Environmental enrichment for stroke and other non‐progressive brain injury
Abstract
Background
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.
Objectives
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.
Search methods
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.
Selection criteria
We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services.
Data collection and analysis
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.
Main results
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.
Authors' conclusions
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.
PICOs
Plain language summary
Treatment using environmental enrichment for supporting rehabilitation following stroke and other brain injuries which do not get worse over time (non‐progressive brain injury)
Background
Rehabilitation helps with recovery after stroke and other non‐progressive brain injuries through therapy. However, outside of therapy hours, people may have very little to keep them stimulated. Environmental enrichment is a relatively new concept in rehabilitation where the environment itself is designed to be engaging and to include physical, thinking, and social activities like exercises and games. For example, a nursery for babies may be interesting and stimulating but a hospital environment for adults is generally not. The design of the environment alone should encourage (but not force) activities without additional specialised rehabilitation.
Review question
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives.
Search date
The evidence is current to 26 October 2020.
Study characteristics
Population: we planned to include studies in which participants were adults who had had a stroke or a non‐progressive brain injury (such as traumatic brain injury but not dementia, Alzheimer's diease, or multiple sclerosis).
Intervention: environmental enrichment interventions will usually include multiple activities, such as computers plus gaming technology plus music and reading.
Comparison: we planned to compare environmental interventions with usual care (regular physiotherapy, speech therapy, occupational therapy) or alternative treatment.
Outcomes: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on psychological well‐being (anxiety, depression, stress) and coping. Secondary outcomes focused on quality of life, physical function, communication and cognitive function, and activity levels. We also planned to report adverse events.
Key results
We found one trial that compared environmental intervention alone with usual care or alternative treatment. The trial included 53 participants who had had a stroke and was based in a hospital rehabilitation ward. The trial compared 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. The main outcomes related to psychological well‐being and coping. We were uncertain of the results because the trial was very small and highly prone to bias.
Conclusion
The gap in current research does not mean that environmental enrichment is ineffective. Further research is needed with strong study designs and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (in hospital versus out of hospital), which components of environmental enrichment are effective, whether environmental enrichment is cost‐effective, and if it is safe for people following stroke or other non‐progressive brain injuries.
Authors' conclusions
Summary of findings
| Environmental enrichment compared to standard care following stroke | ||||||
|---|---|---|---|---|---|---|
| Patient population: adults (aged 18 or older) with a diagnosis of stroke Settings: inpatient rehabilitation unit Intervention: environmental enrichment ‐ access to individual and/or communal enriched environment equipment and activities Comparison: standard care | ||||||
| Outcomes | Illustrative comparative risks* | Number of participants | Quality of the evidence (GRADE) | Comments | ||
| Assumed risk | Corresponding risk | |||||
| Standard care | Environment enrichment | |||||
| Psychological well‐being and coping (primary outcome) | Outcome measure 1: depression, Anxiety and Stress Scale score at discharge from hospital (end of intervention) | Mean in the intervention group was 24.1 lower (40.1 lower to 7.2 lower) (favours environmental enrichment) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Outcome measure 2: multidimensional Health Locus of Control score at discharge from hospital (end of intervention) | Mean in the intervention group was 3.7 higher (0.5 higher to 7.1 higher) (favours environmental enrichment) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | ||
| Outcome measure 3: Rosenberg Self‐esteem Scale score at discharge from hospital (end of intervention) | Mean in the intervention group was 2.1 higher (0.4 lower to 4.6 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | ||
| Quality of life (secondary outcome) | Outcome measure: Euro‐Quality of life score at discharge from hospital (end of intervention) | Mean in the intervention group was 8 higher (1.4 lower to 17.5 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Physical functional improvement (secondary outcome) | Outcome measure: Functional Independent Measure motor subscale at discharge from hospital (end of intervention) | Mean in the intervention group was 6.7 higher (0.2 higher to 13.1 higher) (favours environmental enrichment) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Communication and cognitive functional improvement (secondary outcome) | Outcome measure 1: Montreal Cognitive Assessment score at discharge from hospital (end of intervention) | Mean in the intervention group was 2.1 higher (0.7 lower to 4.9 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Outcome measure 2: Functional Independent Measure cognition subscale score at discharge from hospital (end of intervention) | Mean in the intervention group was 1.2 higher (1.6 lower to 4.1 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | ||
| Activity levels (secondary outcome) | Outcome measure: activity logs | Data not available | N/A | N/A | ||
| Adverse effects (secondary outcome) | Outcome measure: adverse effects | None | None | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | |
| GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. | ||||||
| CI: confidence interval; GRADE: Grading of Recommendations, Assessment, Development and Evaluation; N/A: not applicable; *The assumed risk is based on the outcome median of the control group. The corresponding risk is based on the outcome median of the comparison group. The relative effect of the intervention is based on mean difference scores (95% CI) denoted in brackets (lower/higher/no difference). aThis study had a mixed neurological population; however, only results for the stroke subgroup have been presented here. bBased on GRADE criteria, the quality of evidence has been downgraded three levels to "very low". Firstly, a single randomised controlled trial with a small cohort of participants is contributing to the overall quality of evidence (imprecision). Secondly, there are significant limitations in the design and implementation of the included study (risk of bias). Thirdly, there was unexplained inconsistency of results (including problems with subgroup analyses). There is also a reasonable likelihood of publication bias. | ||||||
Background
Description of the condition
Stroke is a leading cause of death and disability, and one in six people worldwide will have a stroke in their lifetime (Donnan 2008; WHO 2013). Traumatic brain injury (TBI) is a leading cause of death and disability worldwide (Perel 2006). The annual incidence of TBI is considered to be upwards of 20 to 60 per 100,000 with many of these injuries sustained in young adulthood (Frasca 2013).
These conditions often lead to significant functional and psychosocial impairment, causing limitation in mobility and everyday activities. Many patients receive rehabilitation during the first weeks following their injury and it is during this time that most of their recovery takes place (Frasca 2013; Teasell 2014). There is well‐established evidence (including Cochrane Reviews and overviews) for the effectiveness of various aspects of stroke rehabilitation (Brady 2016; EBRSR 2015; Legg 2006; Pollock 2014a; Pollock 2014b), but questions have been raised as to whether the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. An observational study by King 2011 found that patients following a stroke spent a large proportion of the day in their bedroom, engaged in solitary behaviour, and being inactive. This is supported by more recent studies (Simpson 2021; West 2012).
Description of the intervention
Within the animal literature, the term 'environmental enrichment' is better established, with standardised categories of enrichment types (social, occupational, physical, sensory, and nutritional) (Mench 2010). However, this is a relatively new concept within rehabilitation for humans and the term is less well‐defined and may be used inconsistently. In this Cochrane Review, we define 'environmental enrichment' 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 (Nithianantharajah 2006). The environment should be designed to encourage (but not force) activities and verbal encouragement may be provided. The environment itself should be engaging and interesting enough to encourage participation.
The intervention is not therapist‐dependent as it is not prescribed by a therapist within a tailored, individualised, goal‐oriented rehabilitation programme. The intervention is simply 'just there' and easily and freely accessible by patients. The environment may be supervised either by a health professional (e.g. medical, nursing, or therapist) or non‐professional (family member, other volunteers) so that assistance may be provided (such as setting up a game or playing a game with the patient). Where the supervision is provided by a therapist, the therapist should not be providing a recognised intervention within his or her field of expertise. For example, if supervision is provided by a music therapist, singing technique or rhythmic auditory stimulation or song‐writing should not form part of the activity. The supervisor should easily be replaceable with another with a different skill set or a lay person.
The participant's treating therapists may be asked to approve participation for safety reasons depending on the activity (such as exercise programmes) and the participant then chooses to engage in structured activity that is cognitively stimulating. Environmental enrichment does not include interventions that do not require participant engagement or choice, such as the provision of background music. Additionally, patients may choose to set their own goals (such as complete a 20‐piece jigsaw puzzle). Environmental enrichment should be used to complement, not replace, rehabilitation and patients should be undergoing a concurrent structured individualised rehabilitation programme where appropriate.
Interventions may include:
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reading material (books, magazines, newspapers);
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easily accessible computers with Internet connection;
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virtual reality and interactive gaming through computers or gaming consoles;
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board games (including puzzles, chess);
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music station;
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audiobooks;
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art and craft (drawing, painting, craft‐work);
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interactive recreational activities (e.g. Bingo);
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exercise.
The enriched environment should be multi‐factorial and involve different activities. Settings can be individual (activities available to individuals, e.g. by the bedside) or communal (the structured stimulating environment is within a communal area, such as a designated area within a ward).
