Introduction

What recent research tells us about ADL-based and task-oriented interventions, impairment-based treatment, and the transfer of skills to everyday performance.

As occupational therapy practitioners, our goal is to improve our clients' ability to participate in and perform the occupations that are meaningful to them. In many healthcare settings, improving performance in activities of daily living (ADLs) is a primary focus of our interventions.

Throughout the occupational therapy process, we often identify performance skills and client factors that are impacting ADL performance such as decreased strength, balance, coordination, or cognitive abilities.

In many healthcare settings, we find ourselves utilizing a bottom-up approach, providing interventions that specifically address these performance skills and impairments with the assumption that improvements will translate into better ADL performance. 

But if the evidence does not consistently demonstrate that improvements in underlying performance components translate into better occupational performance, shouldn't we be questioning why we often spend so much time providing isolated impairment-based interventions?

This is a question I've been thinking about as I explore research on ADL-based, activity-based task-oriented, and impairment-based interventions.

Are We Improving Skills or ADL Performance?

As OT practitioners, we understand that strength, coordination, balance, and cognitive abilities can influence a person's ability to perform everyday activities. But we also recognize the influence of the environment, values, beliefs, spirituality, and performance patterns on a client's ADL performance and participation.

Interestingly, the research suggests that improving an underlying skill does not necessarily translate into improved occupational performance.

Doman and colleagues (2016) examined changes in upper extremity capacity and everyday arm use among individuals receiving outpatient occupational therapy following a stroke.

They found that some participants improved both their upper extremity capacity and their daily arm use, while others improved their upper extremity capacity without demonstrating corresponding improvements in everyday use.

Waddell and colleagues (2017) examined a similar question in individuals participating in intensive, task-specific upper extremity training following stroke. Although participants demonstrated improvements in motor capacity, those improvements did not result in corresponding increases in daily arm use measured by wearable sensors.

These findings caught my attention.

Just because someone demonstrates improved performance during therapy, that doesn't necessarily mean that improvement carries over into everyday life.

A client may demonstrate improved movement or strength during therapy without necessarily using those abilities more frequently in everyday life. And increased use of an extremity does not automatically establish improved independence in dressing, bathing, or other ADLs.

It's important to recognize that these studies measured upper extremity capacity and daily arm use rather than independence in specific ADLs. They also did not establish that occupation-based ADL retraining would produce better outcomes.

However, they do raise questions about our assumptions regarding the transfer of skills.

If our goal is improved ADL performance, shouldn't we be measuring whether improvements in underlying skills are actually helping clients perform their daily activities?

Activity-Based Training and ADL Performance: A 2024 Systematic Review

Lee and Howe (2024) published a systematic review in the American Journal of Occupational Therapy examining activity-based task-oriented training (TOT) for upper extremity recovery following stroke.

The review included 16 studies involving 692 participants.

The researchers found moderate-to-strong evidence supporting activity-based task-oriented training for improving upper extremity motor function, motor performance, and ADL performance.

In this review, activity-based task-oriented training meant practicing meaningful, goal directed, real world tasks, rather than isolated movements. Some of those tasks may closely resemble occupations, but task-oriented practice is not automatically the same as participating in an entire occupation within the client's usual context. 

I think this distinction is important.

To me, this demonstrates that meaningful functional tasks can be used therapeutically while also addressing the motor skills required to complete them.

We don't necessarily have to choose between addressing a performance limitation and practicing an occupation. In many situations, we can address both while working toward ADL performance.

However, while this review supports activity-based task-oriented training for improving upper extremity function and ADL performance following stroke, it does not establish that occupation-based interventions are superior to impairment-based interventions. 

A New 2026 Review Raises Additional Questions

In August 2026, Grant and colleagues published a systematic review examining activity-based ADL retraining provided early after stroke in hospital settings.

The researchers reviewed six studies involving 254 participants. The interventions targeted basic ADLs, such as dressing, and/or simple cognitive instrumental activities of daily living (IADLs).

