H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for individuals post stroke

Figures & data

Figure 1. Study design.

Table 1. H-GRASP behavioural-change techniques.

Protocol Features	Explanation	Behavioural Change Technique
Weekly monitoring	Therapists made weekly phone calls to participants to inquire about adherence to program, ascertain level of challenge and progress the program as needed	Prompt self-monitoring; prompt feedback on performance
Identify weekly task goals	Therapists and participants worked collaboratively to identify weekly task goals for increasing upper limb use during daily activities	Prompt goal setting
Monitoring completion of task goals	Therapists reviewed participants' experiences in completing weekly task goals	Prompt review of behavioural goals
Prompting % arm use each week	Therapists prompted participants to report the percent of time they were using their affected upper limb during daily activities	Prompt feedback on performance
Identify barriers and assist with  problem solving	Therapists prompted participants to identify barriers to completing exercise targets and task goals. Assisted participants to problem solve solutions for overcoming barriers (ie. split sessions up into manageable time blocks, ensure a mix of challenging and less challenging task goals)	Prompt barrier identification
Encourage family/caregiver involvement	Participants were encouraged to invite caregivers to training session and be involved with exercise program and upper limb task goals	Prompt social support
Behavioural contract	At H-GRASP training session, participants were asked to sign a behavioural contract in which they agreed to adhere to exercise targets and attempt performance of task goals	Behavioural contract
Identify level of confidence	Participants were asked to identify their level of confidence to adhere to exercise targets. If confidence <8/10, therapist and participant discussed facilitators and barriers to adherence and problem solved strategies for overcoming barriers.	Prompt intention formation

Behavioural change techniques were identified and attached to each protocol feature using behavioural technique codes and definitions from Michie et al.[14,39]

Table 2. Feasibility outcomes.

Feasibility indicator	Outcome	Criteria for success	Result	Success (Y/N)
Process
Recruitment Rate	% of individuals approached who were eligible and agreed to participate	20%	8/30 (26%)	Y
Retention Rate	% participants who completed 8 week H-GRASP intervention	>80% participants complete program	6/8 (75%)	N
Perceived benefit	Exit questionnaire from participants who completed the program	>80% responses at least “4/5”	6/6 (100%)	Y
Resources
Exercise Adherence Rates	% participants who achieved 360 minutes of average weekly exercise	>80% participants	6/8 (75%)	N
Weekly Task Goal Adherence Rates	% participants who attempted ≥ 1 task goal each week	>80% participants	6/8 (75%)	N
Management
Therapist monitoring of participant goal tasks	Prompt participant to report status of task goals (i.e. attempted or not);	80% of sessions	49/52 (94%)	Y
	Prompt participant to generate new task goals	80% of sessions	49/52 (94%)	Y
Promoted feedback on performance	Prompted for weekly % use value	80% of sessions	48/52 (92%)	Y
Scientific
Safety	# of participants with increased pain while performing exercises (as measured by visual analogue scale)	No participants with increased pain while performing exercises at week 8	0/6	Y
Treatment Efficacy	Effect size of the primary and secondary outcomes	n/a		n/a
	CAHAI	n/a	0.944	n/a
	MAL	n/a	0.789	n/a
	Grip strength	n/a	0.947	n/a
	COPM	n/a	0.789	n/a
	% who get over the MCID	n/a		n/a
	CAHAI	n/a	33%	n/a
	MAL	n/a	50%	n/a
	Grip strength	n/a	33%	n/a
	COPM	n/a	50%	n/a

CAHAI: Chedoke Arm and Hand Inventory; MAL: Motor Activity Log; COPM: Canadian Occupational Performance Measure; MCID: Minimally Clinical Important Difference. Note: the MCID values are: 7.1 points for CAHAI;[18] 1.0 point for MAL;[26] 5.0 kilos for grip strength [26] and 1.7 points for COPM.[27]

Figure 2: Participant flow diagram.

