Next Article in Journal
Breaking Bias: Addressing Ageism in Artificial Intelligence
Previous Article in Journal
Independent Living for Older Adults with Cognitive Impairment: A Narrative Review of Stakeholder Perceptions and Experiences with Assistive and Socially Assistive Robots
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JAL
Volume 5
Issue 3
10.3390/jal5030035
jal-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

The Impact of Nature-Based Interventions on Physical, Psychosocial, and Physiological Functioning for Physical Chronic Diseases: A Systematic Review

by
Émilie Fortin
1,2,3,
Marie-Ève Langelier
1,2,
Guillaume Léonard
4 and
Rubens A. da Silva
1,3,5,*
1
Centre Intersectoriel en Santé Durable, Université du Québec à Chicoutimi (UQAC), Saguenay, QC G7H 2B1, Canada
2
Laboratoire d’Expertise et de Recherche en Plein Air (LERPA), Humanities and Social Sciences Department, Université du Québec à Chicoutimi (UQAC), Saguenay, QC G7H 2B1, Canada
3
BioNr Research Laboratory, Health Sciences Department, Université du Québec à Chicoutimi (UQAC), Saguenay, QC G7H 2B1, Canada
4
School of Rehabilitation, Faculty of Medicine, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
5
Centre Intégré de Santé et Services Sociaux du Saguenay—Lac-Saint-Jean (CIUSSS SLSJ), Specialized Geriatrics Services at La Baie Hospital, Saguenay, QC G7H 7K9, Canada
*
Author to whom correspondence should be addressed.
J. Ageing Longev. 2025, 5(3), 35; https://doi.org/10.3390/jal5030035
Submission received: 25 June 2025 / Revised: 30 August 2025 / Accepted: 9 September 2025 / Published: 16 September 2025
Browse Figure
Versions Notes

Abstract

Background: Although nature exposure is recognized for its beneficial effects on psychological, cognitive, and physiological health, its impact on physical function has been underexplored. The main aim of this paper is to cover this gap. Methods: A systematic search of Cochrane, CINAHL Plus, and PubMed databases (2012–2023) was conducted using terms related to nature and physical function. Results: Eight intervention studies (total n = 209, age 25–91) met the inclusion criteria. NBIs, such as horticultural therapy and forest therapy, demonstrated generally positive effects across physical, psychosocial, and physiological outcomes, though effect size and quality varied. Study quality ranged from low to high. Conclusions: NBIs appear to promote multi-dimensional functioning in people living with physical chronic disease and offer promising complementary strategies to traditional rehabilitation.

1. Introduction

Most chronic diseases are associated with reduced physical function [1]. The prevalence of chronic and degenerative diseases increases with age [2]. In Canada, for example, 73% of individuals aged 65 and older have at least 1 of the 10 most common chronic health conditions [2]. Among these conditions, arthritis (38%), ischemic heart disease (27%), osteoporosis (25.1%), cancer (21.5%), chronic obstructive pulmonary disease (COPD) (20.2%), and asthma (10.7%) are the most prevalent. Additionally, 16% of individuals aged 18 to 64 and 27% of older individuals report suffering from chronic pain [3]. The physical consequences of these conditions can include fatigue [3,4,5,6,7], cardiorespiratory deconditioning [5,7], balance disorders [4], loss of strength and muscular endurance [5], reduced mobility [4,6], and pain [3,5,8]. These consequences can further impair daily functioning and diminish quality of life for these individuals [9].
In recent years, a growing body of research has highlighted the benefits of exposure to nature on global health. Studies have widely shown that nature can positively affect mental health, reducing anxiety [10,11,12] and depression [10,13] and increasing well-being [14,15]. Contact with natural elements has also demonstrated benefits in cognitive functioning [16,17,18]. Physiologically, nature exposure is associated with reductions in heart rate [12], blood pressure [19], and cortisol level [20,21,22], along with reduced sympathetic nervous system activity and increased parasympathetic nervous system activity [12,23]. Greenspace exposure is also linked to reduced systemic inflammation and enhanced immune function [24,25] and lower risk of developing certain autoimmune diseases and systemic disorders [26,27], while the actual evidence remains limited [28].
Although the biological mechanisms underlying these benefits are not yet fully understood, several hypotheses have been put forth. Multisensory factors, such as sounds, smells, and the visual contact with nature, are believed to contribute to the positive effects observed [29,30,31]. Beyond chronic conditions, multisensory engagement with natural environments—beyond visual perception alone—has been shown to enhance restorative experiences and promote health [32,33,34]. Moreover, during a forest walk, individuals inhale organic volatile compounds called monoterpenes, released by conifer and broadleaf trees [35]. When absorbed by the body, these compounds may help reduce inflammation [35] and oxidative stress [36], lower stress hormone levels [37], and stimulate the immune system [38]. Additionally, studies have shown that spending time in nature, such as during a forest stay, can enhance the activity of natural killer cells (NK cells) and increase the expression of anticancer proteins such as perforin, GrA, and GRN [38,39], suggesting potential benefits to the immune system. Moreover, greenspace exposure may also influence the human microbiota, promoting microbial diversity and supporting immunoregulation [40,41]. Studies also support the beneficial effects of nature in promoting physical activity [42,43] while simultaneously enhancing social cohesion [44]. Such benefits underscore the need for urban planning strategies that integrate natural elements into buildings, cities, and suburbs (e.g., open spaces, greenways, forest patches, and community gardens) to enhance overall health across populations [45,46,47,48].
Taken together, these observations suggest that nature-based interventions (NBIs) could have positive impacts on individuals with chronic health conditions, particularly those that affect physical function. These interventions, engaging individuals in nature-based activities with the goal of achieving improved health and well-being [49], offer a potentially valuable complementary approach to traditional rehabilitation for chronic diseases. As the prevalence of chronic conditions increases, particularly in aging populations, it is crucial to explore alternative or adjunctive strategies to improve physical function and quality of life.
While previous reviews have mainly examined nature exposure in healthy populations or focused on psychosocial and physiological outcomes [49,50,51,52], evidence on its impact on physical functioning in individuals with chronic diseases remains limited. This systematic review addresses this gap.
Aim: To explore the effects of NBIs on physical functioning while highlighting their effects on the psychosocial and physiological functioning of individuals suffering from chronic diseases affecting their physical functionality.