How the intervention might work
Given that stroke recovery is reliant on neuroplasticity (the ability of the brain to change in structure or function in response to experience), environmental enrichment is a possible alternate option for stimulating neural recovery through functional and cognitive activity. There is evidence suggesting that patients in rehabilitation wards, apart from their scheduled therapy sessions, spend most of their time (waking hours) physically inactive and relatively isolated (Berges 2012a; Berges 2012b; Keith 1987; King 2011; Mackey 1996; Tinson 1989). The amount of practice in functional and cognitive activities therefore needs to be increased to improve their activities and to maximise the rehabilitation experience (Janssen 2014). Previous studies after stroke suggest that engagement in higher levels of therapeutically‐based physical activity is associated with better physical function (Galloway 2019), and greater independence (Kwakkel 2004); and that cognitive or social activity enhances cognitive recovery and improves mood‐related disorders such as depressive symptoms (Cheng 2014; Cheng 2012). Therefore, it is hypothesised that a more stimulating environment is likely to be more conducive to recovery through improved activity levels that reduce a patient's boredom and in turn improves their mood and engagement in their overall rehabilitation programme. The positive role of a stimulating environment is supported by evidence in the area of traumatic brain injury, where a lack of environmental enrichment may play a role in post‐acute cognitive and neural decline (Frasca 2013).
The effectiveness of environmental enrichment has been investigated extensively in animal models. It facilitates brain physiology and enhances recovery by triggering structural changes within the affected brain, which are significant in the process of neuroplasticity (Hirata 2011; Janssen 2012; Nilsson 2007; Nithianantharajah 2006). Diamond 1964 showed increases in cortical neuron size, number and length of dendrites, and the number of dendritic spines in rats exposed to an enriched environment. Moreover, differences were observed in cortical thickness, cortical weight, acetylcholinesterase, cholinesterase and protein and hexokinase levels (Bennett 1964). Beneficial effects of environmental enrichment and exercise have been shown in a wide variety of animal models of brain disorders; these include cognitive enhancement, delayed disease onset, enhanced cellular plasticity, and associated molecular processes (Pang 2013). Enriched environments are also associated with improvement in both physical and cognitive function in animal models of neurodegenerative and psychiatric diseases (Laviola 2008; Puurunen 2002).
A controlled clinical trial (with 29 participants) of enriched environment and activity in a stroke rehabilitation unit showed significantly increased activity in patients and reduced time spent inactive and alone (Janssen 2014). They were more likely to be engaged in any activity compared with those in a non‐enriched environment (almost twice as likely (1.7) to be engaged in cognitive activities, 1.2 times in social activities, 0.7 times as likely to be inactive and alone).
Why it is important to do this review
Environmental enrichment could potentially be a feasible, low‐cost adjunct to conventional rehabilitation. It is important to evaluate the effectiveness of such an intervention for the purpose of guiding future research and influencing clinical practice. Although some Cochrane Reviews have explored the role of similar interventions, such as virtual reality and interactive video gaming (Laver 2017), and music therapy (Magee 2017), within a rehabilitation programme, and other Cochrane Reviews have examined the impact of additional exercise on recovery (Galvin 2012), the role of these interventions as part of environmental enrichment has not previously been studied. Generally, these reviews do not overlap with the review on environmental enrichment as the interventions studied form part of formal rehabilitation therapy programmes and the interventions are delivered by appropriate health professionals using their expertise to support the attainment of specific rehabilitation goals through the prescription of therapy using these modalities (Galvin 2012; Laver 2017; Magee 2017). The same modalities (music, virtual reality, exercise) used within an enriched environment would simply be available and accessible to patients for them to use as they wish. The Cochrane Review on music therapy was updated more recently to include environmental enrichment with music alone. To ensure no overlap, this review has been revised since the protocol to include only environmental enrichment consisting of multiple elements (such as computers plus gaming technology plus music). This review therefore aims to identify the existing evidence for interventions for environmental enrichment in people with stroke and other acquired non‐progressive brain damage and to identify gaps in current knowledge. This would serve the purpose of informing health professionals, stroke and other acquired non‐progressive brain damage survivors and their families, and policy makers about the effectiveness of different environmental enrichment interventions and potentially shape the environment in which rehabilitation is delivered in the future.
Objectives
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.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs), either iIndividually‐randomised trials or cluster‐randomised trials were eligible for inclusion.
Types of participants
Adults aged 18 and over, men and women, with a definition of stroke as defined by the World Health Organization (WHO) (Hatano 1976), or other acquired non‐progressive brain damage were eligible for inclusion. Acquired brain damage includes brain injury, encephalitis, abscess, and arteriovenous malformations. We excluded participants with progressive neurological conditions such as a primary diagnosis of dementia, space‐occupying lesions, and multiple sclerosis.
Included studies were eligible where at least 75% of participants had a diagnosis of stroke or other non‐progressive brain disorders. We also planned to include studies where data for participants with stroke and other non‐progressive brain disorders were reported separately if these diagnostic groups formed a minimum of 50% of the participants within the study.
Types of interventions
We planned to include trials that compared environmental enrichment with standard services. Environmental enrichment is defined as any intervention that facilitates physical, cognitive, and social activity by the provision of equipment and organisation of a stimulating environment whereby the intervention is not therapist‐ (or other health‐professional) dependent and exposure alone to such environments encourages patients to perform activities. The intervention is used as an adjunct to a conventional rehabilitation programme; it is not prescribed by a therapist and does not form part of the formal programme. By nature of the intervention being an adjunct to conventional rehabilitation, all patients must therefore also be concurrently undergoing a formal rehabilitation programme (inpatient, outpatient, or home‐based) where appropriate.
Interventions could include, but were not limited to:
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using easily accessible computers with Internet connection and Skype;
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gaming technology;
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access to library with reading materials;
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board games, puzzles, chess;
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music station (access to a selection of music and an appropriate player).
Interventions could have multiple elements (computers plus gaming technology plus music), could be supervised by an appropriate person (who may or may not be a health professional), and could be facilitated (such as by having a person play board games with the patient). An appropriate person refers to a responsible person who is willing to be present, provide encouragement, and assist the patient when necessary. If they are a health professional, their expertise must not be required in their interactions (such as a musical therapist formulating an individualised playlist for participants), and they should easily be replaced with a lay person.
Within a hospital environment, such interventions might be set up in an area of the ward that is accessible by all patients. Within a home environment, however, an example of environmental enrichment might be an area set up with a music player and various music, a computer with Internet access and board games. Interventions do not have to be provided by the hospital within a hospital environment. For example, if a patient had his own portable laptop computer, this would be an eligible intervention provided use of this was supervised by family members or staff.
The intervention will be compared with standard rehabilitation care. Where there may be trials that have two enriched environment intervention arms compared to standard care, the two intervention arms will be analysed together and compared to the control arm.
Types of outcome measures
Outcome measures were divided into those that measured primary and secondary outcomes. Other than adverse events which were dichotomous, all outcomes were continuous.
Primary outcomes
The primary outcomes were psychological well‐being and coping at four weeks (short term), between four weeks and 12 months (moderate term), and after 12 months (long term). Instruments that measure psychological well‐being and coping could include, but were not limited to:
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Depression Anxiety Stress Scale‐21 (DASS) (Lovibond 1995);
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Hospital Anxiety and Depression Scale (HADS) (Zigmond 1983);
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Rosenberg Self‐Esteem Scale (Rosenberg 1965);
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Multidimensional Health Locus of Control (MHLC) (Wallston 1994)
Secondary outcomes
Secondary outcomes were at four weeks (short term), between four weeks and 12 months (moderate term) and after 12 months (long term). Outcomes included the following.
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Quality of life. Instruments that measure quality of life may include, but were not limited to:
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Stroke and Aphasia Quality of Life Scale‐39 Generic (SAQOL‐39) (Hilari 2003);
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Euro‐Quality of life EQ‐5D (EuroQoL 1990);
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36‐item Short Form Health Survey (SF‐36) or the 12‐item Short Form Health Survey (SF‐12) (Ware 1992; Ware 1995).
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Physical functional improvement (activities of daily living). Instruments that measure physical functional improvement could include, but were not limited to:
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motor component of Functional Independence Measure (FIM) (Granger 1990).
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Communication and cognitive functional improvement. Instruments that measure communication and cognitive functional improvement could include, but were not limited to:
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cognitive and language component of Functional Independence Measure (FIM) (Granger 1990);
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Montreal Cognitive Assessment (MoCA) (Nasreddine 2005).
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Activity levels. Instruments that measure activity levels could include, but were not limited to:
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Structured observational techniques such as behavioural mapping (Ittelson 1974)
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Adverse events such as falls
Search methods for identification of studies
See the methods for the Cochrane Stroke Group Specialised register. We searched for studies in all languages and arranged for the translation of trials where necessary.
Electronic searches
Searches were conducted on the 26 October 2020. We searched the trials registers of the Cochrane Stroke Group, the Cochrane Injuries Group, the Cochrane Infectious Diseases Group, and the following electronic databases.
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Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11) in the Cochrane Library (Appendix 1).
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MEDLINE Ovid (from 1950) (Appendix 2).
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Embase Ovid (from 1980) (Appendix 3).
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CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; from 1982) (Appendix 4).
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AMED Ovid (Allied and Complementary Medicine; from 1985) (Appendix 5).
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PsycINFO Ovid (from 1806) (Appendix 6).
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PEDro (Physiotherapy Evidence Database; www.pedro.org.au) (Appendix 7).
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Center for International Rehabilitation Research Information and Exchange (CIRRIE) Database of International Rehabilitation Research (http://cirrie.buffalo.edu/search/index.php ) (Appendix 8).
