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Flowchart of study. NIHSS National Institutes of Health Stroke Scale, mRS modified Rankin Scale, MSAS Mobility Scale for Acute Stroke, MBI Modified Barthel Index, HADS Hospital Anxiety and Depression Scale, EE enriched environment, AE adverse events, SAE serious adverse events
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Background
Clinical practice guidelines advocate engaging stroke survivors in as much activity as possible early after stroke. One approach found to increase activity levels during inpatient rehabilitation incorporated an enriched environment (EE), whereby physical, cognitive, and social activity was enhanced. The effect of an EE in an acute stroke...
Citations
... On the other hand, the literature consistently shows that stroke survivors spend most of their time inactive and alone in a bed or bedroom, unengaged, and with little social or cognitive stimulation outside of formal therapy [3,129,[131][132][133][134][135]. Commonly, stroke survivors reported feeling bored during their inpatient stay and said they valued, and would like, more physical activity [136]. ...
Environmental enrichment (EE) refers to different forms of stimulation, where the environment is designed to improve the levels of sensory, cognitive, and motor stimuli, inducing stroke recovery in animal models. Stroke is a leading cause of mortality and neurological disability among older adults, hence the importance of developing strategies to improve recovery for such patients. This review provides an update on recent findings, compiling information regarding the parameters affected by EE exposure in both preclinical and clinical studies. During stroke recovery, EE exposure has been shown to improve both the cognitive and locomotor aspects, inducing important neuroplastic alterations, increased angiogenesis and neurogenesis, and modified gene expression, among other effects. There is a need for further research in this field, particularly in those aspects where the evidence is inconclusive. Moreover, it is necessary refine and adapt the EE paradigms for application in human patients.
... In animal models, EE improves cognition and memory, symptomatology of stroke, Alzheimer's disease (AD), Huntington's disease, chronic stress, visceral/ inflammatory pain, depression, and anxiety (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). A translated EE intervention was recently shown to increase physical, social, and cognitive levels in acute stroke patients and to decrease adverse events compared to the standard of care counterparts (18)(19)(20)(21). A recent study associated levels of EE exposure with depressive symptoms through an EE indicator that measured cognitive, social, and physical activity and could differentiate participants with major depression from control subjects (22). ...
Introduction
We have previously shown that Environmental Enrichment (EE)-consisting of social support, novelty, and open spaces—decreased disease progression and anxiety in a rat model of endometriosis. We developed a novel EE intervention to be tested in a pilot randomized clinical trial (RCT) in patients with endometriosis, a painful, stressful disease.
Objective
To translate and evaluate the feasibility and acceptability of an adapted EE intervention as an adjuvant to standard-of-care for endometriosis patients.
Methods
Feasibility was assessed through recruitment, enrollment, and adherence rates. Acceptability was evaluated through a post-intervention survey and focus group discussion 3-months after the end of the intervention.
Results
Of the 103 subjects recruited, 64 were randomized to the intervention group and 39 to the control group. At the start of the intervention, the study groups consisted of 29 (intervention) and 27 (control) subjects. Enrollment rates were 45.3% and 69.2%, and adherence rates were 41.4% and 100% for the intervention and control groups, respectively. Delays resulting from natural events (earthquakes, the COVID-19 pandemic) impacted enrollment and adherence rates. The most common reasons for missing an intervention were period pain (39.1%) and work-study (34.8%). There was high acceptability (>80%) of the intervention's logistics. The majority (82.4%) of subjects would continue participating in support groups regularly, and 95.7% would recommend the intervention to other patients.
Conclusions
We showed that EE could be translated into an acceptable integrative multi-modal therapy perceived as valuable among participants who completed the intervention. High attrition/low adherence indicates that additional refinements would be needed to improve feasibility. Acceptability data indicate that EE has the potential to be integrated into the clinical management of patients with endometriosis and other inflammatory, painful disorders. Studies are ongoing to assess the efficacy of EE in improving pain symptoms, mental health, and quality of life (QoL).
