Takaisin

Extracorporeal shockwave therapy (ESWT) in treatment of lateral tendinopathy

Näytönastekatsaukset
Marja Mikkelsson
22.6.2022

Level of evidence: C

Extracorporeal shockwave therapy (ESWT) may present no clinically relevant benefit in treating lateral tendinopathy compared with sham or control treatment in pain intensity, grip strength, and elbow disability at short-term (< 3 months) and seems to have no clinically relevant benefit in terms of pain relief in mid-term follow-up (up to 1 year).

Although there may be a small between group difference, it is not clinically relevant. These results are based on meta-analysis of 27 RCTs with 59 % rated as high quality according to PEDRO criteria, and 41 % as moderate quality. «Karanasios S, Tsamasiotis GK, Michopoulos K ym. Cl...»1

Table 1. Description of the included studies
Reference Study type Population Intervention and comparison Outcomes Risk of bias
«Karanasios S, Tsamasiotis GK, Michopoulos K ym. Cl...»1 SR/MA
Inclusion criteria were patients > 18 years diagnosed with lateral elbow tendinopathy.

N=1871 patients (median number per trial: 60 participants, with a mean age 45.2 years) from 16 RCTs up to 2/2020.
ESWT used alone or as an additive intervention compared with sham or sham+ additive conservative intervention Pain intensity

Grip strength

Elbow disability

Moderate Randomization (allocation concealment)

Blinding

RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis; ESWT=Extracorporeal shockwave therapy

Table 2. Additional comments for included studies
Reference Comments
«Karanasios S, Tsamasiotis GK, Michopoulos K ym. Cl...»1 The study intended to evaluate the effectiveness of extracorporeal shockwave therapy in reducing pain and improving functional outcomes compared to other non-surgical interventions in the management of lateral elbow tendinopathy in the very-short-term (⩽ 2 months), short-term (> 2 months ⩽ 3 months), mid-term (> 3 to < 12 months) and long term (⩾ 12 months) follow-up times. The authors performed subgroup analyses to compare extracorporeal shockwave therapy with different types of intervention (sham or control, single modalities, multimodal therapy, corticosteroid injections etc.) at different follow-up periods.

Most of the eligible trials showed ‘high quality' (16 trials) or ‘moderate' (11 trials) rating. Risk of bias was due to randomization (allocation concealment) and blinding. The authors rated results between very-low to moderate certainty of evidence due to statistical heterogeneity, high risk of bias, inconsistency and indirectness of interventions. Results of ESWT vs sham or sham combined with control therapies are presented.

At very short-term follow up there were 4 studies that had combination of treatments in both groups: (ESWT+exercise vs sham ESWT + exercise; ESWT+splint+ice vs Sham ESWT+splint+ice; ESWT+ physiotehrapy including ultrasound, TNS, streching and friction massage vs Sham ESWT+ the same physiotherapy program; ESWT+exercise vs exercise only. At short term and mid-term follow up there were 2 of these studies with combination of treatments.

ESWT=Extracorporeal shockwave therapy

Results

Table 3. Outcome 1: Pain intensity (ESWT compared with sham-/ placebo or control intervention, visual analogue scale or numerical pain rating 0–100)
Reference Number of studies and number of patients (I/C) Follow-up time (months) Mean pain score (range), intervention group Mean pain score (range), control goup Standardized mean difference (95% CI)
Level of evidence: very short-term (< 2 months) very low (downgraded due to inconsistency, indirectness and imprecision), short-term (2–3 months) low (downgraded due to indirectness and imprecision), and mid-term moderate (downgraded due to indirectness).
«Karanasios S, Tsamasiotis GK, Michopoulos K ym. Cl...»1 8 (326/316) < 2 43.06 (19–65.9) 46.7 (26–63) -0.31 (-0.69, 0.06)
6 (293/284) 2–3 months 49.6 (26.1–47.9) 44.9

(26.7–51.5)
-0.16 (-0.33, 0.01)
3 (93/90) > 3 to < 12 19.1 (3.7–8.1) 36.1 (33.3–40.7) -1.21 (-1.53, -0.89)

I= intervention; C=comparison; CI=confidence interval

Table 4. Outcome 2: Grip strength (ESWT compared with sham-/ placebo or control intervention)
Reference Number of studies and number of patients (I/C) Follow-up time (months) Mean maximum grip strength (kg) (range), intervention group Mean pain score (range), control goup Mean difference (95% CI)
Level of evidence: low.
The level of evidence is downgraded due to indirectness and imprecision.
«Karanasios S, Tsamasiotis GK, Michopoulos K ym. Cl...»1 3 (58/55) < 2 21.64 (15.9–

27.7)
17.58 (10.1–

22.7)
3.92 (0.91, 6.94)
4 (122/123) 2–3 39.1 (17.3–

58)
35.1 (12.2–

52.1)
4.87 (2.24, 7.50)

I= intervention; C=comparison; CI=confidence interval

Table 5. Outcome 3: Elbow disability (ESWT compared with sham-/placebo or control intervention
Reference Number of studies and number of patients (I/C) Follow-up time (months) Mean score (range), intervention group Mean score (range), control group Standardized mean difference (95% CI)
Level of evidence: low.
The level of evidence is downgraded due to indirectness and imprecision.
«Karanasios S, Tsamasiotis GK, Michopoulos K ym. Cl...»1 5 (106/100) < 2 34.3

(15.3–60.1)
38.6

(9–64.7)
-0.04 (-1.10, 1,03)
4 (123/117) 2–3 13.5 (2.9–31.1) 14.4 (4–39.5) 0.13 (-1.30, 1.56)

References

  1. Karanasios S, Tsamasiotis GK, Michopoulos K ym. Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis. Clin Rehabil 2021;35:1383-1398 «PMID: 33813913»PubMed