{"paper_id":"0f4cd335-efd2-4a98-8b73-d467b07f7f6c","body_text":"Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare): study protocol for a single-group feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare): study protocol for a single-group feasibility study Arve Opheim, Luca Oppici, Ann Marie Hestetun-Mandrup, Katharina Stibrant Sunnerhagen, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9419155/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Home-based rehabilitation after stroke is increasingly important, as pressure on hospital services rise and recovery occurs mostly at home. Enriching the home represents a potential strategy to support rehabilitation by providing continuous task- and context-specific stimulation that promotes functional recovery through frequent and exploratory use of the affected arm. Exploratory behaviour - self-initiated, varied and adaptive movements - is an important driver of motor learning and neuroplasticity. While strong evidence from animal research demonstrates benefits for functional recovery, translation to human home-based rehabilitation remains limited. This study investigates the feasibility of the Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare) intervention. This theory-driven, person-centred intervention, introduces meaningful, targeted and progressive home-modifications to promote exploratory use of the affected arm during daily activities. In this prospective, single group, experimental study, 45 stroke survivors (≥18 years), within 6 months post-stroke across Norway, Sweden and Latvia will participate. Wearable sensors will be used to capture activity patterns, informing objective insights into motor behaviour, and progressive modifications to the home. Primary outcomes of feasibility and acceptability are assessed through questionnaires, logs and interviews. Intervention fidelity, participant adherence and adverse events will be evaluated. Secondary outcomes include changes in arm function, self-perceived activities of daily living and psychosocial outcomes. A dedicated website (www.peerhomecare.com) provides informational resources for all participants and project therapists. This study will provide important knowledge about PEER HOMEcare and provide information for a future trial evaluating its clinical effectiveness in home-based stroke rehabilitation. Trial registration in www.ClinicalTrials.gov on 06-04-2026, NCT07517120. Stroke Rehabilitation Home-based rehabilitation Enriched Environment Upper limb function Activities of Daily Living Motor learning Motion sensors Feasibility Life After Stroke Figures Figure 1 Figure 2 Figure 3 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, as this is an increasingly central component of stroke care [ 6 ]. Home is where most stroke survivors spend most of their time in the post-acute phase, i.e. 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 establishing the home as 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 underly 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, and have provided preliminary evidence of increased physical, social, and cognitive activities [ 20 – 22 ], and reduction in depression, anxiety, and stress levels [ 23 ]. These initial translational efforts indicate a 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” (PEER-HOMEcare) intervention. PEER-HOMEcare is a translational, theory-driven, population-centred, complex intervention, developed in alignment with the framework for complex interventions of the British Medical Research Council [MRC; 24, 25]. PEER HOMEcare 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 which is hypothesized to result in improvement in upper limb functions. The identification of exploratory behaviour is central to obtain, as this will allow for further facilitation of these activities. Movement sensors can be used for this purpose, and will be a part of the intervention. 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-effective 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. Family members are actively involved in the program, thus anchoring interventions in the patient's everyday life and priorities. Since many ADLs requiring adequate limb function limit post-stroke independence, the main objective of the PEER-HOMEcare intervention is to enhance motor function 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 ]. The aim of the current study is to investigate the feasibility, acceptability, fidelity, adherence and potential adverse events of the PEER-HOMEcare intervention in patient’s home. This is an important first step as set out in the MRC framework, as it is critical to investigate feasibility prior to conducting a full scaled randomised controlled trial of an intervention [ 24 ]. The study will also explore preliminary results of clinical effectiveness, which will inform the final choice of outcome measures in a future RCT. 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 PEER HOMEcare intervention will be found to be feasible and acceptable for people post-stroke, their family members, and the healthcare professionals. 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 Health Region South-East 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. Participants 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. Table 1 Illustrative Case Examples: Operationalising S.T.E.P.S. within PEER-HOMEcare intervention. Hypothetical illustrative 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) 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 the doorway as balance and confidence improved. Close supervision due to hot liquids progressed to occasional checking as safety awareness improved. Recruitment Participants will be recruited from the stroke department at Sunnaas Rehabilitation Hospital (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 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 have 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 to feedback their experiences and perspectives of the intervention. PEER HOMEcare Intervention 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 (Fig. 1 ). 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.) (Fig. 2 ). 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). 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 is supported by a 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. 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 PEER-HOMEcare 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. Structure 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 ). 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 feasibility 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. A satisfaction rate of 80% on the acceptability and feasibility questionnaires, will be regarded as a positive outcome for the intervention and show its feasibility in home rehabilitation after stroke. A detailed definition 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, emotional distress, excessive fatigue, 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. Primary clinical measures The following measures will be used at baseline only to characterize the study sample regarding cognitive functioning and activities of daily living: MoCA, SAFE and the Modified Rankin scale. The following clinical outcome measures will be included (See also 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. 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. 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. 