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Turk J Phys Med Rehab 2022;68(3):399-408

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DOI: 10.5606/tftrd.2022.8905
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Available online at www.turkishjournalpmr.com

TU

Original Article

Comparison of the effectiveness of conventional physical therapy and

extracorporeal shock wave therapy on pain, disability, functional status,
and depression in patients with chronic low back pain
Ömer Kızıltaş1, Mehmet Okçu2, Figen Tuncay3, Fatmanur Aybala Koçak3
1
Department of Physical Medicine and Rehabilitation, Dinar State Hospital, Afyonkarahisar, Türkiye
2
Department of Physical Medicine and Rehabilitation, Marmara University Faculty of Medicine, Istanbul, Türkiye
3
Department of Physical Medicine and Rehabilitation, Kırşehir Ahi Evran University Faculty of Medicine, Kırşehir, Türkiye

Received: May 02, 2021 Accepted: January 07, 2022 Published online: August 25, 2022

ABSTRACT
Objectives: The aim of this study was to compare the effectiveness of conventional physical therapy (transcutaneous electrical nerve
stimulation, hot pack, and therapeutic ultrasound) and extracorporeal shock wave therapy (ESWT) on pain, disability, functional status,
and depression in patients with chronic low back pain (LBP).
Patients and methods: Ninety-one patients with chronic LBP were included in the study and randomized to groups that received ESWT
or conventional physiotherapy; of these, 70 completed the study (37 males, 33 females; mean age: 46.4±13.3 years; range, 18 to 65 years).
Outcome measures included the Visual Analog Scale, the pressure pain algometer, Oswestry Disability Index (ODI), Health Assessment
Questionnaire (HAQ), fingertip-to-floor distance, and the Beck Depression Inventory. The assessments were made before treatment and
at the first and 12th weeks after treatment.
Results: Extracorporeal shock wave therapy was more effective than conventional physical therapy in terms of Visual Analog Scale scores,
the pressure algometer, ODI, HAQ, and fingertip-to-floor distance at the first and 12th week.
Conclusion: Extracorporeal shock wave therapy is superior to conventional physical therapy in terms of improving pain, spinal mobility,
and functional status in patients with chronic LBP.
Keywords: Chronic low back pain, conventional physical therapy, extracorporeal shock wave therapy, functional status.

Low back pain (LBP) is a common health problem the rate of disability caused by LBP has been reported
around the world regardless of development level and as 11 to 12%.[2]
a leading cause of morbidity.[1] The financial burden Back pain lasting longer than three months is
is also high due to both diagnosis and treatment costs defined as chronic LBP.[3] It is sometimes associated
and the resulting loss of productivity and physical with a precise etiology, such as radiculopathy or
disabilities.[2] The lifetime prevalence is reported spinal stenosis, but most cases of LBP do not have
to be as high as 84%.[2] Chronic LBP develops in a specific cause. This condition is classified as
approximately one-quarter of patients with LBP, and nonspecific LBP and constitutes at least 90% of

Corresponding author: Mehmet Okçu, MD. Marmara Üniversitesi, Pendik Eğitim Araştırma Hastanesi, Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı,
34899 Pendik, İstanbul, Türkiye. e-mail: [email protected]
Cite this article as:
Kızıltaş Ö, Okçu M, Tuncay F, Aybala Koçak F. Comparison of the effectiveness of conventional physical therapy and extracorporeal shock wave therapy on pain, disability, functional status, and depression
in patients with chronic low back pain. Turk J Phys Med Rehab 2022;68(3):399-408.

