Extracorporeal Shockwave Therapy

Does a systematic review of the literature (2017-2020) justify it being

taught to physical therapy students?

Ægir Óli Kristjánsson

Thesis for the degree of Master of Science in Physical Therapy

Maí 2021
 Höggbylgjumeðferð
Réttlætir kerfisbundin samantektarrannsókn á greinum birtar 2017-2020
að sjúkraþjálfunarnemum sé kennt um meðferðina?

Ægir Óli Kristjánsson

Ritgerð til meistaragráðu í sjúkraþjálfun

Fjöldi eininga: 30

Umsjónarkennari: Sólveig Ása Árnadóttir

Leiðbeinandi: Abigail Grover Snook

Námsbraut í sjúkraþjálfun

Læknadeild

Heilbrigðisvísindasvið Háskóla Íslands

Maí 2021
 Extracorporeal Shockwave Therapy
Does a systematic review of the literature (2017-2020) justify It being taught to
physical therapy students?

Ægir Óli Kristjánsson

Thesis for the degree of Master of Science in Physical Therapy

Number of credits: 30

Supervisor: Sólveig Ása Árnadóttir

Advisor: Abigail Grover Snook

Department of Physical Therapy

Faculty of Medicine

School of Health Sciences

May 2021
Thesis for Master degree in Physiotherapy at the University of Iceland. No part of this
publication may be reproduced in any form without the prior permission of the copyright
holder.
© Ægir Óli Kristjánsson 2021

Reykjavík, Iceland 2021

 Ágrip
Markmið: Þessi rannsókn hefur það markmið að meta gögn sem benda til notkunar
höggbylgjumeðferðar (ESWT) með tilliti til orkuflæðis þéttleika, óháð greiningu eða vefjagerð sem
meðferð er beint að. Einnig til að meta hvort réttlætanlegt er að kenna sjúkraþjálfaranemum um
meðferðina.

Aðferðir: Kerfisbundin samantektarrannsókn á greinum af slembiröðuðum

samanburðarrannsóknum, birtum á árunum 2017 til 2020. PRISMA leiðbeiningum var fylgt við
framkvæmd samanburðarrannsóknar. Gagnagrunnar sem leitað var í voru PubMed, PEDro og
Cochrane. Viðmið fyrir þáttöku voru notkun ESWT og samanburðarhóps, birting námkvæmra upplýsinga
um meðferðarbreytur eins og orkuflæðiþéttni, tíðni, fjöldi höggbylgja í meðferðarlotu og lengd meðferðar.
Hætta á hlutdrægni og nýmundun gagna framkvæmd á greinum sem voru skoðaðar.

Niðurstöður: Tuttugu rannsóknir voru valdar til skoðunar. Það eru sterkar, rökstuddar sannanir fyrir
notkun ESWT, óháð greiningu. Niðurstöður benda til þess að öll svið orkuþéttni sýni áberandi jákvæðar
niðurstöður. Meðalhætta á hlutdrægni er til staðar í athugunum á rannsóknum.

Umræður og niðurstöður: Vísbendingar fyrir virkni meðferðarinnar eru sterkar og rökstuddar og

byggðar á nýlegum rannsóknum. Eldri samantektarrannsóknir segja frá misvísandi niðurstöðum við
sumar niðurstöður greinar en eru í samræmi við aðrar niðurstöður.

Höfundur mælir með því að kerfisbundnar samantektarrannsóknir skilgreini þáttöku og útilokunar

skilyrði frekar til að skoða eitt orkusvið til að koma á framfæri skýrum göngum fyrir rökstuddum
ráðleggingum um bestu notkun byggða á gögnum.

Mælt með kennslu um rafmagnstæki fyrir alla sjúkraþjálfunarnema þar sem þekking og innsýn er
grunnur fyrir frekari þróun meðferðarúrræða og notkunar í framtíðinni.

1
2
 Abstract
Objective: This study aims to evaluate the evidence for the use of extracorporeal shockwave therapy
(ESWT) based on energy flux density range, regardless of diagnosis or tissue type targeted, and to
determine if it is justifiable to teach physical therapy students about the modality.

Methods: A systematic review of randomised controlled trials from 2017 to 2020 following PRISMA
guidelines was conducted on the PubMed, PEDro and Cochrane databases. Inclusion criteria included
reporting on ESWT and a control group and giving detailed treatment parameters such as energy flux
density, frequency, number of shocks per session and length of treatment. Risk of bias assessment and
data synthesis on the articles chosen for review was performed.

Results: Twenty articles were chosen for the review. There was strong, substantiated evidence for
the use of ESWT, regardless of diagnosis. Evidence suggested that all energy flux density ranges show
strong, substantiated evidence but mid-range level showed prominently more positive results. Moderate
level risk of bias was present in the studies reviewed.

Discussion and conclusion: Evidence for the efficacy of ESWT was strong and substantiated within
the recent literature (2017-2020). Older systematic reviews reported conflicting results on some
diagnoses but were consistent with other diagnoses reviewed when compared to the current study.
Future systematic reviews will need to define inclusion and exclusion criteria further using a single
energy level range to establish clear evidence for substantiated recommendation for the optimal use of
the modality in practice. The evidence would suggest that ESWT be taught to physical therapy students
as knowledge and insight are a foundation for further development of treatment opportunities and uses
for modalities.

3
4
 Acknowledgements
Thanks to my advisor, Abby Snook, for her seemingly unending patience and helpfulness and
my girlfriend, Saga Hilma, for putting up with me during the process of this project.

No funding to declare.

5
 Table of Contents

Contents
Ágrip .........................................................................................................................................................1

Abstract.....................................................................................................................................................3

Acknowledgements ..................................................................................................................................5

Table of Contents .....................................................................................................................................6

List of figures ............................................................................................................................................8

List of tables .............................................................................................................................................9

List of abbreviations ................................................................................................................................10

1 Introduction .....................................................................................................................................11

1.1 Radial and focused shockwaves ........................................................................................... 11

1.2 The effect of shockwaves on tissues ..................................................................................... 12

1.3 Parameters with shockwave therapy ..................................................................................... 13

1.4 Previous research on shockwave therapy ............................................................................. 14

2 Aims and objectives ........................................................................................................................15

3 Methods and Materials: ..................................................................................................................16

3.1 Eligibility criteria ..................................................................................................................... 16

3.2 Information sources and search strategy .............................................................................. 17

3.3 Selection process .................................................................................................................. 17

3.4 Data collection process and data items ................................................................................. 17

3.5 Effect measures ..................................................................................................................... 19

3.6 Synthesis ............................................................................................................................... 19

4 Results ............................................................................................................................................21

4.1 Study selection ...................................................................................................................... 21

4.2 Quality assessment ............................................................................................................... 22

4.3 Population characteristics ...................................................................................................... 24

4.4 Research parameters ............................................................................................................ 25

4.5 Outcome measure results ..................................................................................................... 27

4.6 Data synthesis ....................................................................................................................... 29

5 Discussion ......................................................................................................................................30

5.1 Main discussion ..................................................................................................................... 30

5.1.1 Implications and future directions .............................................................................. 31

6
 5.2 Strengths and limitations ....................................................................................................... 32

6 Conclusions ....................................................................................................................................33

References .............................................................................................................................................34

Attachments ............................................................................................................................................38

7
 List of figures
Figure 1 - Graph of pressure vs. time for radial and focused shockwaves ...................................... 11

Figure 2 - Different wave generation and target of shock waves ..................................................... 12

Figure 3 - Flow chart: Exclusion process of choosing papers. ......................................................... 21

8
 List of tables
Table 1 - Effects of energy dose on tendon tissue ........................................................................... 14

Table 2 - Inclusion and exclusion criteria ......................................................................................... 16

Table 3 - Risk of bias ........................................................................................................................ 23

Table 4 - Population characteristics of each article reviewed. ......................................................... 24

Table 5 - Treatment parameters for each article, as well as pathology ........................................... 26

9
List of abbreviations
ESWT – -extracorporeal shockwave therapy

rESWT – radial extracorporeal thockwave therapy

fESWT- focused extracorporeal shockwave therapy

VEGF – vascular endothelial growth factor

SCI – spinal cord injury

Hz – Hertz

mm – millimeter

mJ – millijoule

RCT – randomized controlled trial

PF – plantar fasciitis

AT – Achilles Tendinopathy

PT – patellar tendinopathy

SPS – spasticity post stroke

SCP – spasticity, cerebral palsy

SAPS – subacromial pain syndrome

MPS – myofascial pain syndrome

KOA – knee osteoarthritis

GTPS – greater trochanter pain syndrome

MTSS – medial tibial stress syndrome

SIJP – sacroiliac join pain

CC – claudication

10
1 Introduction
Extracorporeal shockwave therapy (ESWT) is a more recent modality in physical therapy and has been
used to treat orthopedic conditions over the last two decades (Prentice & Thigpen, 2018). In the
beginning, it was used to treat mostly musculoskeletal conditions by physical therapists and by other
medical professionals (e.g., urologists using shockwaves to treat kidney stones (Thiel et al., 2000)). In
more recent years, it has, however, been tested on other conditions such as spasticity in stroke patients
and erectile dysfunction in men (Fojecki et al., 2017) (Xiang et al., 2018). Despite some evidence for its
effectiveness in treating musculoskeletal conditions, spasticity and erectile dysfunction, there also
appears to be conflicting evidence that does not show the same effect when similar studies are done
(Speed, 2014).

