Table 1.

Potential benefits in upper-limb motor function after post-stroke shockwave therapy with a valid measure of methodological quality of clinical trials using the PEDro scale.

Study Author, PEDro Scale, Year	Stage of Stroke	ApplicationArea, Frequency, Pressure, Pulsecount, Bulletsize	Outcome, Measures	MainFindings
Manganotti et al. [80], 2005 PEDro: none	Clinical Trial, n = 20, Chronic	Forearmflexor muscles, Interosseusmuscles, 4700 shots, 0.030 mJ/mm2	Ashworth, NIHSS, Video monitoring with a digitalgoniometer	ESWT reduces hypertonia of the flexor wrist and finger muscles for 12 weeks after treatment.
Bae et al. [81], 2010 PEDro: none	Clinical Trial, n = 32, Chronic	Biceps muscle, Musculotendinousjunction of biceps, 1200 shots, 0.12 mJ/mm2, 4 Hz	Ashworth, Tardieu, Barthel	ESWT for chronic stroke patients’ spasticity of upper limbs has immediate effect. The treatment effect at the musculotendinous junction was greater than on the biceps.
Yoo et al. [82], 2008 PEDro: none	Clinical Trial, n = 21, Chronic	Biceps muscle, Forearmflexor muscles, 1000 shots, 0.069 mJ/mm2, 4 Hz	Ashworth, Tardieu, NIHSS	Patients treated with ESWT showed significant improvement in muscle tone of elbow flexor and wrist pronator after the 1st and 4th weeks. Active elevation of the upper limb with hemiplegia was significantly increased.
Brunelli et al. [83], 2022 PEDro: 5/10	Clinical Trial, n = 32, Subacute	Biceps muscle, Forearmflexor muscles, 2000 shots, 1.5 bar, 10 Hz	Ashworth	The early treatment of upper-limb muscular spasticity after stroke with ESWT seems to avoid progression to higher degrees of spasticity and reduce the use of oral antispasmodic medication.
Li et al. [34], 2016 PEDro: none	Clinical Trial, n = 60, Chronic	Biceps muscle, Forearmflexor muscles, 5500 shots, 3.0–3.5 bar, 5 Hz	Ashworth, FMA	ESWT may decrease flexor spasticity of the hand and wrist with enhancement of hand function and wrist control in patients with chronic stroke. Repetitive sessions of ESWT result in a longer-lasting and more noticeable effects and are necessary for improving functional motricity.
Li et al. [84], 2020 PEDro: 7/10	Clinical Trial, n = 82, Chronic	Biceps muscle, Brachioradialis muscle, 6000 shots, 1.2–1.4 bar, 18 Hz	Tardieu, Ashworth, VAS, FMA	ESWT is an effective therapy for spasticity after stroke, with lasting effects on both agonist and antagonist muscles after 4 weeks. ESWT relieved pain but had no effect on active function or swelling of the upper limbs.
Park et al. [85], 2018 PEDro: 8/10	Clinical Trial, n = 30, Chronic	Forearmflexor muscles, Interosseusmuscles, 4700 shots, 0.03 mJ/mm2	MAS, MMSE-K, FMA	Upper-extremity muscle tone wassignificantly higher in the ESWT group than in the sham group. ESWT is effective for mitigating thedecrease in muscle tone in chronic stroke patients.
Dymarek et al. [86], 2016 PEDro: 6/10	Clinical Trial, n = 20, Chronic	Forearmflexor muscles, 1500 shots 1.5 bar, 0.03 mJ/mm2, 4 Hz	MAS, BI, NIHSS,	A single session of ESWT could be an effective physical treatment aimed at the reduction inupper-limb spasticity and could lead to improvement of trophic conditions of the spastic muscles in post-stroke survivors.
Leng et al. [29], 2021 PEDro: none	Clinical Trial, n = 27, Subacute	Forearmflexor muscles, 1500 shots, 1.5 bar, 0.038 mJ/mm2, 4 Hz, 15 mm	MAS, FMA	ESWT may be more effective for the peripheral component of spasticity in terms of changes in muscle mechanical properties. The optimal intervention regime of post-stroke spasticity should take into consideration both neural and non-neural factors.
Guo et al. [53], 2019 PEDro: 6/10	Clinical Trial, n = 120, Chronic	Forearmflexor muscles, Interosseusmuscles, 2000 shots, 2.0–3.0 bar, 8 Hz	MAS, FMA,	ESWT might be beneficial in the recovery of upper-limb spasticity in post-stroke patients. To evaluate the motor recovery, one canuse the Brunnstrom stages, not justFMA and MAS.
Yoon et al. [87], 2017 PEDro: none	Clinical Trial, n = 80, Chronic	Biceps muscle, 1500 shots, 0.068–0.093 mJ/mm2, 5 Hz	MAS, MTS	ESWT could be effective for treating chronic spasticity after stroke when applied to muscle belly or myotendinous junction.
Senarath et al. [88], 2023 PEDro: none	Clinical Trial, n = 53, Chronic	Teres major muscle, Brachialis muscle, Forearmflexor muscles, 1500 shots, 0.03 mJ/mm2, 5 Hz	MAS, VCG, FMA-UL, ARAT	ESWT could be effective for treating chronic post-stroke upper limb spasticity. The patients showed improved hand functions from the first treatment.
Savevska et al. [89], 2016 PEDro: none	Case Report, n = 1, Chronic	Forearmflexor muscles, Interosseusmuscles, 5000 shots, 2 bar, 10 Hz, 15 mm	MAS, DAS,	ESWT reduced the spasticity of the wrist and finger flexors after stroke. ESWT is a safe, alternative, non-invasive treatment in reducing spasticity after a stroke. This therapy opens a new field of research in the non-invasive treatment of spasticity.
Fan et al. [90], 2021 PEDro: none	Clinical Trial, n = 50, Chronic	Forearmflexor muscles, Biceps muscle, 2000 shots, 0.03 mJ/mm2, 2 bar, 8 Hz	MAS	ESWT interference may affect clinical curative during the treatment phase. Long-term pateint follow-ups after the procedure are necessary to draw conclusions.
Yuan et al. [91], 2023 PEDro: none	Clinical Trial, n = 30, Chronic	Upper limb, 3000 shots, 1.1–1.3 bar, 8–14 Hz	MBI, FMA	ESWT can reduce the muscle tension of patients, alleviate spasticity, promote the motor function of the upper limb, and improve the working performance of patients.
Tabra et al. [92], 2021 PEDro: none	Clinical Trial, n = 20, Chronic	Forearmflexor muscles, Interosseusmuscles, 2000–3000 shots, 0.25–0.84 mJ/cm2, 2.8 bar, 15 Hz	MAS, FMA, MI Electrophysiological assessment of spasticity by Hmax/Mmax amplitude ratio	ESWT is a valuable adjuvant treatment for spasticity of the hand and wrist in stroke patients, which can be seen in terms of improvement infunctional activity. A reduction in wrist and hand spasticity was observed.

Abbreviations: FMA—Fugl–Meyer Assessment;MMSE-K—Mini Mental State Examination –Korea; MAS—Modified Ashworth Scale; BI—Barthel Index; NIHSS—National Institutes of Health Stroke Scale; MTS—Modified Tardieu Scale; VCG—voluntary control grading; UL—upper limb; ARAT—Action Research Arm Test; DAS—Disability Assessment Scale; MBI—Modified Barthel Index; MI—Motricity Index.