Efficacy of extracorporeal shock wave therapy combined with conventional physical therapy for chronic low back pain: a systematic review and network meta-analysis of randomized controlled trials

Objectives To compare the clinical effects of extracorporeal shock wave therapy (ESWT) combined with conventional physical therapy (CPT) versus monotherapy for chronic low back pain (CLBP). Methods A frequentist network meta-analysis was conducted in Stata/MP 18 using the network package. PubMed, Web of Science, Embase, and the Cochrane Library were searched from inception to April 11, 2026. Randomized controlled trials (RCTs) evaluating ESWT with or without CPT in adults with CLBP were included. Two reviewers independently screened studies; disagreements were resolved by consensus with a third reviewer. Two reviewers independently extracted study characteristics, intervention details, and outcomes. Risk of bias was assessed using RoB 2.0, and certainty of evidence using GRADE. Treatment ranking probabilities were estimated using surface under the cumulative ranking curves (SUCRA). Results Fourteen RCTs reported pain score (VAS/NRS) and eight reported functional score (ODI); lower scores indicate improvement. According to SUCRA ranking, combined therapy ranked first for both pain relief (96.0%) and functional improvement (99.3%), followed by ESWT, CPT, and sham ESWT in sequence. Combined therapy (ESWT with CPT) provided greater pain relief than sham ESWT (SMD = −1.70; 95% CI: −2.69 to −0.71) and CPT alone (SMD = −0.88; 95% CI: −1.29 to −0.47). ESWT was also superior to sham ESWT (SMD = −1.22; 95% CI: −1.83 to −0.61). For functional improvement, combined therapy achieved significantly greater reductions in ODI than ESWT (MD = -3.60; 95% CI -6.70 to -0.51), sham ESWT (MD = −7.60; 95% CI: −14.00 to −1.12), and CPT (MD = −5.29; 95% CI: −7.53 to −3.06). Conclusion Combined therapy shows promise for alleviating pain and improving function in patients with CLBP. ESWT may help reduce pain, but no significant effects on functional outcomes have been observed. However, more high-quality randomized controlled trials are needed to confirm these findings. Systematic review registration https://www.crd.york.ac.uk/prospero/ , identifier 420251170304.