An enriched environment improves sensorimotor function post-ischemic stroke

A modified rehabilitation paradigm bilaterally increased rat extensor digitorum communis muscle size but did not improve forelimb function after stroke

Malnutrition after stroke may lessen the beneficial effects of rehabilitation on motor recovery through influences on both brain and skeletal muscle. Enriched rehabilitation (ER), a combination of environmental enrichment and forelimb reaching practice, is used preclinically to study recovery of skilled reaching after stroke. However, the chronic food restriction typically used to motivate engagement in reaching practice is a barrier to using ER to investigate interactions between nutritional status and rehabilitation. Thus, our objectives were to determine if a modified ER program comprised of environmental enrichment and skilled reaching practice motivated by a short fast would enhance post-stroke forelimb motor recovery and preserve forelimb muscle size and metabolic fiber type, relative to a group exposed to stroke without ER. At one week after photothrombotic cortical stroke, male, Sprague-Dawley rats were assigned to modified ER or standard care for 2 weeks. Forelimb recovery was assessed in the Montoya staircase and cylinder task before stroke and on days 5-6, 22-23, and 33-34 after stroke. ER failed to improve forelimb function in either task (p > 0.05). Atrophy of extensor digitorum communis (EDC) and triceps brachii long head (TBL) muscles was not evident in the stroke-targeted forelimb on day 35, but the area occupied by hybrid fibers was increased in the EDC muscle (p = 0.038). ER bilaterally increased EDC (p = 0.046), but not TBL, muscle size; EDC muscle fiber type was unchanged by ER. While the modified ER did not promote forelimb motor recovery, it does appear to have utility for studying the role of skeletal muscle plasticity in post-stroke recovery.

Enriched environment treatment promotes neural functional recovery together with microglia polarization and remyelination after cerebral ischemia in rats

BACKGROUND

Microglia activation and oligodendrocyte maturation are critical for remyelination after cerebral ischemia. Studies have shown that enriched environment (EE) can effectively alleviate stroke-induced neurological deficits. However, little is known about the mechanism associated with glial cells underlying the neuroprotection of EE. Therefore, this study focuses on investigating the effect of EE on activated microglia polarization as well as oligodendrogenesis in the progress of remyelination following cerebral ischemia.

METHODS

The ischemia/reperfusion (I/R) injury model was established by middle cerebral artery occlusion (MCAO) in rats. Animals executed 4 weeks of environmental intervention after performing MCAO or sham surgery and were divided into sham, MCAO, and MCAO+EE groups. Cognitive function, myelin damage, microglia activation and polarization, inflammation, oligodendrogenesis, remyelination, and protein expression of the PI3K/AKT/GSK3β signaling pathway were determined.

RESULTS

The staining of NeuN indicated that the infarct size of MCAO rats was decreased under EE. EE intervention improved animal performance in the Morris water maze test and novel object recognition test, promoting the recovery of cognitive function after I/R injury. EE treatment alleviated myelin damage in MCAO rats, as evidenced by the lower fluorescence intensity ratio of SMI-32/MBP in MCAO+EE group. EE increased the fluorescence intensity ratio of NG2+/Ki67+/Olig2+, MBP, and MOG, enhancing the proliferation and differentiation of OPCs and oligodendrogenesis after MCAO. In terms of remyelination, more myelinated axons and lower G/ratio were detected in MCAO+EE rats compared with MCAO group. Moreover, EE treatment decreased the number of Iba1+/CD86+ M1 microglia, increased the number of Iba1+/CD206+ M2 microglia, and suppressed the inflammation response after I/R injury, which could be attributed to the augmented expression of PI3K/AKT/GSK3β axis.

CONCLUSION

EE improved long‑term recovery of cognitive function after cerebral I/R injury, at least in part by promoting M2 microglia transformation through activation of the PI3K/AKT/GSK3β signaling pathway, inhibiting inflammation to provide a favorable microenvironment for oligodendrocyte maturation and remyelination. The effect of the EE on myelin and inflammation could account for the neuroprotection provided by EE.

Environmental Enrichment in Stroke Research: an Update

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.

Immersive virtual reality-based rehabilitation for subacute stroke: a randomized controlled trial

OBJECTIVE

Few effective treatments improve upper extremity (UE) function after stroke. Immersive virtual reality (imVR) is a novel and promising strategy for stroke UE recovery. We assessed the extent to which imVR-based UE rehabilitation can augment conventional treatment and explored changes in brain functional connectivity (FC) that were related to the rehabilitation.

METHODS

An assessor-blinded, parallel-group randomized controlled trial was performed with 40 subjects randomly assigned to either imVR or Control group (1:1 allocation), each receiving rehabilitation 5 times per week for 3 weeks. Subjects in the imVR received both imVR and conventional rehabilitation, while those in the Control received conventional rehabilitation only. Our primary and secondary outcomes were the Fugl-Meyer assessment's upper extremity subscale (FMA-UE) and the Barthel Index (BI), respectively. Both intention-to-treat (ITT) and per-protocol (PP) analyses were performed to assess the effectiveness of the trial. For both the FMA-UE/BI, a one-way analysis of covariance (ANCOVA) model was used, with the FMA-UE/BI at post-intervention or at follow-up, respectively, as the dependent variable, the two groups as the independent variable, baseline FMA-UE/BI, age, sex, site, time since onset, hypertension and diabetes as covariates.

RESULTS

Both ITT and PP analyses demonstrated the effectiveness of imVR-based rehabilitation. The FMA-UE score was greater in the imVR compared with the Control at the post-intervention (mean difference: 9.1 (95% CI 1.6, 16.6); P = 0.019) and follow-up (mean difference:11.5 (95% CI 1.9, 21.0); P = 0.020). The results were consistent for BI scores. Moreover, brain FC analysis found that the motor function improvements were associated with a change in degree in ipsilesional premotor cortex and ipsilesional dorsolateral prefrontal cortex immediately following the intervention and in ipsilesional visual region and ipsilesional middle frontal gyrus after the 12-week follow-up.

CONCLUSIONS

ImVR-based rehabilitation is an effective tool that can improve the recovery of UE functional capabilities of subacute stroke patients when added to standard care. These improvements were associated with distinctive brain changes at two post-stroke timepoints. The study results will benefit future patients with stroke and provide evidence for a promising new method of stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03086889.

