Abstract
Introduction
Early after stroke, inpatients commonly experience difficulty performing activities of daily living (ADL). Occupational therapists are key to providing early rehabilitation to optimise recovery. However, the effectiveness of early, activity‐based retraining of ADLs is not clear. The aim of this systematic scoping review is to determine whether activity‐based retraining targeting basic activities of daily living (b‐ADL) and/or simple cognitive instrumental activities of daily living (C‐IADL) delivered early after stroke improves functional independence.
Methods
MEDLINE, CINAHL, and Embase were searched. Eligible studies included randomised controlled trials or quasi‐randomised trials, with at least 75% of participants over the age of 18, with a stroke diagnosis, and who received activity‐based interventions within the hospital setting. Articles were screened by two authors using Covidence. Risk of bias was assessed using Cochrane's Risk of Bias tool (RoB2). All results were meta‐analysed using Comprehensive Meta Analysis software (V4.0).
Consumer and community involvement
No consumer or community involvement was included in this study.
Results
A total of 7546 articles were screened, and six studies including n = 254 participants met the inclusion criteria. Performance outcome measure results were meta‐analysed; there was no statistically significant impact of activity‐based interventions on functional performance (standardised mean difference [SMD] = 0.41; 95% confidence interval [CI] −0.06, 0.87; P = 0.09). Two studies reviewed quality of life and satisfaction outcomes; data were not synthesised.
Conclusion
Whereas individual trials suggested improvements early after activity‐based training, our meta‐analysis showed variability in effects in trials to date. Further research is required to determine the clinical and cost‐effectiveness of activity‐based interventions within the hospital setting to guide occupational therapy practice.
Keywords: ADL, hospital, occupational therapy, rehabilitation, stroke
PLAIN LANGUAGE SUMMARY
After stroke, a person may struggle to do the activities they could do before the stroke, meaning they may need to relearn how to complete certain activities. Occupational therapists may use practice of activities to help people. These activities could include dressing or showering. We looked at studies that had tested practising activities to see if they worked. For example, does practising dressing improve someone's dressing ability? We found six studies. We need more studies to know if practising activities in the hospital helps.
Key Points for Occupational Therapy.
Dressing was the most common activity‐based task studied in the hospital setting.
Further targeted research is required to guide occupational therapy clinical practice recommendations.
Occupational therapists should continue to monitor the effectiveness of activity‐based interventions in hospital settings.
1. INTRODUCTION
After stroke, half of people who receive post‐acute stroke care will experience a level of disability that impacts their ability to complete everyday activities (Stroke Foundation, 2020). Stroke is a leading cause of disability for adults (World Health Organisation, 2020), and occupational therapists play an important role early after stroke to address disability. Internationally, systematic reviews and guidelines, including the Australian Stroke Foundation Guidelines, recommend occupational therapy assessment of capability and treatments to optimise independence in activities of daily living (ADL) (Govender & Kalra, 2007; Hildebrand et al., 2023; Intercollegiate Stroke Working Party, 2023; Legg et al., 2017; Rowland et al., 2008; Stroke Foundation, 2023; Winstein et al., 2016; Winterbottom et al., 2023).
Early rehabilitation, inclusive of occupational therapy, is recommended within the first week to month after stroke and is associated with functional improvements (Bernhardt et al., 2017; Biernaskie et al., 2004). Recent research recommends that within Australia, rehabilitation should be prioritised in line with neurological recovery timeframes (Christie et al., 2025). The acute setting has a unique opportunity to engage stroke survivors in early rehabilitation, with the average length of stay in acute care being 5 days within Australia (Lynch et al., 2017). Whereas assessment for rehabilitation need is increasing in the acute hospital setting, less than one quarter of inpatient rehabilitation units offer the recommended amount of therapy (Christie et al., 2025). Access to early rehabilitation within Australia can be optimised not only to improve outcomes for the benefit of stroke survivors but also to reduce the demand on community services (Lynch et al., 2019).