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Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library, latest issue); (Appendix 9). Please note that DARE is no longer updated as of March 2018.
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ProQuest Dissertations & Theses Database (Appendix 10).
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OT Search by the American Occupational Foundation and the American Occupational Therapy Association (www1.aota.org/otsearch/) (Appendix 11).
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Occupational Therapy Systematic Evaluation of Evidence (OTseeker) (www.otseeker.com/) (Appendix 12).
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the National Rehabilitation Information Center REHABDATA Database (www.naric.com/research/rehab/) (Appendix 13).
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SPORTDiscus EBSCO (Appendix 14).
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Trials Central (www.trialscentral.org) (Appendix 15).
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UK Clinical Research Network Portfolio database (public.ukcrn.org.uk/search/) (Appendix 16); (This database is no longer active and has been superseded by the NIHR Clinical Research Network (CRN) Portfolio which can be searched via ISRCTN. This database will therefore not be searched for future iterations of this review).
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PsycBite (www.psycbite.com) (Appendix 17).
We developed the MEDLINE search strategy (Appendix 2) with the help of the Cochrane Stroke Group Information Specialist and adapted it for the other databases. All search strategies deployed were combined with subject strategy adaptations of the highly sensitive search strategy designed by the Cochrane Collaboration for identifying randomised controlled trials and controlled clinical trials (as described in the Cochrane Handbook for Systematic Reviews of Interventions) (Higgins 2021).
To identify further published, unpublished and ongoing trials, we searched the following trials and research registers.
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US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov/) (Appendix 18).
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Stroke Trials Registry (www.strokecenter.org/trials/) (Appendix 19). (This registry is no longer active and will not be searched for future iterations of this review).
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EU Clinical Trials Register (www.clinicaltrialsregister.eu) (Appendix 20).
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ISRCTN Registry (www.isrctn.com/), previously Current Controlled Trials (www.controlled-trials.com) (Appendix 21).
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WHO International Clinical Trials Registry Platform (www.who.int/ictrp/en/) (Appendix 22).
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Australian New Zealand Clinical Trials Registry (www.anzctr.org.au/) (Appendix 23).
The latter four registries listed above (EU Clinical Trials Register, ISRCTN Registry, WHO International Clinical Trials Registry Platform, Australian New Zealand Clinical Trials Registry) are now included in the WHO ICTRP datasets and will therefore not be searched for future iterations of this review.
Searching other resources
To identify further published, unpublished and ongoing trials, we:
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handsearched the reference lists of included trials and review articles;
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tracked citations using Web of Science Cited Reference Search for all included studies;
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contacted experts active in this field (including authors of included trials and excluded studies identified as possible preliminary or pilot work);
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used Google Scholar (scholar.google.co.uk/) for forward searching citations.
Data collection and analysis
Selection of studies
Two review authors (HQ, LN) independently screened titles and abstracts of the references obtained as a result of our searching activities and we excluded obviously irrelevant reports. We retrieved the full‐text articles for the remaining references and two review authors (HQ, LN) independently screened the full‐text articles, identified studies for inclusion, and identified and recorded reasons for exclusion of the ineligible studies. We resolved any disagreements through discussion or, if required, consulted a third review author (AG). We collated multiple reports of the same study so that each study, not each reference, was the unit of interest in the review. We recorded the selection process and completed a PRISMA flow diagram (Figure 1).
Study flow diagram.
Data extraction and management
Two review authors (HQ, LN) independently extracted data from the included study.
We used a pre‐designed data extraction form to extract data from the included study. Two review authors (HQ, LN) independently documented the following.
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Participants: number of participants, age, gender, baseline functional status or level of impairment.
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Methods: inclusion criteria, time since stroke or non‐progressive brain injury, and type, nature and location of lesion.
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Interventions: description of interventions given to each treatment group including the duration, dose (such as access time to intervention—for example, if a participant was able to access computers and Skype for an hour a day, this would be reported), frequency, supervisor (who supervised the intervention) and setting (inpatient, outpatient or home‐based).
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Outcomes: primary and secondary outcomes measured.
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Results: number of participants allocated to each intervention group. For each outcome of interest—sample size, missing participants, data for each intervention group.
We planned to note any important confounding variables. If more than two intervention groups were included in the study, we would have noted the method of including these groups in any subsequent analysis. Two review authors (HQ, LN) planned to resolve any data extraction discrepancies through discussion. If disagreement had persisted, a third review author (AG) would have independently extracted the data.
Assessment of risk of bias in included studies
Two review authors (HQ, LN) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreements by discussion or by involving another author (AG). We assessed the risk of bias according to the following domains.
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Random sequence generation.
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Allocation concealment.
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Blinding of participants and personnel.
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Blinding of outcome assessment.
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Incomplete outcome data.
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Selective outcome reporting.
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Other bias.
We graded the risk of bias for each domain as high, low, or unclear and provided information from the study report together with a justification for our judgement in the risk of bias tables. Given the nature of environmental enrichment, blinding of participants and personnel is difficult. However, it should be possible to blind outcome assessment. Additionally, where randomisation at the individual level was difficult due to risk of contamination, this would also affect allocation concealment. These inherent issues were considered when assessing the risk of bias in the study.
Measures of treatment effect
We planned to use the Cochrane Review Manager software to carry out statistical analyses to determine the treatment effect (RevMan 2020). For dichotomous variables we planned to calculate the treatment effect using a random‐effects model and reported it as odds ratios (ORs) with 95% confidence intervals (CIs).
For continuous data we planned to calculate the treatment effect using standardised mean differences (SMDs) and 95% CIs where different studies used different scales to assess the same outcome, and we would have calculated mean differences (MDs) and 95% CIs where studies have all used the same method of measuring outcome.
We planned to use meta‐analysis as the primary point of analysis. We planned to assess all studies for heterogeneity and in the presence of such, would have used meta‐regression to adjust for potential differences between studies. In the absence of a direct comparison between interventions, we planned to consider mixed‐treatment comparisons or indirect comparisons to determine any differences between various interventions, while standard rehabilitation (control) was used as a common comparator. We would have done this using either the frequentist or Bayesian approach and using Monte‐Carlo Markov simulations.
Unit of analysis issues
If the primary outcome of short‐term patient psychological well‐being and secondary outcomes of short‐, medium‐, and long‐term quality of life and functional improvement comprised of either ordinal data from measurement scales or continuous data, we planned to analyse these as continuous variables. Where reported outcomes had a scale where a lower value indicates a better outcome we would have multiplied the reported values by ‐1 so that in all analyses a higher value would indicate a better outcome.
If studies had reported change values and the baseline value was available, we would have calculated the value at follow‐up (change value − baseline value). If studies reported change values and the baseline value was not available, we would have used these data in meta‐analyses but planned sensitivity analyses to investigate the effect of including these data. We planned to analyse adverse events as dichotomous variables.
Dealing with missing data
If an included study did not report a particular outcome, but it had been included in the battery of measures administered, we planned to contact the authors for the original data. If we were unsuccessful in obtaining the data, we would not have included that study in the analyses of that outcome. We also planned to contact authors for missing intervention details.
If an included study had missing data (e.g. the study reported means but not standard deviations for the follow‐up data), we planned to contact the authors for the missing data. If we were unsuccessful, we would have taken logical steps to enter an assumed value. Such steps may include estimating a standard deviation based on a reported standard error, estimating a follow‐up standard deviation based on a baseline value, using the median as a proxy for the mean, and using a multiple of 0.75 times the interquartile range or 0.25 times the range as a proxy for the standard deviation values (Hozo 2005). We planned to undertake sensitivity analyses to investigate the effect of entering assumed values.
Assessment of heterogeneity
Meta‐analysis using a random‐effects model would have been applied where appropriate in the setting of substantial methodological, statistical and clinical heterogeneity among the trials. We would have used the I2 statistic to examine heterogeneity. If an I2 was > 70%, then substantial heterogeneity would have been assumed and we would have explored the individual trial characteristics to identify potential sources of heterogeneity.
Assessment of reporting biases
We planned to avoid reporting biases by using a comprehensive search strategy that included searching for unpublished studies and searching trials registers. We also planned to assess the completeness of outcome data. If possible, we would have assessed publication bias using a rank correlation test and a funnel plot. This would have been conducted for the primary outcomes and would have been executed only if there were enough data (i.e.10 studies or more reporting the outcome).
Data synthesis
Where we might have considered studies to be sufficiently similar (where similar activities were used, where similar outcomes were sought) and where data were available and of sufficient quality, we would have conducted a meta‐analysis by pooling the appropriate data using RevMan 5.4 (RevMan 2020).
Subgroup analysis and investigation of heterogeneity
If we had found a significant body of literature, we planned to conduct subgroup analyses for the primary outcome by intervention, with subgroups that included:
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enriched environments with a variety of communal and individual activities (Internet, reading material, games, Nintendo Wii, music, audiobooks, books, games, puzzles);
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enriched environments with predominantly sensory stimulation (lights, sounds, textures).