1.1 Radial and focused shockwaves

Shock waves are sound waves with very high peak-pressure amplitudes with rise time of less than 10
nanoseconds and a short lifecycle (10 milliseconds) and a broad frequency spectrum (15-20 Hz) (Ogden
et al., 2001). This describes the characteristics of focused extracorporeal shockwave therapies (fESWT)
as radial extracorporeal shockwave therapies (rESWT) have considerably different physical
characteristics. rESWT, sometimes also called radial pressure waves, have a considerably lower
pressure but over longer time (Dymarek et al., 2014). Radial shock waves tend to have less energy and
so produce less pressure and they last longer while focused shock waves have higher energy, generate
more pressure, and dissipate faster. (See Figure 1 for a graph of both with respect to pressure and
time.)

Figure 1 - Graph of pressure vs. time for radial and focused shockwaves, MPa = MegaPascal; ms
= millisecond; µsec = microsecond (attribution) (Venn Healthcare 2020)

11
 Focused shock wave devices generate energy electromagnetically, electro-pneumatically, or
piezoelectrically which has a small focus area with the maximum energy output targeting up to 12
centimeters subcutaneously (Shrivastava & Kailash, 2005). The energy generated with a fESWT
machine is then delivered to a small point, resulting in more energy in a smaller space. This method has
been used in the treatment of kidney stones for example. When using shockwaves to treat kidney stones
the goal is to get rid of unwanted material without the destruction of the targeted tissue. Each of the
energy generation methods have a different penetration depth and focal volume so, when targeting
different sites or tissues, one method might be better suited than another. Radial shock wave devices,
on the other hand, are most often pneumatically actuated, but can also be electromagnetically
generated, and develop their maximum energy at the skin surface and distribute it radially into the tissue
(Staritz et al., 1989). An advantage of this method over fESWT is that a larger volume of tissue can be
treated and the lower pressure generated has less destructive effect on the tissue targeted (Lohrer et
al., 2010). See Figure 2 for a representation of how the energy is distributed as well as a demonstration
of the difference between rESWT and fESWT as to how the shockwaves spread and how the energy
flux density differs between the modalities (Prentice & Thigpen, 2018). Additional effect of delivering
less pressure over longer time is the reduced chance for patient to require local anesthesia. Local
anesthesia has been shown to reduce the effects of ESWT so reducing the need for anesthesia would
also increase the desirable effects of the treatment (Klonschinski et al., 2011).

Figure 2 - Different wave generation and target of shock waves, (Kiessling, Milz, Frank, Korbel, &
Schmitz, 2015)

1.2 The effect of shockwaves on tissues

The effects of ESWT are different depending on the targeted tissue. The physiological concept is that
the tensile forces generated are stronger than the tensile strength of water and that this tensile force
generates bubbles in intracellular fluids (water). These bubbles can collapse and when they do, they
create microscopic high-energy water jets that heat up and damage the cell. This damage to the cells is
on a smaller scale than the original injury and only works to disrupt the chronic damage. This disruption
of the chronic damage works to restart the healing process and aid in recovery. This effect is highly
dependent upon the water content of the tissue that is being targeted (Prentice & Thigpen, 2018). The

12
water content of tissues is based on the intracellular matrix and water in the extracellular space. The
more water that is inside and between cells in a tissue, the more flow of nutrients and blood there is
(Prentice & Thigpen, 2018). ESWT has been shown to increase the cell permeability, increase flow of
water in tissues and improve the cellular environment for healing in vivo and in vitro (van der Worp et
al., 2013) (Alderfer et al., 2018). The effects of ESWT on tissues are the reasons different parameters
are used when treating ailments affecting different tissues. (Prentice & Thigpen, 2018).

ESWT is thought to have an effect on the interface between cancellous and cortical bone. It is
thought that the shockwave therapy causes cavitation in the tissue and increases cell permeability
allowing increased vascularity and bony regeneration (Prentice & Thigpen, 2018). Additionally, the local
increase in growth factor, neovascularization, and protein synthesis, in addition to the increase in
osteoprogenitor cells, suggests that shockwave therapy can improve the tissue environment for healing
to occur (Yamaya et al., 2014). There are dangers to using shockwave therapy on bone at higher
intensities, however, as the damage caused in the tissue can be too great and the body is unable to
overcome the damage. This damage can delay the healing and cause mechanical instability (Wang et
al., 2002). The process of tendon healing is thought to be the same as in bone but, instead of primary
healing taking place between cancellous and cortical bone, it is thought to take place between the
tendon and the bone (Wang et al., 2002).

There has been animal research conducted on the use of ESWT to encourage vascular growth by
stimulating vascular endothelial growth factor (VEGF) (Yamaya et al., 2014). The authors of this
experiment concluded that low-energy ESWT significantly increased expressions of VEGF in subjects
without any detrimental effect. ESWT also significantly reduced neuronal loss in damaged neural tissue
and improved locomotor function after spinal cord injury (SCI) (Yamaya et al., 2014). These results are
promising in the treatment of patients with SCI as the treatment is non-invasive and according to this
study, harmless. The parameters used in this research were 0.1 mJ/mm2 (2.5 bar is roughly 0.1 mJ/mm2
), 4 Hz with 200 shots per spot and 2 spots per treatment (Rompe, 2010). This was not a human trial
but performed on rats, but the results are none the less promising.

1.3 Parameters with shockwave therapy

Parameters are different for targeted tissue but, in Table 1 below, are explanations of the effects of
different amounts of energy flux density on tendon tissue. Levels above 0.28 mJ/mm 2 are not
recommended for treatment of tendons and have also shown to be harmful in the healing process of
bone (Prentice & Thigpen, 2018; Wang et al., 2002). The number of treatments, the interval between
treatments, the number of shocks/treatment and shock frequency are additional parameters that need
to be considered. A common treatment protocol for ESWT could be 3 sessions with 7 days between
each, 0.15 mJ/mm2 at 2000 pulses per session at frequencies between 5-15 Hz, depending on the
pathology and rESWT or fESWT (International Society for Medical Shockwave Treatment, 2019). The
goal is to get a certain amount of energy to the target so there is an inverse relationship between intensity
of each shock and the number of shocks administered per session. Increasing one would require a
lowering of the other as to maintain the same total energy delivered. The effectiveness of shockwave
therapy is generally though to rely on a few factors. These factors are targeting the desired tissue and

13
delivering enough energy there in a short duration of time. The parameters give us the information on
these factors. The energy flux density (mJ/mm2), number of shocks per session and frequency (hertz)
informs the therapist as to the energy being delivered to the targeted tissue. The targeted tissue however
must be within the focal volume of the shock wave generating device. This focal volume can be
manipulated to make sure the energy is reaching its desired target (Prentice & Thigpen, 2018).

Table 1 - Effects of energy dose on tendon tissue

Energy flux density Effect on tendon Proposed Classification

0.08 mJ/mm2 No effect seen Low

0.28 mJ/mm2 Transient swelling Medium
0.60 mJ/mm2 Paratendious inflammation and increase in High
diameter of tendon

1.4 Previous research on shockwave therapy

There is some evidence for the use of ESWT in bone fractures (Wolfl et al., 2017), tendopathies (Wang,
2012) such as plantar fasciitis, lateral epicondylitis, Achilles tendinopathy and others as well as reducing
spasticity in stroke patients (Xiang et al., 2018). Recent application for the modality is also to use it on
Peyrione’s disease, erectile dysfunction and chronic pelvis pain in men and there is some evidence for
use in these patients (Fojecki et al., 2017).

It would be of interest to look at the research published from beginning of 2017 till the end of
2020. The reason for that is that there are several systematic reviews published around 2017 and earlier
that state a need for clearer reporting on treatment protocols, having a better quality of studies to review,
comparison between fESWT and rESWT and having a longer follow-up period (Fojecki et al., 2017;
Huisstede et al., 2018; Korakakis et al., 2018; Mani-Babu et al., 2015; Roerdink et al., 2017; Schmitz et
al., 2015). Mani-Babu et.al. determined ESWT to be an effective intervention for lower limb
tendinopathies, but suggested more robust RCTs with larger sample sizes, control groups, and objective
functional tests are needed to build upon the limited/moderate evidence that is currently available (Mani-
Babu et al., 2015). Studies on the effect of ESWT on spasticity have, likewise, reported positive findings
but also concluded that there was a need for further meta-analysis with well-designed and large-scale
RCTs (Guo et al., 2017). Reviewing RCTs from the years following these publications, it is fair to
assume that reporting on treatment protocols may be more detailed and would allow for synthesis of
these factors that earlier systematic reviews claimed were lacking.

