What is the Upper limb group?

Upper limb group is a weekly exercise class lasting one hour with a daily
home exercise programme, based on the GRASP programme. Patients
are invited to attend for six weeks, however patients may require longer
than this and may be reviewed on an individual basis and extended if
required. Each patient will receive a logbook which they can use to record
the exercises they have completed and a home exercise programme which
they can take away with them and are encouraged to complete on a daily
basis (Eng, 2012).
Is upper limb group for everyone?
Prior to making a referral for upper limb group, the therapist should
consider the following inclusion and exclusion criteria.
Inclusion criteria
Minimum 10 shoulder range of movement in any plane.
Minimum flickers of activity in fingers: approx. ! range of finger flexion.
Patient to be able to report when in pain or fatigued.
To be able to attempt to carry out one hour of exercise.
To be able to follow a 2-stage command and pay attention for one hour.
To come with own wheelchair if wheelchair is required.
Must agree to participate with a daily upper limb home exercise
programme.

Exclusion criteria
No orthopaedic/spasticity/pain/other factors which will be adversely
affected by exercise.
Receptive aphasia (unless accompanied by a regular caregiver who will
provide one-on-one support).
Low levels of cognition (unless accompanied by a regular caregiver
who will provide one-on-one support).
Unstable cardiac or respiratory conditions.
Uncontrolled incontinence problems.
Requiring more than the light assistance of one to transfer between.
References
ENG, J J. 2012. GRASP (Graded Repetitive Arm Supplementary Program) guidelines. Vancouver
FOLEY, N. MEHTA, S. JUTAI, J. STAINES, E. TEASELL, R. 2013. Upper Extremity Interventions. Retreived from www.ebrsr.com [accessed Feb 2014].
HARRIS, J E. 2009. Studies of Upper Limb Function in Individuals with Sub-Acute Stroke: A Multi-Site Single Blind Randomized Controlled Trial. Vancouver: University of British Columbia
HARRIS, J E, ENG, J J, MILLER, W C, DAWSON, A S. 2009. A Self-Administered Graded Repetitive Arm Supplementary Program (GRASP) Improves Arm Function During Inpatient Stroke
Rehabilitation: A Multi-Site Randomized Controlled Trial. Stroke. American Heart Association
INTERCOLLEIGIATE WORKING PARTY. National Clinical Guidelines for Stroke, 4
th
Edition. London: Royal College of Physicians, 2012
PANG, M Y, HARRIS, J E, ENG, J J. 2006. A Community-Based Upper-Extremity Group Exercise Program Improves Motor Function and Performance of Functional Activities in Chronic Stroke: A
Randomized Controlled Trial. Arch Phys Med Rehabil Vol 8
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GRASP is an arm and hand exercise programme
that was developed for stroke patients with upper
extremity impairments. GRASP provides one
method for patients to undertake a self directed
arm and hand exercise programme and has
three exercise levels to accommodate different
levels of severity (Eng, 2012).
Outcome measures
Patients progress will be measured
by the following outcome measures:
Rivermead motor assessment (Arm
sub score), JAMAR hydraulic hand
dynamometer and the 9-hole peg
test.
What is the evidence to support upper limb group?

By improving participants upper limb function we hope to reduce their care needs and therefore long-term care costs (Harris, 2009).
Research has shown that patients participating in upper limb groups demonstrated improvements in arm and hand function, use of the hand
and grip strength. Participants reported that upper limb groups helped to strengthen the weaker arm, improve the range of motion of the
weaker arm, improve patients ability to use the weaker arm in daily activities, decrease pain and improve life satisfaction (Pang et al, 2006).

GRASP has been tested in a multi-centred randomized trial, the GRASP programme was found to be a safe, time efficient, cost- and
treatment-effective method to improve upper limb recovery. In addition, patients participating in GRASP programmes also had less
depressive symptoms following the trial (Harris, 2009).
What does it involve?
The exercise group will consist of a five minute
warm up then patients are asked to complete eight
minutes of exercise on five different stations. Each
station will have a different focus:
Range of movement
Strength
Weight bearing activities
Functional Activities
Trunk control
Exercises for each station will be graded and the
therapists will select the most appropriate exercises
for each patient to complete. This way patients with
a variety of severity of upper limb weakness can
exercise together (Eng, 2012).
Patients outcome
measures are recorded
at baseline (week 1) and
post participation (week
6).
Contact: Anna.sharland@dhuft.nhs.uk