***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Purpose Hemiplegic shoulder pain is not uncommon after stroke . Its origin is still unknown , and although many different methods of treatment are applied , none have yet been proved to be effective . We sought to study the efficacy of 3 injections of intra-articular triamcinolone acetonide on pain and arm function in stroke patients with hemiplegic shoulder pain . Methods In a multicenter , r and omized , placebo-controlled clinical trial , patients with hemiplegic shoulder pain received either 3 intra-articular injections of 40 mg triamcinolone acetonide or 1 mL physiological saline solution ( placebo ) . Primary outcomes were pain measured according to 3 visual analogue scales ( score range , 0 to 10 ) , and arm function was measured by means of the Action Research Arm test and the Fugl-Meyer assessment scale ; secondary outcomes were passive external rotation of the shoulder and general functioning measured according to Barthel Index and the Rehabilitation Activities Profile . Results In the triamcinolone group ( n=18 ) , the median decrease in pain , 3 weeks after the last injection , was 2.3 ( interquartile range , 0.3 to 4.3 ) versus 0.2 ( interquartile range , −0.5 to 2.2 ) in the placebo group . This result was not statistically significant . The change in the other outcome measures did not differ significantly between the 2 treatment groups . Twenty-five patients reported side effects . Conclusions In the 37 participants included in this study , triamcinolone injections seemed to decrease hemiplegic shoulder pain and to accelerate recovery , but this effect was not statistically significant . Therefore , on the basis of the results of this study , these injections can not be recommended for the treatment of patients with hemiplegic shoulder pain BACKGROUND AND PURPOSE Subluxation is a significant problem in poststroke hemiplegia , result ing in pain and loss of function . Current treatments are not proved and not considered effective . It has been demonstrated that cyclical electrical stimulation of the shoulder muscles can reduce existing subluxation . The purpose of this study was to determine whether electrical stimulation could prevent subluxation in both the short and long terms . METHODS A prospect i ve , r and omized controlled study was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients after cerebrovascular accidents . Forty patients were selected and r and omly assigned to a control or treatment group . They had their first assessment within 48 hours of their stroke , and those in the treatment group were immediately put on a regimen of electrical stimulation for 4 weeks . All patients were assessed at 4 weeks after stroke and then again at 12 weeks after stroke . Assessment s were made of shoulder subluxation , pain , and motor control . RESULTS The treatment group had significantly less subluxation and pain after the treatment period , but at the end of the follow-up period there were no significant differences between the 2 groups . CONCLUSIONS Electrical stimulation can prevent shoulder subluxation , but this effect was not maintained after the withdrawal of treatment BACKGROUND AND PURPOSE  Visual analogue scales ( VAS ) have been used for the subjective measurement of mood , pain , and health status after stroke . In this study we investigated how stroke-related impairments could alter the ability of subjects to answer accurately . METHODS Consent was obtained from 96 subjects with a clinical stroke ( mean age , 72.5 years ; 50 men ) and 48 control subjects without cerebrovascular disease ( mean age , 71.5 years ; 29 men ) . Patients with reduced conscious level or severe dysphasia were excluded . Subjects were asked to rate  the tightness that they could feel on the ( unaffected ) upper arm after 3 low-pressure inflations with a st and ard sphygmomanometer cuff , which followed a predetermined sequence ( 20 mm Hg , 40 mm Hg , 0 mm Hg ) . Immediately after each change , they rated the perceived tightness on 5 scales presented in a r and om order : 4-point rating scale ( none , mild , moderate , severe ) , 0 to 10 numerical rating scale , mechanical VAS , horizontal VAS , and vertical VAS . St and ard tests recorded deficits in language , cognition , and visuospatial awareness . RESULTS Inability to complete scales with the correct pattern was associated with any stroke ( P<0.001 ) . There was a significant association between success using scales and milder clinical stroke subtype ( P<0.01 ) . Within the stroke group , logistic regression analysis identified significant associations ( P<0.05 ) between impairments ( cognitive and visuospatial ) and inability to complete individual scales correctly . CONCLUSIONS Many patients after a stroke are unable to successfully complete self-report measurement scales , including VAS The purpose of this study was to evaluate the effectiveness of a functional electrical stimulation ( FES ) treatment program design ed to prevent glenohumeral joint stretching and subsequent subluxation and shoulder pain in stroke patients . Twenty-six recent hemiplegic stroke patients with shoulder muscle flaccidity were r and omly assigned to either a control group ( n = 13 ; 5 female , and 8 male ) or experimental