Is Environmental Enrichment Ready for Clinical Application in Human Post-stroke Rehabilitation?

Environmental enrichment (EE) has been widely used as a means to enhance brain plasticity mechanisms (e.g., increased dendritic branching, synaptogenesis, etc.) and improve behavioral function in both normal and brain-damaged animals. In spite of the demonstrated efficacy of EE for enhancing brain plasticity, it has largely remained a laboratory phenomenon with little translation to the clinical setting. Impediments to the implementation of enrichment as an intervention for human stroke rehabilitation and a lack of clinical translation can be attributed to a number of factors not limited to: (i) concerns that EE is actually the “normal state” for animals, whereas standard housing is a form of impoverishment; (ii) difficulty in standardizing EE conditions across clinical sites; (iii) the exact mechanisms underlying the beneficial actions of enrichment are largely correlative in nature; (iv) a lack of knowledge concerning what aspects of enrichment (e.g., exercise, socialization, cognitive stimulation) represent the critical or active ingredients for enhancing brain plasticity; and (v) the required “dose” of enrichment is unknown, since most laboratory studies employ continuous periods of enrichment, a condition that most clinicians view as impractical. In this review article, we summarize preclinical stroke recovery studies that have successfully utilized EE to promote functional recovery and highlight the potential underlying mechanisms. Subsequently, we discuss how EE is being applied in a clinical setting and address differences in preclinical and clinical EE work to date. It is argued that the best way forward is through the careful alignment of preclinical and clinical rehabilitation research. A combination of both approaches will allow research to fully address gaps in knowledge and facilitate the implementation of EE to the clinical setting

The impact of environmental enrichment in an acute stroke unit on how and when patients undertake activities

Objectives: To explore the effect of environmental enrichment within an acute stroke unit on how and when patients undertake activities, and the amount of staff assistance provided, compared with a control environment (no enrichment). Design: This is a substudy of a controlled before-after observational study. Setting: The study was conducted in an Australian acute stroke unit. Participants: The study included stroke patients admitted to (1) control and (2) environmental enrichment period. Intervention: The control group received standard therapy and nursing care, which was delivered one-on-one in the participants' bedroom or a communal gym. The enriched group received stimulating resources and communal areas for mealtimes, socializing and group activities. Furthermore, participants and families were encouraged to increase patient activity outside therapy hours. Main measures: Behavioral mapping was performed every 10 minutes between 7.30 a.m. and 7.30 p.m. on weekdays and weekends to estimate activity levels. We compared activity levels during specified time periods, nature of activities observed and amount of staff assistance provided during patient activities across both groups. Results: Higher activity levels in the enriched group (n = 30, mean age 76.7 +/- 12.1) occurred during periods of scheduled communal activity (P < 0.001), weekday non-scheduled activity (P = 0.007) and weekends (P = 0.018) when compared to the control group (n = 30, mean age 76.0 +/- 12.8), but no differences were observed on weekdays after 5 p.m. (P = 0.324). The enriched group spent more time on upper limb (P < 0.001), communal socializing (P < 0.001), listening (P = 0.007) and iPad activities (P = 0.002). No difference in total staff assistance during activities was observed (P = 0.055). Conclusion: Communal activities and environmental resources were important contributors to greater activity within the enriched acute stroke unit

Is environmental enrichment ready for clinical application in human post-stroke rehabilitation?

Environmental enrichment (EE) has been widely used as a means to enhance brain plasticity mechanisms (e.g., increased dendritic branching, synaptogenesis, etc.) and improve behavioral function in both normal and brain-damaged animals. In spite of the demonstrated efficacy of EE for enhancing brain plasticity, it has largely remained a laboratory phenomenon with little translation to the clinical setting. Impediments to the implementation of enrichment as an intervention for human stroke rehabilitation and a lack of clinical translation can be attributed to a number of factors not limited to: (i) concerns that EE is actually the "normal state" for animals, whereas standard housing is a form of impoverishment; (ii) difficulty in standardizing EE conditions across clinical sites; (iii) the exact mechanisms underlying the beneficial actions of enrichment are largely correlative in nature; (iv) a lack of knowledge concerning what aspects of enrichment (e.g., exercise, socialization, cognitive stimulation) represent the critical or active ingredients for enhancing brain plasticity; and (v) the required "dose" of enrichment is unknown, since most laboratory studies employ continuous periods of enrichment, a condition that most clinicians view as impractical. In this review article, we summarize preclinical stroke recovery studies that have successfully utilized EE to promote functional recovery and highlight the potential underlying mechanisms. Subsequently, we discuss how EE is being applied in a clinical setting and address differences in preclinical and clinical EE work to date. It is argued that the best way forward is through the careful alignment of preclinical and clinical rehabilitation research. A combination of both approaches will allow research to fully address gaps in knowledge and facilitate the implementation of EE to the clinical setting

