Laurie's Blog


27 Jun 2020

Efficacy and Safety of Extracorporeal Shockwave Therapy


I found an article that I LOVE!  This time, it’s all about Shockwave.  I know I’ve seen a number of discussions come up in regards to shockwave units, companies, results, methods, etc., so when this article popped across my screen, I quickly downloaded it with the intention of sharing it!


Schmitz C, Császár NB, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015;116(1):115-138.


Now, I don’t want to get into the nitty gritty of how they did their review, because what I want to focus on are the conclusions!  So here they are… the 10 main statements about ESWT based on the RCTs on radial shockwave (rESWT) and focused shockwave (fESWT) listed in the PEDro database.


1.ESWT is effective.

88.5% of the RCTs on rESWT and 81.5% of all RCTs on fESWT had positive outcomes.


2.ESWT is safe.

There were no reports of serious adverse events in any of the studies included in this analysis


3.For certain orthopedic conditions, RCTs on ESWT were the predominant type of RCT listed in the PEDro database and/or obtained the highest PEDro scores among all investigated treatment modalities.

Type of RCT and highest PEDro scores (as compared to all other treatment modalities) were fulfilled for plantafasciopathy, non-calcific supraspinatus tendinopathy, and calcific tendonitis of the shoulder.  RCTs for Achilles tendinopathy and lateral epicondylitis also ranked high.  There were not enough RCTs for ESWT to draw meaningful conclusions regarding greater trochanteric pain syndrome, patellar tendinopathy, knee osteoarthritis, long bone fracture, osteonecrosis of the femoral head, proximal hamstring tendinopathy, long bicipital tenosynovitis, myofascial pain syndrome, myogelosis of the masseter muscle, and spasticity.


4.There was no difference in the ‘quality’ of RCTs on ESWT in PEDro with positive or negative outcomes.


5.Application of local anesthesia adversely affects outcome of ESWT.

The molecular mechanisms underlying this phenomenon are not yet fully understood, but substantial evidence points to a central role of the peripheral nervous system in mediating molecular and cellular effects of shock waves applied to the musculoskeletal system. These effects could be blocked by local anesthesia. Thus, it is now generally recommended to apply shock waves without local anesthesia to the musculoskeletal system.


6.Application of insufficient energy adversely affects outcome of ESWT.

RCTs that showed positive outcomes for rESWT & fESWT for calcifying tendonits of the shoulder used 2.6x more energy flux density (EFD) than studies that showed a negative outcome.   For plantarfasciopathy, positive studies used two times the EFD as negative RCTs.  A similar finding was also made when comparing studies for Achilles tendinopathy.


7.There is no scientific evidence in favour of either rESWT or fESWT with respect to treatment outcome.

It appears that success is more dependent upon sufficient EFD than with the type of ESWT.


8.The distinction between radial ESWT as ‘low-energy ESWT’ and focused ESWT as ‘high-energy ESWT’ is not correct and should be abandoned.

Different authors have used different thresholds for categorizing ‘high’ and ‘low’ energy.  Because there is no consensus in the literature, this distinction appears arbitrary and should be abandoned.


9.There is no evidence that a certain fESWT technology is superior to other technologies.

Focused shock waves can be produced by electrohydraulic, electromagnetic, and piezoelectric shock wave generators.  The RCTs on fESWT in PEDro do no indicate an advantage of a certain fESWT technology over other technologies.


10.An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest EFD that can be applied.

This recommendation is based on the average number of treatment sessions and the average interval between treatment sessions among all RCTs on ESWT in PEDro. With respect to the EFD of the impulses (to be as high as possible, i.e. what can be tolerated by the individual patient without application of local anesthesia), this recommendation is based on findings of one study on rESWT for plantar fasciopathy with positive outcome and another study on fESWT for calcifying tendonitis of the shoulder with positive outcome that ‘more is better’. There is not a single RCT on ESWT in PEDro, contradicting this ‘more is better’ recommendation.


Wow!  I don’t feel like I even need a summarizing comment!  I love all of these statements!  I agree with all of these statements!  My clinical findings mesh very well with these statements!

So, I’ll just cut and paste some of the concluding statements from the paper.


ESWT has been proven as effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system in a multitude of high-quality RCTs.  Therefore, ESWT should be considered by medical doctors, therapists, patients and payers when discussing treatment options for certain musculoskeletal pathologies.


Tags: shockwave , shock wave , extracorporeal , safety , radial , focused , modalities

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