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Table 2 Imaging outcome measures for rotator cuff calcifying tendinitis

From: The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

Author (year)

SWT type

Comparator

Imaging outcome

Follow-up

Period

Baseline - F/U

Mean ± SD

P value

Within group

Between group

Albert (2007) [20]

High SWT

Low SWT

The radiological aspects of calcifications (i.e. type, size and location) were determined through lateral and anteroposterior shoulder views in neutral, external and internal rotation. Changes were graded as no resorption, partial resorption and total or subtotal resorption (over 80% reduction of calcified surface on anteroposterior view)

3 months

High: 6(15%) had total or subtotal resorption. 3(7.5%) had partial resorption

Low: 2(5%) had total or subtotal resorption. 5(12.5%) had partial resorption

NR

NR

Cacchio (2006) [21]

R-SWT

Placebo

The radiological aspects of calcifications (i.e. type, size and location) were determined through lateral and anteroposterior shoulder views in 45 degrees of external and internal rotation were acquired. Type of calcification was evaluated according to the Gartner and Simons classification. A caliper that evaluated calcification length (in millimeters) was used for size measurement.

1 week

39(86.6%) had total resorption, 6(13.4%) had partial resorption, while the control group, no complete disappearance of calcifications was observed.

The mean Calcium deposits diameter (mm) pre-SWT was 21.3 ± 7.5, post-SWT was 0.85 ± 1.2. In contrast, pre-sham was 19.7 ± 8.3, post-sham was 18.85.8 ± 6.4.

< 0.00

< 0.00

Charrin (2001) [22]

F-SWT

None

Calcific deposit appearance was assessed on a plain radiograph in neutral rotation

3,6,12,24 weeks

After 12 weeks, 2/30 had total resorption. 5 deposits had partial resorption.

After 24 weeks, 5/29 had total resorption and 2 deposits had partial resorption

NR

NA

Cosentino (2003) [23]

F-SWT

Placebo

Variations in the dimension of the calcification were evaluated by anteroposterior views. Modification of the calcification (a reduction of size of > 2 mm) was indicated as disintegration; the total disappearance was indicated as dissolution.

1 month

11(31%) had total resorption, 14(40%) had partial resorption. Calcification remained unchanged in the control group

< 0.001

NR

Daecke (2002) [24]

F-SWT

1 vs 2 sessions

Anteroposterior radiograph in internal and external rotation was obtained to show obvious changes in the shape and structure (disintegration) or complete resorption of the calcification

3,6 months, 4 years

30% in group A and 52% in group B had partial or total resorption after 3 months, 47 and 77% after 6 months and 93% for both groups at 4 years

NR

< 0.046 at 6 months

DeBoer (2017) [25]

R-SWT

Ultrasound Needling (UN)

Scoring of calcification deposits was assessed through the Gartner Classification of Calcific Tendinitis.

6 weeks

1/14 (7%) in the R-SWT group had total resorption vs 5/11 (45.5%) in UN group

NR

0.029

DelCastillo-Gonzalez (2016) [26]

F-SWT

Ultrasound-guided percutaneous lavage (UGPL)

Calcification size measurement was assessed by ultrasound imaging.

3,6,12 months

55.6% had total resorption by 12 months in the SWT group vs 86.78% in the UGPL group.

The mean Calcium deposits diameter (mm) pre-SWT was 10.53 ± 5.29, post-SWT was 4.67 ± 6.08 after 12 months. In contrast, pre-UGPL was 12.075 ± 4.85, post-UGPL was 1.56 ± 2.79.

< 0.01

< 0.01

Farr (2011) [27]

F-SWT

Low SWT

Radiological difference of the calcific deposit was rated as improvement, unchanged or worsening

6,12 weeks

58% improved in group A compared to 69% in group B after 12 weeks.

5 in group A, and 4 in group B had total resorption

NR

NR

Gerdesmeyer (2003) [28]

F-SWT

Low SWT and placebo

The radiological aspects of calcifications (i.e. type, size and location) were determined through anteroposterior shoulder views in 45 degrees of external and internal rotation.

3,6,12 months

High: 60% had total resorption within 6 months and 86% after 12 months. Low: 21% had total resorption within 6 months and 37% after 12 months. Placebo: 11% had total resorption within 6 months and 25% after 12 months.

Calcific deposit size (mm2) mean change from baseline after 12 months was − 162.2 (95%CI − 204 to −120) in the High-SWT group, − 91.5 (95%CI − 148 to − 35.1) low-SWT group and − 46.8 (95%CI −74.3 to −19.3) in the placebo group

NR

group 1 vs 3 P < 0.01, group 2 vs 3 P = 0.1, group 1 vs 2 p = 0.04

Hsu (2008) [29]

F-SWT

Placebo

An anteroposterior radiograph with the arm in neutral rotation was obtained. The calcific deposits were categorized according to morphology and size (the longest length of the calcium deposit). Scoring of calcification deposits was assessed through the Gartner Classification of Calcific Tendinitis

6 weeks, 3,6,12 months

7(21.2%) had total resorption, 11(36.6%) had partial resorption. In the control group, none had total resorption and 2(15.3%) had partial resorption.

The mean Calcium deposits diameter (mm) pre-SWT was 11.9 ± 5.4 (3.4–23.5), post-SWT was 5.5 ± 6.3 (0–18.7). In contrast, pre-sham was 10.5 ± 6.4 (2.5–20.4), post-sham was 9.8 ± 5.9 (2.3–21).

< 0.01

< 0.01

Jakobeit (2002) [30]

F-SWT

None

Diagnostic ultrasonography and radiography were used to classify the calcareous deposits in 5 categories according to their morphological appearance and size.