©2022 All right reserved by the Turkish Society of Physical Medicine and Rehabilitation
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the
original work is properly cited and is not used for commercial purposes (http://creativecommons.org/licenses/by-nc/4.0/).
400 Turk J Phys Med Rehab

those experiencing spinal pain; its diagnosis is based PATIENTS AND METHODS
on the exclusion of other specific causes.[4-6]
A total of 110 patients diagnosed with chronic
Although the effect of physical therapy nonspecific LBP in the Kırşehir Ahi Evran University
modalities in reducing pain is controversial, there Faculty of Medicine, Department of Physical
are results showing that it is more successful than Medicine and Rehabilitation between January 2019
placebo.[7] The effectiveness of transcutaneous and April 2019 were evaluated to be enrolled in the
electrical nerve stimulation (TENS), which is one prospective, randomized controlled, open-label study.
of the physical therapy agents, is controversial in Ninety-one patients who met the inclusion criteria
acute pain, and it has been reported that TENS were randomized into two groups (the ESWT group
has short-term positive effects in chronic pain and the CPT group) using the closed envelope method.
in randomized controlled studies conducted to The inclusion criteria were as follows: nonspecific,
compare TENS with placebo. It has been suggested nonradicular (axial) chronic LBP diagnosis (LBP for
that TENS exerts this effect through the gate-control at least three months), a Visual Analog Scale (VAS)
mechanism.[7-9] In addition, it has been reported score of 5 or higher, and sufficient cooperation. The
that hot pack application provides short-term relief exclusion criteria were determined as specific LBP
in LBP.[10] Therapeutic ultrasound is effective in (presence of a specific cause, such as radiculopathy,
spinal stenosis, or infection),[4] radicular pain, surgical
pain, some parameters of quality of life (QoL),
history in the lumbar spine area, vertebral compression
functional performance, and depression in patients
fracture, spinal tumors, intervertebral disc infections,
with chronic LBP.[11-13]
inflammatory rheumatic diseases, pregnancy, heart
Extracorporeal shock wave therapy (ESWT) is a disease, and structural abnormalities in the lumbar
noninvasive method that uses single pulsed acoustic region. The patients' age, sex, educational status,
waves produced outside the body and focused on a height-weight, body mass index (BMI), medications,
specific area of the body. Studies have shown that whether there was any concomitant disease, and the
ESWT is an effective and long-term pain-relieving duration of the symptoms were recorded.
method in soft tissue diseases, such as plantar Transcutaneous electrical nerve stimulation
fasciitis and Achilles tendinopathy.[14,15] Shockwaves (in conventional mode, to the paravertebral region for
stimulate axonal regeneration of peripheral nerves 20 min), hot pack (20 min), ultrasound (in continuous
by various molecular reactions. Extracorporeal shock mode, to paravertebral muscles, 1.5 w/cm2 , 5 min),
wave therapy induces analgesia through biochemical and 10 sessions of CPT were given to the CPT group
changes in the nerve fiber itself and reduces the (n=44). Radial ESWT therapy was given to the
inflammation of soft tissues.[14,15] Additionally, it has ESWT group (n=47). Lumbar stretching, range of
been stated that ESWT supports revascularization motion (ROM) exercises, and lumbar and abdominal
and stimulates or reactivates the healing process of strengthening exercises were given to all patients as
connective tissues, including tendons and bones, thus an exercise program. The patients were provided a
reducing pain and improving function.[16] Few studies brochure containing schematic information regarding
have been conducted with small patient numbers the exercises. The exercise program was practically
investigating the effects of ESWT on chronic LBP. demonstrated by the same physiotherapist during the
Among these studies, no study has made evaluations first session of the treatment. Exercises were performed
using a pressure algometer or spinal mobility, which twice a day.
provide more objective data. In addition, although The ESWT group was given two sessions per week,
ESWT has been shown to be effective in LBP and a total of five sessions of ESWT, ending in two to three
conventional physiotherapy methods consisting of weeks. It was ensured that there were at least two days
TENS, hot packs, and therapeutic ultrasound are between each session. Two patients in the ESWT group
frequently used for low back pain, the number of did not want to continue the treatment after the first
studies comparing these two treatment methods session due to pain. The ESWT probe was applied by
is also very few.[16-19] This study aimed to compare placing the metallic head of the device perpendicular
the effectiveness of conventional physical therapy to the pain areas after applying the joining gel to
(CPT) and ESWT on pain, disability, spinal mobility, facilitate the passage of the pressure waves through
functional status, and depression in patients with the skin. Consistent with the study of Walewicz et
chronic LBP. al.,[18] ESWT was applied to the areas that the patient
Effectiveness of ESWT in low back pain 401

