Occupation-based interventions to improve occupational performance and participation in the hospital setting: a systematic review

Figures & data

Figure 1. Glossary of key terms.

A quick reference for readers with definitions of relevant terms referred to in this systematic review including occupations, occupation-centred, occupation-focused, occupation-based, and component-focused. Occupations refer to the daily activities that people engage in. Occupation-centred refers to the occupational therapy profession-specific perspective. Occupation-focused interventions involve having occupation as the immediate focus of the evaluation of intervention. Occupation-based interventions involve using engagement in occupation as a therapeutic agent of change. Component focused interventions involve focusing on remediating or improving the impairments that may be impacting on occupational performance.

Table 1. Hierarchy of evidence.

Level of evidence	Definition
Level I	Evidence from a systematic review and/or meta-analysis of randomised controlled trials
Level II	Evidence from at least one randomised controlled trial
Level III-1	Evidence from quasi-randomised controlled trials (alternate allocation or some other method)
Level III-2	Evidence from comparative studies with concurrent controls and allocation not randomised (e.g., cohort study, case-control study, or interrupted time series with a control group)
Level III-3	Evidence from comparative studies without concurrent controls (historical control, two or more single-arm studies, or interrupted time series without a parallel control)
Level IV	Evidence from case series with post-test or pre-test/post-test outcomes

Adapted from: National Health and Medical Research Council (1999).

Table 2. Summary of included studies: participants, interventions, outcome measures and results (n = 33).

