Pedagogy and Enriched Environment for Rehabilitation in the Home After Stroke (PEER-HOMEcare): Study Protocol for a Single-Group Feasibility Study
Phase: NA
Conditions: Stroke
Sponsor: Norwegian School of Sport Sciences

 
 
 
 
 
 
Trial Title:  
Pedagogy and enriched environment for rehabilitation in the home after stroke 
(PEERHOMEcare): study protocol for a single-group feasibility study  
Approved: 16th February 2026  
 
Study Protocol and Statistical Analysis Plan (included) 
Date of document: 30th March 2026 
 
  
  
  
  
  
 
  
  
Principal Investigator:  
Prof. James Rudd, PhD  
Department of Teacher Education and Outdoor Studies, NIH  
Contact Information:  
Email: jamesr@nih.no ​
Phone: +47 23 26 22 63  
 
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Title: 
Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare): 
study protocol for a single-group feasibility study 
 
Author information:  
Arve Opheim1,2 (ORCID: 0000-0001-6793-0247)  
Luca Oppici3,4 (ORCID: 0000-0001-7528-1714)  
Ann Marie Hestetun-Mandrup1,5 (ORCID: 0009-0005-1833-0619)  
Katharina Stibrant Sunnerhagen2 (ORCID: 0000-0002-5940-4400),  
Lena Rafsten2 (ORCID 0000-0002-2226-6227)  
Guna Bērziņa6,7(ORCID: 0000-0001-6826-2427) 
Agnese Kārklina6,7 (ORCID: 0000-0002-9587-2391)  
Marianne Løvstad1,8 (ORCID: 0000-0002-8738-8401)  
Hege Prag Øra1,8 (ORCID: 0000-0002-8398-0651)  
Lauren Marcos1,3 (ORCID: 0009-0000-9054-341X)  
Matheus Pacheco9,10 (ORCID: 0000-0002-9822-981)  
Aléxia Fernandes9 (ORCID: 0000-0002-5720-1554)  
James Robert Rudd3* (ORCID: 0000-0003-1546-576X) 
 
1Center for Research and Education, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway 
2Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden 
3The Department of Teacher Education and Outdoor Studies, Norwegian School of Sport Sciences, 
0863 Oslo, Norway 
4Monash University European Research Foundation ETS, Prato, Italy 
5Oslo Metropolitan University, Oslo, Norway 
6Department of Rehabilitation, Riga Stradiņš University, Riga, Latvia 
7Department of Rehabilitation, Riga East University Hospital, Riga, Latvia 
8University of Oslo, Oslo, Norway  
9University of Porto, Porto, Portugal 
10University of São Paulo, São Paulo, Brazil 
*corresponding author email: jamesr@nih.no  
 
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Study protocol  
 
I. Summary/Abstract 
Home-based rehabilitation after stroke is becoming increasingly important, as the pressure on 
hospital-based services are increasing and most spend their recovery in their homes. Therefore, most 
require opportunities to practice meaningful activities in their everyday environment. Enriching the 
home environment may represent a potential strategy to support rehabilitation by providing continuous 
task and context-specific stimulation that promotes recovery and functional independence. through 
frequent and exploratory use of the affected upper limb. Exploratory behaviour, characterised by 
varied, adaptive and self-initiated movements, is considered an important driver of motor learning and 
neuroplasticity. While strong evidence from animal research demonstrates benefits for functional 
recovery, the translation to post-stroke home-based rehabilitation has not been made previously. This 
study investigates the feasibility, acceptability, fidelity, adherence and preliminary clinical effects of the 
Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEERHOMEcare) 
intervention. PEERHOMEcare is a theory-driven, person-centred intervention that introduces 
meaningful, targeted and progressive modifications to the home environment to promote exploratory 
use of the affected upper limb during daily activities. This prospective, single group, experimental 
study will recruit 45 stroke survivors ≥18 years of age, within 6 months post-stroke across Norway, 
Sweden and Latvia. The intervention consists of strategies for enriching the home environment to 
stimulate exploratory and functional movements,primarily through the use of utilising existing 
household materials and objects. Wearable sensors placed on the upper limbs will be used to capture 
activity patterns and provide objective insights into motor behaviour and engagement within the home, 
informing progressive adjustments to the environmental enrichments. Feasibility, acceptability and 
fidelity of the intervention will be assessed with questionnaires and interviews with participants and 
therapists. Preliminary clinical outcomes will be explored with reliable and valid assessments of upper 
limb- and ADL- function, as well as cognitive and emotional function. A dedicated website 
(www.peerhomecare.com) provides study information and educational resources for all participants 
and project therapists. This feasibility study will provide important knowledge about the 
implementation and potential impact of the PEERHOMEcare intervention and will inform the design of 
a future trial evaluating its clinical effectiveness in supporting home-based stroke rehabilitation.  
 
II.  Keywords 
Stroke, Rehabilitation, Home-based rehabilitation, Enriched Environment, Upper limb function, 
Activities of Daily Living, Motor learning, Motion sensors, Feasibility 
 
Statements and Declarations 
All authors contributed to the study conception and design, and all authors commented on previous 
versions of the manuscript. All authors read and approved the final manuscript. 
 
