J. Phys. Ther. Sci.

28: 2232–2237, 2016

The Journal of Physical Therapy Science

Original Article
The effect of Monkey Chair and Band exercise
system on shoulder range of motion and pain in
post-stroke patients with hemiplegia

Hyun-Ju Jeon, PhD1), Sangjoon An, PhD2), Jinwoo Yoo3), No-Hyun Park, PhD4),
Kyu Hoon Lee, PhD5)*
1) Department of Dance, Hanyang University, Republic of Korea
2) Korea Institute of Industrial Technology, Republic of Korea
3) Department of Mechanical and Aerospace Engineering, Seoul National University,

Republic of Korea
4) The Graduate School of Industry, Sejong University, Republic of Korea
5) Department of Physical Medicine and Rehabilitation, College of Medical School, Hanyang

University: 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Republic of Korea

Abstract. [Purpose] A simple rehabilitation device system for strengthening upper limb muscles in hemiplegic
patients was developed. This system, which stimulates active exercise while accounting for intensity, time, and
frequency, was examined in the present pilot study. [Subjects and Methods] Patients had shoulder pain and limited
shoulder movement. Changes in range of motion (ROM) and scores of a visual analog scale (VAS) for pain were
evaluated in the experimental and control groups every four weeks for twelve weeks. The modified motor assess-
ment scale (MMAS) was used before and after experiments. [Results] Significant differences between experimental
times in ROM for shoulder flexion, abduction, and adduction on the paralyzed side were observed in the experimen-
tal group at every time point. Pain VAS scores in the experimental group improved progressively and significantly
with time, indicating a consistently increasing effect of exercise. There were significant differences between the
MMAS scores before and after completion of the program in the experimental group. [Conclusion] Muscle strength-
ening is important in hemiplegic patients, and active exercise was more efficient than passive exercise in this regard.
Rehabilitation with the Monkey Chair and Band system may represent an efficient and important tool in upper limb
training and comprehensive modern rehabilitation therapy.
Key words: Monkey Chair and Band system, Upper extremity, Stroke
(This article was submitted Feb. 16, 2016, and was accepted May 7, 2016)

INTRODUCTION
Shoulder pain, which is experienced by 70–84% of patients with hemiplegic stroke, has become a dominant factor in
delaying participation in a rehabilitation program1, 2). The pain and limited range of motion (ROM) make ambulation more
difficult. In addition to affecting physical activities owing to the compromised ability to maintain balance and restricting
activities of daily living (ADL), this negatively impacts the desire and ability to engage in social activities because of feel-
ings such as fear, frustration, and disappointment3, 4). If the pain is not treated, it also causes edema, joint instability, joint
contracture, and bone and soft tissue atrophy, as well as limits the ability to move the upper limbs5). The goal of rehabilitation
therapy for hemiplegic patients is to allow them to regain independence in activities and make it easier to perform such
activities by improving the movement on the paralyzed side6). Therefore, muscle strengthening is recommended to improve

*Corresponding author. Kyu Hoon Lee (E-mail: dumitru1@hanyang.ac.kr)

©2016 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd)
License <http://creativecommons.org/licenses/by-nc-nd/4.0/>.
the ability to perform exercise7, 8).
Kinesitherapy is essential for preventing muscle tonicity and atrophy in hemiplegic patients. With continuous exercise, it
improves muscular strength and joint flexibility, which allows performing more physical activities. Most studies on exercise
effects show that exercise contributes to the recovery of physical function. Duncan et al. reported that balancing ability was
increased after twelve weeks of complex exercise including bicycling9). According to Smith et al., there was a significant
improvement in the strength of the hamstrings and spastic reflexes in patients who received treadmill exercise in the form
of a low-intensity cardiac rehabilitation program administered three times a week for twelve weeks10). Moreover, Rimmer
et al. reported that patients who had performed one-hour exercise programs three times a week for three months showed
meaningful differences in oxygen uptake, muscle, hamstrings, and spine flexion, and body composition (weight, body mass
index [BMI], thickness of subcutaneous fat)11). The fact that the upper limb motor ability defines the ability to perform ADL
emphasizes the importance of its rehabilitation12). For hemiplegic stroke patients, passive or active exercises using machines
and apparatuses are recommended to increase the ROM of the shoulder joint while simultaneously reducing shoulder pain13).
Generally, physical therapy is combined with apparatus and robotic therapy in rehabilitation of upper limb motor abil-
ity14–16). However, studies on the effectiveness of rehabilitation robotic systems that assist hemiplegic patients in performing
exercises have been lacking. Furthermore, few comparative studies have been conducted. Finally, despite their importance,
there is a deficit of studies on the impact of rehabilitation systems on the effect of exercise programs.
In this study, a simple rehabilitation device system (Monkey Chair and Band System) was developed for strengthening of
upper limb muscles of hemiplegic patients. Unlike the modern complex robotic systems, which utilize only passive exercise,
this system employs active exercise and accounts for factors such as exercise intensity, time, and frequency. The present pilot
study comprehensively investigates the effects of this new system, focusing on the improvement of upper limbs motor ability
by strengthening muscles in hemiplegic patients.