Author/Year/Country/Study design	Diagnosis, n (%)/Age, mean (SD)	Sample size	Intervention	Control	Occupational performance and/or participation outcomes	Results
Arsh et al. 2020^a [41] Pakistan Prospective quasi-experimental, single group, pre-test post-test	SCI = 72 (100%) Mean age = 30.21(13.52)	n = 72	ADL retraining including feeding, bathing, dressing and grooming practice with adaptive aids as required as well as UE exercises (strengthening, resistance, and fine motor tasks). Setting: Inpatient SCI rehabilitation Duration: 6 weeks Intensity: 2 × 45–60-minute sessions, 3 days per week Provider(s): OT	N/A	SCIIM (self-care domains)	Improvements in each self-care domain (feeding, upper body dressing, lower body dressing, grooming) and total SCIM change scores (p < 0.001).
Bertilsson et al. 2014^a [28] Sweden Multicentre RCT	Stroke = 153(100%) Mean age = Inpatient unit 1IG = 77 (7.5)CG = 69 (11.5)Inpatient unit 2IG = 59 (6.0)CG = 56 (10.4)	Total inpatients n = 153Inpatient IG n = 89Inpatient CG n = 64	CO-OP approach in addition to usual care. Setting: Geriatric and medical inpatient rehabilitation units and 1 x outpatient setting Duration: Dependant on goal achievement and discharge Intensity: Not specified Provider(s): OT	ADL therapy as per the routine practice of each rehabilitation unit. Setting: Geriatric and medical inpatient rehabilitation units and 1 x outpatient setting. Duration: Dependant on goal achievement and discharge Intensity: Not specified Provider(s): OT	BIPersonal and Instrumental ADL (KE) SISOGQ	No between-group difference for the BI, KE, SIS, and OGQ change scores (p > 0.05).^b
Christie et al. 2011 [42] Australia Retrospective quasi-experimental single group pre-test post-test	Stroke = 119(100%) Mean age = 74.3(12.3)	n = 119	Twice weekly dressing group in addition to usual care. Supervised by 2 x OTs. Goals focused on outer clothing layers to maintain dignity. Goal setting, multiple repetitions, and feedback were used to maximise performance. Groups of 2–10 participants. Setting: Inpatient stroke rehabilitation Duration: Goal and discharge dependant. On average participants attended 4.0 (SD 3.8) group sessions Intensity: 2 × 1 h group sessions per week Provider(s): OT	N/A	FIM upper body and lower body dressing items.	Patients who practiced upper body dressing (n = 108) had a mean FIM change score of 2.2 (95% CI 1.9–2.5, p = 0.0001). Patients who practiced lower body dressing (n = 82) had a mean FIM change score of 2.7 (95% CI 2.3–3.1, p = 0.0001). Patients who practiced both upper body and lower body dressing (n = 71) had a mean FIM change score of 5.2 (95% CI 4.5–6.0, p = 0.0001).
Cox et al. 2014^a [43] Australia Prospective quasi-experimental cohort study using historical controls	Neurological = 17 (42.5%)Orthopaedic = 7 (17.5%)Lower limb amputation = 6 (15%)Other = 10(25%) Mean age = IG = 70.2(15.46)CG = 63.43(12.71)	n = 70IG = 30CG = 40	Occupation-based groups including breakfast, lunch or afternoon tea preparation and domestic training (cleaning and laundry). Groups followed a standardised process with written procedures. Groups of 2–6 participants. Time was also allocated to organise group therapy referrals, allocate patients to groups, and feedback to treating clinicians in the team meeting held on that ward. Setting: Geriatric and rehabilitation unit Duration: Dictated by goal achievement. Intensity: 1–2 h per group with up to 6 running per week Provider(s): Advanced AHA (with more than 10 years’ experience)	Same procedure as the intervention group with the exception that it was OT-led not AHA-led. Setting: Geriatric and rehabilitation unit Duration: Dictated by goal achievement Intensity: 1–2 h per group with up to 6 groups per week Provider(s): OT	FIM	Both groups improved in functional independence (f(1) = 79.56, p < 0.001). No between-group difference for OT vs AHA-led groups (f(1,136) = 0.53, p = 0.47).
De Vos & Leclair, 2019 [44] Canada Convergent parallel mixed methods	Schizophrenia = 16 (26.7%)Bipolar = 15 (25.0%)Depression = 8 (13.3%)Other = 10 (16.7%)Not reported = 11 (18.3%) Mean age =36.64(15.80)	n = 60	Food skills group with maximum for 4 participants per group. Sessions included using a written recipe, cooking the meal, sharing the meal at a table with modelling of social interactions, and then cleaning up the kitchen. Verbal cueing and demonstration provided dependent on patient performance Setting: Inpatient psychiatric hospital Duration: Goal and discharge dependant Intensity: 60–120 min in length. 2 x food skills groups ran per week, patients participated in 1 of these each week Provider(s): OT	N/A	Self-developed 15 item questionnaire with 5-point Likert Scale rating enjoyment, confidence, motivation to re-attend, and social benefits. Semi structured interviews with n = 20 participants.	>80% participants reported they were satisfied with the food skills group, the group provided opportunity to improve their cooking and social skills and prepare for discharge, and felt the group was important to their recovery.Three main themes emerged from qualitative analysis: 1) importance of engaging/doing; 2) connections with food, and 3) being involved in a group process.
Eyres & Unsworth, 2005 [29] Australia Pilot RCT	General surgical conditions = 15 (100%) Mean age = CG = 78.1(5.79)IG = 81(8.25)	n = 15CG = 8IG = 7	Daily 1:1 ADL practice including self-care and instrumental ADLs such as cooking, laundry, café visits and functional and community mobility practice. In addition to usual care. Setting: Acute Duration: Goal and discharge dependant Intensity: 1–2 h per day- influenced by the nature of the acute setting with many competing demands Provider(s): OT and AHA	Usual care consisted of allied health input if/as needed dependant on nursing staff referrals. Setting: Acute Duration: Not reported Intensity: Not reported Provider(s): OT and other allied health as required (referral-based)	FIMLSI	Improved FIM scores for both groups (CG: t(7) = −3.567, p = 0.009, IG: t(6) = −10.802, p = 0.000). No statistically significant changes in LSI for IG or CG.Between-group differences not calculated due to small sample size.
Fletcher-Smith et al. 2012 [45] England Prospective quasi-experimental, single group, pre-test post-test	Stroke with cognitive impairment = 70(100%) Mean age = Left paresis: 77(11)Right paresis: 76(13)	n = 70Left paresis = 42Right paresis = 28	1:1 upper body dressing retraining. Program consisted of functional approaches including teaching one-handed dressing, problem solving through task practice and repeated practice alongside cognitive approaches such as errorless learning and visual scanning techniques. Setting: Acute stroke unit Duration: 6-weeks Intensity: 3 x sessions per week. Timing not reported Provider(s): OT	N/A	NSDA upper body scores (minus scores for fastenings)Dressing dependence = <100% on NSDA.	Participants completing bimanual dressing were more likely to be independent in dressing at follow-up (p < 0.001). Of the participants dependant on dressing at baseline, 57% of participants in the bimanual group achieved independence at follow-up and 23% of the unimanual group achieved independence at follow-up.
Guidetti et al. 2010^a [25] Sweden Pilot RCT	Stroke = 40(100%) Mean age = CG = 69(15)IG = 66(14)	n = 40CG = 21IG = 19	CO-OP approach in addition to usual care for self-care retraining. Setting: Geriatric, medical, and neurological rehabilitation units Duration: Dependant on goal achievement and discharge Intensity: Not reported Provider(s): OT	Self-care retraining dependant on the routine practice of each rehabilitation unit. Setting: Geriatric, medical, and neurological rehabilitation units Duration: Dependant on goal achievement and discharge Intensity: Not reported Provider(s): OT	BIFIM ADL and motor itemsSIS	No between-group differences across all outcome measures between IG and CG (p > 0.05). Both groups improved on FIM ADL and motor items (p < 0.05).^b
Gustafsson & McKenna, 2010 [51] Australia Prospective exploratory study	Stroke = 20(100%) Mean age = Unit A69(10.7)Unit B 68.1(8.9)	n = 20Unit A (IG)= 8Unit B (CG) = 12	Occupation-based ‘life-skills’ groups in addition to usual care. Groups consisted of a daily breakfast group, daily life skills group, and a weekly community shopping group. Setting: 2 x general rehabilitation units Duration: Not reported Intensity: Not reported Provider(s): OT and AHA	Largely individual therapy (usual care) with a weekly recreational cooking group. Setting: 2 x general rehabilitation units. Duration: Not reported Intensity: Not reported Providers: OT (no AHAs)	SISModified BI	Both groups improved (p < 0.001) on the modified BI with no between-group differences (p = 0.60). Reduced social participation (SIS) that decreased at follow-up (F = 9.94, p = 0.01) for Unit A.
