Consensus statement
Recommendations for the use of extracorporeal shockwave technology in medical indications

Introduction

Building on the experience gained over the past 15 years, the scientific board of the ISMST and experts from National Shockwave Societies around the world, have put together a set of recommendations for the use of shockwave therapy.

Purposefully the experts did not apply Cochrane standards for the assessment of the level of evidence. The most recent meta-analyses published by Cochrane^1. shows "platinum evidence” that shockwave treatment has little or no effect at all. But Cochrane researchers simply cannot ignore the results of several well-designed studies from the past which failed to show any efficacy of ESWT for various disorders. By analysing those studies it could be shown that inclusion criteria, treatment parameters or other conditions are afflicted with systemic biases which turn the results of the studies completely into the opposite. Therefore, as long as the situation is so incoherent the idea of a ranking due to the level of evidence is not reasonable or feasible.

Prerequisites

In order to prevent improper treatment the following are prerequisites for administering the technology:

In addition to a clinical examination, radiological imaging, neurological and/or laboratory-diagnostic tests may be necessary to corroborate the diagnosis.
Only a qualified (certified by National or International Societies) physician may use shockwave therapy to treat pathologies, which have been determined by diagnostic testing.

For the treatment of bone ailments, a high-energy, focused shockwave with positioning technology is to be used. To treat superficial soft tissue conditions, devices with or without focusing technology may be utilized; close attention must be paid to the depth of penetration of the shockwave source when treating deep tissue structures.

Approved standard indications

Chronic tendinopathies:

• Plantar fasciitis with or without heel spur
• Achilles tendon
• Radial epicondylopathy (tennis elbow)
• Rotator cuff with or without calcification
• Patella tendon
• Greater trochanteric pain syndrome

Impaired bone healing function:

• Delayed bone healing
• Stress fractures
• Early stage of avascular bone necrosis (native X-ray without pathology)
• Early stage osteochondritis dissecans (OD) post-skeletal maturity

Urology:

• Lithotripsy (extracorporeal and endocorporeal)

Common empirically-tested clinical uses

Tendinopathy:

• Ulnar epicondylopathy
• Adductor syndrome
• Pes anserinus syndrome
• Peroneal tendon syndrome

Muscular pathologies:

• Myofascial syndrome (fibromyalgia excluded)
• Injury without discontinuity

Impaired wound healing

Burn injuries

Salivary stones

Exceptional indications/expert indications

Spasticity

Early stage osteochondritis dissecans (OD) pre-skeletal maturity

Apophysitis (Osgood Schlatter disease)

Peyronie’s disease (IPP)

Uses under experimental conditions

Myocardial ischemia (extracorporeal/endocorporeal)

Peripheral nerve lesions

Abacterial prostatitis

Periodontal disease

Osteoarthritis

The authors group of the DIGEST	The ISMST Managing Board
Vinzenz Auersperg	Roland Hamisultane
Matthias Buch	Robert Gordon
Ludger Gerdesmeyer	Sergio Russo
Markus Gleitz	Heinz Kuderna
Rolf Rädel	Vinzenz Auersperg
Jan-Dirk Rompe	Wolfgang Schaden
Wolfgang Schaden	Richard Thiele
Richard Thiele	Richard Coombs
Andreas Waubke
Georg Wille

March, 10th, 2008

This statement has been voted for publication on the official website of the ISMST by the AGM (annual general meeting) of the ISMST. Juan les Pins, June 5th, 2008

^1.Buchbinder R, Green SE, Youd JM, Assendelft WJJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003524. DOI: 10.1002/14651858.CD003524.pub2.