... The patients can also be encouraged to use any personal equipment/facilities and/or satisfy hobbies-(feasible in a hospital ambient and which are not harmful and may enhance their personal motivation for rehabilitation)-such as availing/enjoying: mobile devices for IT/C, computer games, different puzzles, books, journals, music, art, all seeming with encouraging outcomes towards functional recovery. At the same time, EE is now consistently augmented and diversified by medical advanced-non-invasive, non-pharmacological/biotechnological therapeuticrehabilitative-interventions based on virtual/augmented reality (VR/AR), including with sensor-based computeraided "serious" [158]/active gaming technologies, thus supplementary augmenting the overall patients' status improvement [159]. Thus, EE is considered-not unanimously (see immediately hereinafter)-to bring a strong added value to a post ischemic stroke rehabilitation program paradigm [113], including as being (also) a "positive regulator" of "… the levels of neurogenesis in the adult brain …" [114]. ...
Considering its marked life-threatening and (not seldom: severe and/or permanent) disabling, potential, plus the overall medico-psycho-socio-economic tough burden it represents for the affected persons, their families and the community, the cerebrovascular accident (CVA)-including with the, by far more frequent, ischemic type-is subject to considerable scientific research efforts that aim (if possible) at eliminating the stroke induced lesions, and consist, as well, in ambitious-but still poorly transferable into medical practice-goals such as brain neuroregeneration and/or repair, within related corollary/upshot of neurorestoration. We have conducted, in this respect, a systematic and synthetic literature review, following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" concept. Accordingly, we have interrogated five internationally renowned medical data bases: Elsevier, NCBI/PubMed, NCBI/PMC, PEDro, and ISI Web of Knowledge/Science (the last one to check whether the initially identified articles are published in ISI indexed journals), based on a large (details in the body text) number of most appropriate, to our knowledge, key word combinations/"syntaxes"-used contextually-and subsequently fulfilling the related, on five steps, filtering/selection methodology. We have thereby selected 114 fully eligible (of which contributive: 83-see further) papers; at the same time, additionally, we have enhanced our documentation-basically, but not exclusively, for the introductive part of this work (see further)-with bibliographic resources, overall connected to our subject, identified in the literature within a non-standardized search. It appears that the opportunity window for morph-functional recovery after stroke is larger than previously thought, actually being considered that brain neurorestoration/repair could occur, and therefore be expected, in later stages than in earlier ones, although, in this context, the number of cases possibly benefitting (for instance after physical and/or cognitive rehabilitation-including with magnetic or direct current transcranial stimulation) is quite small and with more or less conflicting, related outcomes, in the literature. Moreover, applying especially high intense, solicitating, rehabilitation interventions, in early stages post (including ischemic) stroke could even worsen the functional evolution. Accordingly, for clarifications and validation of more unitary points of view, continuing and boosting research efforts in this complex, interdisciplinary domain, is necessary. Until finding (if ever) effective modalities to cure the lesions of the central nervous system (CNS)-including post ischemic stroke-it is reasonable and recommendable-based on rigorous methodologies-the avail of combined ways: physiatric, pharmacologic, possibly also bio-technologic. On a different note, but however connected to our subject: periodic related systematic, synthetic literature reviews reappraisals are warranted and welcome.
... 26 27 However, across these studies, there remains limited evidence of sustained change in inpatient activity. [22][23][24][25] To date, approaches to address inactivity post-stroke have been largely externally designed and researcher led with limited or no involvement of stroke survivors, caregivers or staff in study design or delivery. As an alternative, participatory improvement approaches involve directly engaging service users and providers in a collaborative process to 'co-produce' a service that addresses the needs and wants of stakeholders while ensuring the improved service can be delivered using existing resources. ...
