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
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.[…]