ADLs are the everyday tasks completed by an individual and are often divided into multiple domains to highlight their varying complexity. One method of classification as described by Toglia and Foster (2021) includes basic activities of daily living (b‐ADL) and cognitive instrumental activities of daily living (C‐IADL), both simple (simple C‐IADL) and complex (complex C‐IADL). Basic ADLs ‘rely heavily on physical abilities and procedural memory’ (Toglia & Foster, 2021) and include activities such as self‐feeding, dressing, grooming, and showering, whereas cognitive‐IADLs refer to those activities that require higher level executive functioning skills such as shopping. Simple C‐IADLs are instrumental tasks that ‘are more familiar, contain fewer steps and require less planning or problem solving’ (Toglia & Foster, 2021), such as preparing a hot drink, preparing a simple meal, or folding clothing. Complex C‐IADLs are tasks that are less predictable, involve multitasking, and are typically less structured (Toglia & Foster, 2021).
An early systematic review by Legg et al. (2007) concluded that occupational therapy improves personal ADL outcomes after stroke and recommended further research to identify which specific interventions represent best practice. A subsequent Cochrane review demonstrated that ADL‐focussed occupational therapy delivered in the community improves ADL independence among stroke survivors (Legg et al., 2017). However, evidence for activity‐based interventions in the hospital setting remains limited. A recent systematic review found no significant effect of occupation‐specific interventions on quality of life or activity performance for stroke survivors. However, the authors cautioned that both control and experimental groups received occupation‐specific interventions, making it difficult to isolate the effectiveness of occupation‐specific interventions in comparison to other strategies (Triantis & Liu, 2024). Observational evidence suggests that intensive hospital rehabilitation is associated with improved ADL performance at discharge (Tani et al., 2023), but further research is needed to determine the effectiveness of specific occupational therapy interventions delivered in the inpatient setting.
Therefore, the aim of our study was to determine whether occupational therapist‐led activity‐based interventions designed to target b‐ADLs and simple C‐IADLs within the hospital setting increase functional independence in stroke survivors.
2. METHODS
This systematic review was conducted using the methodological guidelines for authors of Cochrane systematic reviews (Deeks et al., 2023) and is reported in adherence to the standards outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) statement (Moher et al., 2009). The systematic review protocol was registered on PROSPERO 2024 CRD42024562195 (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=562195) prior to commencement (5 July 2024) and published.
2.1. Search strategy
The search strategy was developed in consultation with senior researchers (K. W., A. E. D., and N. A. L.) and drew on the Cochrane Stroke Group tailored search strategies (Legg et al., 2017). Three databases were searched, including Embase (via Ovid), MEDLINE, and CINAHL, from inception until 31/07/2025. Details of the search strategy are outlined in Supporting Information File A.
All articles were screened at title and abstract by one author (T. G., L. J., J. G., D. S., or N. A. L.), and all excluded articles were reviewed by an experienced occupational therapist (K. W.). Full‐text articles were reviewed by two authors (T. G. and N. A. L.), and any disagreements were discussed in the first instance. For articles where a consensus could not be reached, a third researcher within the team was consulted (K. W.). Justification for articles excluded at full text is outlined in Supporting Information File B.
2.2. Study selection
2.2.1. Eligibility criteria
To be eligible for inclusion, studies must have been randomised controlled trials or quasi‐randomised trials and must have involved adult participants following stroke (in mixed population trials, at least 75% of the sample had to have experienced stroke). The intervention of interest was activity‐based retraining, delivered within the domain of an occupational therapist. Activity‐based retraining had to target b‐ADL and/or simple C‐IADL as these are activities able to be trained in the inpatient hospital context. The comparison group must have also received no occupational therapy input, or occupational therapy input not specific to activity‐based retraining, or intervention not defined in the control group. Studies were included if they reported measures of function, either global or specific. Where possible, direct measures of activity performance were used, for example, performance on the same b‐ADL or simple C‐IADL activity that had been trained. When multiple measures of functional performance were reported, the Barthel Index was used in meta‐analyses as it was one of the most used outcome measures. The impact interventions had on quality of life (Stroke Impact Scale, Short Form‐36) and satisfaction (Canadian Occupational Performance Measure [COPM]: Satisfaction and Client Satisfaction Questionnaire) were also examined.