 
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III. Introduction 
Stroke is the third leading cause of death and disability worldwide [1]. In 2021, there were 11.9 million 
new stroke cases and 93.8 million people living with stroke globally [2]. Despite age-adjusted declines 
in those over 70 years, overall numbers continue to rise due to population growth. Stroke imposes a 
substantial societal and healthcare burden, costing about €45 billion annually in Europe [3]. A majority 
of the stroke survivors are left with lasting impairments, for instance upper limb paresis occurs in 
approximately 70% of stroke survivors, and recovery of arm and hand function is a key priority in 
rehabilitation, as it is closely linked to independence in activities of daily living (ADL) [4]. The 
deliberate shift during the last decades of earlier hospital discharge and moving specialist 
rehabilitation services into patients’ homes highlights the urgent need for more effective rehabilitation 
strategies [5]. 
Innovative strategies are needed for home-based rehabilitation, an increasingly central component of 
stroke care [6]. Home is where most stroke survivors spend most of their time in the post-acute 
phase, defined as the initial six months after stroke onset. The post-acute phase represents the most 
sensitive window for neuroplastic reparatory changes to occur and consequently movement functions 
to improve [7, 8]. While some neural repair occurs spontaneously, recovery is largely activity- and 
experience-dependent [9, 10], highlighting the importance of active, exploratory use of affected body 
parts in everyday contexts. Evidence from Early Supported Discharge demonstrates the potential of 
the home environment, where survivors are often more independent and active than in a hospital [11, 
12]. However, the potential of home-based rehabilitation remains underused: only about 50% of 
survivors receive rehabilitation  [13, 14], many feel unprepared for the transition home [15], and 
sedentary behaviour is common [16]. 
Environmental Enrichment (EE) is a promising strategy for improving home-based rehabilitation and 
transforming the home into a stimulating and supportive environment that actively engages patients to 
explore diverse motor, cognitive, sensory, and social activities, thereby promoting neuroplasticity and 
stroke rehabilitation outcomes [17]. Predominantly adopted in animal-based research, EE refers to 
housing conditions, such as enlarged spaces and the provision of equipment, that stimulate enhanced 
activities, exploration, and socialisation [9]. Evidence indicates that housing animal models of stroke in 
an EE improves the rehabilitation process through a series of nested plastic and reparatory 
mechanisms (for a detailed review of the mechanisms, see [18]), which underlie an enhancement of 
cognitive and motor functions [19] leading to an increased autonomy to perform daily functions. A 
handful of studies have translated EE to stroke rehabilitation in stroke units and hospital wards, 
showing increased physical, social, and cognitive activities [20-22], and reduction in depression, 
anxiety, and stress levels [23]. These initial translational efforts confirm the potential of EE to improve 
stroke rehabilitation.  
In response to the current challenges in rehabilitation and the potential of EE to improve current 
practice, we have developed the “Pedagogy and Enriched Environment for Rehabilitation in the 
HOME after stroke” (PEERHOMEcare) intervention. PEERHOMEcare is a translational, theory-driven, 
population-centred, complex intervention, developed in alignment with the framework for complex 
interventions of the Medical Research Council [MRC; 24, 25].  
 
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​
Fig. 1 Diagram showing the intervention elements in the dotted boxes to promote the expected clinical 
outcomes. The process of developing the intervention will be described in detail elsewhere. 
Abbreviations: Project Therapists (PT), S: Stroke survivors, FM: Family Members. Google Sheets.  
 
PEERHOMEcare is a home-based intervention built upon a clear theoretical pathway of change and 
improvement (Fig. 1) to support a patient rehabilitation process. It utilises an innovative translation of 
EE, conceptualising it as a strategy that entails meaningful, targeted, and progressive changes to 
physical and social aspects of the home pertaining to everyday behaviours (for more details, see 
methods and [26]). These changes invite survivors to frequently use the affected upper extremity to 
carry out activities of daily living (ADLs) and to perform enhanced exploratory behaviours, promoting 
neuroplasticity and leading to improvement in upper limb functions. A recent scoping review of 
preclinical EE in stroke models [27] combined with rehabilitation and motor learning sciences informed 
the novel conceptualisation of the paradigm into meaningful (tailored to individuals’ needs and 
routine), targeted (directed towards rehabilitation goals and capacity), and progressive (incremental 
manipulation of complexity, novelty, and variety) environmental modifications (Fig. 2).  
To facilitate EE modifications, the intervention uses the S.T.E.P.S (space, time, equipment, people & 
safety) acronym to guide structured and systematic modifications to the environment (see methods). 
Through this new lens, EE involves simple and cost-free modifications that create numerous 
invitations, tailored to each survivor, to be active and repeatedly use their affected limb throughout the 
day [26]. It is population-centred, meaning it has been co-designed with stakeholders, and it is 
individualised to the conditions, goals, and needs of each stroke survivor and tailored to local 
contexts. Since many ADLs requiring adequate limb function limiting post-stroke independence, the 
main objective of the PEERHOMEcare intervention is to enhance motor functional performance in the 
upper extremity. Being embedded in the individuals’ living environment and targeting functions that 
support ADLs, this intervention fully aligns with Stroke Action Plan for Europe 2018-2030 [6] and the 
WHO definition of rehabilitation “a set of interventions designed to optimise functioning and reduce 
disability in individuals with health conditions in interaction with their environment” [28].  
 