Enriched environment attenuates ferroptosis after cerebral ischemia/reperfusion injury by regulating iron metabolism

Preventing neuronal death after ischemic stroke (IS) is crucial for neuroprotective treatment, yet current management options are limited. Enriched environment (EE) is an effective intervention strategy that promotes the recovery of neurological function after cerebral ischemia/reperfusion (I/R) injury. Ferroptosis has been identified as one of the mechanisms of neuronal death during IS, and inhibiting ferroptosis can reduce cerebral I/R injury. Our previous research has demonstrated that EE reduced ferroptosis by inhibiting lipid peroxidation, but the underlying mechanism still needs to be investigated. This study aims to explore the potential molecular mechanisms by which EE modulates iron metabolism to reduce ferroptosis. The experimental animals were randomly divided into four groups based on the housing environment and the procedure the animals received: the sham-operated + standard environment (SSE) group, the sham-operated + enriched environment (SEE) group, the ischemia/reperfusion + standard environment (ISE) group, and the ischemia/reperfusion + enriched environment (IEE) group. The results showed that EE reduced IL-6 expression during cerebral I/R injury, hence reducing JAK2-STAT3 pathway activation and hepcidin expression. Reduced hepcidin expression led to decreased DMT1 expression and increased FPN1 expression in neurons, resulting in lower neuronal iron levels and alleviated ferroptosis. In addition, EE also reduced the expression of TfR1 in neurons. Our research suggested that EE played a neuroprotective role by modulating iron metabolism and reducing neuronal ferroptosis after cerebral I/R injury, which might be achieved by inhibiting inflammatory response and down-regulating hepcidin expression.

Environmental modifications to rehabilitate social behavior deficits after acquired brain injury: What is the evidence?

Social behavior deficits are a common, debilitating consequence of traumatic brain injury and stroke, particularly when sustained during childhood. Numerous factors influence the manifestation of social problems after acquired brain injuries, raising the question of whether environmental manipulations can minimize or prevent such deficits. Here, we examine both clinical and preclinical evidence addressing this question, with a particular focus on environmental enrichment paradigms and differing housing conditions. We aimed to understand whether environmental manipulations can ameliorate injury-induced social behavior deficits. In summary, promising data from experimental models supports a beneficial role of environmental enrichment on social behavior. However, limited studies have considered social outcomes in the chronic setting, and few studies have addressed the social context specifically as an important component of the post-injury environment. Clinically, limited high-caliber evidence supports the use of specific interventions for social deficits after acquired brain injuries. An improved understanding of how the post-injury environment interacts with the injured brain, particularly during development, is needed to validate the implementation of rehabilitative interventions that involve manipulating an individuals' environment.

Impairments, and physical design and culture of a rehabilitation unit influence stroke survivor activity: qualitative analysis of rehabilitation staff perceptions

PURPOSE

This study aimed to investigate rehabilitation staff perceptions of factors influencing stroke survivor activity outside of dedicated therapy time for the purpose of supporting successful translation of activity promoting interventions in a rehabilitation unit.

MATERIALS AND METHODS

Purposive sampling of multi-disciplinary teams from four rehabilitation units was performed, and semi-structured interviews were conducted by telephone, digitally audio-recorded and then transcribed verbatim. A stepped iterative process of thematic analysis was employed until data saturation was reached.

RESULTS

All but one of the 22 participants were female, the majority were either physiotherapists or occupational therapists, with a median of 4 years (interquartile range, 2-10) working at their respective rehabilitation units. Analysis of the data revealed three themes: (i) stroke survivor characteristics influence their activity outside therapy, (ii) the rehabilitation environment influences physical, cognitive, and social activity, and (iii) institutional priorities, staff culture, and attitude can be barriers to activity. Rehabilitation units were perceived to be unstimulating, and visitors considered enablers of activity when resources were perceived to be scarce.

CONCLUSIONS

Our results suggest careful consideration of the involvement of visitors, an individual's needs and preferences, and the institution's priorities and staff attitude may result in greater stroke survivor activity during rehabilitation.Implications for rehabilitationStaff should consider stroke survivor impairments and a rehabilitation unit's institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity.The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity.Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity.Discussion within the rehabilitation team concerning "ownership" of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same.

Staff and volunteers' perceptions of a Communication Enhanced Environment model in an acute/slow stream rehabilitation and a rehabilitation hospital ward: a qualitative description study within a before-and-after pilot study

PURPOSE

A lack of social interaction during early stroke recovery can negatively affect neurological recovery and health-related quality of life of patients with aphasia following stroke. A Communication Enhanced Environment (CEE) model was developed to increase patient engagement in language activities early after stroke. This study aimed to examine staff (n = 20) and volunteer (n = 2) perceptions of a CEE model and factors influencing the implementation and use of the model. This study formed part of a broader study that developed and embedded a CEE model on two hospital wards.

MATERIALS AND METHODS

Six focus groups and one interview with hospital staff were conducted and analysed using a qualitative description approach. Feedback emailed by volunteers was included in the data set.

RESULTS

Staff and volunteers perceived the CEE model benefitted themselves, the hospital system and patients. Staff identified a range of factors that influenced the implementation and use of the CEE model including individual staff, volunteer and patient factors, hospital features, the ease with which the CEE model could be used, and the implementation approach.

CONCLUSIONS

This study provides valuable insights into staff perceptions which may inform the implementation of interventions and future iterations of a CEE model.Implications for RehabilitationA CEE model may promote efficiency and increased patient engagement in stroke rehabilitation.The CEE model information session and aphasia communication partner training, and the provision of resources, may be useful strategies to increase staff confidence in using communication supporting strategies with patients with aphasia.Behaviour change and implementation science strategies may provide a framework to address barriers and promote facilitators to embed hospital-based interventions that require individual, ward, cultural and systems level change to reduce the evidence-based gap in clinical practice.

Feasibility and acceptability of a mobile model of environmental enrichment for patients with mixed medical conditions receiving inpatient rehabilitation: a mixed methods study

OBJECTIVES

To investigate the feasibility and acceptability of a mobile model of environmental enrichment (EE), a paradigm that promotes activity engagement after stroke, in patients with mixed medical conditions receiving inpatient rehabilitation.

DESIGN

A mixed methods study design was used. An online qualitative survey assessed staff perspectives of acceptability of the mobile EE model including perceived barriers and enablers pre-implementation and post implementation. An A-B quasi-experimental case study of patient activity levels over a 2-week observational period provided feasibility data. This included recruitment and retention rates, completion of scheduled patient activity observations and validated baseline questionnaires, and number of adverse events.

SETTING

A 30-bed mixed medical ward in a public hospital that services Brisbane's southern bayside suburbs. The rehabilitation programme operates with patients co-located throughout the medical/surgical wards.

PARTICIPANTS

Nursing and allied health professionals working across the rehabilitation programme completed pre-implementation (n=19) and post implementation (n=16) qualitative questions. Patients admitted to the ward and who received the inpatient rehabilitation programme from June to November 2016 were also recruited.

INTERVENTIONS

The mobile EE intervention included activities to primarily promote social and cognitive stimulation (eg, puzzles, board games) delivered by hospital volunteers and was designed to be moved throughout the wards.

RESULTS

Four themes emerged from staff reports, suggesting that the role of patient, staff and intervention characteristics, and the ward environment were important barriers and enablers to implementation. Of the 12 eligible patients, six consented to the study, and five completed the intervention. All patients completed the baseline measures. No adverse events were reported.

CONCLUSIONS

As interest grows in human EE models, it will be important to tailor EE interventions to the unique demands of hospital rehabilitation services. A mobile EE model delivered in a small, mixed rehabilitation ward appears feasible and acceptable to study in a larger controlled feasibility trial.

