Posts Tagged extracorporeal shock wave therapy

[Systematic Review] Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials – Full Text

Abstract

Objective: To evaluate whether extracorporeal shock wave therapy significantly improves spasticity in post-stroke patients.

Design: Systematic review and meta-analysis.

Data sources: PubMed, EMBASE, EBSCO, Web of Science, Cochrane CENTRAL electronic databases.

Study selection: Randomized controlled trials assessing the effect of extracorporeal shock wave therapy on post-stroke patients with spasticity were selected for inclusion.

Data extraction: Two authors independently screened the literature, extracted data, and assessed the quality of included studies. Primary outcome was modified Ashworth scale (MAS). Secondary outcomes were Modified Tardieu Scale (MTS), H/M ratio and range of motion.

Data synthesis: Eight randomized controlled trial studies (n = 385 patients) were included in the meta-analysis. There was a high level of evidence that extracorporeal shock wave therapy significantly ameliorates spasticity in post-stroke patients according to the 4 parameters: MAS (standard mean difference (SMD) −1.22; 95% confidence interval (95% CI): −1.77 to −0.66); MTS (SMD 0.70; 95% CI 0.42–0.99,); H/M ratio (weighted mean difference (WMD) –0.76; 95% CI –1.19 to –0.33); range of motion (SMD 0.69; 95% CI 0.06–1.32). However, there was no statically significant difference on the MAS at 4 weeks (SMD –1.73; 95% CI –3.99 to 0.54).

Conclusion: Extracorporeal shock wave therapy has a significant effect on spasticity in post-stroke patients.

 

Lay abstract

The effect of extracorporeal shock wave therapy on spasticity in post-stroke patients has been evaluated in several clinical trials. In addition, a recent meta-analysis suggests that such therapy is effective; however, the measurement of spasticity was based mainly on the modified Ashworth scale, which is insufficient, and a lack of  randomized controlled trials studies in the study design may have biased the results. Therefore, considering the potential limitations of the previous meta-analysis, the aim of the current study was to perform a systematic review and meta-analysis of randomized controlled trials to evaluate the effectiveness of extracorporeal shock wave therapy on spasticity in post-stroke patients. Furthermore, subgroup analysis was performed to identify potential moderators or mediators.

 

Spasticity is a common complication of various neurological diseases, such as stroke, and is often defined as a velocity-dependent increase in muscle tone, with exaggerated tendon jerks, due to hyperexcitability of the stretch reflex (1). Stroke has a high morbidity and sequelae rate. Approximately 80% of stroke patients have motor dysfunction, and spasticity status is considered to be the main determinant of this (2). Approximately 20-–40% of stroke survivors will develop spasticity (3). Futhermore, only 15.6% of post-stroke patients have a clinically relevant degree of spasticity (MAS ≥ 3) (4), and the prevalence of disabling spasticity 1 year after first-ever stroke is 4% (5). Spasticity after stroke not only limits the subject’s limb movements, but also impacts on their ability in activities of daily living (ADL), and seriously reduces quality of life (QoL). Therefore, improving spasticity post-stroke would reduce the rate of disability.

Various therapeutic interventions can be used to reduce spasticity, including botulinum toxin (BTX) injections, pharmacological treatment, physical therapy (electrical stimulation, thermotherapy), occupational therapy, and chemical neurolysis (6–9). Extracorporeal shock waves have been reported to be a potential therapeutic intervention to improve spasticity (10, 11).

Extracorporeal shock waves are a group of mechanical pulse waves characterized by high peak pressure (100 MPa), fast pressurization speed (< 10 ns) and short cycle time (10 μs) (6). The treatments can be divided into focused extracorporeal shock waves (12) and radial extracorporeal shock waves (rESW) (13). rESW is a relatively new technique that was first applied in 1999. Extracorporeal shock wave therapy (ESWT) has been shown to be a safe, effective, non-invasive treatment for spasticity in patients with cerebral palsy, epicondylitis and multiple sclerosis (13–16). Several studies have shown that ESWT is effective for treating spasticity in post-stroke patients (17, 18). Dymarek et al. (19, 20) indicated that ESWT could effectively improve limb spasticity in post-stroke patients. In addition, a recent meta-analysis demonstrated the effectiveness of ESWT for spasticity in post-stroke patients (21). However, this was not a meta-analysis of randomized controlled trials (RCTs), and the quality of the included studies was not high. Considering the potential limitations of this earlier meta-analysis, the aim of the current study was to perform a systematic review and meta-analysis of RCTs to assess whether ESWT significantly improves spasticity in post-stroke patients. Furthermore, subgroup analysis was carried out to identify potential moderators or mediators.