SUBJECTS AND METHODS

Patients with post-stroke hemiparesis were treated at the Rehabilitation Medical Center in Yongin, Korea. They were
enrolled in this study after they understood its purpose. Written informed consent was obtained before enrollment, and the
study was approved by the Institutional Review Board (IRB) (HYI-13-046-1). The inclusion criteria were as follows: 1)
presence of post-stroke hemiparesis for at least 6 months as diagnosed by a medical doctor; 2) stable vital signs (heart rate
under 100/min, blood pressure under 150/80 mmHg) and ability to understand the meaning of this study; 3) ability to acquire
more than twenty-five points in the Korean Mini Mental Status Examination (MMSE-K); 4) presence of shoulder pain; and
5) ability to flex and abduct the shoulder actively over 90° with limitation of shoulder ROM and ability to extend and adduct
the shoulder over 20°. Twelve patients who satisfied the above criteria were assigned randomly to the experimental or control
group such that selection bias in gender, age, and period was eliminated (Table 1).
First, the general characteristics and subjective symptoms of the participants were determined via a pre-test examination,
and an additional physical examination was performed for patients who reported pain. Changes in ROM and scores of the
visual analog scale (VAS) for pain were then measured in the experimental and control groups of the Monkey Chair and Band
program at weeks 0 (pre-test), 4 (first test), 8 (second test), and 12 (third test). Modified motor assessment scale (MMAS)
scores were also evaluated before the experiment and after twelve weeks.
The Monkey Chair was developed to help hemiplegic patients exercise actively during upper limb rehabilitation by improv-
ing stability, accuracy, and coordination between the normal and paralyzed sides. Exercises supported by the device include
flexion & extension, adduction & abduction, and internal rotation & external rotation of the shoulder, flexion & extension of
the elbow, and pressing & unfolding of the palm. The device can provide all the elements of precise, active, repetitive, and
goal-directed exercise for brain plasticity improvement. The height, length, and width of the arms of the Monkey Chair were
adjusted based on the physical condition of the patients such that they were able to hold the spindle comfortably. The intensity
of the rotation of the spindle was increased during the test in 4 steps (1.02 kgf, 2.75 kgf, 4.59 kgf, and 6.12 kgf). The speed
and power of the spindle could be controlled. The Monkey Chair and Band system was designed to strengthen the patients’
shoulder and elbow muscles by facilitating active movements. Before starting exercise, the ability to extend a resistive band
(Thera-Band, Hygenic Corporation, USA) was assessed using the formula ([extension length −stable length]/stable length)

Table 1. The general characteristics of participants

Gender Age Period Hemiparetic Height Weight BMI

Stroke type (n)
Characteristics (n) (years) (months) side (n) (cm) (kg) (kg/m 2)
Group cerebral ischemic
M F M ± SD M ± SD right left M ± SD M ± SD M ± SD
hemorrhage stroke
Experimental 3 3 58.0 ± 13.6 15.8 ± 8.9 5 1 2 4 162.7 ± 12.5 56.5 ± 15.8 21.1 ± 3.7
Control 4 2 50.5 ± 8.9 14.9 ± 7.6 4 2 3 3 165.0 ± 10.5 63.4 ± 10.2 23.6 ± 1.6
M: male; F: female; M: mean; SD: standard deviation; BMI: body mass index

