1. Clinical Question: Do therapeutic exercise for hemiplegic arm cause the shoulder pain in patients with stroke? Searching databank: MEDLINE, PubMed,CINAL Searching strategy: [ rehabilitation & ( adverse effect or harm or complication or side effect ) & stroke ] ; [ physical therapy technique & ( adverse effect or harm or complication or side effect ) & stroke ] ; [ exercise therapy & ( adverse effect or harm or complication or side effect ) & stroke ] Limitation: English and human and clinical trial

2. Citation Kumar R, Metter EJ, Mehta AJ, Chew T: Shoulder pain in hemiplegia - the role of exercise. Am J Phys Med Rehabil 1990;69:205-8.

3. Introduction (1) Exercise is the most important therapy in restoration of physical independence in patients with stroke. PROM is done when there is no voluntary movement in the extremities to avoid joint contracture; AROM and AAROM are added to the program when the patients starts to regain voluntary control.

4. Introduction (2) three type of exercises commonly used during rehabilitation of the UE in patients with stroke Passive range of motion (PROMT) Skate board (SB) Overhead pulley (OP) Purpose of the study To evaluate whether any of these exercises could initiate shoulder pain in patients with stroke

5. Methods (1) First stroke n=48 Receive therapy before admission n=10 Already developed pain n=8 could’n’t complete the program n=2 Severe aphasia and cognition Dysfunction n=6 PROMT n=12 SB n=8 OP n=8

6. Methods (2) Initial evaluation: subluxation of the shoulder, PROM for the upper limb, muscle strength (MMT) Outcome measures: pain at rest or during PROM Record “ yes “ or “ no “ Every month for 3 months Blinded evaluator A.J.M Intervention: performed by OT only 1 / day * 5 days/wk * ? Wks Presence of shoulder pain

7. Scapular plane

8. Results (1) PROMSBOP No. of patients1288 Age (yr)63.270.160.8 Onset to treatment interval (d) 14.5+1.5115.1+3.4013.8+2.36 No. of patients who developed shoulder pain 1 (8%)1 (12%)5 (63%) No. of patients who did not have shoulder pain 11 (92%)7 (88%)3 (37%)  25% (7/28) developed shoulder ; 71% patients in OP group * p<.05

9. Results (2) Motion Mean ROM tp Without painWith pain Adduction153+2496+215.6<0.01 Flexion165+1089+418.1<0.01 IR43+238+44.40<0.01 ER36+1020+123.49<0.01

10. Results (3) ROMTSBOPTotal Subluxation ( n=13) Pain No pain 1034 5409 No subluxation ( n=15) Pain 0123 No pain63312  No sig difference btw groups, p=0.62

11. Results (4) ROMTSBOPTotal Poor strength ( n=16 ) Pain No pain 1135 83011 Fair strength ( n=12 ) Pain 0022 No pain33410  No sig difference btw groups, p=0.25

12. Relative risk (1) Adverse outcome ( shoulder pain)Totals +– Expose to treatment OP5 (a) 3 (b) 8 PROM1 (c) 11 (d) 12 Totals61420  Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (1/12) =7.5  Severe adverse event ( if OR>3)

13. Relative odds (2) Adverse outcome ( shoulder pain)Totals +– Expose to treatment OP5 (a) 3 (b) 8 SB1 (c) 7 (d) 8 Totals61016  Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (1/8) =5  Severe adverse event ( if OR>3)

14. Relative odds (3) Adverse outcome ( shoulder pain)Totals +– Expose to treatment SB1 (a) 7 (b) 8 PROMT1 (c) 11 (d) 12 Totals21820  Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(1/8) / (1/12) =1.5  Minor adverse event

15. Relative odds (4) Adverse outcome ( shoulder pain)Totals +– Expose to treatment OP5 (a) 3 (b) 8 SB+PROM2 (c) 18 (d) 20 Totals72128  Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (2/20) =6.25  Severe adverse event ( if OR>3)

16. Critical Appraisal Worksheet