REVIEW PAPER
Environmental Enrichment in Postoperative Pain and
Surgical Care
Potential Synergism With the Enhanced Recovery After Surgery Pathway
Sung Ching Yeung, MBBS, Michael G. Irwin, MD, and Chi Wai Cheung, MDY
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Background: Holistic biopsychosocial care has been underemphasized in
perioperative pathway designs. The importance and a cost-effective way of
implementing biopsychosocial care to improve postoperative pain and facili-
tate surgical convalescence are not well established, despite the recent
popularization of Enhanced Recovery After Surgery (ERAS) programs.
Objective: We have explored the evidence and rationale of environmental
enrichment (EE) as a complementary multimodal psychosocial care pathway
to reduce postoperative pain, optimize patient recovery and improve existing
weaknesses in surgical care.
Methods: We conducted a database search to identify and grade potential EE
techniques for their evidence quality and consistency in the management of
acute postoperative pain, perioperative anxiety and the etiologically compa-
rable acute procedural or experimental pain.
Findings and Conclusions: The introduction of music, virtual reality, edu-
cational information, mobile apps, or elements of nature into the healthcare
environment can likely improve patients’ experience of surgery. Compared
with traditional psychological interventions, EE modalities are voluntary,
therapist-sparing and more economically sustainable. We have also discussed
practical strategies to integrate EE within the perioperative workflow.
Through a combination of sensory, motor, social and cognitive modalities,
EE is an easily implementable patient-centered approach to alleviate pain and
anxiety in surgical patients, create a more homelike recovery environment and
improve quality of life.
Keywords: enhanced recovery after surgery, environmental enrichment,
postoperative care, postoperative pain
(Ann Surg 2021;273:86–95)
T he enhanced recovery after surgery (ERAS) pathway aims to
deliver the best evidence-based care using multi-disciplinary,
standardized, perioperative modalities.1 However, controversies
exist in ERAS2–5 and research has not provided straightforward
answers to simplify decision-making in surgical care.2,3 Of note, the
inadequate management of postsurgical pain remains problematic,5
and may delay recovery, impair sleep and increase the risks of
postoperative complications and the development of persistent pain.6
Although clinicians tend to favor research resolving practical
debates in surgical practice, patients, on the other hand, often think
differently and prioritize research on improving their experience of
From the Laboratory and Clinical Research Institute for Pain, Department of
Anaesthesiology, The University of Hong Kong, Hong Kong, China.
cheucw@hku.hk.
Reprints will not be available from the authors.
All authors contributed to the conception, evidence review, writing, critical editing,
and the final approval of the manuscript.
All authors had no funding to support this work.
The authors declare no conflict of interests.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.annalsofsurgery.com).
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-0086
DOI: 10.1097/SLA.0000000000003878
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surgery, which usually focuses on pain, stress, anxiety, communica-
tion, and other psychological dimensions.7 In ERAS research, enor-
mous effort has been devoted to determining which, why, when and
how an element works for patients,1,3 perhaps forgetting that some
patients do not always feel comfortable under fast-track care.5,8
Importantly, psychological factors, such as mood, attitude, and
personality traits of the patient, also affect pain and other postopera-
tive outcomes.9 Although there are increasing efforts to integrate
mental healthcare into perioperative pathways as psychological
prehabilitation,9 a lack of strong evidence is still a hurdle to
promoting this culture. On closer examination, these psychological
interventions (typically, information provision, relaxation, hypnosis,
and other cognition- or emotion-oriented activities)10 usually require
the input of a trained professional, and the willingness of patients to
attend a dedicated session. Although we endeavor to improve patient
psychology before and after surgery, can we simplify things?
WHAT IS ENVIRONMENTAL ENRICHMENT (EE)?
Our strategy is to develop indirect therapeutic approaches which
patients can receive and participate even in the absence of healthcare
professionals. In this review, one of our key objectives is to identify the
optimal healing environment for surgical patients which comprises
both natural and man-made elements. The natural environment has not
only nurtured human civilization; its healing power has also become
more apparent.11 A 9-year New Zealand nationwide cohort study
recently revealed that patients living in greener neighborhoods had
significantly greater longevity and lower postoperative opioid use after
total hip arthroplasty.12 Staying in a bed lit by more sunlight,13 having a
window view of natural scenery,14 and indoor ornamental plants15 in
the ward may all promote surgical recovery, and reduce postoperative
pain or analgesic consumption. Artificial natural scenery murals were
also shown to decrease bronchoscopic procedural pain.16 Regarding
man-made modalities, the incorporation of music,17 virtual reality
(VR),18 mobile apps,19 educational materials,10,20 digital games,21
videos,22,23 and aromatherapy24 into the perioperative care environ-
ment may offer analgesic or anxiolytic benefits as well.
EE describes the provision of a psychologically favorable
environment with these multi-dimensional modalities to enhance
patient sensory, motor, social, and cognitive experience in a volun-
tary and stress-free fashion,25,26 and has established its value in
clinical neurorehabilitation.25 The concept originated from classical
preclinical neuroscience research. For example, offering running
wheels and other toys together with cohousing more littermates in
a larger complex cage can promote beneficial neuroplastic changes in
healthy animals, and help treat neuropathological insults, such as
stroke.25 In rodent perioperative research, EE has successfully
attenuated neuroinflammatory outcomes and cognitive dysfunction
after abdominal surgery in aged rats.27 Also, EE has demonstrated
antinociceptive effects in animal pain models.26
In 1984, an early clinical example of perioperative EE was
reported in the journal Science.14 Patients undergoing cholecystec-
tomy who stayed in a room with a window view of natural scenery
Annals of Surgery  Volume 273, Number 1, January 2021
Annals of Surgery  Volume 273, Number 1, January 2021 Perioperative Environmental Enrichment