Sensitivity analysis
We intended to carry out a sensitivity analysis (if necessary) to explore the effect of the following methodological features.
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Allocation concealment: we would have re‐analysed the data, excluding trials with inadequate or unclear allocation concealment.
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Blinding of outcome assessor: we would have re‐analysed the data, excluding trials without or with unclear blinding of outcome assessor.
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Missing outcome data: we would have re‐analysed the data, excluding trials with inadequate or unclear methods of dealing with missing outcome data.
Please refer to the previously mentioned sensitivity analysis under Unit of analysis issues and Dealing with missing data.
Summary of findings and assessment of the quality of the evidence
The main findings of the review, together with key information concerning the quality of evidence, are presented in the summary of findings table. We divided outcomes into primary outcomes (psychological well‐being and coping at short term, moderate term and long term), and secondary outcomes (quality of life, physical function, and communication and cognitive function at short term, moderate term and long term). Where outcomes were not addressed, we reported this in the summary of findings table as "not addressed".
For each pre‐stated primary and secondary outcome, for comparisons of environmental enrichment with standard, we utilised the GRADE approach to assess the quality of evidence (Guyatt 2008; Higgins 2021). GRADE defines the quality of studies as the extent to which one can be certain that an estimate of effect is close to the quantity of interest. Four levels of quality are specified for a body of evidence for an outcome: high, moderate, low, and very low. Assessments are determined through consideration of the following five domains: risk of bias, inconsistency, indirectness, imprecision and publication bias. Factors that may decrease the quality level of the included studies therefore include: methodology limitations suggesting high likelihood of bias, indirectness of evidence such as with indirect populations, unexplained inconsistency of results, imprecision of results (e.g. with wide confidence intervals), and high probability of publication bias.
Summary of findings and assessment of the certainty of the evidence
The main findings of the review, together with key information concerning the quality of evidence, are presented in the ‘Summary of findings’ table. We divided outcomes into primary outcomes (psychological well‐being and coping at short, moderate‐term and long‐term) and secondary outcomes (quality of life, physical function, and communication and cognitive function at short, moderate‐term and long‐term). Where outcomes were not addressed, we reported this in the 'Summary of findings' table as "not addressed".
For each pre‐stated primary and secondary outcome, for comparisons of environmental enrichment with standard, we utilised the GRADE approach to assess the quality of evidence (Guyatt 2008; Higgins 2021). It defines the quality of studies as the extent to which one can be certain that an estimate of effect is close to the quantity of interest. Four levels of quality are specified for a body of evidence for an outcome: high, moderate, low, and very low. Assessments are determined through consideration of the following five domains: risk of bias, inconsistency, indirectness, imprecision and publication bias. Factors that may decrease the quality level of the included studies therefore include: methodology limitations suggesting high likelihood of bias, indirectness of evidence such as with indirect populations, unexplained inconsistency of results, imprecision of results (eg. with wide confidence intervals), and high probability of publication bias.
Results
Description of studies
See: Characteristics of included studies, Characteristics of excluded studies, Characteristics of studies awaiting classification, and Characteristics of ongoing studies.
Results of the search
Electronic and manual searches identified 46,884 citations. See Figure 1. A title and abstract screen removed obviously irrelevant citations such as those that did not describe environmental enrichment or that investigated unimodal environmental enrichment. Of the remaining studies, we selected nine for full‐text review. Upon further review, one study was included in this review, five were listed under excluded studies, two were categorised as 'awaiting classification', and one was listed under ongoing studies.
Included studies
We found one randomised controlled trial (RCT) that investigated the effects of enriched environment on activity and participation of stroke and non‐progressive brain injury patients (Khan 2016). This study was conducted in a single‐centre inpatient rehabilitation setting in Australia. Khan 2016 included participants with neurological conditions (n = 103 in total) and provided a sub‐analysis of data for the participants who had had a stroke (N = 53; intervention group n = 28, control group n = 25). Participants were exposed to activities within the enriched environment in 10‐minute blocks over two‐hour sessions on weekdays only. Activities available included computers, gaming technology, board games, and painting. Health professionals (doctor or nurse and an allied health assistant) supervised the participants and adjusted the complexity of activities for each participant as they improved. It was unclear if the "trained medical or nursing staff and an allied health assistant” were additional staffing required for the intervention or pre‐existing staffing. The enriched environment was located in an area "close to the ward ... (but in a) separate geographical location (with) its own lift access and entry". The control group was permitted to participate in "usual ward‐based activities" such as reading, watching television, and playing games.
The primary outcome measured by Khan 2016 was mood, as measured using the Depression, Anxiety and Stress Scale (DASS). In addition, there were six other outcomes measured: 1) cognition (Montreal Cognitive Assessment: MOCA); 2) motor and cognitive function (Functional Independence Measure: FIM – motor and cognition domains]; 3) neurological impairment (Neurological Impairment Scale: NIS); 4) coping and self‐management (Multidimensional Health Locus of Control: MHLCL); 5) self‐esteem (Rosenberg Self‐Esteem Scale: RSES); and 6) quality of life (Euro‐Quality of Life‐5D: EQ‐5D). Assessment time points were, on admission, at discharge and at three months post‐discharge. Assessments for the first two time points were conducted face‐to‐face, whereas assessments at three‐months post‐discharge were conducted over the telephone. Two outcome measures (MOCA and NIS) were not collected at three‐months post‐discharge due to the requirement for these to be collected in a face‐to‐face format. Additionally, Khan 2016 reported that activity logs were collected for both control and intervention groups; however, the protocol for the activity logs was not described.
Excluded studies
We excluded five studies: three met the criteria for “environmental enrichment” but were non‐RCTs (Janssen 2014; Janssen 2021; Rosbergen 2017), and the remaining two described co‐intervention where environmental enrichment had been added to a specific rehabilitation program (cognitive rehabilitation and physical rehabilitation, respectively) and this was compared with standard care (Jing 2011; Zhang 2005). Zhang 2005 was an RCT where cognitive rehabilitation with a small component of environmental enrichment was compared with standard care. Outcomes were designed to measure the effects of cognitive rehabilitation. Inclusion of this study would therefore have been misleading. Jing 2011 also described a co‐intervention and, additionally, was a non‐RCT. All five studies are listed in Characteristics of excluded studies and further details are provided in additional Table 1.
| Study characteristics | Study design: controlled before‐after pilot study Country: Australia Setting: rehabilitation inpatient unit Participants: n = 15/14 (intervention/control), mean age 77 years, 33%/64% (intervention/control) were men Inclusion criteria: diagnosis of stroke; estimated length of stay ≥ 16 days; pre‐morbid modified Rankin score ≤ 2; able to follow at least one‐step commands; and able to stand with the assistance of 2 people of less Exclusion criteria: behavioural, medical or other factors that would prevent safe participation in routine rehabilitation Intervention: exposure to an enriched environment for 12 days starting from day 5 of observation until day 16. This consisted of both communal and individual activities. Communal activities involved access to computers with Internet connection, reading material, games, and a communal eating area. Nintendo Wii and other recreational activities such as bingo were made available with assistance from a rehabilitation team member. Individual activities involved music, audiobooks, books, puzzles, and board games. Family members were encouraged to bring in activities participants enjoyed prior to their stroke Control: standard care, with no additional therapies, equipment, or activities other than that which was usual within the rehabilitation unit |
|---|---|
| Statistical analysis | Incidence rate ratios (IRR) |
| Outcomes | Assessment time points: four separate 12‐hour days during the 16‐day observation period Primary outcome (well‐being and coping): not applicable Secondary outcome: activity levels (physical, cognitive, or social): behavioural mapping:
|
| Study authors' conclusion | Environmental enrichment was effective in increasing activity in stroke patients and reducing time spent inactive and alone |
| Study characteristics | Study design: non‐randomised cluster trial Country: Australia Setting: 4 rehabilitation inpatient units Participants: n = 91/102 (intervention/control), mean age (SD) 66(15)/71(14) (intervention/control), 73%/69% (intervention/control) were men Inclusion criteria: within 4 weeks of a confirmed stroke, had a pre‐morbid modified Rankin Scale score ≤ 2, were able to stand with the assistance of 2 people or less, were able to follow a one‐stage command and had a predicted length of stay of ≥ 10 days Exclusion criteria: diagnosed with pre‐existing dementia or had any problems which limited safe participation in standard rehabilitation Intervention: participants could access to both individual and communal forms of environmental enrichment for the duration of their stay in the rehabilitation unit. Communal enrichment comprised interactive gaming, a computer with Internet connection, reading material (fiction and non‐fiction books, newspapers), jigsaw puzzles, board games, and a dining area for eating meals. Individual enrichment comprised a satchel which was filled with activities of the participant’s choice including music, audio books, books, word and number puzzles, and any other hobbies and activities that participants enjoyed prior to their stroke. All were instructed to encourage participants to attend the communal enrichment area or use the activities within the satchels, and to provide assistance when needed, but not to force participation. Rehabilitation staff were trained via 2 workshops delivered after the control phase, 3 months apart. At the first workshop, the evidence base for environmental enrichment, requirements for implementation and site‐specific data on pre‐implementation activity levels were presented, with opportunity for discussion of stroke survivor and staff perceived barriers and enablers of activity at their site. Rehabilitation units were advised that they would be provided with a AUD 10,000 (approximately USD 7200) budget for equipment for both the communal and individual enrichment. The second workshop presented site‐nominated specific barriers to implementation of environmental enrichment identified by rehabilitation staff and solutions to overcome, discussion of ideas for equipment to purchase, and the nomination of 2 rehabilitation staff members to act as enrichment champions; their role being to promote environmental enrichment at weekly meetings, be a support to current and new rehabilitation staff, and to identify and solve ongoing barriers to implementation. All participants in the intervention group also underwent standard rehabilitation Control: standard rehabilitation |