Haley & McKay, 2004 [26] England Qualitative study	Acute mental health conditions = 12 (100%) 21–64 years (only range reported)		Baking group involving planning, preparation, eating, and clean-up of cake or biscuits. Setting: Acute mental health Duration: Not reported Intensity: Not reported Participants attended an average of 2 x baking groups Provider(s): OT	N/A	Semi-structured interviews with n = 12 participants	The baking group provided participants with a sense of accomplishment, was an avenue to develop social connections, and provided them with structure and purpose for their day. Participants were more likely to attend if they felt no pressure during the group and preferred afternoon groups. Participants did not feel that their feedback would result in changes to the group.
Hee-Su & Deok-Ju, 2021 [30] Korea RCT	Stroke = 30(100%) Mean age = CG = 65.27(12.73)IG = 65.20(12.17)	n = 30CG = 15IG = 15	ADL-based dual task training (20 min) and conventional OT (10 min). Dual task combined an ADL with either an attention or executive functioning task. ADL activities included climbing stairs, making tea or coffee, folding tops or bottoms, buttoning /unbuttoning shirts and moving beans. Setting: Inpatient stroke rehabilitation Duration: 5-weeks Intensity: 30-minute sessions, 5 days per week Provider(s): OT	Non-ADL-based single task training (20 min) and conventional OT (10 min). The single tasks consisted of sensory stimulation training on the paralysed side, UE muscle strength training, cognitive and perceptual training, and fine hand movement using tools. Setting: Inpatient stroke rehabilitation Duration: 5-weeks Intensity: 30-minute sessions, 5 days per week Provider(s): OT	WHOQOL-BREF	Improvement across all domains of the WHOQOL-BREF for both IG and CG (p < 0.01) with significant between group difference (IG > CG) (z=-3.596 p = 0.000).
Hiraga et al. 2021 [39] Japan Non-RCT	High tibial osteotomy = 31 (100%) Mean age = CG = 68.0(1.8)IG = 67.2(2.3)	n = 31CG = 17IG = 14	OT treatment commenced 3-weeks post-surgery. Goal setting was undertaken using the COPM. Each goal was progressed based on patient capacity and involved repeated and/or graded practice of the activity until the goal was achieved (additional to usual care). Duration: Dependant on discharge (minimum 2-weeks) Intensity: 20–40 min daily Setting: Inpatient rehabilitation Provider(s): OT	All patients followed the same rehabilitation protocols after surgery (both IG and CG). Physical therapy began day 1 post-operation. Approximately 3-weeks post-surgery, walking using a walker was possible. Approximately 5-weeks post-operation, walking with a cane or alone was possible, and the patient was discharged. Duration: Dependant on discharge (minimum 5-weeks) Intensity: 40-minutes of physical therapy daily Setting: Inpatient rehabilitation Provider(s): PT	COPM- IG only	Improved COPM performance (2.6 SD1.6 [baseline] to 8.0 SD1.2 [follow-up]) and satisfaction (2.0 SD1.3 [baseline] to 8.0 SD1.3 [follow-up]). p < 0.01.
Kasprzyk & Kruk, 2020 [46] Poland Prospective, quasi-experimental single group pre-test post-test	Stroke = 10(100%) Mean age =70.3	n = 10	3 x OT visits to assess feeding performance, set-up adaptive wristband, and encourage 1-week of independent task practice and then reassessment of feeding. Duration: 2-weeks Intensity: Timing not reported Setting: Inpatient rehabilitation Provider(s): OT	N/A	COPMTime taken to finish a meal (mins)	Improved COPM performance (6.7 SD1.34 [baseline] to 7.80 SD0.63 [follow-up]) p = 0.03 and satisfaction (4.90 SD0.99 [baseline] to 7.50 SD0.97 [follow-up]) p = 0.005.
Kelly & Nikopoulos, 2010^a [52] England Multiple baseline probe case series	TBI = 2(100%) Ages = 47 and 58	n = 2	Combined errorless learning and strategy training during self-care retraining. Included use of verbal or gestural prompting, demonstration or concurrent imitation, physical assistance, forward/backward chaining, whole-task training, repetitive practice, feedback, visual prompts, and environmental adaptation or modifications. Duration: 8 x sessions for participant 1. 25 x sessions for participant 2 Intensity: 30-minute sessions. 2–3 sessions on any one day for each participant Monday-Friday Setting: Acute neurosurgical unit Provider(s): OT	N/A	FIM%mean(range) of assistance required (verbal, gestural and physical)AMPS	Clinically significant improvements in AMPS process score (0.51 logits) and clinically meaningful improvements in the AMPS motor score (0.31 logits) for Participant 1. Participant 1 improved by 4 points in FIM motor score and 1 point in FIM cognitive score. Clinically significant increase in FIM motor score (18 points) was observed for Participant 2. Nil change in FIM cognitive score. Statistically significant decrease in the AMPs process scores for Participant 2 (0.93 logits). Participant 2 decreased in AMPS motor score as well (0.03 logits).
Khanipour et al. 2022 [31] Iran RCT	Hand and upper extremity burns = 20(100%) Mean age = CG = 40.5(12.14)IG= 43(11.47)	n = 20CG = 10IG = 10	Both groups received traditional rehabilitation for the first two weeks. For the IG this was followed by the CO-OP approach. Duration: 6-weeks Intensity: 3 × 45-minute sessions per week Setting: Specialised burns rehabilitation hospital Provider(s): OT	Traditional rehabilitation, including motor exercises, strengthening, stretching, scar massage, oedema control, and splints, pressure gloves, burns clothes or silicone sheets. Duration: 6-weeks Intensity: 3 × 45-minute sessions per week Setting: Specialised burns rehabilitation hospital Provider(s): OT	COPM	Both CG and IG improved in COPM performance and satisfaction (p < 0.0001). No between group difference.
Kim & Park, 2019 [32] Korea RCT	Stroke = 20 (100%) Mean age = CG = 61.7(7.40)IG = 57.3(9.00)	n = 20CG = 10IG = 10	Occupation-based activities including folding clothes, bathing, make-up application, ironing, hand washing, car washing, sport, dressing, cooking, cleaning, cross-stitching, computer work, woodwork, craft, sewing, and knitting dependant on identified goals. Also received conventional physical therapy. Duration: 4-weeks Intensity: 30-minute sessions, 5 days per week Setting: Inpatient rehabilitation Provider(s): OT	Task-based, bilateral UE training including wiping desks, drinking, moving blocks, cup stacking, and peg activity. Also received conventional physical therapy Duration: 4-weeks Intensity: 30-minute sessions 5 days per week Setting: Inpatient rehabilitation Provider(s): OT	COPMSIS	Between group difference (IG > CG) for COPM performance (p = 0.01, η2 = .44) and COPM satisfaction (p = 0.00, η2 = .72). Between group difference (IG > CG) for SIS ADL/instrumental ADL (p = 0.002, η2=.45). Between group difference (IG > CG) for SIS participation (p = 0.001, η2 = .47).
Landi et al. 2006 [47] Italy Prospective exploratory study	Stroke = 50 (100%) Mean age = CG = 74.9(10.9)IG = 78.3(9.4)	n = 50CG = 25IG = 25	Combined OT/PT intervention. 1:1 self-care retraining (OT-led) included showering, toileting, feeding and dressing practice. During retraining OTs also assessed for the need for adaptive equipment. Delivered in addition to usual care. Duration: 8-weeks Intensity: 3-hours per day Setting: Geriatric rehabilitation unit “CEMI-3” Provider(s): OT, PT	PT input only including functional mobility training, progressive gait training, neuromuscular re-education, muscle tone management, contracture prevention and treatment. Duration: 8-weeks Intensity: 3-hours per day Setting: Geriatric rehabilitation unit “CEMI-2” Provider(s): PT	ADL scale	Between group difference (IG > CG) for ADL scale dressing (p = 0.01) and personal hygiene (p = 0.005).No significant between group differences were observed for toileting or eating change scores.
