Ann Rehabil Med.  2019 Apr;43(2):163-177. 10.5535/arm.2019.43.2.163.

Duration of Treatment Effect of Extracorporeal Shock Wave on Spasticity and Subgroup-Analysis According to Number of Shocks and Application Site: A Meta-Analysis

• Oh JH
• Park HD
• Han SH
• Shim GY
• Choi KY

• KMID: 2448999
• DOI: http://doi.org/10.5535/arm.2019.43.2.163

Abstract

OBJECTIVE
To investigate duration of the treatment effect of extracorporeal shockwave therapy (ESWT) on spasticity levels measured with Modified Ashworth Scale (MAS) regardless of the patient group (stroke, multiple sclerosis, and cerebral palsy) and evaluate its spasticity-reducing effect depending on the number of shocks and site of application.
METHODS
PubMed, EMBASE, the Cochrane Library, and Scopus were searched from database inception to February 2018. Randomized controlled trials and cross-over trials were included. All participants had spasticity regardless of cause. ESWT was the main intervention and MAS score was the primary outcome. Among 122 screened articles, 9 trials met the inclusion criteria.
RESULTS
The estimate of effect size showed statistically significant MAS grade reduction immediately after treatment (standardized mean difference [SMD]=-0.57; 95% confidence interval [CI], -1.00 to -0.13; p=0.012), 1 week after (SMD=-1.81; 95% CI, -3.07 to -0.55; p=0.005), 4 weeks after (SMD=-2.35; 95% CI, -3.66 to -1.05; p<0.001), and 12 weeks after (SMD=-1.07; 95% CI, -2.04 to -0.10; p=0.03). Meta-regression and subgroup analysis were performed for the "˜immediately after ESWT application' group. The prediction equation obtained from metaregression was -1.0824+0.0002* (number of shocks), which was not statistically significant. Difference in MAS grade reduction depending on site of application was not statistically significant either in subgroup analysis (knee and ankle joints vs. elbow, wrist, and finger joints).
CONCLUSION
ESWT effectively reduced spasticity levels measured with MAS regardless of patient group. Its effect maintained for 12 weeks. The number of shocks or site of application had no significant influence on the therapeutic effect of ESWT in reducing spasticity. Ongoing trials with ESWT are needed to address optimal parameters of shock wave to reduce spasticity regarding intensity, frequency, and numbers.

Keyword

Extracorporeal shockwave therapy; Muscle spasticity; Meta-analysis

MeSH Terms

Ankle Joint
Cross-Over Studies
Elbow
Fingers
Humans
Multiple Sclerosis
Muscle Spasticity*
Shock*
Wrist

Figure

• 

  Fig. 1. Preferred Reporting Items for Systemic Reviews and MetaAnalysis (PRISMA) flow chart. RCT, randomized controlled trial; ES, electrical stimulation; ESWT, extracorporeal shockwave therapy; MAS, Modified Ashworth Scale.

• 

  Fig. 2. Risk of bias graph illustrating the proportion of studies with each judgement (‘Yes’, ‘No’, or ‘Unclear’) for each entry in the tool.

• 

  Fig. 3. Risk of bias summary. It presented all judgements in a cross-tabulation of study by entry of + (Yes), – (No), and ? (Unclear).

• 

  Fig. 4. Funnel plot to evaluate publication bias at (A) immediately after ESWT application, (B) 1 week after ESWT application, (C) 4 weeks after ESWT application, and (D) 12 weeks after ESWT application. Std diff, standard difference. ESWT, extracorporeal shockwave therapy.

• 

  Fig. 5. Forest plot of effect sizes at (A) immediately after ESWT application, (B) after excluding outliers (Manganotti-F and Gonkova). ESWT, extracorporeal shockwave therapy; Std diff, standard difference; CI, confidence interval; E, elbow joint; RC, radio-carpal joint; FF, finger joints; GCM, gastrocnemius; W, wrist flexors; F, finger flexors.

• 

  Fig. 6. (A) Sensitivity analysis with effect sizes, sample size, weight, and residual (immediately after ESWT application). (B) Sensitivity analysis with effect sizes after excluding studies one by one (immediately after ESWT application). ESWT, extracorporeal shockwave therapy; Std diff, standard difference; CI, confidence interval; E, elbow joint; RC, radio-carpal joint; FF, finger joints; GCM, gastrocnemius; W, wrist flexors; F, finger flexors.

• 

  Fig. 7. (A) Sensitivity analysis with effect sizes, sample size, weight, and residual (1 week after ESWT application). (B) Sensitivity analysis with effect sizes after excluding studies one by one (1 week after ESWT application). ESWT, extracorporeal shockwave therapy; Std diff, standard difference; CI, confidence interval; W, wrist flexors; F, finger flexors.

• 

  Fig. 8. Forest plot of the effect sizes 1 week after extracorporeal shockwave therapy (ESWT). Std diff, standard difference; CI, confidence interval; W, wrist flexors; F, finger flexors.

• 

  Fig. 9. (A) Sensitivity analysis with effect sizes, sample size, weight, and residual (4 weeks after the ESWT application). (B) Sensitivity analysis with effect sizes after excluding studies one by one (4 weeks after the ESWT application). ESWT, extracorporeal shockwave therapy; Std diff, standard difference; CI, confidence interval; W, wrist flexors; F, finger flexors.

• 

  Fig. 10. Forest plot of effect sizes 4 weeks after extracorporeal shockwave therapy (ESWT). Std diff, standard difference; CI, confidence interval; W, wrist flexors; F, finger flexors.

• 

  Fig. 11. (A) Sensitivity analysis with effect sizes, sample size, weight, and residual (12 weeks after ESWT application). (B) Sensitivity analysis with effect sizes after excluding studies one by one (12 weeks after ESWT application). ESWT, extracorporeal shockwave therapy; Std diff, standard difference; CI, confidence interval; W, wrist flexors; F, finger flexors.

• 

  Fig. 12. Forest plot of the effect sizes 12 weeks after extracorporeal shockwave therapy (ESWT). Std diff, standard difference; CI, confidence interval; W, wrist flexors; F, finger flexors.

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  Fig. 13. Scatterplot of meta-regression under the randomeffects model (immediately after ESWT application). ESWT, extracorporeal shockwave therapy.

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  Fig. 14. Forest plots of knee and ankle-joints group and elbow, wrist, and finger joints group depending on the application site (immediately after ESWT application). ESWT, extracorporeal shockwave therapy; E, elbow joint; RC, radio-carpal joint; FF, finger joints; GCM, gastrocnemius.

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