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. 2025 Aug 6;57(1):2543979. doi: 10.1080/07853890.2025.2543979

Extracorporeal shock wave therapy for peripheral arterial disease-related intermittent claudication: a systematic review and meta-analysis

Peiyuan Tang a,b, Ting Wen a,b, Jingyue Su c,d, Shanshan Gao e, Shengwu Yang c,d, Chunwu Zhang c,d, Wenfeng Xiao a,b, Yusheng Li a,b,✉, Zhenhan Deng c,d,✉
PMCID: PMC12332995  PMID: 40770927

Abstract

Background

Intermittent claudication (IC) is a common manifestation of peripheral arterial disease. This study evaluates the efficacy of extracorporeal shock wave therapy (ESWT), a non-invasive treatment, for patients with IC.

Methods

A systematic review and meta-analysis of four major databases (PubMed, Embase, Cochrane Library, Web of Science) was conducted through March 2025. Eight studies met inclusion criteria for the analysis, which was performed using Review Manager 5.4 with evidence strength assessed by the GRADE system.

Results

The analysis included eight studies with a total of 332 patients (mean age >50 years, 67.5% male). Compared to placebo, ESWT demonstrated significant improvements in functional outcomes. It led to substantial increases in both Pain-Free Walking Distance (MD=26.53, p < 0.01) and Maximum Walking Distance (MD=37.21, p < 0.01). Quality of life was also enhanced, reflected by higher scores on the EQ-5D-3L survey (MD=0.08, p < 0.01) and improvements across SF-36 domains including Physical Function, General Health, Vitality, and Social Functioning. However, ESWT did not produce a significant change in the Ankle-Brachial Index (ABI) (MD=−0.01, p = 0.05).

Conclusion

ESWT is associated with improved walking distance and quality of life in patients with IC. These findings require cautious interpretation due to the limited number of studies and small sample sizes.

Clinical trial number

Not applicable.

Keywords: Extracorporeal shock wave therapy, intermittent claudication, meta-analysis, systematic review

KEY MESSAGES

  • This meta-analysis evaluates the effects of extracorporeal shock wave therapy (ESWT) on walking distance and functional scores in patients with intermittent claudication (IC).

  • ESWT is an effective treatment for patients with IC, leading to improvements in pain-free walking distance, maximum walking distance, and quality of life.

  • Future research on ESWT for intermittent claudication (IC) should focus on larger, multi-center trials with diverse patient populations to improve generalizability and statistical power.

1. Introduction

Intermittent claudication (IC), a common manifestation of peripheral arterial disease (PAD), is characterized by pain or discomfort in the lower extremities during physical activity, which quickly resolves with rest [1]. This condition significantly impairs quality of life by limiting mobility and, in severe cases, can progress to critical limb ischemia, potentially resulting in limb amputation [2]. Globally, the prevalence of PAD is estimated to be 3–10%, with approximately 10–20% of PAD patients presenting with typical IC symptoms [3]. Among individuals over 60 years of age, the prevalence of IC is estimated at 5–10% [4]. The global burden of IC underscores the need for effective treatment strategies to slow disease progression and alleviate symptoms. The management of IC aims to alleviate symptoms, improve walking distance, and prevent disease progression. Cornerstone treatments include lifestyle modifications, such as structured exercise therapy, smoking cessation, and dietary adjustments to manage weight, cholesterol, and blood pressure [5]. Pharmacotherapy, including antiplatelet agents, statins, and vasodilators like cilostazol and pentoxifylline, is used to improve blood flow and reduce the risk of thrombotic events [6]. In more severe cases of IC that do not respond to conservative treatments, revascularization procedures, such as angioplasty or bypass surgery, may be necessary to restore adequate blood flow [7].

In recent years, extracorporeal shock wave therapy (ESWT) has emerged as a promising non-invasive treatment for IC, particularly for patients who are not candidates for surgery or have not responded to pharmacological interventions [8]. ESWT works by delivering high-energy acoustic pulses to the affected area, promoting mechanisms such as angiogenesis, vasodilation, and reduction of inflammation [9]. However, evidence regarding the efficacy of ESWT remains limited and inconclusive. Although a systematic review has summarized the effects of ESWT on IC, the number of included studies is small, and the quality of the studies is low [10]. More comprehensive and updated meta-analyses are needed to address these limitations. This study conducted a meta-analysis to evaluate the effectiveness of ESWT in treating IC and aims to provide both patients and clinicians with a clearer understanding of its efficacy and safety. By clarifying these aspects, the study helps healthcare professionals and patients make informed treatment decisions. We hypothesized that ESWT would significantly benefit IC patients by increasing walking distance and reducing pain.