2233
×100. Depending on the degree of personal adaptation, the exercise intensity was adjusted every fourth week. Maximum
resistance standards were determined based on the ability to pull the band ten times with the same performance. Depending
on the results, the patients then performed exercise using suitable color-coded bands (yellow: 0.7–1.0 kgf, red: 0.9–1.6 kgf,
green: 1.1–1.9 kgf, or blue: 1.4–2.8 kgf). For better consistency of results, shoulder flexion, extension, abduction, and adduc-
tion on the paralyzed side were measured for ROM determination using the same joint protractor (Sammons Preston®, 2003)
by the same researcher. During measurements of the passive maximum angle after the active initial motion, the participants
lay straight on their back while being fixed at each axis. The values at which the patients started to feel constant pain and
the range of joint flexibility were measured. A VAS was used to measure shoulder pain. The MMAS, a tool with verified
reliability and validity in evaluating exercise ability of hemiplegic patients, was used to assess the upper limbs and ability to
walk. The MMAS includes nine elements, with eight of them designed to evaluate exercise ability and one to assess muscle
tension. In this study, upper arm function, hand movement, and walking ability were measured before and after the tests. The
scale consisted of seven points, from 0 to 6, with higher values indicating higher ability. The two groups also received the
general physical therapy for stroke patients at the hospital. The program for the experimental group comprised joint motion
(stretching gymnastics), main training, and relaxation using the Monkey Chair and Band, which were performed three times
a week for 30 minutes each, for a total of thirty-six times in twelve weeks. The exercises were performed at an intensity cor-
responding to a Rating Perceived Exertion (RPE) scale score of 13 points (70% effort) out of 15 points (6–20). If changing the
exercise level induced fatigue as determined based on the RPE score and degree of pain, the exercise was stopped (Table 2).
All analyses were conducted with SPSS (Version 18.0; SPSS, Inc., Chicago, IL, USA), and means and standard devia-
tions were calculated for all data. Repeated measures analysis of variance (RMANOVA) was used to evaluate changes in

Table 2. The Monkey Chair and Band program

Intensity Frequency
Program Method
(RPE) (n/week)
Joint motion Breath, chin to chest, ear to shoulder, face to right & left,
5 min mad & mellow cat, chest circle, twist, shoulder shrugs & rotation, 11 3
(3–5 repetitions) wrist flexion & extension, hands open & closed, piano playing.
(1) Repeated bilateral and unilateral movements according to height of patient,
disk side rotation, length of arm, and shoulder width after setting on the
Monkey Chair. Ten to 15 rotations per motion (shoulder, elbow, and hand).

Main training
13 3
20 min
(2) Repeated resistance exercises with band for strengthening shoulder and arm
muscles in a seating position (shoulder flexing, extension, abduction,
adduction, internal rotation, external rotation; wrist flexion, extension, circular
movement, supination & pronation).

Relaxation
Breath, hold hug, side bend, trunk roll down, spinal twist,
5 min 11 3
wrist circle, arm shake, relax.
(2–3 slow repetitions)
RPE: rating of perceived exertion

2234 J. Phys. Ther. Sci. Vol. 28, No. 8, 2016

ROM of the shoulder and VAS scores for every time point and each group during the twelve weeks of exercise. The level of
significance was set at p<0.05 for all differences, and the degree of freedom was 5.

