Abstract
Background: Access to stroke rehabilitation in low-resource South African areas is limited. Telerehabilitation (TR) offers a promising solution, particularly for upper limb recovery post-stroke.
Aim: To assess the feasibility of a task-oriented TR home programme for mild to moderate upper limb impairment post-stroke in a South African context.
Setting: Bishop Lavis, South Africa, a low-income area.
Methods: A single-site parallel randomised feasibility study was conducted. Feasibility outcomes included: process, resource, management and scientific outcomes. Outcome measures included satisfaction survey, log sheets, Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Chedoke Arm and Hand Activity Inventory (CAHAI), Visual Analogue Scale (VAS) and BORG Rating of Perceived Exertion (RPE) scale. Participants completed an 8-week home programme (H-Graded Repetitive Arm Supplementary Program [GRASP]). The experimental group received weekly TR, while the control group received face-to-face care.
Results: A total of 12 participants were recruited, with 10 completing the programme. The experimental group reported 96.9% perceived benefit, 60.0% exercise and task adherence and had 41 telephonic sessions in total. The control group reported 76.9% perceived benefit, no exercise adherence, 20.0% task adherence and attended 13 face-to-face sessions in total (67.5% non-attendance). Post-intervention, FMA-UE improved significantly (control: p = 0.0003; experimental: p = 0.0013) with a mean difference of 6.0 (95% confidence interval [CI]: -6.2 to 18.2). The CAHAI showed borderline significance (control: p = 0.0556; experimental: p = 0.0601) with a mean difference of -1.0 (95% CI: -3.2 to 1.2).
Conclusion: The feasibility study achieved success in retention rates, safety and perceived benefit for the experimental group, with treatment equivalence in the CAHAI scores. Recruitment rate and exercise and task adherence were below criteria. Perceived benefit in the control group fell short. Treatment equivalence for FMA-UE scores exceeded the set margin.
Contribution: Persons with upper limb impairments post-stroke in low-resource contexts may benefit from a repetitive task-oriented TR home programme.
Keywords: telerehabilitation; stroke; upper limb; feasibility, repetitive task-oriented training.
Introduction
Upper limb (UL) impairment is a common cause of acquired long-term disability in adults with stroke (Lai et al. 2002; Pollock et al. 2013). Sensory and motor deficits are the most common observable UL impairments post-stroke (Lai et al. 2002; Pollock et al. 2013). These impairments contribute to a loss of function in the shoulder, elbow, forearm and hand and consequently contribute to significant activity and participatory restrictions (French et al. 2016; Hebert et al. 2016; Iruthayarajah et al. 2019; Pollock et al. 2013; Raghavan 2015). Upper limb rehabilitation is therefore a critical element of rehabilitation post-stroke.
While rehabilitation plays a vital role in addressing the UL limitations post-stroke, for individuals in low-resource settings, optimal rehabilitation may be hampered by multiple factors such as: access to rehabilitative care, minimal family support, dependence on caregivers, decreased motivation and the lack of knowledge of the diagnosis (Chen et al. 2021; Wilson et al. 2021; Wolf et al. 2015). Specifically, within rural and low-income settings in South Africa, accessibility and compliance remain challenges of stroke rehabilitation. Telerehabilitation (TR) has thus been explored as an alternative method of rehabilitation to ensure continuity of care (Nizeyimana et al. 2022).
Telerehabilitation and home programmes are two ways in which UL interventions can be delivered post-stroke. One of the foremost post-stroke UL interventions identified in research was repetitive task training and task-oriented training (French et al. 2016; Iruthayarajah et al. 2019; Pollock et al. 2013). Task-oriented training requires the use of tasks or parts of tasks relevant to daily life to relearn specific UL movements, while repetitive task training refers to the repetition of these tasks (French et al. 2016; Pollock et al. 2013). An example of an evidence-based UL intervention that uses intensive, repetitive, task-oriented practice is the Graded Repetitive Arm Supplementary Program (GRASP) (Simpson, Eng & Chan 2017). The GRASP was adapted for home use, that is the GRASP – Home version 2.1 or H-GRASP (Simpson et al. 2017). The H-GRASP is a 2-month home programme with self-administered task-oriented exercises adapted from the GRASP. Preliminary research using a pre-post double baseline design showed that when monitored weekly by phone, the programme improved UL function, grip strength and occupational performance (Simpson et al. 2017).