Studies including virtual reality retraining or community‐based interventions were excluded as the focus of our systematic review was on real‐life performance within the inpatient hospital setting. Studies with a control group involving activity‐based retraining were excluded. We also excluded studies that only included complex C‐IADL task practice due to the higher cognitive demand required for successful performance. These decisions were made a priori and on consensus by the authors, given our focus on the early stage of rehabilitation and the hospital environment.
We summarised all included studies using the Template for Intervention Description and Replication (TIDieR) Checklist (Hoffman et al., 2014) and described the interventions using the Occupational Therapy Practice Framework: Domain and Process Fourth Edition (OTPF; American Occupational Therapy Association, 2020). The OTPF tool provided a comprehensive framework for describing the range of occupational therapy approaches and was selected to support the translation of systematic review findings into occupational therapy practice (American Occupational Therapy Association, 2020).
2.3. Data extraction and appraisal
The relevant details were extracted from the included trials by one author (T. G.) and cross‐checked by the senior author (N. A. L.). Information about the method (i.e., design, participants, intervention, and measures) and results (i.e., number of participants and mean [SD] outcome scores) was extracted. Where information was not available in the published trials, details were requested from the author listed for correspondence. Details of the interventions delivered were extracted by one author (T. G.) against the TIDieR Checklist (Hoffman et al., 2014) and OTPF tool (American Occupational Therapy Association, 2020).
2.4. Trial quality
Study quality was appraised using the PEDro scale to examine risk of bias (Maher et al., 2003). Scores published on the OT Seeker or PEDro websites were used when available. When the PEDro score was not available online, two reviewers (T. G. and N. A. L.) completed ratings independently. In addition, the RoB2 risk of bias tool was completed independently by two authors (T. G. and K. W.). When disagreements occurred with rating scores, these were resolved through discussion.
2.5. Strength of evidence
The level of evidence was reviewed by two authors (T. G. and K. W.) according to the Oxford Centre for Evidence‐Based Medicine Working Group (2009). The overall strength of evidence was determined using the U.S. Preventive Services Task Force (2018) guidelines.
2.6. Data synthesis
All data were initially reviewed, and most studies reported pre‐ and post‐intervention mean ± SD; therefore, these data were used to obtain the pooled estimate of the effect of intervention. To determine the effect of activity‐based interventions, change scores were used in the meta‐analysis. Because different scores were reported, data were converted as per the Cochrane Handbook of Systematic Reviews (Deeks et al., 2023) and using the Campbell Collaboration calculator and computational options within Comprehensive Meta Analysis software. The senior author (N. A. L.) reviewed extracted data for all studies prior to the meta‐analysis. Data were entered into the Comprehensive Meta Analysis software (V4.0). Because different measurement tools were used across questions, pooled estimates of the effects were obtained using a random‐effects model and reported as a Cohen's standardised mean difference (SMD, 95% confidence interval [CI]). The I2 statistic was used as a guide to determine the impact of heterogeneity; as heterogeneity was present, a random‐effects model was used. Sub‐group analyses were planned a priori for meta‐analysis, including quality of life and satisfaction. However, only two articles measured these outcomes, so meta‐analysis was not conducted.
2.7. Positionality statement
All authors of this review are occupational therapists with clinical experience in stroke rehabilitation within hospital settings and identify as female. Our professional backgrounds have shaped our interest in activity‐based approaches, including the practice of daily activities such as dressing and showering, as central to occupational therapy practice after stroke. We acknowledge that our professional roles may introduce bias towards intervention‐focussed outcomes and hospital‐based models of care.
As clinicians and researchers trained within biomedical and rehabilitation paradigms, we value approaches that aim to improve functional independence and participation in daily life, and evidence‐based practice. Whereas the perspective of a traditional hierarchy of evidence supports structured and transparent synthesis, it may also have limited consideration of other forms of knowledge not captured in quantitative studies. Together, these perspectives may have influenced how we framed the research question, interpreted the findings, and considered clinical relevance.
3. RESULTS
3.1. Included studies
Following removal of duplicates, 7546 references were retrieved and screened on title and abstract. Following screening of full texts, six studies were included in the review (see PRISMA flow chart, Figure 1).