Patients assessed eligible (n=100)

Randomized (n=91) Excluded (n=19)

Not meeting inclusion criteria (n=13)
Didn’t participate (n=9)

ESWT group (n=47) CPT group (n=44)

Dropped out (n=11)

Dropped out (n=10)
Abandoning treatment (n=2)
Not coming to 3rd month visit (n=10)
Not coming to 3rd month visit (n=9)

Analyzed (n=36) Analyzed (n=34)

Figure 1. Flow of participants in this study.

reported as the most painful at the lumbar and sacral The VAS[20] and a pressure algometer[21] were
spine level. During the session, the patient was in a utilized to evaluate the pain levels of the patients at
prone position. Extracorporeal shock wave therapy pre-treatment and 1 and 12 weeks after treatment.
was performed using an Modus ESWT Touch Shock Visual Analog Scale scores were evaluated over
Waves device (Inceler Medical, Ankara, Türkiye) with 100 mm. The pressure pain threshold (PPT) was
a 20-mm applicator, a pressure of 2.8 bar, and a measured from the forehead and lumbar region
frequency of 10 Hz with 2600 shots. ESWT, CPT, using a pressure algometer (Algometer Commander,
and exercise training were performed by the same JTECH Medical, Salt Lake City, UT, USA). In
physiotherapist. There was no blinding in the study. accordance with the literature, the following

TABLE 1
General characteristics of the participants
ESWT group (n=36) CPT group (n=34)
n % Mean±SD n % Mean±SD p
Age (year) 47.4±14.3 45.3±12.2 0.375†
Sex
Male 23 63.9 14 41.2 0.057‡
Female 13 36.1 20 58.8
Education status
Primary school graduate 14 38.9 19 55.9 0.356‡
High school graduate 11 30.6 7 20.6
Graduated from a university 11 30.6 8 23.5
Body mass index (kg/m2) 28.6±4.9 35.2±36.2 0.617†
Duration of illness (month) 80.2±85.1 60.4±42.5 0.972†
ESWT: Extracorporeal shock wave therapy, CPT: Conventional physical therapy; SD: Standard deviation; † Statistical comparison of
measurements between groups with the Mann-Whitney U test; ‡ Statistical comparison of measurements between groups with the chi-
square test.
402 Turk J Phys Med Rehab