In South Africa, access to home-based face-to-face rehabilitation training is limited because of the economic challenges faced by many communities. Therefore, upscaling access to rehabilitation care post-stroke requires exploring low-cost interventions that can utilise locally available resources, such as everyday items in clients’ homes and equipment. The H-GRASP may be a good fit for this purpose; it is easy to use and suitable for all cultures, which can enhance understanding, participation and sustainability in a low-income context (Simpson et al. 2017). Therefore, given the cost-effectiveness, content, ease to use and scientific rigour of the H-GRASP, it may serve as an option for a TR home programme and treatment modality for low socio-economic communities in South Africa.
While the topic of TR has been widely studied (Chen et al. 2015; Cramer et al. 2019, 2021; Sarfo et al. 2018; Saywell et al. 2021), there is a paucity in the literature on the feasibility of TR in low- to middle-income countries (LMICs) such as South Africa. It was found that the majority of TR programmes were implemented in high-income contexts and relied on computer-based systems (Chen et al. 2019; Cramer et al. 2021; Dodakian et al. 2017; Odetunde et al. 2020). Only a few studies investigated the use of TR in LMICs, where only telephone calls were utilised as TR technology (Niama Natta et al. 2015; Simpson et al. 2017; Wilson et al. 2021). Telephone calls are more readily accessible to most clients, requiring no Internet, mobile data or financial burden, which are common barriers for residents in LMICs such as South Africa. Although the use of TR via telephone was found to be feasible in the respective countries, no information was available on the feasibility of such a programme in South Africa, which differs in culture, socio-economic status, policy, legislation and funding models for stroke rehabilitation.
This study therefore sought to investigate the feasibility of a repetitive, task-oriented TR home programme as an alternative mode of service delivery for UL rehabilitation post-stroke, specifically in low-resourced settings in South Africa where access and continuity of care are limited. Feasibility studies are conducted to see whether a concept or idea is feasible or appropriate in a certain situation or context. Feasibility was operationalised according to the four feasibility outcomes stated by Thabane et al. (2010) as process, resource, management and scientific feasibility. The study focussed on mild to moderate UL impairment post-stroke as authors, including the developers of the H-GRASP (Simpson et al. 2017), have highlighted that persons with more severe UL impairment require more face-to-face intervention.
Research methods and design
A single-site parallel randomised feasibility study within a quantitative design was used. Two randomised groups were given either TR (experimental) or standard care (control). The feasibility outcomes were measured and compared in both groups.
This study adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for reporting a pilot or feasibility trial. It was conducted in Bishop Lavis at the out-patient Rehabilitation Centre (BLRC), a low socio-economic suburb (Statistics South Africa 2013) in the Western Cape of South Africa.
No sample size calculation was conducted, as this feasibility study aimed to estimate the sample size for a larger trial (Arain et al. 2010; Eldridge et al. 2016; Stewart et al. 2020). Recruitment for this study occurred between January 2023 and May 2023, targeting at least 20 participants.
Intervention
The H-GRASP, an 8-week programme, combines levels 2 and 3 of the original GRASP, focussing on mild to moderate UL impairment in stroke patients. Sessions consist of daily 1-h exercises, which could be split into two 30-min sessions if attention or fatigue was a challenge. Minor adjustments were made to fit the study context, including replacing equipment such as hand grippers with more accessible items such as resistance balls and clay. Both groups received the H-GRASP programme, with the experimental group undergoing only weekly TR via telephone (varying between 15 min to 20 min per call) for exercise monitoring and progression. Participants of both groups maintained daily logs and received guidance on task goals and exercise progression. The primary investigator aimed to ensure that each exercise was sufficiently challenging to be therapeutic yet not overly difficult to cause participant frustration or extreme fatigue. The control group received standard care with face-to-face OT sessions every 7–10 days, following the same H-GRASP programme. The 45-min session focussed on improving body functions and structures affected by the stroke (depending on the stage of recovery) and improving independence in activities of daily living (ADLs). Goals for therapy were adjusted based on the individual needs of the patient. Each participant received an equipment kit and hard copy of the H-GRASP manual in their preferred language.