FIGURE 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) flow chart, detailing the flow of studies through the review (Moher et al., 2009). Some articles may have been excluded due to not meeting more than one of the inclusion criteria.
3.2. Study characteristics
The characteristics of the six included studies are outlined in Table 1 and further detailed below.
TABLE 1.
Studies included in the review.
| Activity‐based interventions | |||||
|---|---|---|---|---|---|
| Author/year | Level of evidence Study design Risk of bias | Participants Study setting | Intervention and control groups | Outcome measures | Results |
| Task‐based (part or whole) practice | |||||
| Choi (2022) |
Level 2B RCT Risk of bias: Moderate |
Participants: N = 20 Age: 57.1 years (SD 10.78); Sex: 15 M, 5 F; Stroke type: 13 ischaemia, 7 haemorrhage; Presence and side of hemiplegia: 11 left, 9 right; Time post‐stroke: Not reported Study setting: Acute |
Intervention: Task‐orientated training (n = 10). Facilitated by an occupational therapist, 30 min × 5/week × 6 weeks Control: Table top activity training (n = 10). Facilitated by an occupational therapist, 30 min × 5/week × 6/week |
ADL
Follow up: 0 baseline, 6‐week post‐intervention follow‐up |
Significant findings: Significant group‐by‐time interaction was found for the mean score. Non‐significant findings: However, the main effect was not significant between the control and intervention groups. |
| Edmans et al. (2000) |
Level 2B RCT Risk of bias: Low |
Participations: N = 80 Age: 68.8 years (SD 10.28); Sex: 40 M, 40 F; Stroke type: Not reported; Presence and side of hemiplegia: 45 left, 35 right; Time post‐stroke: Not reported Study setting: Subacute |
Intervention: Functional approach completed by research and ward occupational therapist; 150 min per week × 6 weeks Control: Transfer of training approach completed by occupational therapists; sessions were 150 min/week × 6 weeks |
ADL
Follow up = 0 baseline, 6‐week post‐intervention follow‐up |
Significant findings: Nil Non‐significant findings: No significant differences between functional retraining or transfer of training approach on initial or final ADL outcome measures. |
| Ertas‐Spantgar et al. (2022) |
Level 2B RCT Risk of bias: Low |
Participants: N = 30 (n = 24 analysed) Age: 65.58 years (SD 14.94); Sex: 9 M, 15 F; Stroke type: Not reported; Prescence and side of hemiplegia: Not reported; Time post‐stroke: Not reported; Other: Neglect: 11 right, 8 left, 4 non‐existent, 1 unknown; Apraxia: 9 evident, 15 non‐existent Study setting: Subacute—Rehabilitation unit* |
Intervention: Errorless learning by using the RehaGoal App, completed by a ‘therapist’, 45 min × 7 sessions across 2× weeks. Control: No intervention Both the control and intervention groups received 5 h of daily neurorehabilitation (NP/OT/PT/nursing) |
ADL
|
Significant findings: Errorless learning with the RehaGoal App had no effect on dressing ability. |
| Kim and Park (2019) |
Level 2B RCT, pilot study Risk of bias: Low |
Participants: N = 20 Age: 59.5 years (SD 8.33); Sex: 8 M, 12 F; Stroke type: 10 ischaemia, 10 haemorrhage; Presence and side of hemiplegia: 9 left, 11 right; Time post‐stroke: 8.9 months (SD 2.09); Study setting: Subacute |
Intervention: Occupation‐based bilateral upper extremity training delivered by 5× occupational therapists with 5 years of clinical experience, 5/week × 4 weeks Control: Task‐based bilateral upper extremity training, delivered by 5 occupational therapists with 5 years of clinical experience, 5/week × 4 weeks Both control and intervention groups: Conventional rehabilitation therapy, 30 min × 2 daily × 4 weeks |
ADL
Satisfaction:
Quality of life:
0‐week baseline measure, 4‐week post‐intervention follow‐up |
Significant findings: Statistically significant improvement in the treatment than the control group on performance and satisfaction of occupational performance, ADL, and IADL on the SIS and satisfaction. Non‐significant findings: Nil |
| Landi et al. (2006) |
Level 2B RCT Risk of bias: Moderate |