In recent years, the information and knowledge on the best practice and use of ESWT in clinical
settings has improved. Earlier there were still gaps as to what kind of treatment parameters worked best
on different tissues and pathologies. More recent studies have made a conscious effort to research the
effect of parameters to fill this void of knowledge (Liao et al., 2018; Stania et al., 2019; Thiele et al.,
2015).

14
2 Aims and objectives
The aim of this systematic review of recent literature is to evaluate the latest evidence from 2017-2020
for the use of ESWT with particular interest in treatment parameters. When reviewing the parameters
used, the reviewer can identify further where the evidence leads with regard to optimal parameters and
treatment protocols. The aim was to examine the effectiveness of ESWT for a variety of pathologies,
comparing the modality with a control group to single out the use of shockwave therapy as the
independent variable.

The clinical usage of this these is to provide current evidence of the optimal use in the treatment of
different pathologies and tissues to both clinicians and teachers. With the assessment of current
evidence for the use of ESWT, teachers are more able to weigh whether a modality should be taught to
students. That leads to the question, should ESWT be taught to students in physical therapy?

15
3 Methods and Materials:
A systematic review of recent literature was performed according to the PRISMA (preferred Reporting
Items for Systematic Reviews and Meta-Analyses) guidelines (Page et al., 2021). To achieve a good
overview of the outcomes and statistically significant efficacy of a modality, a systematic review is a
good approach if performed with diligence and good guidelines.

3.1 Eligibility criteria

Table 2 indicates the inclusion and exclusion criteria that were applied during the review.
Table 2 - Inclusion and exclusion criteria
Inclusion Criteria Exclusion Criteria
Study Type Randomized controlled trials Systematic reviews
Randomized clinical trials Meta analyses
Published from January 2017 to Cohort studies
December 2020 Case studies
Studies published before January
1st, 2017.
Population Adults 18-99 Animal studies
Children, aged 5-18 Population that has not given
informed consent
Intervention Extra-corporeal shock wave therapy Lack of a control group
- Focused Comparing ESWT to another modality
- Radial (e.g., Ultrasound)
Control group
- Placebo
- Sham-therapy
- Standard care
Treatment Reporting of relevant parameters Not reporting on energy flux density
such as OR
- Shock Frequency (Hertz) Not reporting on 2 of the other
- Shocks per session parameters
- energy flux density
(mJ/mm2 or bars)
- Length of therapy
- Number of sessions
Outcomes Pain, recorded with a measurement Outcome measures not directly
tool related to pain assessment,
movement, or mobility.
Movement, mobility, or other
clinically relevant outcomes that
relate to physical therapy

16
Articles being searched for were randomized controlled trials and clinical trials of ESWT as a modality
on any pathology, tissue type, or population. Inclusion criteria included that there must be a control
group present. Control groups could receive either placebo, sham-therapy or standard care. Studies
that only compared ESWT to another modality (e.g., ultra-sound) were excluded as, without a control
group, the researchers are unable to make a claim as to whether the condition would have improved
with or without treatment. Furthermore, studies must have presented information on parameters used
for each shock wave treatment, the population, ailments, tissue types targeted, length of treatment,
outcome measures and follow-up duration. Incomplete data on more than one of these excluded a study
from review. Some leeway was given to inclusion of an article if one of the parameters are missing but
others were given, or if one of the two outcome measures were not a part of the study. The studies
selected had a publishing date from the beginning of 2017 to the end of 2020, spanning a 4-year period.
Any studies earlier than that were not included as previous systematic reviews should include any
articles worth reviewing.

3.2 Information sources and search strategy

An electronic search was performed on three databases (PubMed, PEDro and Chochrane) using
appropriate search terms. Terms for searching PubMed were as follows: (ESWT OR "shock wave
therapy" ) AND (2017 OR 2018 OR 2019 OR 2020) AND ("randomized control" OR "placebo" OR
"control" OR systematic" OR "SR" OR "review"). Terms for searching PEDro were: ESWT since 2017
and terms for Cochrane were: ESWT. Some of these search engines allowed for manipulating of the
search criteria without changing the search terms and this was done to some degree in all three
databases. Manipulations of search criteria included excluding animal studies, specifying the publication
range or specifying a research method if it was not stated in the search terms.

3.3 Selection process

When databases had been searched, the results were screened for inclusion criteria and duplicates.
The first screening removed any results that were outside of the publishing window chosen for this study
as well as any studies that did not include a control group or did not appear to have a full-text available
online for further reading. The second screening aimed to remove any duplicates and the third screening
evaluated the information present regarding the therapeutic parameters and population information. Any
articles remaining after this were subject to a full text reading and data extrapolation. Exclusion criteria
from previous scans still applied. Less important information that was missing was evaluated on a case-
by-case basis and consequently marked as such in the results chapter and/or tables.

3.4 Data collection process and data items

All data was gathered and reviewed by one reviewer. Data items gathered from articles chosen for
review were population information, intervention parameters and targeted tissues and pathologies,
general information on the papers and outcome measures. Population information consisted of age
range, number of participants, allocation into intervention and control groups and gender ratio.
Intervention parameters were shocks per session, frequency in hertz, energy flux density (mJ/mm2 or
bars, then converted to mJ/mm2), duration of treatment, length of study and type of shock waves

17
administered (radial or focused). Targeted tissues in the study as well as pathologies were also
recorded. Author name and publication year were also recorded. The outcome measures chosen were
pain (measured with visual analog scale (VAS), numeric rating scale (NRS), Western Ontario and
McMaster Universities osteoarthritis index (WOMAC), pressure pain threshold (PPT), thermometer pain
scale (TPS) and pain-free walking distance (PFWD)) and movement and/or mobility. The latter category
was intentionally broad as no homogeneity was present among articles that study this specific modality.
Some examples of movement and/or mobility measures were the following instruments:

ROM - range of motion

PROM - passive range of motion

HHS - Harris hip score

LEFS - lower extremity function score

EQ-5D - Euro quality of life 5 Dimension

MAS - modified Ashworth scale

FMA - Fugl-Meyer assessment

WOMAC - Western Ontario and McMaster Universities osteoarthritis index

Lequesne

MFC - modified house function classification

AOFAS - American Orthopedic Foot and Ankle Society score

SPADI - shoulder pain and disability index

BSHS-B - burn specific health scale - brief

MWD - maximum walking distance

VISA-P - Victorian Institute of Sport assessment – Pattela

ODI - Oswestry disability index

Running distance

MTS - modified Tardieu scale

proprioception

SF-36 - short-form 36

Six of the seven risk assessment criteria from The Cochrane Collaboration’s Tool for Assessing Risk of
Bias in Randomised Trials were chosen as the reviewer did not feel adequate to judge “other bias”, the
seventh criteria (Higgins, 2011). Risk of bias assessment was performed on six fields of possible bias.

18
These fields were random sequence generation, allocation concealment, blinding of participation,
blinding of personnel, blinding of outcome assessment and incomplete outcome data (Higgins, 2011).
These fields were chosen as they were relevant to the bias of the articles, as well as evaluators
confidence in being able to accurately assess these factors.

Points were assigned to each criteria based on the study meeting the standards set in the
Cochrane assessment tool, not meeting the standards, or if it was unclear. Meeting the standard means
a low (+) risk of bias and scores 2 points for said criteria. If it is unclear if the article meets the criteria or
not, it is rated unclear (?) and scores 1 point. If it is clear the article does not meet the criteria it is rated
a high (-) risk of bias and scores 0 points (Higgins, 2011). Given the scoring mentioned and the 6 criteria,
each article could score a maximum of 12 points. Low risk of bias for an article was defined as scoring
10 or more points out of 12 possible points. Medium risk of bias was defined as scoring between 8 to
10 points out of 12 possible. High risk of bias was defined as scoring fewer than 8 points out of the 12
possible total points (Harniman et al., 2004).

A similar standard was used for the overview of all the articles together. Articles with a high risk
of bias overall were scored 0 points, with a medium risk of bias were scored 1 point, and with a low risk
of bias were scored 2 points. For example, if 20 articles were combined, the maximum score would be
40 points. In this case, if the overview score was 32 or more points out of 40 possible, the overall risk of
bias would be considered low. Score of 24 to 31 would result in a medium risk of bias and any fewer
points than 24 would result in a high risk of bias from the selection.

3.5 Effect measures

Of the outcome measures that were looked at and reported in this thesis, the effect of the treatment
over control group was evaluated by the p values presented in the articles, where significance was most
often set at 95% CI or p <.05 . This data was gathered from the articles as results and were presented
in a table as ESWT either contributing a statistically significant improvement to the rehabilitation process
of patients or not.

3.6 Synthesis
Data was extracted by the reviewing researcher and put into tables for ease of viewing and interpreting.
The information was presented in separate tables, showing the demographic, the parameters, and the
effect on the outcome. To calculate the effectiveness of the modality over non-use or a control group,
results from each trial were gathered and marked within the table.