Data collection
To meet the feasibility objectives, data for both groups were collected before, during and after the 8-week intervention. Each feasibility outcome was measured, analysed and compared between the two groups based on the feasibility targets set prior to the study. The outcome measures included a satisfaction survey (Process feasibility), log sheets (resource and management feasibility) and the Fugl-Meyer Assessment – Upper Extremity (FMA-UE), Chedoke Arm and Hand Activity Inventory (CAHAI), Visual Analogue Scale (VAS) pain rating and Borg Rating of Perceived Exertion (RPE) scale (scientific feasibility).
Outcomes
Table 1 outlines the success criteria for each feasibility objective evaluated during data analysis.
Data analysis
Descriptive statistics were used to analyse demographic information and feasibility outcomes. Exercise adherence was compared using the Mann-Whitney test. The chi-squared test assessed the association between task adherence in the two groups. The paired t-test compared pre- and post-intervention scores between groups and equivalence of interventions was explored using a 95% confidence interval (CI) within a pre-specified margin of ±15%. Wellek and Blettner (2012) emphasised the importance of establishing an equivalent margin between interventions before study planning and analysis, guided by the research question, clinical endpoint and data distribution. Wiens (2002) proposed that equivalence margins can be based on criteria such as a value small enough to show an effect, the minimum value representing a clinically meaningful difference or a value small relative to background variability, although no consensus exists on the best approach. Limited literature addresses specific margins, as most studies focus on proving efficacy rather than equivalence. The original H-GRASP feasibility study had only one group, and thus no margin was set, while Cramer et al. (2019) used a 30% noninferiority margin for Fugl-Meyer Assessment (FMA) score changes in their TR trial although the rationale was not explained.
An equivalence margin was established by the researcher, based on the level of UL impairment classification within the specific outcome measures. A margin of 15% accounts for a difference of 10 points on the FMA-UE and 8 points on the CAHAI between the experimental group and the control group. Because the FMA-UE allows scores to vary by up to 20 points within one level, a margin of 15% was deemed to be clinically appropriate.
Ethical considerations
Ethical approval to conduct this study was obtained from the Stellenbosch University Health Research Ethics Committee (HREC) (No. S22/08/143). All participants gave written informed consent and confidentiality was maintained throughout the study by assigning each participant a number, with no names appearing on any data collection forms or questionnaires.
Results
Process feasibility
A total recruitment rate of 19% (n = 12/62) was achieved with 12 participants meeting the inclusion criteria. Of these 12 participants, 10 completed the intervention (sample size 10: control group = 5 and experimental group = 5). In the control group, one participant dropped out for unknown reasons and was not contactable for follow-up. One participant in the experimental group could not continue because of an unrelated fall injury. This represents a retention rate of 83% for both groups and a loss to follow-up rate of 17%. The participant flow diagram is displayed in Figure 1. The demographic characteristics of the participants are shown in Table 2.
| TABLE 2: Demographic characteristics of the participants. |
For perceived benefit, 76.9% of the control group indicated the intervention was beneficial, compared to 96.9% in the experimental group. Overall, 86.9% of both groups found the H-GRASP beneficial.
Resource feasibility
The experimental group averaged 70 to 630 weekly minutes compared to the 100–200 min of the control group. In the experimental group, 60% (n = 3) adhered to the weekly exercise target in comparison with 0% (n = 0) in the control group. Individual task adherence varied, with only 20% (n = 1) of the control group meeting the goal consistently, compared to 60% (n = 3) in the experimental group.
Management feasibility
The control group attended an average of three sessions per participant (13 sessions in total), totalling 585 min of rehabilitation, with 32.5% attendance and 67.5% of sessions not attended. Each session lasted 45 min – 50 min. The experimental group completed eight telephonic sessions per participant (41 sessions in total), totalling 630 min of rehabilitation provided, with 100% attendance. Each session lasted 15 min – 20 min.