Participants: N = 50 Age: 76.6 years (SD 10.22); Sex: 23 M, 27 F; Stroke type: 50 ischaemia, 0 haemorrhage; Prescence and side of hemiplegia: Not reported; Time post‐stroke: Not reported; Other: ADL living score: 30.75 (SD = 6.93) Intervention setting: Subacute |
Intervention: Combined rehabilitation programme based on occupational therapy and physiotherapy: ‘Individualized specific program based on the personal activities of daily living’ 180 min daily × 8 weeks Control: Physiotherapy, no input from occupational therapists 180 min daily × 8 weeks |
ADL:
Follow‐up: 0‐week baseline measure, 8‐week post‐intervention follow‐up |
Significant findings: Statistically significant improvements were observed for transfers, loco‐motion, dressing, and personal hygiene in favour of the intervention group. Non‐significant findings: Improvement for eating and toilet use was found in the intervention group. However, it did not reach statistical significance. |
| Combination of task‐based practice and education | |||||
| Tomori et al. (2015) |
Level 2B RCT, parallel group, multicentre Risk of bias: Low |
Participants: N = 54 Age: 66.22 years (SD 10.64); Sex: 36 M, 18 F; Stroke type: Not reported; Presence and side of hemiplegia: 27 left, 26 right; 1 bilateral Time post‐stroke: Not reported; Other: MMSE: 26.35 (± 2.86) Study setting: Subacute |
Intervention: Occupation based, delivered by occupational therapists, max 180 min/day Control: Impairment based, delivered by occupational therapists |
ADL:
Satisfaction:
Quality of life:
Follow‐up: 2‐month post‐intervention follow‐up |
Significant findings: Nil Non‐significant findings: General health and role‐emotional in the SF‐36 significantly increased in the post‐intervention group. |
Abbreviations: ADL, activities of daily living; ad‐NSDA, Adapted Nottingham Stroke Dressing Assessment; COPM, Canadian Occupational Performance Measure; F, female; FIM, Functional Independence Measure; M, male; MSD‐PAC ADL, minimum data set post‐acute care activities of daily living scale; RCT, randomised controlled trial; SD, standard deviation; SF‐36, 36‐item Short Form Survey.
Historical study not included, only intervention study.
3.2.1. Setting
Most studies were conducted within a subacute hospital setting (n = 5); the remaining study by Choi (2022) was conducted within the acute hospital setting. Two studies were completed in Korea (Choi, 2022; Kim & Park, 2019), and one study was completed in Italy (Landi et al., 2006), Japan (Tomori et al., 2015), Germany (Ertas‐Spantgar et al., 2022), and the United Kingdom (Edmans et al., 2000).
3.2.2. Participants
The six included studies comprised a total of n = 254 participants, with study sample sizes ranging from 20 to 80 participants. The mean age of participants in the included studies ranged from 57 to 77 years. Four out of the six studies (Choi, 2022; Edmans et al., 2000; Kim & Park, 2019; Tomori et al., 2015) reported on the presence and side of hemiplegia; of those who reported, between 50% and 56% of participants had a left‐sided hemiparesis, with only one study having a participant with bilateral upper limbs affected (Tomori et al., 2015). Although not all studies reported the type of stroke, for the two that did, ischaemic stroke represented 50% (Kim & Park, 2019) and 65% (Choi, 2022). Refer to Table 1 for full details of participant characteristics.
3.2.3. Outcomes
ADL performance was measured across all six studies; outcome measures included the Barthel Index (Edmans et al., 2000; Ertas‐Spantgar et al., 2022), the Korean Modified Barthel Index (Choi, 2022), the COPM (Kim & Park, 2019), the minimum data set post‐acute care (MDS‐PAC) ADL scale (Landi et al., 2006), the Functional Independence Measure (Tomori et al., 2015), the Edmans ADL Index (Edmans et al., 2000), and the Adapted Nottingham Stroke Dressing Assessment (Ertas‐Spantgar et al., 2022).
Two studies measured quality of life using the Short Form Survey (SF‐36) (Tomori et al., 2015) or the Stroke Impact Scale (Kim & Park, 2019). These same studies also measured satisfaction using a client satisfaction questionnaire (Tomori et al., 2015) or the COPM – Satisfaction subscale (Kim & Park, 2019). Given only two studies measured these outcomes, we were unable to meta‐analyse these data.