| Statistical analysis | Random‐effect logistic regression model |
| Outcomes | Assessment time points for activity levels: participants were observed for behavioural mapping for 1‐minute at 10‐minute intervals throughout a 12‐hour day Assessment time points for availability of environmental enrichment: the highest recruiting unit was randomly observed 38 times Assessment time points for other outcomes: baseline, 3 months Primary outcome (well‐being, coping): Hospital Anxiety and Depression Scale (HADS), Stroke Self‐Efficacy Questionnaire
Secondary outcomes Activity levels: behavioural mapping
Availability of environmental enrichment: 1 unit was randomly observed 38 times
Motor function: Rivermead Mobility Index
Cognitive function: Montreal Cognitive Assessment
ADLs: modified Rankin Scale (mRS)
Fatigue: Fatigue Assessment Scale
Quality of life: Assessment of Quality of Life 6D (Visual Analogue Scale)
Adverse events
|
| Study authors' conclusions | Environmental enrichment is feasible and safe but the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes 3 months after stroke do not provide justification for an efficacy trial |
| Study characteristics | Study design: non‐randomised controlled trial Country: China Setting: neurosurgery inpatient unit Participants: n = 25/25 (intervention/control), mean age 49.4/48.2 (intervention/control), 52%/56% (intervention/control ) were men Inclusion criteria: evidence of head trauma; admission to the hospital 8 hours post‐injury; admission Glasgow Coma Score of 3‐8; stable vital signs; loss of conscious duration greater than 6 hours; radiological evidence of brain contusion, intracranial haemorrhage or brainstem injury Exclusion criteria: multi‐system injuries and history of hypertension Intervention: multi‐sensory enriched environment including auditory, visual, taste, and olfactory and tactile stimulation. A comfortable environment with adequate ventilation, sunlight, and a room temperature of 22‐24 degrees Celcius was maintained. Participants were allowed to listen to familiar music or broadcasts and had different coloured lights and objects, familiar photos, and items placed in their rooms. Foods with various tastes and varying odours such as perfumes, flowers, and aromatic Chinese medicine were also provided. In addition to this, participants also received 10 minutes of passive stretching of their major and minor joints, 3‐4 times a day as well as "swallowing training" Control: standard treatment and nursing care including keeping airways unobstructed, medications, hyperbaric oxygen, and appropriate rehabilitation It was unclear whether the control group's environment was altered in any way |
| Statistical analysis | t‐tests |
| Outcomes | Assessment time points: baseline, at discharge, 1‐month follow up and 3‐month follow up Primary outcome (well‐being, coping): not applicable Secondary outcomes
|
| Study authors' conclusion | Enriched environment during the early recovery phase of traumatic brain injury may have a positive effect on motor and cognitive function |
| Study characteristics | Study design: controlled before‐after pilot study Country: Australia Setting: acute stroke inpatient unit Participants: n = 30/30/30 (intervention "enriched"/intervention "sustainability"/control), mean age (SD) 76.7 (12.1)/73.8 (17.4)/76.0 (12.8) (intervention "enriched"/intervention "sustainability"/control), 73.3%/56.7%/56.7%) (intervention "enriched"/intervention "sustainability"/control) were men Inclusion criteria: admitted within 24‐72 hours after onset of ischaemic or haemorrhagic stroke (first and/or recurrent); able to complete a transfer from bed to chair with assistance of 2 persons or less; able to follow single‐stage commands, requiring assistance for basic activities of daily living (ADLs) and premorbidly independent on self‐report Exclusion criteria: noncurrent diagnosis of rapidly deteriorating disease, extensive psychiatric history Intervention: participants had access to a variety of equipment in communal areas within the stroke unit. Equipment included: iPads, books, puzzles, newspapers, games, music, and magazines that were available during and outside therapy hours. There were daily group sessions focusing on stroke education, emotional support, communication, and physical activities. On weekdays, participants had communal breakfast and lunch to stimulate mobilisation and social interactions that were facilitated by therapy assistants. Participants and their families were also given written information that emphasised the importance of activity and how family members could be involved to encourage it. In addition to this, staff facilitating the "enriched" intervention group were given support in the form of the enriched environment protocol with staff responsibilities outlined and 12 nurse champions who encouraged staff adherence. After 14 weeks, this support was withdrawn whilst the enriched environment was maintained and following another 3 months, participants were recruited to the "sustainability" group and received the enriched environment without the additional staff support. This was to investigate whether the effect of the intervention could be sustained 6 months following the implementation of the enriched environment. Staff were not informed of the study's aims or the timing of the sustainability period Control: usual care |
| Statistical analysis | ANCOVA |
| Outcomes | Assessment time points for activity levels ("enriched" and control group): participants were observed for behavioural mapping for 1‐minute at 10‐minute intervals from 7.30 am till 7.30 pm on Tuesday, Thursday and Saturday, to a total maximum of three mapping days within the first 10 days post‐stroke Assessment time points for activity levels ("sustainability" group): behavioural mapping for a single day was performed on a randomly chosen Tuesday, Thursday or Saturday Assessment time points for secondary outcomes ("enriched" and control groups only): baseline, 24 hours post‐discharge, 3 months Primary outcome (well‐being and coping): Hospital Anxiety and Depression Scale (HADS)
Secondary outcomes Activity levels: behavioural mapping
Motor function: Mobility Scale for Acute Stroke (MSAS), 10‐metre walk test
ADLs: Modified Barthel Index (MBI), modified Rankin Scale (mRS)
Quality of Life: EuroQol Visual Analogue Scale (EQVAS)
Adverse events
Hospital length of stay
|
| Study authors' conclusion | Enriched environment in an acute stroke unit can have a significant positive impact on activity levels |
| Study characteristics | Study design: randomised controlled trial Country: China Setting: acute neurosurgery inpatient unit Participants: n = 12/11 (intervention/control), mean age 37.8, 67%/64% (intervention/control ) were men Inclusion criteria: at least 2 months post‐craniotomy for TBI, Ranchos Los Amigos Scale level 7 and above; 20‐55 years of age; obvious cognitive impairment; educational level of at least lower secondary school; able to understand the study and be willing to participate; supportive family members who approved of the individual's participation in the study Exclusion criteria: history of other psychiatric conditions. Intervention: enriched environment and reinforced memory cognitive training. Cognitive training started from easy to harder, ran for a limited time, focusing on memory training through repetition with an emphasis on naming objects used in daily life, associations training using terms related to previous employment/work and training using full sentences instead of phrases only. Family assisted information regarding what the patient was previously interested in, to help with memory. There was use of recordings, videos, pictures including pictures on wall which were colourful and simple and had connection/relevance to patient. Cognitive training time occurred for 45 minutes/day, 4‐6 times a week for 30 days. The enriched environment consisted of colourful pictures, sounds and lights, all of which were interactive and changing to attract attention. Recordings and pictures provided a satisfying environment. Objects in the room were named Control: medications to provide brain nutrition, physical rehabilitation It was unclear if the intervention group also received the same medications and physical rehabilitation as the control group |
| Statistical analysis | t‐tests |
| Outcomes | Assessment time points: baseline, at the completion of intervention Primary outcome (well‐being, coping): not applicable Secondary outcome: memory: cognitive‐behavioural assessment with the domains of orientation, concentration, problem‐solving, repetition, naming, construction, memory, calculation, understanding groupings, judgement
|
| Study authors' conclusion | Enriched environment may be useful in repairing memory function following traumatic brain injury |
CI: confidence interval
MD: mean difference
SD: standard deviation
Two other studies (Walsh 2019; Kusec 2020) are currently at the protocol phase and awaiting classification (Characteristics of studies awaiting classification), and one (Janssen 2023) is ongoing (Characteristics of ongoing studies). We will further assess these studies at the next update of this review.
Risk of bias in included studies
We assessed the risk of bias for Khan 2016 (Figure 2).
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages.
Allocation
In Khan 2016, randomisation was performed using a computer‐generated randomisation schedule by an "independent project officer". Although it is stated that the "allocation sequence was concealed from the treatment teams to avoid bias", the method of allocation concealment was not further described. We therefore judged Khan 2016 to be at low risk of bias for randomisation and at unclear risk of bias for allocation concealment.
Blinding
Khan 2016 reports that efforts were made to ensure blinding of participants; however, this proved to be challenging over the course of the study. Outcome assessors were blinded. We therefore judged this trial to be at high risk of bias with regards to blinding of participants and personnel but at low risk of bias with regards to blinding of outcome assessors.
