TOPUPS: Therapy Options for the Upper Limb Study Investigating the effects of a 4-week physiotherapy programme delivered 3 months after stroke

Participants will be offered a 4-week physiotherapy programme beginning at 3 months post-stroke. The hand and arm therapy programme will be delivered by either a registered physiotherapist or registered occupational therapist. This programme will include 24 sessions in total (6 sessions per week, one hour per session), where 12 sessions are supervised by a research physiotherapist interleaved with 12 sessions completed as independent practice. Supervised sessions are individualised and will be delivered either in person or via telehealth (video call). There will be three groups with varying numbers of in-person and telehealth sessions. These groups are: - 12 in person sessions, no telehealth sessions - 6 in-person sessions, 6 telehealth sessions - 2 in-person sessions, 10 telehealth sessions All supervised therapy sessions which take place in person may occur either at the University of Auckland, or at the participant's home, depending on the mode of delivery of a session and participant preference. Independent practice sessions will take place at the participant's home, and will follow a similar structure and include similar exercises to the supervised sessions. Assistance will be provided to participants to set up appropriate video calling software on a device for telehealth sessions. If a participant does not have a suitable device required for telehealth sessions, the researchers will provide a tablet on loan for the duration of the programme. The therapy programme that will be utilised for this study is the Accelerated Skills Acquisition Program, developed by Prof. Carolee Winstein. This standardised programme is a task-oriented, patient centred upper limb programme using conventional physiotherapy and occupational therapy techniques such as strength training and constraint-induced movement therapy. This therapy programme has been used in previous clinical trials carried out by Professor Winstein and will be adapted for the purposes of this study. Therapy sessions will be tailored to each participant, based on goals identified by each participant that represent real-world tasks. Goals for the therapy programme will be identified at three months post-stroke, prior to beginning the programme. Examples of possible goals include tasks such as carrying groceries 10 m into the house from the car, or being able to button up a shirt. Where needed, researchers will provide equipment for the key tasks for each participant. Adherence to the programme will be encouraged through providing each participant with a diary to log their independent practice sessions. The research therapist will be prompted to review the therapy plans for each participant weekly. The intensity of the supervised and independent sessions will be prescribed using repetitions and task difficulty. For instance, intensity of task practice can be progressed by increasing the number of repetitions that the participant is asked to complete. Intensity can also be progressed by increasing the weight and/or size of objects being lifted or handled. Intensity of fine motor tasks can also be progressed by decreasing the size of objects being handled. Overall, the intensity of practice completed during supervised and independent sessions will be carefully progressed by the research therapist, using combinations of increased repetitions and task difficulty, depending on the goals and current abilities of the participant. Note that for this study, participants will have three baseline assessments between 2 and 3 months post-stroke before beginning a therapy programme, to monitor recovery progress before the intervention. During this time, some participants may achieve a motor outcome by 3 months post stroke which is too good to continue with the planned programme (defined as an ARAT score of more than 45 points out of 57). These participants will instead be offered a 4-week home programme to complete. This programme will include six one-hour sessions per week of independent practice. Participants will be prescribed exercises based on their personalised task goals, similar to the supervised therapy programme. They will receive weekly video calls with a research therapist during this time, which will help them to progress their therapy programme. Participants will be provided with a diary to record their therapy and report it to researchers, if they wish to do so. The quantitative data from these participants will not be included in the study analyses.