3.2.4. Risk of bias
All studies were deemed to be Level 2B studies as per the Oxford Centre for Evidence‐Based Medicine Working Group (2009) as illustrated in Table 2. Four studies were ‘low’ risk of bias, and two were ‘moderate’ risk of bias as scored according to the RoB2 (see Table 2 and Supporting Information File C).
TABLE 2.
RoB2 for included papers (n = 6).
| Citation | Selection bias (risk of bias arising from randomisation process) | Performance bias (effect of assignment to intervention) | Detection bias | Attrition bias Incomplete outcome data (data for all or nearly all participants) | Reporting bias Selective reporting (results being selected for reporting on the basis of the results?) | Overall risk‐of‐bias assessment Overall risk‐of‐bias assessment (low, moderate, high risk) | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Random sequence generation | Allocation concealment (until participants enrolled and assigned) | Baseline differences between intervention groups (suggest problem with randomisation?) | Blinding of participants during the trial | Blinding of study personnel during the trial | Blinding of outcome assessment: Self‐reported outcomes | Blinding of outcome assessment: Objective outcomes (assessors aware of intervention received?) | ||||
| Choi (2022) | + | − | + | − | − | ? | − | − | + | Moderate |
| Edmans et al. (2000) | + | + | − | − | − | ? | + | + | + | Low |
| Ertas‐Spantgar et al. (2022) | + | + | + | − | − | ? | + | − | + | Low |
| Kim and Park (2019) | + | + | + | − | − | ? | − | + | + | Low |
| Landi et al. (2006) | − | − | + | − | − | ? | + | + | + | Moderate |
| Tomori et al. (2015) | + | − | + | − | − | ? | + | + | + | Low |
3.3. Activity‐based interventions
‘Occupation based’ as a term refers to participation in daily life activity within context and in a meaningful manner (American Occupational Therapy Association, 2020). In contrast, activity based is a term that is not specifically related to a person's context or completed in its entirety; instead, they are components of occupations often used within therapy to assist in building on one's abilities or maintaining capabilities (American Occupational Therapy Association, 2020). Both occupation‐based and activity‐based interventions are evident within occupational therapy retraining.
All six studies evaluated the effectiveness of activity‐based retraining interventions delivered face to face in an inpatient hospital setting. The interventions administered were activity based, such as practising putting on a t‐shirt only (Ertas‐Spantgar et al., 2022) or practising the use of chopsticks outside meal time (Choi, 2022); occupation based (Kim & Park, 2019), such as applying makeup, getting dressed, or ironing; or compensatory, including provision of assistive technology for self‐care tasks (Landi et al., 2006). One study included a combination of interventions, including tasks that were both activity and occupation based (Landi et al., 2006). Tomori et al. (2015) evaluated the effectiveness of a combination of education and task‐based practice, involving tasks at both an activity (e.g., using chopsticks to move a sponge in simulated practice ‘to promote skills and activity patterns’) and occupation‐specific level (e.g., eating with chopsticks). One study specified using a ‘functional approach’. However, it was unable to be determined if the approach was activity or occupation specific (Edmans et al., 2000).
Specific activities included in the interventions included b‐ADL activities such as dressing (n = 5), toileting (n = 1), showering (n = 2), feeding oneself (n = 3), and grooming (n = 1). In terms of simple C‐IADLs, interventions focussed on cleaning/laundry (n = 3) and cooking (n = 2). Kim and Park (2019) also reviewed complex C‐IADLs, which were unable to be differentiated from simple C‐IADLs due to the nature of the reporting of the results, and therefore, all results were included.
ADL types have been informed by the Multicontext Approach for Cognitive Rehabilitation (Toglia & Foster, 2021), with the interventions being categorised based on the types of occupational therapy interventions outlined in the Occupational Therapy Practice Framework within the TIDieR template (see Supporting Information File D). Four of the six studies included patient‐centred goal setting. Tools used to complete goal setting included the COPM (Kim & Park, 2019; Tomori et al., 2015), the Goal Attainment Scale (Tomori et al., 2015), and the RehaGoal App (Ertas‐Spantgar et al., 2022). One study did not mention collaborative goal setting and reported that the treatment goal was to improve functional independence (Landi et al., 2006). Choi (2022) highlighted that the tasks included in the intervention programme were selected based on patient counselling.