Objective
To explore facilitators and barriers to using experience-based co-design (EBCD) and accelerated EBCD (AEBCD) in the development and implementation of interventions to increase activity opportunities for inpatient stroke survivors.
Design
Mixed-methods process evaluation underpinned by normalisation process theory (NPT).
Setting
Four post-acute rehabilitation stroke units in England.
Participants
Stroke survivors, family members, stroke unit staff, hospital managers, support staff and volunteers. Data informing our NPT analysis comprised: ethnographic observations, n=366 hours; semistructured interviews with 76 staff, 53 stroke survivors and 27 family members pre-EBCD/AEBCD implementation or post-EBCD/AEBCD implementation; and observation of 43 co-design meetings involving 23 stroke survivors, 21 family carers and 54 staff.
Results
Former patients and families valued participation in EBCD/AEBCD perceiving they were equal partners in co-design. Staff engaged with EBCD/AEBCD, reporting it as a valuable improvement approach leading to increased activity opportunities. The structured EBCD/AEBCD approach was influential in enabling coherence and cognitive participation and legitimated staff involvement in the change process. Researcher facilitation of EBCD/AEBCD supported cognitive participation, collective action and reflexive monitoring; these were important in implementing and sustaining co-design activities. Observations and interviews post-EBCD/AEBCD cycles confirmed creation and use of new social spaces and increased activity opportunities in all units. EBCD/AEBCD facilitated engagement with wider hospital resources and local communities, further enhancing activity opportunities. However, outside of structured group activity, many individual staff–patient interactions remained task focused.
Conclusions
EBCD/AEBCD facilitated the development and implementation of environmental changes and revisions to work routines which supported increased activity opportunities in stroke units providing post-acute and rehabilitation care. Former stroke patients and carers contributed to improvements. NPT’s generative mechanisms were instrumental in analysis and interpretation of facilitators and barriers at the individual, group and organisational level, and can help inform future implementations of similar approaches.
... Group settings are viable means of increasing activity levels as demonstrated in a study by Khan et al. [24] where all patients spend at least 2 hours a day substantially increased activity in a mixed neurological population. Also, Rosbergen et al. [25] introduced environmental enrichment including daily group sessions at an acute stroke unit with a similar promising result. It is interesting from an economical point of view that both in our and the aforementioned studies, active time could be increased within existing staff levels. ...
Background:
Increased intensity of training in the subacute phase after acquired brain injury facilitates plasticity and enhances better function. Group training can be a motivating factor and an effective means of increasing intensity. Reports on patients' and health care professionals' experiences on increasing the amount of active practice through group training during in-patient rehabilitation after acquired brain injury have been limited.
Methods:
Two focus groups, patients and health care professionals, participated each in two interviews, before and after implementation of the Activity block, i.e., 2-hour daily intensive group training. The data from the interviews were analyzed from a phenomenological perspective.
Results:
Three categories emerged from the data analyzes (i) training intensity, (ii) motivation and meaningfulness, and (iii) expectations and concerns. Both groups experienced that the training after implementation of the Activity block had become more intense and that motivation was increased induced by the group setting. Also, both groups found self-management enhanced. Some challenges were also reported. Patients expressed concerns to finding a balance between rest and activity, while the health professionals mentioned practical challenges, i.e., planning the content of the day and finding their role in the Activity block.
Conclusion:
Activity block benefitted a heterogeneous group of patients with acquired brain injury and was perceived as an overall positive experience by patients and health personnel. Matching the training to the individuals' need for support, finding a balance between rest and activity and using tasks that support patients' motivation, appeared important.
... An enriched environment (EE) is an important rehabilitation method to improve cognitive function, and has been widely used in clinical and animal research (Rosbergen et al., 2016;Wang et al., 2016). EE can improve post-stroke cognitive dysfunction and prevent and alleviate senile cognitive impairment (Stein et al., 2016;Wang et al., 2016). ...
