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

Non-pharmacological and non-surgical interventions to manage patients with knee osteoarthritis: An umbrella review 5-year update

Objective

This umbrella review aimed to summarize (and update) the effectiveness of non-pharmacological and non-surgical interventions for patients with knee osteoarthritis.

Methods

The study followed the PRISMA guidelines. Manual and electronic databases were searched, to identify systematic reviews, following the P (knee osteoarthritis) I (non-pharmacological and non-surgical treatments) C (pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical conservative treatments) O (pain, function, quality of life, and other knee-specific measures) model. The quality of evidence was assessed using the R-AMSTAR checklist and GRADE principles.

Results

The search yielded 4086 records, of which 61 met the eligibility criteria. After evaluation with R-AMSTAR, four systematic reviews were excluded, resulting in 57 included systematic reviews, with an overall score of 29.6. The systematic reviews were published between 2018 and 2022 (29.8% in 2022), conducted in 19 countries (52.6% in China), and explored 24 distinct interventions. The systematic reviews encompassed 714 trials (mean of 13 ​± ​7.7 studies per systematic review), and 59,343 participants (mean 1041 ​± ​1002 per systematic review, and 82 ​± ​59.2 per study). The majority of participants were older obese women (61.6 ​± ​4.2 years, 30.2 ​± ​3.6 ​kg/m2, 70%, respectively).

Conclusions

Based on the systematic reviews findings, Diet Therapy, Patient Education, and Resistance Training are strongly supported as core interventions for managing patients with knee osteoarthritis. Aquatic Therapy, Balance Training, Balneology, Dietary Supplements, Extracorporeal Shockwave Therapy, and Tai Ji show moderate support. For other interventions, the evidence quality was low, results were mixed or inconclusive, or there was not sufficient efficacy to support their use.

A critical overview of systematic reviews and meta-analyses of extracorporeal shockwave therapy for knee osteoarthritis

Knee Osteoarthritis (KOA) has become a serious health issue for elderly patients. Several systematic reviews (SRs) and Meta-Analyses (MAs) have reported extracorporeal shockwave therapy (ESWT) has widely been used in the treatment of KOA. This overview aims to summarize and evaluate the available evidence for the efficacy of ESWT for KOA. Eight databases were searched from inception to December 4, 2022. The methodological quality of the included SRs/MAs was assessed by Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to assess the quality of the included studies in terms of outcome indicators. Eight SRs/MAs were finally included in this study. The results of the methodological quality of the included SRs/MAs were generally unsatisfactory. The limitations were a lack of explaining the reasons for selection, a list of excluded literature, reporting bias assessment, and reporting the potential sources of conflict of interest. A total of 49 outcome indicators were assessed by using the GRADE tool. Only 3 items were assessed as moderate quality and the remaining indicators were rated as low and very low. Limitations were the most common downgraded factors. ESWT is regarded as a safe and therapeutically effective non-pharmacological method for the treatment of KOA. However, the reliability of the results is affected by the generally low methodological and evidential quality of the included SRs/MAs. Future researchers should improve the quality of original studies and SRs/MAs to provide a higher level of evidence-based medical evidence.

Adjunctive electrophysical therapies used in addition to land-based exercise therapy for osteoarthritis of the hip or knee: A systematic review and meta-analysis

Objectives

To review evidence for effectiveness of electrophysical therapies (EPTs), used adjunctively with land-based exercise therapy, for hip or knee osteoarthritis (OA), compared with 1) placebo EPTs delivered with land-based exercise therapy or 2) land-based exercise therapy only.

Methods

Six databases were searched up to October 2023 for randomised controlled trials (RCTs)/quasi-RCTs comparing adjunctive EPTs alongside land-based exercise therapy versus 1) placebo EPTs alongside land-based exercise, or 2) land-based exercise in hip or knee OA. Outcomes included pain, function, quality of life, global assessment and adverse events. Risk of bias and overall certainty of evidence were assessed. We back-translated significant Standardised Mean Differences (SMDs) to common scales: 2 points/15% on a 0-10 Numerical Pain Rating Scale and 6 points/15% on the WOMAC physical function subscale.

