Investigation of a communication enhanced environment model after stroke: A mixed methods before-and-after pilot study

Background: Aphasia is an acquired communication disorder that affects approximately 30% of first ever stroke survivors and persists one-year post-stroke in up to 61% of survivors. Aphasia impacts on all communication modalities with significant negative consequences for social participation, interpersonal relationships, autonomy, capacity to work and quality of life. It is recognised that the environment can influence neural remapping during early stroke recovery. However, patients with aphasia (PWA) following stroke have been observed to spend less than 30% of their day communicating and 44% of their day alone during their first weeks of in-patient rehabilitation. Inadequate opportunities for communication places PWA at risk of developing maladaptive behaviours such as learnt non-use of language. This can negatively impact on aphasia language recovery through lack of language use with adverse consequences for healthrelated quality of life. An enriched environment (EE) refers to conditions which promote physical, cognitive and social activity and has been shown in animal models of stroke to enhance neuroplasticity, promote better learning and memory, and contribute to significant improvements in motor function. The human equivalent model in an acute and a rehabilitation unit results in patients following stroke spending more time engaged in activity and less time sleeping and alone, however is yet to demonstrate positive effects on clinical outcomes. Aphasia is a complex language impairment and PWA may need support within an EE. This pilot study explores the development, implementation and investigation of an adapted model of an EE, a Communication Enhanced Environment (CEE) model, as a strategy to provide PWA and patients without aphasia (PWOA) greater opportunities to engage in language activities during in-patient rehabilitation early after stroke. Method: This before-and-after mixed methods pilot study involves one mixed acute and slow stream rehabilitation war