Scientific feasibility
Fugl-Meyer assessment-upper extremity
As can be seen in Table 3, both groups showed an improvement in post-intervention scores. The control group achieved a p-value of 0.0003 (mean difference of 11.2), while the experimental group attained a p-value of 0.0013 (mean difference of 10.8).
| TABLE 3: Fugl-Meyer assessment-upper extremity: Analysis of baseline compared to post-intervention scores. |
Chedoke arm and hand activity inventory
The second outcome measure, CAHAI, measuring the performance of the affected UL in ADLs, also showed an improvement in the post-intervention assessment scores. The analysis for statistical significance for pre- and post-intervention is presented in Table 4. The calculated p-value for the control group is 0.0556 (mean difference 4.2) and the experimental group 0.0601 (mean difference 10.0).
| TABLE 4: Chedoke arm and hand activity inventory: Baseline compared to post-intervention scores. |
Table 5 summarises the results for treatment equivalence of the interventions of the control group versus the experimental group. The difference in mean values between the control group and the experimental group for the FMA-UE measure was 6.0 (CI: -6.2 to 18.2). Similarly, for the CAHAI measure, the mean difference between the two groups was established at -1.0 (CI: -3.2 to 1.2).
| TABLE 5: Treatment equivalence of post-intervention scores. |
Safety
Pain levels tested consistently low for both groups throughout the 8-week intervention. Participants reported their pain using a weekly VAS rating, and their responses were recorded over the 8 weeks on a Likert scale (0–10). In the control group, all the participants (100%) reported 0 = no pain during the 8-week intervention. One participant in the experimental group consistently reported a pain score of 3 (moderate pain) for the first 6 weeks, which subsequently decreased to 2 (mild pain) in the last 2 weeks of the intervention.
The perceived exertion rates for both groups reveals a predominant trend falling within the range of 2 to 5 out of a maximum of 10, indicative of exertion levels spanning from easy to moderately hard, with no participants indicating fatigue levels of > 7 throughout the intervention.
Discussion
Outcomes for the TR group were comparable to face-to-face interventions, particularly for those with mild to moderate impairments. The investigation into process feasibility highlighted challenges in recruitment, including participant non-attendance and eligibility constraints, which highlight the need for strategies addressing logistical and accessibility barriers. Despite these challenges, the high retention rate and participant perceived benefit indicate the intervention’s potential acceptability and sustainability. The TR group, with regular telephonic follow-ups, reported greater benefits in programme orientation, content and practicality, suggesting that the TR approach was comparable to face-to-face intervention, contributing to the programme’s success in Bishop Lavis. Therefore, the use of TR demonstrated promising adaptability and patient-centred care, suggesting its suitability for future implementation, particularly in contexts where in-person approaches face limitations. These findings emphasise the importance of tailoring recruitment strategies and intervention delivery.
Investigating resource feasibility included exercise and task adherence within the context of Bishop Lavis. Exercise adherence was evaluated by comparing exercise time with the H-GRASP protocol’s target of 60 min per day, 5 days a week (300 min) (Simpson et al. 2017). In this study, 60% of the experimental group met this goal, compared to no participants in the control group. Contextual factors such as illness, long clinic visits, funerals and daily routine challenges likely influenced these outcomes (Cramer et al. 2019, 2021; Dodakian et al. 2017; Ogwumike, Badaru & Adeniyi 2014). Participants often modified the programme, splitting exercises across days or focussing on tasks most relevant to their needs, as guided by the therapist. This adaptability, while not meeting strict adherence target, suggests flexibility in TR may support meaningful engagement.
Task adherence, measured by weekly reports of use of the affected hand, aligned with exercise adherence rates, where the experimental group achieved a higher adherence rate than the control group. Though below the target, participants consistently incorporated the affected limb into daily tasks, contributing to improved functional outcomes, as reflected in CAHAI and FMA-UE scores.
The experimental group’s higher adherence and satisfaction highlight the importance of structured feedback and perceived benefits. Literature highlights that tailored, manageable and engaging interventions improve adherence (Ogwumike et al. 2014). Regular monitoring and support, as provided in TR, likely fostered better compliance and outcomes compared to less frequent face-to-face interactions in the control group. This is consistent with findings by Ogwumike et al. (2014) and Mahmood et al. (2021), which highlight that greater satisfaction and enjoyment lead to better adherence among stroke patients.