Mew, 2010 [33] Australia Pilot RCT	Stroke = 5(100%) Mean age = CG = 77.5IG = 73	n = 5CG = 3IG = 2	Dressing practice focused on achieving independence using compensatory strategies, environmental adaptations and aids as well as using the Bobath concept. Duration: Up to 8-weeks Intensity: 3 x per week. No set time however the participant averaged 20-minutes per session Setting: Acute rehabilitation unit Provider(s): OT	Dressing practice using the Bobath concept. Some sessions were co-run by PT due to overlapping nature of LB dressing. Duration: Up to 8-weeks Intensity: 3 x sessions per week. No set time but recorded sessions ranged from 45–57-minutes on average Setting: Acute rehabilitation unit Provider(s): OT/PT	NSDACOPM	No between group difference for NSDA and COPM change scores. All patients improved in dressing independence from baseline to discharge.
Ngooi et al. 2021 [55] Singapore Qualitative descriptive methodology	Depressio n = 2 (33.3%)Psychotic disorder = 2(33.33%)PTSD = 1 (16.66%)Adjustment disorder = 1(16.66%) Mean age = 40.66	n = 6	Structured, activity-based group program based on 5 main themes: 1) physical activity; 2) art creation; 3) utilizing technology games and apps; 4) meal preparation; and 5) music making. Attendance was voluntary but participants were encouraged to attend as part of their daily routine. Duration: Dependant on LOS Intensity: 1-hour daily every weekday Setting: Acute psychiatric hospital Provider(s): OT	N/A	Semi-structured interviews with each participant	Three major themes of benefits of participation in activity-based groups emerged from the interviews: 1) the therapeutic relationship, 2) connection with others, and 3) opportunity to engage.
Nilsson & Nygard, 2003 [56] Sweden Qualitative approach using Grounded Theory	Stroke = 3 (100%) 66–85 (only range provided)	n = 3	Group-based. Each participant had individual goals which were determined by the therapist and patient together. The therapeutic activities embraced both creative activities, e.g., painting and pottery, and household activities, e.g., preparing light meals. All activities were continually adapted to meet the capacities and interests of the participants. Duration: 16 days Intensity: 5 sessions Setting: Inpatient rehabilitation Provider(s): OT	N/A	5 x semi-structured interviews with each of the 3 participants (following participation in each of the 5 group sessions).	Themes described experiences of creativity, pleasure and supportive conditions that promoted learning, gaining new insights into ones’ abilities, and developing strategies and adaptations to discharge home.
Patil et al. 2019 [57] Norway Qualitative descriptive methodology	OT = 4 working with stroke survivors(100%) Mean age N/A	n = 4	Gardening group. Activities adapted to each patient with respect to their skills, motivation, and capacity. Led by 3 x OTs. Horticultural activities included propagating plants, potting, planting, watering, composting, and harvesting. Duration: Varied Intensity: 1–1.5 h per session, twice weekly Setting: Acute stroke unit Provider(s): OT	N/A	Notes written by all four OTs immediately following each group session implemented (49 sessions of which more than 50 patients had participated in).	Six themes were identified: possibilities for skills training, engagement in occupation, mastery of the activity, finding mental rest, connection to past experiences, and shared experiences and hope.
Patterson et al. 2017 [53] Australia Observational cross-sectional study	TBI = 35(100%) Mean age =38(14.1)	n = 35	4 x different groups: twice weekly breakfast group, twice weekly lunch group twice weekly community access, thrice weekly upper limb group and 6 x weekly cognitive rehabilitation group. Frequency of each group was adjusted to reflect patient needs at the time.Referrals come from treating OTs including goals and other clinically relevant information. Group outline documents guide facilitators to plan and structure the groups; content is not manualised to allow for flexibility based on patients’ individual goals. 3–4 participants in each group. Duration: Varied Intensity: 1-hour sessions throughout the week as above Setting: Inpatient rehabilitation Provider(s): OT, AHA, recreation officers and OT students	N/A	Self-developed, 7 item, 4-point Likert scale to explore attitudes towards various aspects of the groups. Responses for occupation-based groups vs. impairment focused groups were explored using Z-scores.	92.8% strongly agreed or agreed that the groups were useful. 86.7% of participants strongly agreed or agreed that the groups were specific to their needs. The proportions of participants who disagreed or strongly disagreed with the group being specific to their needs were higher for the cognitive groups (21.4%) and community access groups (20.0%), compared to the upper limb (9.1%) and meal preparation (3.4%) groups. 86.7% of participants agreed or strongly agreed that groups provided them with opportunity to practice skills they were learning. There were no significant differences in responses between occupation-based and impairment-focused groups based on Z-score calculations.
Patterson et al. 2019 [58] Australia Qualitative phenomenological design	TBI = 15(100%) Mean age =37.9(13.6)	n = 15	Four groups are facilitated multiple times per week. Utilised formal processes for referral, goal setting, participation, and evaluation. See Patterson et al. [53] for further details (same intervention). Duration: Varied Intensity: Not reported- refer to Patterson et al. [53] study for further details Setting: Inpatient rehabilitation Provider(s): OT- refer to Patterson et al. [53] study for further details	N/A	Semi-structured interviews with n = 15 participants	3 key themes: 1) feeling normal, comfortable, and connected, 2) learning by doing, seeing, and sharing, 3) practicalities of groups and recommendations.
Pillastrini et al. 2008 [40] Italy Non-RCT	SCI = 36(100%) Mean age = CG = 32.5(12.58)IG = 31.96(8.29)	n = 36CG = 12IG = 24	OT intervention 5-weeks before discharge in addition to neuromotor rehabilitation. OT sessions ranged from kitchen tasks, bed transfers, self-care, and car transfers. Duration: 5-weeks Intensity: 2 × 60-minute sessions, 5 days per week (2 x OT sessions, 8 x neuromotor rehabilitation sessions) Setting: Inpatient rehabilitation Provider(s): OT, PT	Neuromotor rehabilitation consisting of reflex inhibiting postures, mobilisations, exercises of the trunk and lower limbs and PNF. Duration: 5-weeks Intensity: 2 × 60-minute sessions, 5 days per week (10 neuromotor rehabilitation sessions) Setting: Inpatient rehabilitation Provider(s): PT	VFM	Between-group difference for wheelchair transfers (p = 0.000), wheelchair use (p = 0.005), and total (p = 0.007) change scores on the VFM.No significant between-group difference for remaining items on the VFM (bed mobility, grooming/bathing, dressing and social life).
Shearer & Guthrie, 2013 [48] Australia Non-RCT	Dementia = 13 (27.0%)No dementia = 35 (72.9%) Mean age = CG = 85.9(5.2)IG = 87.1(6.4)	n = 48CG = 26IG = 22	ADL retraining including personal ADLs, simple domestic tasks (e.g., hot or cold drink preparation, toast preparation) and functional mobility. Duration: Not reported Intensity: 3 x per week, ∼1-hour per session Setting: Acute geriatric unit Provider(s): OT, AHA	Usual occupational therapy which included assessment of occupational performance, discharge planning and occasional re-assessment of occupational performance. No ADL retraining. Duration: Not reported Intensity: Not reported Setting: Acute geriatric unit Provider(s): OT	Modified BIProgress notes from AHA regarding progress and level of assistance during ADL retraining	No significant between-group difference on any item or total change score on the modified BI. AHA progress notes indicated progress towards ADL goals including progressing from sitting to standing for showering and dressing, attempting higher levels of washing, drying, or dressing, and progress with mobility.
Skidmore et al. 2011 [54] United States of America Case report	Stroke = 1(100%) Age =31	n = 1	CO-OP approach in addition to usual rehabilitation (5–6-hours of OT/PT/SP per weekday and 2–3-hours on Saturdays). Duration: 14 days Intensity: 1 × 45-minute session per day, 5 days per week Setting: Inpatient rehabilitation Provider(s): OT	N/A	FIMPASS	Clinically meaningful change in FIM score (baseline = 68/100; discharge = 97/100).Clinically meaningful change in PASS score (baseline = 1.1/3; discharge = 2.9/3).