TABLE 2
Visual Analog Scale, HAQ, ODI, FTFD, total PPT, and BDI scores of the patients in the ESWT and CPT groups
ESWT group CPT group
Mean±SD Median Min-Max Mean±SD Median Min-Max p
VAS score
Pre-treatment 65.8±15.7 70a* 20-90 61.9±14.9 60a* 30-100 0.215†
1 week
st
31.1±19.8 30b* 0-65 47.5±18.9 50b* 10-70 0.001†
12th weeks 28.1±18.6 25b* 0-60 47.7±18.5 50b* 10-80 0.001†
P in repeated measurements 0.001‡ 0.001‡
HAQ score
Pre-treatment 9.3±7.6 8a* 0-26 9.5±6.5 9.5a* 0-31 0.702†
1 week
st
5.3±6.4 3.5b* 0-32 8.4±6.6 7a* 0-25 0.018†
12th weeks 4.0±6.3 1.5b* 0-30 9.7±7.5 8.5a* 0-29 0.001†
P in repeated measurements 0.001‡ 0.655‡
ODI score
Pre-treatment 20.8±10.5 20a* 5-41 22.4±7.8 22a* 8-43 0.466†
1st week 11.0±9.8 8b* 0-34 19.2±8.3 20a,b* 0-33 0.001†
12th weeks 9.7±7.8 7b* 0-32 19.7±9.1 19.50b* 2-34 0.001†
P in repeated measurements 0.001‡ 0.018‡
FTFD
Pre-treatment 8.8±8.4 7.5a* 0-32 6.1±10.8 0a* 0-40 0.038†
1st week 5.9±7.3 3.5b* 0-30 4.7±9.5 0a* 0-44 0.100†
12 weeks
th
5.0±6.5 2b* 0-28 4.9±10.8 0a* 0-51.9 0.093†
P in repeated measurements 0.001‡ 0.278‡
TPPT
Pre-treatment 328.2±164.3 350.3a* 83-667.1 365.9±162.0 400.2a* 82.4-664 0.312†
1 week
st
489.0±169.7 494.3b* 189-878.2 375.1±169.7 379.3a* 118.6-855.9 0.006†
12th weeks 455.8±147.2 445.2b* 228.3-795 338.1±147.1 336.4a* 99.8-708.8 0.002†
P in repeated measurements 0.001‡ 0.539‡
BDI score
Pre-treatment 10.3±8.0 8.5a* 0-28 12.9±9.0 10a* 0-33 0.251†
1 week
st
6.5±7.8 4.5b* 0-34 7.2±8.6 5.5b* 21-30 0.282†
12th weeks 4.9±6.9 2b* 0-33 8.9±9.7 6b* 17-34 0.008†
P in repeated measurements 0.001‡ 0.001‡
HAQ: Health Assessment Questionnaire; ODI: Oswestry Disability Index; FTFD: Fingertip-to-floor distance; PPT: Pressure pain threshold; BDI: Beck Depression Inventory;
ESWT: Extracorporeal shock wave therapy; CPT: Con-ventional physical therapy; SD: Standard deviation; VAS: Visual analog skala; TPPT: Total pressure pain threshold;
† Statistical comparison of measurements between groups with the Mann-Whitney U test; ‡ Statistical comparison of repeated measurements within groups with the Friedman
test; In repeated measurements within the group (statistical comparison of values pre-treatment, 1st first week, and 12th week), the same letters (a and b) indicate that there is no
statistically significant difference according to pairwise comparisons with the Bonferroni correction method.

six bilateral points were selected: (i) quadratus crista iliaca; (v) piriformis muscle, the intersection
lumborum muscle, 5 cm lateral to the L3 vertebra; of the two lines from spina iliaca anterior superior
(ii) paravertebral muscles (M. longissimus/M. Erector to the coccyx and from the trochanter major to the
trunci), 3 cm lateral to the L1 vertebra; (iii) os ilium, spina iliaca posterior superior, representing the
the highest point on crista iliaca; (iv) iliolumbar normal position of the piriformis muscle, which
ligament, middle of the triangle given by processus could partly be overlaid by the M. gluteus medius;
costarius of lumbar vertebra L4 and L5 as well as (vi) greater trochanter, posterior to the trochanteric
Effectiveness of ESWT in low back pain 403

prominence (the forehead midpoint was taken as a 12

VAS
reference point, and PPT value was measured).[21] ESWT
CPT
Disability was evaluated using the Oswestry 20

Disability Index (ODI)[22] and the Health Assessment

Questionnaire (HAQ).[23] Depression was assessed 15

VAS score
using the Beck Depression Inventory (BDI) developed
10
by Beck et al.[24] Turkish validity and reliability of
all these scales have been demonstrated.[25-27] The
5
fingertip-to-f loor distance (FTFD) was measured
and recorded to evaluate spinal mobility. The FTFD
0
assesses hip and spine mobility. Higher results Pre-treatment Post-treatment Post-treatment
indicate worse lumbar and hip mobility.[28] These week 1 week 12
evaluations were performed by a single physician Figure 2. Comparison of the VAS scores between groups.
before treatment and at the first and 12th weeks VAS: Visual Analog Scale; ESWT: Extracorporeal shock wave therapy; CPT:
after treatment. In addition to the two patients in Conventional physical therapy.