A synthesis of the data was performed with respect to the energy flux density levels, separated
into low, medium, and high ranges. Low energy flux density range was defined as <0.08 mJ/mm2,
medium energy flux density range was defined as 0.08 – 0.28 mJ/mm2 and high energy flux density
range was defined as >0.28 mJ/mm2. While there is no standard definition for these ranges, they are
commonly accepted and used frequently in research (Ioppolo et al., 2013; J.-D. et al., 2007;
Mouzopoulos et al., 2007; Rompe et al., 1998). The energy flux density reported in each article was
noted and used to determine what range (low, medium, high) was used. If an article cited energy flux
density that spanned two or more ranges, it was marked into all applicable levels as there was no way

19
for an outside reviewer to assess what ranges were effective in treatment. Therefore, the total data
points in the synthesis were expected to exceed the total number of articles applicable for review.

The goal of the synthesis was to be able to provide a statement on where the evidence leads and
how strongly it does so. First of all, research can be classified into 4 classes:

- Class 1 represents RCTs and is of the highest quality.

- Class 2 represents studies with an active intervention and control groups but without
randomization.
- Class 3 represents studies with an active intervention but without a control group.
- Class 4 represents other studies that do not fall into any of the other classes, such as
observational studies, case control studies, cohort studies or case studies (Michlovitz & Nolan
Jr, 2016).

The current systematic review only looked at Class 1 evidence.

Next, the strength of the evidence was evaluated. The proportion of studies is then used as a basis
for the strength of the evidence:

- Strong evidence is when 50% or more of the studies are in class 1.

- Moderate evidence is when greater than 50% of the studies are class 1, 2 or 3.
- Weak evidence is when greater than 50% of the studies are in class 4.
- Lack of evidence is when there are fewer than five studies reporting on the outcomes(Michlovitz
& Nolan Jr, 2016)

Finally, the therapeutic effectiveness was classified as follows:

- Substantiated: when the number of studies reporting improvement is greater or equal to 60%
- Conflicting: when the number of studies reporting improvement is between 40% and 60%
- Unsubstantiated: the number of studies reporting improvement is less than 40%
- Lack of evidence: when there are fewer than five studies of any type.
(Belanger, 2009; Michlovitz & Nolan Jr, 2016)

20
 4 Results
4.1 Study selection
This systematic review included 20 trials. Flow chart 1 provides the flow diagram of the search and
selection process. All the trials that met the inclusion criteria presented in Table 3 were assessed and
included.

Figure 3 - Flow chart: Exclusion process of choosing papers. ESWT = extracorporeal shockwave
therapy; RCT = randomized controlled trial

21
4.2 Quality assessment
The RCTs revealed a mixed risk of bias. Table 3 provides a detailed overview of biases per study.
This was performed in accordance with the Cochrane handbook for systematic reviews of interventions,
version 5.1.0. (Higgins, 2011).

Generally, these studies eliminated risk of bias with regards to random sequence generation,
allocation concealment and incomplete data well but the other areas of risk of bias presented more
mixed results. Blinding of personnel seemed to be the most difficult to eliminate the risk of bias since
the personnel applying the modality is generally aware of their actions but there are precautions that
can be taken and were in a minority of studies.

Half of the studies, or ten, presented with a low risk of bias (earning 2 points each), six studies
presented with a medium risk of bias (earning 1 point each), and 4 presented with a high risk of bias
(earning 0 points). When all the scores were added together (26 points) and were divided by the total
number of points possible (40 points) the overall risk of bias was considered being a medium level of
risk of bias based on the system used. Therefore, some caution should be exercised when assessing
the results.

22
 Table 3: Risk of bias

generation (selection

(performance bias)

Blinding of outcome
(performance bias)
Random sequence

(attrition bias)
(detection bias)

outcome data
concealment

incomplete
Blinding of

assessment
Allocation

personnel
participant
Blinding of
bias)
(Joo et al., 2020) ? + + - ? +
(Uysal et al., 2020) + + + + ? ?
(Cinar et al., 2020) + + + + ? +
(Ramon et al., 2020) + + + + + +
(Zhong et al., 2019) + + + + + +
(Guo et al., 2019) + + - - + +
(Farhan et al., 2019) + + - - - +
(Takla & Rezk, 2019) + + - + - +
(Aktürk et al., 2018) + + + + ? ?
(Vahdatpour et al., 2018) + + + - + +
(Samhan & Abdelhalim, 2019) + + + - + +
(Kvalvaag et al., 2018) + + + - + +
(Dolibog et al., 2018) + + - - - +
(Harwood et al., 2018) + + + - + +
(Akinoglu et al., 2017) + + - - ? -
(Taheri et al., 2017) + + - - ? +
(Yoon et al., 2017) + + + - - +
(Moon et al., 2017; Thijs et al., 2017) ? + + - + +
(Moon et al., 2017) + + + - + +
(Gomez Garcia et al., 2017) + + - - + +

- signifies high risk of bias, + signifies low risk of bias, ? signifies unclear risk of bias

23
4.3 Population characteristics
The total number of articles was 20 with a total of 1161 participants, treating 6 different tissue types and
using both radial and focused shock waves. The order in which the articles are presented in Tables 4-6
is based on the range of energy used to treat going from low to high. Additional information on the
population characteristics of each article can be seen in table 4 below. Muscles and tendons were the
most targeted tissues and spasticity was the most common pathology, followed by plantar fasciitis.
Studies were mostly on adults, aged 30 to 70 and women were better represented in the population.

Table 4: Population characteristics of each article reviewed.

Research Article Tissue targeted Pathology R/F Size (study/control) Age Gender (f/m)
(Kvalvaag et.al. 2018) tendon SPS R 143(74/69) 25-70 78/65
(Cinar et.al. 2020) fascia PF R 44 (23/21) 36-55 40/4
(Takla et.al. 2019) fascia PF F 52 (27/25) 43-66 24/28
(Farhan et.al. 2019) muscles SCP R 32(16/16) 5-15 15/17
(Samhan et.al. 2018) skin Burn F 45 (22/23) 18-55 23/22
(Joo et.al. 2020) skin Burn F 48 (23/25) 36-60 3/45
(Yoon et.al. 2017) muscle SPS F 124 (90/34) 40-80 6/118
(Aktürk et.al. 2018) muscles and fascia MPS R 40 (20/20) 18-60 27/13
(Uysal et.al. 2020) bone KOA R 104 (52/52) 50-70 85/19
(Guo et.al. 2019) muscles/tendons SPS R 60 (30/30) 34-75 38/32
(Moon et.al. 2017) bone SAJP F 25 (14/11) 30-80 21/4
(Taheri et.al. 2017) muscle SPS F 25 (13/12) 40-65 12/13
(Zhong et.al. 2019) cartilage/bone KOA R 63 (32/31) 55-70 40/23
(Harwood et.al. 2017) muscles CC F 30 (15/15) 50-70 12/18
(Dolibog et.al. 2018) skin Ulcers F + R 50 (17r/15f/18c) 59-80 33/17
(Ramon et.al. 2020) tendon GTPS F 103 (53/50) 44-60 58/45
(Thijs et.al. 2017) tendon PT F 52 (22/30) 18-45 14/38
(Garcia et.al. 2017) bone, muscle MTSS F 42 (23/19) 18-30 9/33
(Vahdatpour et.al. 2018) tendon AT F+R 43(22/21) 18-70 35/8
(Akinoglu et.al. 2017) fascia PF R 36 (18/18) 39-59 36/0
SPS – Spasticity post stroke; SCP – Spasticity, cerebral palsy; PT – patellar tendinopathy; AT – Achilles
Tendinopathy; PF – plantar fasciitis; MPS – Myofascial pain syndrome; KOA – Knee osteoarthritis; GTPS – Greater
trochanter pain syndrome; MTSS – Medial tibial stress syndrome; SIJP – Sacroiliac join pain; CC – Claudication; R
– Radial; F – Focused; f – female; m - male

24
4.4 Research parameters
Table 5 provides the treatment parameters for each article. Duration of treatment is the length of the
active treatment protocol and the length of the study refers to the time from the start of treatment until
the final measurements. The frequency range for the selected studies was between 2 and 16 with most
reporting a frequency between 4 and 8 Hz. The energy flux density ranged from .01 mJ/mm 2 to .35
mJ/mm2 with most studies in the low and medium ranges. The most common impulses per session were
2000 impulses per session. Majority of the studies treated once per week for 3 weeks and follow-up
ranged from the duration of the treatment or 3 weeks and 12 months, with most following up the results
for 2-3 months from the beginning of treatment.