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Fig. 2 Conceptual framework of environmental modifications in PEERHOMEcare intervention, 
comprising three components: meaningful (tailored to individuals’ needs and routines), targeted 
(aligned with rehabilitation goals and capacity), and progressive (gradual increases in complexity, 
novelty, and variety). 
 
The aim of the study is to investigate the feasibility, acceptability, fidelity, adherence and adverse 
events of the PEERHOMEcare intervention in patient’s homes. This is an important first step as set 
out in the MRC framework, as it is critical to investigate the feasibility prior to conducting a full scaled 
randomised controlled trial of an intervention [24]. The study will also investigate preliminary results of 
the clinical effectiveness. The feasibility trial will be carried out in three different countries, Norway, 
Sweden, and Latvia to evaluate feasibility in different healthcare systems and contexts. It is 
hypothesised that the delivery of the PEERHOMEcare intervention will be found to be feasible and 
acceptable for people post-stroke, their family members, and the healthcare professionals.  
 
IV. Materials and Methods 
Design 
This study uses a prospective, single group, experimental design and is conducted in accordance with 
the CONSORT checklist for feasibility studies [36] (Supplement 1.0). The study uses a combination of 
quantitative and qualitative methods to ensure a complete and person-centred approach on the 
investigation. The flow chart and design of the study is presented in Fig. 3. 
Study settings 
The study will take place in the regions of Oslo in Norway, Gothenburg in Sweden and Riga in Latvia. 
The intervention will take place in the home of the participants. 
 
Participants 
A total of 45 participants from Sweden, Latvia and Norway will be recruited, with approximately 15 
individuals from each site to allow for variation in ages, living conditions and stroke type and severity. 
They will be adults of both sexes, diagnosed with stroke no more than 6 months prior to enrolment. 
They should either be about to be discharged or already have been discharged to their home 
following inpatient rehabilitation.​
 
PEERHOMEcare Intervention 
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The intervention provides a progressive, home-based rehabilitation experience that integrates EE 
principles to stimulate motor learning through everyday activities. The intervention focuses on making 
meaningful, targeted, and progressive modifications to the home environment to promote frequent, 
varied, and exploratory use of the affected upper limb. 
Meaningful refers to modifications centred on activities that matter to the stroke survivor, thus 
connected to their identity, independence, daily roles, or enjoyment. Targeted indicates that 
modifications are aligned with individualised rehabilitation goals and current capabilities to increase 
purposeful use of the affected limb. Progressive reflects the gradual adjustment of environmental 
demands over time, ensuring the survivor is safely challenged to engage in increasingly varied and 
exploratory movements, thereby supporting independence, skill acquisition, and confidence. 
Environmental modifications focus on Spaces, Time, Equipment, and People involved in a task, within 
safe boundaries (S.T.E.P.S.). These are co-designed together with the participant and the project 
therapist (PT), implemented through (i) home visits from the project therapist that include structured 
screening and assessments to identify the participant’s goals for the intervention, (ii) educational 
resources and materials (e.g. including a daily activity diary), and (iii) motion sensors to track 
movement behaviour. 
Meaningful ADLs are here defined as activities that align with the survivor’s rehabilitation goals, 
functional capacity, preferences, and daily routines [29]. Through home visits by the project therapist, 
goal identification begins with an inspired version of the Canadian Occupational Performance 
Measure (COPM), which is modified and used collaboratively with the survivor to prioritise personally 
meaningful activities and establish initial rehabilitation goals. Motor capacity, functional ADL 
performance and cognitive and psychological constructs are identified using the assessments as 
outlined in Table 4. These assessments are further considered to individualise the intervention to 
enable the identification of three meaningful goals and three routine ADLs.  
Targeted EE modifications focus on the selected meaningful and routine ADLs, with the aim of 
increasing independence and task-specific engagement of the affected limb during task performance. 
Through collaborative discussions, the project therapist and survivor co-design changes according to 
S.T.E.P.S. Depending on current performance, modifications may facilitate the affected limb’s 
contribution to bimanual tasks or encourage its use in unimanual activities. 
Progression EE modifications are systematically progressed over time to increase task challenge 
through increasing complexity, variety, and novelty. This progression promotes diverse and 
exploratory task engagement while maintaining safety (see Table 1 for illustrative examples).​
 
Table 1: Illustrative Case Examples: Operationalising S.T.E.P.S. within PEERHOMEcare intervention.  
​
Participant profile.​
A 62-year-old right-hand-dominant male presented with left hemiparesis and left hemi-spatial 
neglect. Visual acuity was intact; however, perceptual awareness of the left side was impaired, with 
a pronounced right-sided attentional bias. Deficits affected functional mobility, safety, and ADL 
performance, particularly tasks requiring bilateral coordination and environmental scanning. He 
lived at home with his wife and two adult sons (18 and 21 years). COPM goals included walking his 
dog, independent dressing (buttoning jeans), and playing chess with his sons. SAFE score for the 
left upper limb was 4 (shoulder abduction = 2, finger extension = 2). Rehabilitation priorities were 
upper-limb motor recovery, neglect management, functional independence, and home safety 
optimisation.​
 
ADL Activity 
Identified  
 
Dressing 
 
Preparing breakfast  
(making coffee and toast) 
 
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Meaningful 
This activity was selected because it 
was personally meaningful identified 
in COPM, occurred daily, and 
required bilateral coordination, 
postural control, and visual attention 
to the left side. 
 