Although adherence rates fell short of targets, findings indicate TR is feasible and beneficial for promoting exercise and task engagement. Future studies should explore strategies such as behavioural contracts and individualised support to optimise adherence within diverse contexts.
Management feasibility evaluated the delivery of the intervention programme, focussing on the practicality of therapist follow-ups. The TR approach demonstrated advantages, with weekly telephonic follow-ups proving accessible and resource efficient. These shorter but frequent sessions facilitated consistent patient-therapist interaction, enabling better monitoring and personalisation of care. The absence of financial burdens for participants, such as transport costs, and the simplicity of telephone-based communication made this mode of delivery particularly suited for the community. It also reduced the impact of missed appointments, a common issue in face-to-face therapy, by allowing therapists to use their time more effectively. These factors correspond with the facilitators of TR in Bishop Lavis, identified in the case study of De Villiers et al. (2022).
In contrast, face-to-face sessions faced logistical barriers, including financial constraints, the lack of caregiver support and weather-related challenges. These barriers align with common challenges faced by persons with stroke in LMICs and highlight the barriers that persons face when required to attend face-to-face sessions at BLRC (Chen et al. 2019, 2021; Wilson et al. 2021; Wolf et al. 2015). These limitations affected attendance and resulted in less consistent follow-ups, impacting adherence to the programme. While face-to-face sessions provided more intensive interactions when attended, their inconsistent nature affected the overall effectiveness.
The TR approach’s flexibility and reduced time demands enhanced access to occupational therapy for participants who might otherwise have missed out on treatment. The telephone calls were accessible to all participants, requiring no Internet, data or costs, making the process feasible for both the therapist and participants. The use of telephone calls aligns with the findings of a scoping review conducted in 2022, which specifically recognised this approach for similar reasons, particularly in LMICs (Jahromi & Ayatollahi 2022). Therefore, the barriers of TR in Bishop Lavis, identified by De Villiers et al. (2022), could have been eliminated through telephonic follow-ups, enabling this method to be feasible within this context. This also allowed therapists to allocate resources more efficiently, minimising wasted time from non-attendance and maximising patient engagement. The findings highlight TR may be a feasible and effective alternative, especially in settings where in-person therapy is impractical or inaccessible.
For scientific feasibility, across all participants, a consistent improvement in post-intervention scores was observed. Although statistical tests were not performed for the H-GRASP, as its effectiveness has already been established in the literature, the focus was on evaluating treatment outcomes within the context of Bishop Lavis to inform future studies (Simpson et al. 2017). As feasibility studies typically aim to assess methods and outcomes rather than effectiveness, treatment equivalence was the primary goal. This result demonstrated treatment equivalence in terms of the CAHAI outcome measure, and it offers motivation for pursuing a larger study despite the deviation from the margin seen in the FMA-UE analysis. When clinical significance is considered, it is important to note that both outcome measures fall within the predetermined margins, indicating that the interventions might yield comparable results. The 95% CI, calculated based on a notably limited sample size, introduces challenges in drawing definitive conclusions regarding equivalence.
The FMA-UE and CAHAI scores, along with clinical significance measures, support the intervention’s potential in improving post-stroke UL function. These results align with the original H-GRASP research and support the effectiveness of repetitive task-oriented training for UL impairments in-person with stroke (Carolee et al. 2016; French et al. 2016; Hebert et al. 2016; Pollock et al. 2013; Simpson et al. 2017) The small sample size and unequal group distribution, however, suggest that further research with larger groups is necessary to confirm these findings.
Interestingly, despite the control group spending less time on H-GRASP exercises, they still showed significant improvements. This highlights the programme’s suitability for the context of Bishop Lavis. However, the control group had higher initial scores which likely contributed to their better recovery trajectory. It has been shown that early recovery of UL movement is indicative of a favourable prognosis, which could explain their improved outcomes (Hunter & Crome 2002). Furthermore, consistent engagement in daily tasks might have positively influenced the final intervention results.