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. The Patient Health Questionnaire (PHQ-9) assesses 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 clinical measures - movement sensors 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 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 screening instruments and the primary clinical outcome measures that will be used in the PEER HOMEcare intervention. 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) ♦ ♦ ♦ ♦ Statistical analysis All quantitative data will be analysed using IBM SPSS. Baseline characteristics and screening measures will be summarised using descriptive statistics, as will feasibility, acceptability, fidelity, and adherence outcomes. 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. Primary clinical 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 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. Secondary clinical outcome measures, which are the 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 ( \\(\\:\\:\\:-{\\sum\\:}_{\\:}^{\\:}{p}_{i}\\cdot\\:{\\text{log}}_{2}\\left({p}_{i}\\right)\\) , 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. Process evaluation – quantitative and qualitative data A process evaluation will be conducted to understand how the intervention was conducted 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, therapist training, 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. 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) in March 2026. 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, and in accord with each countries legislation 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. The study has been registered in Clinical Trials (clinicaltrials.gov), registration number NCT07517120. 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. A future full scale Randomized controlled trial in the same countries is currently being planned for. Data management and data storage All data handling and storage will be confidential and be in line with national privacy protection regulations from all participating countries 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 study 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 research 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 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. Declarations Author Contribution 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. References Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke. 2022;17(1):18–29. GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795–820. Wafa HA, Wolfe CDA, Emmett E, Roth GA, Johnson CO, Wang Y. Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years. Stroke. 2020;51(8):2418–27. Rudberg AS, Berge E, Laska AC, Jutterström S, Näsman P, Sunnerhagen KS, et al. Stroke survivors' priorities for research related to life after stroke. Top Stroke Rehabil. 2021;28(2):153–8. Nordin Å, Sunnerhagen KS, Axelsson ÅB. 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Disabil Rehabil. 2014;36(3):255–62. Janssen H, Ada L, Middleton S, Pollack M, Nilsson M, Churilov L, et al. Altering the rehabilitation environment to improve stroke survivor activity: A Phase II trial. Int J Stroke. 2022;17(3):299–307. Rosbergen IC, Grimley RS, Hayward KS, Walker KC, Rowley D, Campbell AM, et al. Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before-after pilot study. Clin Rehabil. 2017;31(11):1516–28. Khan F, Amatya B, Elmalik A, Lowe M, Ng L, Reid I, et al. An enriched environmental programme during inpatient neuro-rehabilitation: A randomized controlled trial. J Rehabil Med. 2016;48(5):417–25. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. O'Cathain A, Croot L, Duncan E, Rousseau N, Sworn K, Turner KM, et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ Open. 2019;9(8):e029954. Oppici L, Hestetun-Mandrup AM, Opheim A, Rudd JR. Skill Acquisition in Physiotherapy & Rehabilitation: An Affordance-Based Perspective. In: Coughlan E, Kearney P, Dunton A, Logan O, Roberts W, editors. Skill Acquisition in ActionIn press. Oppici L, Bērziņa G, Hestetun-Mandrup AM, Løvstad M, Opheim A, Pacheco MM, et al. A scoping review of preclinical Environmental Enrichment protocols in models of poststroke to set the foundations for translating the paradigm to clinical settings. Transl Stroke Res. 2025;16:1850–73. World Health Organization. Rehabilitation https://www.who.int/news-room/fact-sheets/detail/rehabilitation2024 [. Turner A, Foster M, Johnson SE. Occupational therapy and physical dysfunction: principles, skills and practice. Churchill Livingstone; 2002. Modell BS, Isak Opheim A, Robert Rudd J, Oppici L. Acceptability of wearing IMU sensors in a home environment in stroke patients. Gait Posture. 2025;121:232. Pacheco MM, Oppici L, Rudd J, Opheim A. Identifying the type and number of sensors required to capture behavioral complexity in daily activities in chronic stroke patients. Gait Posture. 2025;121:174–5. Santos CCA, Pacheco MM, Fernandes A. A scoping review on motor exploration definitions, measures, and effects in motor learning, development, and rehabilitation. OSF Preprints. 2024;2024 Oct 30. Hsieh TY, Pacheco MM, Newell KM. Entropy of space-time outcome in a movement speed-accuracy task. Hum Mov Sci. 2015;44:201–10. Williams GP. Chaos Theory Tamed. Washington: Joseph Henry; 1997. PEER-HOMEcare. Peer Homecare [Internet]: Available from: http://www.peerhomecare.com/ ; 2026 [. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ. 2016;355:i5239. Platz T, Pinkowski C, van Wijck F, Kim IH, di Bella P, Johnson G. Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clin Rehabil. 2005;19(4):404–11. Yozbatiran N, Der-Yeghiaian L, Cramer SC. A standardized approach to performing the action research arm test. Neurorehabil Neural Repair. 2008;22(1):78–90. Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13–31. Penta M, Tesio L, Arnould C, Zancan A, Thonnard JL. The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. Stroke. 2001;32(7):1627–34. Jones F, Partridge C, Reid F. The Stroke Self-Efficacy Questionnaire: measuring individual confidence in functional performance after stroke. J Clin Nurs. 2008;17(7b):244–52. Duncan PW, Bode RK, Min Lai S, Perera S. Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale. Arch Phys Med Rehabil. 2003;84(7):950–63. Mahoney FI, Barthel DW. FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J. 1965;14:61–5. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. Pacheco MM, García-Salazar LF, Gomes LHSC, Marques FS, Pereira ND. Shaping Exploration: How Does the Constraint-Induced Movement Therapy Helps Patients Finding a New Movement Solution. J Funct Morphology Kinesiol [Internet]. 2023;8(1):4. García-Salazar LF, Pacheco MM, Alcantara CC, Russo TL, Pereira ND. Lower Extremity Constraint-Induced Movement Therapy Increase Variability in the Intra-Limb Coordination during Walking in Chronic Post-Stroke. Ecol Psychol. 2022;34(3):109–31. Berger DJ, d'Avella A. Persistent changes in motor adaptation strategies after perturbations that require exploration of novel muscle activation patterns. J Neurophysiol. 2023;130(5):1194–9. Ganachaud C, Ganière C, Hacques G, Rochat N, Seifert L, Adé D. Exploring in a climbing task during a learning protocol: a complex sense-making process. Psychol Res. 2023;87(8):2365–79. Rohrer B, Fasoli S, Krebs HI, Hughes R, Volpe B, Frontera WR, et al. Movement Smoothness Changes during Stroke Recovery. J Neurosci. 2002;22(18):8297. Levin MF, Kleim JA, Wolf SL. What do motor recovery and compensation mean in patients following stroke? Neurorehabil Neural Repair. 2009;23(4):313–9. Hogan N, Sternad D. Sensitivity of Smoothness Measures to Movement Duration, Amplitude, and Arrests. J Mot Behav. 