Hospital GRASP

Graded Repetitive Arm

Supplementary Program

1
Exercise Manual

Level 1
(Version 2)
 GRASP Terms and Conditions

“UBC” means The University of British Columbia, a corporation continued under the University Act
of British Columbia with offices at 103-6190 Agronomy Road;

“The Developers” means: Dr. Janice Eng, Department of Physical Therapy, UBC;

“GRASP ” means the Graded Repetitive Arm Supplementary Program, created by The Developers
at UBC, including related materials, information, manuals, documents and know-how.

Terms of Use
Use of GRASP is being licensed to you on the following terms and conditions:
• UBC owns GRASP and on your acceptance of these terms and conditions grants you a non-
exclusive, non-transferable license to use GRASP ;
• You acknowledge that the information contained in GRASP is intended for use only under the
supervision of an experienced physician OR a licensed health practitioner OR a trained
instructor, who are advised to use it only in conjunction with other sources of information, and in
keeping with acceptable best practices and standards of care. GRASP is not intended to replace
sound professional judgment in individual situations;
• You acknowledge and agree that any copies, modifications, and/or derivative works shall be
subject to the same terms and conditions as GRASP, as described herein, and that you accept
responsibility for keeping with acceptable best practices and standards of care in developing,
using, or distributing any such copies, modifications, and/or derivative works.

Disclaimer
The information included in GRASP is based on clinical research and is not intended to be fully
systematic or complete, nor does inclusion here imply any endorsement or recommendation by
UBC or the developers. Users are advised to consult with a physician or other healthcare
professional regarding any specific clinical situation or diagnosis. You hereby assume full
responsibility for ensuring the appropriateness of any use of GRASP, and you acknowledge that
neither UBC nor any of the developers of GRASP accept any responsibility for decisions made by
you based on the use of the GRASP materials and/or program.
Moreover, as a condition of using GRASP you acknowledge and agree that UBC and Developers
make no representations and extend no warranties of any kind, either express or implied about the
value or utility for any purpose of the information and resources contained in GRASP. Without
limiting the foregoing, you acknowledge that:
(a) You assume all risk for selection and use of information about GRASP and you acknowledge
that UBC and Developers will not be responsible for any errors, misstatements, inaccuracies or
omissions encountered in using GRASP; and
(b) The UBC and Developers undertake no obligation to supplement or update the content of
GRASP.

Limitation of Liability
UBC will not be liable to you or any other person or entity (including but not limited to persons
treated by you or on your behalf) for any liability, loss or damages caused or alleged to have been
caused, either directly or indirectly, by the use of GRASP. Without limitation, in no event will UBC
be liable for any tort, personal injury, medical malpractice, misdiagnosis, death, product liability,
loss of profit or data, or for special, indirect, consequential, incidental or punitive damages, however
caused and regardless of the theory of liability, arising out of or related to the use of or inability to
use GRASP, even if UBC has been advised of the possibility of such loss or damages.

2
 Welcome to the GRASP Program!

GRASP is a program designed to improve your arm and hand strength,

coordination, and your ability to use your stroke-affected arm in daily activities.
While GRASP is often started in the hospital and continued at home, it can be
started in the home setting.

Your therapist will help you learn the exercise program and check on your
progress weekly. Remember this is a HOMEWORK-based program so YOU are
responsible for doing your exercises daily and using your stroke-affected hand
as much as possible during your waking hours. This is the second version of the
Hospital GRASP which provides more guidance on progressing the exercises and
using your stroke-affected arm as much as possible for day to day tasks. We
hope that your family and friends will support and help you with your exercise
program.

Time Commitment:
We are asking you to do 1 hour of prescribed exercises 7 days a week for 4
weeks. You can divide the exercises up into two 30-minute sessions if you wish.
You are also responsible for trying to use your stroke-affected hand as much as
possible during the day.

Why do I need to spend so much time on these

exercises?
When you’ve had a stroke, some of the brain pathways are damaged and the
brain will try to repair these pathways as well as use other brain pathways.
However, THOUSANDS of CHALLENGING repetitions need to be practiced to
get these brain pathways active.

