Environmental enrichment for stroke and other non-progressive brain injury

Rehabilitation is effective for recovery after stroke and other non-progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input.

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.

We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers.

We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services.

Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach.

We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non-RCTs and two described co-interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment.

The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost-effectiveness, and safety of the intervention in people following stroke or other non-progressive brain injuries. It should be noted, however, that it is challenging to randomise or double-blind trials of environmental enrichment given the nature of the intervention.