In terms of safety, the intervention showed no significant adverse effects, with no participant reporting increased pain or severe fatigue. The majority of the control group found the exercises easy, while the experimental group reported moderate to hard levels of exertion. Both groups experienced a decrease in fatigue as the programme progressed although the control group’s ratings plateaued at a lower intensity. This could be because of the lack of exercise progression in the control group, as opposed to the experimental group, which had more frequent follow-ups and progressive adjustments to the programme. The experimental group also had lower pre-intervention UL scores, which may have contributed to their higher initial fatigue levels. Overall, the findings suggest that the H-GRASP intervention delivered via TR is safe and effective. The promising results highlight the potential of this TR programme to improve UL function and activity participation in the Bishop Lavis context.
Conclusion
This study provides preliminary evidence that the H-GRASP intervention improves UL function and activity participation for persons with stroke in LMIC. The outcomes of the TR group were comparable to those of face-to-face sessions.
Telephonic follow-ups made the TR process feasible, as they were accessible, did not require Internet, data or other costs and addressed barriers to in-person attendance. This method allowed for more regular follow-ups without needing a therapist’s physical presence. The study highlights both the benefits of the TR approach and the challenges of in-person stroke management in low-resourced areas such as Bishop Lavis.
The feasibility study demonstrated success in several areas, including retention rates, which exceeded the 75% criterion for both the experimental (83%) and control groups (83%), as well as safety, with no participants reporting increased pain or severe fatigue during exercises. Perceived benefit was achieved in the experimental group, with a satisfaction rate of 96.9%, and treatment equivalence was met for the CAHAI scores. However, some targets were not met. The recruitment rate narrowly missed the > 20% threshold (19.0%), perceived benefit in the control group fell short of the > 80% target (76.9%), and both exercise and task adherence were below the set targets, particularly in the control group (0% and 20%, respectively). In addition, treatment equivalence for the FMA-UE scores exceeded the established margin of 15%. These findings highlight both strengths and areas for improvement in preparation for a larger trial. Although not all feasibility targets were met, the research offers valuable insights and sets the stage for future studies on TR interventions in LMICs. Further research with a larger and more diverse sample could enhance the understanding and applicability of these findings.
Limitations and recommendations
The small sample size limits generalisability and may not fully represent the target population’s diversity. Recruitment challenges, such as delays in baseline assessments and non-attendance, impacted the process. Reliance on self-reported data introduces potential biases, while the satisfaction survey lacked detail, limiting insights for programme improvement. In addition, the absence of long-term follow-up restricts understanding of sustained intervention effects beyond 8 weeks.
Recommendations for future studies include extending recruitment time and broadening of inclusion criteria to increase sample size and improve generalisability. Immediate baseline assessments after eligibility screening can help reduce dropouts, and multi-centre studies or using different recruitment channels, such as home visits, would increase the reach and diversity of participants. Combining objective measures with self-reported data, documenting caregiver involvement and conducting follow-up assessments at multiple time points are recommended. Behavioural contracts, goal-setting strategies and increased involvement of caregivers are essential for enhancing programme adherence. In addition, adjusting the exercise requirements to accommodate participants’ preferences and local challenges would help make the programme more sustainable. Telerehabilitation should use low-data platforms for real-time communication and adjust exercise plans to improve adherence. Educational workshops on stroke and TR benefits, integrating TR into undergraduate education and ongoing professional development for clinicians are suggested to raise awareness and improve access to rehabilitation services.
Acknowledgements
The authors would like to thank the team at Bishop Lavis at the out-patient Rehabilitation Centre (BLRC) for their support and assistance in the research process.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
L.J.J-N.K. serves as an editorial board member of this journal. The peer review process for this submission was handled independently, and the author had no involvement in the editorial decision-making process for this article. The authors have no other competing interests to declare.
Authors’ contributions
L.v.W. performed the measurements, processed the experimental data, performed the analysis and calculations, aided in interpreting the results, drafted the article and designed the figures. M.K. and L.J.J.-N.K. were involved in planning and supervised the work. All authors discussed the results and commented on the article.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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