Retrospective Study of Shockwave Therapy: Long-Term Outcomes and Efficacy of Multimodal Protocols
Jacob Knapton DC, Erick Bingham DC
Abstract
Objective: To evaluate the efficacy of shockwave therapy protocols for musculoskeletal conditions over 18 months.
Design: Retrospective observational study.
Methods: Surveys were sent to 217 patients treated with shockwave therapy; Device used was the Electromagnetic Precision Pulse FX focused shockwave machine. 27 responded (12.4% response rate). Data included demographics, treatment details, immediate outcomes (pain/mobility improvement), and long-term outcomes (12–18 months). Outcomes were analyzed by session count and adjunct therapies (Chiropractic Manipulative Therapy [CMT], Physical Therapy [PT]).
Results: Of 27 patients (16 males, 11 females, mean age 45.6 years), 85% reported immediate symptom improvement (mean pain improvement 63%, SD 25.3%; mobility 62%, SD 24.8%). Long-term, 80% maintained initial improvement (SD 33.2%), with 74% achieving Significant Improvement or Full Resolution. Patients with 6+ sessions (n=6) maintained 93.3% improvement (SD 34.9%), versus 74.6% (SD 37.8%) for 2–5 sessions (n=13). CMT+PT (n=4) yielded 87.5% maintenance (SD 20.6%), outperforming CMT alone (81.3%), PT alone (76.7%), or other modalities (76%). Home-care adherence enhanced outcomes (79.7% for “Extremely Well”).
Conclusion: Tailored shockwave therapy, particularly with 6+ sessions and CMT+PT, is effective for chronic musculoskeletal conditions, achieving 80% long-term maintenance with no worsening outcomes, supporting evidence-based non-invasive treatment strategies.
Introduction
Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment modality increasingly utilized in physical therapy to address musculoskeletal conditions, such as plantar fasciitis, tendonopathies, and calcific tendinitis.¹,² At Utah Valley Chiropractic, ESWT is administered following a comprehensive examination to diagnose the root cause of pain or injury and screen for contraindications. Therapy is tailored to each patient, targeting pathological tissue based on clinical reasoning and proprietary protocols, consistent with evidence supporting individualized ESWT protocols.³ This study aims to evaluate the efficacy of these protocols by analyzing patient-reported outcomes from a cohort treated over the past 18 months. Surveys were sent to 217 patients, with 27 responses received, providing a valuable data set to assess immediate and long-term effects across a variety of musculoskeletal conditions, building on prior evidence of ESWT’s efficacy.⁴
Methods
Study Design
This retrospective observational study analyzed data from a survey distributed to 217 patients who received shockwave therapy at our clinic between November 2023 and May 2025. The survey collected demographic information, treatment details, immediate outcomes, and long-term outcomes. Of the 217 surveys sent, 27 complete responses were received, representing a 12.4% response rate. Patients were referred by chiropractors, potentially influencing the prevalence of Chiropractic Manipulative Therapy (CMT) as an adjunct treatment.
Patient Characteristics
The cohort included 27 patients (16 males, 11 females) with a mean age of 45.6 years (range: 14–65 years). Conditions treated varied widely, including tendonopathies, muscle spasms, impingements, frozen shoulders, and overuse injuries. Symptom duration before treatment ranged from less than 1 week to over 1 year, with 40.7% of patients reporting symptoms for 3–12 months. Treatment protocols involved Radial (14 patients) or Focused (13 patients) shockwave therapy, with the decision made based on the best application for each patient’s condition, as supported by studies indicating distinct clinical indications for Radial and Focused ESWT.¹,⁵ Treatment sessions ranged from 1 to 14, with a median of 3 sessions. Adjunct therapies included CMT alone for 8 patients (29.6%), Physical Therapy (PT) alone for 3 patients (11.1%), a combination of CMT and PT for 4 patients (14.8%), other condition-specific modalities (e.g., ozone or platelet-rich plasma injections, Magnetic Transduction Therapy, Low-Level Laser Therapy) for 5 patients (18.5%), or no adjunct treatments for 6 patients (22.2%).
Data Collection
Data were collected through a structured questionnaire administered via email to 27 patients who underwent shockwave therapy. The questionnaire captured demographic information, including age and sex, to characterize the study cohort. Treatment details encompassed the primary condition treated, duration of symptoms prior to intervention, number of shockwave therapy sessions, type of shockwave therapy (Radial or Focused), adjunct therapies received (such as CMT, PT, Magnetic Transduction Therapy, or injections), and the duration of the treatment period. Immediate outcomes were assessed by recording the time to symptom improvement, percentage improvement in pain and mobility (rated on a 0–100% scale), and qualitative changes in condition, categorized as Significant Improvement, Slight Improvement, About the Same, or Worse. Long-term outcomes, evaluated 12–18 months post-treatment, included the percentage of initial improvement maintained (0–100%), current condition relative to pre-treatment (classified as Fully Resolved, Significantly Improved, Slightly Improved, About the Same, or Worse), and the need for additional treatments. Home-care adherence was measured by patients’ self-reported compliance with post-treatment instructions, rated as Extremely Well, Moderately Well, or Not at All, though no patients reported non-compliance.