The duration of therapy provided for participants in intervention groups in five studies ranged significantly between 150 and 900 minutes per week. The exact time frame of therapy provided by Kim and Park (2019) was unclear. However, it was a minimum of five sessions per week. The intervention periods within studies ranged between 2 and 8 weeks.
3.4. Effectiveness of activity‐based interventions for stroke survivors within the inpatient setting
ADL performance measures for all six studies were meta‐analysed using a random‐effects model and SMD. There were no statistically significant differences in activity‐based interventions in comparison with control interventions (SMD = 0.41; 95% CI −0.06, 0.87; P = 0.09) (see Figure 2).
FIGURE 2.
Activities of daily living (ADL) performance.
4. DISCUSSION
This review found insufficient evidence to yet recommend commencing activity‐based rehabilitation early after stroke (i.e., in the inpatient hospital setting). The six studies to date have used varied methods of measurement, and whereas a small to moderate effect is suggested in our findings, the wide CI indicates variability across studies and a need for further, targeted research. Although in‐hospital evidence is limited, there is stronger evidence that activity‐based rehabilitation is beneficial in the community (post‐hospital) contexts (Legg et al., 2017). Within the inpatient hospital setting, research beyond activity‐based training (such as upper limb therapy) supports early rehabilitation and intensive doses for optimising recovery after stroke (Kwakkel et al., 2006; Stroke Foundation, 2023). Thus, not only should future research test the effectiveness of activity‐based rehabilitation but should do so with considering the time post‐stroke and the dose of the intervention to establish which interventions are most beneficial with respect to improving self‐care ability after stroke.
This review builds upon the recent systematic review by Triantis and Liu (2024), with the aim to provide further guidance to clinicians on implementation of activity‐based retraining. Our review excluded studies that, for example, focussed on part‐practice of movements or tasks (such as constraint‐induced movement therapy [CIMT]) as our aim was to establish the effectiveness of activity‐based interventions only, and any additional interventions meant that isolating that effect would not have been possible. Previous authors who have synthesised activity‐based training have highlighted this as an issue, with Triantis and Liu (2024) identifying that many studies included in their review included ‘other interventions added to the experimental group’. Their analysis reported no significant effect of activity‐based interventions in hospital settings. However, interpretation was limited by this overlap in intervention components. Our systematic review builds on these findings by providing a comparison to understand the effectiveness of activity‐based interventions. By highlighting a more distinct gap, we can confirm the need for future rigorously designed trials that compare active interventions to an appropriate control condition (Hayward et al., 2024) without contamination of intervention types.
Studies testing the effectiveness of ADL interventions, particularly those examining dressing retraining, do suggest a likely benefit to stroke survivors when delivered in a hospital setting (e.g., Christie et al., 2011; Walker et al., 2012; Yamakawa et al., 2023). As independence in ADL performance is central to discharge planning and ongoing care (Britton et al., 2015), these findings highlight the clinical relevance of targeted interventions and the important role occupational therapists play in the inpatient setting. In addition to supporting functional recovery, occupational therapy interventions may realise system‐level benefits, including reduced hospital length of stay (Yamakawa et al., 2023) and potential economic savings for health services (Wales et al., 2022). However, the broader evidence base supporting activity‐based interventions in inpatient hospital settings remains limited, and none of the reviewed trials sought to understand the health economic or system‐level benefits.
Future research should explicitly report the details of each intervention, including the task targeted and intervention components delivered, and the frequency and dosage of intervention, and describe the intervention according to the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association, 2020) to provide replicable information for clinicians. Providing this detail is essential to guide clinician decision‐making to ensure translation of research into practice and allow estimation of cost‐effectiveness. It would be beneficial to expand the ADL types researched as many common clinical activities have not yet been researched at all such as mobile telephone use or basic money management. And finally, future research studies should continue to report on ADL performance but extend outcomes to additionally include quality of life, satisfaction with performance, and sense of self‐efficacy or enablement.
