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Table 2 Therapists’ use of GRASP in clinical practice

From: A formative evaluation of the implementation of an upper limb stroke rehabilitation intervention in clinical practice: a qualitative interview study

Coverage (who should receive the intervention)
  Intervention component from GRASP Guideline Manual Therapists use
1 Provide GRASP to stroke survivors in rehabilitation who can actively elevate their scapula against gravity and have palpatable wrist extension (grade 1); are aware of their safe bounds of ability; have sufficient cognition to be able to follow the programme; are able to report pain or fatigue GRASP was reported to be used not only in stroke rehabilitation units but it is also used in acute care (n = 2), outpatient (n = 2), and community settings (n = 2); and with other population groups with neurological conditions.
One therapist reported using the Fugl-Myer to select the appropriate GRASP level for each patient; the remainder selected the appropriate level based on observation of active movement and tone.
Content (the content of the intervention)
  Intervention component from GRASP Guideline Manual Therapists use
2 Provide a GRASP manual which includes unilateral and bilateral strengthening, range of motion, weight-bearing, and trunk control exercises along with gross and fine motor exercises One therapist reported always providing the full GRASP manual to patients. The majority of therapists selected the most appropriate exercises from the manuals and printed them off individually.
3 Provide a variety of GRASP equipment which can be substituted Two sites provide full kits of equipment, one site provides half sets of equipment which are the more difficult pieces to source (e.g., donut weight for hand), one provides equipment piece by piece as needed, two use gym equipment that is cleaned and reused and two sell pieces of equipment to patients (e.g., theraputty).
4 Provide a log sheet to monitor time spent completing exercises Six therapists mentioned using/trying to use a written checklist or log sheet to monitor exercise completed. The remainder used verbal feedback from the stroke survivor and the clinical team to monitor whether or not exercises were being completed.
5 Progress to next GRASP level when the patient can complete over 50% of the exercises in the current level As therapists do not always use the full GRASP manual, progression was discussed in terms of adding in new sheets of exercises or increasing repetitions as opposed to more structured progression through the levels of manuals.
6 Advise to complete the GRASP exercises outside of therapy time Nine therapists reported that stroke survivors, where able, would be advised to complete exercises outside of therapy time. Barriers to prescribing exercises to be completed outside of therapy time included therapists’ beliefs about patients’ ability to correctly complete exercises, patient safety awareness, cognitive impairment and lack of family support for self-directed exercise. As a result GRASP exercises were most often completed with the supervision/assistance of a rehabilitation assistant.
7 Encourage to keep moving their paretic arm as best they can, improper movement should not be the cause of omitting an exercise All therapists made references to concerns they had about the quality of the exercises that stroke survivors would do and the amount of compensation. Exercises are regularly modified or omitted if it was felt that they were not being done correctly—particularly exercises resulting in shoulder hiking.
8 Teach GRASP exercises to family/carers were possible All therapists reported that family played an important role in GRASP. The readiness and willingness of family members, as determined by the therapists, would influence the extent to which they would be involved. A systematic approach to involving family members or carers in rehabilitation was not reported.
Dose (frequency and duration)
  Intervention component from GRASP Guideline Manual Therapists use
9 Advise to do the GRASP exercises for 60 minutes five times per week Patients were advised by therapists to carry out the exercises as much as they could tolerate on a daily basis, rather than specifying 60 minutes daily. Therapists discussed different approaches to getting patients to complete the desired amount of practice, such as splitting GRASP up throughout the day and providing extra sessions with the rehabilitation assistant.