2009;41(6):529–34. da Silva ICM, van Hees VT, Ramires VV, Knuth AG, Bielemann RM, Ekelund U, et al. Physical activity levels in three Brazilian birth cohorts as assessed with raw triaxial wrist accelerometry. Int J Epidemiol. 2014;43(6):1959–68. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 02 May, 2026 Reviews received at journal 02 May, 2026 Reviews received at journal 01 May, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 18 Apr, 2026 Editor assigned by journal 18 Apr, 2026 Submission checks completed at journal 15 Apr, 2026 First submitted to journal 14 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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19:38:25\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9419155/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9419155/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":107916466,\"identity\":\"76ee65a8-c31d-420e-bed3-08a06b0b48d8\",\"added_by\":\"auto\",\"created_at\":\"2026-04-27 14:14:52\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":169731,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eDiagram 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.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9419155/v1/7429b5c1dcc710817bb917ac.jpg\"},{\"id\":107916467,\"identity\":\"65d5669f-db50-47dd-8435-9a1b0d59cdac\",\"added_by\":\"auto\",\"created_at\":\"2026-04-27 14:14:52\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":57540,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eConceptual framework of environmental modifications in PEER-HOMEcare 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).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9419155/v1/ad6392254491202168797891.jpg\"},{\"id\":107916468,\"identity\":\"472e659d-3e35-473d-bf1a-05542e26a8f9\",\"added_by\":\"auto\",\"created_at\":\"2026-04-27 14:14:52\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":100570,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlow of the study design of the PEER-HOMEcare feasibility study\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9419155/v1/44383927566eb65ad543290d.png\"},{\"id\":108006922,\"identity\":\"c8c5b6d6-42ea-4cad-843f-48017217826f\",\"added_by\":\"auto\",\"created_at\":\"2026-04-28 12:57:56\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":674023,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9419155/v1/9cf7a21e-f64f-4dd9-9a0c-3314ad031de8.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare): study protocol for a single-group feasibility study\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eStroke is the third leading cause of death and disability worldwide [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. In 2021, there were 11.9\\u0026nbsp;million new stroke cases and 93.8\\u0026nbsp;million people living with stroke globally [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. 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 \\u0026euro;45\\u0026nbsp;billion annually in Europe [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. 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) [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. The deliberate shift during the last decades of earlier hospital discharge and moving specialist rehabilitation services into patients\\u0026rsquo; homes highlights the urgent need for more effective rehabilitation strategies [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eInnovative strategies are needed for home-based rehabilitation, as this is an increasingly central component of stroke care [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Home is where most stroke survivors spend most of their time in the post-acute phase, i.e. 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 [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. While some neural repair occurs spontaneously, recovery is largely activity- and experience-dependent [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e], 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 [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. However, the potential of home-based rehabilitation remains underused: only about 50% of survivors receive rehabilitation [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e], many feel unprepared for the transition home [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], and sedentary behaviour is common [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eEnvironmental Enrichment (EE) is a promising strategy for improving home-based rehabilitation and establishing the home as 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 [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. 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 [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. 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 [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]), which underly an enhancement of cognitive and motor functions [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e] 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, and have provided preliminary evidence of increased physical, social, and cognitive activities [\\u003cspan additionalcitationids=\\\"CR21\\\" citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e], and reduction in depression, anxiety, and stress levels [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. These initial translational efforts indicate a potential of EE to improve stroke rehabilitation.\\u003c/p\\u003e \\u003cp\\u003eIn response to the current challenges in rehabilitation and the potential of EE to improve current practice, we have developed the \\u0026ldquo;Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke\\u0026rdquo; (PEER-HOMEcare) intervention. PEER-HOMEcare is a translational, theory-driven, population-centred, complex intervention, developed in alignment with the framework for complex interventions of the British Medical Research Council [MRC; 24, 25].\\u003c/p\\u003e \\u003cp\\u003ePEER HOMEcare is a home-based intervention built upon a clear theoretical pathway of change and improvement (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e) 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 [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]). 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 which is hypothesized to result in improvement in upper limb functions. The identification of exploratory behaviour is central to obtain, as this will allow for further facilitation of these activities. Movement sensors can be used for this purpose, and will be a part of the intervention. A recent scoping review of preclinical EE in stroke models [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e] combined with rehabilitation and motor learning sciences informed the novel conceptualisation of the paradigm into meaningful (tailored to individuals\\u0026rsquo; needs and routine), targeted (directed towards rehabilitation goals and capacity), and progressive (incremental manipulation of complexity, novelty, and variety) environmental modifications (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTo facilitate EE modifications, the intervention uses the S.T.E.P.S (space, time, equipment, people \\u0026amp; safety) acronym to guide structured and systematic modifications to the environment (see methods). Through this new lens, EE involves simple and cost-effective modifications that create numerous invitations, tailored to each survivor, to be active and repeatedly use their affected limb throughout the day [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. 