Efficacy of Physical Modalities for Hemiplegic Shoulder Pain After Stroke: A Systematic Review

BACKGROUND AND PURPOSE: Hemiplegic shoulder pain (HSP) represents a common and disabling complication following stroke, which has multiple causes and important functional consequences. Physical modalities are frequently used to manage HSP, but evidence on their effectiveness remains inconsistent. Our aim is to systematically review the evidence from randomized controlled trials (RCTs) on the efficacy and safety of physical modalities, compared with sham or standard care, for improving pain and function in adults with poststroke HSP. METHODS: This systematic review was conducted following the Cochrane Guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We included RCTs assessing physical modalities versus sham or standard therapy in adult stroke survivors with HSP. The primary outcome was pain reduction; secondary outcomes included functional mobility, quality of life, and adverse events. A comprehensive search was conducted in MEDLINE, EMBASE, CENTRAL, PEDro, CINAHL, Web of Science, ClinicalTrials.gov, and World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP) up to July 30, 2025. Risk of bias was assessed using the Cochrane Risk of Bias tool 2. RESULTS: Twelve RCTs involving 567 participants were included. Interventions comprised electrotherapy (n = 6), shock wave therapy (n = 3), and laser therapy (n = 3). Most studies showed significant pain reduction compared with control. Electrotherapy provided sustained analgesia; extracorporeal shock wave therapy improved structural abnormalities and pain; laser therapy enhanced both pain and functional outcomes. Adverse events were mostly mild. However, safety conclusions are limited by incomplete and inconsistent adverse event reporting. Heterogeneity in interventions and outcomes precluded meta-analysis. DISCUSSION AND CONCLUSIONS: Based on low to very low certainty evidence, physical modalities may offer benefit for HSP, but uncertainty remains regarding both long-term effectiveness and safety. Integration into multimodal rehabilitation protocols may be considered.