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 could’n’t complete the program n=2 Receive therapy before admission n=10 Severe aphasia and cognition Dysfunction n=6 Already developed pain n=8 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) * p<.05 * p<.05  25% (7/28) developed shoulder ; 71% patients in OP group

9. Results (2)

10. Results (3)  No sig difference btw groups, p=0.62

11. Results (4)  No sig difference btw groups, p=0.25

12. Relative risk (1) • 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) •  Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (1/8) =5 • Severe adverse event ( if OR>3)

14. Relative odds (3) •  Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(1/8) / (1/12) =1.5 • Minor adverse event

15. Relative odds (4) •  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