Results

Forty studies (2831 patients) evaluated nine different EPTs for knee OA. Medium-term effects (up to 6 months) were evaluated in seven trials, and one evaluated long-term effects (>6 months). Adverse events were reported in one trial. Adjunctive laser therapy may confer short-term effects on pain (SMD -0.68, 95%CI -1.03 to -0.34; mean difference (MD) 1.18 points (95% CI -1.78 to -0.59) and physical function (SMD -0.60, 95%CI -0.88 to -0.34; MD 12.95 (95%CI -20.05 to -5.86)) compared to placebo EPTs, based on very low-certainty evidence. No other EPTs (TENS, interferential, heat, shockwave, shortwave, ultrasound, EMG biofeedback, NMES) showed clinically significant effects compared to placebo/exercise, or exercise only.

Conclusions

Very low-certainty evidence supports laser therapy used adjunctively with exercise for short-term improvement in pain and function. No other EPTs demonstrated clinically meaningful effects.

The efficacy of extracorporeal shock wave therapy for knee osteoarthritis : an umbrella review

BACKGROUND

An umbrella review was conducted to compare the effectiveness of extracorporeal shock wave therapy (ESWT) versus non-ESWT in the treatment of knee osteoarthritis (KOA).

MATERIALS AND METHODS

Three databases including PubMed, Embase and Web of science were searched up to September 2023. Literature screening, quality evaluation, and data extraction were performed according to inclusion and exclusion criteria. Meta-analysis of outcome indicators was performed using Revman 5.4 software.

RESULTS

A total of eight meta-analysis were included in this umbrella review. All meta-analysis were graded against a Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) and scored between 8 and 11. Compared to the sham group, the ESWT group showed better results in WOMAC (Western Ontario and McMaster Universities Arthritis Index) [mean difference (MD)=-2.94, 95% CI: -5.52, -0.37, P=0.03, I²=60%], Visual Analog Scale (VAS) (MD=-2.0, 95% CI: -2.5, -1.5, P<0.01, I²=0%), range of motion (ROM) (MD=17.55, 95% CI: 13.49, 21.61, P<0.00001, I²=0%), and Lequesne index (MD=-2.85, 95% CI: -3.64, -2.07, P<0.00001, I²=48%).

CONCLUSION

Based on the results of our analysis, ESWT is now an effective therapy for improving pain and function in patients with KOA.

Evaluation of treatment parameters for focused-extracorporeal shock wave therapy in knee osteoarthritis patients with bone marrow lesions: a pilot study

OBJECTIVES

To evaluate the effect of different dosage parameters of focused-extracorporeal shock wave therapy on pain and physical function in knee osteoarthritis patients with bone marrow lesions. In addition, to investigate pathophysiological changes based on imaging and biomarker measures.

METHODS

Using a single-case experimental design, a total of 12 participants were randomly allocated in 4 equal groups of 3 to receive different dosages of focused-extracorporeal shock wave therapy. Each group received either 4 or 6 sessions of 1500 or 3000 shocks over 4 or 6 weekly sessions. Participants underwent repeated measurements during the baseline, intervention, and post-intervention phases for Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, aggregated locomotor function score and pressure pain threshold. Imaging and inflammatory biomarker outcomes were measured at baseline and 3 months following the intervention.

RESULTS

The group receiving the highest dosage of focused-extracorporeal shock wave therapy showed clinical improvements superior to those of participants in the other 3 groups. Statistically significant changes during the follow-up phase in contrast to baseline measurements for the WOMAC score (Tau-U= -0.88, p < 0.001), aggregated locomotor function score (Tau-U= -0.77, p = 0.002), and pressure pain threshold (Tau-U= 0.54, p = 0.03) were observed. Bone marrow lesion and inflammatory cytokines demonstrated no change.

