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

Abstract

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.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

“…Two reviews investigated the effect of shockwave therapy in soft tissue [55] or musculoskeletal [57] conditions and discussed plantar fasciitis separately in their reviews. Speed conducted a systematic review including 12 RCTs without meta-analysis and concluded that high-dosed focused ESWT and radial shockwave have benefits in pain reduction at 12 weeks [55].…”

“…Speed conducted a systematic review including 12 RCTs without meta-analysis and concluded that high-dosed focused ESWT and radial shockwave have benefits in pain reduction at 12 weeks [55]. Al-Abbad et al performed a meta-analysis of seven studies and showed an overall reduction in plantar fascia thickness after ESWT at 4 weeks, 6 weeks, 3 months, and 6 months, and a greater reduction was found when radiologic guidance was used [57].…”

Advancing frontiers in rheumatic and musculoskeletal imaging

“…The articles published in this Article Collection clearly show the efforts of researchers to find innovative applications of musculoskeletal imaging in clinical practice and to face the crucial challenges that remain in the interpretation and quality control of images. Indeed, highly performing diagnostic technologies are currently available to early diagnose and accurately monitor several musculoskeletal disorders [ 1 – 3 ], but also to guide personalized interventional therapeutic procedures tailored to the individual patients in the emerging process of precision medicine [ 4 – 7 ]. Among these new modalities, some are particularly promising and thereby subject to several lines of research in RMDs, including SPECT-CT and dual-energy CT [ 8 , 9 ], novel MRI sequences [ 10 – 12 ], high and ultra-high frequency ultrasound with effective tools like shear wave elastography [ 13 – 16 ].…”

Imaging of calcific tendinopathy around the shoulder: usual and unusual presentations and common pitfalls

“…As mentioned above, US-PICT and ESWT are the most commonly used procedures to treat RCCT. Previous studies have used CR and/or US to assess imaging response to treatment [ 45 ]. Most studies demonstrated a progressive and complete resorption of calcific deposits, while a minor part of authors reported the fragmentation or significant reduction of calcium deposit size already after 1 week [ 46 ], 3 months [ 47 ], and 12 months [ 48 , 49 ].…”

“…Notably, total calcium resorption has been reported to be higher after US-PICT than ESWT [ 48 , 49 ]. Furthermore, pre-treatment calcification size seems to be an independent predictor for changes in imaging outcomes after ESWT [ 45 ].…”