Data Analysis
Data were cleaned to ensure consistency, with percentage values converted to numerical format (e.g., “60%” to 60) and categorical variables standardized. Descriptive statistics summarized patient demographics, treatment characteristics, and outcomes. The dose-response relationship was analyzed by grouping patients by number of sessions (1, 2–3, 4–5, 6+) and calculating mean improvements in pain, mobility, and long-term maintenance. The impact of adjunct treatments, particularly the CMT+PT combination, was assessed by comparing long-term maintenance percentages across treatment groups. Statistical significance was not calculated due to the small sample size (n=27), but clinical significance was emphasized through mean differences and outcome distributions.
Ethical Considerations
As a retrospective study using anonymized patient-reported data, ethical approval was not required. Patients provided consent for data use during treatment, and all data were de-identified to protect privacy.
Results
Immediate Outcomes
Of 27 patients, 23 (85%) reported immediate symptom improvement following shockwave therapy, with one patient noting improvement after 2–3 sessions, two after 5–6 sessions, and one reporting no improvement. The mean immediate pain improvement was 63% (SD 25.3%), and mean mobility improvement was 62% (SD 24.8%), indicating moderate variability. Qualitatively, 20 patients (74%) reported Significant Improvement, 5 (18.5%) reported Slight Improvement, 1 (3.7%) reported About the Same, and 1 (3.7%) reported Worse. Patients receiving one session or fewer exhibited the most favorable outcomes, likely due to the acute nature of their conditions, such as muscle spasms, which are less severe and more responsive to single interventions. Conversely, the 2–5 session group showed lower outcomes, possibly due to incomplete treatment courses limiting therapeutic efficacy. See Table 1 for a detailed summary.
Table 1: Pain Improvement Immediately Following Shockwave Therapy.
Graph 1: Mean immediate pain improvement by number of shockwave therapy sessions.
Long-Term Outcomes
Long-term outcomes were assessed 12–18 months post-treatment in 27 patients to evaluate maintenance of symptom relief. The overall mean maintenance was 80% (SD 33.2%), reflecting variability across predominantly chronic and degenerative conditions, such as osteoarthritis, degenerative disc disease, facet hypertrophy, and stenosis. Among the cohort, 21 patients received 1–5 sessions, yet no patients reported worsening symptoms, and only 1 (3.7%) reported About the Same. Patients with 6+ sessions (n=6) maintained 93.3% (SD 34.9%) of their initial improvement, compared to 74.6% (SD 37.8%) for 2–5 sessions (n=13) and 65% (SD 33.1%) for 1 session (n=8). Current condition included 8 patients (29.6%) with Full Resolution, 13 (48.1%) with Significant Improvement, 5 (18.5%) with Slight Improvement, and 1 (3.7%) with About the Same, with no worsening cases. The high maintenance in the 6+ session group suggests extended protocols are effective for chronic conditions, while the absence of worse outcomes underscores the therapy’s safety. See Table 2 for details.
Table 2: Long-Term Outcomes (12-18 Months) Following Shockwave Therapy
Graph 2: Distribution of current condition outcomes 12–18 months post-shockwave therapy
Dose-Response Relationship
The dose-response analysis revealed distinct outcomes based on session number. Patients with a single session (n=8) achieved a 50% Full Resolution rate, likely due to acute conditions amenable to minimal intervention. Patients with 2–5 sessions (n=13) had the lowest Full Resolution rate at 15.4%, possibly reflecting incomplete treatment of chronic conditions. The 6+ session group (n=6) had a 33.3% Full Resolution rate and 93.3% maintenance, indicating a direct correlation with sustained relief. This inverse relationship between Full Resolution and session number, coupled with a positive correlation with maintenance, highlights the therapy’s efficacy for chronic conditions like osteoarthritis and degenerative disc disease, marking a non-invasive management breakthrough. See Table 3 for details.
Table 3: Dose-Response Relationship in Shockwave Therapy Outcomes
Graph 3: Full Resolution rates by number of shockwave therapy sessions
Impact of Adjunct Treatments
Adjunct treatments influenced long-term maintenance. Patients receiving CMT and PT (n=4) achieved 87.5% maintenance (SD 20.6%), likely due to PT’s enhancement of blood flow and CMT’s support for nervous system communication.⁶ CMT alone (n=8) yielded 81.3%, PT alone (n=3) 76.7%, other combinations (n=5, e.g., ozone injections, Electro-Magnetic Transduction Therapy) 76%, and no adjuncts (n=6) 75%. The higher CMT maintenance may reflect availability bias in a chiropractic setting. Surprisingly, other combinations underperformed, suggesting CMT+PT is optimal, consistent with evidence on multimodal approaches.⁷,⁸
Table 4: Impact of Adjunct Treatments on Long-Term Maintenance (12–18 Months)
Graph 4 shows long-term maintenance by adjunct treatment group.