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. Family members are actively involved in the program, thus anchoring interventions in the patient's everyday life and priorities. Since many ADLs requiring adequate limb function limit post-stroke independence, the main objective of the PEER-HOMEcare intervention is to enhance motor function performance in the upper extremity. Being embedded in the individuals\\u0026rsquo; living environment and targeting functions that support ADLs, this intervention fully aligns with Stroke Action Plan for Europe 2018\\u0026ndash;2030 [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e] and the WHO definition of rehabilitation \\u0026ldquo;a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment\\u0026rdquo; [\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe aim of the current study is to investigate the feasibility, acceptability, fidelity, adherence and potential adverse events of the PEER-HOMEcare intervention in patient\\u0026rsquo;s home. This is an important first step as set out in the MRC framework, as it is critical to investigate feasibility prior to conducting a full scaled randomised controlled trial of an intervention [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. The study will also explore preliminary results of clinical effectiveness, which will inform the final choice of outcome measures in a future RCT. 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 PEER HOMEcare intervention will be found to be feasible and acceptable for people post-stroke, their family members, and the healthcare professionals.\\u003c/p\\u003e\"},{\"header\":\"Materials and Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eDesign\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study uses a prospective, single group, experimental design and is conducted in accordance with the CONSORT checklist for feasibility studies [\\u003cspan class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e] (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.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStudy settings\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study will take place in the regions of Health Region South-East in Norway, Gothenburg in Sweden and Riga in Latvia. The intervention will take place in the home of the participants.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eParticipants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA 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. Participants 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.\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eIllustrative Case Examples: Operationalising S.T.E.P.S. within PEER-HOMEcare intervention.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHypothetical illustrative participant profile\\u003c/p\\u003e\\n \\u003cp\\u003eA 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\\u0026thinsp;=\\u0026thinsp;2, finger extension\\u0026thinsp;=\\u0026thinsp;2). Rehabilitation priorities were upper-limb motor recovery, neglect management, functional independence, and home safety optimisation.\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eADL Activity Identified\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDressing\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreparing breakfast\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(making coffee and toast)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMeaningful\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eThis 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.\\u003c/p\\u003e\\n \\u003cp\\u003eIndependently 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.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eThis 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.\\u003c/p\\u003e\\n \\u003cp\\u003ePreparing coffee each morning represented independence and resumption of normal life roles. The participant reported that \\u0026ldquo;starting the day myself\\u0026rdquo; was emotionally important, making it a high-salience activity for practice.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTargeted\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInitial 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.\\u003c/p\\u003e\\n \\u003cp\\u003eThe task was simplified by using the participant\\u0026rsquo;s own trousers with a magnetic clip and Velcro fastening, preserving the meaningful goal while reducing fine motor demands.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInitial 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.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eProgressive using S.T.E.P.S\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSpace\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePractice 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.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePractice 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.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTime\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eThe 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.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eThe task was practised daily at breakfast. It was performed slowly at first to support attention, then progressed to normal speed.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eEquipment\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePractice 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.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eLightweight mugs, a non-slip mat, and an easy-pour kettle were used initially and gradually removed as ability improved.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePerson\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInitially, the wife provided physical assistance. Over time, the participant initiated the task independently, with the wife stepping back to standby support.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVerbal prompts and close support were provided at first. The participant progressed to initiating the task independently, with reduced input from his wife.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSafety\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAssistance progressed from hands-on support to supervision from the doorway as balance and confidence improved.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eClose supervision due to hot liquids progressed to occasional checking as safety awareness improved.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRecruitment\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eParticipants will be recruited from the stroke department at Sunnaas Rehabilitation Hospital (Norway) as well as from Sahlgrenska University Hospital (Gothenburg, Sweden) and Riga East University Hospital (Riga, Latvia).\\u003c/p\\u003e\\n\\u003cp\\u003ePotentially eligible participants will be identified and screened by therapists experienced in stroke care and rehabilitation (see Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e 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\\u0026thinsp;\\u0026ge;\\u0026thinsp;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\\u0026thinsp;\\u0026lt;\\u0026thinsp;10) will be excluded.