Incomplete outcome data
The dropout rate in Khan 2016 was low. Of the 103 participants in the total cohort (which included participants with neurological conditions other than stroke), a small number (three each in both the control and intervention groups) were lost to follow‐up at the three‐month follow‐up assessment. Given the low dropout rate, we therefore judged Khan 2016 to be at low risk of bias.
Selective reporting
Khan 2016 reported all measures other than the results of the activity logs. Given that the control group also had access to activities on the ward, and that the premise of the study was to investigate the effect of enriched environment activities, it would have been important to confirm a difference in activity levels between the intervention and control groups. We therefore judged Khan 2016 to be at unclear risk of bias.
Other potential sources of bias
There were some additional concerns with the data reported. Key examples are as follows.
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The sample size in Khan 2016 had not been calculated on the basis of the number of participants with stroke; the sample size for the stroke subset would therefore not have been adequately powered.
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There was likely selection bias. Almost a third (42) of 145 eligible participants with the reason for some being "not ambulant" even though this had not previously been stated within the exclusion criteria. Further, a closer assessment of the results reported in Table 3 of the study showed that the total DASS score difference between control and intervention group at discharge was similar to the baseline differences between the two groups (53.0 ± 30.9 versus 41.6 ± 35.2). Hence, even though the baseline difference had not been deemed to be statistically significant (P = 0.08), the 12‐point difference raises the possibility of selection bias.
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It was also noted that the authors reported the standard deviation (SD) and mean scores for DASS for the participants and that the SD for DASS scores were > 50% of the mean scores reported. In some cases, the reported SD was either equal to or higher than the mean. This suggests that data at all three time points were potentially skewed. In the absence of any statement of whether continuous data were tested for normality prior to data analysis, or any reports of skewedness and kurtosis, the results of this study should be interpreted with caution.
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There were some inconsistencies on closer scrutinisation of the reported data. For example, the mean difference (MD) between groups (total cohort including stroke subset) from baseline to discharge for EQ‐5D self‐care was reported as 0.3, a number which sat outside of the reported 95% confidence interval (CI) of ‐0.7 to 0.1. Whilst this likely represented a minor error, without further clarification from the authors, the data should be interpreted with caution.
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Finally, between baseline and discharge, there appeared to be a significantly higher impact of the intervention in the stroke subgroup compared to participants with other neurological conditions as measured by DASS total (MD ‐24.1 (95% CI ‐40.1 to ‐7.2) versus ‐4.8 (‐21.1 to 11.6). However, the participants in the stroke subgroup also deteriorated more significantly following discharge when compared to the group with other neurological conditions (stroke subgroup mean differenceMD between discharge to baseline ‐24.1, MD between three‐month follow up and baseline ‐8.2, representing a change of approximately 16 points; other neurological conditions subgroup MD between discharge to baseline ‐4.8, MD between three‐month follow up and baseline 2.3, representing a change of approximately 7 points). Given the natural trajectory of stroke recovery where the most significant recovery is often seen in the inpatient setting, this raises the possibility that the results may have been affected by condition‐specific recovery.
We therefore judged Khan 2016 to be at high risk of bias on the basis of other potential sources of bias.
Effects of interventions
See: Summary of findings 1 Environmental enrichment compared to standard care following stroke
It was not possible to perform a meta‐analysis of the results, given the single included study. The effects of interventions on the stroke subset participants in the study is presented in brief, with further details available in Characteristics of included studiesTable 1 and summary of findings Table 1. It should be noted that Khan 2016 reported the mean difference scores of outcome variables for the subgroup of participants following stroke, but not the SD and mean scores. Attempts to obtain further information and clarification from the first two authors of Khan 2016 were unsuccessful, hence further analysis was limited.
Khan 2016 found that there was significant improvement in the intervention group compared to the control group at discharge in the primary outcome of mood as measured by DASS. The MD (95% CI) for DASS total was ‐24.1 (‐40.1 to ‐7.2) (P = 0.006), DASS Depression subscale ‐8.3 (‐41.0 to ‐7.2) (P = 0.008), DASS Anxiety subscale ‐7.3 (‐12.7 to ‐1.9) (P = 0.009), and DASS Stress subscale ‐8.5 (‐14.6 to ‐2.3) (P = 0.008). There was also significant improvement in the intervention group compared to the control group at discharge in coping and self‐management as measured by MHLC "Internal" with an MD (95% CI) of 3.7 (0.5 to 7.1) (P = 0.026). Motor function improved significantly in the intervention group as measured by FIM Motor Total score where an MD (95% CI) of 6.7 (0.2 to 13.1) (P = 0.043) was reported. Subscales of the FIM motor function such as self‐care and mobility also showed improvement (MD and 95% CI of 3.5 (0.4 to 6.6) P = 0.028 and 2.0 (0.3 to 3.8) P = 0.024, respectively). There was no difference however between other subscales of FIM motor function such as sphincter and locomotion (MD and 95% CI of 0.2 (‐1.4 to 1.7) P = 0.841 and 0.9 (‐0.7 to 2.6) P = 0.249, respectively) at discharge. There were no differences between groups for other outcomes (FIM cognition, MOCA, NIS, RSES, EQ‐5D) at discharge. There were also no differences between groups in any outcome measures at three months post‐discharge. Khan 2016 reported no adverse events, suggesting that the intervention was safe. We judged the certainty of all these findings to be very low (GRADE), as this evidence comes from a single, small RCT with a number of methodological limitations (see summary of findings Table 1).
Discussion
Summary of main results
Environmental enrichment is a relatively new concept in rehabilitation among stroke survivors. As such, there is a lack of established terminology in this area of research and the very large number of citations found in this review (46,884) reflects the broad search that was required to ensure comprehensiveness. We identified one randomised controlled trial (RCT) with 53 participants with stroke in this review that investigated the effects of environmental enrichment alone on people following stroke or non‐progressive brain injury. Outcomes were moderate term (three months).
We used the GRADE approach to provide a best‐evidence synthesis based on the quality of evidence. Based on one small RCT at high risk of bias (Khan 2016), data are insufficient to provide any reliable indication of benefit or risk of environmental enrichment in an inpatient rehabilitation setting for improving mood, cognition, motor function, coping or quality of life. No adverse events were reported in the study.
Overall completeness and applicability of evidence
Only RCTs were eligible for inclusion in this review. We included only one study as there was a paucity of literature in general. Whilst undertaking the review, five studies were identified which addressed the primary objective but did not meet the inclusion criteria (Janssen 2014; Janssen 2021; Jing 2011; Rosbergen 2017; Zhang 2005). Three of these were non‐RCTs that compared environmental enrichment with standard services (Janssen 2014; Janssen 2021; Rosbergen 2017); the other two (one RCT, one non‐RCT) described co‐intervention with the rehabilitation component being the more substantive component (Jing 2011; Zhang 2005). These studies have been described, and their key messages summarised in Table 1. As such studies have not been systematically reviewed, the bias and errors of non‐systematic reviews will apply. Although these studies have not been included in the synthesis of best evidence for environmental enrichment for people following stroke or non‐progressive brain injury, the description of environmental enrichment in these studies and the various study designs used may be useful for researchers when planning for future studies.
To date, most of the studies have been conducted in the inpatient setting. Future directions include taking the enriched environment approach into the community, such as the ESTEEM After Stroke study (see Ongoing studies), a multi‐site (N = 3), three‐arm RCT (n = 80/site) which aims to determine the efficacy of a community‐based enrichment model using activities such as singing, dancing, and art to stimulate patient recovery following stroke. Outcomes are anticipated to focus on functional recovery (primary outcome), emotional distress, and quality of life (community participation and cognitive function/memory).
Qualitative data exploring patient and staff perceptions of environmental enrichment may help to inform future study designs. Involvement of family and socialisation between participants, family, and staff are perceived to be facilitators of environmental enrichment whilst barriers include poor communication between staff and patients regarding activity options, participation limitations as a result of stroke‐related disability, personal preferences and personality types, hospital rules (real or perceived), and layout (Janssen 2019a; Janssen 2019b; Rosbergen 2019b). In addition, Rosbergen 2019a affirmed the importance of staff engagement and found that appropriate leadership, education, and transparent responsibilities amongst staff as facilitators. Future studies should therefore consider the impact of culture change, staff attitudes, and also the physical environment when optimising engagement in an enriched environment.
This review has highlighted a number of research challenges in the area of environmental enrichment. The difficulty of conducting an RCT at a single site where the risk of introducing unacceptable bias through contamination is high can be overcome by the use of a multi‐site, cluster‐RCT or a stepped‐wedge design for future studies (Rosbergen 2017). The alternative design of having the enriched environment located separately to the ward is not desirable given the barriers that already exist even when the enriched environment is embedded within the ward itself. Successful implementation of enriched environments are complex, often requiring changes in multiple areas such as service delivery and physical environment and at both ward and potentially hospital levels (Janssen 2021). Recruitment of participants is limited by the size of inpatient rehabilitation wards, hence multi‐site recruitment is generally required to adequately power a study. Lastly, there does not appear to be a consensus on outcome measurement. It is noted that Rosbergen 2017 adapted the behavioural mapping protocol used by Janssen 2014, but Khan 2016 did not report on activity levels at all and it is unclear what protocol was used for their activity logs. Consistent use of outcome measurement would allow comparison between studies.