Qualitative investigation of the perceptions and experiences of nursing and allied health professionals involved in the implementation of an enriched environment in an Australian acute stroke unit

An enriched environment embedded in an acute stroke unit can increase activity levels of patients who had stroke, with changes sustained 6 months post-implementation. The objective of this study was to understand perceptions and experiences of nursing and allied health professionals involved in implementing an enriched environment in an acute stroke unit.A descriptive qualitative approach.An acute stroke unit in a regional Australian hospital.We purposively recruited three allied health and seven nursing professionals involved in the delivery of the enriched environment. Face-to-face, semistructured interviews were conducted 8 weeks post-completion of the enriched environment study. One independent researcher completed all interviews. Voice-recorded interviews were transcribed verbatim and analysed by three researchers using a thematic approach to identify main themes.Three themes were identified. First, staff perceived that 'the road to recovery had started' for patients. An enriched environment was described to shift the focus to recovery in the acute setting, which was experienced through increased patient activity, greater psychological well-being and empowering patients and families. Second, 'it takes a team' to successfully create an enriched environment. Integral to building the team were positive interdisciplinary team dynamics and education. The impact of the enriched environment on workload was diversely experienced by staff. Third, 'keeping it going' was perceived to be challenging. Staff reflected that changing work routines was difficult. Contextual factors such as a supportive physical environment and variety in individual enrichment opportunities were indicated to enhance implementation. Key to sustaining change was consistency in staff and use of change management strategies.Investigating staff perceptions and experiences of an enrichment model in an acute stroke unit highlighted the need for effective teamwork. To facilitate staff in their new work practice, careful selection of change management strategies are critical to support clinical translation of an enriched environment.ANZCTN12614000679684; Results

The effect of an enriched environment on activity levels in people with stroke in an acute stroke unit: protocol for a before-after pilot study

Background: Clinical practice guidelines advocate engaging stroke survivors in as much activity as possible early after stroke. One approach found to increase activity levels during inpatient rehabilitation incorporated an enriched environment (EE), whereby physical, cognitive, and social activity was enhanced. The effect of an EE in an acute stroke unit (ASU) has yet not been explored. Methods/design: We will perform a prospective non-randomized before-after intervention study. The primary aim is to determine if an EE can increase physical, social, and cognitive activity levels of people with stroke in an ASU compared to usual care. Secondary aims are to determine if fewer secondary complications and improved functional outcomes occur within an EE. We will recruit 30 people with stroke to the usual care block and subsequently 30 to the EE block. Participants will be recruited within 24–72 h after onset of stroke, and each block is estimated to last for 12 weeks. In the usual care block current management and rehabilitation within an ASU will occur. In the EE block, the ASU environment will be adapted to promote greater physical, social, and cognitive activity. Three months after the EE block, another 30 participants will be recruited to determine sustainability of this intervention. The primary outcome is change in activity levels measured using behavioral mapping over 12 h (7.30 am to 7.30 pm) across two weekdays and one weekend day within the first 10 days of admission. Secondary outcomes include functional outcome measures, adverse and serious adverse events, stroke survivor, and clinical staff experience. Discussion: There is a need for effective interventions that starts directly in the ASU. The EE is an innovative intervention that could increase activity levels in stroke survivors across all domains and promote early recovery of stroke survivors in the acute setting. Trial registration: Australian New Zealand Clinical Trial Registry, ANZCTN12614000679684Medicine, Faculty ofNon UBCPhysical Therapy, Department ofReviewedFacult

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before-after pilot study

Objectives: To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events