The purpose of the review was to determine whether these activity-based interventions improved functional independence following stroke.

Although the pooled results favored activity-based interventions numerically, the difference compared with control interventions was not statistically significant. The researchers also noted variability across the studies and the limited amount of available evidence.

At first glance, that might seem surprising.

If practicing everyday activities is so central to occupational therapy, shouldn't we expect research to consistently demonstrate its effectiveness?

These findings do not establish that activity-based ADL retraining is ineffective or equivalent to other interventions. Instead, they highlight the need for additional research to determine which approaches are most effective in the hospital setting.

So, Is Occupation-Based Intervention Better Than Impairment-Based Treatment?

That's the question I keep coming back to.

Tomori and colleagues (2015) conducted a randomized feasibility study comparing occupation-based and impairment-based occupational therapy for individuals recovering from stroke.

The study did not establish that either approach was superior. 

Taken together, these studies do not establish that occupation-based interventions are consistently more effective than impairment-based treatment. However, only the Tomori study directly compared those two approaches. The other studies examined different interventions and outcomes, so we need to be cautious about drawing conclusions across them.

But it also does not demonstrate that addressing isolated performance components consistently produces better occupational outcomes.

And that's where I think we should challenge ourselves as OT practitioners.

If our ultimate goal is improved ADL performance, why wouldn't we begin with the ADL whenever it is appropriate?

Why would we assume that improving an isolated skill will automatically improve the person's ability to perform the activities that matter to them?

I don't think the research gives us a reason to eliminate impairment-based interventions. But I do think it challenges us to consider why we're choosing them. Is it because our occupational analysis has identified a specific need? Or could it sometimes be because these interventions are familiar, easier to implement, or fit more readily into the productivity demands of our practice settings?

When treatment time is limited, shouldn't we prioritize interventions that directly address the occupations our clients want and need to perform, while using preparatory interventions when there is a clear clinical rationale?

“Why Am I Doing This?”

How many times have we heard a client ask, 'Why am I doing this?'

Maybe we're asking someone to complete an exercise, practice a movement, or perform a repetitive task. We understand the professional reasoning behind the intervention, but does the client?

Now imagine asking that same person to practice getting dressed, washing their hair or to shave.

The purpose of the intervention may become much easier to understand because the activity itself is connected to something they want or need to do.

I think this is one of the benefits of ADL-based intervention that deserves our attention.

When we begin with a meaningful occupation, we may not have to spend as much time explaining how an activity relates to the client's goals. The connection is already there.

Of course, we still need to explain our interventions and collaborate with our clients. And there are times when an intervention to support occupation is appropriate, necessary, or consistent with the client's preferences.

But I wonder whether we sometimes spend too much time addressing impairments with the expectation that ADL performance will improve, and not enough time actually helping clients perform those ADLs.

With Less Treatment Time, Are We Prioritizing the Right Interventions?

Over my years in occupational therapy, I've seen changes in how much time we have to work with our clients.

In many of the settings where I've practiced, treatment episodes have become shorter, and it seems that we're preparing individuals for discharge sooner.

That makes me question how we prioritize our treatment sessions.

If someone needs to be able to dress independently before returning home, how much time should we spend on isolated strengthening or coordination activities before we begin practicing dressing?

Wouldn't it make sense to begin with actual ADL practice, identify what's limiting performance, and then determine which interventions are needed?

I'm not suggesting that strengthening, balance training, or other interventions to support occupation should never be used.

But I do think we should be asking whether those interventions are the most effective use of the time we have with our clients.

Especially when discharge is approaching, how can I know whether someone can perform the activities they'll need to manage in their everyday environment if I haven't observed them actually performing those activities?

If I'm only assessing performance skills, I may be estimating their ability to complete an ADL rather than observing what they can actually do.

An improvement in strength or coordination may be encouraging, but does that improvement mean the person can get dressed, complete toileting tasks and shave?

Those are the outcomes that matter.