25
 Table 5 Treatment parameters for each article, as well as pathology

Impulses per Duration of Length of

Research article Pathology Hz Energy flux density Range session treatment study
2000 per
(Kvalvaag et.al. tendon 1x a week, 4
2018) SPS - 0.01-0.35 mJ/mm2 L/M/H targeted weeks 12 months
1x a week, 3
(Cinar et.al. 2020) PF - 0.02 mJ/mm2 L 2000 weeks 3 months
1x a week for
(Takla et.al. 2019) PF 4 0.02-0.28 mJ/mm2 L/M/H 2000 3 weeks 12 weeks
800 per
(Farhan et.al. muscle, 5200 1x a week for
2019) SCP 10 0.03 mJ/mm2 L total 8 weeks 2 months
(Samhan et.al. 1x a week, 4
2018) Burn 4 0.05-0.20 mJ/mm2 L/M 1000-2000 weeks 4 weeks
1x a week, 4
(Joo et.al. 2020) Burn 4 0.05-0.30 mJ/mm2 L/M/H 1000-2000 weeks 4 weeks
1x a week, 3
(Yoon et.al. 2017) SPS 5 0.068 -0.093 mJ/mm2 L/M 1500 weeks 3 weeks
(Aktürk et.al. 11- 4 sessions
2018) MPS 16 0.07-0.12 mJ/mm2 L/M 2000-3000 within 10 days 2 months
1x a week, 3
(Uysal et.al. 2020) KOA 10 0.09-0.12 mJ/mm2 M 2000 weeks 3 months
5x a week, 4
(Guo et.al. 2019) SPS 8 0.09-0.12 mJ/mm2 M 2000 weeks 12 months
(Moon et.al. 2017) SIJP 3 0.09-0.25 mJ/mm2 M 2000 1 session 4 weeks
(Taheri et.al. 1x a week, 3
2017) SPS 4 0.1 mJ/mm2 M 1500 weeks 12 weeks
(Zhong et.al. 1x a week, 4
2019) KOA 8 0.105 mJ/mm2 M 2000 weeks 3 months
(Harwood et.al. 3x a week, 3
2017) CC 5 0.16 mJ/mm2 M 6000 weeks 12 weeks
(Dolibog et.al. 5F 0.173 mJ/mm2F 100 6 treatments
2018) Ulcers 5R 0.17 mJ/mm2 R M impulses/cm2 over 30 days 6 weeks
(Ramon et.al. 1x a week, 3
2020) GTPS 5 0.2 mJ/mm2 M 2000 weeks 6 months
1x a week, 3
(Thijs et.al. 2017) PT 4 0.2 mJ/mm2 M 1000 weeks 24 weeks
(Garcia et.al.
2017) MTSS 5 0.20 mJ/mm2 M 1500 1 session 4 weeks
(Vahdatpour et.al. 2,3 F 0.25-0.4 mJ/mm2 F 1500 focused, 1x a week, 4
2018) AT 2.2 R 1.8-2.6 mJ/mm2 R M/H 3000 radial weeks 12 weeks
(Akinoglu et.al. 1x a week, 3
2017) PF 8 0.3 mJ/mm2 H 2000 weeks 4 weeks
SPS – Spasticity post stroke; SCP – Spasticity, cerebral palsy; PT – patellar tendinopathy; AT – Achilles
Tendinopathy; PF – plantar fasciitis; MPS – Myofascial pain syndrome; KOA – Knee osteoarthritis; GTPS
– Greater trochanter pain syndrome; MTSS – Medial tibial stress syndrome; SAJP – Sacroiliac join pain;
CC – Claudication; R – Radial; F – Focused; L – Low; M – Medium; H – High; mJ – Millijoule; mm2 –
millimeters squared;

26
4.5 Outcome measure results
Table 6 provides the outcome measures of each article, as well as energy flux density, the range
assigned to the energy, whether there was a statistically significant improvement (green) or not (red) or
grey if not reported. Measurement tools are also reported with each outcome. Clinically significant
results are marked as a positive and then explained how they are beneficial over the control group and
what measurement tool was used to assess. Results that do not meet the clinically significant values
are marked as negative as the use of the modality in that case is not contributing to the effective
treatment of that patient population.

Of the studies reviewed, 80% of them reported a positive result in either one or both domains
of outcome measures. This was regardless of energy level, tissue targeted or diagnosis. This is
indicative of a wide applicability of the modality in practice.

27
 Table 6 Results and outcome measures

Research
article Tissue targeted Pathology Energy flux density Range Pain Movement/mobility
(Kvalvaag
et.al. 2018) tendon SPS 0.01-0.35 mJ/mm2 L/M/H NRS SPADI
(Cinar et.al.
2020) fascia PF 0.02 mJ/mm2 L
(Takla et.al.
2019) fascia PF 0.02-0.28 mJ/mm2 L/M/H VAS and PPT FFI - disability subscale
(Farhan
et.al. 2019) muscles SCP 0.03 mJ/mm2 L Not reported MAS and MHC
(Samhan NRS, PPT and physical capabilities
et.al. 2018) skin Burn 0.05-0.20 mJ/mm2 L/M NRS (BSHS-B)
(Joo et.al.
2020) skin Burn 0.05-0.30 mJ/mm2 L/M/H VAS
(Yoon et.al. Less spasticity MAS imp
2017) muscle SPS 0.068-0.093 mJ/mm2 L/M not reported hand function MTS scores
(Aktürk muscles and VAS, PPT and
et.al. 2018) fascia MPS 0.07-0.12 mJ/mm2 L/M TPS imp SF-36 scores
(Uysal et.al.
2020) bone KOA 0.09-0.12 mJ/mm2 M VAS imp. perf and ROM
(Guo et.al.
2019) muscles/tendons SPS 0.09-0.12 mJ/mm2 M MAS MAS and FMA
(Moon et.al.
2017) bone SIJP 0.09-0.25 mJ/mm2 M NRS ODI
(Taheri reduced spasticity (LEFS)
et.al. 2017) muscle SPS 0.1 mJ/mm2 M VAS and increased P-ROM
(Zhong VAS and
et.al. 2019) cartilage/bone KOA 0.105 mJ/mm2 M WOMAC womac and Lequesne
(Harwood max walking distance
et.al. 2017) muscles CC 0.16 mJ/mm2 M PFWD (MWD)
(Dolibog 0.173 mJ/mm2 F
et.al. 2018) skin Ulcers 0.17 mJ/mm2 R M not reported reduced ulceration area
QoL and performance
(Ramon during ADL, (HHS, LEFS,
et.al. 2020) tendon GTPS 0.2 mJ/mm2 M VAS EQ-5D)
(Thijs et.al.
2017) tendon PT 0.2 mJ/mm2 M NRS VISA-P
(Garcia
et.al. 2017) bone, muscle MTSS 0.20 mJ/mm2 M VAS increased running distance
(Vahdatpour 0.25-0.4 mJ/mm2 F
et.al. 2018) tendon AT 1.8-2.6 mJ/mm2 R M/H VAS AOFAS
(Akinoglu increased proprioception
et.al. 2017) fascia PF 0.3 mJ/mm2 H and AOFAS score

SPS – Spasticity post stroke; SCP – Spasticity, cerebral palsy; PT – patellar tendinopathy; AT – Achilles
tendinopathy; PF – plantar fasciitis; MPS – Myofascial pain syndrome; KOA – Knee osteoarthritis;
GTPS – Greater trochanter pain syndrome; MTSS – Medial tibial stress syndrome; SAJP – Sacroiliac
join pain; CC – Claudication; R – Radial; F – Focused; mJ – Millijoule; mm2 – millimeters squared.

28
4.6 Data synthesis
Table 7 provides the data synthesis on the energy ranges and provides level of evidence for the use of
the modality. All studies were considered class 1 making the evidence provided strong. Each of the
criteria meets the minimum requirement of five studies to be able to make a claim regarding ESWT’s
therapeutic effectiveness. As over 60% of the studies show improvement in pain and mobility, the overall
evidence is considered substantiated for all energy levels (Belanger, 2009; Michlovitz et al., 2012).

Based on the studies reviewed, published 2017 to 2020, there is strong, substantiated evidence
for the use of ESWT, regardless of tissue targeted or diagnosis, presented with a medium risk of bias
of the studies reviewed.

Table 7: data synthesis on energy ranges.

% of positive results for:
Energy Number of Pain Mobility/movement Level of evidence
range articles
Low 8 66% (4 of 6) 62.5% (5 of 8) Strong, substantiated evidence for the use of low
energy ESWT
Medium 17 80% (12 of 15) 82% (14 of 17) Strong, substantiated evidence for the use of
medium energy ESWT
High 5 60% (3 of 5) 60% (3 of 5) Strong, substantiated evidence for the use of
high energy ESWT

In addition, the author has made available an online dataset where all the information from Tables 4-6
is combined into one Table. It can be viewed at bit.ly/ESWTsr .

29
5 Discussion
5.1 Main discussion
This systematic review contributed to the current knowledge by reviewing the ESWT literature from
2017-2020. The goal was to create evidence-based information for clinicians and teachers about the
effectiveness of ESWT with various energy flux density ranges in the treatment of various pathologies.
Eighty percent of the studies reviewed reported positive findings for one or both domains of outcome
measures. This is substantial evidence for the efficacy of the modality. Coupled with the bias
assessment and data synthesis, it can be said that there is strong, substantiated evidence for the use
of ESWT, with an overall medium risk of bias. The bias adds a caveat that cannot be overlooked when
interpretating these results but, nonetheless, the results are positive.