Table 3. Participant characteristics.

Characteristic N = 8
Age, mean (SD; range)	66.4 (7.8; 53–76)
Females, N (%)	4 (50%)
Days Post Stroke, mean (SD; range)	273.0 (64.2; 168–347)
Right Side Affected, N (%)	7 (87.5%)
Dominant Side Affected, N (%)	7 (87.5%)
Caregiver assistance with H-GRASP, N (%)	2 (25%)
Grip Strength, N (SD; range)	10.5 (6.9; 3.8–24.3)
CAHAI, N (SD; range)	33.8 (12.8; 17–55)
MALQ, N (SD; range)	1.6 (0.7; 0.4–2.6)

CAHAI: Chedoke Arm and Hand Activity Inventory (0–63); MALQ: Motor Activity Log Quality of Movement Scale (0–5).

Table 4: Clinical outcomes and exercise minutes.

	Clinical Measures (N = 6)*
Average weekly minutes (N = 8)	Mean (SD; range)	Initial	Baseline	Post H-GRASP	3M Follow up	6M Follow up
472.2 (107.1; 295–592)	Grip Strength†‡ (kg)	7.3 (2.9; 3.8–11.1)	8.0 (2.8; 5.2–11.6)	10.6 (3.6; 5.0–14.0)	12.0 (3.8; 6.2–16.7)	13.4 (3.7; 7.7–17.3)
	CAHAI†	28.8 (9.8; 17–42)	33.5 (13.7; 18–49)	41.3 (18.4; 17–60)	42.7 (18.1; 16–62)	44.9 (18.3; 19–63)
	MALQ†	1.4 (0.6; 0.4–2.2)	1.8 (0.7; 1.0–2.8)	2.7 (1.1; 1.1–4.2)	2.6 (0.9; 1.0–3.8)	2.5 (1.0; 0.7–3.5)
	COPM§	NA	3.2 (1.8; 1.8–6.5)	5.1 (2.2; 2.4–8.2)	NA	NA

CAHAI: Chedoke Arm and Hand Inventory (0–63); MALQ: Motor Activity Log, Quality of Movement Scale (0–5); COPM: Canadian Occupational Performance Measure (1–10).

*Values are shown for individuals who completed the 8 week H-GRASP. One individual was excluded from the three month and six month assessments as he broke his wrist prior to the three month assessment date.

†Post-hoc Wilcoxon Signed Rank test revealed significant difference between baseline and Post H-GRASP scores (Grip Strength, p = 0.046; CAHAI, p = 0.046; MALQ, p = 0.03).

‡Post-hoc Wilcoxon Signed Rank test revealed significant difference between Post H-GRASP and 6M Follow up scores, p = 0.043.

§Wilcoxon Signed Rank test revealed significant difference between baseline and Post H-GRASP scores, p = 0.03.

Figure 3: Participant outcome measure profiles. This graph displays clinical measure scores across the study period by participant. CAHAI: Chedoke Arm and Hand Inventory (0–63); MALQ: Motor Activity Log Quality of Movement Scale (0–5); Grip: Grip Strength; COPM: Canadian Occupational Performance Measure (1–10)

Table 5. COPM activities and scores by participant.

Participant	Activities deemed important	Baseline COPM score	Post H-GRASP COPM score
1	Crocheting	3.4	5.4
	Knitting
	Using dustpan
	Cutting food
	Driving
2	Baking	6.5	8.3
	Cutting meat
	Slicing food
	Playing cards/scrabble
3	Painting	2.2	2.4
	Dressing
	Weeding
	Household tasks
	Using computer
4	Feeding	3.2	3.6
	Dressing
	Using tools
	Writing
	Driving lawnmower
5	Using fork	1.9	7.0
	Using fishing rod
	Buttoning
	Picking up grandchild
6	Styling hair	1.8	3.7
	Cooking
	Volunteering
	Returning to work
	Writing

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