The GRASP program will help you activate key arm and hand muscles, so your
brain can re-learn how to control these muscles. It can be frustrating to
practice difficult exercises over and over again. However, research has shown
that the ability to repair the brain is greatest in the first 3 months following a
stroke. That is why it is important to do as much as you can safely tolerate now.
3
Why do I need to spend so much time on these
exercises?

Exercises that activate your arm and hand muscles can:

• Repair some of the brain pathways damaged from the stroke
•Strengthen and improve the range of motion of your stroke-
affected arm
•Improve your ability to use your stroke-affected arm in daily
activities
• Decrease pain in your stroke-affected arm, and improve life
satisfaction

We encourage you to use your stroke-affected hand

as much as possible during your regular daily
activities. See suggestions of how throughout the
manual.

How to be successful in this program:

1. Have regular prescribed time for the GRASP exercises

2. Monitor your progress by tracking your GRASP

exercise time

3. Ensure the GRASP exercises are challenging

4. Use the stroke-affected arm as

much as you can in your waking
hours 4
Progressing the Exercises

Work with your therapist to determine which level to start with for each
exercise. To make the exercise more challenging, there are multiple levels
available for some exercises. The exercises can be made more difficult by
increasing the number of repetitions in a set, increasing the resistance of the
weight or increasing the speed of the movement. Check in frequently with
your therapist to ensure that you are doing the exercises at the appropriate
level of difficulty. As you recover more finger control, ask your therapist if you
should move to the level 2 exercise manual which focuses much more on
hand and finger exercises.

Family/Caretaker Involvement

We encourage your family to do the exercise program with you. Here are
some ways they can be involved:

√ Encourage you to use your stroke-affected hand as much as possible

throughout the day when it is safe to do so
√ Help you to organize the exercise equipment for quick changes between
exercises
√ Help you to put exercise equipment away after each exercise is done
√ Keep track of your exercise time on the Daily Log Sheet (at end of book)
√ And most of all, help encourage and motivate!

Safety

Please tell your therapist as soon as possible if:

• pain stops you from doing your exercises
• you feel so tired after doing your exercises that you cannot participate fully
in your regular daily activities

5
 GRASP Commitment

As GRASP requires substantial commitment, it may not be appropriate for

everyone. We ask you to assess your own commitment to determine if this
program is realistic for you.

Participant living with a stroke

I will do the GRASP exercises ONE hour each day, seven times
a week starting ___________(date) and ending
__________(date).

How confident am I that I will do this? _______

Use a scale of 0 to 10, with 0 being not at all confident and
10 being completely confident.

Signed ____________________ (patient)

Family/Caregiver (if available)

I will assist _______________(patient name) with the GRASP

exercises ________times per week starting
__________(date) and ending _________(date)

How confident am I that I will do this? _______

Use a scale of 0 to 10, with 0 being not at all confident and
10 being completely confident.

Signed _____________________ (family/caregiver)

6
 Facility & Equipment

The exercises are meant to be completed in your home. A chair and table are
required as the exercises are best completed in a sitting position. The
following items are required for the Hospital GRASP Level 1. Ensure
equipment used in the GRASP program is frequently sanitized by regular dish
soap, sanitization solution or wipes.

Target Board – see

Wrist weight- 0.5-1lb Cup
template at end of book

Towel Hand Gripper- 5lb Theraputty

resistance

Tennis ball Beanbag

7
Structure of Exercises

This manual groups exercises into 4 sections.

Stretching

Arm Strengthening
Coordination

Hand Strengthening
8
Section 1: Stretching

The first section of exercises is to help warm-up your

upper extremities.

• Stretches should be done

slowly.
1.
• Stretches can be done in
between other exercises if
you feel your muscles are
2. getting tight

9
Total Arm Stretch

1. Sit straight in your

chair and lean
forward over your
knees.
2. Make sure that your
arms hang loosely
in a relaxed stretch.
3. You should feel a
pull through your
shoulders.
4. Hold the stretch for
a count of 10 and
then slowly
straighten up.
5. Repeat 2 times.

GRASP Level #1 Stretching

10
Shoulder Shrug
1. Sit in a chair with
your arms by your
side.
2. Make sure your
back is touching
the back of the
chair.
3. Raise your
shoulders
towards your ears
for a count of 3.
4. Return to starting
position.
5. Repeat 5 times

GRASP Level #1 Stretching

11
Hand & Wrist Stretch
1. Place your palms
together.
2. Push the left hand
against the right.
3. Hold for a count of
3.
4. Push the right hand
against the left.
5. Hold for a count of
3.
6. Repeat 5 times for
each side.