had significantly better recovery than matched patients with a view of
a brick wall. Interestingly, the outcomes were comparable to ERAS
criteria and included shorter length of stay (LOS), lower analgesic
consumption, fewer negative clinical evaluation, and nonsignifi-
cantly, lower postoperative complication rates.14 Subsequently, EE
has gradually gained its modern multifaceted outlook from neuro-
rehabilitation research. Various EE modalities, such as computers
with Internet connection, board games, music stations, books, puz-
zles, art workshops, and simulated shopping corners, have enhanced
physical, cognitive, and social activity levels in stroke patients, and
their psychological wellbeing.25
Given that many outcome measures of EE (eg, LOS,10,14,17,20
postoperative complication rates,14 mortality rates,12 functional
recovery,28 and pain) share remarkable similarities with contempo-
rary ERAS research,1 we are interested in whether these underex-
plored psychosocial care elements can play a synergistic role in
enhancing fast-track systems, or even the universal standard of
perioperative care from a wider perspective.
addressed in different surgical fields. Comparatively, preoperative
pain is often not treated as seriously as other comorbidities such as
anemia, diabetes, and cardiorespiratory diseases,32 despite being a
known risk factor for the prevention of persistent postsurgical pain.6
Although the importance of preoperative opioid tapering is increas-
ingly recognized, the often neglected psychological optimization of
pain is also essential, not just in offering alternatives to opioid
analgesia, but also taking into account that psychological distress is
associated with attenuated opioid analgesia.33 Additionally, lower
patient social connectedness has been found to be associated with
greater preoperative pain and anxiety, which continues to predict a
more difficult recovery trajectory after major operations.34 While
ERAS studies have mostly focused on major surgeries, we may have
optimistically presumed a good prognostic course for patients under-
going minor surgeries. Intriguingly, in a study of 179 surgical subtypes,
appendectomy, hemorrhoidectomy, and tonsillectomy were ranked as
some of the top 25 most painful surgeries,35 implying that patient
analgesic needs in short-stay surgeries are often underestimated.

HAS THE ERAS PATHWAY ADDRESSED REVIEW METHODOLOGY

EVERYTHING?
ERAS is advocated as a standardized set of preoperative,
intraoperative and postoperative interventions to shorten patient
LOS and reduce postsurgical complications,1 mainly by suppressing
the surgical stress response. However, the implementation of fast-track
programs has generally been slow.29 The ERAS pathway presents a
radical challenge to traditional surgical doctrines by recommending a
replacement package composed of elements with variable evidence
base and procedure-specificity.2,29 Besides, introducing external
ERAS guidelines for local use necessitates a dynamic adaptation
process to resolve regional, administrative, cultural and resource
availability issues without sacrificing guideline integrity.30 As ERAS
components are primarily designed for the inpatient setting, there is
often an abrupt drop in the quality and intensity of care as patients
transit to home convalescence, owing to limited investment in post-
discharge care.5,8,31 In fact, the advantage of short LOS in ERAS can
potentially induce stress for patients who need to self-manage their
home recovery without readily accessible health advice.8,31 Thus,
controversy has arisen regarding whether standardized care or person-
alized medicine is more preferable for surgical recovery.5 A one-size-
fits-all fast-track protocol may compromise patient-centered care for
clients who are less physically competent for fast-track recovery.31
Also, the prevention of persistent postsurgical pain and opti-
mal management of preoperative pain are often inadequately
We hypothesized that perioperative EE or its constituent
modalities would reduce postoperative pain and anxiety. However,
in view of the limited amount of literature directly addressing this
hypothesis, we aimed to capture a wider range of creative ideas by
simultaneously evaluating a secondary hypothesis that EE constit-
uents can influence acute procedural or experimental pain (sharing a
similar acute, predictable nature with postoperative pain) and peri-
operative anxiety or stress (both as a cause and effect of postoperative
pain). Studies examining EE for intraoperative pain or anxiety were
also included.
The databases PubMed, Cochrane Library, and PsycINFO
were searched from January 1, 1980 to September 4, 2019. A
complete list of search terms used is shown in Supplemental
Table 1 (Supplemental Digital Content, http://links.lww.com/SLA/
C79). Briefly, they can be categorized as terms related to: (1) EE
directly, (2) EE components in sensory, motor, social, and cognitive
dimensions, (3) surgery, procedure, pain, and anxiety. The reference
list of relevant publications were explored for additional articles. We
preferentially looked for meta-analyses, followed by systematic
reviews, randomized trials, and nonrandomized trials. Systematic
reviews done on a similar topic in separate years were still included.
We could not quote all relevant studies due to article reference limits.
Other elements of the search strategy were listed in Table 1. For each
distinct EE modality, a rapid grading of the evidence level and