Methods

Data sources

A systematic review and meta-analysis was performed according to the guidelines of the Cochrane Handbook for Systematic Reviews (22) and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement (23). PubMed, EMBASE, EBSCO, Web of Science, Cochrane CENTRAL electronic databases were searched systematically from the establishment of the database to December 2017, with the key search terms: “extracorporeal shock wave therapy” and “stroke”. The reference lists of the resulting publications and reviews identified in the initial searches were scanned for further references. The literature search was limited to publications in English.

Selection criteria

The inclusion criteria for selection of studies were: (i) double or single-blind RCTs; (ii) participants with a diagnosis of ischaemic stroke or haemorrhagic stroke who had spasticity of the lower or upper limb with a MAS score >1; (iii) experimental groups treated with ESWT alone or ESWT combined with other interventions; (iv) control groups treated with sham ESWT alone or sham ESWT combined with other interventions; (v) English language publications.

The exclusion criteria were: (i) studies that were not RCTs; (ii) studies in which the participants were children or adolescents (aged less than 18 years); (iii) reviews, case reports/series; (iv) non-English articles; (v) duplicated data; (vi) studies in which relevant outcome indexes were not reported.

 

Data extraction

Two reviewers (WW, WFJ) independently extracted the following data: (i) sample characteristics (sample size, mean age, sex); (ii) clinical features (diagnosis, spasticity at baseline and study end-point); (iii) ESWT therapy protocol (frequency, intensity, site, number of treatment sessions). Study outcome was based on MAS, MTS, H/M ratio and range of motion before and after ESWT.

Risk of bias assessment

The quality of RCTs was assessed independently using the methods recommended by the Cochrane review (24). Two investigators (WW, WFJ) independently assessed the quality of the study, and any disagreements were resolved by discussion and consensus with a third author (QCQ). The quality assessment includes 6 domains: random sequence generation, allocation concealment, blinding of investigators and/or participants, blinding of outcome assessment, degree of incompleteness of outcome data, and selective reporting of study outcomes. Each domain has low, moderate, or high risk.

Statistical analysis

All statistical analyses were conducted using RevMan 5.3 (The Cochrane Collaboration, Software Update, Oxford, UK) and Stata 12.0 (Stata Corp, College Station, TX, USA). All continuous outcomes are expressed as mean differences (standardized and weighted to be determined by available data). Sensitivity analysis was performed to examine the influence of a single study on the overall estimate by omitting 1 study in turn. A p -value <0.05 was considered statistically significant. If p < 0.05 and Ivalue > 50%, the random-effects model was used; otherwise, the fixed effects model was used.[…]

 

Continue —> Journal of Rehabilitation Medicine – Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials – HTML

Fig. 1. Flowchart for study selection. RCT: randomized controlled trial.

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[ARTICLE] Effect of Radial Shock Wave Therapy on Spasticity of the Upper Limb in Patients With Chronic Stroke: A Prospective, Randomized, Single Blind, Controlled Trial – Full Text

Abstract

Recently, studies have reported that extracorporeal shock wave therapy (ESWT) is a safe, noninvasive, alternative treatment for spasticity. However, the effect of ESWT on spasticity cannot be determined, because most studies to date have enrolled small patient numbers and have lacked placebo-controlled groups and/or long-term follow-up. In addition, whether varying the number of ESWT sessions would affect the duration of the therapeutic effect has not been investigated in a single study. Hence, we performed a prospective, randomized, single blind, placebo-controlled study to investigate the long-term effect of radial ESWT (rESWT) in patients with poststroke spasticity and surveyed the outcome of functional activity.

