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The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient- rated pain reduction

Korakakis, V., Whiteley, R., Tzavara, A. and Malliaropoulos, N., 2018. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. British journal of sports medicine, 52(6), pp.387-407.

In today’s letter

Overview of the evidence of shockwave on various MSK conditions

• Rapid Results =

  • Further investigation required due to moderate-level evidence indicating shockwave therapy is not significantly better than placebo in patellar tendinopathy

  • Shockwave therapy demonstrates effectiveness with a large effect size in proximal hamstring tendinopathy, supported by moderate-level evidence.

  • Low-level evidence supports the effectiveness of shockwave therapy in treating Achilles tendinopathy and greater trochanteric pain syndrome.

  • No evidence supports the effectiveness of shockwave therapy in treating medial tibial stress syndrome.

• Top 3 reads to check out: To further your knowledge about:

  Shockwave

• Dank meme! Have a friend with knee pain? 😁 

Aim of study

• This review intended to evaluate the short term (≤3 months), mid-term (3 to <12 months) and long term (≥12 months) effectiveness of Extracorporeal Shockwave Therapy (ESWT) in the treatment of Achilles tendinopathy, Greater trochanteric pain syndrome, Medial tibial stress syndrome, Patellar tendinopathy and Proximal hamstring tendinopathy by following published guidelines, robust quality assessment criteria, well-described measures of treatment effect and an established approach for quality of evidence and recommendations.

• A secondary objective was to document, where possible, the specifics of successful ESWT parameters in the conditions under investigation.

Did you Know?

• Shockwave: Rapid, short-duration acoustic wave carrying energy, propagating through tissue.

• Extracorporeal Shockwave Therapy (ESWT): Believed to act as a mechanical stimulus inducing biological effects in tissue, promoting healing processes like tissue regeneration, wound healing, angiogenesis, bone remodeling, and anti-inflammation

• ESWT commonly treats lower limb conditions like Achilles tendinopathy, greater trochanteric pain syndrome (GTPS), medial tibial stress syndrome (MTSS), patellar tendinopathy, and proximal hamstring tendinopathy.

• Guidelines such as the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement aim to improve reporting quality in systematic reviews.

• Recent systematic reviews evaluating ESWT effectiveness have not adhered to recommended guidelines, potentially affecting their reliability.

• Inconsistent conclusions and recommendations in systematic reviews are often due to arbitrary selection of quality assessment tools and poor reporting standards.

Results

Mid portion Achilles tendinopathy

Low level of evidence:

1. Radial ESWT is comparable to eccentric training at mid-term follow-up (4 months) for VISA-A, pain scores, self-perceived recovery and patient rating of pain reduction (both much improved).

2. Radial ESWT is superior to a wait-and-see policy at mid- term follow-up (4 months) for disability scores, pain, self- perceived recovery and patient rating of pain reduction (much improved compared with minimally improved).

Very low level of evidence:

1. Radial ESWT combined with eccentric training is superior to eccentric training alone at mid-term follow-up (4 months) for VISA-A scores, self-perceived recovery and patient-rated pain reduction (very much improved compared with much improved).

Insertional Achilles tendinopathy

Low level of evidence:

1. Radial ESWT is superior to eccentric training at mid-term follow-up (4 months) for disability scores, pain, self-per- ceived recovery and patient rating of pain reductio

(much improved compared with minimally improved).

Greaterter trochanteric pain syndrome

What is it? Here is the link to our article to find out more

Conclusion and recommendations

Very low level of evidence:

1. Radial ESWT is superior to control treatment (physiotherapy,stretching and strengthening) at short (3 months) and long- term follow-up (12 months) for disability scores (HHS).

Low level of evidence:

1. Radial ESWT is superior to control treatment (physiotherapy, stretching and strengthening) at short (1–3 months) and mid- term follow-up (4 months) in self-perceived recovery.

2. Corticosteroid injection is superior to radial ESWT at short- term (1month) follow-up in self-perceived recovery, pain scores and patient-rated pain reduction.

3. Radial ESWT is superior to corticosteroid injection at mid-term (4 months) and long-term follow-up (>12 months) in self-perceived recovery, pain scores and patient-rated pain reduction.

4. Radial ESWT produces comparable results to control treatment (physiotherapy, stretching and strengthening) at long-term follow-up (>12 months) in self-perceived recovery, pain scores and patient-rated pain reduction.

Medial tibial stress syndrome (MTSS)

• Moen et al. found that adding five sessions of focused ESWT to a graded running program significantly reduced time to full recovery (mean 32 days) compared to running alone, as assessed by a treadmill test.

• In contrast, a high-quality RCT utilising the same ESWT protocol without additional controlled intervention showed no significant differences between ESWT and sham dose ESWT groups at 10-week follow-up in pain during muscle pressure, pain-limited distance run, and self-perception of change.

• Interestingly, pain during bone pressure was significantly reduced in the control group compared to the ESWT group at 10-week follow-up.

• Rompe et al. reported that radial ESWT added to a standardised home training program provided significant benefits in reducing pain and self-perceived global improvement in MTSS patients.

• At 4 and 15 months follow-up, pain reduction was 4.3 and 5.4 points for the ESWT group compared to 1.6 and 3.2 for the home training group, respectively, indicating higher patient ratings of improvement in the ESWT group

No evidence for the effectiveness of ESWT in patients with MTSS.

Patellar tendinopahy

Moderate level of evidence:

1. No difference between focused ESWT and placebo ESWT at short (3 months) and mid-term (5–6 months) follow-up inVISA-P, pain scores and patient-rated pain reduction.

Low level of evidence:

1. No difference between focused ESWT and placebo ESWT in self-perceived recovery.

Proximal hamstring Tendinopathy

Moderate level of evidence:

1. Radial ESWT produces superior results to conservative

   treatment (consisted of rest, NSAIDs, physiotherapy, and exercise programme) in patients with proximal hamstring tendinopathy at short-term, mid-term and long-term follow-up (up to 12 months) in Nirschl rating scale, self-perceived recovery, pain scores and patient-rated pain reduction.

Top 3 reads

That will further your knowledge about shockwave

1. Shockwave use in aspetar - https://www.aspetar.com/en/about-us/press-room/news/advanced-shockwave-therapy

2. History of shockwave - https://www.hindawi.com/journals/bmri/2016/3850461/

3. A quick look into sports injuries that may benefit from shockwave - https://journals.lww.com/acsm-csmr/Fulltext/2021/06000/Extracorporeal_Shockwave_Therapy_in_the_Management.5.aspx

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