Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis

Ann Phys Rehabil Med. 2022 Sep;65(5):101602. doi: 10.1016/j.rehab.2021.101602. Epub 2021 Nov 19.


Background: Hemiplegic shoulder pain (HSP) is a disabling complication affecting stroke survivors. In this context, rehabilitation might play a key role in its clinical management. Recent systematic reviews of the impact of rehabilitative approaches on pain reduction in patients with HSP are lacking.

Objective: This systematic review of randomized controlled trials (RCTs) with meta-analysis aimed to investigate the efficacy of rehabilitative techniques in reducing HSP in stroke survivors.

Methods: PubMed, Scopus, and Web of Science were searched from inception to March 8, 2021 to identify RCTs of stroke survivors with HSP undergoing specific rehabilitative techniques combined with conventional therapy to reduce pain intensity. A network meta-analysis and meta-analysis of the Bayesian network of random effects were performed. The risk of bias of studies was assessed with Version 2 of the Cochrane Risk of Bias tool for randomized trials.

Results: Of 1139 articles identified, 12 were included in the final synthesis. We analyzed data for 723 stroke survivors, reporting a significant overall decrease in pain intensity after a rehabilitative approach by the Bayesian meta-analysis (standardized mean difference 2.78, 95% confidence interval 0.89;-4.59; p = 0.003). We report a significant reduction in HSP with botulinum toxin type A injection (p = 0.001), suprascapular nerve pulsed radiofrequency (p = 0.030), suprascapular nerve block (p = 0.020), and trigger-point dry needling (p = 0.005) as compared with conventional rehabilitation. Concerning the effect size, we identified a Bayesian factor10 of 97.2, with very strong evidence of superiority of rehabilitative techniques.

Conclusions: The present systematic review and meta-analysis showed that adding other rehabilitative techniques to conventional rehabilitation was significantly more effective than conventional rehabilitation alone in the complex management of patients affected by HSP.

Keywords: Botulinum toxin; Dry needling; Hemiplegic shoulder pain; Pain; Rehabilitation; Stroke.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Hemiplegia
  • Humans
  • Injections, Intra-Articular
  • Pain Measurement
  • Shoulder Pain
  • Stroke Rehabilitation*
  • Stroke*