Effectiveness and Safety of Type- and Energy-based Extracorporeal Shockwave Therapy in Clinical Practice: Umbrella Review and Evidence Mapping

BackgroundThe role of distinct type- and energy-based extracorporeal shockwave therapy (ESWT) in clinical practice is unclear. ObjectivesTo appraise meta-analytically determined effectiveness and safety of type- and energy-based ESWT for diseases or conditions, and visualize evidence maps of findings. MethodsNine online databases and reference lists were systematically searched for systematic reviews (SRs) of randomized controlled trials (RCTs) evaluating the effectiveness or safety of ESWT from inception to September 2023. SRs were then updated if up-to-date RCTs were eligible. Overall effects were re-estimated using random-effects model and reported as relative risk or standardized mean difference with 95% confidence intervals. Methodological quality, certainty of evidence, and safety were assessed with AMSTAR 2, GRADE tool, and MedDRA, respectively. ResultsOur research identified 210 relevant SRs encompassing 636 RCTs and 41649 participants across 7 therapeutic areas and 37 diseases and conditions. Methodological quality of most published SRs was low or critically low. Four treatment statuses of type- and energy-based ESWT were identified, including potential dominant efficacy (plantar fasciitis, erectile dysfunction, lateral epicondylitis, knee osteoarthritis, frozen shoulder, cerebral palsy spasticity, post-stroke lower limb spasticity; GRADE moderate), potential positive efficacy (chronic prostatitis/chronic pelvic pain syndrome, myofascial pain syndrome, patellar tendinopathy, achilles tendinopathy, stenosing tenosynovitis, frozen shoulder, rotator cuff tear, cerebral palsy spasticity, post-stroke upper limb spasticity, cervical spondylotic radiculopathy; GRADE low or very low), potential similar efficacy (osteonecrosis of the femoral head, plantar heel pain, patellar tendinopathy; GRADE low or very low), and potential adverse efficacy (patellar tendinopathy; GRADE very low). Along with courses of ESWT treatment, pain, flushing, and swelling were the most prevalent side effects and serious adverse reactions were limited. ConclusionVariable type- and energy-based ESWT is probably effective and safe in clinical practice. Due to lack of available data and high certainty in current evidence, future research should prioritize large-scale and well-designed studies. RegistrationPROSPERO number CRD42023477234