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Within our GRASP: Patient-led Stroke Recovery

Aerobic exercise and strength training can restore muscle mobility and functionality

When Dr. Janice Eng first began investigating the impact of vigorous exercise on stroke recovery, she was advised to back off.

When I published one of my early papers, one of the leading experts in stroke rehabilitation said, ‘You shouldn’t be trying to get these people to exert themselves. It will exacerbate spasticity.’ The belief at the time was, ‘Don’t do this; it will make them worse.’ The thinking has changed drastically.”

The University of British Columbia’s Dr. Eng has been a leading force behind that change in thinking and the subsequent paradigm shift in stroke therapy. Over the past 10 years, she has demonstrated that aerobic and muscle-strengthening exercises not only improve stroke survivors’ mobility, they enhance cardiovascular health, strengthen bone density and enrich quality of life.

Making strong use of information technology, she has also translated her findings into clinical practice: two exercise programs she created to help stroke survivors regain strength and muscle function are now in use around the world.

With more than 50,000 strokes in Canada each year – one every 10 minutes – improving all aspects of life after stroke is an increasingly urgent concern. More than 300,000 Canadians currently live post-stroke lives,¹ a number that will most likely grow given our aging population and the fact that incidence of stroke doubles each decade after age 55.²

After a stroke, people typically avoid using their weakened arm and hand, leading to a further loss in strength, decreased range of motion, and deterioration of fine motor skills. To overcome this, Dr. Eng developed the Graded Repetitive Arm Supplementary Program (GRASP).

“The belief at the time was, ‘Don’t do this; it will make them worse.’ The thinking has changed drastically.” – Dr. Janice Eng

Ideally begun within four weeks of the stroke as an hour-a-day complement to routine physiotherapy, GRASP consists of a series of simple exercises that, when repeated dozens or perhaps hundreds of times daily, can significantly improve arm and hand function for basic tasks, such as buttoning up a shirt, unscrewing the lid of a jar or brushing teeth.³ Stroke survivors can do their GRASP exercises at home, using simple household objects and items that can be purchased at dollar stores.

Evidence in Action: Affordable, convenient stroke rehabilitation

GRASP consists of a series of simple exercises that patients can perform on their own, using simple household objects and items that can be purchased at dollar stores. The program is in clinical use in at least 100 sites spread across 10 countries.

“In occupational therapy and physiotherapy, the number of repetitions can be low – maybe 30 to 50 times – because there are so many things to do in a session,” says Dr. Eng. “But the number of repetitions needs to be very high to change the brain. With GRASP, if you do it over an hour, you’re getting 900 repetitions of hand and arm movements.”

GRASP has proved remarkably popular, adopted by clinics from Abbotsford Regional Hospital in BC to Western General Hospital in Edinburgh, Scotland.

“I don't know the exact number of users, but I believe it is in operation in at least 10 countries and 100 sites,” says Dr. Eng. “I gave a talk at the American Congress of Rehabilitation Medicine in Vancouver in October 2012 and when I asked how many of the clinicians had used GRASP, the majority of people put up their hands – at least 40 in just that room. I had a similar response for a talk I did in Melbourne.”

Visitors from 488 cities in 49 countries have accessed GRASP more than 17,000 times since it went online at UBC’s Neurorehabilitation Research Program website in the spring of 2012. The GRASP patient books have been translated into Chinese, Hindi, Punjabi, Farsi and Vietnamese.

What the world’s therapists say about GRASP

“It’s a wonderful technique, sometimes magical … we’ve been using this in our hospital.” Bangalore, India

“I have used this program before and feel that it is very beneficial. I have had positive patient outcomes.” Melbourne, Australia

“I love the manuals and have used them in the acute and community settings and completed training sessions on them.” London, England

“The GRASP program gives the much-needed structure of upper extremity exercise that patients and family members can use.” Medicine Hat, Alberta

Sarah Rowe, Physiotherapy Practice Coordinator for GF Strong Rehab Centre and Vancouver General Hospital, says GRASP should be the standard of care for stroke patients who fit the criteria – those who have some muscle activation of the wrist extensors – because it gets results. “That’s what we’re trying to promote. For those who meet those criteria, you can see improvement.”