Optimising rehabilitation and recovery after a stroke

Stroke can cause significant disability and impact quality of life. Multidisciplinary neurorehabilitation that meets individual needs can help to optimise recovery. Rehabilitation is essential for best quality care but should start early, be ongoing and involve effective teamwork. We describe current stroke rehabilitation processes, from the hyperacute setting through to inpatient and community rehabilitation, to long-term care and report on which UK quality care standards are (or are not) being met. We also examine the gap between what stroke rehabilitation is recommended and what is being delivered, and suggest areas for further improvement.

The role of enriched environment in neural development and repair

In addition to genetic information, environmental factors play an important role in the structure and function of nervous system and the occurrence and development of some nervous system diseases. Enriched environment (EE) can not only promote normal neural development through enhancing neuroplasticity but also play a nerve repair role in restoring functional activities during CNS injury by morphological and cellular and molecular adaptations in the brain. Different stages of development after birth respond to the environment to varying degrees. Therefore, we systematically review the pro-developmental and anti-stress value of EE during pregnancy, pre-weaning, and “adolescence” and analyze the difference in the effects of EE and its sub-components, especially with physical exercise. In our exploration of potential mechanisms that promote neurodevelopment, we have found that not all sub-components exert maximum value throughout the developmental phase, such as animals that do not respond to physical activity before weaning, and that EE is not superior to its sub-components in all respects. EE affects the developing and adult brain, resulting in some neuroplastic changes in the microscopic and macroscopic anatomy, finally contributing to enhanced learning and memory capacity. These positive promoting influences are particularly prominent regarding neural repair after neurobiological disorders. Taking cerebral ischemia as an example, we analyzed the molecular mediators of EE promoting repair from various dimensions. We found that EE does not always lead to positive effects on nerve repair, such as infarct size. In view of the classic issues such as standardization and relativity of EE have been thoroughly discussed, we finally focus on analyzing the essentiality of the time window of EE action and clinical translation in order to devote to the future research direction of EE and rapid and reasonable clinical application.

Effects of environmental enrichment and sexual dimorphism on the expression of cerebellar receptors in C57BL/6 and BTBR + Itpr3tf/J mice

OBJECTIVE

Environmental enrichment is used to treat social, communication, and behavioral deficits and is known to modify the expression of synaptic receptors. We compared the effects of environmental enrichment in the expression of glutamate and endocannabinoid receptors, which are widely expressed in the cerebellar cortex. These two receptors interact to regulate neuronal function and their dysregulation is associated with behavioral changes. We used BTBR + Itpr3tf/J mice, a strain that models behavioral disorders, and C57BL/6 mice for comparison. We studied the effects of genetic background, sex, environmental conditions, and layer of the cerebellar cortex on the expression of each receptor.

RESULTS

The influence of genetic background and environmental enrichment had the same pattern on glutamate and endocannabinoid receptors in males. In contrast, in females, the effect of environmental enrichment and genetic background were different than the ones obtained for males and were also different between the glutamate and endocannabinoid receptors. Furthermore, an analysis of both receptors from tissue obtained from the same animals show that their expression is correlated in males, but not in females. Our results suggest that environmental enrichment has a receptor dependent and sexual dimorphic effect on the molecular expression of different receptors in the cerebellar cortex.

Effect of environmental enrichment on behavioral and morphological outcomes following neonatal hypoxia-ischemia in rodent models: A systematic review and meta-analysis

Neonatal hypoxia-ischemia (HI) is a major cause of mortality and morbidity in newborns and, despite recent advances in neonatal intensive care, there is no definitive treatment for this pathology. Once preclinical studies have shown that environmental enrichment (EE) seems to be a promising therapy for children with HI, the present study conducts a systematic review and meta-analysis of articles with EE in HI rodent models focusing on neurodevelopmental reflexes, motor and cognitive function as well as brain damage. The protocol was registered a priori at PROSPERO. The search was conducted in PubMed, Embase and PsycINFO databases, resulting in the inclusion of 22 articles. Interestingly, EE showed a beneficial impact on neurodevelopmental reflexes (SMD= -0.73, CI= [-0.98; -0.47], p< 0.001, I²= 0.0%), motor function (SMD= -0.55, CI= [-0.81; -0.28], p< 0.001, I²= 62.6%), cognitive function (SMD= -0.93, CI= [-1.14; -0.72], p< 0.001, I²= 27.8%) and brain damage (SMD= -0.80, CI= [-1.03; -0.58], p< 0.001, I²= 10.7%). The main factors that potentiate EE positive effects were enhanced study quality, earlier age at injury as well as earlier start and longer duration of EE exposure. Overall, EE was able to counteract the behavioral and histological damage induced by the lesion, being a promising therapeutic strategy for HI.

Patients' experiences of a Communication Enhanced Environment model on an acute/slow stream rehabilitation and a rehabilitation ward following stroke: a qualitative description approach

BACKGROUND

Patients in hospital following stroke express a desire to continue therapy tasks outside of treatment activities. However, they commonly describe experiences of boredom and inactivity. An enriched environment aims to provide opportunities for physical, cognitive and social activity and informed the development of a Communication Enhanced Environment (CEE) model to promote patient engagement in language activities.

PURPOSE

Explore patient perceptions of a CEE model, and barriers and facilitators to engagement in the model.

METHODS

A qualitative description study from a larger project that implemented a CEE model into acute and rehabilitation private hospital wards in Western Australia. Semi-structured interviews were conducted with seven patients, including four with aphasia, within 22 days post-stroke who had access to the CEE model.

RESULTS

Patients described variable experiences accessing different elements of the CEE model which were influenced by individual patient factors, staff factors, hospital features as well as staff time pressures. Those who were able to access elements of the CEE model described positive opportunities for engagement in language activities.

CONCLUSIONS

While findings are encouraging, further exploration of the feasibility of a CEE model in this complex setting is indicated to inform the development of this intervention.Implications for rehabilitationPatient access to a CEE model is challenging in a hospital setting.Patients who were able to access elements of the CEE model described positive opportunities for engagement in language activities.Patients' access to the CEE model was influenced by patient factors, staff factors, hospital features as well as staff time pressures.

Investigation of the implementation of a Communication Enhanced Environment model on an acute/slow stream rehabilitation and a rehabilitation ward: A before-and-after pilot study

OBJECTIVES

Develop and implement a Communication Enhanced Environment model and explore its effect on language activities for patients early after stroke.

METHOD AND DESIGN

Before-and-after pilot study.

SETTING

An acute/slow stream rehabilitation and a rehabilitation ward in a private hospital in Perth, Western Australia.

PARTICIPANTS

Fourteen patients recruited within 21 days of stroke. Seven recruited during the before-phase (control group: patients with aphasia = 3, patients without aphasia = 4) and seven recruited in the after-phase (intervention group: patients with aphasia = 4, patients without aphasia = 3).

INTERVENTION

The intervention group exposed to a Communication Enhanced Environment model had access to equipment, resources, planned social activities and trained communication partners. Both groups received usual stroke care.

