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Shock wave therapy improves outcomes in patients with calcific tendinitis of the shoulder
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January 2014
Shock wave therapy improves outcomes in patients with calcific tendinitis of the shoulder
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:2
Journal Level of Evidence:N/A
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. 2013 Sep;94(9):1699-706Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Six randomized control trials involving 460 patients were included in this meta-analysis and systematic review to determine the effectiveness of shock wave therapy on calcific tendinitis of the shoulder. Pain, disability and calcium reabsorption can be improved with shock wave therapy in patients suffering from calcific tendonitis of the shoulder according to the findings of this meta-analysis and systematic review. This study also suggests that high-energy levels have superior outcomes when compared to low-energy shock wave therapy.
Publication Funding Details
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Funding:
Not Reported
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
3/4
Results
2/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Surgery is used as a last resort treatment for calcific tendinitis of the shoulder (CTS) due to large costs and a lengthy leave of absence required from work. A variety of conservative treatment methods for calcific tendinitis have been created, with one of the most widely debated being shock wave therapy. Shock wave therapy has been shown to relieve pain, improve clinical symptoms and reduce calcifications. The ideal level of energy required to dissipate calcifications and overall effectiveness of shock was therapy is unclear, and so this study was brought forward to clarify these unknowns.
What was the principal research question?
Is shock wave therapy effective at treating calcific tendinitis of the shoulder?
Study Characteristics
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Data Source:
MEDLINE, Embase, CINAHL, Ovid database, Physiotherapy Evidence Database (PEDro), and the Cochrane Library were searched for the period from August 1992 through December 2011
Index Terms:
Calcific AND "tendinopathy" OR "tendinopathy" OR "tendinitis" OR "tendonitis"(rotator cuff, supraspinatus tendon); Shoulder pain AND shock AND wave; Extracorporeal; Radial; Clinical Trial OR Randomized Controlled Trial OR Controlled Clinical Trial; Physical therapy; Rehabilitation
Study Selection:
6 randomized control trials were included in this meta-analysis. All studies compared shock wave therapy with a placebo or against no treatment at all in patients older than 18 years with Shoulder pain or tenderness from calcific tendonitis in patients with type I or II calcification according to the radiographic classification of Gartner and Simons. All studies were written in English and measured shoulder function scales, and resorption of calcific deposits, defined through radiographic examinations. Studies were selected by two independent authors and disagreements were settled by a third.
Data Extraction:
Outcome data was extracted and cross-checked by two independent reviewers. Data on number and sex of patients, history of symptoms, follow-up, treatment groups, and outcome measures was organized in a table.
Data Synthesis:
Data from the 6 included studies was pooled and analyzed using Stata Software. Fixed- and random-effects models were used and heterogeneity was assessed with an I-squared statistic. 4 studies examining 2 treatment groups were evaluated using meta-analysis, however the remaining 2 studies included that examined 3 treatment groups were analyzed descriptively.
What were the important findings?
- 4 studies in a fixed-effects model confirmed radiologic rate of resorption of calcific deposits at 6 months’ follow-up suggested that shock wave therapy is superior to no treatment or placebo for total resorption of calcium (RR of 27.19; 95% CI 7.20-102.67) without significant heterogeneity (p= 0.552). Three pooled studies in a fixed effects model analyzed partial reabsorption, (RR of 16.22; 95% CI 3.33-79.01). Estimates were not heterogeneous across studies (p=0.845).
- Tashjian et al determined the minimal difference of 1.4, in a ten point visual analog scale (VAS), to signify clinical importance. In the 3 studies that used VAS as an outcome measure, and at six weeks, the average change in pain was deemed clinically relevant by Tashjian et al’s standards.
- In the study by Hsu et al, the Constant-Murley score assessing physical evaluation and the patients’ subjective evaluation, an improvement of 25.5 points was observed in the treatment group compared to a decrease of 1.9 points in the control group after 6 months. The study by Hearden et al, an increase of 11% in the Constant-Murley score was found in 45% of treated patients opposed to the comparison group in which no change was noted. Gerdesmeyer et al also found improvements in the Constant-Murley score between both high (score of 31.0) and low energy (15.0) shock waves and the sham group (6.6) at 6 months. In the study by Cosentino et al, the mean improvement found in the Contant-Murley score of the shock wave group at six months was 69% compared to no significant improvement in the control group.
- Cacchio et al used the University of California Los Angeles Shoulder Rating Scale and noticed a significant improvement in mean function in the experimental group
- Hearnden et al’s study observed no signs of calcific deposits at 6 months in 54.5% of patients receiving SWT, while Cacchio noticed 86.6% total absorption and 13.4% partial absorption 1 week following treatment, a finding that was maintained at the 6 month follow-up. Rompe et al recorded a complete disappearance of calcium deposits more frequently in patients with type II calcifications according to Gartner and Simons’ classification. The study by Hsu et al reported a total resorption rate of 21.2% and a partial resorption rate of 33.3% in the experimental group; whereas the study by Cosentino reported a total resorption rate of 31.4% and a partial resorption rate of 40%.
- Peters et al observed high energy therapy (.44mJ/mm2) is more effective than low-energy therapy (.15mJ/mm2) in dissolving calcifications at 6 months; no residual calcifications and no recurrence of pain was observed in the high-energy group, whereas in the low energy group, all subjects showed residual deposits, and 87% of patients experienced a recurrence of pain.
- Gerdesmeyer compared high-energy (.32mJ/mm2) and low energy (.08mJ/mm2) shock wave therapy and patients experienced a better response to high energy therapy with a rate of 60% of complete disappearance of calcific deposits at 6 months’ follow-up and 86% at 12 months’ follow-up, whereas in the low-energy treatment group the rate of dissolution was 21% at 6 months and 25% at 12 months.
What should I remember most?
The change in pain with shock wave therapy was reported as clinically relevant in all 3 studies that assessed pain with a visual analog scale. Shock wave therapy improved the Constant-Murley score in 4 studies whereas the sham patients experienced no change. Significant improvements were noticed in the University of California Shoulder Rating Scale with shock wave therapy in one study. Calcium reabsorption rates were higher with shock wave therapy compared to the control group. High energy therapy was deemed more effective in reducing calcific deposits compared to low energy therapy.
How will this affect the care of my patients?
Patients suffering from calcific tendinitis of the shoulder can benefit from the use of shock wave therapy. Shock wave therapy provided superior pain relief, improved function and higher calcium reabsorption than the sham or placebo groups. Also, it was found that high energy shock wave therapy leads to greater improved effects than low energy therapy.
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