TABLE 1. Criteria for Database Search and Evidence Evaluation

Criteria Description
Participants Patients or healthy volunteers with the following conditions:
Acute postoperative pain ¼ pain immediately after surgery and <3 months
Perioperative anxiety or stress ¼ anxiety or distress in patients before or after operation which is relevant to the surgery
Acute procedural pain ¼ acute pain during or after any medical procedures, excluding surgery
Acute experimental pain ¼ acute pain induced by a known brief controlled stimulus
Interventions Any voluntary sensory, motor, social or cognitive activities which may produce analgesic or anxiolytic effects without
requiring dedicated supervision from a professional therapist.
Comparisons Any forms of superiority, non-inferiority or equivalence comparisons
Outcomes Any direct, surrogate or composite measures of pain or anxiety
Exclusion criteria Interventions that are unpleasant or not tolerable
Interventions with perceivable health hazards
Interventions that require technique training, professional skills, or real-life guidance (eg, meditation and massage)
Interventions primarily designed for children below the age of 4 (eg, sugar water for infants)
Articles not written in English
Handling of inconsistencies S.C.Y. and C.W.C. each performed independent search and evidence grading, including the AMSTAR assessment for
meta-analyses. Inconsistencies were resolved by seeking another opinion from M.G.I.

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Yeung et al Annals of Surgery  Volume 273, Number 1, January 2021

TABLE 2. Rapid Grading Scheme for the Evidence Level and Consistency
Evidence level Implications behind the number of stars
$$$ Presence of at least 1 systematic review/meta-analysis
$$ Presence of at least 1 randomized study
$ Presence of at least 1 nonrandomized study
— Absence of relevant studies
Consistency Implications behind the color of stars
$ Black star Likely to produce an overall benefit.
§ White star Likely to produce no apparent benefit.
Grey star Unable to make an overall judgement of benefit due to issue(s) below:
# Evaluation of intraoperative pain or anxiety only
A Benefits measured using Alternative, indirect or special measures of pain
A1: analgesic consumption
A2: temporal summation and conditioned pain modulation tests
A3: composite scoring with pain components, eg, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC
score)
A4: observer-reported pain
C Significant Conflicting results between systematic reviews or meta-analyses, or between 2 clinical trials when no systematic
review or meta-analysis is available
EM Presence of therapeutic Effect Modifier (eg, catastrophizing attitude)
N No conclusion can be derived within a single review

consistency was performed (as explained in Table 2) based on 1–3
representative studies. The search summary and grading are shown in
Table 3. If research findings were generally inconsistent, 2 recent
studies with similar sample sizes but conflicting results were cited in
Table 3, whenever possible. The quality assessment of individual
trials was beyond the scope of this review because of
significant heterogeneity.
To complement the rapid grading approach, all meta-analyses
cited in Table 3 were formally evaluated with the AMSTAR appraisal
tool.36 This comprises 11 questions regarding search strategy, data
reporting, statistical methods, risk of bias, conflicts of interest and
other quality indicators of a meta-analysis. Each question answered
with ‘‘yes’’ scores 1 point, whereas all other answers (‘‘no,’’ ‘‘can’t
answer,’’ and ‘‘not applicable’’) score 0 points. A total score of 8 or
above represents high methodological quality, 4–7 indicates moder-
ate quality, whereas 0–3 reflects low quality.37 The breakdown of
AMSTAR scoring is illustrated in Supplemental Table 2 (Supple-
mental Digital Content, http://links.lww.com/SLA/C80). We did not
review the primary studies included in the meta-analyses or perform
any secondary reanalysis of the existing literature. In Fig. 1, we

TABLE 3. Evidence Summary of EE Modalities for the Relief of Acute Postoperative Pain, Perioperative Anxiety or Stress, Acute
Procedural or Experimental Pain
EE Modality Acute Postoperative Pain Perioperative Anxiety or Acute Procedural or
Stress Experimental Pain
Sensory modules
17,38 17,38 39,40
Music $$$ $$$ $$$
Aromatherapy C24,45 N68 N24
15 15 69
Indoor ornamental plants $$ $$ $$
Stress ball #22 C22,57 #22 C22,57 C46,70
Natural scenery A112,14 §§ 71
$$ 16,72

Sunlight A113 $ 13
— —
70
Distraction cards — — — — §§ 70
Balloon inflating — — — — §§
Motor modules
Voluntary/unsupervised/recreational A348,49 — — A250
physical activities
Social modules
Text messaging #A151 — — $$ 52
57 57,73 55
Social touch/hand-holding §§ C $
53
Verbal interaction with carer — — — — $$
54
Casual telephone call — — — — $$
56
Photo of romantic partner — — — — $
Cognitive modules
Educational information C10,20,28 $$$ 20,28
§§§ 41

Virtual reality (VR) N59 C18,58 $$$ 42,43

19 19
Mobile applications $$ $$ A460
22 22,23 22,23 46,53
Television/videos/movies # C $$ $$
Emotional disclosure EM61 §§ 61
EM62
21 21 53
Digital games §§ $$ $$
EE indicates environmental enrichment.

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Annals of Surgery  Volume 273, Number 1, January 2021 Perioperative Environmental Enrichment