Sixty patients were randomized into 3 groups. Group A patients received 1 session of rESWT per week for 3 consecutive weeks; group B patients received a single session of rESWT; group C patients received one session of sham rESWT per week for 3 consecutive weeks. The primary outcome was Modified Ashworth Scale of hand and wrist, whereas the secondary outcomes were Fugl-Meyer Assessment of hand function and wrist control. Evaluations were performed before the first rESWT treatment and immediately 1, 4, 8, 12, and 16 weeks after the last session of rESWT.

Compared to the control group, the significant reduction in spasticity of hand and wrist lasted at least 16 and 8 weeks in group A and B, respectively. Three sessions of rESWT had a longer-lasting effect than one session. Furthermore, the reduction in spasticity after 3 sessions of rESWT may be beneficial for hand function and wrist control and the effect was maintained for 16 and 12 weeks, respectively.

rESWT may be valuable in decreasing spasticity of the hand and wrist with accompanying enhancement of wrist control and hand function in chronic stroke patients.

INTRODUCTION

Extracorporeal shock wave therapy (ESWT) is defined as a sequence of acoustic pulses characterized by high peak pressure (100 MPa), fast pressure rise (<10 ns), short duration (10 μs), and an energy density ranging from 0.003 to 0.890 mJ/mm.1 Different studies and clinical experiments have demonstrated the efficacy of ESWT in the treatment of musculoskeletal disorders such as chronic tendinopathies, calcific tendinitis of the shoulder, lateral epicondylitis, and plantar fasciitis, etc.1 The side effects of ESWT including aching, tingling, redness, or bruising are relatively rare and transitory.1

Radial ESWT (rESWT), a type of pneumatically generated shock wave, has a low to medium energy compared with traditional focused ESWT (fESWT). These unforced shock waves disperse eccentrically from the applicator tip without focusing the energy to a targeted spot. The penetrative depth is therefore less than that of fESWT (up to 3 vs 12 cm).2 A recent systematic review and meta-analysis reported potential advantages of rESWT over fESWT in patients with plantar fasciitis because rESWT has a larger treatment area, specific focusing is less important, it does not require additional local anesthesia, and it is cheaper.2

Spasticity is a common complication in patients with stroke and is defined as a velocity-dependent enhancement in muscle tone in response to passive stretching because of supraspinal disinhibition of stretch reflexes. The prevalence of spasticity is reported as 39% in patients with 1st-ever stroke after 12 months.3 The constant contraction of spastic muscles can produce pain, declined mobility, contractures, and skeletal deformities, which may limit the potential effect of rehabilitation.4 Common management of spasticity consists of passive stretching, splints, drug, phenol injection, and botulinum toxin (BTX) injection. However, current treatments of spasticity in poststroke survivors are often unsatisfactory.5

In recent years, studies have reported that ESWT is a safe, noninvasive, alternative treatment for spasticity that does not cause muscle weakness or unpleasant effects in patients with stroke,6–15cerebral palsy,16–19 and multiple sclerosis.20 Although a recent small meta-analysis (including only 5 studies) reported that ESWT had a significant effect on improving spasticity 4 weeks after treatment compared with baseline in patients with brain injury,21 the effect of ESWT on spasticity cannot be determined because most studies to date have enrolled small patient numbers, and have lacked placebo-controlled groups and/or long-term follow-up. Among these studies, only 3 have included a placebo-controlled group in patients with cerebral palsy,17 stroke,7 and multiple sclerosis.20 To the best of our knowledge, only 1 study, without a control group, has applied rESWT for spasticity of the upper extremity in stroke patients.14Whether varying the number of ESWT sessions would affect the duration of the therapeutic effect has not been investigated in a single study. Moreover, the general improvement in functional disability after reduction of spasticity via ESWT application to the upper limb has rarely been investigated in previous studies.

Hence, we performed a prospective, randomized, single blind, placebo-controlled study to investigate the long-term effect of rESWT in patients with poststroke spasticity and surveyed the outcome of functional activity.

Continue —> Effect of Radial Shock Wave Therapy on Spasticity of the Upp… : Medicine

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