Tip:
If it is hard to put your
hands flat together, make
a fist with your weaker
hand and place your
stronger hand over top.

GRASP Level #1 Stretching

12
Use your stroke-affected hand
as much as possible today

Set your daily target

Today, I will use my stroke-affected hand

_____% of the time whenever I need to do
something with my arms or hands.

Try the below suggestions today. Try to use your stroke-

affected hand as much as possible with minimal help from
your stronger hand.

Dry yourself with Push lever to

Close a cupboard
towel after flush toilet
door
shower

13
Section 2: Arm Strengthening

The next section of exercises is for increasing arm strength.

• Your muscles should feel tired after each

set
1.

• The exercises should be difficult to do,

but not painful in any way
2.
• If your arm is stiffening up (hard to
move), perform the Total Arm Stretch to
3. relax your arm (page 9).

14
Push Ups
1. Place the table
against a wall
2. Place your hands on
the table, palms
down or you can
place your palms on
the edge of the
table.
3. Lean your chest
towards the table
for a count of 5.
4. Try to put as much
weight as you can
through your arms/
5. Push away from the
table for a count of
5.
6. Repeat 10 times.

Tip:
Try to put as much weight
through your weaker arm. If
you cannot put your weaker
hand flat on the table, place
your forearms on the table
and then do the push-up.

GRASP Level #1 Arm Strengthening

15
One Arm Push-Ups
1. Place your weaker
hand flat on the
table. Use your
stronger hand to
help keep your
hand in place.
2. Lean your chest
toward the table
for a count of 5.
3. Push away from
the table for a
count of 5.
4. Repeat this
exercise 10 times.

Tip:
Try to put as much weight as you can through your weaker
hand.

GRASP Level #1 Arm Strengthening

16
Shoulder Exercises: Arm to the Front

1. Place the weight

around your weaker
wrist or palm.
2. Raise your arm as
high as you can but
not higher than your
shoulder, for a count
of 3.
3. Lower your arm
down for a count of
3.

Tip: To help keep your

shoulder from hiking
up, place your
stronger hand on it.

☐ 2 sets of 5 repetitions
☐ 3 sets of 5 repetitions

GRASP Level #1 Arm Strengthening

17
Shoulder Exercises: Arm to the Side

1. Place the weight

around your
weaker wrist or
palm.
2. Raise your arm out
to the side as high
as you can but not
higher than your
shoulder, for a
count of of 3.
3. Lower your arm
down for a count
of 3.

Tip: To help keep your

shoulder from hiking
☐ 2 sets of 5 repetitions up, place your
☐ 3 sets of 5 repetitions stronger hand on it.

GRASP Level #1 Arm Strengthening

18
Elbow Exercises

1. Put the weight

around your
weaker wrist.
2. Place your hand,
palm up, on the
table
3. Keeping your
elbow on the
table, raise your
hand towards your
shoulder for a
count of 3.
4. Lower your hand
down for a count
of 3.

Tip: If you can’t raise your

hand to shoulder height, raise
☐ 2 sets of 5 repetitions
it as high as you can and then
use the other hand to assist.
☐ 3 sets of 5 repetitions

GRASP Level #1 Arm Strengthening

19
Wrist Exercises- Part I

1. Put the weight

around the fingers
and knuckles of
your weaker hand.
2. Put your forearm on
the table, palm
facing down.
3. Stabilize your
weaker arm with
your stronger hand.
4. Lift your wrist as
high as you can for a
count of 3.
5. Lower your wrist
down for a count of
3.

Tip:
☐ 2 sets of 5 repetitions Keep your forearm flat
☐ 3 sets of 5 repetitions on the table and focus
on lifting only the hand

GRASP Level #1 Arm Strengthening

20
Wrist Exercises- Part 2

1. Keep the weight on

your hand.
2. Place your arm on
the table with your
hand over the edge
of a table or binder.
3. Stabilize your
weaker arm with
your stronger hand.
4. Lift your wrist as
high as you can for a
count of 3.
5. Lower your wrist
down for a count of
3.