Quality of the evidence
We identified one RCT in this review, which was at high risk of bias. Whilst the authors made attempts to ensure blinding of participants and personnel where possible, it is recognised that this is difficult with such interventions. The included study had a small sample size and did not report on activity log data despite both the intervention and control groups having access to activities. Based on GRADE criteria, the quality of evidence has been downgraded three levels to 'very low'. Firstly, a single RCT with a small cohort of participants is contributing to the overall quality of evidence (imprecision). Secondly, there are significant limitations in the design and implementation of the included study (risk of bias). Thirdly, there was unexplained inconsistency of results (including problems with subgroup analyses). There is also a reasonable likelihood of publication bias.
Potential biases in the review process
We applied a comprehensive search strategy and included searches of clinical trial registers and grey literature. It is possible, however, that we may have missed relevant studies.
Agreements and disagreements with other studies or reviews
Previous Cochrane Reviews have explored the effectiveness of activities such as virtual reality and interactive video gaming (Laver 2017), music (Magee 2017), and exercise (Galvin 2012), which appear to be commonly used in enriched environments. Laver 2017 included 72 trials that involved 2470 participants. Although there was a large number of RCTs, the evidence was mostly of low quality when rated using the GRADE system, and Laver 2017 noted that control groups in the trials usually received no intervention or therapy based on a standard‐care approach. They found that whilst the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy in improving upper limb function, virtual reality could improve upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time), which is how it could be used in an enriched environment. Magee 2017 included 29 trials involving 775 participants and concluded that music interventions may be helpful in improving communication, mood, cognition, function, and quality of life. Listening to patient‐preferred music was found to be most beneficial in reducing agitation (Magee 2017). Again, the authors assessed the overall quality of the evidence to be low. They further noted that only three studies assessed mood as an outcome despite the prevalence of depression following stroke and its negative impact on patients’ engagement with rehabilitation (Magee 2017). The findings of Laver 2017 and Magee 2017 seem to suggest that virtual reality and interactive video gaming, and music could be effective components of environmental enrichment. The review by Galvin 2012 is currently at the protocol stage and does not yet have results.
In addition to these Cochrane systematic reviews, a non‐Cochrane systematic review addressing environmental enrichment was published by Reid 2016. This review aimed to determine the effectiveness of single‐ or multi‐component environmental enrichment on neurological outcomes across a broad range of neurological conditions. Following a search of six databases (MEDLINE, Embase, CINAHL, AMED, Cochrane Controlled Trials Register and Psycinfo), 3930 citations were retrieved and three studies with 109 participants (either post‐stroke or traumatic brain injury) met the inclusion criteria (Reid 2016). The three included studies comprised two RCTs (one with three reports), both assessed to be of 'moderate quality' based on GRADE and to be single‐component interventions. Särkämö 2008, Särkämö 2010, and Särkämö 2014 studied the effectiveness of music on stroke recovery and found improvement in cognitive function and mood but not quality of life. Sinclair 2014 assessed the effectiveness of light on traumatic brain injury recovery and found an improvement in fatigue. The third study was by Janssen 2014, which has already been described. Although Reid 2016 concluded that current evidence tentatively suggested that environmental enrichment improved cognitive function, mood, and activity levels, it is unlikely, given the paucity and heterogenous nature of the data, that there could have been any reliable indication of benefit. Many of these RCTs included in Reid 2016 consisted of single‐component environmental enrichment only, which would not have met the inclusion criteria of this Cochrane Review. The significant difference in the selection of studies for inclusion however highlights the challenges in the interpretation of intervention in relation to the concepts of environmental enrichment.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages.
| Environmental enrichment compared to standard care following stroke | ||||||
|---|---|---|---|---|---|---|
| Patient population: adults (aged 18 or older) with a diagnosis of stroke Settings: inpatient rehabilitation unit Intervention: environmental enrichment ‐ access to individual and/or communal enriched environment equipment and activities Comparison: standard care | ||||||
| Outcomes | Illustrative comparative risks* | Number of participants | Quality of the evidence (GRADE) | Comments | ||
| Assumed risk | Corresponding risk | |||||
| Standard care | Environment enrichment | |||||
| Psychological well‐being and coping (primary outcome) | Outcome measure 1: depression, Anxiety and Stress Scale score at discharge from hospital (end of intervention) | Mean in the intervention group was 24.1 lower (40.1 lower to 7.2 lower) (favours environmental enrichment) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Outcome measure 2: multidimensional Health Locus of Control score at discharge from hospital (end of intervention) | Mean in the intervention group was 3.7 higher (0.5 higher to 7.1 higher) (favours environmental enrichment) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | ||
| Outcome measure 3: Rosenberg Self‐esteem Scale score at discharge from hospital (end of intervention) | Mean in the intervention group was 2.1 higher (0.4 lower to 4.6 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | ||
| Quality of life (secondary outcome) | Outcome measure: Euro‐Quality of life score at discharge from hospital (end of intervention) | Mean in the intervention group was 8 higher (1.4 lower to 17.5 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Physical functional improvement (secondary outcome) | Outcome measure: Functional Independent Measure motor subscale at discharge from hospital (end of intervention) | Mean in the intervention group was 6.7 higher (0.2 higher to 13.1 higher) (favours environmental enrichment) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Communication and cognitive functional improvement (secondary outcome) | Outcome measure 1: Montreal Cognitive Assessment score at discharge from hospital (end of intervention) | Mean in the intervention group was 2.1 higher (0.7 lower to 4.9 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | |
| Outcome measure 2: Functional Independent Measure cognition subscale score at discharge from hospital (end of intervention) | Mean in the intervention group was 1.2 higher (1.6 lower to 4.1 higher) (no significant difference) | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | Effect not sustained at 3‐month follow‐up | ||
| Activity levels (secondary outcome) | Outcome measure: activity logs | Data not available | N/A | N/A | ||
| Adverse effects (secondary outcome) | Outcome measure: adverse effects | None | None | 53 (1 studya) | ⊕⊝⊝⊝ Very lowb | |
| GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. | ||||||
| CI: confidence interval; GRADE: Grading of Recommendations, Assessment, Development and Evaluation; N/A: not applicable; *The assumed risk is based on the outcome median of the control group. The corresponding risk is based on the outcome median of the comparison group. The relative effect of the intervention is based on mean difference scores (95% CI) denoted in brackets (lower/higher/no difference). aThis study had a mixed neurological population; however, only results for the stroke subgroup have been presented here. bBased on GRADE criteria, the quality of evidence has been downgraded three levels to "very low". Firstly, a single randomised controlled trial with a small cohort of participants is contributing to the overall quality of evidence (imprecision). Secondly, there are significant limitations in the design and implementation of the included study (risk of bias). Thirdly, there was unexplained inconsistency of results (including problems with subgroup analyses). There is also a reasonable likelihood of publication bias. | ||||||
| Study characteristics | Study design: controlled before‐after pilot study Country: Australia Setting: rehabilitation inpatient unit Participants: n = 15/14 (intervention/control), mean age 77 years, 33%/64% (intervention/control) were men Inclusion criteria: diagnosis of stroke; estimated length of stay ≥ 16 days; pre‐morbid modified Rankin score ≤ 2; able to follow at least one‐step commands; and able to stand with the assistance of 2 people of less Exclusion criteria: behavioural, medical or other factors that would prevent safe participation in routine rehabilitation Intervention: exposure to an enriched environment for 12 days starting from day 5 of observation until day 16. This consisted of both communal and individual activities. Communal activities involved access to computers with Internet connection, reading material, games, and a communal eating area. Nintendo Wii and other recreational activities such as bingo were made available with assistance from a rehabilitation team member. Individual activities involved music, audiobooks, books, puzzles, and board games. Family members were encouraged to bring in activities participants enjoyed prior to their stroke Control: standard care, with no additional therapies, equipment, or activities other than that which was usual within the rehabilitation unit |
|---|---|
| Statistical analysis | Incidence rate ratios (IRR) |
| Outcomes | Assessment time points: four separate 12‐hour days during the 16‐day observation period Primary outcome (well‐being and coping): not applicable Secondary outcome: activity levels (physical, cognitive, or social): behavioural mapping:
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| Study authors' conclusion | Environmental enrichment was effective in increasing activity in stroke patients and reducing time spent inactive and alone |