Independently being able to fasten 
and put on jeans or trousers 
represented dignity, privacy, and 
reduced reliance on his partner. The 
participant identified dressing without 
assistance as a key marker of 
recovery.​
 
This task was selected because it occurred 
daily, required bimanual coordination, and 
when discussing previous daily routines 
with the participant it was found to be highly 
meaningful for morning routine and general 
happiness. 
 
Preparing coffee each morning represented 
independence and resumption of normal 
life roles. The participant reported that 
“starting the day myself” was emotionally 
important, making it a high-salience activity 
for practice. 
 
Targeted 
Initial observation, supported by 
survey data, showed minimal 
contribution of the affected limb, with 
reliance on the wife for balance and 
fastening. Modifications therefore 
aimed to increase active initiation and 
stabilisation by the affected limb while 
maintaining task success. 
The task was simplified by using the 
participant’s own trousers with a 
magnetic clip and Velcro fastening, 
preserving the meaningful goal while 
reducing fine motor demands. 
Initial observation showed dominant use of 
the right arm and reduced attention to the 
left side. Modifications aimed to increase 
left-arm use for reaching and stabilising and 
to improve attention toward the left space. 
 
 
Progressive using S.T.E.P.S  
 
 
 
Space 
Practice was integrated into the daily 
routine in the bedroom and bathroom. 
Trousers were positioned on the left 
side of the bed to encourage attention 
to the affected side. As performance 
improved, the original button was 
reintroduced and practised repeatedly 
while watching TV to increase 
repetition. 
Practice occurred in the kitchen during the 
morning routine. Items were initially placed 
on the left side and later returned to typical 
locations to increase independence. 
 
 
Time 
The task was practised at least five 
times per day as part of their normal 
routine (dressing, going to the toilet 
etc). Initially it was completed slowly 
to allow concentration, with speed 
increasing as performance improved. 
The task was practised daily at breakfast. It 
was performed slowly at first to support 
attention, then progressed to normal speed. 
 
 
 
 
Equipment 
Practice began in sitting (bed, chair, 
or toilet). A mirror was added on the 
affected side for visual feedback, and 
later a table was introduced to 
support posture and task 
organisation. 
Lightweight mugs, a non-slip mat, and an 
easy-pour kettle were used initially and 
gradually removed as ability improved. 
 
Person 
Initially, the wife provided physical 
assistance. Over time, the participant 
initiated the task independently, with 
the wife stepping back to standby 
support. 
Verbal prompts and close support were 
provided at first. The participant progressed 
to initiating the task independently, with 
reduced input from his wife. 
 
Safety 
Assistance 
progressed 
from 
hands-on support to supervision from 
Close supervision due to hot liquids 
progressed to occasional checking as 
safety awareness improved. 
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the 
doorway 
as 
balance 
and 
confidence improved. 
 
 
Motion Sensor Monitoring and Use with the Activity Diary 
Participants will be asked to wear four CE-marked Inertial Measurement Unit (IMU) sensors (Xsens, 
Movella Inc., California, USA) for up to two hours per day. Sensors are worn over clothing using 
straps, and are positioned on the sternum, affected and non-affected forearms, and the affected upper 
arm. The number of sensors and their placement were determined based on pilot studies [30, 31] that 
provided the minimum number of sensors to capture movement information from stroke patients. 
Project therapists will provide instruction on how to place the sensors and operate the receiver device, 
with additional guidance available in the training materials. The therapist and participant will decide 
together the most appropriate time of day for sensor use. The sensors will record acceleration and 
orientation of the body segments in three dimensions that will be captured by a custom-made 
application developed in Python (Version 3.9.24) (Python Software Foundation, python.org).  
From these signals, quantitative metrics will be derived from another custom-made application 
developed in Matlab R2025b (Version 25.2.0.3150157) (Mathworks, Natick, MA). As stated, it is of 
primary importance to capture exploratory activity with the upper limb as to guarantee that 
manipulations in the home environment are effective and stimulating for recovery. For this reason, we 
derived measures of movement variability (entropy), smoothness, novelty of motor patterns, 
compensation (use of trunk when performing affected limb movements), use of the affected upper 
limb and proportion of time spent in moderate-to-vigorous physical activity. Variability and novelty are 
common aspects considered in the literature to capture exploratory behaviour [32]. We measure 
variability through entropy [33, 34] of the signal provided by the sensors in four different ways: 1) 
considering acceleration and orientation or 2) just orientation, 3) considering all sensors or 4) just the 
affected limb. These four types of variability allow interpretation from the project therapist on different 
aspects of the ADLs. Variation in ways to perform the same movement (changes in acceleration), 
varied movements (changes in joint orientations) emphasising, or not, the affected limb. Novelty was 
considered as to directly point when modifications of the environment led to new forms of acting, thus 
demonstrating whether exploration (entropy/ variability) lead to new movements. Compensation, use 
of the affected limb, and smoothness are measures directly related to how the participant performs 
the movements during ADL. The time spent in moderate-to-vigorous physical activity is an additional 
measure informing whether modifications lead to more active behaviours in the home. 
To help interpret the information from the sensors, participants complete the activity diary on the same 
days as they wear the sensors. The diary provides an understanding of the stroke survivors’ daily 
activity patterns. It provides context about what activities were being performed, where they took 
place, and how much assistance was needed Combining sensor data with diary entries allows the 
therapy team to adjust S.T.E.P.S. modifications so the intervention remains appropriate relevant, 
progressive and safe. 
Educational resources 
The delivery and implementation of the intervention are supported by a fully functioning website 
(www.peerhomecare.com) that serves as the program’s digital companion. This intranet-style portal 
provides a centralised, secure access point for all individuals involved in the study, including project 
therapists, stroke survivors, and their support networks, including family members. Access is 
role-based, ensuring that users are presented with the specific training, information, and ongoing 
support materials relevant to their participation. 
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For participants with stroke and their family members, the educational content will focus on 
familiarisation with the intervention, including peer-led mentorship and motivational input from other 
stroke survivors, guidance on collecting and managing motion sensor data, and strategies to support 
active involvement in their own rehabilitation. PTs will utilise the portal as a standardised training-suite 
for administering and interpretating objective assessments, including sensor data, instructions on the 
intervention and application of PEERHOMEcare Enriched Environment strategies. 
To ensure the portal is accessible and user-friendly for survivors with post-stroke visual or cognitive 
impairments, the interface utilises adaptive accessibility features, such as high-contrast modes, 
scalable text, and a simplified, ‘one-click’ menu structure to minimise cognitive load. The resources 
primarily consist of short videos alongside clear, written content and illustrative images to ensure ease 
of understanding for all users. All digital resources are mirrored in a professional, print-ready format to 
be provided as physical manuals for participants who prefer or require paper-based materials ([35] 
http://www.peerhomecare.com/) Access to the learning materials and resources in the portal will be 
restricted to individuals involved in the study. 
 