Home-Care Adherence
Home-care adherence impacted long-term outcomes. Patients adhering “Extremely Well” (n=19) maintained 79.7% of initial improvement, compared to 75% for “Moderately Well” (n=8). No patients reported non-compliance. This difference underscores the importance of patient engagement in post-treatment care, such as exercises, for chronic condition management. See Table 5 for details.
Table 5: Impact of Home-Care Adherence on Long-Term Maintenance (12–18 Months)
Discussion
This retrospective study of 27 patients demonstrates the robust efficacy of shockwave therapy protocols. Immediate symptom improvement in 85% of patients reflects precise diagnosis and tailored application and dosage of Radial or Focused Shockwave Therapy, consistent with systematic reviews showing ESWT’s efficacy for tendonopathies and chronic pain.¹,⁴ Single-session patients had favorable outcomes, likely due to acute conditions like muscle spasms, while the 2–5 session group’s lower outcomes suggest incomplete treatment compromises efficacy, aligning with evidence that higher-dose regimens improve outcomes.³ Long-term, 80% mean maintenance, with 21 patients receiving 1–5 treatment sessions, is notable, with no worsening symptoms and only one unchanged case. The 6+ session group’s 93.3% maintenance highlights extended protocols’ efficacy for chronic conditions like osteoarthritis and degenerative disc disease, a clinical advancement supported by meta-analyses.²,⁴ Dose-response analysis shows single-session patients’ 50% Full Resolution rate vs. 15.4% for 2–5 sessions, indicating premature cessation risks, as noted in prior studies.³ The direct correlation between sessions and maintenance aligns with chronic condition needs. CMT and PT integration yielded 87.5% maintenance, reflecting synergistic benefits, consistent with evidence that combining SMT with exercise or PT enhances pain relief and function.⁶,⁷ Other combinations (76%) underperformed, suggesting CMT+PT’s superiority, as supported by RCTs showing multimodal approaches outperform single modalities.⁸ Home-care adherence enhanced outcomes, with the Extremely Well group at 79.7%. Compared to reported literature, where maintenance often ranges from 60–70% (e.g., Smith et al., 2020), our 80% rate is superior, validating protocol safety and efficacy. The 12.4% response rate may favor positive outcomes, warranting cautious interpretation, consistent with challenges in retrospective studies.⁹ These findings support the efficacy of shockwave therapy for long-term relief of pain and mobility in chronic musculoskeletal cases.
Limitations
The study’s small sample size (n=27) limits generalizability, as larger cohorts could yield robust conclusions. The 12.4% response rate introduces potential selection bias, as non-responders may have different outcomes. Recall bias is a concern, with outcomes reported 12–18 months post-treatment. The lack of a control group restricts attributing improvements solely to shockwave therapy, as natural recovery may contribute. The chiropractic cohort, with patients referred by chiropractors, may have influenced CMT prevalence and efficacy. In non-chiropractic settings, adjunct therapy outcomes may vary. Few studies directly evaluate ESWT combined with CMT and PT, necessitating further RCTs to confirm our findings.⁷,⁸ Future research should use prospective, controlled designs with larger, diverse populations.
Conclusion
This study of 27 patients validates tailored shockwave therapy protocols. Immediate improvement in 85% of patients highlights precise Radial or Focused Shockwave Therapy applications. Long-term, 80% maintenance, with 74% achieving Significant Improvement or Full Resolution, underscores durability. The 6+ session group’s 93.3% maintenance demonstrates efficacy for chronic conditions, while single-session patients’ 50% Full Resolution rate suits acute cases. CMT and PT integration achieved 87.5% maintenance, reinforcing multimodal care. Strong home-care adherence (79.7% maintenance) enhanced outcomes. The absence of worsening outcomes highlights safety. These results support the Shockwave Mastery Program, empowering clinicians with non-invasive strategies for musculoskeletal conditions.
Key Points
Findings: Shockwave therapy achieved 85% immediate symptom improvement and 80% long-term maintenance, with 74% of patients reporting Significant Improvement or Full Resolution.
Implications: The study validates tailored shockwave protocols, particularly with 6+ sessions and CMT+PT, offering clinicians effective non-invasive strategies for chronic musculoskeletal conditions.
Caution: The small sample size (n=27) and 12.4% response rate limit generalizability, with potential selection and recall biases affecting outcome interpretation.
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