RESULTS
The differences in ROM of the shoulder on the paralyzed side between the experimental and control groups and the
changes at baseline and weeks 4, 8, and 12 are shown in Table 3. Significant differences were found in shoulder flexion at
baseline and weeks 4, 8, and 12. Different trends of changes in flexion were revealed in the experimental and control groups
(p<0.05). The experimental group showed an especially remarkable increase in ROM with time (p<0.01). The changes in
shoulder abduction at baseline and weeks 4, 8, and 12 were statistically significant (p<0.001). There were also significant
changes in abduction ROM between the experimental and control groups (p<0.05). The two groups differed in terms of
trends of changes in abduction ROM, with a significant increase observed in the experimental group (p<0.001). Significant
differences were also found in shoulder adduction at baseline and weeks 4, 8, and 12 (p<0.05). Differences in the trends of
changes of adduction ROM between the two groups were observed at each time point, with the experimental group showing
a noticeable increase (p<0.05). No improvements were detected in ROM for flexion, extension, abduction, and adduction in
the control group during the twelve weeks. The experimental and control groups showed almost identical ROMs for flexion,
abduction, and adduction at baseline (week 0, pre-test).
The changes and differences in the scores of the pain VAS during the twelve weeks of the program are shown in Table 4.
Significant differences between the experimental group and the control group were detected at each time point. The experi-
mental group showed a remarkable positive change at a 1% significance level and demonstrated a significant difference after
each four-week period (p<0.001). Based on these results, the program was considered efficient in reducing pain. Moreover,
the change in VAS scores in the experimental group was rapid, with remarkable improvements present already at week 4.
The changes and differences in MMAS scores during the twelve weeks of the program are shown in Table 5. The addition
of the twelve-week Monkey Chair and Band program to the traditional physical therapy resulted in a statistically significant
difference between the scores before and after the program in the experimental group (p<0.05), while the control group did
not show a significant difference.

Table 3. The statistical comparison of shoulder ROM on the Table 4. The statistical comparison of pain VAS scores between
paralyzed side between the experimental and control the experimental and control groups at different time
groups at different time points points

Variable Experimental Control group Variable Experimental Control group

group (n=6) (n=6) group (n=6) (n=6)
M ± SD M ± SD M ± SD M ± SD
Shoulder baseline 48.3 ± 24.0 45.0 ± 10.5
baseline 130.0 ± 29.5 127.8 ± 4.0 VAS week 4 40.0 ± 27.6 43.3 ± 8.2
ROM for week 4 150.0 ± 27.8 127.0 ± 4.0 score week 8 33.3 ± 26.6 35.0 ± 10.5
flexion week 8 159.2 ± 20.4 126.2 ± 3.8 week 12 10.0 ± 11.0 * 35.0 ± 12.2
week 12 165.0 ± 19.5 * 126.2 ± 3.8 M: mean; SD: standard deviation; VAS: visual analogue scale;
baseline 25.8 ± 10.7 36.3 ± 13.2 *p<0.05 significant difference at this time point in the group
ROM for week 4 36.7 ± 16.6 36.3 ± 13.2
extension week 8 40.0 ± 20.0 36.5 ± 13.2
Table 5. The statistical comparison of MMAS scores between
week 12 41.7 ± 20.9 36.5 ± 13.2
the experimental and control groups
baseline 123.3 ± 33.7 117.8 ± 18.3
ROM for week 4 143.3 ± 32.0 118.7 ± 18.3 Variable Experimental Control group
abduction week 8 160.0 ± 22.8 118.7 ± 18.3 group (n=6) (n=6)
M ± SD M ± SD
week 12 166.7 ± 21.6 * 118.7 ± 18.3
Before 2.7 ± 1.9 2.7 ± 2.3
baseline 21.7 ± 7.5 20.0 ± 4.9 5
After 4.3 ± 1.5 ** 3.5 ± 2.0
ROM for week 4 27.5 ± 4.2 20.3 ± 5.2
MMAS Before 2.0 ± 2.4 2.0 ± 2.3
adduction week 8 30.0 ± 6.3 20.8 ± 4.9 6
score After 3.2 ± 2.3 ** 2.2 ± 2.4
week 12 30.8 ± 5.9 * 20.8 ± 4.9
Before 4.0 ± 1.1 3.5 ± 1.4
M: mean; SD: standard deviation; ROM: range of motion; 8
*p<0.05 significant difference at this time point in the group After 5.3 ± 0.5 * 3.7 ± 1.2
M: mean; SD: standard deviation; MMAS: modified motor as-
sessment scale; 5: upper arm function; 6: hand movement; 8:
walking; *p<0.05, **p<0.01 between scores before and after
program

