Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Emanuela Elena Mihai,Luminita Dumitru,Ilie Valentin Mihai,Mihai Berteanu

doi:10.3390/jcm10010086

Abstract

The purpose of this systematic review and meta-analysis is to evaluate the long-term efficacy of Extracorporeal Shock Wave Therapy (ESWT) on reducing lower limb post-stroke spasticity in adults. A systematic electronic search of PubMed/ MEDLINE, Physiotherapy Evidence Database (PEDro), Scopus, Ovid MEDLINE(R), and search engine of Google Scholar was performed. Publications that ranged from January 2010 to August 2020, published in English, French, Spanish, Portuguese, and Italian language and available as full texts were eligible for inclusion and they were searched without any restrictions of country. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. Two authors screened the references, extracted data, and assessed the risk of bias. The primary outcome was spasticity grade mainly assessed by the Modified Ashworth Scale (MAS). Secondary outcomes were passive range of motion (PROM), pain intensity, electrophysiological parameters, gait assessment, and adverse events. A total of seven recent randomized controlled trials (RCTs) were included in the systematic review and meta-analysis, and a beneficial effect on spasticity was found. The high level of evidence presented in this paper showed that ESWT ameliorates spasticity considering the parameters: MAS: standardized mean difference (SMD) = 0.53; 95% confidence interval (95% CI): (0.07–0.99); Modified Tardieu Scale (MTS): SMD = 0.56; 95% CI: (0.01–1.12); Visual Analogue Scale (VAS): SMD = 0.35; 95% CI: (−0.21–0.91); PROM: SMD = 0.69; 95% CI: (0.20–1.19). ESWT presented long-term efficacy on lower limb post-stroke spasticity, reduced pain intensity, and increased range of motion. The effect of this novel and non-invasive therapy was significant and the intervention did not present adverse events, proving a satisfactory safety profile.

Highlights

Over the past decade, death caused by cerebrovascular accidents has significantly decreased, but stroke is ranked as the second leading cause of death worldwide with an annual mortality rate of 5.5 million and the third leading cause of disability [1,2,3].Following stroke, patients may often present diverse sensory-motor disturbances, such as spasticity, muscle weakness, or impaired sensation [4,5,6]
In patients with upper motor neuron syndrome (UMNS), hypertonia can be classified, as follows: hypertonia that is mediated by the stretch reflex, which corresponds to spasticity and hypertonia due to soft tissue changes, which corresponds to nonreflex hypertonia or intrinsic hypertonia [8]
One author was contacted for clarifications, but, since no response was received, the study could not be included in the present systematic review and meta-analysis

Summary

Introduction

Patients may often present diverse sensory-motor disturbances, such as spasticity, muscle weakness, or impaired sensation [4,5,6]. Lance defines spasticity as a motor disorder that is characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks due to the hyperexcitability of the stretch reflex, as a component of the upper motor neuron syndrome (UMNS) [7]. In patients with UMNS, hypertonia can be classified, as follows: hypertonia that is mediated by the stretch reflex, which corresponds to spasticity and hypertonia due to soft tissue changes, which corresponds to nonreflex hypertonia or intrinsic hypertonia [8]. Spasticity is more often present in the flexor muscles of the upper limb and in the extensor muscles of the lower limb [8]

Methods

Results

Discussion

Conclusion