2
Modality Pain context No of Sample size SMD (95% CI) Random-effects model I Pub bias AMSTAR
studies (int / con) (%) (Egger’s P)
17
Music Postoperative 45 2153+ / 2125+ -0.77 (-0.99, -0.56) 90 SFP 8
38
Music Postoperative 42 1642 / 1630 -0.50 (-0.66, -0.34) 78 SFP 9
38
(SA) Low risk-of-bias trials only 15 733 / 721 -0.34 (-0.55, -0.13) 73 ü 9
17
Music Analgesic use 34 1665+ / 1621+ -0.37 (-0.54, -0.20) 75 # 8
39
Music Procedural (urology) 10 435 / 452 -1.00 (-1.25, -0.75) (Fixed EM) 69 ? 6
40
Music Procedural (burn care) 6 260 (Σ) -1.26 (-1.83, -0.68) 82 0.27 << 7
24
Aroma Postoperative 3 155 / 157 -1.79 (-2.08, -1.51) < 98 << 4
28
PIE Postoperative (orthopedic) 12 622 / 620 -0.21 (-0.39, -0.02) 12 # 9
10
PIE Postoperative 10 462 / 424 0.12 (-0.16, 0.40) NA # 7
20
PIE Postoperative (cardiac) 4 351 / 353 0.00 (-0.15, 0.15) 0 << 7
28
PIE Analgesic use (orthopedic) 10 433 / 427 -0.06 (-0.24, 0.13) 0 # 9
41
PIE Procedural (venipuncture) 4 155 / 158 -0.18 (-0.60, 0.23) 69 << 9
42
VR Procedural 16 403 / 407 -0.49 (-0.83, -0.14) 81 SFP 10
44
VR Procedural (children) 14 749 (Σ) -1.30 (-1.91, -0.68) 93 0.11 8
44
(SA) Exclude low-quality/ outlier 11 582 (Σ) -0.73 (-1.11, -0.35) 78 ü 8

A SA = sensitivity analysis; Fixed EM = fixed-effects model -2 -1 0

 Favors EE Favors control 

2
Modality Perioperative anxiety No of Sample size SMD (95% CI) Random-effects model I Pub bias AMSTAR
studies (int / con) (%) (Egger’s P)
17
Music Postoperative 43 2105+ / 2071+ -0.68 (-0.95, -0.41) 92 # 8
38
Music Postoperative 47 1993 / 1935 -0.69 (-0.88, -0.50) 87 ASFP 9
38
(SA) Low risk-of-bias trials only 16 926 / 862 -0.61 (-0.94, -0.29) 91 ü 9
28
PIE Preoperative (orthopedic) 12 621 / 639 -0.27 (-0.44, -0.10) 0 # 9
28
PIE Postoperative (orthopedic) 11 452 / 469 -0.26 (-0.43, -0.08) 0 # 9
20
PIE Postoperative (cardiac) 6 422 / 407 -0.96 (-1.37, -0.54) 85 << 7

-1.5 -1 -0.5 0
B  Favors EE Favors control 
2
Modality Other benefits No of Sample size SMD (95% CI) Random-effects model I Pub bias AMSTAR
studies (int / con) (%) (Egger’s P)
17
Music Length of stay 6 224 / 219 -0.11 (-0.35, 0.12) 0 << 8
10
PIE Length of stay 19 1080 / 903 -0.31 (-1.02, 0.36) < (MD) NA # 7
20
PIE Length of stay (cardiac) 5 649 / 626 -0.05 (-0.34, 0.23) 81 << 7
10
PIE Postop negative affect 15 585 / 599 -0.25 (-0.64, 0.14) NA # 7
 Favors EE Favors control 
28
PIE Postop recovery (orthopedic) 18 816 / 839 0.13 (-0.01, 0.27) 0 # 9
28
PIE Postop QoL (orthopedic) 4 143 / 143 0.02 (-0.27, 0.32) 0 << 9
17
Music Postop patient satisfaction 14 649 / 655 1.09 (0.51, 1.68) > 93 # 8

Aroma = aromatherapy; PIE = Preparation/ Information/ Education; VR: virtual reality;

Cardiac = cardiac surgery; Postop = postoperative; QoL = quality of life -1 0 1
Favors control Favors EE 
SMD = standardized mean difference; 95% CI = 95 percent confidence intervals. MD = mean difference provided instead of SMD. NA = Not available.
Sample size (int / con): sample size in intervention and control arms respectively. If respective size not provided, sum of both arms is noted with (Σ). If total
sample size not explicitly stated, a sum was estimated from other available data in the paper (dashed line).

Pub bias (publication bias): P-value of Egger’s test is shown if available. P<0.1 = significant publication bias. If Egger’s test not performed, SFP =
Symmetrical Funnel Plot. ASFP = Asymmetrical Funnel Plot. # = Incomprehensive publication bias assessment, not generalizable to the setting.
C << = insufficient included studies (<10) for proper evaluation of publication bias. ? = not assessed

FIGURE 1. Summary of meta-analyses cited in Table 3. Effect models are random unless noted otherwise.

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Yeung et al Annals of Surgery  Volume 273, Number 1, January 2021

