Clinical Question: Do therapeutic exercise for hemiplegic a

rm 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

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.

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.

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

Methods (1)

First stroken=48

Receive therapy before

admission n=10

Already developed painn=8

could’n’t complete the program n=2

Severe aphasia and cognitionDysfunction n=6

PROMTn=12

SBn=8

OPn=8

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

Scapular plane

Results (1)

PROM SB OPNo. of patients 12 8 8

Age (yr) 63.2 70.1 60.8

Onset to treatment interval (d)

14.5+1.51 15.1+3.40 13.8+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 * p<.05

Results (2)

Motion

Mean ROM

t pWithout pain With pain

Adduction 153+24 96+21 5.6 <0.01

Flexion 165+10 89+41 8.1 <0.01

IR 43+2 38+4 4.40 <0.01

ER 36+10 20+12 3.49 <0.01

Results (3)

ROMT SB OP Total

Subluxation( n=13)

Pain

No pain

1 0 3 4

5 4 0 9

No subluxation( n=15)

Pain

0 1 2 3

No pain 6 3 3 12

No sig difference btw groups, p=0.62

Results (4)

ROMT SB OP Total

Poor strength( n=16 )

Pain

No pain

1 1 3 5

8 3 0 11

Fair strength( n=12 )

Pain

0 0 2 2

No pain 3 3 4 10

No sig difference btw groups, p=0.25

Relative risk (1)

Adverse outcome

( shoulder pain) Totals

+ –

Expose to treatment

OP 5 (a) 3 (b)8

PROM 1 (c) 11 (d)12

Totals 6 14 20

Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (1/12) =7.5

Severe adverse event ( if OR>3)

Relative odds (2)

Adverse outcome

( shoulder pain) Totals

+ –

Expose to treatment

OP 5 (a) 3 (b)8

SB 1 (c) 7 (d)8

Totals 6 10 16

Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (1/8) =5

Severe adverse event ( if OR>3)

Relative odds (3)

Adverse outcome

( shoulder pain) Totals

+ –

Expose to treatment

SB 1 (a) 7 (b)8

PROMT 1 (c) 11 (d)12

Totals 2 18 20

Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(1/8) / (1/12) =1.5

Minor adverse event

Relative odds (4)

Adverse outcome

( shoulder pain) Totals

+ –

Expose to treatment

OP 5 (a) 3 (b)8

SB+PROM 2 (c) 18 (d)20

Totals 7 21 28

Relative Risk = RR = [a/(a+b)]/[c/(c+d)] =(5/8) / (2/20) =6.25

Severe adverse event ( if OR>3)

Critical Appraisal Worksheet