CONCLUSION

A dose-dependent effect for focused-extracorporeal shock wave therapy on osteoarthritis-related symptoms was suggested. However, these improvements were not associated with changes in the underlying pathophysiological mechanisms.

Effect of extracorporeal shock wave therapy on pain and function in patients with knee osteoarthritis: a systematic review with meta-analysis and grade recommendations

Objective

To investigate extracorporeal shock wave therapy effect on knee osteoarthritis compared to a sham or kinesiotherapy by a systematic review and meta-analysis of randomized clinical trials.

Data Sources

The search was performed in: Cochrane Library, PubMed, PEDro, Web of Science, EMBASE, Scopus, LILACS, and Scielo.

Review methods

We performed the online search until October, 2022. The following terms were used (Osteoarthritis) AND (“knee joint”) AND (“Extracorporeal Shockwave Therapy”). Eligibility criteria: (1) randomized clinical trials; (2) effects comparison of shockwave therapy to a sham or kinesiotherapy in individuals with knee osteoarthritis; (3) pain and physical function as outcome variables. Risk of bias assessed using the PEDro scale. PROSPERO registration (CRD42021235597).

Results

We identified 4217 studies, and 12 were included in the qualitative synthesis and the meta-analysis, totaling 403 individuals submitted to the intervention and 331 control individuals. Compared to sham, shockwave was favored in short-term for the function outcome (SMD = −1.93; 95%CI: [−2.77; −1.09]; I² = 83%; P < 0.01). For the pain outcome, the shockwave was favored in the short (MD = −2.05; 95%CI: [−2.59; −1.51]; I² = 84%; P < 0.01), medium (MD = −3.46; 95%CI: [−4.03; −2.89]; I² = 0%; P < 0.01) and long-term (MD = −2.01; 95%CI: [−3.36; −0.65]; I² = 98%; P < 0.01). The association with kinesiotherapy was favored in the short term for the function outcome (SMD = -1.88; 95%CI: [−2.98; −0.78]; I² = 94%; P < 0.01) and favored for the pain outcome in the short (MD = −1.44; 95%CI: [−1.81; −1.07]; I² = 37%; P = 0.14), medium (MD = −1,31; 95%CI: [−1.76; −0,85]; I² = 0%; P = 0.41), and long terms (MD = −1.63; 95%CI: [−1.73; −1.52]; I² = 0%; P = 0.43).

Conclusion

Shockwave therapy may improve functionality in patients with knee osteoarthritis in the short term and pain in all follow-up moments, compared with sham. When associated to kinesiotherapy, it may improve function in the short term and pain in all follow-up time points, although improvement in pain may not be clinically significant.

How to report parameters and procedures for shockwave therapy in musculoskeletal disorders: A narrative review

Shockwave therapy (SWT) has been successful in the management of musculoskeletal conditions. The limitations of the use of SWT in clinical practice regard a lack of familiarity with the device and the lack of uniformity in information reported in scientific publications. Standardization in the reporting of these parameters could facilitate the reproduction and interpretation of data in future studies. Most studies fail to offer a detailed description of the parameters. Therefore, the aim of the present paper is to prepare a report on how to standardize the presentation of this information and serve a reference guide to report physical parameters and procedures of SWT when used on patients with musculoskeletal disorders. The terms were selected from the Medical Subject Headings database of controlled vocabulary. An extensive process of systematic searching of databases was performed, after which experts met and discussed on the main findings, and a consensus was achieved. SWT parameters were described, including the physiological meaning and clinical relevance of each parameter. Also, the description of patient and equipment positioning was added. The consensus-based guideline on how to report SWT parameters for the treatment of musculoskeletal conditions was developed to help clinicians and researchers.

