Effectiveness of extracorporeal shock wave therapy in patients with tennis elbow: A meta-analysis of randomized controlled trials

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.

Radial extracorporeal shockwave therapy (rESWT) for coccydynia: a prospective study of 14 patients

Background

Coccydynia is defined as pain in the coccyx. We investigated the effect of radial extracorporeal shockwave therapy (rESWT) in the management of coccydynia.

Methods

In this prospective study, patients (≥18 years) diagnosed with coccydynia at a sports clinic located in Thessaloniki, Greece, were eligible for rESWT treatment when they reported a visual analogue scale (VAS) pain level ≥6. Treatment sessions were once weekly and ended when VAS pain levels decreased to ≤3. Recurrence rates were documented at 3-month and 12-month follow-ups.

Results

Fourteen patients were treated using rESWT. The mean age and symptom duration of our cohort was 33.6±7.9 (range: 20-45) years and 9.4±8.5 (range: 3-36) months, respectively. The mean number of treatment sessions per patient was 6.4±1.6 (range: 4-8). The mean device pressure, frequency, and number of pulses was 1.2±0.1 (range: 1-1.4) bar, 5.0±0.1 (range: 5-6) Hz, and 2082±74.8 (range: 2000-2300) pulses, respectively. Treatment alleviated pain in all patients, and no recurrence of symptoms was reported during follow-up. There was a positive correlation between symptom duration and the number of treatment sessions (r=0.701, P=0.005). Pairwise comparison highlighted significant reductions in VAS pain levels between each stage of treatment (P<0.001).

Conclusion

Our study affirms the safety and efficacy of rESWT in managing coccydynia.

Current concepts of natural course and in management of medial epicondylitis: a clinical overview

Medial epicondylitis (ME), called "golfer's elbow", is not frequent or serious disease but can cause symptoms that are bothersome in everyday life. Therefore knowledge about this condition may improve diagnostic-therapeutic process. In this article detailed information concerning pathophysiology and symptomatology of ME was described. Great attention was paid to issues related to the diagnosis of the disease both in terms of differentiation with other elbow disorders as well as examination techniques. Finally, current therapeutic options were presented in detail and their efficacy was discussed based on the available data.

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review

Objective

The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.

Methods

An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words "tennis elbow," "lateral epicondylitis," "non-operative," and "non-surgical modalities." The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.

Results

There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Conclusion

A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments

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Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm.

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The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time.

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Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments.

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In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Comparison of extracorporeal shock wave therapy and high-intensity laser therapy on pain, grip strength, and function in patients with lateral epicondylalgia: a randomized controlled study

This study aimed to compare the effects of extracorporeal shockwave therapy (ESWT) and high-intensity laser therapy (HILT) on pain, grip strength, and function in patients with lateral epicondylalgia. This prospective randomized controlled study included 42 patients (22 women and 20 men, mean age: 37) divided into 3 groups. The first group received physiotherapy (n = 14), the second received physiotherapy combined with ESWT (n = 14), and the third received physiotherapy combined with HILT (n = 14). All participants underwent 10 physiotherapy sessions for 2 weeks, 5 sessions per week. In addition to physiotherapy, the ESWT group received 4 ESWT sessions, 2 sessions per week, and the HILT group received 4 HILT sessions, 2 sessions per week. The outcomes were pain intensity as assessed by Visual Analog Scale, grip strength by hand dynamometer, and function by the Duruoz Hand Index and Patient-Rated Tennis Elbow Evaluation-Turkish version questionnaire. The participants were assessed at the beginning of the study (T1/week 0), at the end of treatment (T2/2nd week), and at follow-up (T3/6th week). At follow-up (T3), a significant improvement was observed in all outcomes compared to baseline (T1) in all groups (P < 0.05). Inter-group comparison of the mean differences between baseline and end values showed that the HILT group was superior in all outcomes (P < 0.05). This study showed that physiotherapy alone combined with ESWT and HILT positively affected the treatment of lateral epicondylalgia. Physiotherapy combined with HILT was found to be the most effective for improving pain, grip strength, and function. Clinical trial number: NCT674325.

Issues Related to the Effectiveness of Extracorporeal Shock Wave Therapy for the Management of Lateral Elbow Tendinopathy

One of the most popular recommended physical therapy modalities for the management of lateral elbow tendinopathy (LET) is extracorporeal shock wave therapy (ESWT) [...]

Extracorporeal Shock Wave Therapy Shows Superiority Over Injections for Pain Relief and Grip Strength Recovery in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis

PURPOSE

To examine the efficacy of extracorporeal shock wave therapy (ESWT) and injection therapies by synthesizing direct and indirect evidence for all pairs of competing therapies for lateral epicondylitis.

METHODS

PubMed, EMBASE, and Web of Science databases were searched for all appropriate randomized controlled trials (RCTs), assessing the effect of ESWT or injection therapies. The primary outcome was short-term (≤3 months) and medium-term (>3 months but ≤12 months) pain, while the secondary outcomes were grip strength and patient-reported outcome measures. All outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of treatments. Sensitivity analysis was performed to eliminate potential therapeutic effects of normal saline (NS) and exclude trials that included patients with acute lateral epicondylitis (LE).

RESULTS

40 RCTs were included to evaluate ESWT and five different injection therapies, including corticosteroids (CSs), autologous whole blood, platelet-rich plasma (PRP), botulinum toxin A (BoNT-A), and dextrose prolotherapy (DPT). DPT (-.78 [-1.34 to -.21]), ESWT (.57 [-.89 to -.25]), PRP (-.48 [-.85 to -.11]), and BoNT-A (-.43 [-.84 to -.02]) outperformed placebo for short-term pain relief; ESWT (-.44 [-.85 to -.04]) outperformed placebo for medium-term pain relief. DPT was ranked as the most optimal short-term and medium-term pain reliever (SUCRA, 87.3% and 98.6%, respectively). ESWT was ranked as the most optimal short-term and medium-term grip strength recovery (SUCRA; 79.4% and 86.4%, respectively).

CONCLUSIONS

DPT and ESWT were the best two treatment options for pain control and ESWT was the best treatment option for grip strength recovery. CSs were not recommended for the treatment of LE. More evidence is required to confirm the superiority in pain control of DPT among all these treatment options on LE.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I randomized controlled trials.

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.

Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy.

DATA SOURCES

MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries.

REVIEW METHODS

We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach.

RESULTS

Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: -1.21, 95% confidence interval:-1.53, -0.89, P < 0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P = 0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P < 0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P < 0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: -1.54, 95% confidence interval: -2.60, -0.48, P = 0.005).

CONCLUSION

Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively.Level of Evidence: Therapy, level 1a.