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eEligibility, inclusion and exclusion criteria\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInclusion criteria:\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eExclusion criteria:\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eadults (\\u0026ge;\\u0026thinsp;18 years old)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003epresence of other neurological conditions\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ediagnosed with first or second haemorrhagic or ischaemic stroke\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ereported limited life expectancy due to other medical conditions during the study period\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003estroke onset no more than six months before study enrolment\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003esevere mental health disorders, including substance use disorders\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003edischarged to their home following inpatient rehabilitation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ea history of violence\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ereporting functional impairments in the upper extremity that affect functioning and participation in everyday life due to the latest stroke.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003esevere 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\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003escore at least 4 points on the Shoulder Abduction\\u0026thinsp;+\\u0026thinsp;Finger Extension (SAFE) measure.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eunwillingness of persons sharing the household to participate and accept the intervention\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eadequate language skills and cognitive functioning to be able to understand intervention material, perform outcome assessments and co-operate throughout the intervention\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eUncontrolled medical issues such as unstable angina, severe hypertension, or severely limiting orthopaedic conditions\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ewilling to participate and able to provide written consent\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003econsent for participation also by closest family members, if they live in the same household\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eOnce participants are screened and have 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.\\u003c/p\\u003e\\n\\u003cp\\u003eInformation 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.\\u003c/p\\u003e\\n\\u003cp\\u003eA cohabitant and/or healthcare professional clinically working with the participant, will also be invited to participate in the study to feedback their experiences and perspectives of the intervention.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePEER HOMEcare Intervention\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe 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 (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMeaningful 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.\\u003c/p\\u003e\\n\\u003cp\\u003eEnvironmental modifications focus on Spaces, Time, Equipment, and People involved in a task, within safe boundaries (S.T.E.P.S.) (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). 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\\u0026rsquo;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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eMeaningful\\u003c/em\\u003e ADLs are here defined as activities that align with the survivor\\u0026rsquo;s rehabilitation goals, functional capacity, preferences, and daily routines [\\u003cspan class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. 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\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e. These assessments are further considered to individualise the intervention to enable the identification of three meaningful goals and three routine ADLs.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eTargeted\\u003c/em\\u003e 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\\u0026rsquo;s contribution to bimanual tasks or encourage its use in unimanual activities.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eProgression\\u003c/em\\u003e 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\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e for illustrative examples).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMotion Sensor Monitoring and Use with the Activity Diary\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eParticipants 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 [\\u003cspan class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e] that provided the minimum number of sensors to capture movement information from stroke patients.\\u003c/p\\u003e\\n\\u003cp\\u003eProject 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).\\u003c/p\\u003e\\n\\u003cp\\u003eFrom 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 [\\u003cspan class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]. We measure variability through entropy [\\u003cspan class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e] 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.\\u003c/p\\u003e\\n\\u003cp\\u003eTo 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\\u0026rsquo; 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEducational resources\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe delivery and implementation of the intervention is supported by a website (\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ewww.peerhomecare.com\\u003c/span\\u003e\\u003c/span\\u003e) that serves as the program\\u0026rsquo;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.\\u003c/p\\u003e\\n\\u003cp\\u003eFor 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 PEER-HOMEcare Enriched Environment strategies.\\u003c/p\\u003e\\n\\u003cp\\u003eTo 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, \\u0026lsquo;one-click\\u0026rsquo; 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 ([\\u003cspan class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e] \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://www.peerhomecare.com/\\u003c/span\\u003e\\u003c/span\\u003e) Access to the learning materials and resources in the portal will be restricted to individuals involved in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStructure of the intervention\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOnce 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\\u0026rsquo;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.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eOver the following 5 weeks (T1-T2), modifications to the home environment will be made and followed up (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The project therapist will perform 1\\u0026ndash;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\\u0026ndash;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.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOutcome measures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePrimary feasibility outcomes\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFeasibility 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. A satisfaction rate of 80% on the acceptability and feasibility questionnaires, will be regarded as a positive outcome for the intervention and show its feasibility in home rehabilitation after stroke. A detailed definition of feasibility variables, assessment tools, and outcome descriptions are provided in Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003ctable id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eOverview over the variables, the assessment tools and their descriptions in the feasibility trial of the PEER HOMEcare intervention.