The Development of a Toolkit to Support the Use of a Programme of Self-directed Upper Limb Exercise after Stroke

Background: There is evidence that to promote recovery in the arm after stroke, many hundreds of repetitions of exercises need to be completed. Delivering this intensity of exercise is challenging within resource limited health systems such as the UK NHS. Effective self-directed exercise may be a way of increasing in-patient rehabilitation intensity in in-patient settings.

Research Question: An intervention called GRASP was found in efficacy trials in Canada to improve arm function after stroke: It is a prescribed set of exercises and advice for rehabilitation of the arm. It is available freely online, and has been widely adopted in the UK.

Evidence shows in Canada it is rarely used in the way that was originally described in the closely controlled environment of the randomised controlled trial. There is some evidence that suggests this is also the case in the UK.

Can we: (i) find out to what extent, and why, UK therapists use and adapt GRASP; and (ii) co-design a toolkit developed to facilitate the implementation of GRASP in the UK without losing its active ingredients?

Aim: To support people with stroke to be able to increase the intensity of upper limb exercises they undertake to a therapeutic level. Objectives: 1.

To use existing literature to develop a programme theory to explain how the GRASP intervention achieves its outcomes. 2.

To understand to what extent, and why, therapists who use GRASP in the UK do not implement it with fidelity to the guidance provided. 3. To identify the barriers and facilitators for people with stroke in using GRASP. 4.

To co-design a toolkit that supports delivery of GRASP, with increased fidelity to the components that the programme theory indicates make it effective. Methods Realist methodology provides an overall framework for the study. The first objective will be achieved by conducting a realist review.

The second objective will be achieved by undertaking observations and interviews using a teacher-learner cycle approach to determine how self-directed exercise is prescribed on stroke rehabilitation units.

The third objective will be completed through interviews with people with stroke and caregivers, familiar with using GRASP. The findings from objectives 2 and 3 will be used to refine the programme theory.

In a series of workshops, drawing on the programme theory, key stakeholders will co-design an online toolkit to support the implementation of GRASP with fidelity to its active ingredients, and evidence based tailoring options for different contexts, e.g. for use with people with aphasia, people without family members to help.

Finally, the usability and acceptability of the toolkit will be assessed through trialling it in the hospital setting with observations and follow up interviews.

Anticipated Impact and Dissemination This research will produce a toolkit to support an existing intervention to promote arm recovery.

It will be available online for therapists to use, and will help people who have had a stroke to increase the intensity of arm rehabilitation they receive. This will be disseminated via academic forums, patient facing media forums and conferences.