the ESWT group who did not want to continue the

treatment after the first session, nine patients in
the ESWT group and 10 patients in the CPT group
did not attend the third-month follow-up. As a TPPT
12
result, 70 patients (37 males, 33 females; mean age: ESWT
46.4±13.3 years; range, 18 to 65 years) were included CPT
20
in the final analysis, with 36 patients and 34 patients
in the ESWT group and the CPT group, respectively
TPPT score

15
(Figure 1).
Statistical analysis 10

The power analysis was done using PASS 11 (NCSS, 5

LLC. Kaysville, UT, USA) per the method of Hintze.
Minimum group sample sizes of 29 and 29 were 0
determined by a two-sided two-sample t-test power Pre-treatment Post-treatment Post-treatment
analysis with 80% power level and 5% alpha error level week 1 week 12

(Effect size Cohen's d=0.758; based on the study of Figure 3. Comparison of total PPT scores between groups.
Han et al.[17]). The patients were included in the study, TPPT: Total pressure pain threshold; ESWT: Extracorporeal shock wave
therapy; CPT: Conventional physical therapy.
considering that there would be dropouts from the
study.
The data were analyzed by the IBM SPSS
version 20.0 software (IBM Corp, Armonk, NY,
USA). Frequency and percentage were preferred for 12
ODI
displaying categorical data, and the mean ± standard ESWT
CPT
deviation, median, and min-max were preferred for 20
displaying continuous data. The compatibility of
the data to normal distribution was tested using 15
ODI score

the Shapiro-Wilk test. The chi-square test was used

for the comparison of categorical data. The Mann- 10
Whitney U test was used in the comparison of
means according to the compliance with normal 5
distribution. In the analysis of repeated measures, the
Friedman test was used according to the compliance 0
Pre-treatment Post-treatment Post-treatment
with normal distribution. Pairwise comparisons week 1 week 12
were performed with the Bonferroni correction
Figure 4. Comparison of the ODI scores between groups.
method. In addition, between-group comparisons of ODI: Oswestry Disability Index; ESWT: Extracorporeal shock wave therapy;
repeated measurements were performed by analyzing CPT: Conventional physical therapy.
404 Turk J Phys Med Rehab

the differences between measurements with the group (Figures 2, 3 and 4). The ESWT group had
Mann-Whitney U test. A p value of <0.05 was significantly higher scores in terms of total PPT at the
accepted as statistically significant. first and 12th weeks. There were significantly higher
FTFD scores in the ESWT group before the treatment,
RESULTS whereas there was no significant difference between
the two groups at one and 12 weeks.
The ESWT group was found to be statistically
similar to the CPT group in terms of age, sex, Decreases in the VAS score, HAQ score, ODI score,
educational status, BMI, and disease duration and FTFD were significantly higher in the ESWT
(Table 1). Significant improvement was found in group than in the CPT group after one and 12 weeks.
VAS, HAQ, ODI, FTFD, total PPT, and BDI scores The increase in total PPT was significantly higher in
in the ESWT group at the first and 12th weeks after the ESWT group than in the CPT group both after
the treatment compared to pre-treatment. In the one and 12 weeks. We found no significant difference
CPT group, only the VAS, ODI, and BDI scores between the groups in terms of change in BDI scores
improved at the first and 12 th weeks compared after one and 12 weeks (Table 3).
to pre-treatment (Table 2). Initially, there was no Two patients in the ESWT group felt severe pain
difference between the VAS, HAQ, ODI, total PPT, during the first session of the procedure and did not
and BDI scores of the two groups; however, the want to continue the study. The pain of these two
ESWT group had significantly lower scores in terms patients at the first hour and the first day of the first
of VAS, HAQ, ODI at the first and 12th weeks and in session was the same as before the procedure. No
terms of BDI at the 12th week compared to the CPT adverse events were observed in other patients.

