Unpacking the Research on Veterinary Shock Wave Therapy

Extracorporeal Shock Wave Therapy continues to be a subject of regular conversation, with new research articles published annually that are specific to the Veterinary Industry.

In 2022, two systematic reviews were published – one specific to the Equine industry, and the other looking at Equine and Small Animal publications. In addition to the resources on this modality that are available in the Onlinepethealth Memberships, I will share some of the findings of the second literature review that focuses on small animal and equine literature.

 

In the Onlinepethealth Memberships, you can learn more about ESWT in the following resources:

1. SAAPRA Journal Club on ESWT (Discussion and review of the literature)
2. Extracorporeal Shockwave Therapy raises Mechanical Nociceptive Threshold in Horses with Thoracolumbar Pain (Research Refresh)
3. Extracorporeal Shockwave Therapy for Supraspinatus and Biceps Tendinopathies (Research Refresh)
4. The Pressure to Perform: Choosing an ESWT Device, with Melissa King (webinar)
5. Extracorporeal Shockwave Therapy for Small Animals, with Kristin Kirkby Shaw (Webinar)
6. The use of Therapeutic Shockwave in the Horse, with Dr Kent Allen (Webinar)
7. Shockwave Therapy Basics & Clinical Applications, with Marti Drum (Webinar)

 Let’s dive into the recently published Systematic Review on the use of ESWT in veterinary medicine.

 

Systematic Review of Complementary and Alternative Veterinary Medicine in Sport and Companion Animals: Extracorporeal Shockwave Therapy

Anna Boström, Anna Bergh, Heli Hyytiäinen, and Kjell Asplund. 2022.

This systematic review is what I believe to be, the highest level of evidence we currently have that evaluates the use of ESWT in veterinary medicine, across species. This paper looks at the literature published on dogs and horses. Cats would have been included, but unfortunately, no publications are evaluating the use of this modality in cats.

Studies included were either randomized controlled clinical trials, interventional studies or observational studies. Case studies were included only if 5 or more subjects were included in the study. The included studies needed to evaluate the effects of ESWT on a single indication, and without combining ESWT with other complementary therapies.

Each article was evaluated for risk of bias, which was based on the study design, statistical power, deviation from planned therapy, loss to follow-up, type of outcome assessed, relevance, and risk of confounding factors in observational studies.

The authors summarised the evidence for each condition studied, using the GRADE system. This categorises the certainty of evidence as high, moderate, low or very low. The criteria that negatively impacts this scale include risk of bias or limitations in study design, inconsistency of results, and low statistical power.

 

Results  

This review shows that the evidence for the use of this modality to treat conditions affecting bones, ligaments, tendons and muscles in horses and dogs is favourable but weak. There are a few reasons that they found the evidence to be weak, including:

• Few available studies
• Small sample sizes
• Methodological problems,
• Results not replicated in independent studies.

For indications such as short-term pain relief, ligament ailments and osteoarthritis, there are promising results that warrant further exploration in high-quality studies.

Of 356 articles, 36 were included in the final study meeting the inclusion criteria. 27 articles were performed with horses and 9 were performed with dogs.

The authors compared the results for specific conditions studied:

 

Bone Mass

The studies: 

1. Pyles, M.D.; da Fonseca, B.P.A.; Machado, V.M.V.; Alves, A.L.G. Determinação da densidade mineral e da elasticidade óssea após a aplicação de ondas de choque extracorpóreas no terceiro metacarpiano de equinos atletas. Braz. J. Vet. Tes. Anim. Sci. 2011, 48, 495–502. [Google Scholar] [CrossRef][Green Version]
2. Ringer, S.K.; Lischer, C.J.; Ueltschi, G. Assessment of scintigraphic and thermographic changes after focused extracorporeal shock wave therapy on the origin of the suspensory ligament and the fourth metatarsal bone in horses without lameness. Am. J. Vet. Res. 2005, 66, 1836–1842. [Google Scholar] [CrossRef]

Findings: 

• Over 72 days, a statistically significant decrease in bone mass was observed in healthy metacarpal bones treated with ESWT.
• No difference in radiopharmaceutical activity was found in two sites treated with ESWT after 19 days.