2. Methods

This article has been reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) guidelines to ensure methodological rigor and transparency in the reporting of systematic reviews and meta-analyses [11,12] (Supplementary Material S1) The conduct of this systematic review and meta-analysis followed the methodological guidelines outlined in the Cochrane Handbook for Systematic Reviews [13,14]. This study has been registered with PROSPERO.

2.1. Search strategy

Four databases were searched: Embase, PubMed, Web of Science, and the Cochrane Library—up to March 2025. Two authors conducted the database searches independently, while a third author helped resolve any discrepancies through consensus. The search strategy involved combining subject terms and free terms. The main keywords used in the search were as follows: Extracorporeal Shockwave Therapy, Shock Wave Therapies, Intermittent Claudication, and Extracorporeal Shock Wave Therapy. For further details on the search process, please refer to Supplementary Material S2.

2.2. Eligibility criteria

The eligibility criteria for the systematic review and meta-analysis were based on the PICO framework: P: Studies involving patients with intermittent claudication; I: Intervention group receiving ESWT; C: Control group (placebo); O: Reporting at least one functional outcome (Pain free walking distance; Maximum walking distance; Ankle brachial pressure index; EuroQol 5-Dimension 3-Level survey; 36-item Short-Form Quality of Life questionnaire).

Inclusion criteria for studies: 1. Randomized controlled trials (RCTs) or cohort studies. 2. Participants diagnosed with stable calf intermittent claudication (Fontaine class II). 3. Comparison of ESWT against control intervention. 4. Reported quantitative outcomes for walking distance or quality of life.

Exclusion criteria for studies: 1. Studies where >20% participants had non-PAD causes of claudication. 2. Studies with mixed populations that did not separate outcomes for IC patients. 3. Case reports, reviews, or non-human studies. 4. Studies without accessible outcome data.

2.3. Data extraction and quality assessment

Data extraction and quality evaluation were performed independently by two authors, with a third author assisting in resolving any discrepancies and reaching a consensus. Information such as the author’s name, patient count, results, average age, sex ratio, and other relevant details were extracted. The main outcome measures included in this study were: pain-free walking distance (PWD), defined as the maximal distance walked (m) before the onset of ischemic pain, and maximum walking distance (MWD), representing the absolute limit of walking tolerance (meters) due to pain. Additionally, the ankle–brachial index (ABI) was assessed as an objective hemodynamic measure, calculated as the ratio of systolic blood pressure at the ankle to that in the brachial artery. Patient-reported outcomes focused on health-related quality of life, utilizing the standardized EuroQol 5-Dimension 3-Level (EQ-5D-3L) survey, which generates a single utility index from five health dimensions, and the 36-item Short-Form Quality of Life questionnaire (SF-36), a multi-dimensional instrument yielding scores across eight health domains and two summary components. The mean and standard deviation were primarily extracted for each outcome. For cases where direct extraction was not possible, results were converted into mean and standard deviation values [15]. All randomized trials were evaluated for risk of bias using the Cochrane assessment method [16]. The quality of the included case series studies was assessed using the Newcastle–Ottawa Scale (NOS) [17].

2.4. Grading the evidence

The strength of the evidence for the outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system [18]. This evaluation considered five factors: Risk of Bias, Inconsistency, Indirectness, Imprecision, and Publication Bias. Based on these criteria, the evidence was classified into one of four levels: high, moderate, low, or very low.

2.5. Statistical analyses

Meta-analyses were performed using Review Manager 5.4, with statistical significance defined by a two-sided P value of less than 0.05. The results for continuous outcomes were summarized as mean differences (MD) with the corresponding 95% confidence intervals (CI). In cases of substantial heterogeneity, a random-effects model was used to calculate pooled effect sizes; otherwise, a fixed-effect model was applied. Heterogeneity beyond sampling error was assessed using the χ2 and I2 statistics. I2 values were interpreted as follows: low (<25%), low to moderate (25–50%), moderate to substantial (50–75%), or substantial (>75%). Significant clinical heterogeneity was addressed through subgroup analyses.

