The Effectiveness of ESWT in Lower Limb Tendinopathy: Response

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Medicine
The American Journal of Sports
http://ajs.sagepub.com/content/43/10/NP44
The online version of this article can be found at:
DOI: 10.1177/0363546515609179
2015 43: NP44Am J Sports Med
Dylan Morrissey, Sethu Mani-Babu and Christian Barton
The Effectiveness of ESWT in Lower Limb Tendinopathy: Response
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The Effectiveness of ESWT
in Lower Limb Tendinopathy:
Letter to the Editor
DOI: 10.1177/0363546515608114
Dear Editor:
We read with interest the recent paper entitled ‘‘The
Effectiveness of Extracorporeal Shock Wave Therapy in
Lower Limb Tendinopathy: A Systematic Review’’ by
Mani-Babu et al
4
in the March 2015 issue.
The use of extracorporeal shock wave therapy within
sports medicine professionals is rising globally, and there-
fore this systematic review represents an important paper
that allows evidence-based prescription of this intervention.
On close inspection of the raw data used to generate the
described effect sizes, we suspect a few errors that have
influenced the ultimate outcomes as calculated and reported
may have inadvertently crept in to the final analyses.
The authors have used dichotomous classifications (ie,
Roles and Maudsley score and 6-point Likert scale) of
treatment outcome (success/failure) as reported in the
studies reviewed to classify outcomes of complete recovery
and much improvement (success) compared to somewhat
improved, same, worse, and much worse (failure).
We suspect that in several instances these classifica-
tions have been reversed, and the unfavorable outcomes
were used for effect size calculation. The differences that
were observed between the systematic review and the orig-
inal papers in successful outcomes for effect size calcula-
tions are presented in Table 1.
We have also included a snippet from the original
papers referenced in this article for your comparison (see
the Appendix at http://ajsm.sagepub.com/supplemental).
Vasileios Korakakis, PhD
Rodney Whiteley, PhD
Doha, Qatar
TABLE 1
Differences Observed Between the Systematic Review
and the Original Papers in Successful Outcomes
Used for Effect Size Calculations
a
Figure 2, C and D
4
(greater trochanteric pain syndrome)
Roles and Maudsley score: successful outcomes
Mani-Babu et al (2015)
4
Furia et al (2009)
3
ESWT Controls ESWT Controls
1st month 16/33 25/33 17/33 8/33
3rd month 7/33 24/33 26/33 9/33
12th month 7/33 21/33 26/33 12/33
Likert scale (1-6): successful outcomes
Mani-Babu et al (2015)
4
Rompe et al (2009)
8
ESWT CS ESWT HT ESWT CS ESWT HT
1st month 68/78 18/75 68/78 71/76 10/78 56/75 10/78 5/76
4th month 25/78 37/75 25/78 45/76 53/78 38/75 53/78 31/76
(continued)
TABLE 1
(continued)
Figure 2, C and D
4
(greater trochanteric pain syndrome)
15th month 20/78 39/75 20/78 15/76 58/78 36/75 58/78 61/76
Figure 3C
4
(patellar tendinopathy)
Roles and Maudsley score: successful outcomes
Mani-Babu et al (2015)
4
Peers et al (2003)
5
ESWT Surgery ESWT Surgery
.12 months 4/14 5/12 10/14 7/12
Mani-Babu et al (2015)
4
Wang et al (2007)
9
ESWT Controls ESWT Controls
.12 months 3/30 12/24 27/30 18/24
Figure 4, C and D
4
(Achilles tendinopathy)
Roles and Maudsley score: successful outcomes
Mani-Babu et al (2015)
4
Furia et al (2008)
1
ESWT Controls ESWT Controls
1st month 10/34 27/34 24/34 7/34
3rd month 5/34 25/34 29/34 9/34
.12 months 5/34 25/34 29/34 9/34
Mani-Babu et al (2015)
4
Furia et al (2006)
2
ESWT Controls ESWT Controls
1st month 22/35 21/33 13/35 12/33
3rd month 6/35 20/33 29/35 13/33
.12 months 6/35 20/33 29/35 13/33
Likert scale (1-6): successful outcomes
Mani-Babu et al (2015)
4
Rompe et al (2007)
7
ESWT ECC Wait ESWT ECC Wait
4th month 12/25 10/25 19/25 13/25 15/25 6/25
Mani-Babu et al (2015)
4
Rompe et al (2008)
6
ESWT ECC ESWT ECC
4th month 9/25 18/25 16/25 7/25
Mani-Babu et al (2015)
4
Rompe et al (2009)
8
Ecc-ESWT ECC Ecc-ESWT ECC
4th month 6/34 15/34 28/34 19/34
a
CS, CS, corticosteroid injection; Ecc, eccentric loading; Ecc-ESWT,
eccentric loading plus extracorporeal shock wave therapy; ESWT, extracor-
poreal shock wave therapy; HT, home training; Wait, wait-and-see policy.
The American Journal of Sports Medicine, Vol. 43, No. 10
Ó2015 The Author(s)
NP43
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Address correspondence to Korakakis Vasileios, PhD (email:
Vasileios.Korakakis@aspetar.com).
The authors have declared no conflicts of interest in the
authorship and publication of this contribution.
REFERENCES
1. Furia JP. High-energy extracorporeal shock wave therapy as a treat-
ment for chronic noninsertional Achilles tendinopathy. Am J Sports
Med. 2008;36:502-508.
2. Furia JP. High-energy extracorporeal shock wave therapy as a treat-
ment for insertional Achilles tendinopathy. Am J Sports Med.