☐ 2 sets of 5 repetitions
☐ 3 sets of 5 repetitions

GRASP Level #1 Arm Strengthening

21
Total Arm Stretch
1. Sit straight in your
chair and lean
forward over your
knees.
2. Make sure that
your arms hang
loosely in a relaxed
stretch.
3. You should feel a
pull through your
shoulders.
4. Hold the stretch
for a count of 10
and then slowly
straighten up.
5. Repeat 2 times.

GRASP Level #1 Stretching 22

Use your stroke-affected hand as
much as possible today

How often did you use your stroke-

affected hand yesterday? (for
example, 50% of the time during
tasks that required hand use)

Think of some challenging (but safe) ways that you

can use your stroke-affected hand more. For
example, use your stroke-affected hand today to…

Brush
Brush Eat your
your
your hair lunch
teeth

If your stroke-affected hand is your non-dominant

hand (left, for most people), you might not use it
much. To maximize your hand recovery, brush your
hair or hold your phone in your stroke-affected
hand, even if you usually use your other hand.

23
Section 3: Hand Strengthening

The next section of exercises is for increasing the strength

of your hand. Here are some tips:

• Your muscles should feel tired after each

set
1.

• If your hand muscles are stiffening up,

try the hand and wrist stretch (page 11).
2.

• Instead of using the gripper (on page 24),

use the ball.
3.

24
Grip Power

1. Place your weaker

arm on the table.
2. Place the gripper
in your palm
between your
knuckles and your
thumb pad.
3. Squeeze the
gripper as hard as
you can for a count
of 3.
4. Relax your hand
for a count of 3.

☐ 2 sets of 5 repetitions
☐ 3 sets of 5 repetitions
☐ 2 sets of 8 repetitions

GRASP Level #1 Hand Strengthening 25

Squeeze the Ball

1. Place your weaker

arm on the table.
2. Place the ball in
your hand and
squeeze as hard as
you can for a count
of 5.
3. Relax your hand
for a count of 5.

☐ 2 sets of 5 repetitions
☐ 3 sets of 5 repetitions
☐ 2 sets of 8 repetitions

GRASP Level #1 Hand Strengthening 26

Finger Power

1. Place the putty on

the table and roll
into a thick rope. Use
your weaker hand as
much as possible.
2. Take each finger of
your weaker hand,
starting with your
thumb, and push
into the putty.
3. After your finish all 5
fingers, re-roll the
putty with your
weaker hand.
4. Do this whole
sequence 5 times.

Tip: Get a stiffer putty if

this exercise is easy. Do
not hyper-extend the
fingers – that is don’t
bend the fingers
backward.

GRASP Level #1 Hand Strengthening 27

Use your stroke-affected hand
as much as possible today
during walking hours

Think of 3 challenging (but safe) ways that

you will use your stroke-affected hand
today.

Open the Brush your Eat your

Door teeth lunch

28
Section 4: Coordination

The next section of exercises is to help increase

coordination and increase your ability to do your day to
day activities. If you find your arm is tired or stiffening up
(hard to move), try the following:

• Decrease the amount of

repetitions you perform, but
increase the number of sets
1. with rests in between

• Rotate between doing exercise

with your weaker and stronger
2. arm/hand.

29
Waiter

1.Place the object

(beanbag or ball) in
your weaker hand.
2.Place the object on the
1st dot. Leave the
objectl on the dot and
return your weaker
hand in your lap.
3.Then reach with your
weaker hand to pick up
the object, placing it
on 2nd dot. Continue
this pattern until you
have placed the object
on each dot. Release
and return your hand
to your lap each time.
4.Once you have finished
the arc, start at dot 5
and re-trace your
steps. Release and
return your hand to
your lap each time.
5.Repeat the whole
sequence 3 times. ☐ Use ball
6.Then, repeat the whole ☐ Use beanbag
sequence as fast as
you can 2 times!

GRASP Level #1 Coordination 30

Waiter – Cup
1. Place a cup in your
weaker hand.
2. Place the cup on the
1st dot. Leave the
cup on the dot and
return your weaker
hand in your lap.
3. Then reach with
your weaker hand
to pick up the cup,
placing it on 2nd dot.
Continue this
pattern until you
have placed the cup
on each dot.
Release and return
your hand to your
lap each time.
4. Once you have
finished the arc,
start at dot 5 and
re-trace your steps. Tip: If possible, grasp the
Release and return side of the cup as if you
your hand to your were going to drink from
lap each time. it, not the top of the cup
5. Repeat the whole
sequence 2 times.