| Study characteristics | Study design: non‐randomised cluster trial Country: Australia Setting: 4 rehabilitation inpatient units Participants: n = 91/102 (intervention/control), mean age (SD) 66(15)/71(14) (intervention/control), 73%/69% (intervention/control) were men Inclusion criteria: within 4 weeks of a confirmed stroke, had a pre‐morbid modified Rankin Scale score ≤ 2, were able to stand with the assistance of 2 people or less, were able to follow a one‐stage command and had a predicted length of stay of ≥ 10 days Exclusion criteria: diagnosed with pre‐existing dementia or had any problems which limited safe participation in standard rehabilitation Intervention: participants could access to both individual and communal forms of environmental enrichment for the duration of their stay in the rehabilitation unit. Communal enrichment comprised interactive gaming, a computer with Internet connection, reading material (fiction and non‐fiction books, newspapers), jigsaw puzzles, board games, and a dining area for eating meals. Individual enrichment comprised a satchel which was filled with activities of the participant’s choice including music, audio books, books, word and number puzzles, and any other hobbies and activities that participants enjoyed prior to their stroke. All were instructed to encourage participants to attend the communal enrichment area or use the activities within the satchels, and to provide assistance when needed, but not to force participation. Rehabilitation staff were trained via 2 workshops delivered after the control phase, 3 months apart. At the first workshop, the evidence base for environmental enrichment, requirements for implementation and site‐specific data on pre‐implementation activity levels were presented, with opportunity for discussion of stroke survivor and staff perceived barriers and enablers of activity at their site. Rehabilitation units were advised that they would be provided with a AUD 10,000 (approximately USD 7200) budget for equipment for both the communal and individual enrichment. The second workshop presented site‐nominated specific barriers to implementation of environmental enrichment identified by rehabilitation staff and solutions to overcome, discussion of ideas for equipment to purchase, and the nomination of 2 rehabilitation staff members to act as enrichment champions; their role being to promote environmental enrichment at weekly meetings, be a support to current and new rehabilitation staff, and to identify and solve ongoing barriers to implementation. All participants in the intervention group also underwent standard rehabilitation Control: standard rehabilitation |
| Statistical analysis | Random‐effect logistic regression model |
| Outcomes | Assessment time points for activity levels: participants were observed for behavioural mapping for 1‐minute at 10‐minute intervals throughout a 12‐hour day Assessment time points for availability of environmental enrichment: the highest recruiting unit was randomly observed 38 times Assessment time points for other outcomes: baseline, 3 months Primary outcome (well‐being, coping): Hospital Anxiety and Depression Scale (HADS), Stroke Self‐Efficacy Questionnaire
Secondary outcomes Activity levels: behavioural mapping
Availability of environmental enrichment: 1 unit was randomly observed 38 times
Motor function: Rivermead Mobility Index
Cognitive function: Montreal Cognitive Assessment
ADLs: modified Rankin Scale (mRS)
Fatigue: Fatigue Assessment Scale
Quality of life: Assessment of Quality of Life 6D (Visual Analogue Scale)
Adverse events
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| Study authors' conclusions | Environmental enrichment is feasible and safe but the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes 3 months after stroke do not provide justification for an efficacy trial |
| Study characteristics | Study design: non‐randomised controlled trial Country: China Setting: neurosurgery inpatient unit Participants: n = 25/25 (intervention/control), mean age 49.4/48.2 (intervention/control), 52%/56% (intervention/control ) were men Inclusion criteria: evidence of head trauma; admission to the hospital 8 hours post‐injury; admission Glasgow Coma Score of 3‐8; stable vital signs; loss of conscious duration greater than 6 hours; radiological evidence of brain contusion, intracranial haemorrhage or brainstem injury Exclusion criteria: multi‐system injuries and history of hypertension Intervention: multi‐sensory enriched environment including auditory, visual, taste, and olfactory and tactile stimulation. A comfortable environment with adequate ventilation, sunlight, and a room temperature of 22‐24 degrees Celcius was maintained. Participants were allowed to listen to familiar music or broadcasts and had different coloured lights and objects, familiar photos, and items placed in their rooms. Foods with various tastes and varying odours such as perfumes, flowers, and aromatic Chinese medicine were also provided. In addition to this, participants also received 10 minutes of passive stretching of their major and minor joints, 3‐4 times a day as well as "swallowing training" Control: standard treatment and nursing care including keeping airways unobstructed, medications, hyperbaric oxygen, and appropriate rehabilitation It was unclear whether the control group's environment was altered in any way |
| Statistical analysis | t‐tests |
| Outcomes | Assessment time points: baseline, at discharge, 1‐month follow up and 3‐month follow up Primary outcome (well‐being, coping): not applicable Secondary outcomes
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| Study authors' conclusion | Enriched environment during the early recovery phase of traumatic brain injury may have a positive effect on motor and cognitive function |
| Study characteristics | Study design: controlled before‐after pilot study Country: Australia Setting: acute stroke inpatient unit Participants: n = 30/30/30 (intervention "enriched"/intervention "sustainability"/control), mean age (SD) 76.7 (12.1)/73.8 (17.4)/76.0 (12.8) (intervention "enriched"/intervention "sustainability"/control), 73.3%/56.7%/56.7%) (intervention "enriched"/intervention "sustainability"/control) were men Inclusion criteria: admitted within 24‐72 hours after onset of ischaemic or haemorrhagic stroke (first and/or recurrent); able to complete a transfer from bed to chair with assistance of 2 persons or less; able to follow single‐stage commands, requiring assistance for basic activities of daily living (ADLs) and premorbidly independent on self‐report Exclusion criteria: noncurrent diagnosis of rapidly deteriorating disease, extensive psychiatric history Intervention: participants had access to a variety of equipment in communal areas within the stroke unit. Equipment included: iPads, books, puzzles, newspapers, games, music, and magazines that were available during and outside therapy hours. There were daily group sessions focusing on stroke education, emotional support, communication, and physical activities. On weekdays, participants had communal breakfast and lunch to stimulate mobilisation and social interactions that were facilitated by therapy assistants. Participants and their families were also given written information that emphasised the importance of activity and how family members could be involved to encourage it. In addition to this, staff facilitating the "enriched" intervention group were given support in the form of the enriched environment protocol with staff responsibilities outlined and 12 nurse champions who encouraged staff adherence. After 14 weeks, this support was withdrawn whilst the enriched environment was maintained and following another 3 months, participants were recruited to the "sustainability" group and received the enriched environment without the additional staff support. This was to investigate whether the effect of the intervention could be sustained 6 months following the implementation of the enriched environment. Staff were not informed of the study's aims or the timing of the sustainability period Control: usual care |
| Statistical analysis | ANCOVA |
| Outcomes | Assessment time points for activity levels ("enriched" and control group): participants were observed for behavioural mapping for 1‐minute at 10‐minute intervals from 7.30 am till 7.30 pm on Tuesday, Thursday and Saturday, to a total maximum of three mapping days within the first 10 days post‐stroke Assessment time points for activity levels ("sustainability" group): behavioural mapping for a single day was performed on a randomly chosen Tuesday, Thursday or Saturday Assessment time points for secondary outcomes ("enriched" and control groups only): baseline, 24 hours post‐discharge, 3 months Primary outcome (well‐being and coping): Hospital Anxiety and Depression Scale (HADS)
Secondary outcomes Activity levels: behavioural mapping
Motor function: Mobility Scale for Acute Stroke (MSAS), 10‐metre walk test
ADLs: Modified Barthel Index (MBI), modified Rankin Scale (mRS)
Quality of Life: EuroQol Visual Analogue Scale (EQVAS)
Adverse events
Hospital length of stay
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| Study authors' conclusion | Enriched environment in an acute stroke unit can have a significant positive impact on activity levels |
| Study characteristics | Study design: randomised controlled trial Country: China Setting: acute neurosurgery inpatient unit Participants: n = 12/11 (intervention/control), mean age 37.8, 67%/64% (intervention/control ) were men Inclusion criteria: at least 2 months post‐craniotomy for TBI, Ranchos Los Amigos Scale level 7 and above; 20‐55 years of age; obvious cognitive impairment; educational level of at least lower secondary school; able to understand the study and be willing to participate; supportive family members who approved of the individual's participation in the study Exclusion criteria: history of other psychiatric conditions. Intervention: enriched environment and reinforced memory cognitive training. Cognitive training started from easy to harder, ran for a limited time, focusing on memory training through repetition with an emphasis on naming objects used in daily life, associations training using terms related to previous employment/work and training using full sentences instead of phrases only. Family assisted information regarding what the patient was previously interested in, to help with memory. There was use of recordings, videos, pictures including pictures on wall which were colourful and simple and had connection/relevance to patient. Cognitive training time occurred for 45 minutes/day, 4‐6 times a week for 30 days. The enriched environment consisted of colourful pictures, sounds and lights, all of which were interactive and changing to attract attention. Recordings and pictures provided a satisfying environment. Objects in the room were named Control: medications to provide brain nutrition, physical rehabilitation It was unclear if the intervention group also received the same medications and physical rehabilitation as the control group |
| Statistical analysis | t‐tests |
| Outcomes | Assessment time points: baseline, at the completion of intervention Primary outcome (well‐being, coping): not applicable Secondary outcome: memory: cognitive‐behavioural assessment with the domains of orientation, concentration, problem‐solving, repetition, naming, construction, memory, calculation, understanding groupings, judgement
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| Study authors' conclusion | Enriched environment may be useful in repairing memory function following traumatic brain injury |
| CI: confidence interval MD: mean difference SD: standard deviation | |