Conclusion:

The certainty of evidence for ESWT to have an effect on bone mass or radiopharmaceutical activity was very low. This was due to inconsistent results and low statistical power.

 

Wound Healing

The studies: 

1. Link, K.A.; Koenig, J.B.; Silveira, A.; Plattner, B.L.; Lillie, B.N. Effect of unfocused extracorporeal shock wave therapy on growth factor gene expression in wounds and intact skin of horses. Am. J. Vet. Res. 2013, 74, 324–332. [Google Scholar] [CrossRef]
2. Morgan, D.D.; McClure, S.; Yaeger, M.J.; Schumacher, J.; Evans, R.B. Effects of extracorporeal shock wave therapy on wounds of the distal portion of the limbs in horses. J. Am. Vet. Med. Assoc. 2009, 234, 1154–1161. [Google Scholar] [CrossRef] [PubMed]
3. Silveira, A.; Koenig, J.B.; Arroyo, L.G.; Trout, D.; Moens, N.M.; LaMarre, J.; Brooks, A. Effects of unfocused extracorporeal shock wave therapy on healing of wounds of the distal portion of the forelimb in horses. Am. J. Vet. Res. 2010, 71, 229–234. [Google Scholar] [CrossRef] [PubMed]

Findings:

• ESWT treatment reduces the formation of granulation tissue and reduces signs of early inflammation.
• No acceleration in healing occurred.
• ESWT was associated with reduced TGF-1 expression and increased IGF-1 expression. 
• Faster healing time of wounds treated weekly with ESWT. 

Conclusion: 

The certainty of evidence for beneficial effects in wound healing was low, this is due to the low statistical power of the published studies. That being said, two of the three published studies reported positive outcomes. 

 

Navicular disease 

Studies: 

1. Urhahne, P.; Röcken, M.; Gerhards, H. Eine klinische Studie zur Behandlung häufiger Erkrankungen des Bewegungsapparates des Pferdes mittels fokussierter extrakorporaler Stoßwellentherapie (ESWT). Pfederheilkunde 2005, 21, 545–550. [Google Scholar]
2. Blum, N.; Kreling, K.; Öitzke, L.-F. Der Einsatz der Extrakorporalen Stoßwellentherapie zur Behandlung des Podotrochlose-Syndroms. Pferdeheilkunde 2005, 21, 29–38. [Google Scholar] [CrossRef][Green Version]
3. Brown, K.E.; Nickels, F.A.; Caron, J.P.; Mullineaux, D.R.; Clayton, H.M. Investigation of the immediate analgesic effects of extracorporeal shock wave therapy for treatment of navicular disease in horses. Vet. Surg. 2005, 34, 554–558. [Google Scholar] [CrossRef] [PubMed]
4. Byron, C.; Stewart, A.; Benson, B.; Tennent-Brown, B.; Foreman, J. Effects of radial extracorporeal shock wave therapy on radiographic and scintigraphic outcomes in horses with palmar heel pain. Vet. Comp. Orthop. Traumatol. 2009, 22, 113–118. [Google Scholar]

Findings: 

• After 6 weeks, 47% of horses treated against the frog were sound. 80% of horses treated against the bulb of the heel were sound. 
• Radiographic and scintigraphic evaluation of the area revealed no change after one treatment – no acute effect. 
• Force plate analysis revealed no beneficial acute effect of ESWT. 
• 6 out of 12 horses treated with ESWT were sound at 3 months, and 5 remained sound at 6 months. 

Conclusions: 

The studies were poorly designed, and all results had a high risk of bias. Both positive and no effects were reported in these studies, only one study had a control group for the treatment of Navicular disease.

