Radial extracorporeal shock wave therapy in patients with spasticity after stroke based on randomized clinical trials: a systematic review and meta-analysis, and trial sequential analysis

Introduction
Extracorporeal shock wave therapy (ESWT) was first used to treat kidney stones with lithotripsy. The present meta-analysis aims to evaluate radial ESWT (rESWT) in patients with spasticity after stroke in randomized controlled trials (RCTs) comparing the timing of Modified Ashworth Scale (MAS) measurement as a primary outcome in these patients.

Material and methods
A comprehensive literature search was conducted across multiple databases, such as PubMed/Medline, Web of Science, Scopus, and Cochrane Library, until January 16, 2024, without any limitations to find relevant RCTs. The Review Manager 5.3 software was used to compute the effect sizes, which were expressed as the standardized mean difference (SMD) along with a 95% confidence interval (CI). A total of 25 RCT articles were included in the meta-analysis. The estimate of effect size showed statistically significant MAS grade reduction immediately after treatment, 1 week after, 2 weeks after, 3 weeks after, 4 weeks after, 6 weeks after, 8 weeks after, and 12 weeks after.

Results
Twenty-five RCTs were entered into the meta-analysis. The pooled SMDs of MAS score for spasticity in post-stroke patients before compared to after rESWT were as follows: 1.82 (95% CI: 1.32, 2.32, p < 0.00001) immediately after, 1.25 (95% CI: 0.85, 1.66, p < 0.00001) one week after, 2.30 (95% CI: 1.07, 3.53, p = 0.0002) after two weeks, 1.19 (95% CI: 0.88, 1.49, p < 0.00001) after four weeks, 1.21 (95% CI: 0.88, 1.54, p < 0.00001) after eight weeks, and 1.83 (95% CI: 1.94, 2.73, p < 0.0001) twelve weeks after rESWT.

Conclusions
The research revealed that rESWT was associated with a notable decrease in the MAS score in patients who had suffered a stroke at all observed time points. Both upper and lower limbs showed significant improvement, especially in the upper limb. All ethnic groups, particularly Arabs, showed significant improvement in MAS scores after treatment.