Timmer et al. 2020 [34] Australia RCT	Reconditioning for older adults = 100(100%) Mean age = CG = 81(7)IG = 80(8)	n = 100CG =49IG = 51	Activity pacing intervention including occupation-centred (Wii sport, Wii balance, puzzles, mobility practice) and occupation-based (bed making, hanging washing, bowling, golf, gardening, shopping) activities. In addition to usual OT intervention. Duration: 9 days commencing 3 days post admission Intensity: 1 × 30-minute education session day 1 and day 9. 5 x consecutive 45-minute group sessions in-between Setting; Inpatient rehabilitation Provider(s): OT	Usual OT consisting of occupational performance assessment, interventions to facilitate safe discharge home and return to desired occupations. Patients received 1 x activity pacing education session. Duration: Not reported Intensity: 1 × 45-minute pacing education session in addition to usual care Setting; Inpatient rehabilitation Provider(s): OT	AusTOMs-OT impairment and activity limitation scales 1, 4, 7, 8, participation restriction and distress/well-being items.	Improvements in activity limitation, participation, and well-being items from admission to discharge (p < 0.05) for CG and IG. Significant between-group difference for activity limitation scale 4: carry out daily life tasks and routines (F(1.96 (=4.125, p = 0.045, η^2 =0.41) (IG > CG). Data from 3-month follow-up should be interpreted with caution due to significant loss of participants (retention rate of 64%).
Tomori et al. 2015 [35] Japan RCT	Stroke = 54 (100%) Mean age = CG= 64.19(10.16)IG = 68.26(10.9)	n = 54CG= 27IG =27	1:1 occupation-based practice e.g., using chopsticks to eat food, cooking, self-cares, and knitting. More than two thirds of the intervention time was allocated to occupation-based practice and the remaining third was for basic function exercises and simulated occupational practice. Duration: Goal and discharge dependant Intensity: Up to 3-hours per day between OT/PT/SP therapy dependant on patient goals and needs Setting: Inpatient rehabilitation Provider(s): OT	1:1 impairment-based therapy focused on restoring capacities e.g., PNF, strengthening exercises and cognitive training. Two thirds of therapy time was dedicated to impairment-based therapy with the remaining third dedicated to occupation-based practice. Duration: Goal and discharge dependant Intensity: Up to 3-hours per day between OT/PT/SP therapy dependant on patient goals and needs Setting: Inpatient rehabilitation Provider(s): OT	FIM	No between group difference between IG and CG (p > 0.05). Significant (p < 0.05) improvements in the FIM change scores. (CG p = 0.00005 95% CI = −19.81–−8.38; IG p = 0.0001, 95% CI= −17.37–−6.88) for CG and IG.
Trevena-Peters et al. 2018 [36] Australia RCT	TBI in PTA =104(100%) Mean age = CG= 40.24(19.06)IG= 45.78(19.64)	n = 104CG= 55IG =49	Treatment as usual with additional manualised ADL retraining based on errorless learning principles. Included initial functional assessment, task analysis, goal setting using the GAS and individual retraining program. Simple ADLs such as self-feeding would be addressed first, followed by other personal ADLs and then basic meal preparation in accordance with participant progress. Duration: Duration of PTA Intensity: Not reported. Participants completed a mean of 15.39 + 14.51 sessions during PTA (range 2–63) Setting: Inpatient rehabilitation Provider(s): OT	Treatment as usual comprised of daily PT and/or SP during PTA. All participants received comprehensive rehabilitation following emergence from PTA including OT input. Duration: Duration of PTA Intensity: Not reported Setting: Inpatient rehabilitation Provider(s): PT, SP	FIM	Post hoc analyses demonstrated greater FIM change between baseline and PTA emergence (p = 0.001) for IG that maintained at discharge (p = 0.001). No significant between group differences at 2-month follow-up.
Trevena-Peters et al. 2019^c [49] Australia Mixed methods (Retrospective single group pre-test, post-test and qualitative study)	TBI in PTA = 49 (100%) Mean age =45.78(19.64) OTs= 4(100%)	TBI n = 49 OTsn= 4	See Trevena-Peters et al. [36] (same intervention). Duration: Duration of PTA Intensity: Up to 60-minutes each weekday Setting: Inpatient rehabilitation Provider(s): OT	N/A	FIMGASSemi-structured interviews with n = 4 OTs	Improvement in GAS scores at PTA emergence (t(41) = 15.18, p<.001, d = 3.91 CI [4.64, 3.15]).Strong correlation between GAS t-scores and FIM change (baseline to PTA emergence) (r = 0.52, p < 0.001).9 themes emerged from semi-structured interviews. The intervention improved independence, helped build a therapeutic relationship, and enhanced engagement. Manualised design provided structure and guidance however, OTs also questioned whether it was limiting the scope of potential ADLs that could have been targeted. Fatigue was biggest barrier to implementation.
Udovicich et al. 2020 [50] Australia Retrospective single group pre-test, post-test	Cancer = 31 (100%) Mean age =71.61(12.57)	n = 31	Domestic ADL group intervention consisting of task-based retraining and education targeting meal preparation. Maximum of 3 patients per group. Duration: 1 × 60-minute group Intensity: 60-minutes Setting: Acute cancer centre Provider(s): OT	N/A	COPM	Improved (p < 0.02) COPM performance (95% CI 6.156–8.054) and satisfaction (95% CI 3.490–5.769).
Vanderploeg et al. 2008 [37] United States of America RCT	TBI = 360(100%) Mean age = CG= 33.2(13.5)IG= 31.7(12.9)	n = 360CG = 180IG = 180	Functional-experiential intervention received a group-based program consisting of occupation-based practice using errorless learning. Activities included newspaper reading and TV watching, daily planning, card games, sports, cooking, shopping, cleaning, exercise, and prevocational tasks such as interviews and giving speeches. More complex tasks were added as patients achieved mastery of simpler ones. In addition to usual care. Duration: 20–60 days dependant on LOS and goal attainment Intensity: 1.5–2.5-hours every weekday with additional 2–2.5 h of daily OT/PT Setting: Acute Provider(s): OT	Cognitive-didactic intervention was 1:1 and impairment-based. Participants practiced progressively more difficult paper-and-pencil or computerized cognitive tasks targeting attention, memory, executive function and/or pragmatic communication. Error-based learning was used to try and build self-awareness. In addition to usual care. Duration: 20–60 days dependant on LOS and goal attainment Intensity: 1.5–2.5 h every weekday with additional 2–2.5-hours of daily OT/PT Setting: Acute Provider(s): OT	Self-reported return to work/schoolFunctional independence (ability to live independently with <3hours per week of services)FIM	No significant between group difference at 1 year follow-up for return to work and functional independence outcomes.Significant improvement in the cognitive items on FIM for cognitive-didactic intervention compared with the functional-experiential at completion of the intervention (t332 = 2.56, p = 0.01). No between group difference for FIM motor items at completion of the intervention.
Yoshida et al. 2019 [38] Japan RCT	Cerebral or spinal disease = 30(41.7%)Musculoskeletal disease = 42(58.3%) Mean age = CG= 75.17(9.99)IG = 74.11(11.73)	n = 72CG = 36IG = 36	Began with goal setting (COPM) and assessment of occupational performance. Clients rated the challenge and skill required to perform the task on a 7-point Likert scale. ADL practice was then continued with the OT adjusting the challenge of each task using compensatory approaches, environmental adjustments, or assistive devices if necessary. Clients continued to re-evaluate the challenge and skill level of each activity following any adjustments from the OT. Activities practiced included upper limb and movement, eating, dressing, toileting, showering, walking, cleaning, laundry, meal preparation, shopping, driving and work. Duration: Dependant on LOS Intensity: Not reported Setting: Inpatient rehabilitation Provider(s): OT	Usual OT including goal setting with the COPM and assessment of occupational performance. Based on this assessment the OT provided therapy in accordance with the general guidelines of occupational therapy practice. Duration: Dependant on LOS Intensity: Not reported Setting: Inpatient rehabilitation Provider(s): OT	FIMReturn to school/work (%)Living independently in the community (<3 h of weekly home-help) (%)	Both groups improved on FIM with no between group difference (t(354)=0.89, p = 0.37). No between group difference for return to work/school and living independently in the community at 1-year follow-up.