The mechanisms of age-associated memory impairment may be associated with glutamate receptor function and chromatin modification. To observe the effect of an enriched environment on the cognitive function of mice with age-associated memory impairment, 3-month-old C57BL/6 male mice (“young” mice) were raised in a standard environment, while 24-month-old C57BL/6 male mice with memory impairment (“age-associated memory impairment” mice) were raised in either a standard environment or an enriched environment. The enriched environment included a variety of stimuli involving movement and sensation. A water maze test was then used to measure cognitive function in the mice. Furthermore, quantitative real-time polymerase chain reaction and western blot assays were used to detect right hippocampal GluN2B mRNA as well as protein expression of GluN2B and CREB binding protein in all mice. In addition, chromatin immunoprecipitation was used to measure the extent of histone acetylation of the hippocampal GluN2B gene promoters. Compared with the young mice, the water maze performance of age-associated memory impairment mice in the standard environment was significantly decreased. In addition, there were significantly lower levels of total histone acetylation and expression of CREB binding protein in the hippocampus of age-associated memory impairment mice in the standard environment compared with the young mice. There were also significantly lower levels of histone acetylation, protein expression, and mRNA expression of GluN2B in the hippocampus of these mice. In contrast, in the age-associated memory impairment mice with the enriched environment intervention, the water maze performance and molecular biological indexes were significantly improved. These data confirm that an enriched environment can improve cognitive dysfunction in age-associated memory impairment mice, and suggest that the mechanisms may be related to the increased expression of CREB binding protein and the increased degree of total histone acetylation in the hippocampus of age-associated memory impairment mice, which may cause the increase of histone acetylation of GluN2B gene promoter and the enhancement of GluN2B mRNA transcription and protein expression in hippocampus. The animal experiment was approved by the Animal Ethics Committee of Yangzhou University, China (approval No. 20170312001) in March 2017.
... While there are many studies using mind-body practices and alternative medicine modalities independently for inflammatory and painful disorders, we are proposing to use a combined multi-level systematic approach (social support, novelty and open, natural environments), based on what has proven effective in the endometriosis rat model. A translated EE intervention was recently shown to be effective in acute stroke patients, who benefitted from increased physical, social, and cognitive levels, and decreased adverse events compared to the standard of care counterparts [134][135][136][137][138]. Still, very few studies of multi-modal interventions involving features of EE have been conducted in humans [139,140], and none in pain or inflammatory disorders despite ample evidence from animal models alluding to its antistress and anti-inflammatory effects. ...
There is strong evidence from humans and animal models showing that abnormal functioning of the hypothalamic-pituitary-adrenal (HPA) axis and/or the inflammatory response system disrupts feedback regulation of both neuroendocrine and immune systems, contributing to disease. Stress is known to affect the physiology of pelvic organs and to disturb the HPA axis leading to chronic, painful, inflammatory disorders. A link between stress and disease has already been documented for many chronic conditions. Endometriosis is a complex chronic gynecological disease associated with severe pelvic pain and infertility that affects 10% of reproductive-aged women. Patients report the negative impact of endometriosis symptoms on quality of life, work/study productivity, and personal relationships, which in turn cause high levels of psychological and emotional distress. The relationship between stress and endometriosis is not clear. Still, we have recently demonstrated that stress increases the size and severity of the lesions as well as inflammatory parameters in an animal model. Furthermore, the “controllability” of stress influences the pathophysiology in this model, offering the possibility of using stress management techniques in patients. The crosstalk between stress-inflammation-pain through HPA axis activity indicates that stress relief should alleviate inflammation and, in turn, decrease painful responses. This opens up the opportunity of altering brain-body-brain pathways as potential new therapeutic option for endometriosis. The goal of this review is to gather the research evidence regarding the interaction between stress (psychological and physiological) and the development and progression of endometriosis on the exacerbation of its symptoms with the purpose of proposing new lines of emerging research and possible treatment modalities for this still incurable disease.