DATA COLLECTION

Hospital site champions monitored the availability of the intervention. Behavioural mapping completed during the first minute of each 5-minute interval over 12 hours (between 7 am and 7 pm) determined patient engagement in language activities.

RESULTS

Seventy-one percent of the Communication Enhanced Environment model was available to the intervention group who engaged in higher, but not significant (95% CI), levels of language activities (600 of 816 observation time points, 73%) than the control group (551 of 835 observation time points, 66%). Unforeseen reorganisation of the acute ward occurred during the study.

CONCLUSIONS

Implementation of a Communication Enhanced Environment model was feasible in this specific setting and may potentially influence patients' engagement in language activities. The unforeseen contextual challenges that occurred during the study period demonstrate the challenging nature of the hospital environment and will be useful in future research planning.

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

BACKGROUND

Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

OBJECTIVES

To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

MAIN RESULTS

The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.  Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

AUTHORS' CONCLUSIONS

An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.

The Comparison and Interpretation of Machine-Learning Models in Post-Stroke Functional Outcome Prediction

Prediction of post-stroke functional outcomes is crucial for allocating medical resources. In this study, a total of 577 patients were enrolled in the Post-Acute Care-Cerebrovascular Disease (PAC-CVD) program, and 77 predictors were collected at admission. The outcome was whether a patient could achieve a Barthel Index (BI) score of >60 upon discharge. Eight machine-learning (ML) methods were applied, and their results were integrated by stacking method. The area under the curve (AUC) of the eight ML models ranged from 0.83 to 0.887, with random forest, stacking, logistic regression, and support vector machine demonstrating superior performance. The feature importance analysis indicated that the initial Berg Balance Test (BBS-I), initial BI (BI-I), and initial Concise Chinese Aphasia Test (CCAT-I) were the top three predictors of BI scores at discharge. The partial dependence plot (PDP) and individual conditional expectation (ICE) plot indicated that the predictors’ ability to predict outcomes was the most pronounced within a specific value range (e.g., BBS-I < 40 and BI-I < 60). BI at discharge could be predicted by information collected at admission with the aid of various ML models, and the PDP and ICE plots indicated that the predictors could predict outcomes at a certain value range.

Environmental Enrichment Sharpens Sensory Acuity by Enhancing Information Coding in Barrel Cortex and Premotor Cortex

Environmental enrichment (EE) is beneficial to sensory functions. Thus, elucidating the neural mechanism underlying improvement of sensory stimulus discrimination is important for developing therapeutic strategies. We aim to advance the understanding of such neural mechanism. We found that tactile enrichment improved tactile stimulus feature discrimination. The neural correlate of such improvement was revealed by analyzing single-cell information coding in both the primary somatosensory cortex and the premotor cortex of awake behaving animals. Our results show that EE enhances the decision-information coding capacity of cells that are tuned to adjacent whiskers, and of premotor cortical cells.

Effectiveness and mechanisms of enriched environment in post-stroke cognitive impairment

Post-stroke cognitive impairment (PSCI) is one of the most common complications of stroke, it is also an important reason for the poor prognosis in stroke patients with motor and speech dysfunction. Enriched Environment (EE), a novel and easy-to-implement rehabilitation treatment strategy, is thought to be a potential intervention for PSCI recently. In this paper, we review the therapeutic effects and related mechanisms of EE in PSCI from the level of animal research and clinical application. Besides, we further discuss the application prospects and limitations of EE in PSCI patients.

Altering the rehabilitation environment to improve stroke survivor activity: A Phase II trial

BACKGROUND

Environmental enrichment involves organization of the environment and provision of equipment to facilitate engagement in physical, cognitive, and social activities. In animals with stroke, it promotes brain plasticity and recovery.

AIMS

To assess the feasibility and safety of a patient-driven model of environmental enrichment incorporating access to communal and individual environmental enrichment.

METHODS

A nonrandomized cluster trial with blinded measurement involving people with stroke (n = 193) in four rehabilitation units was carried out. Feasibility was operationalized as activity 10 days after admission to rehabilitation and availability of environmental enrichment. Safety was measured as falls and serious adverse events. Benefit was measured as clinical outcomes at three months, by an assessor blinded to group.

RESULTS

The experimental group (n = 91) spent 7% (95% CI -14 to 0) less time inactive, 9% (95% CI 0-19) more time physically, and 6% (95% CI 2-10) more time socially active than the control group (n = 102). Communal environmental enrichment was available 100% of the time, but individual environmental enrichment was rarely within reach (24%) or sight (39%). There were no between-group differences in serious adverse events or falls at discharge or three months or in clinical outcomes at three months.

CONCLUSIONS

This patient-driven model of environmental enrichment was feasible and safe. However, the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes three months after stroke do not provide justification for an efficacy trial.

Doing nothing? An ethnography of patients' (In)activity on an acute stroke unit

Health research has begun to pay increasing attention to inactivity in its broadest sense as lack of meaningful activity and boredom. Few studies however have taken a critical look at this phenomenon. We explore (in)activity drawing on ethnographic data from observations in an acute stroke unit and post-discharge interviews with stroke survivors and their families. Four themes emerged that explain patients’ (in)activity: (i) planned activities; (ii) ‘doing nothing’, (iii) the material environment of the unit; (iv) interactions with staff. Considering these themes, we seek to problematise received conceptual and methodological approaches to understanding (in)activity. We argue that (in)activity is best conceived not as lack of action or meaning, but as a situated practice encompassing both bodily and mental activities that reflect and reproduce the way in which life is collectively organised within a specific healthcare setting.

Environmental Complexity and Research Outcomes

Environmental complexity is an experimental paradigm as well as a potential part of animals' everyday housing experiences. In experimental uses, researchers add complexity to stimulate brain development, delay degenerative brain changes, elicit more naturalistic behaviors, and test learning and memory. Complexity can exacerbate or mitigate behavioral problems, give animals a sense of control, and allow for expression of highly driven, species-typical behaviors that can improve animal welfare. Complex environments should be designed thoughtfully with the animal's natural behaviors in mind, reported faithfully in the literature, and evaluated carefully for unexpected effects.

Enriched environment alleviates post-stroke cognitive impairment through enhancing α7-nAChR expression in rats

ABSTRACT Background: Enriched environment (EE) is a simple and effective intervention to improve cognitive function in post-stroke cognitive impairment (PSCI), partly due to the rebalancing of the cholinergic signaling pathway in the hippocampus. α7-nicotinic acetylcholine receptor (α7-nAChR) is a cholinergic receptor whose activation inhibits inflammation and promotes the recovery of neurological function in PSCI patients. However, it is still unclear whether EE can regulate α7-nAChR and activate the cholinergic anti-inflammatory pathway (CAP) in PSCI. Objective: To investigate the effects of EE on cognitive impairment, and the role of α7-nAChR in PSCI. Methods: A PSCI rat model was induced by middle cerebral artery occlusion and reperfusion (MCAO/R) and were reared in standard environment (SE) or EE for 28d, control group with sham surgery. Cognitive function was determined by Morris water maze test. The long-term potentiation (LTP) was assessed by Electrophysiology. Histopathological methods were used to determine infarct volume, α7-nAChR expression and the cytokines and cholinergic proteins expression. Results: Compared with SE group, rats in EE group had better cognitive function, higher expression of α7-nAChR positive neurons in hippocampal CA1 region. In addition, EE attenuated unfavorable changes induced by MCAO/R in cytokines and cholinergic proteins, and also enhanced LTP promoted by nicotine and attenuated by α-BGT; but showed no significantly difference in infarct volume. Conclusions: EE markedly improves cognitive impairment and enhances neuroplasticity in PSCI rats, which may be closely related to enhancement of α7-nAChR expression.