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVariable\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAssessment tools\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDescription\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFeasibility\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eQuestionnaires; study logs; observational notes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePractical feasibility of delivering the intervention, including recruitment processes, resource requirements, time demands, and logistical considerations\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAcceptability\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eQualitative interviews; questionnaires\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eParticipant and healthcare professional perceptions of the intervention, the training materials, and use of body-worn motion sensors\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAdherence\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMotion sensor data; activity diary; study logs; website analytics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eParticipant engagement with intervention components, including sensor use, diary completion and use of digital resources\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFidelity\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTherapist questionnaires; protocol checklists\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eExtent to which the intervention is delivered as intended according to the protocol and training procedures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAdverse events\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStudy logs; interviews\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRecording of any adverse events affecting participants or family members, such as falls, injuries, emotional distress, excessive fatigue, or other unexpected events\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eSemi-structured interviews will be conducted with a purposive sample of approximately 12\\u0026ndash;18 participants across the three participating countries (4\\u0026ndash;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).\\u003c/p\\u003e\\n\\u003cp\\u003eIn 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePrimary clinical measures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe following measures will be used at baseline only to characterize the study sample regarding cognitive functioning and activities of daily living: \\u003cspan class=\\\"SmallCaps\\\"\\u003eMoCA, SAFE and the Modified Rankin scale.\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe following clinical outcome measures will be included (See also Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eAction Research Arm Test (ARAT) [\\u003cspan class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e] 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.\\u003c/p\\u003e\\n\\u003cp\\u003eFugl Meyer Assessment Upper Extremity (FMA-UE) [\\u003cspan class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e] 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.\\u003c/p\\u003e\\n\\u003cp\\u003eAbilhand [\\u003cspan class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e] is a self-report questionnaire about perceived difficulties with bimanual hand skills. Abilhand is found to be valid and reliable in stroke research.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Stroke Self-Efficacy Questionnaire (SSEQ) assesses stroke survivors\\u0026rsquo; perceived confidence in performing functional and self-management activities. It provides a validated measure of self-efficacy relevant to poststroke rehabilitation and independence [\\u003cspan class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003eThe 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 [\\u003cspan class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003eBarthel Index (BI) [\\u003cspan class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e], will be used to assess basic ADL and self-care function. BI is considered valid and reliable to use in stroke research.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Patient Health Questionnaire (PHQ-9) assesses depressive symptom severity over the preceding two weeks. It is validated for screening and monitoring depression in clinical and research contexts [\\u003cspan class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003eThe General Anxiety Disorder-7 (GAD-7) measures the severity of generalised anxiety symptoms and has strong psychometric properties and clinical utility [\\u003cspan class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e]\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSecondary clinical measures - movement sensors\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eEntropy\\u003c/em\\u003e measures will be used to assess exploratory behaviour. \\u003cem\\u003eEntropy general -\\u003c/em\\u003e considers all segments or the single affected limb and will demonstrate changes combining what and how movements were explored. \\u003cem\\u003eEntropy joints -\\u003c/em\\u003e 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 [\\u003cspan class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eNovelty\\u003c/em\\u003e 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 [\\u003cspan class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSmoothness\\u003c/em\\u003e has been demonstrated as an important indicator of stroke recovery [\\u003cspan class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e]. 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eCompensation\\u003c/em\\u003e has long been demonstrated to be one way that stroke survivors improve function over time [\\u003cspan class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e]. 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eUse of the affected limb\\u003c/em\\u003e 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 use of the affected limb to support goal achievement. In the long term, large values would hold learned non-use of the affected limb\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003ctable id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eThe screening instruments and the primary clinical outcome measures that will be used in the PEER HOMEcare intervention.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth rowspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth colspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTime of assessments\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eT0 Baseline\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eT2 End\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eScreening instruments\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVoluntary Muscle strength in shoulder abduction and finger extension (SAFE)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCognitive functioning:\\u003c/p\\u003e\\n \\u003cp\\u003eMontreal cognitive assessment (MoCA)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eActivities of daily living and dependence: Modified Rankin scale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCLINICAL OUTCOMES\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMotor ability for upper limb\\u003c/p\\u003e\\n \\u003cp\\u003eAction Research Arm Test (ARAT)\\u003c/p\\u003e\\n \\u003cp\\u003eFugl-Meyer Assessment (FMA-UE)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSelf-reported arm use: Abilhand\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSelf-efficacy and disability\\u003c/p\\u003e\\n \\u003cp\\u003eStroke self-efficacy questionnaire (SSEQ)\\u003c/p\\u003e\\n \\u003cp\\u003eStroke impact scale (SIS)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eActivities of daily living: Barthel Index\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDepression and anxiety\\u003c/p\\u003e\\n \\u003cp\\u003ePatient health questionnaire-9 (PHQ-9)\\u003c/p\\u003e\\n \\u003cp\\u003eGeneralised anxiety disorder (GAD-7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026diams;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll quantitative data will be analysed using IBM SPSS. Baseline characteristics and screening measures will be summarised using descriptive statistics, as will feasibility, acceptability, fidelity, and adherence outcomes. 