Recruitment 
Participants will be recruited from the stroke department at Sunnaas Rehabilitation Hospital and from 
specialised rehabilitation institutions and local municipalities in South-Eastern Norway, as well as from 
Sahlgrenska University Hospital (Gothenburg, Sweden) and Riga East University Hospital (Riga, 
Latvia). 
Potentially eligible participants will be identified and screened by therapists experienced in stroke care 
and rehabilitation (see Table 2 for full eligibility criteria). Individuals will receive verbal and written 
information about the study, with accessible and adapted materials provided for those with 
communication or cognitive difficulties. Screening will include assessment of upper-limb motor 
function using the Shoulder Abduction and Finger Extension (SAFE) test (minimum score ≥ 4) and 
cognitive function using the Montreal Cognitive Assessment (MoCA). Because this is a feasibility 
study, we will explore how cognitive impairments influence participation; therefore, individuals with 
severe cognitive impairment (MoCA < 10) will be excluded. ​
 
Table 2: Eligibility, inclusion and exclusion criteria 
Inclusion criteria: 
Exclusion criteria: 
adults (≥18 years old)  
presence of other neurological conditions  
diagnosed with first or second haemorrhagic or 
ischaemic stroke 
reported limited life expectancy due to other 
medical conditions during the study period 
stroke onset no more than six months before 
study enrolment 
severe mental health disorders, including 
substance use disorders 
discharged to their home following inpatient 
rehabilitation 
a history of violence 
reporting functional impairments in the upper 
extremity that affect functioning and participation 
in everyday life due to the latest stroke. 
severe communication and/or cognition deficits 
(MoCA 
below 
10 
points) 
that 
prevent 
participants from being able to participate in the 
intervention, understand interview questions, or 
study-related instructions 
score at least 4 points on the Shoulder 
Abduction + Finger Extension (SAFE) measure. 
unwillingness of persons sharing the household 
to participate and accept the intervention 
adequate 
language 
skills 
and 
cognitive 
functioning to be able to understand intervention 
material, perform outcome assessments and 
co-operate throughout the intervention 
Uncontrolled medical issues such as unstable 
angina, 
severe 
hypertension, or severely 
limiting orthopaedic conditions 
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willing to participate and able to provide written 
consent 
 
consent for participation also by closest family 
members, if they live in the same household  
 
 
Once participants are screened and consented to participate in the study, descriptive characteristics 
will also be obtained to include stroke severity, location and type of stroke, date of stroke, dominant 
side, and modified Rankin Scale (mRS) score.  
Information about the home environment will also be recorded, including type of residence (e.g., 
apartment or single house), number and types of rooms, presence of stairs, geographical setting 
(urban, semi-urban, rural), and cohabitants. 
A cohabitant and/or healthcare professional clinically working with the participant, will also be invited 
to participate in the study.  
Timeline of the intervention  
Once the participants have been recruited to the intervention, they and their family member (FM) will 
be given access to the web-based or paper-based information resources. One-to-five weeks after 
recruitment, the intervention will begin with a home visit by the project therapist. In week 1 (T0 -T1), 
the baseline testing of the clinical outcome measures will be made in the participant’s home. The 
project therapist will identify and observe participants routines, daily and leisure activities, and goals, 
map the home environment, hand out and start using the motion sensors, and begin with the home 
modifications (Fig. 3).  
Over the following 5 weeks (T1-T2), modifications to the home environment will be made and followed 
up (Table 1). The project therapist will perform 1-2 home visits per week with the addition of phone 
calls and/or videoconferences. The number and type of contacts with the project therapists will be 
tailored to the participants individual needs and preferences. The participants will keep an activity 
diary, recording the time and duration of the most important and relevant motor tasks. At T2, the 
primary clinical outcomes and the feasibility study outcomes will be assessed. These assessments 
will take around 1-2 hours and be carried out in the home. Three months after T2, the project therapist 
will conduct a follow-up call with the participants and FM to understand their thoughts about the 
intervention and to what extent they have continued to follow the EE principles afterwards (Fig. 3).  
 