The Relevance of Operant Behavior in Conceptualizing the Psychological Well-Being of Captive Animals

The term "psychological well-being" is used in reference to husbandry with animals in human care settings such as research, agriculture, and zoos. This article seeks to clarify and conceptualize the term based upon two approaches that draw from several bodies of literature: the experimental analysis of behavior, experimental psychology, animal welfare and husbandry, farm animal behavior, zoo husbandry, and ethology. One approach focuses on the presence of problem behavior such as stereotypies, depressive-like behavior, and aggression, and emphasizes the conditions under which aberrant behavior in animals under human care occurs. The second approach examines what might be considered wellness by emphasizing opportunities to engage with its environment, or the absence of such opportunities, even if problematic behavior is not exhibited. Here, access to an interactive environment is relatively limited so opportunities for operant (voluntary) behavior could be considered. Designing for operant behavior provides opportunities for variability in both behavior and outcomes. Operant behavior also provides control over the environment, a characteristic that has been a core assumption of well-being. The importance of interactions with one's environment is especially evident in observations that animals prefer opportunities to work for items necessary for sustenance, such as food, over having them delivered freely. These considerations raise the importance of operant behavior to psychological well-being, especially as benefits to animals under human care.

Randomized Trial of Combined Aerobic, Resistance, and Cognitive Training to Improve Recovery From Stroke: Feasibility and Safety

Background Physical exercise and cognitive training have been recommended to improve cognitive outcomes poststroke, but a multifaceted strategy including aerobic, resistance, and cognitive training to facilitate poststroke recovery has not been investigated. We aimed to assess the feasibility, adherence, and safety of a combined aerobic, resistance, and cognitive training intervention (CARET+CTI) after stroke. Methods and Results We prospectively randomized patients presenting with recent stroke to a comparison of a supervised 12-week CARET+CTI program and a control group receiving sham CARET+CTI. Participants were scheduled for 3 weekly CARET and CTI sessions. All participants underwent pre- and postintervention assessments of strength, endurance, and cognition. The primary outcomes were feasibility and adherence, defined as the ratio of scheduled and observed visits, and safety. We enrolled 131 participants, of whom 37 withdrew from the study. There were 17 (20%) withdrawals in the CARET+CTI and 20 (44%) in the control group. The observed-over-expected visit ratio was significantly higher in the intervention than in the control group (0.74±0.30 versus 0.54±0.38; P=0.003). A total of 99 adverse events were reported by 59 participants, none of which were serious and related to the intervention. Greater gains in physical, cognitive, and mood outcomes were found in the CARET+CTI group than in the control group, but were not statistically significant after adjustments. Conclusions A CARET+CTI intervention, after stroke, is safe, feasible, and has satisfactory participant adherence over 12 weeks. REGISTRATION URL: https://www.clini​caltr​ials.gov. Unique identifier: NCT02272426.

Environmental enrichment, new neurons and the neurobiology of individuality

'Enriched environments' are a key experimental paradigm to decipher how interactions between genes and environment change the structure and function of the brain across the lifespan of an animal. The regulation of adult hippocampal neurogenesis by environmental enrichment is a prime example of this complex interaction. As each animal in an enriched environment will have a slightly different set of experiences that results in downstream differences between individuals, enrichment can be considered not only as an external source of rich stimuli but also to provide the room for individual behaviour that shapes individual patterns of brain plasticity and thus function.

How do patients spend their time in stroke rehabilitation units in England? The REVIHR study

AIM

To examine how patients spend their time in stroke rehabilitation units in England.

METHODS

We recruited 144 patients within a month after stroke from four stroke rehabilitation units and observed their activity type, interactions and location. Each participant was observed for 1 min every 10-minutes, for a total of 20 h, over three consecutive days. Multilevel modelling was performed to assess differences across sites.

RESULTS

Across the four sites a total of 12,248 observations were performed. Patients spent on average 37% of the observed time inactive and 60% alone. A health care professional was present for 18% of the observations and patients' most frequent contact was with family members (19%). Patients were mainly physically active in the presence of therapists, but they practiced self-care activities of daily living most frequently in the presence of nursing staff. There were limited opportunities for activity away from the bedside. Significant differences were found between the units, including patients' level of contact with rehabilitation assistants and nursing staff, but not in their time with occupational therapists and physiotherapists.

CONCLUSIONS

Stroke patients in England spend a large proportion of their day inactive and alone. Opportunities to promote a rehabilitation focused environment may include: a) enhancing the role of rehabilitation assistants, b) supporting nursing staff in maximising opportunities for the practice of activities of daily living and c) involving family members in the rehabilitation process.IMPLICATIONS FOR REHABILITATIONClinicians need to consider stroke patients' activity levels and rehabilitation experience outside formal therapy.The role of rehabilitation assistants and nursing staff can be key in promoting patient activity and practice of self-care ADL tasks.Pragmatic strategies to encourage family involvement in the rehabilitation process need to be developed.

An MRI Study of Neurovascular Restorative After Combination Treatment With Xiaoshuan Enteric-Coated Capsule and Enriched Environment in Rats After Stroke

Xiaoshuan enteric-coated capsule (XSEC) is a Chinese medicinal compound widely used for treatment of ischemic cerebrovascular diseases. Enriched environment (EE) is an effective rehabilitative protocol designed to enhance sensorimotor, cognitive and social stimulation. This study aimed to apply magnetic resonance imaging (MRI) to non-invasively assess whether EE could augment the therapeutic benefits of XSEC on post-ischemic neurovascular remodeling. Male Sprague–Dawley rats were subjected to permanent middle cerebral artery occlusion (MCAO) and treated with XSEC and EE alone or combination for 30 consecutive days. Beam walking test and Morris water maze (MWM) test were performed to evaluate motor and cognitive function, respectively. Multimodal MRI was applied to examine alterations to brain structures, intracranial vessels, and cerebral perfusion on the 31st day after MCAO. Double-immunofluorescent staining was used to evaluate neurogenesis and angiogenesis. Western blot and RT-PCR were used to detect the expressions of vascular endothelial growth factor (VEGF), angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), and the axon guidance molecules. Combination therapy with XSEC and EE significantly reduced cystic volume compared with XSEC and EE monotherapies. In line with this, combination treated rats performed better in the beam walking test and exhibited improved spatial memory in the probe trial of the MWM. Moreover, XSEC and EE combination treatment improved cerebral blood flow (CBF), amplified angiogenesis and upregulated VEGF protein levels. This proangiogenic effect was consistent with the increased progenitor cell proliferation and neuronal differentiation in the peri-infarct cortex and striatum. Specifically, the combined therapy of XSEC and EE markedly increased the Netrin-1 and Robo-1 protein expression levels compared with vehicle group, while no difference was observed between XSEC or EE monotherapy and vehicle group. Together, these findings indicate that the combination of XSEC and EE benefits neurovascular reorganization. This correlates with restoration of CBF, promotion of neurogenesis and angiogenesis, and activation of the intrinsic axonal guidance molecules, thereby facilitating greater physical rehabilitation after ischemic stroke.