 

Ligament injury, Desmitis and Sesamoiditis 

Studies: 

1. Caminoto, E.H.; Alves, A.L.; Amorim, R.L.; Thomassian, A.; Hussni, C.A.; Nicoletti, J.L. Ultrastructural and immunocytochemical evaluation of the effects of extracorporeal shock wave treatment in the hind limbs of horses with experimentally induced suspensory ligament desmitis. Am. J. Vet. Res. 2005, 66, 892–896. [Google Scholar] [CrossRef]
2. Giunta, K.; Donnell, J.R.; Donnell, A.R.; Frisbie, D.D. Prospective randomized comparison of platelet rich plasma to extracorporeal shockwave therapy for treatment of proximal suspensory pain in western performance horses. Res. Vet. Sci. 2019, 126, 38–44. [Google Scholar] [CrossRef]
3. Siedler, C.; Stanek, C.; Brems, R. Proximal suspensory desmitis in the horse: Extracorporeal shock wave therapy compared to injections according to Dr. Muller-Wohlfahrt. A field study. Tierärtzl. Prax. 2003, 31, 342–351. [Google Scholar]
4. Crowe, O.M.; Dyson, S.J.; Wright, L.M.; Schramme, M.C.; Smith, R.K.W. Treatment of chronic or recurrent proximal suspensory desmitis using radial pressure wave therapy in the horse. Equine Vet. J. 2004, 36, 313–316. [Google Scholar] [CrossRef]
5. Lischer, C.J.; Ringer, S.K.; Schnewlin, M.; Imboden, I.; Fürst, A.; Stöckli, M.; Auer, J. Treatment of chronic proximal suspensory desmitis in horses using focused electrohydraulic shockwave therapy. Schweiz. Arch. Tierheilk. 2006, 148, 561–568. [Google Scholar] [CrossRef]
6. Löffeld, S.; Boening, K.-J.; Weirkamp, K.; Stadlwer, P. Radiale extrakorporale Stoßwellentherapie® bei Pferden mit chronischer Insertionsdesmopathie am Fesselträgerursprung– eine kontrollierte Studie. Pferdeheilkunde 2002, 18, 147–154. [Google Scholar] [CrossRef]
7. Urhahne, P.; Röcken, M.; Gerhards, H. Eine klinische Studie zur Behandlung häufiger Erkrankungen des Bewegungsapparates des Pferdes mittels fokussierter extrakorporaler Stoßwellentherapie (ESWT). Pfederheilkunde 2005, 21, 545–550. [Google Scholar]

Findings: 

• Stimulation of the healing process
• 76% of ESWT-treated horses returned to full work after one year
• 52% of horses return to full work after 6 months 
• 71% of treated horses return to full work after 6 months 

Conclusions: 

Most of these studies reported on the treatment of chronic proximal suspensory ligament Desmitis and had a high risk of bias resulting from the study design. Even so, one randomized controlled trial, one non-randomized trial and two observational studies reported positive results and warrants the potential use of ESWT in the treatment of these conditions. 

 

Tendon injury

Studies:

1. Bosch, G.; de Mos, M.; van Binsbergen, R.; van Schie, H.T.; van de Lest, C.H.; van Weeren, P.R. The effect of focused extracorporeal shock wave therapy on collagen matrix and gene expression in normal tendons and ligaments. Equine Vet. J. 2009, 41, 335–341. [Google Scholar] [CrossRef] [PubMed]
2. Bosch, G.; Lin, Y.L.; van Schie, H.T.; van De Lest, C.H.; Barneveld, A.; van Weeren, P.R. Effect of extracorporeal shock wave therapy on the biochemical composition and metabolic activity of tenocytes in normal tendinous structures in ponies. Equine Vet. J. 2007, 39, 226–231. [Google Scholar] [CrossRef] [PubMed]
3. Hunter, J.; McClure, S.R.; Merritt, D.K.; Reinertson, E. Extracorporeal shockwave therapy for treatment of superficial digital flexor tendonitis in racing Thoroughbreds: 8 clinical cases. Vet. Comp. Orthop. Traumatol. 2004, 17, 152–155. [Google Scholar] [CrossRef]

Findings: 

• 3 hrs after treatment, glycosaminoglycan and protein synthesis increased, but synthesis decreased 6 weeks after treatment
• 3 hrs after treatment a disorganisation of the normal collagen structure could be seen, with remnants of the treatment still seen after 6 weeks.
• In a case series, 5 out of 8 horses returned to successful racing.