2006;34:733-740.
3. Furia JP, Rompe JD, Maffulli N. Low-energy extracorporeal shock
wave therapy as a treatment for greater trochanteric pain syndrome.
Am J Sports Med. 2009;37:1806-1813.
4. Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The
effectiveness of extracorporeal shock wave therapy in lower limb
tendinopathy: a systematic review. Am J Sports Med. 2015;43:752-
761.
5. Peers KHE, Lysens RJJ, Brys P, Bellemans J. Cross-sectional out-
come analysis of athletes with chronic patellar tendinopathy treated
surgically and by extracorporeal shock wave therapy. Clin J Sport
Med. 2003;13:79-83.
6. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock
wave treatment for chronic insertional achilles tendinopathy: a ran-
domized, controlled trial. J Bone Joint Surg Am. 2008;90:52-61.
7. Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-
wave treatment, or a wait-and-see policy for tendinopathy of the
main body of tendo Achillis: a randomized controlled trial. Am J Sports
Med. 2007;35:374-383.
8. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home
training, local corticosteroid injection, or radial shock wave therapy for
greater trochanter pain syndrome. Am J Sports Med. 2009;37:1981-
1990.
9. Wang CJ, Ko JY, Chan YS, Weng LH, Hsu SL. Extracorporeal shock-
wave for chronic patellar tendinopathy. Am J Sports Med.
2007;35:972-978.
The Effectiveness of ESWT
in Lower Limb Tendinopathy:
Response
DOI: 10.1177/0363546515609179
Authors’ Response:
Thank you for the opportunity to respond to this
communication.
We thank the authors of the letter for their questions and
commend them on their attention to detail. To paraphrase,
the question seems to be whether we have entered the data
incorrectly into the graph-generating software (RevMan), as
it appears that the responders and nonresponders are
reversed, therefore giving an incorrect clinical message.
In short, the answer is that the data have been entered
correctly, hence the results being consistent with the liter-
ature. However, in order to align scales that may have dif-
ferent vectors (eg, the Victorian Institute of Sport
Assessment Questionnaire–Achilles runs from 0 to 100
with the latter optimal, while the opposite is true on
a visual analog scale [VAS] from 0 to 10), it was decided
to multiply a scale by 21 or to invert the responders/
nonresponders with dichotomized data in order to ensure
that there was consistency of display of a given outcome
on the same side of any given graph.
For example, when entering pain VAS scores into Rev-
Man for this review, plots to the left (lower scores) indicate
that extracorporeal shock wave therapy (ESWT) is the
favored intervention. When entered in their raw form,
other variables evaluated in the literature (eg, dichoto-
mized data from Likert scales of perceived success) do
not present the same in forest plots—that is, results favor-
ing ESWT will lead to a plot on the right of the graph.
Therefore, nonresponders were entered instead, meaning
these plots favoring ESWT align to the left, consistent
with VAS scores. You may have noted that the graphical
representation of findings, along with the conclusions in
our review, are reflective of the results and conclusions
reported in original studies.
As a specific example, please consider Table 4 in the Furia
et al
1
(2009) paper relating to treatment of greater trochanter
pain syndrome. The VAS is entered in its original form and
correctly shows an outcome in favor of ESWT at 1 month,
with the VAS being reduced from 8.5 to 5.1, as compared to
a smaller reduction from 8.5 to 7.6 in the control group.
The Harris Hip Score improves by increasing from 49.6 to
69.8 in the shockwave group, whereas the control group
moves from 50.4 to 54.4. We have therefore multiplied the
Harris score by 21 to make it align appropriately on the
graph. The Roles and Maudsley score has higher values as
being worse pathology as per the Harris Hip Score. However,
as it is dichotomized, the solution was to reverse the numbers
of responders and nonresponders. These measures give cor-
rect estimates of treatment success and align scores that
have opposite vectors of severity.
Ofcourse,asthestatisticofchoice was a Mantel-Haenszel
fixed-effects risk ratio, the effect sizes and negative confi-
dence intervals are visually different to what they would be
if positive.
It could reasonably be argued that we could have made
this clearer in the methods, or perhaps the legends of the
relevant figures, and we will certainly consider that for
future work. Nonetheless we hope that our review will
assist to stimulate further research evaluating the effec-
tiveness of ESWT, with focus on identifying what the
most effective protocols are, which patients are most likely
to benefit, and how ESWT may interact with other effica-
cious interventions such as tendon loading programs.
Once again, we thank our colleagues for their letter.
NP44 Letter to the Editor The American Journal of Sports Medicine
by guest on January 13, 2016ajs.sagepub.comDownloaded from

Dylan Morrissey, PhD
Sethu Mani-Babu, MBBS
Christian Barton, PhD
London, UK
Address correspondence to Dylan Morrissey, PhD (email:
d.morrissey@qmul.ac.uk).
One or more of the authors has declared the following potential
conflict of interest or source of funding: The authors of the article
referenced in this letter received funding for a clinical trial and
mechanisms study from the UK government via the Engineering
and Physical Sciences Research Council that also has an element
of funding from a manufacturer of ESWT devices (Spectrum
technology). This statement applies to Professor Maffuli, Dr
Screen, Dr Morrissey, and Dr Waugh. This did not fund this study
directly.
REFERENCE
1. Furia JP, Rompe JD, Maffulli N. Low-energy extracorporeal shock
wave therapy as a treatment for greater trochanteric pain syndrome.
Am J Sports Med. 2009;37:1806-1813.
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