Delayed exposure to environmental enrichment improves functional outcome after stroke

Stroke is one of the leading causes of long-term disabilities worldwide. Although exposure to an enriched environment (EE) initiated in the acute phase after stroke has neuroprotective effects and improves stroke outcome, it remains unclear whether EE has positive effects when started in a delayed time frame. Here we show that exposure to EE in the delayed phase notably ameliorates the ischemia-induced impairments in neurological functions and spatial learning and memory. In addition, delayed EE exposure after stroke significantly promotes the survival and neuronal fate choice of hippocampal newborn cells, increases synaptic density of hippocampal mature neurons, and enhances the migration of subventricular zone (SVZ)-derived cells towards the ischemic striatum. Histone deacetylase 2 (HDAC2), synapse-associated proteins and brain-derived neurotrophic factor (BDNF) may respectively mediate these roles of delayed EE. Our findings provide the suggestion that exposure to EE initiated in the delayed phase after stroke promotes plastic changes via affecting neurogenesis, synaptogenesis and neuronal migration, and thus improves stroke outcome. Because EE initiated earlier than 24 h is clinically feasible, our work could be introduced into clinical studies of stroke directly and may provide stroke survivors with a new strategy for their functional recovery.

Finding the Intersection of Neuroplasticity, Stroke Recovery, and Learning: Scope and Contributions to Stroke Rehabilitation

Aim

Neural plastic changes are experience and learning dependent, yet exploiting this knowledge to enhance clinical outcomes after stroke is in its infancy. Our aim was to search the available evidence for the core concepts of neuroplasticity, stroke recovery, and learning; identify links between these concepts; and identify and review the themes that best characterise the intersection of these three concepts.

Methods

We developed a novel approach to identify the common research topics among the three areas: neuroplasticity, stroke recovery, and learning. A concept map was created a priori, and separate searches were conducted for each concept. The methodology involved three main phases: data collection and filtering, development of a clinical vocabulary, and the development of an automatic clinical text processing engine to aid the process and identify the unique and common topics. The common themes from the intersection of the three concepts were identified. These were then reviewed, with particular reference to the top 30 articles identified as intersecting these concepts.

Results

The search of the three concepts separately yielded 405,636 publications. Publications were filtered to include only human studies, generating 263,751 publications related to the concepts of neuroplasticity (n = 6,498), stroke recovery (n = 79,060), and learning (n = 178,193). A cluster concept map (network graph) was generated from the results; indicating the concept nodes, strength of link between nodes, and the intersection between all three concepts. We identified 23 common themes (topics) and the top 30 articles that best represent the intersecting themes. A time-linked pattern emerged.

Discussion and Conclusions

Our novel approach developed for this review allowed the identification of the common themes/topics that intersect the concepts of neuroplasticity, stroke recovery, and learning. These may be synthesised to advance a neuroscience-informed approach to stroke rehabilitation. We also identified gaps in available literature using this approach. These may help guide future targeted research.

Combined Adipose Tissue-Derived Mesenchymal Stem Cell Therapy and Rehabilitation in Experimental Stroke

Background/Objective: Stroke is a leading global cause of adult disability. As the population ages as well as suffers co-morbidities, it is expected that the stroke burden will increase further. There are no established safe and effective restorative treatments to facilitate a good functional outcome in stroke patients. Cell-based therapies, which have a wide therapeutic window, might benefit a large percentage of patients, especially if combined with different restorative strategies. In this study, we tested whether the therapeutic effect of human adipose tissue-derived mesenchymal stem cells (ADMSCs) could be further enhanced by rehabilitation in an experimental model of stroke. Methods: Focal cerebral ischemia was induced in adult male Sprague Dawley rats by permanently occluding the distal middle cerebral artery (MCAO). After the intravenous infusion of vehicle (n = 46) or ADMSCs (2 × 10⁶) either at 2 (n = 37) or 7 (n = 7) days after the operation, half of the animals were housed in an enriched environment mimicking rehabilitation. Subsequently, their behavioral recovery was assessed by a neurological score, and performance in the cylinder and sticky label tests during a 42-day behavioral follow-up. At the end of the follow-up, rats were perfused for histology to assess the extent of angiogenesis (RECA-1), gliosis (GFAP), and glial scar formation. Results: No adverse effects were observed during the follow-up. Combined ADMSC therapy and rehabilitation improved forelimb use in the cylinder test in comparison to MCAO controls on post-operative days 21 and 42 (P < 0.01). In the sticky label test, ADMSCs and rehabilitation alone or together, significantly decreased the removal time as compared to MCAO controls on post-operative days 21 and 42. An early initiation of combined therapy seemed to be more effective. Infarct size, measured by MRI on post-operative days 1 and 43, did not differ between the experimental groups. Stereological counting revealed an ischemia-induced increase both in the density of blood vessels and the numbers of glial cells in the perilesional cortex, but there were no differences among MCAO groups. Glial scar volume was also similar in MCAO groups. Conclusion: Early delivery of ADMSCs and combined rehabilitation enhanced behavioral recovery in an experimental stroke model. The mechanisms underlying these treatment effects remain unknown.

Enriching Communicative Environments: Leveraging Advances in Neuroplasticity for Improving Outcomes in Neurogenic Communication Disorders

Purpose Research manipulating the complexity of housing environments for healthy and brain-damaged animals has offered strong, well-replicated evidence for the positive impacts in animal models of enriched environments on neuroplasticity and behavioral outcomes across the lifespan. This article reviews foundational work on environmental enrichment from the animal literature and considers how it relates to a line of research examining rich communicative environments among adults with aphasia, amnesia, and related cognitive-communication disorders. Method Drawing on the authors' own research and the broader literature, this article first presents a critical review of environmental complexity from the animal literature. Building on that animal research, the second section begins by defining rich communicative environments for humans (highlighting the combined effects of complexity, voluntariness, and experiential quality). It then introduces key frameworks for analyzing and designing rich communicative environments: distributed communication and functional systems along with sociocultural theories of learning and development in humans that support them. The final section provides an overview of Hengst's and Duff's basic and translational research, which has been designed to exploit the insights of sociocultural theories and research on environmental complexity. In particular, this research has aimed to enrich communicative interactions in clinical settings, to trace specific communicative resources that characterize such interactions, and to marshal rich communicative environments for therapeutic goals for individuals with aphasia and amnesia. Conclusions This article concludes by arguing that enriching and optimizing environments and experiences offers a very promising approach to rehabilitation efforts designed to enhance the reorganization of cognitive-communicative abilities after brain injury. Such interventions would require clinicians to use the principles outlined here to enrich communicative environments and to target distributed communication in functional systems (not the isolated language of individuals).