Conclusions:

The certainty of the evidence for the beneficial effects of ESWT on tendon healing was graded as very low.

 

Osteoarthritis

Studies:

1. Frisbie, D.D.; Kawcak, C.E.; McIlwraith, C.W. Evaluation of the effect of extracorporeal shock wave treatment on experimentally induced osteoarthritis in middle carpal joints of horses. Am. J. Vet. Res. 2009, 70, 449–454. [Google Scholar] [CrossRef]
2. Urhahne, P.; Röcken, M.; Gerhards, H. Eine klinische Studie zur Behandlung häufiger Erkrankungen des Bewegungsapparates des Pferdes mittels fokussierter extrakorporaler Stoßwellentherapie (ESWT). Pfederheilkunde 2005, 21, 545–550. [Google Scholar]
3. McCarroll, G.D.; McClure, S.R. Initial experiences with extracorporeal shock wave therapy for treatment of bone spavin in horses—Part II. Vet. Comp. Orthop. Traumatol. 2002, 15, 184–186. [Google Scholar] [CrossRef]

Findings: 

• After 70 days, horses with induced carpal OA treated with ESWT had an improved level of lameness compared to the two control groups.
• Horses diagnosed with bone spavin showed an improved level of lameness at 3 months after a single treatment.

Conclusions:

In a randomized study, experimentally induced carpal OA improved with the use of ESWT. In clinical cohort studies, the risk of bias was high and the certainty of the evidence was graded as very low.

 

Analgesic effects

Studies:

1. Bolt, D.M.; Burba, D.J.; Hubert, J.D.; Strain, G.M.; Hosgood, G.L.; Henk, W.G.; Cho, D.Y. Determination of functional and morphologic changes in palmar digital nerves after nonfocused extracorporeal shock wave treatment in horses. Am. J. Vet. Res. 2004, 65, 1714–1718. [Google Scholar] [CrossRef]
2. Bolt, D.M.; Burba, D.J.; Hubert, J.D.; Pettifer, G.R.; Hosgood, G.L. Evaluation of cutaneous analgesia after non-focused extracorporeal shock wave application over the 3rd metacarpal bone in horses. Can. J. Vet. Res. 2004, 68, 288–292. [Google Scholar]
3. Waldern, N.M.; Weishaupt, M.A.; Imboden, I.; Wiestner, T.; Lischer, C.J. Evaluation of skin sensitivity after shock wave treatment in horses. Am. J. Vet. Res. 2005, 66, 2095–2100. [Google Scholar] [CrossRef][Green Version]
4. Trager, I.R.; Funk, R.A.; Clapp, K.S.; Dahlgren, L.A.; Werre, S.L.; Hodgson, D.R.; Pleasant, R.S. Extracorporeal shockwave therapy raises mechanical nociceptive threshold in horses with thoracolumbar pain. Equine Vet. J. 2020, 52, 250–257. [Google Scholar] [CrossRef] [PubMed]
5. Alves, A.L.G.; Almeida da Fonseca, B.P.; Hussni, C.A.; Soares, L.V. Tratamento da desmite supra e interespinhosa em equinos utilizando a terapia por ondas de choque extracorpóreas. Vet. Zootec. 2009, 18, 143–151. [Google Scholar]
6. Dahlberg, J.A.; McClure, S.R.; Evans, R.B.; Reinertson, E.L. Force platform evaluation of lameness severity following extracorporeal shock wave therapy in horses with unilateral forelimb lameness. J. Am. Vet. Med. Assoc. 2006, 229, 100–103. [Google Scholar] [CrossRef] [PubMed]

Findings:

• Conduction velocity of the medial and lateral palmar branches of the digital sensory nerves decreases at 3 and 7 days after treatment, with some decrease still present at 35 days.
• No changes in skin sensitivity occur following treatment.
• Improved mechanical nociceptive threshold 56 days after treatment, in horses with back pain.
• Improvement in clinical lameness related to back pain 90 days after treatment.
• Improvement in echogenicity was assessed by US 120 days after treatment, in horses with thoracolumbar Desmitis.