It was encouraging to see that studies appear to have improved at reporting treatment parameters.
Looking at older systematic reviews, it was common to read about a study that reported no treatment
parameters but only outcome measures. This kind of reporting provides very little insight into the efficacy
of the modality as the result is worthless if there is no way to evaluate the treatment parameters (Alves
et al., 2009). Continued efforts should be made to thoroughly report treatment parameters in future
research.

By reviewing the recent literature, there were fields of study that have not been explored before
regarding the use of ESWT. One such that has increased in recent years is the use of ESWT on
spasticity, as there was a stark increase in publications on this subject beginning in 2013. According to
the current study, there continues to be promising evidence for the use of ESWT for patients with
spasticity (see Table 6). This is the sort of unconventional application that may cause a new approach
to a diagnosis or a treatment and requires knowledge and insight into the modality to be possible.
Introducing physical therapists to these mechanics and ideas early in their career can form a foundation
for further research in these areas.

When viewing the results of this review in context with previous studies, there were interesting
findings. With respect to plantar fasciitis and Achilles tendinopathy, this review found very little evidence
for the use of ESWT in the treatment of these conditions. However, Mani-Babu et.al. claimed the
modality to be an effective intervention and stated it should be considered for greater trochanter pain
syndrome, plantar fasciitis and Achilles tendinopathy (Mani-Babu et al., 2015). These contrasting
findings may need to be evaluated further. Although there was some conflict between studies on Achilles
tendinopathy and plantar fasciitis, this review also found good evidence pointing to ESWT’s efficacy
when treating greater trochanter pain syndrome.

Another systematic review on ESWT treatment for lower limb conditions presented contrasting
findings on some pathologies but similar findings on others when compared to the current study.
Korakakis et.al., (2018) presented no evidence for the effectiveness of ESWT on medial tibial stress
syndrome, which is contrary to the findings of this review. They also stated that there was moderate-
level evidence that suggested that ESWT is no better than placebo for patellar tendinopathy, as well as
low-level evidence for the efficacy of ESWT for greater trochanter pain syndrome. Their results agree
with the findings of this review. Finally, regarding their findings of low-level evidence for the effectiveness

30
of ESWT on Achilles tendinopathy, this review is in opposition as it did not find the same evidence.
ESWT has also been studied as a modality for treatment of burn patients. Aguilera-Sáez et.al. reported
positive findings, even if the evidence was weak due to scarcity of studies and their low quality (Aguilera-
Sáez et al., 2019). These results agree with the findings from this thesis as a positive effect was found
for the treatment of burn patients with ESWT.

5.1.1 Implications and future directions

The evidence strongly suggests ESWT to be an effective therapeutic modality in the field of physical
therapy, but it is not taught everywhere, and sometimes different professionals provide the treatment.
For example, in the United States, ESWT is often provided by physicians and not physical therapists
and as such it is not taught to physical therapy students. There is no obstacle to teaching physical
therapists about this modality, especially if they are already using other modalities in their practice, like
ultrasound or transcutaneous electrical nerve stimulation. Adding ESWT to the curriculum of future
physical therapists could potentially add a tool to the patient centered treatment the field aims to be.

In the data synthesis, the energy flux density level range that displayed the most promising results
were in the mid-range, where the data synthesis showed strong, substantiated evidence for the use of
EWST, which was far more than the other energy flux density ranges studied (see Table 7). Both
outcome domains (pain and mobility) had a higher percentage of studies that showed a statistically
significant improvement in the mid-range, but there were also more studies which lends even more
weight to the evidence. This is an indication for practitioners to aim for that gap of .08 mJ/mm2 to .28
mJ/mm2 when choosing the parameter of energy flux density. One reason could be the intermediate
effect - not using too much energy as to cause unnecessary damage to the tissue but also providing
enough energy as to cause the desired effects at the target site.

Although there is some evidence for treatment within the mid-range, the range of energy flux
densities used in the articles that were part of the current study continues to be too broad. That results
in inability to be able to confidently say which range is the most effective, what range is the least effective
and what range is destructive. When the energy flux density ranges from .01 to .35 mJ/mm 2 it is very
difficult to determine at what stage the desired effect is being caused. Doing a systematic review of
ESWT in the future where the inclusion criteria require that the energy flux density fall completely within
one of the level ranges and targeting a single tissue type or a single diagnosis could lead to a more
robust result. This could result in clinical guidelines for that specific treatment or determining it to be
sub-optimal when compared with other energy flux density ranges. There is still need for more research,
or at least further reviewing of the research being done. Future research should be more selective and
precise with inclusion/exclusion criteria to work towards the statements of optimal parameters of use.
This would provide reviewers with a more substantial and significant evidence that would allow them to
make optimal recommendations for best practice in a clinical setting. To further progress the knowledge
and field of applications, a more stringent treatment protocol for a research could be beneficial as to
determine the precise effects of a specific protocol on a pathology.

31
5.2 Strengths and limitations
The quality of the studies selected as RCTs (class 1) is a strength of this review. The RCTs presented
a medium risk of bias, which while not optimal is still a satisfactory result. The studies provided a good
insight into the treatment protocols so inquiring further into a single study is bound to bear fruit if those
specific criteria are similar between the study and practice. The studies are also recent so previous
reviews and studies were available for them to build upon and avoid pitfalls which may have been more
common earlier in the study of ESWT. ESWT is being used in more fields now than before so having
RCTs studying newer uses, such as spasticity post stroke or caused by cerebral palsy, sheds a new
light on the versatility of the modality and further possibilities for treatment. It should be noted that only
RCTs were considered for this review so there must be some speculation as to the strength of the review
regarding the substantiation of the evidence since non-RCTs were excluded from the analysis.

There were some limitations to the study. The evidence presented is on a wide variety on
parameters, pathologies, and populations over a brief period (2017-2020). This results in a very broad
take on the use of the modality across many pathologies, but limits coming to clear and precise
recommendations regarding best use for a particular pathology in a clinical setting. In addition, the
review was performed by a single, inexperienced reviewer, which may have led to an unknown personal
bias. Having another reviewer would have added a different view and made it possible to challenge one
another in the article screening, establishing criteria and other facets of the review process. Having
reviewers that possessed greater experience in the field of conducting reviews would avoid this limitation
as well but would lead to fewer reviewers over time as learning through actions is required to learn and
gain the experience.

The outcome measures used to assess the effectiveness of the modality were broad. This
broadness allowed for a wider comparison but also limited the certainty with which the evidence can be
claimed to be effective. Circumventing this limitation in the future could be to define specific outcome
measures to be in the inclusion criteria and excluding others. This would provide reviewers with the
ability to make claims on the effectiveness or a lack of on those specific outcome measures.

32
6 Conclusions
The author of this thesis draws the conclusion, based on data synthesis and the articles reviewed, that
there is strong, substantiated evidence for the use of ESWT. When care and effort is put into the
treatment with the modality, it shows statistically relevant improvements over sham therapies or control
groups. The evidence shows that there is good reason to use all energy ranges but showing a slight
preference for the mid-range. Using each energy range for their optimal situation yields better results
instead of using a modality with only one set of parameters for all pathologies.

The evidence presented presents a solid case for the teaching of ESWT to physical therapy students.
Not only is ESWT providing statistically better results in practice today but teaching future physical
therapists the mechanics and optimal use is a good foundation to build best practices on. Having
informed physical therapists that are knowledgeable about a subject will provide the users of healthcare
with a better service. Having the insight into the modality also opens the doors for a different view on
possible uses, spawning new uses for a modality that may or may not be useful but has not been
explored yet. Knowledge, insight and understanding are a solid foundation to build upon and serves as
fuel for the innovation and experimentation for future practitioners.