group ( n = 13 ; 6 female , and 7 male ) . Both groups received conventional physical therapy . The experimental group received additional FES therapy where two flaccid/paralyzed shoulder muscles ( supraspinatus and posterior deltoid ) were induced to contract repetitively up to 6 hours a day for 6 weeks . Duration of both the FES session and muscle contraction/relaxation ratio were progressively increased as performance improved . The experimental group showed significant improvements in arm function , electromyographic activity of the posterior deltoid , range of motion , and reduction in subluxation ( as indicated by x-ray ) compared with the control group . We concluded that the FES program was effective in reducing the severity of shoulder subluxation and pain , and possibly facilitating recovery of arm function Ninety seven patients with stroke who had participated in a r and omised trial of conventional physical therapy nu an enhanced therapy for arm function were followed up at one year . Despite the emphasis of the enhanced therapy approach on continued use of the arm in everyday life , the advantage seen for some patients with enhanced therapy at six months after stroke had diminished to a non-significant trend by one year . This was due to some late improvement in the conventional therapy group whereas the enhanced therapy group remained static or fell back slightly . It is recommended that trials should be conducted comparing very intensive therapy for the arm with controls without treatment . This would provide a model of the effects of therapy on intrinsic neural recovery that would be relevant to all areas of neurological rehabilitation Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia . A detailed study was carried out of recovery of arm function after acute stroke , and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning . In a single-blind r and omised trial , 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups . At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength , range and speed of movement . This effect seemed concentrated amongst those who had a milder initial impairment . More work is needed to discover the reasons for this improved recovery , and whether further development of this therapeutic approach might offer clinical ly significant gains for some patients Effects of intra-articular triamcinolone acetonide on pain and passive range of motion ( ROM ) in the painful hemiplegic shoulder were studied . A Multiple baseline ( or AB ) design across seven subjects was used . The length of the baseline condition ( or A phase ) was either 2 or 3 wk , and r and omized across subjects . Subsequently , a treatment condition ( or B phase ) of 4 wk was applied during which three intra-articular injections of triamcinolone acetonide were administered at day 1 , 8 , and 22 . Pain and ROM were the primary outcome parameters and were measured three times each week by means of a visual analogue scale ( VAS ) and a fluid-filled goniometer , respectively . In addition , a number of secondary outcome parameters were assessed , i.e. , spastic muscle activity ( Ashworth scale ) , motor function ( Fugl-Meyer index ) , upper limb function ( action research arm test ) and signs and symptoms of a shoulder h and syndrome ( clinical scoring list ) . Statistical analysis of the combined time series showed significant effects on pain ( P = 0.025 ) . Analysis of the individual time series revealed that five out of seven patients had significant reduction of pain . ROM improved significantly in four out of seven patients . However , improvement of ROM did not reach significance at the group level ( P = 0.13 ) . None of the secondary parameters showed significant changes . The correlation coefficient between upper limb function ( ARA ) at intake and size of treatment effect approached a level of significance ( P = 0.09 ) . The results indicate that intra-articular triamcinolone may be of benefit in reducing hemiplegic shoulder pain Shoulder pain and stiffness is a serious problem in patients following stroke . The purpose of this study was to investigate the effect of a shoulder positioning protocol on shoulder joint pain and range in the affected upper limb . Twenty-eight subjects were r and omly assigned to the experimental or control groups and participated in a multidisciplinary rehabilitation program . In addition , the experimental group received prolonged positioning of the shoulder daily for six weeks .  Resting pain , pain on dressing , pain-free active abduction and passive external rotation range were measured on entry to the study and after six weeks . Twenty-three subjects completed the study . The differences between the groups were not statistically significant ( p < 0.05 ) , however , because of low statistical power the results are inconclusive The aim of this paper is to evaluate the effectiveness of high-intensity versus low-intensity transcutaneous electrical nerve stimulation ( TENS ) and versus placebo for treatment of hemiplegic shoulder pain . Three groups of 20 patients each ( A , B , C ) were studied . In group A high-intensity TENS was delivered at 3 times the sensory threshold with frequency of 100 Hz ; in group B low-intensity TENS was delivered at the sensory threshold