Fig 3 Flow of the study design of the PEERHOMEcare feasibility study 
 
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Outcome measures 
The primary outcomes of this study are the feasibility and acceptability of the intervention and study 
procedures. Secondary outcomes will explore preliminary changes in domains aligned with the 
intervention targets, including upper-limb motor recovery, real-world arm use, activity and 
participation, and psychosocial outcomes. These measures are exploratory and will inform outcome 
selection and sample size estimation for a future RCT. 
Primary outcomes 
Feasibility and acceptability of the intervention and study procedures will be assessed across key 
domains, including recruitment processes, delivery of intervention components, use of technology and 
educational resources, and implementation of home modifications. Fidelity to the intervention by 
project therapists and participant adherence to intervention components will also be evaluated. 
Adverse events, including falls or injuries, will be documented. 
Detailed definitions of feasibility variables, assessment tools, and outcome descriptions are provided 
in Table 3. 
 
Table 3. Overview over the variables, the assessment tools and their descriptions in the feasibility trial 
of the PEER HOMEcare intervention. 
Variable 
Assessment tools 
Description 
Feasibility 
Questionnaires; study logs; 
observational notes 
Practical feasibility of delivering the intervention, 
including recruitment processes, resource 
requirements, time demands, and logistical 
considerations 
Acceptability 
Qualitative interviews; 
questionnaires 
Participant and healthcare professional 
perceptions of the intervention, the training 
materials, and use of body-worn motion sensors 
Adherence 
Motion sensor data; activity 
diary; study logs; website 
analytics 
Participant engagement with intervention 
components, including sensor use, diary 
completion and use of digital resources 
Fidelity 
Therapist questionnaires; 
protocol checklists 
Extent to which the intervention is delivered as 
intended according to the protocol and training 
procedures 
Adverse events 
Study logs; interviews 
Recording of any adverse events affecting 
participants or family members, such as falls, 
injuries, or other unexpected events 
 
Semi-structured interviews will be conducted with a purposive sample of approximately 12–18 
participants across the three participating countries (4–6 participants per country), to capture a range 
of experiences and perspectives. The interviews will explore participants experiences, perceived 
acceptability and self-reported effects of the intervention. The interviews will be guided by topics 
related to the intervention and analysed using thematic analysis  Data collection will take place shortly 
after completion of the intervention (T2). 
In addition, the feasibility and relevance of collaboration with local healthcare professionals (HCPs) 
that also work with the participants will be explored. HCPs will be invited to share their perspectives 
and experiences of delivering or supporting the intervention within community services.  
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Clinical outcomes 
A complete list of the outcome measures of the intervention is provided in Table 4.  
Action Research Arm Test (ARAT) [37, 38]  will be used to assess functional motor activities in the 
upper limbs. ARAT is a valid and reliable outcome measure that has been used extensively in stroke 
research and rehabilitation (Action Research Arm Test | RehabMeasures Database).    
Fugl Meyer Assessment Upper Extremity (FMA-UE) [39] will be used to assess sensorimotor 
impairments in the upper limbs. FMA-UE is both valid and reliable and widely used in stroke research 
and rehabilitation (Fugl-Meyer Assessment | Institute of Neuroscience and Physiology, University of 
Gothenburg).   
Abilhand [40] is a self-report questionnaire about perceived difficulties with bimanual hand skills. 
Abilhand is found to be valid and reliable in stroke research (ABILHAND | RehabMeasures Database). 
The Stroke Self-Efficacy Questionnaire (SSEQ) assesses stroke survivors’ perceived confidence in 
performing functional and self-management activities. It provides a validated measure of self-efficacy 
relevant to poststroke rehabilitation and independence [41]. 
The Stroke Impact Scale (SIS) is a stroke specific patient-reported outcome measure capturing the 
multidimensional consequences of stroke across physical, emotional, cognitive, and participation 
domains. It is widely used to quantify recovery and quality of life [42]. 
Barthel Index (BI) [43], will be used to assess basic ADL and self care function. BI is considered valid 
and reliable to use in stroke research (Barthel Index | RehabMeasures Database)  
The Patient Health Questionnaire (PHQ-9) is a short assessment of depressive symptom severity 
over the preceding two weeks. It is validated for screening and monitoring depression in clinical and 
research contexts [44]. 
The General Anxiety Disorder-7 (GAD-7) measures the severity of generalised anxiety symptoms and 
has strong psychometric properties and clinical utility [45] 
 