ADLs: Activities of daily living; AHA: Allied Health Assistant; AMPS: Assessment of Motor and Process Skills; APA: Activity Pacing Assessment; AusTOMs-OT: Australian Therapy Outcome Measures- Occupational Therapy; BI: Barthel Index; CG: Control group; CO-OP: Cognitive Orientation to daily Occupational Performance; COPM: Canadian Occupational Performance Measure; CI: Confidence Interval; FIM: Functional Independence Measure; GAS: Goal Attainment Scale; IG: Intervention group; LIS: Life Satisfaction Index: LOS: Length of stay; NSDA: Nottingham Stroke Dressing Assessment; OGQ: Occupational Gaps questionnaire; OT: Occupational Therapist/Occupational Therapy; PASS: Performance Assessment of Self-Care Skills; PT: Physical Therapist; PTA: Post Traumatic Amnesia; PTSD: Post Traumatic Stress Disorder; PNF: Proprioceptive Neuromuscular Facilitation; RCT: Randomised Controlled Trial; SCI: Spinal Cord Injury; SCIIM: Spinal Cord Injury Independence Measure; SIS: Stroke Impact Scale; SP: Speech Pathology; TBI: Traumatic Brain Injury; UE: Upper Extremity; VFM: Valutazione Funzionale Mielolesi scale; WHOQOL-BREF: World Health Organisation Quality of Life- BREF.

