Rehabilitation is effective for recovery after stroke and other non‐progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input.
To assess the effects of environmental enrichment on well‐being, functional recovery, activity levels and quality of life in people who have stroke or non‐progressive brain injury.
We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers.
We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services.
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.
We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non‐RCTs and two described co‐interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment.
The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective.
Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost‐effectiveness, and safety of the intervention in people following stroke or other non‐progressive brain injuries. It should be noted, however, that it is challenging to randomise or double‐blind trials of environmental enrichment given the nature of the intervention.
The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses . PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome
See more on using PICO in the Cochrane Handbook.
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)
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.
We wanted to find out whether treatment with environmental enrichment is better or worse than alternatives.
The evidence is current to 26 October 2020.
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.
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.
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.