Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

Christoph Schmitz, Nikolaus B M Császár, Stefan Milz, Matthias Schieker, Nicola Maffulli, Jan-Dirk Rompe, John P Furia, Christoph Schmitz, Nikolaus B M Császár, Stefan Milz, Matthias Schieker, Nicola Maffulli, Jan-Dirk Rompe, John P Furia

Abstract

Background: Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

Sources of data: This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

Areas of agreement: ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

Areas of controversy: The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

Growing points: There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

Areas timely for developing research: Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Keywords: ESWT; PEDRo; RSWT; musculoskeletal system.

© The Author 2015. Published by Oxford University Press.

Figures

Fig. 1
Fig. 1
Working principle of focused and radial extracorporeal shock wave technology. In case of focused shock waves, single acoustic pulses are generated either with a spark-gap (electrohydraulic principle), a technology similar to a loudspeaker (electromagnetic principle) or piezocrystals (piezoelectric principle) (details are provided in Fig. 2). By means of reflectors of certain shape, the acoustic pulses are converted into a focused acoustic pressure wave/shock wave with a point of highest pressure at the desired target within pathological tissue. In case of radial shock waves, a projectile is fired within a guiding tube that strikes a metal applicator placed on the skin. The projectile generates stress waves in the applicator that transmit pressure waves into tissue. It is of note that any disturbance in the pathway of the acoustic pulses between a focused shock wave source and the target within tissue (such as bone, calcifications, etc.; grey dots in the figures) may result in some parts of the acoustic pulse not reaching the target and, thus, weakening the shock wave energy (i.e. the energy flux density) at the target. The same disturbances would not impact the energy of radial shock waves at the target. This is most probably the reason why in muscle tissue, the energy of focused shock waves was found to be decreased by >50% compared with measurements in water, whereas for radial shock waves, measurements in muscle tissue and water were consistent.
Fig. 2
Fig. 2
Schematic representation of the mode of operation of focused (A–C) and radial (D) extracorporeal shock wave generators. (A) Electrohydraulic principle (fESWT): a high voltage discharges rapidly across two electrode tips (spark-gap) (1) that are positioned in water. The spark-gap serves as the first focal point (1). The heat generated by this process vaporizes the surrounding water. This generates a gas bubble centered on the first focal point, with the gas bubble being filled with water vapor and plasma. The result of the very rapid expansion of this bubble is a sonic pulse, and the subsequent implosion of this bubble causes a reverse pulse, manifesting a shock wave. By means of reflectors of certain shape (2), this shock wave can be converted into a convergent/focused acoustic pressure wave/shock wave with a point of highest pressure at the second focal point (3). (B) Electromagnetic principle (fESWT): a strong, variable magnetic field is generated by passing a high electric current through a coil (4). This causes a high current in an opposed metal membrane (5), which causes an adjacent membrane (6) with surrounding liquid to be forced rapidly away. Because the adjacent membrane is highly conductive, it is forced away so rapidly that the compression of the surrounding liquid generates a shock wave within the liquid. By means of an acoustic lens (7) of certain shape, this shock wave can be converted into a convergent/focused acoustic pressure wave/shock wave with a point of highest pressure at a focal point (8). (C) Piezoelectric principle (fESWT): a large number of piezocrystals (9) are mounted in a bowl-shaped device (10); the number of piezocrystals can vary from a few to several thousands (typically between 1000 and 2000). When applying a rapid electrical discharge, the piezocrystals react with a deformation (contraction and expansion), which is known as the piezoelectric effect. This induces an acoustic pressure puls in the surrounding water that can steep into a shock wave. Because of the design of the bowl-shaped device an acoustic pressure wave/shock wave can emerge with a point of highest pressure at a focal point (11). (D) Ballistic principle (rESWT): compressed air (pneumatic principle; 12) or a magnetic field (not shown) is used to fire a projectile (13) within a guiding tube (14) that strikes a metal applicator (15) placed on the patient's skin. The projectile generates stress waves in the applicator that transmit pressure waves into tissue (16).
Fig. 3
Fig. 3
Systematic review flow chart of the first literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. *, one study addressed both radial and focused ESWT and, thus, was listed in both categories rESWT+ and fESWT+.
Fig. 4
Fig. 4
Mean and standard error of the mean (SEM) of the number of treatment sessions (A), interval between treatment sessions (B), number of impulses per treatment session (C), energy flux density of the impulses (D), total energy flux density that was applied (E) and the PEDro score of all RCTs on radial (rESWT) and focused (fESWT) extracorporeal shock wave therapy with positive (+) or negative (−) outcome listed in the PEDro database (deadline: May 17, 2015). Details are provided in the main text.

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