A biomechanical analysis of the effectiveness of the Graded Repetitive Arm Supplementary Program (GRASP) for chronic stroke rehabilitation

Is your doctor, hospital and therapists that fucking incompetent that in 14 years they haven't implemented this program for stroke survivors?  I wrote about this in March, 2011.

GRASP PROGRAM FOR HAND AND ARM THERAPY  March, 2011 

GRASP (6 posts to March 2011)

 A biomechanical analysis of the effectiveness of the Graded Repetitive Arm Supplementary Program (GRASP) for chronic stroke rehabilitation

Madeleine A. Grealy, Luke Meneilly, Lesley-Anne Rollins & William J. McGeown To cite this article: Madeleine A. Grealy, Luke Meneilly, Lesley-Anne Rollins & William J. McGeown (05 Jul 2025): A biomechanical analysis of the effectiveness of the Graded Repetitive Arm Supplementary Program (GRASP) for chronic stroke rehabilitation, Disability and Rehabilitation, DOI: 10.1080/09638288.2025.2530158 To link to this article: https://doi.org/10.1080/09638288.2025.2530158 © 2025 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 05 Jul 2025. https://doi.org/10.1080/09638288.2025.2530158 

 RESEARCH ARTICLE Madeleine A. Grealy , Luke Meneilly, Lesley-Anne Rollins and William J. McGeown Department of Psychological Sciences and health, University of Strathclyde, Glasgow, Uk 

 ABSTRACT 

 Purpose: 

The Graded Repetitive Arm Supplementary Program (GRASP) is used widely to reduce arm impairment from stroke. Evidence for its effectiveness in chronic stroke survivors is based on studies that used clinical measures and different treatment lengths. This study aimed to examine whether GRASP changes movement quality by conducting a biomechanical analysis of chronic stroke survivors’ movements prior to, during and after GRASP; assess whether changes in kinematic and clinical measures are associated and an intervention duration shorter eight-weeks could be similarly effective. 

 

Materials and methods: 

Chronic stroke survivors (n = 27) completed the baseline measures, GRASP for eight weeks and post-measures. They practiced one-hour daily at home for six days/week and visited the University weekly, where arm movements were recorded. 

 Results: 

There were significant GRASP related improvements in movement duration and smoothness in the affected arm. Significant improvements in arm function, self-efficacy and quality of life were also observed, but these did not consistently significantly correlate with kinematic changes. There was no evidence to support shortening the program. 

 Conclusion: 

Kinematic changes in movement patterns were evident across the GRASP program as were benefits on clinical measures, but additional research is needed to determine the benefits of GRASP for chronic stroke rehabilitation.  

KEYWORDS 

 Stroke; chronic; GRASP; rehabilitation; kinematics; biomechanics 

 • The Graded Repetitive Arm Supplementary Program (GRASP) is an effective therapy for stroke survivors in the chronic stage of recovery. 

 • GRASP resulted in faster and smoother movements of the affected arm whilst performing an everyday task. 

 • GRASP should be practiced for at least eight weeks. 

 • GRASP is not suitable for chronic stroke survivors living with severe arm and hand disability. 

 • It is currently not clear whether GRASP is more effective than other therapies for the rehabilitation of arm and hand function in chronic stroke survivors. 