constructed forest plots with the extracted data from meta-analyses
along with their methodological parameters, including heterogeneity
(I2 statistic), publication bias (Egger’s test or funnel plot symmetry)
and AMSTAR ratings. The results of relevant subgroup or sensitivity
analyses in these meta-analyses were also included.
RESULTS
As shown in Table 3, we included 11 meta-analyses, 3 system-
atic reviews, 24 randomized controlled trials (RCTs), 4 observational
studies, and 2 human neuroscience studies. We found 20 unique EE
modality subtypes classified under the 4 major dimensions (sensory,
motor, social and cognitive). Fig. 1 summarizes the 11 meta-analyses
of RCTs included in our review (4 for music,17,38–40 4 for preparation/
information/education (PIE),10,20,28,41 2 for VR interventions,42,43 1
for aromatherapy24).
The data evaluated by the meta-analyses encompassed pain-
related outcomes (postoperative pain, analgesic use, and procedural
pain, Fig. 1A), anxiety outcomes (preoperative or postoperative,
Figure 1B) and other perioperative benefits (LOS, postoperative
recovery, quality of life (QoL), negative affect and patient satisfac-
tion, Fig. 1C). All included meta-analyses reported I2 heterogeneity
measures, except a component network meta-analysis.10 Most anal-
yses revealed an I2 > 65%, except for PIE interventions.20,28 These
variations mostly originated from the study design, the context of
surgical procedures, the age of participants, the delivery protocol of
interventions and the time of outcome assessment. Given the pres-
ence of substantial heterogeneity, most meta-analyses employed the
more appropriate random-effects model, except one which used a
fixed-effects model.39 Regarding publication bias, Egger’s test was
only performed in 2 meta-analyses.40,44 A directly relevant funnel
plot was available from 3 other studies.17,38,42 Other meta-analyses
did not contain sufficient studies for assessment20,24,40,41 or did not
comprehensively examine publication bias for every eligible out-
come and subgroup analysis.10,17,28 Notably, funnel plot asymmetry
was reported for studies investigating the anxiolytic effects of
music,38 but a symmetrical funnel plot was generally found for
the pain-related outcomes of music and VR interventions.17,38,42,43
The risk of publication bias was unclear in all other settings. For
AMSTAR scores, 6 meta-analyses are of high methodological qual-
ity (score 8), whereas the remaining 5 have a moderate quality
(score 4–7).
PRINCIPAL FINDINGS
In sensory enrichment, music has the most established evi-
dence-based benefits across different spectrums of pain and anxiety
(Fig. 1). On average, music has been estimated to reduce postopera-
tive pain scores by around 10- to 23-mm on a 100-mm visual analog
scale.17,38 Interestingly, the analgesic-sparing effects of intraopera-
tive music were still observed when patients were under general
anesthesia.17 However, publication bias is suspected in studies
exploring its anxiolytic effects.38 Also, the potential risk of bias
in individual music trials has been highlighted, particularly when
only 16 out of 47 included music RCTs (about 35%) in a meta-
analysis were considered eligible for a separate low-risk-of-bias
subgroup analysis.38 The benefits of aromatherapy, as a form of
complementary therapy for postoperative pain,24,45 require more
confirmation. Elements of the nature, be they natural scenery,14
sunlight,13 or indoor decorative plants,15 seem useful. Stress balls,
as tactile enrichment, may offer pain distraction only in certain
settings.22,46
Motor enrichment differs from traditional physiotherapy reha-
bilitation or the emerging exercise prehabilitation concept47 in the
ERAS setting, because it emphasizes voluntary, nonprescribed phys-
ical activity participation (explained in Table 4). In fact, compared
with conventional physiotherapy, unsupervised home exercises under
pictorial and written guidance yielded a similar improvement in
osteoarthritis outcomes after total hip replacement,48,49 which par-
ticularly appealed to non-Medicare patients who did not wish to have
out-of-pocket expenses and take extra time off work to receive formal
outpatient physiotherapy.49 Studies have also pinpointed that a
higher physical activity level is associated with more favorable
functioning of the endogenous pain modulatory systems,50 lending
support for the role of an active lifestyle in postoperative pain control.
Regarding social enrichment, intraoperative text messaging
may reduce analgesic use for patients undergoing conscious sur-
gery.51 Similarly, sending supportive text messages helped relieve
pain after outpatient orthodontic procedures.52 For other forms of
social communication, having verbal interaction with parents was
shown capable of reducing pain during venepuncture in a child.53
After dental procedures, patients who received a follow-up phone
call reported less pain than those receiving no call, regardless of the
content delivered.54 There have been noteworthy research efforts to
explore the analgesic mechanisms of social interactions, such as

TABLE 4. A Comparison of Exercise Prehabilitation, ERAS Rehabilitation, and Motor Enrichment

Features Exercise Prehabilitation47
Principle To increase functional reserve in
anticipation of surgery and
anesthesia challenge
Target patients Patients who have unsatisfactory
preoperative cardiopulmonary
functions or physical fitness
Modalities Moderate-intensity aerobic and
resistance exercises are
common; High-intensity interval
training sometimes adopted
Intensity Moderate to strong
Supervision Recommended
Safety and tolerability Generally tolerable
Main outcomes of interest Postoperative complication rates
ERAS indicates enhanced recovery after surgery.
ERAS Rehabilitation74
To accelerate functional recovery
after surgery
Patients under ERAS surgical care
Aerobic and resistance trainings are
similar to prehabilitaion
Depend on postoperative functional
status and protocol requirement
Recommended
Generally tolerable
Early ambulation
Motor Enrichment
To enhance endogenous pain
modulation50 and functional
recovery48,49
All patients (regardless of insurance
status)
Self-directed recreational exercises,
walking, mind-body exercises
Voluntary decision, can be done at
home
Not necessary, cost-saving
Stay active only within perceivable
limits
Postoperative pain and gross
functional recovery