GRASP Level #1 Coordination 31

Start the ball rolling with a
partner
1. Sit at each end of
the long side of
the table.
2. Roll or push the
ball back and
forth with your
weaker hand.
3. Roll the ball
between you so
each person
catches the ball
10 times.
4. Now do it as fast
as you can 10
times.

GRASP Level #1 Coordination 32

Start the ball rolling- no partner

1. Place your hands

shoulder width
apart.
2. Roll or push the
ball back and
forth between
your hands.
3. Continue until
you have caught
the ball with your
weaker hand 20
times.

Modification:
If this is easy for your, try
rolling the ball faster or
placing your hands
further apart.

If this is hard for you, use

the bean bag and push it
towards each hand.

GRASP Level #1 Coordination 33

Start the ball rolling- Advanced

1. Place your
weaker hand in
your lap and your
stronger on the
table.
2. Roll or push the
ball and try to
catch the ball
with your weaker
hand.
3. Return your
weaker hand to
your lap between
each roll.
Continue until
you have caught
the ball with your
weaker hand 20
times.

GRASP Level #1 Coordination 34

Wash Cloth Twist

1. Take the towel and

fold in half length
wise.
2. Place one hand on
each end of the
towel.
3. Twist the towel
back and forth like
you are wringing
out a wet wash
cloth. Make sure
your weaker hand
is doing the work.

☐ 2 sets of 5 repetitions
☐ 3 sets of 5 repetitions
☐ 2 sets of 8 repetitions

GRASP Level #1 Coordination 35

Have you completed one hour
of exercise?

If it took you less than one hour to complete your

exercises, you can start with the last exercise (Wash Cloth
Twist) and move backwards in the book until at least one
hour has passed.

The MORE you activate your muscles and move your arms and
hands, the more your brain re-learns how to control the
muscles!

The exercises should be so difficult that you drop or

mishandle an object 1 out of every 5 repetitions.

Here are some ideas to increase the challenge:

• Increase the repetitions
• Increase the weight
• Try to do the exercises faster
• Ask your therapist if the Level 2 Manual might be
appropriate for you if you are finding the exercises
easy

36
Congrats on finishing your exercises today. Record the
number of minutes you practiced the exercises today in
your log sheet (next page).

Set your daily target.

Today, I will use my stroke-affected hand
_____% of the time whenever I need to do
something with my arms or hands.

Use your stroke-affected hand as much as possible today!

Try these examples below today:

Make your Turn off light Open a

bed switch drawer

37
 GRASP Log Sheet
Customize the calendar by writing in month and dates on the lines. Write the
number of minutes you did GRASP exercises each day. Note unusual events such
as flu or surgery that may have prevented GRASP practice. Also note if pain or
excessive fatigue.

Month: _________

Day Mon Tues Wed Thur Fri Sat Sun

_____ _____ _____ _____ _____ _____ _____

GRASP
minutes
_____ _____ _____ _____ _____ _____ _____

GRASP
minutes
_____ _____ _____ _____ _____ _____ _____

GRASP
minutes
_____ _____ _____ _____ _____ _____ _____

GRASP
minutes
_____ _____ _____ _____ _____ _____ _____

GRASP
minutes

38
 GRASP Progress Tracker
Items #Sets #Reps Easy? Note/Tips
Hard?
1 Total Arm Stretch
2 Shoulder Shrug
3 Hand and Wrist Stretch
4 Push-ups
5 One Arm Push-ups
6 Shoulder exercise: Arm to
Front
7 Shoulder exercise: Arm to
Side
8 Elbow Exercise
9 Wrist Exercises – Part 1
10 Wrist Exercises – Part 2
11 Grip Power
12 Squeeze the Ball
13 Finger Power
14 Waiter
15 Waiter- Cup
16 Start the Ball Rolling
17 Start the Ball Rolling – no
partner
18 Start the Ball Rolling –
Advanced
19 Wash Cloth Twist

39
Target Board Print-Out

1
40
4

5
41