How does context influence arm use after stroke? A qualitative content analysis among rural community-dwelling stroke survivors

OBJECTIVE

To explore the personal and environmental contextual factors that influence use of affected arm for function among stroke survivors.

METHODS

We conducted a qualitative phenomenological study using an interpretivist paradigm among 23 stroke survivors in their late sub-acute and chronic stages and their relatives living in the rural regions of India using maximum variation sampling. Semi-structured interviews were conducted to identify personal and environmental contextual factors relevant to arm use. Their current level of arm use, motor and functional ability were evaluated using Motor Activity Log, AbilHand and Lawton Instrumental Activities of Daily Living scales and the scores were categorized in order to describe and compare the participant's characteristics before analyzing each interview. Differences among the contextual factors of participants with high and low levels of functional arm use and exercise using paretic limb were analyzed using qualitative content analysis.

RESULTS

Study participants followed active exercises or passive interventions to improve their arm. Their immediate social environment influenced these decisions. Lack of awareness on how to self-engage or scale down their physical environment to match their abilities demoted active functional task performance. Ability to perceive small gains in arm function helped them sustain their efforts.

CONCLUSION

Context influences arm use. Addressing contextual determinants influencing arm use such as facilitating understanding about the need for active functional task engagement; identifying and addressing factors moderating motivation to sustain functional task practice and enriching objects to match their movement abilities can increase arm use and promote upper limb recovery.

Is Environmental Enrichment Ready for Clinical Application in Human Post-stroke Rehabilitation?

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) represent the 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.

Synergistic Effects of Enriched Environment and Task-Specific Reach Training on Poststroke Recovery of Motor Function

BACKGROUND AND PURPOSE

Reach training in concert with environmental enrichment provides functional benefits after experimental stroke in rats. The present study extended these findings by assessing whether intensive task-specific reach training or enrichment initiated alone would provide similar functional benefit. Additionally, we investigated whether the 70% recovery rule, or a combined model of initial poststroke impairment, cortical infarct volume, and rehabilitation intensity, could predict recovery in the single-pellet task, as previously found for the Montoya staircase.

METHODS

Rats were trained on single-pellet reaching before middle cerebral artery occlusion via intracerebral injection of ET-1 (endothelin-1). There were 4 experimental groups: stroke+enrichment, stroke+reaching, stroke+enrichment+reaching, and sham+enrichment+reaching. Reaching rehabilitation utilized a modified Whishaw box that encouraged impaired forelimb reaching for 6 hours per day, 5 days per week, for 4 weeks. All treatment paradigms began 7 days after ischemia with weekly assessment on the single-pellet task during rehabilitation and again 4 weeks after rehabilitation concluded.

RESULTS

Rats exposed to the combination of enrichment and reaching showed the greatest improvement in pellet retrieval and comparable performance to shams after 3 weeks of treatment, whereas those groups that received a monotherapy remained significantly impaired at all time points. Initial impairment alone did not significantly predict recovery in single-pellet as the 70% rule would suggest; however, a combined model of cortical infarct volume and rehabilitation intensity predicted change in pellet retrieval on the single-pellet task with the same accuracy as previously shown with the staircase, demonstrating the generalizability of this model across reaching tasks.

CONCLUSIONS

Task-specific reach training and environmental enrichment have synergistic effects in rats that persist long after rehabilitation ends, and this recovery is predicted by infarct volume and rehabilitation intensity.

Time use and physical activity in a specialised brain injury rehabilitation unit: an observational study

OBJECTIVES

To determine what is the use of time and physical activity in people undertaking inpatient rehabilitation in a specialised brain injury unit. To determine participants' level of independence related to the use of time and physical activity.

METHODS

Design: Cross-sectional observation study.

PARTICIPANTS

Fourteen people [mean (SD) age 40 (15) years] with brain injuries undertaking inpatient rehabilitation.

PROCEDURE

Participants were observed every 12 minutes over 5 days (Monday to Friday from 7:30 am until 7:30 pm) using a behaviour mapping tool.

OUTCOME MEASURES

Observation of location, people present, body position and activity engaged in (both therapeutic and nontherapeutic). Functional Independence Measure (FIM) scores were determined for each participant.

RESULTS

Participants spent a large part of their time alone (34%) in sedentary positions (83%) and in their bedrooms (48%) doing non-therapeutic activities (78%). There was a positive relationship between a higher level of independence (higher FIM score) and being observed in active body positions (r=0.60; p=0.03) and participating in physically active therapeutic activities (r=0.53; p=0.05).

CONCLUSION

Similar to stroke units, inpatients in a specialised brain injury unit spend large parts of the day sedentary, alone and doing non-therapeutic activities. Strategies need to be evaluated to address this problem, particularly for people with greater physical dependence.

Behavioral Mapping of Patient Activity to Explore the Built Environment During Rehabilitation

AIM

To explore the use of a rehabilitation-focused behavioral mapping method to identify changes in patient physical activity, location, and social interaction following the relocation of a rehabilitation ward.

BACKGROUND

Rehabilitation wards are unique healthcare environments where patient activity is encouraged to improve recovery. Little is known about the impact of building design on patient behavior within a rehabilitation setting. We examined this issue when a rehabilitation ward was relocated without altering other aspects of the healthcare service.

METHOD

The setting was a publicly funded inpatient general rehabilitation ward with a separate therapy area. Before and after ward relocation, patient behavior (location, physical, and social activities) was observed at 10-min intervals between 8:00 a.m. and 5:00 p.m. Patients and staff performed their usual activities during data collection.

RESULTS

Twenty-three patients participated in the old ward and 24 in the new ward, resulting in 1,150 and 1,200 observation time points, respectively. Patient location and behaviors were similar between wards ( p > .05). Participants were in bedrooms for more than half of the observations (67% old ward, 58% new ward), sitting down (62.8% old ward, 59.0% new ward), and alone (42.0% old ward, 38.0% new ward). Design features, such as separation of the therapy area and ward, may have impacted on patient behavior.

CONCLUSIONS

The rehabilitation-focused behavioral mapping method provided a rich description of relevant patient behaviors, indicating that it is a feasible and useful method for exploring the impact of the built environment in rehabilitation settings.

Enhancing endogenous capacity to repair a stroke-damaged brain: An evolving field for stroke research

Stroke represents a severe medical condition that causes stroke survivors to suffer from long-term and even lifelong disability. Over the past several decades, a vast majority of stroke research targets neuroprotection in the acute phase, while little work has been done to enhance stroke recovery at the later stage. Through reviewing current understanding of brain plasticity, stroke pathology, and emerging preclinical and clinical restorative approaches, this review aims to provide new insights to advance the research field for stroke recovery. Lifelong brain plasticity offers the long-lasting possibility to repair a stroke-damaged brain. Stroke impairs the structural and functional integrity of entire brain networks; the restorative approaches containing multi-components have great potential to maximize stroke recovery by rebuilding and normalizing the stroke-disrupted entire brain networks and brain functioning. The restorative window for stroke recovery is much longer than previously thought. The optimal time for brain repair appears to be at later stage of stroke rather than the earlier stage. It is expected that these new insights will advance our understanding of stroke recovery and assist in developing the next generation of restorative approaches for enhancing brain repair after stroke.