3. Results

3.1. Search results

Initially, 55 articles were identified through the search strategy. Following the removal of duplicates, 29 articles were excluded, leaving 26 articles for further screening. After a thorough review of titles and abstracts, 12 additional studies were excluded, resulting in 14 eligible studies. Following full-text evaluation, six more studies were excluded (Supplementary Material S3) A total of 8 studies were included in this systematic review and meta-analysis, 5 of which were randomized controlled trials and 3 were cohort studies. The literature screening process is illustrated in Figure 1.

Figure 1.

Figure 1.

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The Preferred Reporting Items for Systematic reviews and meta-analysis (PRISMA) flow diagram to show study selection.

3.2. Study characteristics

This systematic review included a total of eight studies [8,19–25], five of which were randomized controlled trials (RCTs) [8,19–21,24]. A total of 332 patients were included in this review, comprising 224 male (67.5%) and 108 female (32.5%) patients. The mean age of patients exceeded 50 years. All studies reported the proportion of patients with diabetes among those presenting with intermittent claudication. Five studies also reported the proportion of smokers among patients with intermittent claudication [8,20–24]. All included studies had a minimum follow-up period of 8 weeks. The essential features of each study that was analyzed are compiled in Table 1.

Table 1.

Baseline characteristics of included literatures.

Study Year Region Sample size
 Age
 Gender
 Number of smokers Diabetes Follow-up (M)
ESWT Placebo ESWT Placebo Male Female
Cai [8] 2024 United Kingdom 68 70 66 ± 10.7 67 ± 8.5 67% 33% 127 41 12
Ali [19] 2022 Egypt 30 30 50.5 ± 3.51 51.83 ± 4.53 62% 38% NA 60 6
Harwood [20] 2018 United Kingdom 15 15 64.3 ± 9.4 67.5 ± 9.3 60% 40% 27 8 3
Green [21] 2018 United Kingdom 15 15 64.3 ± 9.37 67.5 ± 9.26 60% 40% 27 9 12
Tara [22] 2014 Japan 10 NA 71.3 ± 9.0 NA 90% 10% NA 8 NA
Serizawa [23] 2012 Japan 12 NA 60–86 NA 83% 17% 9 4 6
Ciccone [24] 2012 Italy 12 10 67 ± 9 68 ± 12 86% 14% 20 12 2
Belcaro [25] 2005 Italy 30 NA 72.4 ± 6 NA 70% 30% NA 0 3
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NA: Not access.

3.3. Quality evaluation

A total of 8 studies were included: five randomized controlled trials (RCTs) and three cohort studies. All of RCTs described suitable random sequence generation and randomization methods. However, one study had reporting bias, which could have led to varying degrees of bias [24]. One study was of medium quality while the other four were of high quality (Figure 2). For case series studies, only Serizawa F’s [23] study was of medium quality, and the other two were of high quality [22,25] (Supplementary Material S4).

Figure 2.

Figure 2.

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A figure displaying the risk of bias for each of the included randomized studies. The color represents the quality in each of the domains (red = high risk, yellow = uncertain, and green = low risk).

3.4. GRADE results

The GRADE rating results of each outcome indicator are shown in Figure 3. GRADE evidence was classified into two levels: moderate (PFD, ABI) and low (MWD).

Figure 3.

Figure 3.

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GRADE evidence for outcomes of intermittent claudication treated with extracorporeal shock wave therapy.

3.5. Results of meta-analysis

3.5.1. Pain free walking distance

A total of 4 RCTs reported PWD, involving 232 patients. Fixed-effect model analysis revealed statistically significant differences between the ESWT and placebo groups that were statistically significant (MD = 26.53, 95% CI: 22.24, 30.82, p < 0.01, I2 = 30%) (Figure 4). The PWD was divided into three subgroups based on follow-up duration: 4, 8, and 12 weeks, to evaluate the efficacy and safety of ESWT and explore whether the efficacy changes over time. (Supplementary Material S5 – Figure 1) In the 4-week follow-up subgroup, there was a significant statistical difference between the ESWT and placebo groups (MD = 30.16, 95% CI: 1.06, 59.27, p = 0.04, I2 = 49%). In the 8-week follow-up subgroup, a significant statistical difference was observed between the ESWT and placebo groups (MD = 62.62, 95% CI: 25.51, 99.73, p < 0.01, I2 = 53%). Similarly, in the 12-week follow-up subgroup, there was a significant statistical difference between the ESWT and placebo groups (MD = 61.66, 95% CI: 28.14, 95.18, p < 0.01, I2 = 74%). No significant heterogeneity was found among the subgroups (Ch I2 = 2.67, p = 0.26, I2 = 25.2%). When all subgroups were combined, the results indicated that the ESWT group was superior to the placebo group in terms of MWD (MD = 48.61, 95% CI: 29.70, 67.52, p < 0.01, I2 = 53%).