Comparative Effectiveness of Focused Extracorporeal versus Radial Extracorporeal Shockwave Therapy for Knee Osteoarthritis—Randomized Controlled Study

Both focused extracorporeal shockwave (f-ESWT) and radial extracorporeal shockwave therapy (r-ESWT) can alleviate symptoms in patients with knee osteoarthritis, but no trials have directly compared f-ESWT with r-ESWT for knee osteoarthritis. This study aimed to compare the effectiveness of f-ESWT and r-ESWT on knee osteoarthritis. Forty-two patients with bilateral knee osteoarthritis were randomly assigned to receive three sessions of either f-ESWT or r-ESWT at 1-week intervals. The patients were evaluated at baseline and at 4 and 8 weeks after the final treatment. The primary outcome was the change in pain intensity, as measured on the visual analog scale (VAS). Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion of the knee joint, and the 6-minute walk test. At the end of 4 weeks, the VAS score was substantially reduced in both groups (f-ESWT, −4.5 ± 2.5 points; r-ESWT, −2.6 ± 2.0 points), with a greater reduction in the f-ESWT group. Both groups showed significant improvement in secondary outcomes; however, the f-ESWT group yielded greater improvement in the VAS score, WOMAC score, and 6-minute walk test. Our results showed that f-ESWT was more effective than r-ESWT in improving pain and physical function in patients with knee osteoarthritis.

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.

A harm reduction model to assess the impact of new treatments for pain over standard of care among patients with osteoarthritis

BACKGROUND: Osteoarthritis (OA) affects millions of adults in the United States and can result in substantial pain, functional impairment, and significant clinical and economic burden. To manage chronic pain associated with OA, treatment guidelines recommend a variety of pharmacologic treatments, including traditional oral nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors (COX-2s), and opioids. While these drug treatments can be effective at pain management, they are also associated with significant clinical and economic burden. New treatments for chronic pain among patients with OA of the hip and/or knee have the potential to reduce the occurrence of such negative clinical outcomes, including cardiovascular events, renal events, and opioid use disorder (OUD), thereby reducing health care resource use (HRU) and medical costs. OBJECTIVE: To develop a harm reduction model (HRM) to assess potential reductions of negative clinical outcomes, HRU, and medical costs associated with the use of new treatments in place of oral NSAIDs, tramadol, and non-tramadol opioids among patients with OA of the hip and/or knee in the United States. METHODS: The HRM model integrated findings from the literature and inputs from a variety of sources, along with assumptions regarding potential ability of new treatments to replace existing treatments and market penetration into a unified framework to estimate outcomes and costs. The model outputs included estimated per-patient and population-level reductions in negative clinical outcomes associated with prescribing new treatments in place of oral NSAIDs or opioids along with number needed to treat (NNT) associated with new treatments. The model assumed that new treatments will primarily be used in place of non-tramadol opioids, but more modest adoption in place of oral NSAIDs and tramadol. RESULTS: Among patients with OA of the hip and/or knee who were prescribed oral NSAIDs, tramadol, or non-tramadol opioids for chronic use (≥ 90 days), the HRM estimated total cost savings of $3.8 billion, $5.1 billion, and $29.9 billion, respectively, from prescribing new treatments for OA pain over a 36-month period. The reduced economic burden was driven by significant reductions in the incidence of negative clinical outcomes. Estimates of the NNT to avoid a negative clinical event related to NSAID and opioid treatment initiation were low for most outcomes. Estimates of NNT associated with NSAID use ranged from 4 to 17 patients, depending on outcome, and estimates of NNT associated with opioid use was 35 non-tramadol and 134 tramadol patients for OUD and ranged from 6 to 21 patients for the other clinical outcomes, depending on treatment and outcome. CONCLUSIONS: Results from the HRM suggest that prescribing new treatments in place of oral NSAIDs and/or opioids for OA pain results in a potentially substantial reduction in patients experiencing negative clinical outcomes and reductions in all-cause HRU and costs. DISCLOSURES: This study was sponsored by Pfizer and Eli Lilly and Company. Silverman was a paid consultant to Pfizer and Eli Lilly and Company in connection with this study. Beck and Schepman are employees of Pfizer with stock and/or stock options. Robinson is an employee and minor stockholder of Eli Lilly and Company. Rice, White, and Fernan are employees of the Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study and development of the manuscript.

