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Stroke is a leading cause of disability, commonly resulting in difficulty completing basic and instrumental activities of daily living. Rehabilitation is recommended to improve functional performance; however, it remains unknown whether early (hospital-based) intervention is effective; nor is it known what intervention components should be delivered.
We propose a systematic review to summarize the evidence for the effectiveness of activity-based interventions, led by occupational therapists, for improving performance of basic activities of daily living (b-ADL) or simple cognitive instrumental activities of daily living (C-IADL) among adults with stroke. Reviewing simple C-IADLs as opposed to instrumental activities of daily living will allow us to review interventions for activities with similar executive functioning demands. By identifying effective interventions, we aim to improve outcomes for stroke survivors by maximizing independence during hospitalization.
Searches will be conducted in MEDLINE, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials. We will include randomized controlled trials and quasi-randomized controlled trials that include adult stroke survivors and tested interventions (delivered in the hospital setting) aiming to improve or promote independence in b-ADLs or C-IADLs. Two reviewers will independently screen full-text articles, and one reviewer will extract data, with a second reviewer providing confirmation. The Physiotherapy Evidence Database (PEDro) scale will be used to assess the methodological quality of studies. The Cochrane
Results will be presented based on subgroup analyses where possible, including activity type (activity or occupation level), time after stroke (within or after 1 week), and delivery of intervention (group or individualized).
This systematic review will address the current gap in the literature regarding activity-based interventions for stroke survivors in the inpatient setting and provide clinical guidance on the most effective methods, if any, for improving independence early after stroke.
PROSPERO CRD42024562195; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024562195
DERR1-10.2196/73133
Stroke is a leading cause of adult disability [
Effective rehabilitation enables stroke survivors to achieve optimal functional outcomes across all areas of their life [
Stroke survivors should receive intensive rehabilitation throughout their inpatient stay to support a meaningful recovery [
Therefore, this systematic review will synthesize activity-based intervention studies that aim to improve performance of b-ADLs and/or simple C-IADLs in the hospital setting among stroke survivors. Complex C-IADLs were excluded from this review as the demands of these tasks were identified as being significantly different from b-ADLs and simple C-IADLs. The guiding research question developed was as follows: Do occupational therapy–led, activity-based interventions designed to target b-ADLs and/or simple C-IADLs in the hospital setting increase functional independence in stroke survivors?
The protocol was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocols statement [
The primary objective of this review is to synthesize effectiveness research on rehabilitation interventions delivered in the hospital setting to improve independence after stroke. We will include publications from any date in our search.
Studies will be included if they are full publications of randomized controlled trials (RCTs) and quasi-RCTs.
Studies that include adults (aged ≥18 years) diagnosed with stroke who are inpatients in the hospital setting will be included. Studies involving mixed diagnoses will be included where the data from those with a diagnosis of stroke are able to be extracted, or where ≥75% of the participants have a diagnosis of stroke. Studies involving mixed age groups will be included where the data from those aged ≥18 years are able to be extracted, or where ≥75% of the participants are aged ≥18 years. Studies will be excluded if they were performed with people who reside in the community setting, including care-based facilities (eg, residential aged care).
Studies that provide an activity-based intervention completed in the hospital setting and that fit within the scope of occupational therapy will be reviewed. Retraining interventions specific to b-ADLs and simple C-IADLs will be included in our systematic review. Both compensatory and remedial rehabilitation strategies will be included. We will exclude community-based interventions and computer-based or virtual reality interventions given the focus of the systematic review on the effects of real-life training in the hospital environment. For studies that include a combination of activity-based interventions alongside other interventions, studies will be included where the effects can be isolated (ie, the only difference between the experimental group and the comparator group is the activity-based intervention).
Included studies may have either an inactive comparison (where the control group received no occupational therapy input) or an active comparison, such as those where participants received an occupational therapy intervention that was not specific to activity-based retraining for ADLs or where a nondescriptive intervention was used in the control group. Examples of this include impairment-based treatments, such as upper limb treatment or visual scanning retraining.
We will record the outcome measures that the included studies used to report outcomes related to b-ADLs and simple C-IADLs to determine the effectiveness of activity-based interventions on stroke survivors’ functional independence. All clinical measures used to evaluate the effectiveness of activity-based interventions will be considered. Outcome measures may be reported as a global measure of function, such as the Functional Independence Measure, or specific evaluations of b-ADLs or simple C-IADLs, such as the Nottingham Dressing Assessment or Barthel index.