Practicing ADLs Allows Us to Fully Apply Occupational Analysis

One of the things I appreciate most about occupational therapy is our ability to analyze occupations and identify the many factors that influence performance.

Consider a client who is having difficulty getting dressed.

We could begin by addressing upper extremity strength or coordination. Those may certainly be contributing factors.

But what might we discover if we observe the client actually performing the dressing task?

Perhaps the difficulty involves sequencing, sitting balance, fatigue, problem-solving, clothing selection, the way the environment is arranged or how the caregiver approaches the task.

We may identify opportunities to grade the activity, modify the environment, introduce adaptive equipment, or teach compensatory strategies.

We may determine that strength and coordination need to be addressed, but we may also discover opportunities to address these limitations while the client practices the actual ADL.

This is where I see the value of a top-down approach.

Rather than beginning with an isolated impairment and assuming that improvement will transfer, we begin with the ADL and identify what is interfering with successful performance.

We can then select interventions that address those specific barriers while continuing to evaluate whether the client's ADL performance is improving.

This approach also allows us to incorporate the client's priorities, routines, habits, and environment into our reasoning.

A Question Worth Asking Ourselves

Perhaps the question isn't whether impairment-based interventions have a place in occupational therapy.

The question is whether we are using them intentionally, with a clear connection to the ADLs our clients want and need to perform.
  

Are we reassessing the actual activity of daily living to determine whether our interventions are making a difference?

Or are we assuming that improvement in an underlying skill will automatically result in better ADL performance?

If our goal is improved ADL performance, shouldn't we be spending more of our time helping clients perform ADLs?

And when we choose to address an underlying performance skill, shouldn't we be able to explain how that intervention supports the client's occupational goals and determine whether those gains actually transfer into everyday life?

Reflecting on Your Own Practice

When do you choose to address underlying performance skills first, and when do you begin directly with the ADL?

Have you ever seen a client improve strength, coordination, or another skill without seeing that improvement carry over into their ADL performance?

We'd love to hear your perspectives and experiences! Join us for an upcoming Tried & True Tips for ADLs: Strategies That Work in Everyday OT Practice live webinar or in-person workshop, where practitioners share their favorite strategies, learn from one another, and explore practical approaches to ADL retraining.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Doman, C. A., Waddell, K. J., Bailey, R. R., Moore, J. L., & Lang, C. E. (2016). Changes in upper-extremity functional capacity and daily performance during outpatient occupational therapy for people with stroke. American Journal of Occupational Therapy, 70(3), 7003290040p1–7003290040p11.
https://doi.org/10.5014/ajot.2016.020891

Grant, T., Wales, K., Jolliffe, L., Schneider, E. J., Glascott, J., Sansonetti, D., Drummond, A. E., & Lannin, N. A. (2026). Systematic review of hospital-based interventions to improve post-stroke independence in activities of daily living. Australian Occupational Therapy Journal, 73(4), e70119. https://doi.org/10.1111/1440-1630.70119

Lee, C.-Y., & Howe, T.-H. (2024). Effectiveness of activity-based task-oriented training on upper extremity recovery for adults with stroke: A systematic review. American Journal of Occupational Therapy, 78(2), 7802180070. https://doi.org/10.5014/ajot.2024.050391

Tomori, K., Nagayama, H., Ohno, K., Nagatani, R., Saito, Y., Takahashi, K., Sawada, T., & Higashi, T. (2015). Comparison of occupation-based and impairment-based occupational therapy for subacute stroke: A randomized controlled feasibility study. Clinical Rehabilitation, 29(8), 752–762. https://doi.org/10.1177/0269215514555876

Waddell, K. J., Strube, M. J., Bailey, R. R., Klaesner, J. W., Birkenmeier, R. L., Dromerick, A. W., & Lang, C. E. (2017). Does task-specific training improve upper limb performance in daily life poststroke? Neurorehabilitation and Neural Repair, 31(3), 290–300. https://doi.org/10.1177/1545968316680493