TABLE 3
Changes in VAS, HAQ, ODI, FTFD, total PPT, and BDI scores of the patients in the ESWT and CPT groups
ESWT group CPT group
Mean±SD Median Min-Max Mean±SD Median Min-Max p
VAS score
Pre-treatment vs. 1st week -34.7±18.4 -30 -80 to -10 -14.4±21.5 -15 -70 to 25 0.001†
Pre-treatment vs. 12th weeks -37.8±17.6 -30 -80 to -10 -14.3±19.2 -12.5 -70 to 20 0.001†
HAQ score
Pre-treatment vs. 1st week -3.9±6.3 -3 -19 to 12 -1.1±6.8 -0.5 -18 to 22 0.048†
Pre-treatment vs. 12th weeks -5.3±6.0 -4 -23 to 4 0.2±6.7 -0.5 -12 to 23 0.001†
ODI score
Pre-treatment vs. 1st week -9.8±8.7 -10.5 -34 to 12 -3.2±6.8 -3.5 -20 to 16 0.001†
Pre-treatment vs. 12 weeks
th
-11.1±7.2 -9.5 -28 to 3 -2.7±7.2 -3.5 -20 to 14 0.001†
FTFD
Pre-treatment vs. 1st week -2.9±4.6 -1 -17 to 5 -1.4±8.3 0 -38.7 to 20 0.020†
Pre-treatment vs. 12th weeks -3.7±4.8 -2 -18.5 to 1 -1.3±10.4 0 -38.7 to 39.9 0.009†
TPPT
Pre-treatment vs. 1st week 160.9±66.8 155.15 35.3 to 291.7 9.2±100.2 -3.25 -245.3 to 285.1 0.001†
Pre-treatment vs. 12 weeks
th
127.7±78.8 124.1 -9.2 to 339 -27.8±102.0 -10.35 -325.8 to 182.4 0.001†
BDI score
Pre-treatment vs. 1st week -3.8±7.7 -3 -22 to 18 -5.7±9.9 -3 -43 to 9 0.953†
Pre-treatment vs. 12 weeks
th
-5.4±6.5 -4.5 -22 to 12 -3.9±6.7 -3 -20 to 12 0.349†
VAS: Visual Analog Scale; HAQ: Health Assessment Questionnaire; ODI: Oswestry Disability Index; FTFD: Fingertip-to-floor distance; PPT: Pressure pain threshold; BDI: Beck
Depression Inventory; ESWT: Extracorporeal shock wave therapy; CPT: Conventional physical therapy; SD: Standard deviation; TPPT: Total pressure pain threshold; † Statistical
comparison of change in measurements between groups with the Mann-Whitney U test; Negative values represent decrease in scores and positive values represent increase in
scores.
Effectiveness of ESWT in low back pain 405