Participants: at least 75% aged 18 years or older with a diagnosis of stroke
Intervention: activity-based retraining (basic activities of daily living [b-ADLs] or simple cognitive instrumental activities of daily living [c-IADLs]); intervention delivered in inpatient setting
Comparison: no occupational therapy input, no allied health, occupational therapy not specific to activity-based retraining for activities of daily living, or intervention not defined in the control group
Outcomes: (1) determine the effectiveness of activity-specific interventions (b-ADLs and/or simple C-IADLs) on stroke survivors’ functional independence; (2) identify and describe the assessments and occupational therapy interventions designed to target b-ADLs and simple C-IADLs currently being used with adult stroke survivors in the hospital setting
Study design: randomized controlled trials and quasi-randomized controlled trials
Intervention: computer-based or virtual reality retraining; community-based interventions
Electronic searches will be conducted in CINAHL, EMBASE (via Ovid) and MEDLINE. The search strategy will be developed with senior researchers. The search strategy will include key terms such as
All studies identified by the search strategy will be uploaded to Covidence (Veritas Health Innovation Ltd), and duplicates will be removed. All articles will be screened at the title and abstract stage by one reviewer, in line with the exclusion and inclusion criteria. Duplicate studies (ie, those with the same authors, setting, location, and interventions) will be removed. All articles excluded at the title and abstract screening stage will be reviewed by a senior researcher to ensure no articles were inadvertently excluded. Full-text articles will then be reviewed by 2 research team members. If there are conflicts in decision-making, a third research team member will be consulted for a third review. Authors of studies may be contacted if there is missing information or further details are required to ensure articles are not inadvertently excluded or included. Details of the data screening will be presented in a PRISMA study flow chart.
One reviewer (TG) will extract data using a predetermined form; all data extraction will be confirmed by the senior author (NAL). If discrepancies occur, these will be resolved by discussion between the authors. If the discrepancies are not resolved, a third author will independently extract the data. The data extraction form will extract variables necessary for describing the study and conducting data analysis, including the following: the title of the paper, the authors’ names, the year the study was completed, the study design (eg, RCT or quasi-RCT), the country where the study was completed, participant age and sex, time after stroke of participants, primary and secondary assessments used, intervention and comparison details (according to the Template for Intervention Description and Replication [TIDieR] checklist items [
The Physiotherapy Evidence Database (PEDro) scale will be used to critically appraise the studies to determine any risk of bias [
A meta-analysis will be completed to compare effects between treatment and control groups. RevMan will be used to conduct a statistical analysis to calculate effect measures. The treatment effect measure will be determined by the data located. For instance, continuous data may be calculated using the standard mean difference and 95% CI when studies measure the same concept but have used a different measurement scale. The mean difference and 95% CI may be used when the results are expressed using the same measurement scale. The impact of heterogeneity will be reviewed. If results are too dissimilar, a sensitivity analysis will be considered and a narrative synthesis will be considered as an alternative.
Results will be discussed based on subgroup analyses where possible, including activity type (activity or occupation level), time after stroke (within or after one week), and delivery of intervention (group or individualized). Data extraction and analysis were completed in February 2025, and the results of the study and the submission of a manuscript for peer review are expected in July 2025.
The findings from this systematic review will aim to address the gap in the literature regarding activity-based interventions for stroke survivors in the inpatient setting. Clinicians will be able to use the results to make evidence-informed decisions regarding activity-based interventions and rehabilitation for reducing long-term disability.
This review will only search for and synthesize studies published in English; this limitation will be acknowledged in the systematic review when it is published. We acknowledge that the heterogeneity of the intervention types and of the clinical measures used to evaluate independence may not permit direct comparisons between studies. These limitations are not uncommon in systematic reviews of complex interventions.
Prior reviews [
This systematic review will provide a detailed summary of the current evidence for the effectiveness of activity-based interventions on functional independence for stroke survivors. The findings of this review will guide clinicians in their selection of rehabilitation interventions and enable researchers to determine future evidence needs. Synthesis of published effectiveness trials will not only support evidence-based practice from an occupational therapy perspective, but will also guide future trial design, given the limited overall research available to date in the inpatient setting.
activity of daily living
basic activity of daily living
cognitive instrumental activity of daily living
Physiotherapy Evidence Database
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
International Prospective Register of Systematic Reviews
randomized controlled trial
Template for Intervention Description and Replication
This research received no specific grant from any funding agency in the commercial or not-for-profit sectors. TG is supported by an Australian Government Research Training Program Scholarship (Monash University). NAL is supported by a Heart Foundation (Australia) Future Leader Fellowship (106762).
The data generated and analyzed during this study will include content extracted from published, peer-reviewed journal articles. Additional data generated and analyzed during the study will be available from the corresponding author upon reasonable request.
Conceptualization: TG, LJ, NAL (equal)
Investigation: TG (lead); LJ, NAL (supporting)
Methodology: TG, LJ, KW, NAL (equal); ES, AED (supporting)
Project administration: TG (lead)
Writing—original draft: TG (lead); LJ, KW, NAL (supporting)
Writing—review and editing: TG (lead); LJ, KW, ES, AED, NAL (supporting)
None declared.