She says GRASP is particularly useful to motivated patients and their families. “There is a population of patients who have high motivation and are able to participate. It really meets their needs. It also gives family members something they can do to assist the patients. They feel a bit helpless, and this gives them a really clear idea of what they can do.”

In fact, stroke survivors with family or caregivers who help them with GRASP do significantly better than those who do not have the same support.⁴

Based on the GRASP results, the Canadian Best Practice Recommendations for Stroke Care, a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada, now recommend that sub-acute stroke patients receive a supplementary upper extremity program.

What the experts say

“Programs like GRASP are the future, allowing patients to continue their recovery using scientifically proven therapeutic approaches in their own homes and communities with little cost to the health care system. It does not require expensive equipment and has been proven to be highly effective. As such, it is quickly being adopted around the country, and international interest and use continue to grow.” Dr. Robert Teasell, Medical Director, Stroke Rehabilitation Program, Parkwood Hospital, St. Joseph's Health Care London

“GRASP is a feasible, cost-effective way of enhancing stroke recovery. In the cash-strapped health care system, GRASP demonstrates that extra practice can enhance stroke recovery without excessive burden on busy rehabilitation therapists.” Dr. Mark Bayley, Medical Director of the Neuro Rehabilitation Program at Toronto Rehab

The GRASP program grew out of early research Dr. Eng undertook to help people get moving after the “brain insult” of stroke.

“We wanted to look at improving walking ability. The majority of stroke survivors go on to walk – 90% have some degree of ambulation – but not that well. We wanted to create a program that would improve people’s walking ability.”

Her Fitness and Mobility Exercise (FAME) program, similar to a circuit-training fitness routine, requires participants do a series of tasks to improve balance, increase walking speed and strengthen muscles. Unlike most stroke rehab regimens, which are one-on-one sessions with a physiotherapist or occupational therapist in a hospital in the days and weeks after a stroke, FAME can be led by trained fitness instructors working with small groups of stroke survivors in community settings.

Dr. Eng has demonstrated that FAME improves cardio-respiratory fitness, mobility, strengthens leg muscles and is effective at preventing secondary conditions such as additional strokes, heart attacks and injuries from falls.⁵

Freely downloadable from the UBC website, it has been accessed by more than 2,000 visitors from 223 cities in 35 countries. Communities across Canada and around the globe have since taken up the thrice-weekly, instructor-led FAME program.

As successful as FAME has been, its uptake in Canada has been limited by how stroke rehabilitation is funded, says Dr. Eng. “One of the major constraints is the way our health care system is structured. We cover one-on-one care to our stroke patients, which is effective and personalized though not sustainable, but health care doesn’t cover group exercise provided in community settings.”

Meanwhile, Dr. Eng continues to innovate. Her current work in progress is SPIRAL – the Supplementary Program in Repetitive Activity of the Leg, a series of lower limb exercises that stroke patients can do at home to get stronger and more mobile. It’s hoped that SPIRAL will do for the legs what GRASP has shown it can do for the arms.

“It’s a work in progress,” says Dr. Eng. “We will have the results from the clinical trial next year.”

1. Canadian Stroke Network. Centre for Stroke Recovery Begins National Expansion, press release (Oct. 29, 2012).
2. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century, Lancet Neurology 2, 1 (2003): 43–53.
3. A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial, Stroke 40, 6 (2009): 2123–28. doi: 10.1161/STROKEAHA.108.544585.
4. The role of caregiver involvement in upper-limb treatment in individuals with subacute stroke, Physical Therapy 90, 9 (2010): 1302–10. doi: 10.2522/ptj.20090349.
5. A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized controlled trial, Journal of the American Geriatrics Society 53, 10 (2005): 1667–74.