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.\\u003c/p\\u003e\\n\\u003cp\\u003ePrimary clinical 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 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 \\u0026lt;\\u0026thinsp;0.05 will be reported for completeness.\\u003c/p\\u003e\\n\\u003cp\\u003eSecondary clinical outcome measures, which are the sensor data, will be analysed with a custom-made script in Matlab. Entropy measures will be calculated following [\\u003cspan class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. 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\\u003c/p\\u003e\\n\\u003cp\\u003e(\\u003cspan class=\\\"InlineEquation\\\"\\u003e\\u003cspan class=\\\"mathinline\\\"\\u003e\\\\(\\\\:\\\\:\\\\:-{\\\\sum\\\\:}_{\\\\:}^{\\\\:}{p}_{i}\\\\cdot\\\\:{\\\\text{log}}_{2}\\\\left({p}_{i}\\\\right)\\\\)\\u003c/span\\u003e\\u003c/span\\u003e,\\u003c/p\\u003e\\n\\u003cp\\u003ewhere pi is the probability of the ith bin). Smoothness follows [\\u003cspan class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. 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 [\\u003cspan class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e]. 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eProcess evaluation \\u0026ndash; quantitative and qualitative data\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA process evaluation will be conducted to understand how the intervention was conducted 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.\\u003c/p\\u003e\\n\\u003cp\\u003eThe 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, therapist training, 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.\\u003c/p\\u003e\"},{\"header\":\"Notes\",\"content\":\"\\u003cp\\u003e \\u003cb\\u003ePatient and public involvement\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003ePatients, 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.\\u003c/p\\u003e \\u003cp\\u003e 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.\\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eCompliance with Ethical Standards\\u003c/strong\\u003e \\u003cp\\u003e \\u003cb\\u003eand registrations\\u003c/b\\u003e \\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e 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) in March 2026. 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, and in accord with each countries legislation\\u003c/p\\u003e \\u003cp\\u003e All participants will give written informed consent, which includes information about the study\\u0026rsquo;s purposes and consequences, participants\\u0026rsquo; 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.\\u003c/p\\u003e \\u003cp\\u003eAll authors declare no conflict of interest, neither of financial or non-financial nature.\\u003c/p\\u003e \\u003cp\\u003eThe study has been registered in Clinical Trials (clinicaltrials.gov), registration number NCT07517120.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eDissemination of results\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe 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. A future full scale Randomized controlled trial in the same countries is currently being planned for.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eData management and data storage\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eAll data handling and storage will be confidential and be in line with national privacy protection regulations from all participating countries 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.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eTrial status\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn preparation\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eProject management\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe study 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 research 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.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eFinancing\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe 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.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eAll 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.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eFeigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke. 2022;17(1):18\\u0026ndash;29.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990\\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795\\u0026ndash;820.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWafa HA, Wolfe CDA, Emmett E, Roth GA, Johnson CO, Wang Y. Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years. Stroke. 2020;51(8):2418\\u0026ndash;27.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRudberg AS, Berge E, Laska AC, Jutterstr\\u0026ouml;m S, N\\u0026auml;sman P, Sunnerhagen KS, et al. Stroke survivors' priorities for research related to life after stroke. Top Stroke Rehabil. 2021;28(2):153\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNordin \\u0026Aring;, Sunnerhagen KS, Axelsson \\u0026Aring;B. Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study. BMC Neurol. 2015;15:235.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNorrving B, Barrick J, Davalos A, Dichgans M, Cordonnier C, Guekht A, et al. Action Plan for Stroke in Europe 2018\\u0026ndash;2030. Eur Stroke J. 2018;3(4):309\\u0026ndash;36.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJ\\u0026oslash;rgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, St\\u0026oslash;ier M, Olsen TS. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1995;76(5):406\\u0026ndash;12.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKwakkel G, Stinear C, Essers B, Munoz-Novoa M, Branscheidt M, Cabanas-Vald\\u0026eacute;s R, et al. Motor rehabilitation after stroke: European Stroke Organisation (ESO) consensus-based definition and guiding framework. Eur Stroke J. 2023;8(4):880\\u0026ndash;94.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNithianantharajah J, Hannan AJ. Enriched environments, experience-dependent plasticity and disorders of the nervous system. Nat Rev Neurosci. 2006;7(9):697\\u0026ndash;709.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRegenhardt RW, Takase H, Lo EH, Lin DJ. Translating concepts of neural repair after stroke: Structural and functional targets for recovery. Restor Neurol Neurosci. 2020;38(1):67\\u0026ndash;92.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNational Institute for Health and Care Excellence (NICE). Stroke rehabilitation in adults: NICE guideline \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.nice.org.uk/guidance/ng236/chapter/Recommendations2023\\u003c/span\\u003e\\u003cspan address=\\\"https://www.nice.org.uk/guidance/ng236/chapter/Recommendations2023\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e [.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNational Institute for Health and Care Excellence (NICE). Evidence reviews for early supported discharge: Stroke rehabilitation in adults (update): Evidence review A3. London2023.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFeigin VL. Driving your recovery post stroke. Neuro-epidemiology. 