Conclusion:

While there is some evidence that ESWT has an analgesic effect in horses, the results remain inconsistent. The certainty of the evidence for analgesia was graded as low because of inconsistent results and low statistical power in all studies.

 

Canine research

Bone healing

Studies: 

1. Barnes, K.; Faludi, A.; Takawira, C.; Aulakh, K.; Rademacher, N.; Liu, C.C.; Lopez, M.J. Extracorporeal shock wave therapy improves short-term limb use after canine tibial plateau leveling osteotomy. Vet. Surg. 2019, 48, 1382–1390. [Google Scholar] [CrossRef]
2. Barnes, K.; Lanz, O.; Were, S.; Clapp, K.; Gilley, R. Comparison of autogenous cancellous bone grafting and extracorporeal shock wave therapy on osteotomy healing in the tibial tuberosity advancement procedure in dogs. Radiographic densitometric evaluation. Vet. Comp. Orthop. Traumatol. 2015, 28, 207–214. [Google Scholar]
3. Kieves, N.R.; MacKay, C.S.; Adducci, K.; Rao, S.; Goh, C.; Palmer, R.H.; Duerr, F.M. High energy focused shock wave therapy accelerates bone healing. A blinded, prospective, randomized canine clinical trial. Vet. Comp. Orthop. Traumatol. 2015, 28, 425–432. [Google Scholar] [CrossRef]

Findings:

• Improved bone healing in dogs that underwent TPLO.
• Another study found no difference in bone healing or density between treatment and control groups that underwent TPLO.
• Non-union fracture healing may be improved.

Conclusions:

While promising results have been reported, the only study with a low risk of bias showed no beneficial effects of ESWT. Further research is warranted.

 

Patellar Ligament Desmitis

Studies:

1. Gallagher, A.; Cross, A.R.; Sepulveda, G. The effect of shock wave therapy on patellar ligament desmitis after tibial plateau leveling osteotomy. Vet. Surg. 2012, 41, 482–485. [Google Scholar] [CrossRef]

Findings:

• At 6 and 8 weeks post TPLO surgery, the patella tendon was significantly less thick in treated dogs.
• Blinded US scans showed no significant difference between the two groups concerning ligament disruption and oedema.

Conclusion:

The certainty of the evidence for this condition was graded as low, as there was only one study with limited statistical power.

 

Tendon injuries

Studies:

• Leeman, J.J.; Shaw, K.K.; Mison, M.B.; Perry, J.A.; Carr, A.; Shultz, R. Extracorporeal shockwave therapy and therapeutic exercise for supraspinatus and biceps tendinopathies in 29 dogs. Vet. Rec. 2016, 179, 385. [Google Scholar] [CrossRef][Green Version]

Findings:

• 17 out of 20 dogs with supraspinatus and infraspinatus tendinopathies reported good to excellent outcomes, with 10 of the dogs still on medications or nutraceuticals.

Conclusion:

As only one retrospective study is available, the evidence for beneficial results was graded as low.