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 shockwave treatment in knee osteoarthritis: therapeutic effects and possible mechanism

Osteoarthritis (OA), the most common degenerative joint disease, is characterized by the cardinal symptoms of chronic pain and restricted joint activity. The complicated pathological changes associated with OA and unclear mechanistic etiology have rendered existing non-surgical OA management options unsatisfactory. Increasing clinical and experimental evidence suggests that extracorporeal shockwave therapy (ESWT) is beneficial in OA treatment. ESWT is found to have modifying effects on cartilage and subchondral bone alterations in OA progression, as well as the clinical complaints of patients, including chronic pain and limited joint activities. However, the specific treatment strategy regarding the dosage and frequency of ESWT is still underdetermined. This review discusses the existing evidence regarding the therapeutic indications and possible mechanism of ESWT for OA treatment.

Osteoarthritis year in review 2020: rehabilitation and outcomes

OBJECTIVE

Systematically review and synthesize guidelines, systematic reviews, or randomized controlled trials (RCTs) published between April 1, 2019 and April 30, 2020 which evaluated or made recommendations for rehabilitation of persons with osteoarthritis.

DESIGN

Five electronic databases (Medline, EMBASE, Cochrane CENTRAL, CINHAL, Web of Science) were searched with a comprehensive search strategy. Guidelines for rehabilitation of persons with osteoarthritis, and systematic reviews and RCTs evaluating osteoarthritis rehabilitation that included at least one patient-reported outcome measure and/or clinical test of function were included. Two authors independently screened records and assessed methodological quality using the AGREE-II (guidelines), AMSTAR-2 (systematic reviews) or PEDro scale (RCTs). Data were extracted to summarize included records and a narrative synthesis of findings related to core recommended osteoarthritis rehabilitation treatments performed.

RESULTS

Of 2,479 potential records, 253 records were reviewed. Two guidelines, 18 systematic reviews and 38 RCTs were included. 84% (n = 49) of included records related to knee osteoarthritis, 13% (n = 8) to hip, 10% (n = 6) to hand, 3% (n = 2) to mixed, and 1% (n = 1) to foot osteoarthritis. Exercise-therapy, methods to deliver exercise-therapy remotely, and approaches to facilitate exercise-therapy behaviour change were the most commonly evaluated interventions (n = 27). 94% of systematic reviews and 63% of RCTs rated high-quality.

CONCLUSIONS

Osteoarthritis rehabilitation research continues to focus on knee osteoarthritis and exercise-based interventions. Emerging topics include rehabilitation of comorbid populations, exercise behaviour change and technology supports. A better understanding of rehabilitation of osteoarthritis in joints other than the knee, and methods to determine and promote ideal exercise-therapy prescription are needed.

Effects of extracorporeal shock wave therapy in patients with knee osteoarthritis: A cohort study protocol

BACKGROUND

Osteoarthritis is the most common form of arthritis, and is a major cause of disability and chronic pain in adults. However, there is very limited evidence in the scientific literature to support the effectiveness of extracorporeal shockwave therapy (ESWT) in human knee osteoarthritis. This retrospective study aimed to compare the efficacy of ESWT treatment with sham-ESWT on pain, walking speed, physical function, and adverse effects in knee osteoarthritis.

METHODS

This study will be performed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology checklist. We reviewed patients diagnosed with knee osteoarthritis at our academic center from 2016 to 2017. This retrospective cohort study was approved by the institutional review board in Ruijin Hospital. The primary outcome measure was pain on movement measured by a 100-cm visual analog scale. The secondary outcome measures included the Western Ontario and McMaster University Osteoarthritis Index, range of motion, and adverse effects. Statistical analysis was performed using Statistical Package for Social Sciences version 20.0 (IBM Corporation, Armonk, NY). A P-value of <.05 was defined as statistical significance.