2018;51:113\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChristensen H, Pezzella FR, Roaldsen MB, Tomek A, Wilkie A, Christensen L et al. Stroke Action Plan for Europe 2018\\u0026ndash;2030 (SAP-E): mid-term review and update. Eur Stroke J. 2026;11(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLindblom S, Ytterberg C, Laska AC, Tistad M, Elf M, von Koch L, et al. Navigating Complexity: Lessons Learned from Co-Designing a Care Transition Intervention for People with Stroke. Int J Integr Care. 2025;25(2):3.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFini NA, Holland AE, Keating J, Simek J, Bernhardt J. How Physically Active Are People Following Stroke? Systematic Review and Quantitative Synthesis. Phys Ther. 2017;97(7):707\\u0026ndash;17.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNeves LT, Paz LV, Wieck A, Mestriner RG, de Miranda Monteiro VAC, Xavier LL. Environmental Enrichment in Stroke Research: an Update. Transl Stroke Res. 2024;15(2):339\\u0026ndash;51.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcDonald MW, Hayward KS, Rosbergen ICM, Jeffers MS, Corbett D. Is Environmental Enrichment Ready for Clinical Application in Human Post-stroke Rehabilitation? Front Behav Neurosci. 2018;12:135.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJanssen H, Bernhardt J, Collier JM, Sena ES, McElduff P, Attia J, et al. An enriched environment improves sensorimotor function post-ischemic stroke. Neurorehabil Neural Repair. 2010;24(9):802\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJanssen H, Ada L, Bernhardt J, McElduff P, Pollack M, Nilsson M, et al. An enriched environment increases activity in stroke patients undergoing rehabilitation in a mixed rehabilitation unit: a pilot non-randomized controlled trial. 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Psychol Res. 2023;87(8):2365\\u0026ndash;79.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRohrer B, Fasoli S, Krebs HI, Hughes R, Volpe B, Frontera WR, et al. Movement Smoothness Changes during Stroke Recovery. J Neurosci. 2002;22(18):8297.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLevin MF, Kleim JA, Wolf SL. What do motor recovery and compensation mean in patients following stroke? Neurorehabil Neural Repair. 2009;23(4):313\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHogan N, Sternad D. Sensitivity of Smoothness Measures to Movement Duration, Amplitude, and Arrests. J Mot Behav. 2009;41(6):529\\u0026ndash;34.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eda Silva ICM, van Hees VT, Ramires VV, Knuth AG, Bielemann RM, Ekelund U, et al. Physical activity levels in three Brazilian birth cohorts as assessed with raw triaxial wrist accelerometry. Int J Epidemiol. 2014;43(6):1959\\u0026ndash;68.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"translational-stroke-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"trsr\",\"sideBox\":\"Learn more about [Translational Stroke Research](http://jcmr-online.biomedcentral.com)\",\"snPcode\":\"12975\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12975/3\",\"title\":\"Translational Stroke Research\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Stroke, Rehabilitation, Home-based rehabilitation, Enriched Environment, Upper limb function, Activities of Daily Living, Motor learning, Motion sensors, Feasibility, Life After Stroke\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9419155/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9419155/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eHome-based rehabilitation after stroke is increasingly important, as pressure on hospital services rise and recovery occurs mostly at home. Enriching the home represents a potential strategy to support rehabilitation by providing continuous task- and context-specific stimulation that promotes functional recovery through frequent and exploratory use of the affected arm. Exploratory behaviour - self-initiated, varied and adaptive movements - is an important driver of motor learning and neuroplasticity. While strong evidence from animal research demonstrates benefits for functional recovery, translation to human home-based rehabilitation remains limited. This study investigates the feasibility of the Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare) intervention. This theory-driven, person-centred intervention, introduces meaningful, targeted and progressive home-modifications to promote exploratory use of the affected arm during daily activities. In this prospective, single group, experimental study, 45 stroke survivors (≥18 years), within 6 months post-stroke across Norway, Sweden and Latvia will participate. Wearable sensors will be used to capture activity patterns, informing objective insights into motor behaviour, and progressive modifications to the home. Primary outcomes of feasibility and acceptability are assessed through questionnaires, logs and interviews. Intervention fidelity, participant adherence and adverse events will be evaluated. Secondary outcomes include changes in arm function, self-perceived activities of daily living and psychosocial outcomes. A dedicated website (www.peerhomecare.com) provides informational resources for all participants and project therapists. This study will provide important knowledge about PEER HOMEcare and provide information for a future trial evaluating its clinical effectiveness in home-based stroke rehabilitation.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTrial registration in www.ClinicalTrials.gov on 06-04-2026, NCT07517120.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Pedagogy and Enriched Environment for Rehabilitation in the HOME after stroke (PEER HOMEcare): study protocol for a single-group feasibility study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-27 14:14:48\",\"doi\":\"10.21203/rs.3.rs-9419155/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-02T18:36:43+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-02T07:53:32+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-01T15:02:32+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"149287719637363927270666207852985057409\",\"date\":\"2026-04-18T20:05:48+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"270404398600426099344622697612015760269\",\"date\":\"2026-04-18T19:17:13+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-18T18:49:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-04-18T18:46:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-04-15T14:06:36+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Translational Stroke Research\",\"date\":\"2026-04-14T19:29:07+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"translational-stroke-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"trsr\",\"sideBox\":\"Learn more about [Translational Stroke Research](http://jcmr-online.biomedcentral.com)\",\"snPcode\":\"12975\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12975/3\",\"title\":\"Translational Stroke Research\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"2f99f758-4798-4404-8abd-2589bf5a7480\",\"owner\":[],\"postedDate\":\"April 27th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-02T18:36:43+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-02T07:53:32+00:00\",\"index\":34,\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-01T15:02:32+00:00\",\"index\":33,\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-02T18:39:48+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-27 14:14:48\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9419155\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9419155\",\"identity\":\"rs-9419155\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}