Figure 4.

Figure 4.

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Forest plots of pain free walking distance.

3.5.2. Maximum walking distance

A total of 3 RCTs reported MWD, involving 198 patients. Analysis with the random-effects model showed no significant differences between the ESWT and placebo groups. (MD = 45.64, 95% CI: −1.97, 93.26, p = 0.06, I2 = 77%) (Figure 5) The MWD was divided into three subgroups based on follow-up duration: 4, 8, and 12 weeks (Supplementary Material S5 – Figure 2). In the 4-week follow-up subgroup, there was a significant statistical difference between the ESWT and placebo groups (MD = 28.27, 95% CI: 8.83, 47.72, p < 0.01, I2 = 0%). In the 8-week follow-up subgroup, a significant statistical difference was observed between the ESWT and placebo groups (MD = 41.73, 95% CI: 21.20, 62.25, p < 0.01, I2 = 52%). Similarly, in the 12-week follow-up subgroup, there was a significant statistical difference between the ESWT and placebo groups (MD = 43.13, 95% CI: 21.71, 64.56, p < 0.01, I2 = 80%). No significant heterogeneity was found among the subgroups (χ2 = 1.29, p = 0.52, I2 = 0%). When all subgroups were combined, the results indicated that the ESWT group was superior to the placebo group in terms of MWD (MD = 37.21, 95% CI: 25.42, 49.00, p < 0.01, I2 = 44%).

Figure 5.

Figure 5.

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Forest plots of maximum walking distance.

3.5.3. Ankle brachial pressure index

A total of 3 RCTs reported ABI, involving 122 patients. Analysis with the fixed-effect model found no significant differences between the ESWT and placebo groups (MD=–0.01, 95% CI: −0.02, 0.00, p = 0.05, I2 = 0%) (Figure 6).

Figure 6.

Figure 6.

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Forest plots of ankle brachial pressure index.

3.5.4. EuroQol 5-dimension 3-level survey

The EQ-5D-3L was divided into three subgroups based on follow-up duration: 4, 8, and 12 weeks (Figure 7). In the 4-week follow-up subgroup, there was a statistical difference between the ESWT and placebo groups (MD = 0.08, 95% CI: 0.03, 0.14, p < 0.01, I2 = 8%). In the 8-week follow-up subgroup, no significant statistical difference was observed between the ESWT and placebo groups (MD = 0.04, 95% CI: −0.01, 0.08, p = 0.45, I2 = 0%). In the 12-week follow-up subgroup, there was a statistical difference between the ESWT and placebo groups (MD = 0.05, 95% CI: 0.01, 0.09, p = 0.02, I2 = 60%). No significant heterogeneity was found among the subgroups (χ2 = 1.82, p = 0.40, I2 = 0%). When all subgroups were combined, the results indicated that there was a statistical difference between the ESWT and placebo groups (MD = 0.05, 95% CI: 0.03, 0.08, p < 0.01, I2 = 16%).

Figure 7.

Figure 7.

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Forest plots of Euroqol 5-dimension 3-level survey.