DISCUSSION radiofrequency neurotomy, and ESWT in their study

involving 60 patients with LBP originating from facet
In the present study, ESWT was found to be
joints. They found that ESWT and radiofrequency
superior to CPT in patients with chronic non-specific
neurotomy were significantly more effective than
LBP in terms of FTFD, VAS, HAQ, ODI, and total pain
corticosteroid injections. Similar to these studies,
threshold scores. This study has the largest number
ESWT provided significantly superior improvements
of participants among studies evaluating the effects
in VAS scores in the present study. In addition, unlike
of ESWT on chronic LBP. It is also the first in which
other studies, the algometer and FTFD were used as
pressure algometry and spinal mobility assessments
a relatively objective assessment tool in this study.
were performed.
In the evaluation performed in six bilateral areas
The effectiveness of ESWT in chronic pain detected in the lumbar region with an algometer for
syndromes is known, and today, ESWT is widely the pain threshold, a statistically significant increase
used in the treatment of diseases such as plantar was found in the ESWT group in the one-and
fasciitis, lateral epicondylitis, tendinopathies, stress 12-week measurements compared to pre-treatment.
fractures, nonhealing fractures, and myofascial pain Consequently, it is understood that ESWT reduces
syndrome.[29] There are few studies in the literature pain and increases the pain threshold. In addition,
on the effectiveness of ESWT in chronic LBP, with a in the present study, the spinal mobility of the
small number of participants.[16,17,19] Therefore, this patients was evaluated using FTFD. No improvement
study was conducted to obtain more detailed and in FTFD was observed with treatment in the CPT
precise information about the effectiveness of ESWT group, whereas a significant improvement in FTFD
in chronic LBP. was detected in the ESWT group at one and 12 weeks
compared to pre-treatment. Another advantage of
In the evaluation of VAS scores, although a ESWT over CPT is that it provides these results with
decrease was observed in the measurements fewer sessions.
performed in the first and 12th weeks after the
treatment in both groups, it was observed that Low back pain has been associated with
ESWT was significantly more effective in terms of disability.[31,32] In the study of Salvetti et al.[33]
pain severity. In the study of Han et al.[17] with 30 evaluating the incidence of disability and factors
patients with chronic LBP (15 ESWT, 15 CPT), they affecting it with 177 patients with chronic LBP, it
found that ESWT was significantly more effective was shown that individuals with severe disability had
on pain severity, as evaluated using VAS. Similarly, higher pain severity and were exposed to pain for a
in the present study, a more significant VAS longer time. In the study conducted by Kim et al.[31] in
improvement was found with ESWT. In addition, patients with chronic LBP, it was shown that there is a
the three-month evaluation and evaluation with positive relationship between VAS scores and the ODI
an algometer were among the strengths of the and Roland Morris Disability Questionnaire scores,
present study. In a study conducted by Lee et al.,[16] which evaluate the disability. The HAQ and ODI
28 patients (13 ESWT, 15 CPT) with chronic LBP were used to assess disability in the present study, and
were investigated for the effectiveness of ESWT ESWT provided significantly greater improvement
in terms of dynamic balance abilities and pain in ODI and HAQ scores compared to CPT. Similar
severity, and the BioRescue results were evaluated to the present study, Han et al.[17] compared the
to measure the dynamic balance of the patients efficacy of ESWT and CPT in patients with chronic
in the ESWT group. Although improvement was LBP and demonstrated that ESWT was significantly
observed in all directions in the ESWT group, more effective than CPT on disability, as in many
improvement was observed only in the left and parameters. Çelik et al.[19] also found that ESWT was
posterior directions in the CPT group. In addition, more effective on disability than placebo.
according to the post-treatment VAS results, they Chronic pain has been associated with depressive
obtained significantly superior results in the ESWT disorders.[34] Although the pathophysiology of the
group compared with the conservative group. Çelik relationship between chronic pain and depressive
et al.[19] conducted a study with 45 patients (25 ESWT, disorders has not been clarified, it is a known
20 placebo ESWT) with chronic LBP and found fact that pain increases depression and depression
that ESWT was significantly more effective than increases pain.[35] Chronic pain disrupts the patient’s
placebo in terms of pain. Nedelka et al.[30] compared business, family, and social life, distancing them from
the efficacy of facet joint corticosteroid injections, previously enjoyed activities, causing job loss and
406 Turk J Phys Med Rehab