4 weeks

57/80 (71.25%) had total resorption. 16/80 (20%) had partial resorption

NR

NA

Kim (2014) [31]

F-SWT

Ultrasound Needling

Radiographic evaluations were performed by standard shoulder anteroposterior radiographs in neutral, internal, and external rotation together with axillary and supraspinatus outlet views to determine the size, morphology, and location of the calcific deposits. Resorption of the calcific deposit was graded as none, partial, or complete.

6 weeks, 3,6,12 months

The mean Calcium deposits diameter (mm) pre-SWT was 11 ± 1 (4.9–19.3), post-SWT was 5.6 ± 0.8. In contrast, pre-US needling was 14.8 ± 1.7 (6.6–31), post-US needling was 0.45 ± 0.3.

In the SWT group, 42.6% had total resorption, 16.7% had partial resorption. In the US needling group 72.2% had total resorption and 11.1% had partial resorption.

< 0.05

=0.001

Kransy (2005) [32]

F-SWT

Ultrasound Needling combined with SWT

Anteroposterior radiographs were taken in internal and external rotation together with axial and supraspinatus-outlet views to determine the size, morphology and location of the calcific deposits.

4.1 ± 0.5

In the SWT only group, 13(32.5%) had total resorption, 14 (35%) had partial resorption. In the US needling combined with SWT group 24(60%) had total resorption and 10 (25%) had partial resorption.

NS

=0.024

Loew (1999) [33]

F-SWT

Low SWT and control

Radiographs included an anteroposterior view in internal and external rotation and a supraspinatus outlet view. Effective treatment was recorded when the calcification had completely disappeared or showed obvious resorption with inhomogeneity and reduction in size

3,6 months

There was total resorption in 4/20 in group 1, 11/20 in group 2, 12/20 in group 3, in contrast to 2/20 in the control group

Group 1 = 0.37

Group 2, 3 < 0.01

NR

Lowe (1995) [34]

F-SWT

None

Radiological assessment of the calcification was made in three different planes.

6,12 weeks

After 12 weeks, changes were seen in 12 patients; 7 showed a total resorption of the calcium deposits

NR

NA

Moretti (2005) [35]

F-SWT

None

Radiographs in anteroposterior of shoulder, acromial outlet view and sonography were evaluated to study the type of calcium deposit according to DePalma criteria

1,6 months

29/54 (54%) had total resorption and 19/54 (35) had partial resorption after 1 month. These findings appeared unvaried at 6 months follow-up

NR

NA

Pan (2003) [36]

F-SWT

TENS

High-resolution ultrasonography (HRUS) was used for imaging measurements. The morphology of calcific plaque of the shoulder on HRUS was classified into 4 types: (1) arc-shaped (echogenic arc with clear shadowing), (2) fragmented (at least 2 separated echogenic plaques with or without shadowing) or punctuated (tiny calcific spots without shadowing), (3) nodular (echogenic nodule without shadowing), and (4) cystic types (bold echogenic wall with echo-free content)

2,4,12 weeks

The mean of difference in Calcium deposits diameter (mm) in the SWT group was 4.39 ± 3.76 after 12 weeks. In contrast, the TENS group was 1.65 ± 2.83.

16/33(48.5%) changed in the type of calcification In the SWT group while 3/29 (10.3) in the TENS group.

< 0.01

0.002

Pigozzi (2000) [37]

F-SWT

None

Radiological assessment of anteroposterior, internal and external rotation and trans-glenoid projection was performed

1 month

7/19 (37%) had reduction or fragmentation of the calcium deposit

NR

NA

Pleiner (2004) [38]

F-SWT

Placebo

Anteriorposterior, axial and outlet-view images were used. Changes calcifications were assessed using the Gartner scale in which a score of 1: indicates no change or a worsening, a score of 2: a decrease of at least 50% in the area and density of the calcification, and a score of 3: complete remission of the calcification

3,7 months

6/31 (19.4%) had total resorption and 6/31 (19.4%) had partial resorption in the SWT group, in contrast to 2/26 (7.7%) had total resorption and 2/26 (7.7%) had partial resorption in the control group after 7 months

NR

=0.07

Rompe (1995) [39]

F-SWT

None

On radiographs, any sign of disintegration was rated as success

6,24 weeks

4/40 (10%) had total resorption and 17/40 (42.5%) had partial resorption after 6 weeks.

After 24 weeks, 6/40 (15%) had total resorption and 19/40 (47.5%) had partial resorption

NR

NA

Rompe (2001) [40]

F-SWT

Surgical extirpation

On the anteroposterior radiological views, resorption was graded as none, partial, or complete.

12 months

47% had total resorption and 33% had partial resorption in the SWT group. In the surgical group, 85% had total resorption and 15% had partial resorption. There was no significant difference regarding the radio-morphologic features

NR

< 0.01

Sabeti-Aschraf (2005) [41]

F-SWT

Navigation vs feedback

No change in the radiographs was graded as 4, a 3 indicated slight alteration of the calcium deposit, reduction in deposit size and radiographic density was graded as 2, and a 1 was given if the calcium deposit was no longer evident

3 months

6/25 (24%) had total resorption and 7/25 (28%) had extensive resorption in the navigation group, in contrast to 1/25 (4%) had total resorption and 5/25 (20%) had partial resorption in the feedback group

NR

0.041

Tornese (2011) [42]

F-SWT

Neutral vs hyperextended internal rotation arm position

Changes between pre- and post-treatment radiographs were graded as no resorption, partial resorption and total or subtotal resorption (> 80% reduction in calcified surface on anteroposterior view)

3 months

12/18 (66.7%) had total resorption in the hyperextended internal rotation group, in contrast to 6/17 (35.3%) in the neutral position group

NR

< 0.05

  1. F-SWT focused SWT, R-SWT radial SWT, NR not reported, NS not significant, NA not applicable