 

Osteoarthritis

Studies:

1. Dahlberg, J.A.; Fitch, G.; Evans, R.B.; McClure, S.R.; Conzemius, M. The evaluation of extracorporeal shockwave therapy in naturally occurring osteoarthritis of the stifle joint in dogs. Vet. Comp. Orthop. Traumatol. 2005, 18, 147–152. [Google Scholar]
2. Mueller, M.; Bockstahler, B.; Salicky, M.; Mlacnik, E.; Lorinson, D. Effects of radial shockwave therapy on the limb function of dogs with hip osteoarthritis. Vet. Rec. 2007, 160, 762–765. [Google Scholar] [CrossRef]
3. Bockstahler, B.; Müller, M.; Skalicky, M.; Mlacnik, E.; Lorinson, D. Die extrakorporale radiale Stoßwellentherapie bei der Cubarthrose des Hundes-eine mittels Messung von Bodenreaktionskräften evaluierte Studie. Tierärzl. Mschr. 2006, 93, 39–46. [Google Scholar]

Findings:

• Over 98 days, Dogs with stifle OA showed little change in kinetic force plate analysis and goniometry, while the control group worsened.
• Dogs with hip OA showed an improvement in lameness at 6 months post-treatment, while in control dogs there was no change.
• In dogs with elbow OA, there was an improvement in lameness 4 weeks after treatment with no control group.

Conclusions:

Although the results are positive, two of the studies are observational with a high risk of bias, while the one randomized controlled clinical trial has limited statistical significance.

 

In Conclusion:

“The present systematic review has revealed significant gaps in scientific knowledge regarding the effects of ECSWT in horses and dogs. For the use of ECSWT in cats, no scientific articles were retrieved. For some of the musculoskeletal indications, at least some research documentation was available in horses and/or dogs. However, due to small sample sizes, lack of control groups, and other methodological limitations, few articles with a low risk of bias were identified. Where beneficial results were reported, they were seldom replicated in independent studies.

The large proportion of studies with a high risk of bias emphasizes the need for more high-quality research using precise methodologies to evaluate the potential therapeutic effects of ECSWT. For a few indications, notably wound healing, ligament injuries, desmitis, and osteoarthritis, some results seem interesting enough to warrant further exploration in high-quality observational or interventional studies. The possible analgesic effects of

ECSWT may also be subject to more in-depth investigations. At present, the scientific evidence for the clinical effect of ECSWT in sport and companion animals is limited.”

 

While the below articles are covered in the above Systematic review, I wanted to share a few of the positive outcomes we found when performing the Research Refresh. 

 

3 take-home points for pain in the equine back: Research Refresh

Trager et al., 2019, examined different pathologies in the equine spine, specifically in the thoracic and lumbar areas. They performed three treatments of ESWT at two-week intervals, measuring pain at set time points throughout the period and beyond. They concluded the following:

1. ESWT will provide pain relief in the equine with back pain and pathology.
2. Horses may need fewer treatments in the thoracic area than in the lumbar area, as the thoracic area responded to ESWT after one treatment, while the lumbar area required three treatments.
3. Shock wave treatment should be accompanied by a rehab plan to address the other goals of rehab, such as strengthening spinal stabilisers and improving posture and mobility.

 

3 take-home points for treatment of the canine supraspinatus and infraspinatus

I learnt so much about the conditions of supraspinatus and infraspinatus while working on this Research Refresh, that I wrote a blog focusing on these conditions. Leeman et al., 2016, performed a retrospective study and evaluated several aspects of these conditions, comparing dogs that received ESWT treatment only with dogs that received ESWT together with a therapeutic exercise programme. They concluded the following:

1. 75% of dogs no longer needed pain medication at the end of the study period.
2. The best outcomes were reported in moderate and severe cases.
3. There was no difference in results between the group receiving only ESWT and those receiving ESWT together with therapeutic exercise.

 

I have included two short summaries of two more papers that you may find of particular interest: 

Extracorporeal shockwave therapy improves short-term limb use after canine tibial plateau levelling osteotomy (TPLO)

Barnes et al., 2019, compared cranial cruciate ligament ruptures (CCLR) in dogs treated with TPLO only with dogs treated with both TPLO and ESWT. The results were as follows:

1. Weight-bearing increased faster amongst dogs treated with ESWT.
2. There was no difference between the two groups when it came to the occurrence of post-op complications.
3. There was no difference in many of the outcome measures, including stifle circumference, goniometry measurements, and subjective pain scores at all evaluated time points.
4. Ground reaction force values improved in the ESWT treatment group and decreased in the group with TPLO only at the two-week mark.
5. At the two-week mark, the TPLO group had a reduced ground reaction force, while the ESWT group had an improved GRF compared to the pre-operative level.