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Annals of Surgery  Volume 273, Number 1, January 2021
hand-holding55 and viewing the photo of a romantic partner.56 Yet,
their potential clinical benefits await further exploration.57
Concerning cognitive enrichment, meta-analyses (Fig. 1) have
indicated that offering procedural PIE may help reduce perioperative
anxiety,20,28 but their role in pain management is less estab-
lished.10,20,28 The analgesic effect of VR exposure is notable in
acute procedural pain42,43; however, results are less consistent in
postsurgical pain and anxiety.18,58,59 A multi-center postoperative
mobile app initiative encouraging patients to report their daily feel-
ings of recovery has been shown to significantly reduce surgical
wound pain, anxiety, and other wellbeing parameters when compared
to standard care.19 Generally, using multimedia materials (eg, com-
edy films,23 DVDs,22 a smartphone serious game,21 video games,53
and tablet computer60) for pain distraction or anxiety reduction is of
unclear efficacy, but is inexpensive to try. Means of emotional
disclosure may particularly help patients who have high social
constraints61 or those who tend to catastrophize.62
Generally, individual EE interventions alone over a short
duration do not exert a significant influence on classical clinical
outcomes (Fig. 1C), such as the LOS17,20 and postoperative func-
tional recovery.28 For patient-reported outcomes aside from pain and
anxiety, music interventions seem highly efficacious in raising
patient satisfaction.17 However, educational interventions may have
a limited role in enhancing postoperative QoL 28 and reducing
negative affect.10
AN IMPLEMENTABLE EE PROTOCOL
To convert research evidence into a clinical protocol, we need
to consider the nature of our patients, perioperative teams, and the
hospital. First, patients undergoing surgery in a tertiary referral
center may experience greater psychological turmoil than those in
regional centers, potentially due to extensive investigations, multi-
morbidity, polypharmacy, or neoadjuvant chemotherapy. The need
for EE is more obvious. Second, the key performance metrics
employed in the hospital are relevant. Traditionally, clinical out-
comes, such as the LOS and postoperative complication rates, are
mainstay indicators of the effectiveness and efficiency of surgical
care.1,9 Recently, the Medicare system in the United States has
placed increasing emphasis on patient experience and satisfaction
as important quality indicators that may influence the amount of
receivable hospital reimbursement.18 Yet, extra perioperative ser-
vices outside routine care may not always be refundable. Thus,
inexpensive patient-centered initiatives are required. The story will
also be different for emergency operations and in deluxe private
hospitals serving more affluent patients. In the following, we outline
the general approaches of perioperative EE with reasonable start-up
costs for most surgical centers.
Mobile Charging and Wi-Fi Stations
Our proposed first step is to offer free mobile phone charging
and Wi-Fi access in appropriate hospital areas. Mobile communica-
tion devices are essential for patients to seek social interaction,
entertainment, and healthcare information. However, for concerns
over safety and potential interference with medical equipment,
patients are often prohibited to use these devices in the ward. This
has discouraged inpatients from using their smartphone, because a
low battery may eventually render them unable to communicate with
family members. A fully charged mobile phone with free Internet
access is a versatile facilitator of various EE modalities, including
music, text messaging, telephone calls, digital games, photo viewing,
video watching, self-help education, and health-promotion apps.
Healthcare administrators may presume that this is only a patient
satisfaction initiative driven by social pressure. However, this article
has highlighted the potential for it to become an evidence-based pain
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Perioperative Environmental Enrichment
and anxiety reduction strategy. If technical difficulties exist in setting
up charging stations, pre-charged portable power banks may be lent
to patients instead.
Sunlight Triage
The literature has suggested that patients with greater sunlight
exposure13 or a window view of natural scenery14 may have better
postoperative recovery. We advocate a non-random allocation algo-
rithm of bed space which acknowledges the under-explored value of
sunlight in hospitals. When multiple bed choices are available to
accommodate a newly arrived patient, the ward administrator should
preferentially reserve the brighter window-side beds for higher-risk
surgical patients with an expected longer LOS to increase patient
sunlight exposure. Patients allotted to a dimmer bed near the central
corridor may, instead, benefit from staying closer to the nurses’
station and the washrooms. However, patients should still be asked
for any relative contraindications such as insomnia, photophobia,
fever, and dehydration. Patient autonomy is respected if they refuse
the arrangement. It is not mandatory to implement sunlight triage
every day, especially when available beds are limited.
Perioperative Patient Diary
A procedure-specific diary booklet is distributed to all patients
booked for elective surgery. This contains educational information
about the surgery, including preoperative preparation and daily light-
intensity exercise advice. Patients can personalize this diary by
attaching personal photos which may serve as pain distracters.56
They are also encouraged to write down any discomfort or concerns
they may have before and after surgery, which can be addressed by a
perioperative team member. The content of the diary may facilitate
perioperative monitoring, but does not carry medicolegal implica-
tions and cannot replace the hospital medical records edited by
clinicians. To encourage perioperative voluntary physical activity,
each page of the diary contains brief questions about patient activity
levels or ambulatory distances. It also provides a list of relevant
patient support groups with their contacts.
As an essential way to signify the continuity of care, a post-
discharge diary can also be supplied that covers written and pictorial
guidance for regular independent home physiotherapy,48,49 adjust-
ment strategies in performing activities of daily living, red-flag signs
suggesting the need to seek medical attention, and other relevant
information of home management plans. Patients may self-monitor
their activity levels with a provided portable pedometer or a smart-
watch. We encourage patients to visit nearby countryside areas,
gardens, and parks for relaxation and recreation, as a greater expo-
sure to foliage has been linked with better postoperative prognosis.12
In the future, an electronic diary may also be developed with mobile
apps that assess postoperative recovery19 to enhance patient-
reported outcomes.
Other Multifaceted Features
The above fundamental approaches of EE are relatively
inexpensive and feasible for most surgical centers, irrespective of
their routine perioperative workflow. Other modalities may require a
greater initial investment or free open space. At the hospital level,
public pianos, or other musical instruments can be placed in the
transit lounges, lobby, or waiting areas to offer patients opportunities
to make and listen to live music. Similarly, if space allows, commu-
nity groups or artists should be welcomed for charitable hospital
visits, mini-performances, or exhibitions. Public arts contributions,
such as the paintings of medical humanities by staff and students,
photographs of local scenic spots, and patient artworks, can be
displayed on hallway walls and along hospital corridors, which
may encourage patients to have a higher level of postoperative
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Yeung et al Annals of Surgery  Volume 273, Number 1, January 2021