with frequency of 100 Hz . Group C received placebo stimulation . The treatment protocol consisted of 12 sessions ( 4 weeks ) . Before treatment , at the end of it and one month after , passive range of motion ( PROM ) for flexion , extension , abduction and external rotation were evaluated . Statistically significant improvements of PROMs were recorded for group A , but not for groups B or The object of this study is to determine if the functional motor capacity of the paretic extremity can be improved by stimulation with low intensity low frequency ( 1.7 Hz ) transcutaneous electric nerve stimulation ( Low-TENS ) , started 6 - 12 months after a stroke . Forty-four patients who had a paretic arm as a consequence of their first stroke were included and r and omly assigned to either a treatment group ( n = 26 ) or a control group ( n = 18 ) . Patients in both groups received physiotherapy at a day-care center , usually twice a week . The treatment group received , in addition , Low-TENS for 60 min , five days a week for three months . Results showed that motor function increased significantly in the treatment group , compared to controls . The Low-TENS did not decrease either pain or spasticity . It is concluded that stimulation by means of Low-TENS could be a valuable complement to the usual training of arm and h and function in the rehabilitation of stroke patients One of the causes for shoulder pain associated with hemiplegia is thought to be vigorous range of motion to the involved upper extremity . The objective of this study was to analyze the occurrence of pain in patients treated with one of the three exercise programs commonly used in the rehabilitation of hemiplegia : 1 ) range of motion by the therapist , 2 ) skate board and 3 ) overhead pulley . Of the 48 hemiplegic patients evaluated , 28 were assigned to one of the three exercise groups . Comparing the number of patients who developed pain in each group , there was a significant difference , with 8 % of the patients in the range of motion by the therapist group , 12 % of the patients in the skate board group and 62 % of the patients in the overhead pulley group developing pain ( x2=8.44 ) ( P=0.014 ) . The three groups did not differ in the side of involvement ( P=0.57 ) , extent of hemiplegia ( P=0.25 ) or presence of subluxation ( P=0.84 ) . Use of overhead pulley has the highest risk of developing shoulder pain and should be avoided during rehabilitation of stroke patients Objective : To determine whether strapping the shoulder in hemiplegic stroke patients : ( 1 ) prevents the development , or reduces the severity , of shoulder pain , ( 2 ) preserves range of movement in the shoulder , and ( 3 ) improves the functional outcomes for the arm and patient overall . Design : A prospect i ve , r and omized , single-blind controlled trial of shoulder strapping versus no strapping . Setting : Care of the elderly wards in a teaching hospital , Christchurch , New Zeal and . Subjects : All patients admitted with an acute hemiplegic stroke , who had persisting weakness of shoulder abduction . Intervention : The treatment group had their affected shoulder strapped for six weeks from r and omization in addition to st and ard physiotherapy . Main outcome measures : All subjects were assessed at entry ( week 0 ) , at end of the treatment phase ( week 6 ) and two months later ( week 14 ) . A visual analogue scale ( VAS ) was used to assess shoulder pain severity whereas shoulder range of movement to the point of pain ( SROMP ) assessed passive range of movement and pain . Functional Independence Measure ( FIM ) , Motor Assessment Scale ( MAS ) and Rankin Disability Index measured functional outcomes . Results : Ninety-eight subjects participated ( 49 strapped , 49 controls ) . Intention to treat analysis showed no significant difference in pain , range of movement or functional outcomes after the intervention phase or at the final assessment . However there were trends for less pain at six weeks ( VAS , p = 0.11 ) and better final upper 
    Output:
    
With this limited evidence , no single intervention has been identified that offers a dramatic effect in terms of treating pain in the hemiplegic shoulder .
There is potential for some benefits for the patient 's functional and comfort status , thereby improving their quality of life and maximising their social participation .
Preventive interventions demonstrated that a shoulder positioning policy had no statistically significant effect on pain .
Some studies did suggest evidence of improvement , albeit limited .
However , some of the exercise techniques aggravated  shoulder pain .
Treatment interventions demonstrated that electromyogram biofeedback can not be evaluated as a st and -alone therapy as it is used in conjunction with relaxation therapy .
Intra-articular Triamcinolone Acetonide injections in a small RCT have not been proven to be beneficial , and are associated with a high incidence of side-effects .
Different exercise techniques may aggravate  shoulder pain  more than others ( e.g. Bobath technique compared to cryotherapy ) .
The systematic review on the effectiveness of functional electrical stimulation was used for prevention and treatment and concluded that there is currently no evidence for effect