Can the physical environment itself influence neurological patient activity?

PURPOSE

To evaluate if a changed physical environment following redesign of a hospital ward influenced neurological patient physical and social activity.

METHODS

A "before and after" observational design was used that included 17 acute neurological patients pre-move (median age 77 (IQR 69-85) years Ward A and 20 post-move (median age 70 (IQR 57-81) years Ward B. Observations occurred for 1 day from 08.00-17.00 using Behavioral Mapping of patient physical and social activity, and location of that activity. Staff and ward policies remained unchanged throughout. An Environmental Description Checklist of each ward was also completed.

RESULTS

Behavioral Mapping was conducted pre-/post-move with a total of 801 Ward A and 918 Ward B observations. Environmental Description Checklists showed similarities in design features in both neurological wards with similar numbers of de-centralized nursing stations, however there were more single rooms and varied locations to congregate in Ward B (30% more single-patient rooms and separate allied health therapy room). Patients were alone >60% of time in both wards, although there was more in bed social activity in Ward A and more out of bed social activity in Ward B. There were low amounts of physical activity outside of patient rooms in both wards. Significantly more physical activity occurred in Ward B patient rooms (median = 47%, IQR 14-74%) compared to Ward A (median = 2% IQR 0-14%), Wilcoxon Rank Sum test z = -3.28, p = 0.001.

CONCLUSIONS

Overall, patient social and physical activity was low, with little to no use of communal spaces. However we found more physical activity in patient rooms in the Ward B environment. Given the potential for patient activity to drive brain reorganization and repair, the physical environment should be considered an active factor in neurological rehabilitation and recovery. Implications for Rehabilitation Clinicians should include consideration of the impact of physical environment on physical and social activity of neurological patients when designing therapeutic rehabilitation environments. Despite architectural design intentions patient and social activity opportunities can be limited. Optimal neurological patient neuroplasticity and recovery requires sufficient environmental challenge, however current hospital environments for rehabilitation do not provide this.

Qualitative investigation of the perceptions and experiences of nursing and allied health professionals involved in the implementation of an enriched environment in an Australian 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.

The IMPROVE Guidelines (Ischaemia Models: Procedural Refinements Of in Vivo Experiments)

Most in vivo models of ischaemic stroke target the middle cerebral artery and a spectrum of stroke severities, from mild to substantial, can be achieved. This review describes opportunities to improve the in vivo modelling of ischaemic stroke and animal welfare. It provides a number of recommendations to minimise the level of severity in the most common rodent models of middle cerebral artery occlusion, while sustaining or improving the scientific outcomes. The recommendations cover basic requirements pre-surgery, selecting the most appropriate anaesthetic and analgesic regimen, as well as intraoperative and post-operative care. The aim is to provide support for researchers and animal care staff to refine their procedures and practices, and implement small incremental changes to improve the welfare of the animals used and to answer the scientific question under investigation. All recommendations are recapitulated in a summary poster (see supplementary information).

Affective immunology: where emotions and the immune response converge

Affect and emotion are defined as “an essential part of the process of an organism's interaction with stimuli.” Similar to affect, the immune response is the “tool” the body uses to interact with the external environment. Thanks to the emotional and immunological response, we learn to distinguish between what we like and what we do not like, to counteract a broad range of challenges, and to adjust to the environment we are living in. Recent compelling evidence has shown that the emotional and immunological systems share more than a similarity of functions. This review article will discuss the crosstalk between these two systems and the need for a new scientific area of research called affective immunology. Research in this field will allow a better understanding and appreciation of the immunological basis of mental disorders and the emotional side of immune diseases.

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before-after pilot study

OBJECTIVES

To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events.

DESIGN

Controlled before-after pilot study.

SETTING

An acute stroke unit in a regional Australian hospital.

PARTICIPANTS

Acute stroke patients admitted during (a) initial usual care control period, (b) an enriched environment period and (c) a sustainability period.

INTERVENTION

Usual care participants received usual one-on-one allied health intervention and nursing care. The enriched environment participants were provided stimulating resources, communal areas for eating and socializing and daily group activities. Change management strategies were used to implement an enriched environment within existing staffing levels.

MAIN MEASURES

Behavioural mapping was used to estimate patient activity levels across groups. Participants were observed every 10 minutes between 7.30 am and 7.30 pm within the first 10 days after stroke. Adverse and serious adverse events were recorded using a clinical registry.

RESULTS

The enriched environment group ( n = 30, mean age 76.7 ± 12.1) spent a significantly higher proportion of their day engaged in 'any' activity (71% vs. 58%, P = 0.005) compared to the usual care group ( n = 30, mean age 76.0 ± 12.8). They were more active in physical (33% vs. 22%, P < 0.001), social (40% vs. 29%, P = 0.007) and cognitive domains (59% vs. 45%, P = 0.002) and changes were sustained six months post implementation. The enriched group experienced significantly fewer adverse events (0.4 ± 0.7 vs.1.3 ± 1.6, P = 0.001), with no differences found in serious adverse events (0.5 ± 1.6 vs.1.0 ± 2.0, P = 0.309).

CONCLUSIONS

Embedding an enriched environment in an acute stroke unit increased activity in stroke patients.

Histological and functional assessment of the efficacy of constraint-induced movement therapy in rats following neonatal hypoxic-ischemic brain injury

Constraint-induced movement therapy (CIMT) is used in stroke rehabilitation to promote recovery of upper limb motor function. However, its efficacy in improving functional outcomes in children with hemiplegic cerebral palsy has not been clearly determined in clinical or experimental research. The aim of our study was to assess the efficacy of a new experimental model of CIMT, evaluated in terms of mortality, stress, motor and cognitive function in rats having undergone a neonatal hypoxic-ischemic (HI) brain injury. Neonatal HI injury was induced at post-natal day 7 through unilateral ligation of the common carotid artery followed by exposure to hypoxia for 2 h. CIMT was implemented at 3 weeks, post-HI injury, using a pouch to constrain the unimpaired forelimb and forcing use of the affected forelimb using a motorized treadmill. After HI injury, animals demonstrated motor and cognitive deficits, as well as volumetric decreases in the ipsilateral hemisphere to arterial occlusion. CIMT yielded a modest recovery of motor and cognitive function, with no effect in reducing the size of the HI lesion or post-HI volumetric decreases in brain tissue. Therefore, although animal models of stroke have identified benefits of CIMT, CIMT was not sufficient to enhance brain tissue development and functional outcomes in an animal model of hemiplegic cerebral palsy. Based on our outcomes, we suggest that CIMT can be used as an adjunct treatment to further enhance the efficacy of a program of rehabilitation in children with hemiplegic cerebral palsy.