So, very interestingly, ESWT impacted the amount of weight bearing positively but had no impact on the other outcome measures. It is possible that the pain-relieving effect of ESWT enabled the dogs to increase their weight bearing in the first two weeks post-op. As the research on equine back pain concluded, it is necessary to include other therapeutic modalities to address and improve other specific outcomes, such as stifle circumference.

 

Review of the application and efficacy of extracorporeal shock wave therapy in equine tendon and ligament injuries

Yocom et al., 2019, performed a literature review covering research on several aspects of ESWT; the underlying physics of the modality, the molecular changes, the combination of ESWT with regenerative medicine, safety aspects, analgesia, equipment needed, specific soft tissue injuries including suspensory ligament desmitis, superficial digital flexor tendonitis, accessory ligament of the DDFT, and back pain. It also makes further literature recommendations.

Some of the take-home points that stand out to me include:

1. ESWT treatment for soft tissue injuries in horses does have healing effects and provides pain relief.
2. When it comes to proximal suspensory injuries, ESWT can aid in returning horses to sport faster and filling in defects in the tendon sooner.
3. For superficial digital flexor tendinopathy, ESWT may help to fill in the defect faster, but whether or not there is an effect on the lameness score or a faster return to function is still inconclusive.
4. ESWT does provide pain relief for back pain. In many studies, ESWT is combined with other therapies, and so the true effect of ESWT is not clear.
5. Specific treatment protocols still need to be validated.

 

A valuable tool for our toolbox

It seems clear that we still lack a great deal of information on specific treatment protocols for different conditions and on the therapeutic effects on specific tissues. While there are positive outcomes reported in the literature, there is also a high degree of bias and poor study protocols, with contradicting results. This makes it difficult to conclude with regard to the evidence base of ESWT as a therapeutic modality while providing enough support for clinical use in certain conditions and applications.

 

References

1. Boström, A.; Bergh, A.; Hyytiäinen, H.; Asplund, K. Systematic Review of Complementary and Alternative Veterinary Medicine in Sport and Companion Animals: Extracorporeal Shockwave Therapy. Animals 2022, 12, 3124. https://doi.org/10.3390/ani12223124
2. Trager LR, Funk RA, Clapp KS, Dahlgren LA, Werre SR, Hodgson DR, Pleasant RS. Extracorporeal shockwave therapy raises mechanical nociceptive threshold in horses with thoracolumbar pain. Equine Vet J. 2020 Mar;52(2):250-257. doi: 10.1111/evj.13159. Epub 2019 Sep 4. PMID: 31393628.
3. Leeman JJ, Shaw KK, Mison MB, Perry JA, Carr A, Shultz R. Extracorporeal shockwave therapy and therapeutic exercise for supraspinatus and biceps tendinopathies in 29 dogs. Vet Rec. 2016 Oct 15;179(15):385. doi: 10.1136/vr.103487. Epub 2016 Jul 21. PMID: 27444781.
4. Barnes K, Faludi A, Takawira C, Aulakh K, Rademacher N, Liu CC, Lopez MJ. Extracorporeal shock wave therapy improves short-term limb use after canine tibial plateau leveling osteotomy. Vet Surg. 2019 Nov;48(8):1382-1390. doi: 10.1111/vsu.13320. Epub 2019 Aug 30. PMID: 31469432.
5. Yocom, A. F., & Bass, L. D. (2019). Review of the application and efficacy of extracorporeal shockwave therapy in equine tendon and ligament injuries. Equine Veterinary Education, 31(5), 271-277. https://doi.org/10.1111/eve.12780