Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Emanuela Elena Mihai, Luminita Dumitru, Ilie Valentin Mihai, Mihai Berteanu, Emanuela Elena Mihai, Luminita Dumitru, Ilie Valentin Mihai, Mihai Berteanu

Abstract

The purpose of this systematic review and meta-analysis is to evaluate the long-term efficacy of Extracorporeal Shock Wave Therapy (ESWT) on reducing lower limb post-stroke spasticity in adults. A systematic electronic search of PubMed/ MEDLINE, Physiotherapy Evidence Database (PEDro), Scopus, Ovid MEDLINE(R), and search engine of Google Scholar was performed. Publications that ranged from January 2010 to August 2020, published in English, French, Spanish, Portuguese, and Italian language and available as full texts were eligible for inclusion and they were searched without any restrictions of country. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. Two authors screened the references, extracted data, and assessed the risk of bias. The primary outcome was spasticity grade mainly assessed by the Modified Ashworth Scale (MAS). Secondary outcomes were passive range of motion (PROM), pain intensity, electrophysiological parameters, gait assessment, and adverse events. A total of seven recent randomized controlled trials (RCTs) were included in the systematic review and meta-analysis, and a beneficial effect on spasticity was found. The high level of evidence presented in this paper showed that ESWT ameliorates spasticity considering the parameters: MAS: standardized mean difference (SMD) = 0.53; 95% confidence interval (95% CI): (0.07-0.99); Modified Tardieu Scale (MTS): SMD = 0.56; 95% CI: (0.01-1.12); Visual Analogue Scale (VAS): SMD = 0.35; 95% CI: (-0.21-0.91); PROM: SMD = 0.69; 95% CI: (0.20-1.19). ESWT presented long-term efficacy on lower limb post-stroke spasticity, reduced pain intensity, and increased range of motion. The effect of this novel and non-invasive therapy was significant and the intervention did not present adverse events, proving a satisfactory safety profile.

Keywords: extracorporeal shock wave therapy; hemiplegia; neurological rehabilitation; spasticity; stroke.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of the selection process of studies for the systematic review and meta-analysis according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Figure 2
Figure 2
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) for spasticity assessed by Modified Ashworth Scale (MAS) before and after extracorporeal shock wave therapy (ESWT) on the short-term. Wu et al. 2017a: radial ESWT (rESWT); Wu et al. 2017b: focused ESWT (fESWT); Tirbisch 2015a: soleus muscle assessment; Tirbisch 2015b: gastrocnemius muscle assessment; Lee et al. 2019a: follow-up at 30 min. after ESWT; Lee et al. 2019b: follow-up at one week after ESWT.
Figure 3
Figure 3
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) for spasticity assessed by Modified Ashworth Scale (MAS) before and after extracorporeal shock wave therapy (ESWT) on the long-term. Lee et al. 2019c: follow-up at four weeks after treatment; Taheri et al. 2017a: follow-up at three weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment; Tirbisch 2015a: soleus muscle assessment; Tirbisch 2015b: gastrocnemius muscle assessment; Wu et al. 2017a1: radial ESWT (rESWT) and follow-up at four weeks after treatment; Wu et al. 2017a2: radial ESWT (rESWT) and follow-up at eight weeks after treatment; Wu et al. 2017b1: focused ESWT (fESWT) and follow-up at four weeks after treatment; Wu et al. 2017b2: focused ESWT (fESWT) and follow-up at eight weeks after treatment; Yoon et al. 2017a: muscle belly application; Yoon et al. 2017b: myotendinous junction application.
Figure 4
Figure 4
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) for spasticity assessed by Modified Ashworth Scale (MAS) comparing the control group (CG) and the experimental group (EG) after extracorporeal shock wave therapy (ESWT) on the long-term. Lee et al. 2019c: follow-up at four weeks after treatment; Taheri et al. 2017a: follow-up at three weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment; Tirbisch 2015a: soleus muscle assessment; Tirbisch 2015b: gastrocnemius muscle assessment; Yoon et al. 2017a: muscle belly application; Yoon et al. 2017b: myotendinous junction application.
Figure 5
Figure 5
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) for spasticity assessed by Modified Ashworth Scale (MAS) comparing the control group (CG) and experimental group (EG) on the long-term. Sensitivity analysis. Lee et al. 2019c: follow-up at 4 weeks after treatment; Taheri et al. 2017a: follow-up at three weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment; Yoon et al. 2017a: muscle belly application; Yoon et al. 2017b: myotendinous junction application.
Figure 6
Figure 6
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) for spasticity assessed by Modified Tardieu Scale (MTS) before and after extracorporeal shock wave therapy (ESWT) on the long-term. Yoon et al. 2017a: muscle belly application; Yoon et al. 2017b: myotendinous junction application.
Figure 7
Figure 7
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating the short-term and long-term effects on pain intensity assessed by Visual Analogue Scale (VAS) before and after extracorporeal shock wave therapy (ESWT). Taheri et al. 2017: follow-up at one week after treatment; Taheri et al. 2017a: follow-up at three weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment.
Figure 8
Figure 8
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating the short-term and long-term effects on pain intensity assessed by Visual Analogue Scale (VAS) comparing the control group (CG) and experimental group (EG) after extracorporeal shock wave therapy (ESWT). Taheri et al. 2017: follow-up at one week after treatment; Taheri et al. 2017a: follow-up at three weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment.
Figure 9
Figure 9
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating long-term effects on pain intensity assessed by Visual Analogue Scale (VAS) comparing the control group (CG) and the experimental group (EG) after extracorporeal shock wave therapy (ESWT). Taheri et al. 2017a: follow-up at three weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment.
Figure 10
Figure 10
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating the short-term effects for Timed Up and Go Test (TUG) before and after extracorporeal shock wave therapy (ESWT). Radinmehr et al. 2017c1: follow-up immediately after treatment; Radinmehr et al. 2017c2: follow-up at 1 h after the end of treatment; Radinmehr et al. 2019c1: follow-up immediately after treatment; Radinmehr et al. 2019c2: follow-up at 1 h after the end of treatment.
Figure 11
Figure 11
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating the short-term effects on Hmax/Mmax ratio before and after extracorporeal shock wave therapy (ESWT). Radinmehr et al. 2017c1: follow-up immediately after treatment; Radinmehr et al. 2017c2: follow-up at 1 h after the end of treatment; Radinmehr et al. 2019c1: follow-up immediately after treatment; Radinmehr et al. 2019c2: follow-up at 1 h after the end of treatment.
Figure 12
Figure 12
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating the long-term effects on passive range of motion (PROM) before and after extracorporeal shock wave therapy (ESWT). Taheri et al. 2017a: follow-up at 3 weeks after treatment; Taheri et al. 2017b: follow-up at 12 weeks after treatment; Lee et al. 2019c: follow-up at four weeks after treatment.
Figure 13
Figure 13
Forest plot of the standardized mean difference (SMD) and 95% confidence interval (95% CI) evaluating short-term and long-term effects on passive range of motion (PROM) comparing focused extracorporeal shock wave therapy (fESWT) to radial extracorporeal shock wave therapy (rESWT). Wu et al. 2017c1: follow-up at 1 week after radial ESWT (rESWT) and focused ESWT (fESWT); Wu et al. 2017c2: follow-up at 4 weeks after radial ESWT (rESWT) and focused ESWT (fESWT); Wu et al. 2017c3: follow-up at 8 weeks after radial ESWT (rESWT) and focused ESWT (fESWT).

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Source: PubMed

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