... This is a substudy of a prospective controlled before-after observational pilot study. 7,9,10 The study was undertaken in a 16-bed acute stroke unit in a regional hospital, which provided stroke care per Australian National Clinical Stroke Guidelines. 11 Stroke patients admitted to the unit were screened and consecutively enrolled when eligibility criteria were met. ...
... Demographical and clinical data were collected at enrollment and included age, gender, premorbid modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS). 12 We classified stroke severity based on hospital admission scores (or day 1 if thrombolysed) as mild (<8), moderate (8)(9)(10)(11)(12)(13)(14)(15)(16) and severe (>16). 13 Behavioral mapping was used to determine the primary outcome "activity levels" expressed in "any," physical, social and cognitive activity during specified time periods, as well as the nature of patient activity. ...
Objectives::
To explore the effect of environmental enrichment within an acute stroke unit on how and when patients undertake activities, and the amount of staff assistance provided, compared with a control environment (no enrichment).
Design::
This is a substudy of a controlled before-after observational study.
Setting::
The study was conducted in an Australian acute stroke unit.
Participants::
The study included stroke patients admitted to (1) control and (2) environmental enrichment period.
Intervention::
The control group received standard therapy and nursing care, which was delivered one-on-one in the participants' bedroom or a communal gym. The enriched group received stimulating resources and communal areas for mealtimes, socializing and group activities. Furthermore, participants and families were encouraged to increase patient activity outside therapy hours.
Main measures::
Behavioral mapping was performed every 10 minutes between 7.30 a.m. and 7.30 p.m. on weekdays and weekends to estimate activity levels. We compared activity levels during specified time periods, nature of activities observed and amount of staff assistance provided during patient activities across both groups.
Results::
Higher activity levels in the enriched group ( n = 30, mean age 76.7 ± 12.1) occurred during periods of scheduled communal activity ( P < 0.001), weekday non-scheduled activity ( P = 0.007) and weekends ( P = 0.018) when compared to the control group ( n = 30, mean age 76.0 ± 12.8), but no differences were observed on weekdays after 5 p.m. ( P = 0.324). The enriched group spent more time on upper limb ( P < 0.001), communal socializing ( P < 0.001), listening ( P = 0.007) and iPad activities ( P = 0.002). No difference in total staff assistance during activities was observed ( P = 0.055).
Conclusion::
Communal activities and environmental resources were important contributors to greater activity within the enriched acute stroke unit.
... Patients remain inactive, alone and in their bed/bedroom for large proportions of the day ( Table 3, Fini et al., 2017). While evidence is limited, it also appears that stroke patients demonstrate low levels of social and cognitive activity: in acute care, social activity represented ∼29.3% of time observed, while cognitive activity represented ∼44.7% of time (Rosbergen et al., 2016) and in subacute rehabilitation, social activity occurred in 32% of observations and cognitive activity in only 4% of observations (Janssen et al., 2014). ...
... The acute stroke unit is a unique rehabilitation environment, as the majority of stroke patients are more dependent and require frequent assistance from staff to undertake activities. The EE adaptation tested by Rosbergen et al. (2017) in the acute stroke unit included access to communal areas with a variety of equipment to enhance activities away from the bedside including iPads, books, puzzles, newspapers, games, music and magazines available 24 h a day. Daily group sessions (1-h duration) were provided with a focus on different aspects of stroke recovery such as stroke education, emotional support, communication and upper limb, balance, mobilization activities. ...
... Daily group sessions (1-h duration) were provided with a focus on different aspects of stroke recovery such as stroke education, emotional support, communication and upper limb, balance, mobilization activities. An opportunity for communal breakfast and lunch was included to stimulate frequency of mobilization and social interaction, as well as encourage sitting upright for mealtimes (Rosbergen et al., 2016). In addition to environmental changes, stroke patients and families received information that explained the importance of activity after stroke, outlined organizational structure of the unit and how stroke patients and families could contribute to encourage activity out of therapy hours (Rosbergen et al., 2016). ...