RESULTS

The hypothesis was that ESWT would be an effective treatment for improving pain and physical function in knee osteoarthritis to control symptoms.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5801).

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 effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

BACKGROUND

Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT.

METHODS

A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects.

RESULTS

Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI -4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI -0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes.

CONCLUSIONS

SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

Extracorporeal Shock Wave Therapy for the Treatment of Osteoarthritis: A Systematic Review and Meta-Analysis

Background

Osteoarthritis is the most common musculoskeletal disease. Extracorporeal shockwave therapy had shown an effect on osteoarthritis in both some animal experiments and clinical studies, but there was no systematic review to confirm the value of shockwave therapy in the treatment of all types of osteoarthritis and compare it with other traditional therapies (especially traditional Chinese medicine).

Method

PubMed, Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, WANFANG database, and VIP database were searched up to December 10, 2019, to identify randomized controlled trials comparing shockwave therapy and other treatments for osteoarthritis. Visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index were extracted and analyzed by RevMan and STATA software as outcomes of pain reduction and functional improvement. Adverse reactions were recorded to evaluate the safety of shockwave therapy.

Results

Shockwave therapy had significant improvement in both pain reduction and functional improvement compared with placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (P < 0.05). In functional improvement, shockwave therapy showed statistical improvement compared with kinesiotherapy and moxibustion (P < 0.05) but not with acupotomy surgery (P = 0.24). A significant difference between shockwave therapy and platelet-rich plasma was observed in pain reduction (P < 0.05) but not in functional improvement (P = 0.89). Meanwhile, a statistical difference was found between shockwave therapy and fumigation in functional improvement (P < 0.05) but not in pain reduction (P = 0.26). Additionally, there was no statistically significant difference between shockwave therapy and manipulation in both pain reduction (P = 0.21) and functional improvement (P = 0.45). No serious adverse reaction occurred in all of studies.

Conclusions

Extracorporeal shockwave therapy could be recommended in the treatment of osteoarthritis as a noninvasive therapy with safety and effectiveness, but the grade of recommendations needs to be discussed in a further study.

Application and efficacy of extracorporeal shockwave treatment for knee osteoarthritis: A systematic review and meta-analysis

The increasing aging of the world population is accompanied by a rise in the incidence of knee osteoarthritis (KOA). There has been a growing interest in shockwave treatment for orthopedic diseases, including KOA. In previous trials, extracorporeal shockwave therapy (ESWT) was compared to physical therapy or placebo in the treatment of KOA. However, the efficacy and safety of ESWT for KOA remains disputed. The present meta-analysis assessed the effects of ESWT in KOA. The PubMed, Medline, Embase, Web of Science, Research Gate and the Cochrane Library were searched to identify comparative studies involving ESWT for patients with KOA. The outcome indicators included the visual analog scale (VAS) score, range of motion (ROM), the Lequesne index (LI) and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC). In the comparison of the ESWT vs. placebo groups, the primary outcomes included the VAS score and ROM, while the LI was the secondary outcome. In the comparison of the ESWT vs. physical therapy groups, the primary outcomes included the pain score and ROM, while the secondary outcome was the WOMAC index. Relevant data were analyzed using RevMan v5.3. The ESWT group had a lower VAS core, larger ROM and a better LI than the placebo group after 1 month of therapy (P<0.05). Furthermore, at 1 month post-therapy, the ESWT group had a lower VAS score, larger ROM and a better WOMAC than the physical therapy group (P<0.05). The outcomes regarding pain, ROM, LI and WOMAC were significantly different between the two different groups (P<0.05). The present meta-analysis suggested that ESWT may achieve a better therapeutic effect for patients with KOA as compared to physical therapy. However, high-quality trials with large sample sizes are essential to substantiate these results.