ambulation.63 Patient education leaflets and booklets can be made
available from a public bookshelf. Having more indoor ornamental
plants is also likely helpful.15
Inside the ward, patients can be encouraged to bring in gadgets
or small items that may help alleviate their pain and anxiety, such as a
tablet computer,60 stress balls,22 essential oils,24 and photos.56 For
surgical teams with more resources, VR head-mounted displays18
may be offered to further improve pain and anxiety control. The
previously validated EE neurorehabilitation protocols25 may also be
transferrable to perioperative care, especially for neurosurgical
patients who may receive the dual benefits of strengthened cognitive
rehabilitation and psychosomatic outcomes from EE.
Healthcare facility biophilic design characteristics are also
important and largely define the baseline level of EE in the hospital
environment and the patient’s residential neighborhood.11,12 For
example, many private hospitals take pride in their spaciousness,
daylighting features, the size of windows, the floor area of recrea-
tional zones, the number of healing gardens, terraces and staircases,
and the number of non-medical retail stores in the hospital complex.
individual EE components, which may not predict their combined
therapeutic effects in actual practice. In our search strategy, because
we preferentially reported results from meta-analyses and systematic
reviews, we might have missed some high-quality clinical trials not
included in the most recent systematic review of the topic. For our
included meta-analyses, publication bias assessment was often unsatis-
factory or not available. For individual trials, the interpretation of results
was often affected by the small sample sizes and large heterogeneity in
result estimates. Unlike the rapid therapeutic response seen after surgery
or the initiation of targeted therapy for cancer, it is often natural for many
patients not to respond well to analgesic interventions whereas some
responders can exhibit dramatic benefits.65 Given the complex individ-
ualized experience and adaptation to pain and anxiety in patients, it is
difficult to predict the efficacy of an EE modality based on a few small
studies, unless a plausible scientific mechanism has been identified.55,56
Another specific challenge in nonpharmacological trials is the difficulty
in blinding participants and investigators to the intervention and the risks
of suboptimal bias control.17,38,42 Some other issues influencing the
significance of research results were mentioned in Table 2.

STRENGTHS AND LIMITATIONS CAN ERAS BE ENRICHED?

Although the efficacy of EE in preclinical pain research has
been reviewed,26 this is the first article to address its translational
feasibility for surgical patients with a broad coverage of potential
interventions. A unique feature of EE research is the relatively low
degree of interest from pharmaceutical or medical technology com-
panies, which may represent a smaller risk of research bias. Particu-
larly, a decreased reliance on perioperative medications is a potential
benefit of EE.13,64 It is also worth noting that some negative
perioperative EE research has been published in good journals57,58
aside from major positive findings,14,17,18 showing a trend towards
reduced publication bias. We believe our methodological approach
will allow readers to independently critique the evidence.
As no clinical trial has yet tested perioperative EE in its mature
multi-modal framework, we could only cover studies investigating
In Table 5, we have attempted to compare ERAS and EE as
multi-modal pathways that may potentially complement each other,
because both concepts can be thoughtfully and stepwise imple-
mented along the surgical journey. In particular, EE emphasizes
flexible psychosocial care to create a patient-friendly recovery
environment, whereas ERAS aims to minimize surgical risks and
pain through a standardized physiological approach backed with
regular auditing of outcomes and cost-effectiveness. Although more
definitive evidence may still be needed to support an enriched ERAS
protocol containing EE elements, Table 5 highlights the relatively
greater ease in implementing EE. Hence, we have also considered a
possibility that some clinicians who have some success with EE may,
subsequently, use that as an intermediate step towards the full uptake
of the ERAS pathway.

TABLE 5. A Comparison of ERAS With EE in Perioperative Care

Enhanced Recovery After Surgery (ERAS)1 Environmental Enrichment (EE)
Objective To advocate pain- and risk-free surgeries to facilitate To create a homelike recovery environment for higher
accelerated recovery healthcare quality and patient satisfaction
Principle Surgical stress response suppression Biopsychosocial pain management and surgical care
Components Multiple standardized elements along the surgical Multiple flexible and optional modalities for patients
journey to accumulate marginal gains to freely enroll
Origin of ideas Organizing the best current evidence into an Learning from neurorehabilitation and preclinical
implementable package research; innovative care hypotheses
Timeline Pre-admission, preoperative, intraoperative and Continuous care from decision to undergo surgery to
postoperative phases post-discharge recovery
Scope of surgery Usually for major elective surgeries with long All major and minor surgeries
recovery time
Outcome criteria Clinical outcomes more frequently emphasized than Mainly patient-oriented outcomes, e.g. pain, patient
patient-reported outcomes satisfaction, quality of life
Financial sustainability Small investment leads to huge hospital cost-savings75 Therapist-sparing with low operational costs
Pain management More opioid-sparing than traditional care; focus on Interventions start before surgery and continue after
intra- and early postoperative phases discharge; aim for modest but sustained analgesia
Multidisciplinary collaboration Continual multidisciplinary collaboration is essential; Patients and caretakers are main stakeholders;
involves considerable cultural changes healthcare professionals are less involved
Role of patient Receive preoperative education; actively prepare for Receive lifestyle advice; voluntarily partake in EE
surgery and recovery as specified by protocol without predefined therapeutic goals
Protocol variation Stringent: refinement is only possible after rigorous Dynamic: embrace patient autonomy and sociocultural
auditing background
Resistance to implementation Moderate: defy traditional surgical doctrines; need Low-moderate: EE is compatible with any surgical
long time to introduce all ERAS elements care philosophy
Scientific mechanisms Insufficiently explored More established

