Is environmental enrichment useful for stroke and other non-progressive brain injury? A Cochrane Review summary with commentary

1Background

Stroke and traumatic brain injuries are the leading cause of death and disability worldwide. They adversely affect the functional abilities, activities of daily living and restrict the societal participation of individuals.(Dye et al., 2015; Qin et al., 2021) Traditional rehabilitation services are generally provided or supervised by a trained rehabilitation professional. Environmental enrichment for stroke and brain injury rehabilitation is an emerging concept which aims to modify the environment to promote engagement in physical, social and cognitive activities (Nithianantharajah and Hannan 2006). It is not dependent on presence of a health care professional and exposure to such an environment encourages patient’s participation, with the aim of improving functional recovery. It is provided as an adjunct service and is not part of the formal rehabilitation services. The interventions may include computers with internet access, reading material, audio books, video games, board games, interactive recreational activities and music stations. Environmental enrichment is a possible alternative option for stimulating neural recovery by engaging patients in a variety of functional and cognitive activities. (Berges et al., 2012). Environmental enrichment has been recommended as a possible intervention for patients undergoing stroke rehabilitation in the 2016 American Heart Association/American Stroke Association Stroke Rehabilitation Guidelines. However, there is a need for further robust evidence for its effectiveness.

Environmental enrichment for stroke and other non-progressive brain injury

(Helen Qin, Isabella Reid, Alexandra Gorelik, Louisa Ng 2021).

2Objective

The aim of this Cochrane Review was to assess the effects of environmental enrichment on well-being, functional recovery, activity levels and quality of life in people who have stroke or non-progressive brain injury.

3What was studied and methods

The population addressed in this review was adults of both genders with age≥ to 18 years having stroke or other acquired non-progressive brain damage. Authors included Randomized controlled trials (RCTs), comparing environmental enrichment with standard rehabilitation services. The primary outcomes of interest were psychological well-being and coping measured by Depression Anxiety Stress Scale-21 (DASS), Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale and Multidimensional Health Locus of Control (MHLC). Secondary outcomes included quality of life (QoL), physical functional improvement, communication and cognitive functional improvement, activity levels and adverse events. The review authors were interested in outcomes measured at four weeks (short term), between four weeks and 12 months (moderate term), and at 12 months (long term). Multiple global databases were searched on 20^th Oct 2020, including Cochrane Central Register of Controlled Trials, Medline, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, PsycINFO Ovid and other databases. Authors also attempted to identify further published, unpublished and ongoing trials by contacting the authors, tracking citations and hand searching the reference list.

4Results

Only one randomized controlled trial with 53 participants was included. This study was conducted in a single-center inpatient rehabilitation setting in Australia. Participants were exposed to activities within the enriched environment in 10- minute blocks over two-hour sessions on weekdays only. Three assessments were done on admission, at discharge and at three months post-discharge.

Based on this single study, the review concludes that:

Adverse events were not reported suggesting that the intervention was safe.

Conclusions: The authors concluded that insufficient results from a single randomized controlled trial should not be interpreted as proof of ineffectiveness of environmental enrichment.. Further large scale adequately designed and powered trials should be conducted to evaluate the effectiveness and safety of environmental enrichment in stroke and other traumatic brain injury patients.

5Implications for practice in neurorehabilitation

Due to improvements in the emergency and neurology services around the globe, more patients are surviving with long term neurological impairments which can be addressed by providing rehabilitation services. Although this review discusses role of environmental enrichment during in-patient stay, there is a need to enhance neuroplasticity once the patient has been discharged from the inpatient rehabilitation. Manypatients following a stroke spent a large proportion of the day in their bedroom in isolation and being inactive.Enviromental enrichemnt is a promising adjunct to the traditional rehabiltiation services which can potentially enhance the recovery process in patients with various forms of traumatic and non-traumatic brain injuries. Some options for environmental enrichment are not resource intensive and are readily available in most parts of the globe including the developing countries. They do not require a specialized medical setup or supervision of a trained rehabilitation professional and no side effects have been reported. However, some interventions are technology dependent. It is important that future research considers the cost and resource implications, and specifically explores the evidence for interventions that are readily available in developing countries.There is a need to conduct well designed large scale clinical trials on the role of environmental enrichment in a variety of settings and using different options.

Conflict of interest

The authors declare no conflicts of interest.