has not been treated before for this impairment.

DIAGNOSIS

The diagnosis of DD was based on clinical features and ultrasound images.

INTERVENTIONS

Four weekly sessions of radial ESWT with 1400 impulses 3 bar each, 12 Hz.

OUTCOMES

The limitations in activities of daily living were analyzed through the Disabilities of Arm Shoulder and Hand Questionnaire (DASH) and Michigan Hand Outcome Questionnaire (MHQ) at baseline, after four sessions of radial ESWT and at 4-months follow-up. Data analysis showed a significant reduction of hand deformities and an improvement of daily living performance. The effects continued at the 4-months follow-up.

CONCLUSION

This case report demonstrates the feasibility of radial ESWT. Radial ESWT sessions may be carried out by a physiotherapist in outpatient clinics with cost reduction compared with surgical treatment and focused ESWT. Radial ESWT is a non-invasive, well tolerated therapy, so it should be considered in the DD treatment.

Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of the paper is to use research reports on ESWT in patients with Achilles tendinopathy to help practising physiotherapists establish the most effective intervention parameters. A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science. The papers were checked for relevant content and were included based on the following criteria: full-text article published in English and including comprehensive description of shock wave application. Twenty-two articles met the inclusion criteria. Most studies on the effectiveness of ESWT for Achilles tendinopathy included in this narrative review were randomized controlled trials. Two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were also considered. The majority were prospective studies. Only a few authors presented the findings from retrospective observations. The two modalities of shock wave therapy used for Achilles tendinopathy are focused shock waves and radial shock waves. The literature contains reports presenting mainly beneficial effects of ESWT in patients with Achilles tendinopathy.

Clinical efficacy of extracorporeal shockwave therapy for knee osteoarthritis: a systematic review and meta-regression of randomized controlled trials

OBJECTIVE

This study determined the clinical efficacy of extracorporeal shockwave therapy and the predictors of its efficacy for knee osteoarthritis.

DATA SOURCES

Electronic databases and search engines, namely MEDLINE, PubMed, EMBASE, Cochrane Library Database, Physiotherapy Evidence Database (PEDro), China Academic Journals Full-text Database, and Google Scholar, were searched until 5 March 2019, for randomized controlled trials without restrictions on language and publication year.

REVIEW METHODS

Eligible trials and extracted data were identified by two independent investigators. The included articles were subjected to a meta-analysis and risk of bias assessment. Outcomes of interest included treatment success rate, pain, and physical function outcomes. A meta-regression analysis was performed to determine the predictors of treatment outcomes following shockwave therapy.

RESULTS

We included 50 trials (4844 patients) with a median (range) PEDro score of 6 (5-9). Meta-analyses results revealed an overall significant effect favoring shockwave therapy on the treatment success rate (odds ratio 3.22, 95% confidence interval (CI) 2.21-4.69, P < 0.00001; heterogeneity (I²) = 62%), pain reduction (standardized mean difference (SMD) -2.02, 95% CI -2.38 to -1.67, P < 0.00001; I² = 95%), and Western Ontario and McMaster Universities Osteoarthritis Index function outcome (SMD -2.71, 95% CI -3.50 to -1.92, P < 0.00001; I² = 97%). Follow-up duration and energy flux density were independent significant predictors of shockwave efficacy.

CONCLUSION

Shockwave therapy is beneficial for knee osteoarthritis. Shockwave dosage, particularly the energy level and intervention duration, may have different contributions to treatment efficacy.