33
 References

Aguilera-Sáez, J., Muñoz, P., Serracanta, J., Monte, A., & Barret, J. P. (2019). Extracorporeal shock
wave therapy role in the treatment of burn patients. A systematic literature review. Burns.
https://doi.org/10.1016/j.burns.2019.07.023
Akinoglu, B., Köse, N., Kirdi, N., & Yakut, Y. (2017). Comparison of the Acute Effect of Radial Shock
Wave Therapy and Ultrasound Therapy in the Treatment of Plantar Fasciitis: A Randomized
Controlled Study. Pain Med, 18(12), 2443-2452. https://doi.org/10.1093/pm/pnx113
Aktürk, S., Kaya, A., Çetintaş, D., Akgöl, G., Gülkesen, A., Kal, G. A., & Güçer, T. (2018). Comparision of
the effectiveness of ESWT and ultrasound treatments in myofascial pain syndrome:
randomized, sham-controlled study. J Phys Ther Sci, 30(3), 448-453.
https://doi.org/10.1589/jpts.30.448
Alderfer, L., Wei, A., & Hanjaya-Putra, D. (2018). Lymphatic Tissue Engineering and Regeneration.
Journal of Biological Engineering, 12(1), 32. https://doi.org/10.1186/s13036-018-0122-7
Alves, E. M., Angrisani, A. T., & Santiago, M. B. (2009). The use of extracorporeal shock waves in the
treatment of osteonecrosis of the femoral head: a systematic review. Clin Rheumatol, 28(11),
1247-1251. https://doi.org/10.1007/s10067-009-1231-y
Belanger, A. Y. (2009). Therapeutic Electrophysical Agents: Evidence Behind Practice (Second edition
ed.). Lippincott Williams and Wilkins.
Cinar, E., Saxena, S., Akkurt, H. E., & Uygur, F. (2020). Extracorporeal shockwave therapy in the
management of plantar fasciitis: A randomized controlled trial. Foot (Edinb), 44, 101679.
https://doi.org/10.1016/j.foot.2020.101679
Dolibog, P., Dolibog, P., Franek, A., Brzezińska-Wcisło, L., Arasiewicz, H., Wróbel, B., Chmielewska, D.,
Ziaja, J., & Błaszczak, E. (2018). Randomized, controlled clinical pilot study of venous leg
ulcers treated with using two types of shockwave therapy. Int J Med Sci, 15(12), 1275-1285.
https://doi.org/10.7150/ijms.26614
Dymarek, R., Halski, T., Ptaszkowski, K., Slupska, L., Rosinczuk, J., & Taradaj, J. (2014). Extracorporeal
shock wave therapy as an adjunct wound treatment: a systematic review of the literature.
Ostomy Wound Manage, 60(7), 26-39.
Farhan, S. N., Abdullah, S. S., & Abdulgani, F. M. (2019). Impact of Extracorporeal Shock Wave
Therapy on Spastic HandFunction with Assistive Devices in Children with Cerebral Palsy.
Annals of Tropical Medicine and Health, 22, 60-69.
Fojecki, G. L., Tiessen, S., & Osther, P. J. (2017). Extracorporeal shock wave therapy (ESWT) in
urology: a systematic review of outcome in Peyronie's disease, erectile dysfunction and
chronic pelvic pain. World J Urol, 35(1), 1-9. https://doi.org/10.1007/s00345-016-1834-2
Gomez Garcia, S., Ramon Rona, S., Gomez Tinoco, M. C., Benet Rodriguez, M., Chaustre Ruiz, D. M.,
Cardenas Letrado, F. P., Lopez-Illescas Ruiz, Á., & Alarcon Garcia, J. M. (2017). Shockwave
treatment for medial tibial stress syndrome in military cadets: A single-blind randomized
controlled trial. Int J Surg, 46, 102-109. https://doi.org/10.1016/j.ijsu.2017.08.584
Guo, J., Qian, S., Wang, Y., & Xu, A. (2019). Clinical study of combined mirror and extracorporeal
shock wave therapy on upper limb spasticity in poststroke patients. Int J Rehabil Res, 42(1),
31-35. https://doi.org/10.1097/mrr.0000000000000316
Guo, P., Gao, F., Zhao, T., Sun, W., Wang, B., & Li, Z. (2017). Positive Effects of Extracorporeal Shock
Wave Therapy on Spasticity in Poststroke Patients: A Meta-Analysis. Journal of Stroke and
Cerebrovascular Diseases, 26(11), 2470-2476.
https://doi.org/https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.08.019
Harniman, E., Carette, S., Kennedy, C., & Beaton, D. (2004). Extracorporeal shock wave therapy for
calcific and noncalcific tendonitis of the rotator cuff: a systematic review. Journal of Hand
Therapy, 17(2), 132-151. https://doi.org/https://doi.org/10.1197/j.jht.2004.02.003

34
Harwood, A. E., Green, J., Cayton, T., Raza, A., Wallace, T., Carradice, D., Chetter, I. C., & Smith, G. E.
(2018). A feasibility double-blind randomized placebo-controlled trial of extracorporeal
shockwave therapy as a novel treatment for intermittent claudication. J Vasc Surg, 67(2),
514-521.e512. https://doi.org/10.1016/j.jvs.2017.07.105
Higgins, J. (2011). Cochrane handbook for systematic reviews of interventions. Version 5.1. 0
[updated March 2011]. The Cochrane Collaboration. www. cochrane-handbook. org.
Huisstede, B. M., Hoogvliet, P., Franke, T. P., Randsdorp, M. S., & Koes, B. W. (2018). Carpal Tunnel
Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated
Systematic Review of Randomized Controlled Trials. Arch Phys Med Rehabil, 99(8), 1623-
1634.e1623. https://doi.org/10.1016/j.apmr.2017.08.482
International Society for Medical Shockwave Treatment. (2019). DIGEST Guildelines for
Extracorporeal Shock Wave Therapy.
https://www.shockwavetherapy.org/fileadmin/user_upload/ISMST_Guidelines.pdf
Ioppolo, F., Tattoli, M., Di Sante, L., Venditto, T., Tognolo, L., Delicata, M., Rizzo, R. S., Di Tanna, G., &
Santilli, V. (2013). Clinical improvement and resorption of calcifications in calcific tendinitis of
the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and
meta-analysis. Arch Phys Med Rehabil, 94(9), 1699-1706.
https://doi.org/10.1016/j.apmr.2013.01.030
J.-D., A., J., M., P., G., F., M., T., B., H., T., & G., C. (2007). High-energy extracorporeal shock-wave
therapy for calcifying tendinitis of the rotator cuff. The Journal of Bone and Joint Surgery.
British volume, 89-B(3), 335-341. https://doi.org/10.1302/0301-620x.89b3.18249
Joo, S. Y., Lee, S. Y., Cho, Y. S., & Seo, C. H. (2020). Clinical Utility of Extracorporeal Shock Wave
Therapy on Hypertrophic Scars of the Hand Caused by Burn Injury: A Prospective,
Randomized, Double-Blinded Study. J Clin Med, 9(5). https://doi.org/10.3390/jcm9051376
Klonschinski, T., Ament, S. J., Schlereth, T., Rompe, J. D., & Birklein, F. (2011). Application of local
anesthesia inhibits effects of low-energy extracorporeal shock wave treatment (ESWT) on
nociceptors. Pain Med, 12(10), 1532-1537. https://doi.org/10.1111/j.1526-
4637.2011.01229.x
Korakakis, V., Whiteley, R., Tzavara, A., & Malliaropoulos, N. (2018). The effectiveness of
extracorporeal shockwave therapy in common lower limb conditions: a systematic review
including quantification of patient-rated pain reduction. Br J Sports Med, 52(6), 387-407.
https://doi.org/10.1136/bjsports-2016-097347
Kvalvaag, E., Roe, C., Engebretsen, K. B., Soberg, H. L., Juel, N. G., Bautz-Holter, E., Sandvik, L., & Brox,
J. I. (2018). One year results of a randomized controlled trial on radial Extracorporeal Shock
Wave Treatment, with predictors of pain, disability and return to work in patients with
subacromial pain syndrome. Eur J Phys Rehabil Med, 54(3), 341-350.
https://doi.org/10.23736/s1973-9087.17.04748-7
Liao, C. D., Xie, G. M., Tsauo, J. Y., Chen, H. C., & Liou, T. H. (2018). Efficacy of extracorporeal shock
wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of
randomized controlled trials. BMC Musculoskelet Disord, 19(1), 278.
https://doi.org/10.1186/s12891-018-2204-6
Lohrer, H., Nauck, T., Dorn-Lange, N. V., Schöll, J., & Vester, J. C. (2010). Comparison of Radial Versus
Focused Extracorporeal Shock Waves in Plantar Fasciitis Using Functional Measures. Foot &
Ankle International, 31(1), 1-9. https://doi.org/10.3113/fai.2010.0001
Mani-Babu, S., Morrissey, D., Waugh, C., Screen, H., & Barton, C. (2015). The Effectiveness of
Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy:A Systematic Review. The
American Journal of Sports Medicine, 43(3), 752-761.
https://doi.org/10.1177/0363546514531911
Michlovitz, S. L., Bellew, J. W., & Nolan, T. (2012). Modalities for therapeutic intervention.
http://search.credoreference.com/content/title/fadavistherint
Michlovitz, S. L., & Nolan Jr, T. P. (2016). Modalities for therapeutic intervention.