decreased QoL, and revealing psychiatric signs and the short term; however, current evidence does not
symptoms.[36] Therefore, when evaluating patients support the use of therapeutic ultrasound in chronic
with pain, psychological and behavioral aspects LBP. Although conventional physical therapy methods,
should be considered as well as sensory aspects. It such as TENS and ultrasound, are frequently used in
is necessary to evaluate the emotional state of the the treatment of chronic LBP, their effectiveness is
patient. Therefore, the BDI was administered to controversial in the literature, and they are less effective
both groups to evaluate the depressive mood and than ESWT in the current treatment. Therefore, ESWT
post-treatment changes in the patients participating may be an alternative to conventional physical therapy
in the study. In both groups, BDI scores decreased methods in chronic LBP.
statistically significantly after treatment compared This study had some limitations. There was no
to pre-treatment. There was no significant difference long-term follow-up, analgesic use was not recorded,
between the groups in terms of the change in BDI and the participants' daily activities and compliance
scores at one week and 12 weeks. In a study conducted with given exercises could not be completely
by Dündar et al.[37] with 83 participants (41 chronic controlled. To make a comparison independent of
LBP, 42 healthy participants), they found that BDI the effectiveness of the exercise, having a third group
scores were significantly higher in patients with prescribed only an exercise routine could improve the
chronic LBP compared to healthy participants, which quality of the study. The absence of a third group that
negatively affected the QoL. They also concluded that was given only exercise therapy is another limitation
psychiatric evaluation would contribute to treatment of the study. The absence of blinding in the study
outcomes and QoL in patients with chronic LBP. is another limitation. However, our study has the
There are various opinions about the mechanisms highest number of participants among the studies
of action of ESWT. Extracorporeal shock wave examining ESWT in LBP, and it is the first study
therapy increases axonal regeneration of peripheral in which pressure algometry and spinal mobility
nerves and also induces analgesia by reducing assessments were performed and depression and
inf lammation in soft tissues and through some disability were considered.
biochemical changes in neurons.[14,15] Additionally, In conclusion, ESWT treatment was found to be
it reduces pain by activating the healing process more effective on pain, disability, functional status,
in tendons, bones, and connective tissues.[16] spinal mobility, and depression in patients with
Extracorporeal shock wave therapy has been reported chronic LBP compared to CPT. However, studies
to stimulate nitric oxide production by stimulating evaluating the longer-term effects of ESWT in chronic
neurogenesis, angiogenesis, and neuronal nitric LBP are required.
oxide synthase through the vascular endothelial Ethics Committee Approval: The study protocol was
growth factor.[38-40] It has been determined that the approved by the Kırşehir Ahi Evran University Faculty
increase in nitric oxide slows down the conduction of Medicine Clinical Research Ethics Committee (Date:
of pain, reduces pain through an opiate-like effect, 13.11.2018, No: 2018-21/173) and the Türkiye Ministry
increases perfusion by stimulating vasodilation, and of Health, Pharmaceuticals and Medical Devices Agency
results in nerve recovery.[41] These positive effects of (Date: 11/12/2018 Number of paperwork No. 71146310-511.06-
E.213625). The study was conducted in accordance with the
ESWT may have led to the results in this study.
principles of the Declaration of Helsinki.
Although TENS, ultrasound, and superficial heat Patient Consent for Publication: A written informed
treatments are frequently applied in LBP, their effects consent was obtained from each patient.
are controversial. In their meta-analysis, Jauregui et
Data Sharing Statement: The data that support the
al.[8] reported that TENS was effective in reducing findings of this study are available from the corresponding
pain and the need for analgesics in chronic LBP. In the author upon reasonable request.
systematic review of Khadilkar et al.,[42] it was reported
Author Contributions: Data collection, literature review,
that current evidence does not support the use of analysis, writing the article: Ö.K.; Idea/concept, design, control/
TENS in the treatment of chronic LBP. Khan et al.[12] supervision, analysis, data collection, critical review, literature
found that adding therapeutic ultrasound to exercise review: M.O.; Design, control/supervision, critical review: F.T.;
in chronic LBP is effective in reducing pain. Ebadi et Control/supervision, critical review, analysis: F.A.K.
al.,[43] in their systematic review examining the effect Conflict of Interest: The authors declared no conflicts of
of ultrasound in chronic LBP, reported few studies interest with respect to the authorship and/or publication of
revealing that therapeutic ultrasound is effective in this article.
Effectiveness of ESWT in low back pain 407

Funding: The authors received no financial support for 15. Ciampa AR, de Prati AC, Amelio E, Cavalieri E, Persichini
the research and/or authorship of this article. T, Colasanti M, et al. Nitric oxide mediates anti-
inflammatory action of extracorporeal shock waves. FEBS
Lett 2005;579:6839-45.
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