Secondary Outcomes- movement sensor measures 
Entropy measures will be used to assess exploratory behaviour. Entropy general - considers all 
segments or the single affected limb and will demonstrate changes combining what and how 
movements were explored. Entropy joints - consider all segments or the single affected limb and will 
describe changes in how movements were explored. Entropy, as a measure of variability, have been 
used with success to demonstrate the necessary changes in movement behaviour anticipating 
improvements [46, 47]. 
Novelty is a direct measure of whether new segment orientations were observed when the sensors 
were used. In this current form, this measure has not been used before, but novelty has been 
proceduralised in other ways before in the field of motor control/ learning [48, 49]. 
Smoothness has been demonstrated as an important indicator of stroke recovery [50]. This will be 
used, therefore, as a day-to-day measure of motor function. Use of the affected limb is a direct 
measure of presence of movements with the affected limb. This is of relevance provided the goal of 
the participants. 
Compensation has long been demonstrated to be one way that stroke survivors improve function over 
time [51]. A common to compensate for the impaired limb is by moving the trunk while moving the 
affected limb. Thus, this measure captures whenever the trunk was moved simultaneously as the 
affected limb performed a movement. 
Use of the affected limb is a simple measure estimating the amount of time (percentage), that the 
participant moved the affected limb. This measure verifies whether the manipulations require/afford 
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use of the affected limb to support goal achievement. In the long term, large values would hold 
learned non-use of the affected limb 
 
Table 4. The clinical outcome measures and screening instruments that will be used in the PEER 
HOMEcare intervention. 
Clinical outcome measures 
Time of assessments 
 
T0 
Baseline 
T2 End 
Screening instruments 
 
 
Voluntary Muscle strength in shoulder abduction and finger extension 
(SAFE) 
♦ 
 
Cognitive functioning: 
Montreal cognitive assessment (MoCA) 
♦ 
 
Activities of daily living and dependence: Modified Rankin scale 
♦ 
 
CLINICAL OUTCOMES 
♦ 
 
Motor ability for upper limb 
Action Research Arm Test (ARAT) 
Fugl-Meyer Assessment (FMA-UE) 
 
♦ 
♦ 
 
♦ 
♦ 
Self-reported arm use: Abilhand  
♦ 
♦ 
Self-efficacy and disability 
Stroke self-efficacy questionnaire (SSEQ) 
Stroke impact scale (SIS) 
 
♦ 
♦ 
 
♦ 
♦ 
Activities of daily living: Barthel Index 
♦ 
♦ 
Depression and anxiety 
Patient health questionnaire-9 (PHQ-9) 
Generalised anxiety disorder (GAD-7)  
 
♦ 
♦ 
 
♦ 
♦ 
 
Process evaluation – quantitative and qualitative data 
A process evaluation will be conducted to understand how the intervention was implemented and 
experienced across the three participating countries. This will include examination of implementation 
fidelity, participant engagement, and contextual factors influencing delivery. Quantitative data from 
feasibility metrics, adherence measures, and study logs will be combined with qualitative findings from 
participant and healthcare professional interviews. 
The process evaluation will explore how participants interacted with intervention components, 
including home modifications, educational resources, and motion sensors, and how these contributed 
to perceived benefits or challenges. Contextual influences such as home environment, support from 
family members, and differences in healthcare systems will also be considered. Findings will be used 
to refine the intervention and inform the design of a future definitive trial. 
Statistical analysis 
All quantitative data will be analysed using IBM SPSS. Baseline characteristics and screening 
measures will be summarised using means and standard deviations or medians and interquartile 
ranges, as appropriate. Feasibility, acceptability, fidelity, and adherence outcomes will be summarised 
using descriptive statistics, including counts and percentages. The outcomes of the feasibility 
assessments will be interpreted as follows: A satisfaction rate of more than 80% will be regarded as a 
positive outcome and considered indicative of positive feasibility. The success criteria are described in 
Supplement 2.0.  
Secondary outcome measures will be described with descriptive statistics. Exploratory analyses will 
examine changes between T0 and T2 using paired parametric or non-parametric tests, depending on 
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30th March 2026 

 
data distribution and variable type. As this is a feasibility study, these analyses will be interpreted 
cautiously and primarily used to estimate variability and inform the design of a future definitive trial. A 
p-value of <0.05 will be reported for completeness. 
Sensor data will be analysed with a custom-made script in Matlab. Entropy measures will be 
calculated following [30, 31]. The data is first discretised in bins (with specific bin sizes for 
acceleration and orientation) and the frequency of the 6-dimensional time series bins is calculated. 
Then, using the probability of each bin occurrence, the entropy is calculated 
 (
,  
   −
 
 
∑𝑝𝑖· 𝑝𝑖
( ) 
where pi is the probability of the ith bin). Smoothness follows [52]. To have a single dimension of 
acceleration, we calculated the norm of the three dimensions. This was then integrated to have a 
peak speed and differentiated to identify jerk. The smoothness measure was the negative mean of 
absolute jerk divided by peak speed. Novelty considers the whole history of movements performed 
while wearing the sensors and calculates the percentage, from movements currently performed, that 
were novel. Use of affected upper limb delimits a threshold of acceleration at which moving of the arm 
is considered. From this, the percentage of time that movement occurred is calculated. Compensation 
considers the previous measure (use of the affected limb) and calculates whether the sternum was 
also moving at the time that the affected limb was moving. This cooccurrence of movement in trunk 
and affected limb is then divided by all motion of the affected limb to provide a percentage. Moderate 
to vigorous physical activity will be calculated following the general guidelines for wrist-worn 
accelerometers [53]. The Euclidean norm (minus one) of the acceleration provided by the forehand 
sensor will be calculated and summed over a period of 5 seconds. An epoch that shows values above 
a given threshold (to be validated in terms of the forearm) will be provided as an epoch of activity. 
Minutes that show more than 80% of activity will be considered a minute of moderate-to-vigorous 
physical activity. 
 