2235
 DISCUSSION
The shoulder joint is one of the most flexible joints of the body, with the greatest ROM. Hemiplegic stroke patients
experience limitation in shoulder ROM and shoulder pain. This results in a vicious circle of constantly restricted activities.
The Monkey Chair and Band system described in this study seems to maintain muscle balance by continuously stimulating
the flexor and extensor muscles, and it reduces muscle tone while increasing joint flexibility. In the control group, however,
there were no remarkable improvements in ROM. In some cases, reduction in ROM is caused by unstable position, inactivity,
and decreased muscle and joint flexibility of the affected side. Therefore, the new system should be efficient in stroke patients
who feel frustrated by the long-term rehabilitation, resulting in insufficient engagement in the rehabilitation program. Similar
to the studies of Bertiti as well as Brouwer et al., a positive effect of resistance exercise on ROM in hemiplegic stroke patients
was detected in the present work17, 18).
Exercises improving both ROM and weigh resistance are necessary for enhancing upper limbs strength. Moreover, ex-
ercises for muscular strength of the elbow and fingers are also needed, as well as training aimed at improving hand skills
and functional work ability19). According to Wolf et al., constraint-induced movement therapy led to recovery of functional
exercise ability of the arms in patients three to nine months after a stroke20). The authors suggested that the improvement in
motor ability was due to changes in the central nervous system. This observation further supports the results of the present
study.
A previous study of the effects of reaching exercise in hemiplegic patients did not detect significant differences in MMAS
scores for upper limb motor skills21). In contrast, according to the present results, the exercise program aimed at stabilization
and strength training of the shoulder using the Monkey Chair and Band system improved the MMAS scores.
Patients in the experimental group, who had suffered from pain, experienced pain relief and increase in ROM after the
completion of the Monkey Chair and Band program. No significant differences in pain intensity were observed in the control
group, whereas muscular strength and movement control declined. The differences in shoulder extension ROM were less
significant than the differences in ROM for other shoulder movements. This could be caused by differences in the state of
patients in the experimental and control groups. Furthermore, body movement instead of joint movement was measured dur-
ing the extension exercise. The use of the Monkey Chair and Band system led to especially large improvements in shoulder
flexion (up to 92% compared to 72% at baseline), whereas conventional manual therapy resulted in no improvement. It can
be concluded that further improvements are needed in remedial exercise equipment, including a wider range of motion.
Furthermore, additional studies are necessary on automation of clinical exercise testing and frame motion.
This study has the following limitations. 1) Other treatments for shoulder pain (acupuncture, oral agents, electrotherapy,
and joint cavity injections) were not controlled for because of ethical issues. 2) Physical therapy and exercises within the
regular rehabilitation therapy differed for patients of the control group because each of them had an individual treatment
program. 3) The results cannot be generalized owing to the insufficient sample size and study period. 4) Patients who could
not flex and abduct the shoulder beyond 90° and extend and adduct the shoulder beyond 20° were not included in the study.
The use of the Monkey Chair and Band upper limbs strengthening program resulted in significant differences in both
ROM improvement and pain relief compared to the general therapy, as well as in improvement of muscle strength. According
to Kawahira et al., repetition of a facilitation technique promoted the functional recovery of the hemiplegic upper limb to
a greater extent than the conventional rehabilitation22). The present study demonstrated the positive effect of repetitive and
intensive training according to the Monkey Chair and Band program in hemiplegic stroke patients.
The rehabilitation system presented in this study is more efficient both in terms of time and cost than the use of complex
apparatuses without a systemic program. Moreover, the developed program is repetitive and easy to adapt to other rehabilita-
tion programs. Active resistant exercise yielded better results in terms of ROM, pain VAS scores, and MMAS scores than
passive robot-assisted exercises while being less expensive to implement. The use of the Monkey Chair and Band system
developed in this study to strengthen the upper limb muscles via simple active exercise administered according to the therapy
program led to remarkable improvements in ROM and pain VAS scores of hemiplegic upper limbs compared to passive
therapies. Muscle strengthening is clearly of high importance for patients with hemiplegia, and an active therapy produced
a greater effect than a passive therapy. Therefore, the rehabilitation program utilizing the simple Monkey Chair and Band
apparatus can be considered an important tool in efficient training of upper limbs and comprehensive modern rehabilitation
therapy.

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