Comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave therapy in adults with plantar heel pain: A systematic review and network meta-analysis.

Objective: To estimate the comparative clinical efficacy and acceptability of different intensity levels of extracorporeal shock wave therapy (ESWT) in adults with plantar heel pain (PHP). TYPE: Systematic review and network meta-analysis.

Literature Survey: PubMed, EMBASE, Cochrane Library electronic databases and Web of Science for randomized controlled trials from inception to March 2024.

Methodology: We included placebo-controlled and head-to-head trials of different intensity levels of ESWT used to treat adults with PHP. Data were extracted following a predefined hierarchy. We assessed the studies' risk of bias in according to the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Primary outcomes were efficacy (success rate) and acceptability (all-course discontinuation rate). Secondary outcomes were pain and function scores changes. All interventions were ranked using the surface under the cumulative ranking curve to determine the hierarchy of treatment.

Synthesis: 22 RCTs comprising 2299 participants met the inclusion criteria. In terms of efficacy, all intensity levels of ESWT were more effective than placebo, with ORs ranging from 2.29 (95% CI 1.39-3.76) for medium intensity M-ESWT (M-ESWT) to 5.50 (95% CI 1.00-30.29) for low intensity ESWT (L-ESWT). In terms of acceptability, there was no statistically significant difference between all intensity levels of ESWT and placebo, with ORs ranging from 0.83 (0.47-1.45) for M-ESWT to 1.42 (0.19-10.71) for L-ESWT. For pain relief, only M-ESWT and H-ESWT were superior to placebo (SMD -0.60, 95% CI -0.94 to -0.26; SMD -0.28, 95% CI -0.44 to -0.11), whereas there was no difference between them (p = .05). For function improved, there was no statistically significant difference between all intensity levels of ESWT and placebo (range of ORs 1.02-3.44). In contrast, there were no significant differences among the intensity levels in all outcomes. Of the 22 trials, 7 (32%) were assessed as high risk, and the rest (68%) were assessed as unclear risk. The certainty of evidence was low to very low.

Conclusion: Compared to the placebo, all intensity levels of ESWT were more favorable in terms of efficacy, but there was no difference in terms of acceptability. In addition, M-ESWT appeared to provide additional benefits in pain and function for patients with PHP compared to the other intensity levels. The results provide an evidence-based basis for considering ESWT as an alternative for patients with PHP for whom conservative treatment is not effective, and also highlight future research priorities to providing more decision-making for the clinical management of PHP.