^a Additional statistical data or intervention information was unavailable, or no response was received from the corresponding author.

^b Participants were followed up at 3-months only. Their outcome measures were not reported upon discharge from the rehabilitation units with some patients continuing the intervention with an outpatient service. As a result, these outcomes reflect a component of outpatient therapy for a proportion of the sample.

^c Study conducted additional analysis of trial data.

Table 3. Level of evidence and quality assessment scores for included RCTs using the PEDro scale (n = 12).

Study	Level of evidence	Eligibility criteria specified	Random allocation	Concealed allocation	Baseline similarities	Subject blinding	Therapist blinding	Assessor blinding	Adequate follow-up (>85%)	Intention to treat analysis	Between-group statistical comparisons provided	Point measure and variability provided	Score (0–10)^a
Bertilsson et al. 2014^b [28]	II	✔	✔	X	✔	X	X	✔	✔	✔	✔	✔	7/10
Eyres & Unsworth, 2005 [29]	II	✔	✔	✔	✔	X	X	✔	✔	✔	X	✔	7/10
Hee-Su & Deok-Ju, 2021 [30]	II	✔	✔	✔	✔	X	X	X	✔	✔	✔	✔	7/10
Guidetti et al. 2010 [25]	II	✔	✔	✔	✔	X	X	✔	X	✔	✔	✔	7/10
Khanipour et al. 2022 [31]	II	✔	✔	✔	✔	X	X	✔	✔	✔	✔	✔	8/10
Kim & Park 2019^b [32]	II	✔	✔	✔	✔	X	X	X	✔	X	✔	✔	6/10
Mew, 2010^b [33]	II	✔	✔	✔	X	X	X	✔	X	X	X	X	3/10
Timmer et al. 2020^b [34]	II	✔	✔	✔	✔	X	X	✔	✔	✔	✔	✔	8/10
Tomori et al. 2015^b [35]	II	✔	✔	X	✔	X	X	✔	X	✔	✔	✔	6/10
Trevena-Peters et al. 2018^b [36]	II	✔	✔	✔	✔	X	X	✔	✔	X	✔	✔	7/10
Vanderploeg et al. 2008^b [37]	II	✔	✔	✔	✔	X	X	✔	✔	✔	✔	✔	8/10
Yoshida et al. 2019 [38]	II	✔	✔	✔	✔	X	X	X	✔	✔	✔	✔	7/10

PEDro: Physiotherapy Evidence Database Scale.

✔: indicates that a study has met this criterion and receives a score of “1” in accordance with the PEDro guidelines.

X: indicates a study did not meet this criterion or insufficient information was provided in the published article and receives a score of “0.”

^a as per the PEDro guidelines, no score is awarded for criterion 1 “eligibility criteria.”

^b extracted from PEDro database.

Table 4. Level of evidence and quality assessment scores for all other study designs using the MMAT (n = 21).

