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A phone-monitored upper limb home exercise program for post-stroke individuals

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By:

Armita Shadgan

This is a summary of a study conducted by doctoral student Lisa Simpson and Dr. Janice Eng. Dr. Eng’s research team, located at the GF Strong Rehabilitation Centre in Vancouver, focuses on using physical rehabilitation to improve recovery for people who have experienced spinal cord injury and stroke.

Click here to access the original article, published in Disability and Rehabilitation.


Post stroke recovery- The ideal rehabilitation program

Up to 75% of stroke survivors have upper limb impairments that make everyday tasks like grasping a cup or utensil difficult. Many of these individuals become reluctant to use their affected limb in daily activities (called “learned non-use”). This can be detrimental to their long-term health, since reduced arm use has been associated with consequences such as decreased strength and bone density.

A widely implemented program, the Graded Repetitive Arm Supplementary Program (GRASP) was effective in increasing the function and use of the affected upper limb for individuals undergoing inpatient rehabilitation. GRASP is a self-administered, task-oriented and cost effective exercise program, monitored through weekly face-to-face appointments with a therapist.

Weekly face-to-face appointments, however, are a limitation in the GRASP. As hospital stays are becoming shorter, discharged individuals living in rural areas may not have access to intensive therapies or outpatient care, making these appointments inconvenient for some individuals. As transportation concerns are one of the largest barriers to community participation for individuals after a stroke, the authors of the study proposed that the GRASP design can be adapted for use at home and monitored by phone for post-stroke members of the community. They developed a program called the Home-GRASP (H-GRASP) aimed to save time and transportation costs (thus more convenient for all individuals), using behavioral change strategies to overcome learned non-use and initiating an at home rehabilitation program, making it easier for improvements to be transferred to daily tasks. This study assessed the feasibility of the H-GRASP among post-stroke individuals living in the community.

Who Participated?

Eight participants were recruited from outpatient stroke rehabilitation programs from two hospitals. They were all 2-12 months post stroke, lived in the community, and had trouble using their affected upper limb. Participants were assessed twice initially, took part in the 8-week program, and then underwent 3 follow-up assessments.

What was the intervention?

The training program:

  • focused on exercises to improve range of motion, strength, and motor skills
  • was taught by Occupational Therapists during a single session at the local hospital
  • provided each participant with a binder containing instructions for each exercise
  • encouraged participants to make the exercises more challenging as they improved, by increasing the difficulty

After training, the participants:

  • practised the exercises for 60 min/day, 6 days/week, for 8 weeks at home
  • kept a daily log of the number of sets and repetitions of each exercise and amount of time spent completing them
  • set weekly task goals to foster motivation and a sense of accomplishment
  • were phones weekly by a therapist who monitored their progress

After the intervention was completed, a survey assessed how beneficial the participants found the program. The feasibility outcomes were then organized into four categories: process, resource, management, and scientific.

Summary of feasibility results:

Process feasibility (getting participants started, completing the program, and perceived benefit):

  • 6/8 participants completed the H-Grasp.
  • All 6 belived to have benefited and would recommend the program to others.
  • The exercise instructions were found easy to follow by the majority of participants.
Resource feasibility (Meeting exercise and weekly goal targets):

  • Among the participants who completed the H-GRASP, all but one met the exercise target of 60 min/day, 6 days/week, for 8 weeks, and all but one achieved at least one task goal each week.
Management feasibility (Monitoring and encouragement from therapists):

  • Weekly phone follow-ups took only 10-20 minutes.
  • Almost every week, participants were asked about completed task goals, encouraged to make new ones, and were also asked about how often they were using their affected upper limb.
Scientific feasibility (Safety and effectiveness):

  • 2 participants experienced pain during the program but, with the therapists’ help, made adjustments and by the end of the intervention period were able to complete the program pain-free.
  • Improvements in upper limb function, grip strength and occupational performance were observed right after completion of the intervention.
  • Improvements in upper limb function and use were maintained 6 months after completion of the intervention, and grip strength continued to improve 6 months after the intervention.

Was the H-GRASP feasible?

All of the feasibility indicators were achieved among the people who completed the H-GRASP interventions. The H-GRASP may be a feasible phone-monitored home-exercise program for individuals in the community who are less than a year post-stroke. Behavioral change strategies involving self-management techniques and the active engagement of participants is a key factor in promoting long-term health and may be effective in overcoming learned non-use. The H-GRASP incorporates such strategies to promote use of the affected upper limbs in daily activities. Furthermore, setting weekly task goals and working toward achieving them can be motivating for individuals post-stroke. There was evidence suggesting that this program may improve the function, strength, and use of the affected upper limb, allowing participants to overcome learned non-use and to continue using their rehabilitation gains to perform vital daily tasks with more ease. Future studies that incorporate a control group and objective measures of arm use are an important next step for examining the efficacy of H-GRASP.