<![CDATA[[An Exploratory Study] Enriched, Task-Specific Therapy in the Chronic Phase After Stroke

Background and Purpose:

There is a need to translate promising basic research about environmental enrichment to clinical stroke settings. The aim of this study was to assess the effectiveness of enriched, task-specific therapy in individuals with chronic stroke.

Methods:

This is an exploratory study with a within-subject, repeated-measures design. The intervention was preceded by a baseline period to determine the stability of the outcome measures. Forty-one participants were enrolled at a mean of 36 months poststroke. The 3-week intervention combined physical therapy with social and cognitive stimulation inherent to environmental enrichment. The primary outcome was motor recovery measured by Modified Motor Assessment Scale (M-MAS). Secondary outcomes included balance, walking, distance walked in 6 minutes, grip strength, dexterity, and multiple dimensions of health. Assessments were made at baseline, immediately before and after the intervention, and at 3 and 6 months.

Results:

The baseline measures were stable. The 39 participants (95%) who completed the intervention had increases of 2.3 points in the M-MAS UAS and 5 points on the Berg Balance Scale (both P < 0.001; SRM >0.90), an improvement of comfortable and fast gait speed of 0.13 and 0.23 m/s, respectively. (P < 0.001; SRM = 0.88), an increased distance walked over 6 minutes (24.2 m; P < 0.001; SRM = 0.64), and significant improvements in multiple dimensions of health. The improvements were sustained at 6 months.

Discussion and Conclusions:

Enriched, task-specific therapy may provide durable benefits across a wide spectrum of motor deficits and impairments after stroke. Although the results must be interpreted cautiously, the findings have implications for enriching strategies in stroke rehabilitation.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A304).

INTRODUCTION

The overall burden of stroke has increased across the globe and is the second commonest cause of death and a leading cause of adult disability worldwide.¹ Many individuals with stroke face long-term consequences, which are usually complex and heterogeneous and can result in problems across multiple domains of functioning.² The most common deficit after stroke is hemiparesis, which predisposes individuals to sedentary behaviors, seriously hampers postural control, and increases the risk of falls.³ Restoring impaired movement and associated functions is therefore a key goal in stroke rehabilitation.

Over the years, various approaches to physical rehabilitation for recovery of function and mobility after stroke have been developed.⁴ Many rehabilitation strategies used task-oriented and goal-directed training and include feedback, repetition, intensity, and specificity to regain lost functions.²^,⁴ Such task- and context-specific training should target goals that are relevant for the needs of individuals with stroke.² Many treatment methods are available to minimize functional disability, such as constraint-induced movement therapy, weight-supported treadmill training, cardiovascular training, and goal-directed physical exercise.² High-intensity, high-dose, task-specific treatment strategies for stroke rehabilitation have also been developed.⁵ Nevertheless, individuals with stroke are increasingly left with persistent impairment,² and many lack adequate stimulation, exercise, and socialization.⁶ The stroke rehabilitation field consequently faces a dual challenge: implementing new strategies to improve long-term outcome and tailoring treatment regimens to meet the needs of individuals with stroke.⁷

A growing amount of research suggests that the key to maximizing functional recovery after stroke is to combine a selection of components from different approaches.⁴^,⁸^,⁹ Combinational therapies have considerable potential to provide optimal gains in functional recovery after stroke by tapping into the multiple, complementary mechanisms that underlie neuroplasticity and repair.¹⁰ To further aid recovery from stroke, task-specific therapy could be combined with environmental enrichment (EE).¹⁰ Environmental enrichment that enhances motor, cognitive, sensory, and social stimulation is shown to increase neuroplasticity in rodents, as compared with standard housing (Figure 1A and B).⁸^,¹⁰

Figure 1: (A). A typical enriched environment condition composed of increased space and equipped with various objects that stimulate motor function by providing exercise, balancing or climbing activities (running wheel, igloos, tunnels, tube mazes, and ladders), and cognition (a variety of toys and objects to interact with and navigate in). The location and types of objects are changed regularly to maintain the concept of novelty and complexity in the environment, thereby offering multisensory stimulation (visual, acoustic, smell, touch, push, and sensory-motor challenges). Multiple animals are introduced to the stimulating environment simultaneously to facilitate social interaction (allogrooming, sniffing, and play-soliciting activities). (B). A standard housing condition that generally entails a cage with bedding and access to water and food.

A combination of different therapies is expected to have additive or even synergistic effects on neuroplasticity processes harnessed to aid rehabilitation after stroke.⁶^,⁸^,¹⁰^,¹¹ These findings support the idea that combinational therapies can aid recovery from stroke-related deficits.¹² Despite the evidence that supports the potential of EE to enhance brain plasticity, it has largely remained a laboratory phenomenon, with little translation to clinical settings.¹³

Based on the fundamental principle of EE—that interventions should engage participants in concurrent physical, sensory, cognitive, and social activities or experiences—we designed an exploratory study of the EE paradigm in a clinical setting. Specifically, we investigated whether an intervention that combines high-dose and task-specific therapy with the sensory-motor, social, and cognitive stimulation inherent to EE could aid the recovery from stroke. The aim of the study was to assess the effectiveness of an enriched, task-specific therapy (ETT) program in enhancing functional motor performance as well as balance, gait, hand strength, and dexterity in individuals with residual hemiplegia in the chronic phase after stroke. We also investigated whether ETT improves confidence in task performance and health-related quality of life and reduces fatigue and depression.[…]