Author/Year	Study Design	Level of evidence	MMAT (responses to the relevant criteria for each specific study design)
Arsh et al. 2020 [41]	Prospective quasi-experimental, single group, pre-test post-test	III-3	3.1 Are the participants representative of the target population? No. 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Not clear 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Christie et al. 2011 [42]	Retrospective quasi-experimental single group pre-test post-test	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? No 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Cox et al. 2014 [43]	Prospective quasi-experimental cohort study using historical controls	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
De Vos & Leclair, 2019 [44]	Convergent parallel mixed methods	III-3	1.1. Is the qualitative approach appropriate to answer the research question? Yes 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis, and interpretation? Yes 4.1. Is the sampling strategy relevant to address the research question? Yes 4.2. Is the sample representative of the target population? Yes 4.3. Are the measurements appropriate? Yes 4.4. Is the risk of nonresponse bias low? Yes 4.5. Is the statistical analysis appropriate to answer the research question? Yes 5.1. Is there an adequate rationale for using a mixed methods design to address the research question? Yes 5.2. Are the different components of the study effectively integrated to answer the research question? Yes 5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted? Yes 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed? Yes 5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved? Yes
Fletcher-Smith et al. 2012 [45]	Prospective, observational cohort study.	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Gustafsson & McKenna, 2010 [51]	Prospective exploratory observational cohort	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Haley & McKay, 2004 [26]	Qualitative	N/A	1.1. Is the qualitative approach appropriate to answer the research question? Not clear 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis, and interpretation? Yes
Hiraga et al. 2021 [39]	non-RCT	III-2	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Kasprzyk & Kruk, 2020 [46]	Prospective, quasi-experimental single group pre-test post-test	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Kelly & Nikopoulos, 2010 [52]	Multiple baseline probe case series	IV	4.1. Is the sampling strategy relevant to address the research question? Unclear 4.2. Is the sample representative of the target population? No? 4.3. Are the measurements appropriate? Yes 4.4. Is the risk of nonresponse bias low? Yes 4.5. Is the statistical analysis appropriate to answer the research question? Yes
Landi et al. 2006 [47]	Prospective observational cohort	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Ngooi et al. 2021 [55]	Qualitative descriptive methodology	N/A	1.1. Is the qualitative approach appropriate to answer the research question? Yes 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? Yes
Nilsson & Nygard, 2003 [56]	Qualitative approach using Grounded Theory	N/A	1.1. Is the qualitative approach appropriate to answer the research question? Yes 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis, and interpretation? Yes
Patil et al. 2019 [57]	Qualitative descriptive methodology	N/A	1.1. Is the qualitative approach appropriate to answer the research question? Yes 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation? Yes- pending answer to 1.2
Patterson et al. 2017 [53]	Observational cross-sectional	IV	4.1. Is the sampling strategy relevant to address the research question? Yes 4.2. Is the sample representative of the target population? Yes 4.3. Are the measurements appropriate? Yes 4.4. Is the risk of nonresponse bias low? Yes 4.5. Is the statistical analysis appropriate to answer the research question? Yes
Patterson et al. 2019 [58]	Qualitative phenomenological design	N/A	1.1. Is the qualitative approach appropriate to answer the research question? Yes 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis, and interpretation? Yes
Pillastrini et al. 2008 [40]	Non-RCT	III-2	3.1 Are the participants representative of the target population? No 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? No 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Shearer & Guthrie, 2013 [48]	Prospective quasi-experimental time series cohort	III-3	3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes
Skidmore et al. 2011 [54]	Case report	IV	4.1. Is the sampling strategy relevant to address the research question? Yes 4.2. Is the sample representative of the target population? No 4.3. Are the measurements appropriate? Yes 4.4. Is the risk of nonresponse bias low? Yes 4.5. Is the statistical analysis appropriate to answer the research question? Yes
Trevena-Peters et al. 2019^a [49]	Mixed methods (Retrospective single group pre-test, post-test and qualitative study)	III-3	1.1. Is the qualitative approach appropriate to answer the research question? Yes 1.2. Are the qualitative data collection methods adequate to address the research question? Yes 1.3. Are the findings adequately derived from the data? Yes 1.4. Is the interpretation of results sufficiently substantiated by data? Yes 1.5. Is there coherence between qualitative data sources, collection, analysis, and interpretation? Yes 3.1 Are the participants representative of the target population? Yes 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes 5.1. Is there an adequate rationale for using a mixed methods design to address the research question? Yes 5.2. Are the different components of the study effectively integrated to answer the research question? Yes 5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted? Yes 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed? Yes 5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved? Yes
Udovicich et al. 2020 [50]	Retrospective single group pre-test, post-test	III-3	3.1 Are the participants representative of the target population? No.Convenience sampling of a retrospective sample was used. 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)? Yes 3.3. Are there complete outcome data?^aYes 3.4. Are the confounders accounted for in the design and analysis? Yes 3.5. During the study period, is the intervention administered (or exposure occurred) as intended? Yes

MMAT: Mixed Methods Appraisal Tool; RCT: Randomised Controlled Trial.

^a >85% follow-up for outcome measures.

Figure 2. PRISMA Flow diagram.

A flow chart diagram showing the process of identifying and screening articles for this systematic review. Titles and abstracts of 4196 articles were screened and 4096 were excluded. Full-texts were sought for 100 articles and eight were unavailable in English. Ninety-two full text articles were screened and 31 met the inclusion criteria. An additional two were identified through reference list screening. Reasons for exclusion during full-text screening included wrong setting (n = 28), wrong intervention (n = 20), wrong form of publication e.g., review, poster, conference proceeding (n = 9), wrong outcome measures (n = 3), and paediatric population (n = 1).

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