Enriched, Task-Specific Therapy in the Chronic Phase After Stroke: An Exploratory Study

Sara Vive, Jean-Luc Af Geijerstam, H Georg Kuhn, Lina Bunketorp-Käll, Sara Vive, Jean-Luc Af Geijerstam, H Georg Kuhn, Lina Bunketorp-Käll

Abstract

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).

Trial registration: ClinicalTrials.gov NCT02889939.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1.
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.
Figure 2.
Figure 2.
Flowchart of the study design. ETT indicates enriched, task-specific therapy; ITT, intention-to-treat.
Figure 3.
Figure 3.
The various enriching components acting in the clinical translation of the EE model in this study.
Figure 4.
Figure 4.
Line charts of the total mean scores on the Berg Balance Scale (BBS) and the Modified Motor Assessment Scale (MAS) according to Uppsala University Hospital at tests 1, 2, 3, and 5. BBS indicates Berg Balance Scale; ETT, enriched, task-specific therapy; M-MAS, Modified Motor Assessment Scale.

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