VI. Notes 
Patient and public involvement 
Patients, family members and partner organisations with lived experience of stroke were involved in 
the development of the intervention and study procedures, with one recruited from one of the largest 
stroke organisations within Norway. Their input informed the selection of meaningful activities, the 
design of home-based components, and the format of educational materials to ensure relevance, 
usability, and acceptability. Feedback was also used to refine participant information, diary formats, 
and the timing of assessments to minimise burden. 
During the feasibility study, participants will contribute further through qualitative interviews exploring 
their experiences of the intervention. The findings will inform refinement of the intervention and the 
design of a future definitive trial. Patients and the public will not be involved in recruitment or data 
collection beyond their role as study participants. 
​
Compliance with Ethical Standards and registrations 
This study has been approved by The Regional Committee for Medical and Health Research Ethics 
for South-East of Norway in February 2026 (ID nr.816325).   Latvia has also received approval from 
the Research Ethics Committee of Riga Stradiņš University (ID nr.2-PĒK-4/225/2026) and the Science 
Department of Riga East University Hospital (ID nr.AP/08-08.1/26/49) in February 2026. In Sweden 
the study was approved by the Authorities for Ethics in Research (ID nr. 2026-00409-01). The study 
will be performed in accordance with the ethical standards as laid down in the 1964 Declaration of 
Helsinki and its later amendments or comparable ethical standards. 
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30th March 2026 

 
All participants will give written informed consent, which includes information about the study’s 
purposes and consequences, participants’ rights, confidentiality, data management, and emphasises 
the right to withdraw from the study at any time without giving any reason. Participants will not be 
asked to refrain from any ongoing treatment during the trial. 
All authors declare no conflict of interest, neither of financial or non-financial nature.​
 
Dissemination of results 
The results from the project will be published in peer-reviewed, scientific journals. The results will also 
be presented at conferences within the fields of physical medicine and rehabilitation, stroke and 
neurology, movement science as well as in motor learning and pedagogy. The project has established 
close cooperation with stakeholders in the patient organisations in all countries, and the results, 
experiences and knowledge gained in the project will be shared with them through joint meetings, 
newsletters and other information channels. The project has developed a specific web site where all 
relevant information and results from the project will be available for all. 
 
 
Data management and data storage 
All data handling and storage will be confidential and be in line with Norwegian, Portuguese, Swedish, 
and Latvian privacy protection regulations and the General Data Protection Regulation (EU 
2016/679). The main storage location will be the Services for Sensitive Data (TSD) at the University of 
Oslo, a highly secure platform for sensitive data with strict access control via two-factor 
authentication. All participant data will be pseudonymised using a unique project ID. The identification 
key, linking names and other personal identifiers to the project IDs, will be stored securely at each site 
responsible for recruitment of participants, accessible only to the PI and authorised data managers. A 
joint data controller agreement for the data on the TSD platform has been signed by all partners. 
Qualitative interviews will be recorded using a secure audio-recording service connected to TSD. 
Questionnaires, observations, and consent forms are accessed through Nettskjema into TSD. Some 
may initially be collected on paper and will be stored in fireproof, locked cabinets accessible only to 
the responsible PI at each site. All analyses will be conducted inside the TSD environment; raw or 
de-identified data will never be transferred out. Only fully anonymised results may be exported, 
subject to TSD approval. At project completion, anonymised datasets may be archived in the Open 
Science Framework (OSF) in compliance with GDPR and TSD rules. All project data will be retained 
for 5 years after completion, after which the PI will ensure secure destruction within TSD and any 
approved repositories.  
Trial status 
In preparation 
Project management 
The project will be managed by the Norwegian School of Sport Sciences, in close collaboration with 
Sunnaas Rehabilitation Hospital, University of Gothenburg and Riga Stradins University. The project 
team consists of a multidisciplinary group of researchers from these institutions with long experience 
in both clinical and research activities, with a various competence in motor learning, pedagogy, 
physical and occupational therapy, rehabilitation medicine, cognition, motion analysis and stroke 
rehabilitation.   
Financing 
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30th March 2026 

 
The project is financed with EU-funds through the Transforming Health Care Systems Joint National 
Call 2023 (THCS) programme (Agreement number 101195654) and is administered by the Norwegian 
Research Council and the Latvian Research Council. and the project for Norway and Latvia has been 
fully financed by THCS. The Swedish participation is financed through grants to the University of 
Gothenburg.  There is no financial interest in the project by any of the partners or by their institutions. 
  
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