 Introduction 

 Stroke is a leading cause of long-term disability worldwide [1] with many experiencing deficits in sen sation, movement and co-ordination of the arm and hand contributing to a loss of independence and a reduction in health-related quality of life [2,3]. Evidence indicates that intensive rehabilitation can significantly improve arm function [4–6], however, the costs associated with intensive therapy are often prohibitive. This has led to an increase in demand for home-based, low-cost interventions that are largely self-directed or require minimal professional supervision. One such freely available home-based intervention is the Graded Repetitive Arm Supplementary Program (GRASP) which targets arm impairment with intensive exercise and encourages the use of the affected arm in daily tasks. CONTACT madeleine A. Grealy George Street, GlasgowG1 1Qe, Uk m.grealy@strath.ac.uk Department of Psychological Sciences and health, University of Strathclyde, 40 © 2025 the Author(s). Published by informa Uk Limited, trading as taylor & Francis Group this is an open Access article distributed under the terms of the creative commons Attribution-noncommercial-noDerivatives License (http://creativecommons. org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. the terms on which this article has been published allow the posting of the Accepted manuscript in a repository by the author(s) or with their consent. 2 M. A. GREALY ET AL. GRASP is a manual based exercise program that comprises range of motion, strengthening and weight-bearing exercises along with functional tasks and fine motor skills. It has three levels of diffi culty, and it uses a variety of objects that are inexpensive and easily sourced. Participants are advised to practice daily for one hour and to progressively increase the difficulty and number of repetitions of each exercise. GRASP was originally designed for acute stroke patients to augment their regular hos pital therapy without the need for additional supervision from physio- or occupational therapists [7] but it has since been adapted for home use. The randomised control trial (RCT) conducted by Harris et al. in 2009 [7] assessed acute stroke survivors in rehabilitation centres self-administering GRASP, and showed positive outcomes after 4 weeks on the Chedoke Arm and Hand Activity Inventory which assesses functional recovery on tasks such as opening a jar and pouring. Since then, GRASP has been widely adopted in rehabilitation facilities in a number of countries [8], however, there have been relatively few additional studies, particularly on the use of GRASP in community settings with people in the chronic stages of stroke recovery. A recent systematic review [9] found eight studies published prior to December 2022 where GRASP had been used in a variety of clinical and non-clinical settings and included patients in acute care through to people several years post-stroke. All these studies demonstrated improvements, but as a variety of outcome measures were used, mainly clinical tests, it was not possible to conduct a meta-analysis. Additionally, the validity and sensitivity of the standardised clinical tests used as outcome measures in stroke intervention trials has recently been ques tioned as they do not directly measure movement quality, making it difficult to determine whether an improved score reflects a shift towards “normal” motor control or the adoption of compensatory, and potentially maladaptive movements to achieve the task. The use of biomechanical analysis, derived from 3D motion capture, where changes in kinematic measurements are tracked over time, would allow us to assess whether GRASP related changes are predominantly compensatory or restorative. The use of kinematic analysis in rehabilitation research has increased in recent years [10] and there is evidence to suggest that kinematic measures show different patterns of recovery when compared to functional tests. For example, Cortes et al. [11] used kinematic analysis to assess recovery of arm motor control in people who had recently experienced a stroke. Their analyses showed that performance on the kinematic measures plateaued after five weeks, however, improvements on the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT) continued over 54 weeks. This suggested that these tests assess different aspects of recovery that have different time courses. Further comparisons of clinical and kinematic measures indicate that they may differ in sensitivity. For example, the meta-analysis by Villepinte et al. [12] compared changes on clinical and kinematic measures of con straint induced movement, trunk restraint and bilateral arm therapies, and found that the Motor Activity Log, Fugl-Meyer Assessment and Wolf Motor Function Test showed greater improvements than kinematic measures of smoothness, duration, efficiency and peak velocity. It may therefore be the case that some tests, particularly those that are more subjective, might over-estimate the effect of an intervention. Whilst positive changes in movement kinematics associated with constraint induced movement therapy (CIMT), bilateral arm training and mirror therapy have been demonstrated using RCTs, this has not been established for the effectiveness of GRASP in a chronic stroke population. The first aim of this study was to conduct a biomechanical analysis to examine whether changes in movement quality are evident in chronic stroke survivors who complete GRASP at home. If GRASP does improve motor control during the chronic phase of stroke recovery, we would expect to see similar patterns of improvement in both movement kinematics and functional tests such as the ARAT. Moreover, if these changes are substantial and meaning ful then improvements in quality of life and the person’s beliefs about their capabilities may also be evi dent. Conversely, if GRASP primarily promotes compensatory behaviours in chronic strokes survivors, little improvement in movement quality would be expected, although changes on functional tests may still occur. Therefore, the second aim was to examine whether there were intervention related improvements on the ARAT and its four subscales, and to see if these correlated with changes on the kinematic measures. Similarly, we looked to see if there were more general improvements in self-reported measures of quality of life and self-beliefs, and whether these were related to changes in movement kinematics. The most prevalent deficits in movement kinematics associated with stroke are longer movement times, lower peak velocities, more curved and less smooth movements [13]. However, there are many ways in which movement quality can, and has, been assessed. A systematic review of studies that used GRASP bIOMECHAnICS In STROKE 3 kinematic assessments of upper limb movements after stroke [10] identified 225 studies that used a variety of tasks resulting in 151 different metrics. Similarly, there are numerous clinical, observational and self-reported stroke measures. For the purpose of this study, we chose the ARAT test, a widely used observational measure of functional performance used by physiotherapists and occupational therapists. We picked one functional task from the ARAT, lifting a block and placing it on a shelf, for the biome chanical analysis. We recorded arm movements before, during and after the eight-week GRASP program and we measured both arms so we could account for learning effects and meaningful change in the affected arm. We assessed the person’s belief in their ability and overall quality of life, more generally, using the self-report measures detailed below. The final aim of this study was to examine changes in the kinematic variables over the eight-week program to assess whether performance improvements were evident throughout, or whether these pla teaued prior to the end. Currently, there is no recommended duration for this program and previous studies have used different treatment lengths, some at four weeks [7,14,15], eight weeks [16] and ten weeks [17,18]. Most have used designs comparing pre- and post-intervention scores and have not col lected data during the intervention. As GRASP requires one hour of daily practice it can be burdensome over eight or ten weeks, it is worth examining whether shortening the program could be achieved with out reducing the effectiveness of the intervention.

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