92 | www.annalsofsurgery.com ß 2020 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Surgery  Volume 273, Number 1, January 2021
RATIONALE OF PERIOPERATIVE EE
If the key questions to advocate ERAS are ‘‘Why is the patient
still in hospital today?’’ and ‘‘Why is the surgical high-risk patient
still at risk?,’’29 then the question for EE is ‘‘Why is the surgical
patient not feeling good today?.’’ A shift of focus to a more patient-
centered approach and from physical to psychological wellbeing
is implied.
Our first proposed vision of EE is to create a homelike
environment in the hospital or, at least, make it more pleasant.
Patients often regard the ward to be a poor venue for surgical
recovery due to rest disturbances, and the inconvenience in doing
daily activities and receiving social support from carers who travel
from afar.8 Although patients will inevitably have a temporary stay in
the wards, EE attempts to minimize the stress associated with
inpatient stay to facilitate postoperative pain relief and functional
recovery. More importantly, EE teaches patients that rehabilitation in
the hospital is not a mechanical process defined by checklists and
instructions, but rather the opportunity for them to test and practice if
they can resume daily activities at home again. If a patient feels
unwell even when watching a movie, it may be time for the doctor to
reassess the current drug regimen and decide if the patient is truly fit
for discharge.
The second proposed vision of EE is to enhance patient QoL
and healthcare satisfaction from pre-admission to post-discharge
care. Pre-emptive EE intends to empower patients to optimize their
physical and emotional health with an active, meaningful lifestyle
before surgery; and post-discharge EE aims to lengthen the recovery
benefits of hospital-based interventions to smoothen the typically
stressful and under-prepared transition5,32 to outpatient recovery.
Our advocacy of perioperative EE is also a wish to increase the
benefit-to-harm ratio for patients who decide to undergo an operation
despite the availability of conservative management options. Any
surgery, regardless of the scale and risk, is a traumatic experience and
is often a necessary sacrifice to enhance patient longevity or, at least,
the postoperative QoL. Nevertheless, recent research has revealed
that pre-existing pain66 and QoL measures67 may not necessarily
improve after surgery. Thus, optimizing patient psychological
dynamics along the perioperative journey, potentially through EE,
is an essential but often underemphasized goal to ensure that we are
doing more good than harm for patients. It is also worth noting that
the ERAS system has generated unique psychological challenges for
patients. For instance, how should patients balance their bodily
discomfort with the need to reach their expected postoperative
recovery milestones?5
It is imperative for us to acknowledge that acute postoperative
pain and perioperative care as a whole are dynamic processes with
psychosocial determinants similar to chronic pain.4,28,34 While the
chronic pain therapy repertoire is continuously expanding,65 the
dominating ERAS standardization concept may be driving acute
pain management in the opposite direction. EE can, thus, be seen as a
complementary remedy to the narrowing diversity in fast-track care,
which maintains evidence-based ERAS recommendations and
empowers patients to engage in recreational activities for health
improvement based on personal preferences.
FUTURE DIRECTIONS
The launch of an RCT on multi-modal EE in perioperative care
using concepts proposed in this review and previous experience in
neurology25 is welcomed. Patients undergoing nononcological sur-
gery (eg, Cesarean section and total knee arthroplasty) may be more
grateful for all the healthcare efforts dedicated to create an enriched
and less traumatic surgical experience. To facilitate a comparison of
EE with analgesic medications, future trials should report analgesic
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Perioperative Environmental Enrichment
efficacy not just by differences in pain scores, but also the number
needed to benefit. The differential benefits of EE in different age, sex,
preoperative health status, and surgical subtype groups should be
explored. Moreover, the nature of EE should be clarified: is it a
psychocognitive modulation beyond a temporary pain distractor that
produces sustainable analgesia and anxiolysis even with short inter-
mittent exposure? This may unleash greater financial incentives for
EE as lower analgesic consumption, less frequent adverse drug
reactions, and shorter LOS will reduce healthcare expenditure.
For example, music generally carries analgesic-sparing potential17
and its anxiolytic efficacy may be comparable to 1–2 mg of preop-
erative intravenous midazolam.64 One trial found that sunlight
exposure might even help save 20% of analgesic medication costs
in postoperative patients.13 Besides, other potential psychosomatic
benefits of EE deserve exploration, such as its role in counteracting
surgery-induced immunosuppression.
CONCLUSIONS
Apart from enrolling patients into ERAS programs, postoper-
ative pain and distress may be reduced by introducing music, sensory
arts, social opportunities, and recreational resources to create an
enriched recovery environment. The emerging concept of EE cur-
rently has modest evidence for its analgesic and anxiolytic benefits,
yet its ease of implementation and safety should enable clinicians to
determine its benefits in everyday practice with minimal costs.
Despite being only a small step away from healthcare paternalism
and the biomedical preconceptions of surgical care, perioperative EE
may turn out to be a great leap in advancing patient-centered
biopsychosocial care.
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