Lack of evidence is not evidence of a lack of effect, and therefore, findings of our review should not be interpreted that activity‐based retraining is not effective. However, it is concerning that so much remains unknown about early activity‐based retraining for stroke survivors, given that occupation is the core of the profession, and clear recommendations exist for implementation of early occupational therapy assessment and intervention (e.g., Intercollegiate Stroke Working Party, 2023; Stroke Foundation, 2023, 2025; Winstein et al., 2016). Until further rigorous evidence is generated, clinicians will need to use their clinical expertise and experience as well as patient preferences (Hoffmann et al., 2024) to make informed decisions regarding the application of activity‐based interventions for stroke survivors in the hospital setting. In addition, clinicians can continue to contribute to this growing body of evidence within their practice by monitoring interventions delivered in hospital settings, describing the specific details of each intervention, and ensuring appropriate evaluation using standardised outcome measures.
The main limitation of this review was the small number of studies that met the inclusion criteria; none were classified as Level 1 evidence, and although most were assessed to have a low to moderate risk of bias, moderate heterogeneity was found to be present. Restricting the review to English language studies may have introduced language bias, as translation resources were not available. Despite these limitations, our review represents an up‐to‐date synthesis of activity‐based interventions in hospital settings and contributes novel insights by excluding studies where control groups received overlapping activity‐based elements, thereby strengthening the validity of the findings.
5. CONCLUSION
Although activity‐based interventions demonstrate benefit in community settings, our review did not find evidence to suggest that there is a significant advantage in commencing these interventions in the hospital setting. However, the limited research conducted early after stroke highlights a critical gap in rehabilitation research. Addressing this gap through rigorous and methodologically sound trials is essential to inform clinical guidelines and enable occupational therapists to deliver best‐practice care that optimises independence early after stroke. Until further rigorous evidence is available, and in the absence of such evidence, occupational therapists should continue to deliver activity‐based interventions in the hospital setting for people post‐stroke.
AUTHOR CONTRIBUTIONS
Tayla Grant led investigation, project administration, and writing and co‐led conceptualisation, methodology, analysis, and appraisal. Kylie Wales contributed equally to methodology, data analysis, and appraisal and supported drafting, review, and editing of the manuscript. Laura Jolliffe co‐led conceptualisation and methodology and supported investigation, drafting, review, and editing of the manuscript. Emma J. Schneider supported methodology, reviewing, and editing. Jade Glascott and Danielle Sansonetti assisted with article screening and supported the review and editing of the manuscript. Avril E. Drummond contributed to methodology, reviewing, and editing. Natasha A. Lannin co‐led conceptualisation, methodology, data analysis, and appraisal and supported investigation, writing the original draft, and reviewing and editing the manuscript. All authors approved the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to declare.
DECLARATION OF USE OF ARTIFICIAL INTELLIGENCE
Artificial intelligence was not used.
Supporting information
File A Search strategy.
File B Excluded articles.
File C Risk of bias assessment.
File D Description of interventions within included studies using the Template for Intervention Description of Replication (TIDieR).
ACKNOWLEDGEMENTS
The authors have no additional acknowledgements to report. Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australasian University Librarians
Grant, T. , Wales, K. , Jolliffe, L. , Schneider, E. J. , Glascott, J. , Sansonetti, D. , Drummond, A. E. , & Lannin, N. A. (2026). Systematic review of hospital‐based interventions to improve post‐stroke independence in activities of daily living. Australian Occupational Therapy Journal, 73(4), e70119. 10.1111/1440-1630.70119
Funding information No specific grant was received for this research. T. G. is supported by an Australian Government Research Training Program (RTP) Scholarship (Monash University), L. J. is supported by a Monash Partners Strategic Translation and Research (STAR) Program, and N. A. L. is supported by a Heart Foundation (Australia) Fellowship (#106762).
Registration PROSPERO 2024 CRD42024562195 (5 July 2024).
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
File A Search strategy.
File B Excluded articles.
File C Risk of bias assessment.
File D Description of interventions within included studies using the Template for Intervention Description of Replication (TIDieR).
Data Availability Statement
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.