35
Moon, Y. E., Seok, H., Kim, S. H., Lee, S. Y., & Yeo, J. H. (2017). Extracorporeal shock wave therapy for
sacroiliac joint pain: A prospective, randomized, sham-controlled short-term trial. J Back
Musculoskelet Rehabil, 30(4), 779-784. https://doi.org/10.3233/bmr-150405
Mouzopoulos, G., Stamatakos, M., Mouzopoulos, D., & Tzurbakis, M. (2007). Extracorporeal shock
wave treatment for shoulder calcific tendonitis: a systematic review. Skeletal Radiology,
36(9), 803-811. https://doi.org/10.1007/s00256-007-0297-3
Ogden, J. A., Toth-Kischkat, A., & Schultheiss, R. (2001). Principles of shock wave therapy. Clin Orthop
Relat Res(387), 8-17. https://doi.org/10.1097/00003086-200106000-00003
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L.,
Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson,
A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., McGuinness, L. A.,
Stewart, L. A., Thomas, J., Tricco, A. C., Welch, V. A., Whiting, P., & Moher, D. (2021). The
PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Systematic
Reviews, 10(1), 89. https://doi.org/10.1186/s13643-021-01626-4
Prentice, W. E., & Thigpen, C. A. (2018). Therapeutic modalities in rehabilitation. McGraw Hill
Professional. http://accessphysiotherapy.mhmedical.com/qa.aspx?resourceID=2225
Ramon, S., Russo, S., Santoboni, F., Lucenteforte, G., Di Luise, C., de Unzurrunzaga, R., Vetrano, M.,
Albano, M., Baldini, R., Cugat, R., Stella, G., Balato, G., Seijas, R., Nusca, S. M., Servodidio, V.,
& Vulpiani, M. C. (2020). Focused Shockwave Treatment for Greater Trochanteric Pain
Syndrome: A Multicenter, Randomized, Controlled Clinical Trial. J Bone Joint Surg Am,
102(15), 1305-1311. https://doi.org/10.2106/jbjs.20.00093
Roerdink, R. L., Dietvorst, M., van der Zwaard, B., van der Worp, H., & Zwerver, J. (2017).
Complications of extracorporeal shockwave therapy in plantar fasciitis: Systematic review. Int
J Surg, 46, 133-145. https://doi.org/10.1016/j.ijsu.2017.08.587
Rompe, J. D., Kirkpatrick, C. J., Kullmer, K., Schwitalle, M., & Krischek, O. (1998). Dose-related effects
of shock waves on rabbit tendo Achillis. A sonographic and histological study. J Bone Joint
Surg Br, 80(3), 546-552. https://doi.org/10.1302/0301-620x.80b3.8434
Samhan, A. F., & Abdelhalim, N. M. (2019). Impacts of low-energy extracorporeal shockwave therapy
on pain, pruritus, and health-related quality of life in patients with burn: A randomized
placebo-controlled study. Burns, 45(5), 1094-1101.
https://doi.org/10.1016/j.burns.2019.02.007
Schmitz, C., Csaszar, N. B., Milz, S., Schieker, M., Maffulli, N., Rompe, J. D., & Furia, J. P. (2015).
Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a
systematic review on studies listed in the PEDro database. Br Med Bull, 116, 115-138.
https://doi.org/10.1093/bmb/ldv047
Shrivastava, S. K., & Kailash. (2005). Shock wave treatment in medicine. J Biosci, 30(2), 269-275.
https://doi.org/10.1007/BF02703708
Speed, C. (2014). A systematic review of shockwave therapies in soft tissue conditions: focusing on
the evidence. Br J Sports Med, 48(21), 1538-1542. https://doi.org/10.1136/bjsports-2012-
091961
Stania, M., Juras, G., Chmielewska, D., Polak, A., Kucio, C., & Król, P. (2019). Extracorporeal Shock
Wave Therapy for Achilles Tendinopathy. Biomed Res Int, 2019, 3086910.
https://doi.org/10.1155/2019/3086910
Staritz, M., Rambow, A., Mildenberger, P., Goebel, M., Scherfe, T., Grosse, A., Junginger, T.,
Hohenfellner, R., Thelen, M., & Meyer zum Büschenfelde, K. H. (1989). Electromagnetically
generated extracorporeal shock waves for gallstone lithotripsy: in vitro experiments and
clinical relevance. Eur J Clin Invest, 19(2), 142-145. https://doi.org/10.1111/j.1365-
2362.1989.tb00208.x
Taheri, P., Vahdatpour, B., Mellat, M., Ashtari, F., & Akbari, M. (2017). Effect of Extracorporeal Shock
Wave Therapy on Lower Limb Spasticity in Stroke Patients. Arch Iran Med, 20(6), 338-343.
Takla, M. K. N., & Rezk, S. S. R. (2019). Clinical effectiveness of multi-wavelength photobiomodulation
therapy as an adjunct to extracorporeal shock wave therapy in the management of plantar

36
 fasciitis: a randomized controlled trial. Lasers Med Sci, 34(3), 583-593.
https://doi.org/10.1007/s10103-018-2632-4
Thiel, M., Nieswand, M., & Dorffel, M. (2000). The use of shock waves in medicine--a tool of the
modern OR: an overview of basic physical principles, history and research. Minim Invasive
Ther Allied Technol, 9(3-4), 247-253. https://doi.org/10.1080/13645700009169655
Thiele, S., Thiele, R., & Gerdesmeyer, L. (2015). Lateral epicondylitis: This is still a main indication for
extracorporeal shockwave therapy. International Journal of Surgery, 24, 165-170.
https://doi.org/https://doi.org/10.1016/j.ijsu.2015.09.034
Thijs, K. M., Zwerver, J., Backx, F. J., Steeneken, V., Rayer, S., Groenenboom, P., & Moen, M. H.
(2017). Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar
Tendinopathy: A Double-Blinded Randomized Study. Clin J Sport Med, 27(2), 89-96.
https://doi.org/10.1097/jsm.0000000000000332
Uysal, A., Yildizgoren, M. T., Guler, H., & Turhanoglu, A. D. (2020). Effects of radial extracorporeal
shock wave therapy on clinical variables and isokinetic performance in patients with knee
osteoarthritis: a prospective, randomized, single-blind and controlled trial. Int Orthop, 44(7),
1311-1319. https://doi.org/10.1007/s00264-020-04541-w
Vahdatpour, B., Forouzan, H., Momeni, F., Ahmadi, M., & Taheri, P. (2018). Effectiveness of
extracorporeal shockwave therapy for chronic Achilles tendinopathy: A randomized clinical
trial. J Res Med Sci, 23, 37. https://doi.org/10.4103/jrms.JRMS_413_16
van der Worp, H., van den Akker-Scheek, I., van Schie, H., & Zwerver, J. (2013). ESWT for
tendinopathy: technology and clinical implications. Knee Surg Sports Traumatol Arthrosc,
21(6), 1451-1458. https://doi.org/10.1007/s00167-012-2009-3
Venn Healthcare (2020). Radial vs Focus Shockwave Therapy What is the Difference? Retrieved 07/05
from https://www.vennhealthcare.com/blog/2018/8/7/radial-vs-focus-shockwave-therapy-
what-is-the-difference
Wang, C. J. (2012). Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg
Res, 7, 11. https://doi.org/10.1186/1749-799X-7-11
Wang, F. S., Yang, K. D., Chen, R. F., Wang, C. J., & Sheen-Chen, S. M. (2002). Extracorporeal shock
wave promotes growth and differentiation of bone-marrow stromal cells towards
osteoprogenitors associated with induction of TGF-beta1. J Bone Joint Surg Br, 84(3), 457-
461. https://doi.org/10.1302/0301-620x.84b3.11609
Wolfl, C., Schuster, L., Honer, B., Englert, S., Klein, R., Hirche, C., Munzberg, M., Grutzner, P. A.,
Kneser, U., & Harhaus, L. (2017). Influence of extracorporeal shock wave therapy (ESWT) on
bone turnover markers in organisms with normal and low bone mineral density during
fracture healing: a randomized clinical trial. GMS Interdiscip Plast Reconstr Surg DGPW, 6,
Doc17. https://doi.org/10.3205/iprs000119
Xiang, J., Wang, W., Jiang, W., & Qian, Q. (2018). Effects of extracorporeal shock wave therapy on
spasticity in post-stroke patients: A systematic review and meta-analysis of randomized
controlled trials. J Rehabil Med, 50(10), 852-859. https://doi.org/10.2340/16501977-2385
Yamaya, S., Ozawa, H., Kanno, H., Kishimoto, K. N., Sekiguchi, A., Tateda, S., Yahata, K., Ito, K.,
Shimokawa, H., & Itoi, E. (2014). Low-energy extracorporeal shock wave therapy promotes
vascular endothelial growth factor expression and improves locomotor recovery after spinal
cord injury. J Neurosurg, 121(6), 1514-1525. https://doi.org/10.3171/2014.8.JNS132562
Yoon, S. H., Shin, M. K., Choi, E. J., & Kang, H. J. (2017). Effective Site for the Application of
Extracorporeal Shock-Wave Therapy on Spasticity in Chronic Stroke: Muscle Belly or
Myotendinous Junction. Ann Rehabil Med, 41(4), 547-555.
https://doi.org/10.5535/arm.2017.41.4.547
Zhong, Z., Liu, B., Liu, G., Chen, J., Li, Y., Chen, J., Liu, X., & Hu, Y. (2019). A Randomized Controlled
Trial on the Effects of Low-Dose Extracorporeal Shockwave Therapy in Patients With Knee
Osteoarthritis. Arch Phys Med Rehabil, 100(9), 1695-1702.
https://doi.org/10.1016/j.apmr.2019.04.020

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 Attachments
Web address for online document with information from this systematic review, accessible for viewing
by practitioners or the curious: bit.ly/ESWTsr

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