Environmental enrichment (EE) has been widely used as a means to enhance brain plasticity mechanisms (e.g., increased dendritic branching, synaptogenesis, etc.) and improve behavioral function in both normal and brain-damaged animals. In spite of the demonstrated efficacy of EE for enhancing brain plasticity, it has largely remained a laboratory phenomenon with little translation to the clinical setting. Impediments to the implementation of enrichment as an intervention for human stroke rehabilitation and a lack of clinical translation can be attributed to a number of factors not limited to: (i) concerns that EE is actually the “normal state” for animals, whereas standard housing is a form of impoverishment; (ii) difficulty in standardizing EE conditions across clinical sites; (iii) the exact mechanisms underlying the beneficial actions of enrichment are largely correlative in nature; (iv) a lack of knowledge concerning what aspects of enrichment (e.g., exercise, socialization, cognitive stimulation) representthe critical or active ingredients for enhancing brain plasticity; and (v) the required“dose” of enrichment is unknown, since most laboratory studies employ continuous periods of enrichment, a condition that most clinicians view as impractical. In this review article, we summarize preclinical stroke recovery studies that have successfully utilized EE to promote functional recovery and highlight the potential underlying mechanisms. Subsequently, we discuss how EE is being applied in a clinical setting and address differences in preclinical and clinical EE work to date. It is argued that the best way forward is through the careful alignment of preclinical and clinical rehabilitation research. A combination of both approaches will allow research to fully address gaps in knowledge and facilitate the implementation of EE to the clinical setting.
... The enriched environment intervention in the acute stroke unit included three key elements: (1) a stimulating ward environment that included communal areas for socialising and structured mealtimes, group activities and resources on the ward and at the bedside, (2) patient and carer(s) involvement to encourage patient engagement in activities outside therapy hours and (3) the use of change management strategies to support staff in the delivery of this complex intervention. 14 15 To understand relationships between implementation, the unique context of the acute stroke unit, and how the delivered intervention created change, 16 investigating staff perceptions and experiences is one key component of process evaluation. 16 The primary aim of this study was to understand the perceptions and experiences of nursing and allied health professionals who implemented the enriched environment within the acute stroke unit. ...
Objective
An enriched environment embedded in an acute stroke unit can increase activity levels of patients who had stroke, with changes sustained 6 months post-implementation. The objective of this study was to understand perceptions and experiences of nursing and allied health professionals involved in implementing an enriched environment in an acute stroke unit.
Design
A descriptive qualitative approach.
Setting
An acute stroke unit in a regional Australian hospital.
Participants
We purposively recruited three allied health and seven nursing professionals involved in the delivery of the enriched environment. Face-to-face, semistructured interviews were conducted 8 weeks post-completion of the enriched environment study. One independent researcher completed all interviews. Voice-recorded interviews were transcribed verbatim and analysed by three researchers using a thematic approach to identify main themes.
Results
Three themes were identified. First, staff perceived that ‘the road to recovery had started’ for patients. An enriched environment was described to shift the focus to recovery in the acute setting, which was experienced through increased patient activity, greater psychological well-being and empowering patients and families. Second, ‘it takes a team’ to successfully create an enriched environment. Integral to building the team were positive interdisciplinary team dynamics and education. The impact of the enriched environment on workload was diversely experienced by staff. Third, ‘keeping it going’ was perceived to be challenging. Staff reflected that changing work routines was difficult. Contextual factors such as a supportive physical environment and variety in individual enrichment opportunities were indicated to enhance implementation. Key to sustaining change was consistency in staff and use of change management strategies.
Conclusion
Investigating staff perceptions and experiences of an enrichment model in an acute stroke unit highlighted the need for effective teamwork. To facilitate staff in their new work practice, careful selection of change management strategies are critical to support clinical translation of an enriched environment.
Trial registration number
ANZCTN12614000679684 ; Results.