3.5.5. 36-item short-form quality of life questionnaire

The SF-36 was divided into ten subgroups based on scale type. (Supplementary Material S5 – Figure 3). In the SF-36-Physical Function (PF) subgroup, there was a statistical difference between the ESWT and placebo groups (MD = 4.59, 95% CI: 0.79, 8.40, p = 0.02, I2 = 88%). In the SF-36-General Health (GH) subgroup, a significant statistical difference was observed between the ESWT and placebo groups (MD = 5.01, 95% CI: 1.11, 8.92, p = 0.01, I2 = 16%). In the SF-36-Physical Component Summary (PCS) subgroup, there was no statistical difference between the ESWT and placebo groups (MD = 3.33, 95% CI: −0.03, 6.70, p = 0.05, I2 = 69%). In the SF-36-vitality (VT) subgroup, there was a statistical difference between the ESWT and placebo groups (MD = 4.31, 95% CI: 0.12, 8.49, p = 0.04, I2 = 0%). In the SF-36-Role Emotional (RE) subgroup, no significant statistical difference was observed between the ESWT and placebo groups (MD = 4.96, 95% CI: −1.63, 11.56, p = 0.14, I2 = 30%). In the SF-36-Mental Health (MH) subgroup, there was no statistical difference between the ESWT and placebo groups (MD = 3.28, 95% CI: −1.40, 7.96, p = 0.17, I2 = 66%). In the SF-36-Mental Component Summary (MCS) subgroup, no significant statistical difference was observed between the ESWT and placebo groups (MD = 3.43, 95% CI: −1.80, 8.66, p = 0.20, I2 = 70%). In the SF-36-Role Physical (RP) subgroup, there was no statistical difference between the ESWT and placebo groups (MD = 1.53, 95% CI: −2.84, 5.91, p = 0.49, I2 = 68%). In the SF-36-Bodily Pain (BP) subgroup, there was no statistical difference between the ESWT and placebo groups (MD = 2.64, 95% CI: −1.36, 6.64, p = 0.20, I2 = 63%). In the SF-36-Social Functioning (SF) subgroup, there was a statistical difference between the ESWT and placebo groups (MD = 4.35, 95% CI: −0.05, 8.75, p = 0.05, I2 = 72%). No significant heterogeneity was found among the subgroups (χ2 = 2.25, p = 0.99, I2 = 0%). When all subgroups were combined, the results indicated that there was a statistical difference between the ESWT and placebo groups (MD = 3.71, 95% CI: 2.36, 5.05, p < 0.01, I2 = 42%). In addition, a subgroup analysis of each subclass of SF-36 was performed in terms of follow-up time. Subgroup analysis by follow-up time is presented in Supplementary Material S5 (Figures 3–13).

4. Discussion

The study’s primary results are that compared with the placebo group, First, ESWT significantly improved PWD compared to placebo. Subgroup analysis based on follow-up duration revealed that the beneficial effects of ESWT on PWD were maintained at 4, 8, and 12 weeks post-treatment. Second, although the overall analysis of maximum walking distance (MWD) did not show a statistically significant difference between ESWT and placebo groups, subgroup analysis based on follow-up duration was performed due to substantial heterogeneity. The subgroup analysis demonstrated significant improvements in MWD at 4, 8, and 12 weeks post-treatment, with no significant heterogeneity among the subgroups. When all subgroups were combined, the results indicated that ESWT was superior to placebo in terms of MWD. Third, no significant differences were observed between ESWT and placebo groups in terms of ABI. Fourth, ESWT improved quality of life, as assessed by the EQ-5D-3L. Finally, ESWT significantly improved several domains of the SF-36, including Physical Function, General Health, Vitality, and Social Functioning, compared to placebo.

This study’s findings were compared with those of previous studies. The results of Cayton, Thomas et al.’s [10] study are consistent with ours. Their findings report that ESWT can improve PWD and MWD. The possible mechanisms by which ESWT can improve walking distance and scale score in IC patients are as follows: ESWT primarily stimulates angiogenesis and neovascularization, leading to improved blood supply to ischemic tissues [26]. This enhancement in vascular health is supported by ESWTs ability to improve endothelial function and vascular reactivity, contributing to better overall blood flow regulation [10]. ESWT exerts anti-inflammatory effects, reducing local inflammation in affected blood vessels and tissues [27]. This anti-inflammatory action, coupled with ESWT’s ability to stimulate tissue repair and regeneration, contributes to improved health of affected muscles and other tissues [28]. On a cellular level, ESWT influences local metabolism in affected tissues, improving energy utilization and reducing ischemic damage [29]. This metabolic modulation enhances tissue resilience to ischemic conditions. ESWT alters pain signaling pathways, leading to reduced pain perception during walking. This analgesic effect is evident in the improved pain-free walking distances observed in treated patients. Treatment safety considerations are paramount. There is growing evidence that ESWT has a good safety profile and is highly tolerated in patients with IC. Green et al. [21] conducted a 12-month follow-up study and found no long-term safety concerns. In addition, ESWT appears to have a higher safety profile compared to more invasive treatments [23].

Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment method that eliminates the need for surgery or anesthesia, thereby significantly reducing the associated risks compared to invasive procedures [30]. The treatment and recovery times for ESWT are notably shorter, allowing patients to resume their daily activities more swiftly without the need for extended rehabilitation [20]. In comparison to pharmacological treatments, ESWT has fewer side effects, with the most common being transient pain or discomfort at the treatment site, which usually resolves on its own [31]. Additionally, ESWT substantially lowers the risk of complications that are typically associated with invasive procedures such as percutaneous transluminal angioplasty, thus avoiding issues like infections and other surgical risks [20].

5. Study limitations

First, only articles written in English were included in this study. Second, the number of included studies and the sample sizes of individual trials were relatively small, which may limit the statistical power and generalizability of our findings. Third, many RCTs only cover patients from specific regions, populations, or conditions, which might restrict the applicability to a larger group of people. Therefore, these limitations need to be carefully weighed when interpreting and inferring the findings and incorporated into a comprehensive analysis of the results.

6. Future research

Future research on ESWT for intermittent claudication (IC) should focus on larger, multi-center trials with diverse patient populations to improve generalizability and statistical power. Long-term follow-up studies are needed to assess the durability and safety of ESWT. Exploring combined therapies, personalized treatment strategies, and understanding the molecular mechanisms behind ESWT’s effects could further enhance its efficacy. Economic evaluations and comparative studies with other non-invasive treatments would help establish ESWT’s cost-effectiveness. Additionally, future RCTs should prioritize collecting comprehensive demographic data including ethnicity, socioeconomic status, and cultural backgrounds to enable equity-focused analyses.

7. Conclusion

ESWT is associated with improvements in pain-free walking distance, maximum walking distance, and quality of life for patients with intermittent claudication. However, these findings should be interpreted with caution due to the limited number of included studies and small sample sizes.

Supplementary Material

Supplemental Material
IANN_A_2543979_SM3607.zip (628.6KB, zip)

Acknowledgements

Not applicable. Peiyuan Tang: Methodology, software, validation, formal analysis, investigation, data curation, writing–original draft preparation, writing–review and editing, visualization. Ting Wen: Methodology, software, investigation, data curation, writing–review and editing, visualization. Jingyue Su: Software, formal analysis, writing–review and editing. Shanshan Gao: Software, formal analysis, writing–review and editing. Shengwu Yang: Validation, writing–review and editing. Chunwu Zhang: Validation, writing–review and editing. Yusheng Li: Conceptualization, methodology, formal analysis, investigation, resources, data curation, writing–review and editing, supervision, project administration, funding acquisition. Wenfeng Xiao: Conceptualization, methodology, formal analysis, investigation, resources, data curation, writing–review and editing, supervision, project administration, funding acquisition. Zhenhan Deng: Conceptualization, methodology, formal analysis, investigation, resources, data curation, writing–review and editing, supervision, project administration, funding acquisition. All authors read and approval the final version of the manuscript.

Glossary

Abbreviations

PWD

Pain free walking distance

MWD

Maximum walking distance

ABI

Ankle brachial pressure index

EQ-5D-3L

EuroQol 5-Dimension 3-Level survey

SF-36

36-item Short-Form Quality of Life questionnaire

Funding Statement

This work was supported by National Key R&D Program of China (No. 2023YFC3603400), National Natural Science Foundation of China (No. 82472495, 82072506, 92268115, 82272611), Hunan Provincial Science Fund for Distinguished Young Scholars (No. 2024JJ2089), Science and Technology Innovation Program of Hunan Province (No. 2021RC3025, No. 2023SK2024, No.2021JJ31105, No.2023JJ30949), National Clinical Research Center for Geriatric Disorders (Xiangya Hospital, Grant No.2021LNJJ05, Grant No.2021KFJJ02).

Systematic review registration

This study has been registered with in the International Prospective Register of Systematic Reviews (PROSPERO).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Clinical trial number

Not applicable.

Data availability statement

All data generated or analysed during this study are included in this published article and its supplementary information files. The data synthesized and presented in the results section have been well-referenced as an update systematic review article. However, raw data used in the statistical analysis will be made available on request through the corresponding author (Zhenhan Deng).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material
IANN_A_2543979_SM3607.zip (628.6KB, zip)

Data Availability Statement

All data generated or analysed during this study are included in this published article and its supplementary information files. The data synthesized and presented in the results section have been well-referenced as an update systematic review article. However, raw data used in the statistical analysis will be made available on request through the corresponding author (Zhenhan Deng).

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