Feasibility of creating an enriched environment and subsequent impact on activity levels for stroke patients in an acute stroke unit

Abstract

Individuals with stroke in an acute stroke unit spend the majority of their day inactive and alone.There is strong evidence that greater physical activity, and emerging evidence that greater social and cognitive activity after stroke promotes functional recovery. One approach found to increase activity levels in all these activity domains following stroke is an enriched environment, which is an intervention designed to stimulate physical, social and cognitive activity. The enriched environment is well investigated in animal models post stroke and refers to housing conditions that are designed to stimulate motor and sensory functions, as well as social and cognitive activity. Evidence has shown that rodents recovering within an enriched environment starting 24-hours post stroke showed greater functional recovery than recovery in standard housing conditions. The first clinical translation of an enriched environment was undertaken in the subacute inpatient rehabilitation setting, which showed that individuals with stroke (n=14) undergoing enriched rehabilitation were 1.2 times more engaged in 'any activity' as compared to no enrichment. However, the enriched environment has not yet been explored in an acute stroke unit. Thus, the primary aim of this thesis was to investigate whether an enriched environment embedded in an acute stroke unit could increase activity levels in physical, social, cognitive and combined activity domains across individuals with acute stroke.Study 1 examined the effect of embedding an enriched environment in an acute stroke unit on activity levels using a controlled before-after observational design. Activity levels were observed in a control group receiving usual care, and subsequently in a group who recovered in an enriched acute stroke unit. The enriched environment focused on three key areas: 1) creating a stimulating environment including communal areas for eating, socialising and group activities, and provision of resources throughout the ward and at the patient bedside; 2) involvement of patients and families to increase activity outside therapy hours, and 3) using change management strategies to support staff to implement the enriched environment within existing staffing levels. Behavioural mapping was used to determine the primary outcome measure 'any', physical, social and cognitive activity.Participants were observed every 10-minutes from 7.30am till 7.30pm on weekday and weekends.We found that the enriched group (n=30) spent a significantly greater proportion of their day engaged in 'any activity' (p=0.005), physical (p<0.001), social (p=0.007) and cognitive activity (p=0.002) as compared to the control group (n=30). Furthermore, the enriched group spent a lower proportion in a supine position, in their room and being alone. The secondary aims were to explore the impact of an enriched environment on functional outcomes, adverse events and length of stay.No differences between groups were found for functional outcomes at discharge from the acute Publications during candidature Peer...