2. Materials and Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [53], including flow diagrams from all articles in selection and in analysis, as well as Appendix A (Appendix A (three tables with keyword’s query and search bases)) as well as the quality assessment from studies selected for final analysis. The protocol was developed prior to the study; however, it was not registered, as the study was not initially intended for publication and was instead incorporated as part of a final professional master’s degree project in physiotherapy.

2.1. Search Strategy and Study Selection

The research was conducted during the year 2023. Three main databases were consulted: Cochrane, CINAHL Plus with Full Text (EBSCOHost), and PubMed. To minimize the risk of selection bias, a variety of keywords and keyword combinations were used. The main keywords included two main themes, such as nature and chronic disease, and variables such as “mobility”, “balance”, “pain”, “quality of life”, and “physical endurance”.
The following structure was adopted: ((MH “Nature”) OR Ecotherapy OR “Green spaces”) AND (“Chronic disease” OR “Chronic pain”) AND ((MH “Quality of life”) OR Pain OR Function* OR Balance OR Strength OR mobility OR “physical endurance”). In each database, language filters (English and French), age (≥18 years), and publication date filters (from 2012 to May 2023) were applied (see the complete query for each database in Appendix A). A total of 618 studies were identified for the first step of this research (see Figure 1).
Four reviewers carried out the initial search strategy in the databases, extracting the titles and abstracts. Subsequently, the selection of studies, evaluation, and data extraction were conducted independently by two evaluators (two physiotherapy master’s students) based on the reading of titles and abstracts. Potentially eligible articles were read in full.

2.2. Inclusion and Exclusion Criteria

The selection criteria for the articles were as follows: (i) studies with an intervention design, (ii) a population of men and women, (iii) aged 18 years and older, and (iv) suffering from a chronic disease affecting their physical function. The exclusion criteria were as follows: (i) studies written in a language other than French or English and (ii) studies published before 2012.
As shown in Figure 1, the duplicates (n = 3) and articles not respecting inclusion/exclusion criteria (n = 577) were removed to obtain a total of 38 articles corresponding to the research subject (n = 38). After analyzing their abstracts, 13 articles were kept for full reading (n = 13). From that reading, seven articles were excluded, and two articles that met our review’s inclusion criteria were hand-picked from a systematic review [54]. This brings the total to eight articles for this review (n = 8).

2.3. Quality Assessment

The evaluation of the quality was made using the Quality Assessment for Diverse Studies (QuADS) tool, designed for systematic reviews with studies of different designs. This tool has demonstrated excellent inter-rater reliability (k = 0.66), face validity and content validity, when applied to systematic reviews in health services research using mixed or multimethod approaches [55]. The grid consists of 13 criteria rated from 0 (i.e., no mention) to 3 (i.e., a detailed description). Indeed, this grid does not have a minimal threshold for a study to be considered of low or high quality. It is recommended to evaluate and discuss the methodological quality of the studies by considering each criterion separately, rather than calculating an overall score [55].
In the context of this mixed literature review, prioritized criteria were chosen and highlighted by the team (four physiotherapy master’s students and Rubens A. da Silva) to determine the overall quality of the studies (the criteria chosen have been indicated in bold in Table 1). Since the subject is still emerging in the literature, the research team decided that studies needed to establish a solid theoretical foundation (criteria 1 from Table 1), clearly define their objectives (criteria 2 from Table 1) and explicitly describe the research intervention and the targeted population (criteria 3 from Table 1), use a study design appropriate for the research objectives (criteria 4 from Table 1), explain in detail the choice of measurement tools (criteria 6 from Table 1) and the data collection procedure (criteria 8 from Table 1), use an appropriate analysis method to address the research aims (criteria 1 from Table 1), and provide a precise thorough description of the research’s strengths and limitations (criteria 13 from Table 1).
Then, to assess the overall quality of the study, it was agreed by consensus that if a study met four criteria with a score of 3 and at least three criteria with a score of 2, its overall quality was considered high. If a study satisfied three criteria with a score of 3 and at least four criteria with a score of 2, its overall quality was judged to range from moderate to high. When a study predominantly presented criteria rated at 2, it indicated moderate overall quality. If a study met three criteria with a score of 2 and four criteria with a score of 1 or 0, its overall quality was assessed as ranging from low to moderate. Finally, a study mainly comprising criteria rated 1 or 0 was considered to have low quality. Table 1 presents the study evaluation grid along with the associated ratings.

2.4. Data Collection and Synthesis Process

Two tables were initially created to organize the data from the selected studies in accordance with the review objectives. The first table was designed to present the general characteristics of the studies (Table 2), while the second table summarized the results (Table 3). Data for half of the studies were collected by two physiotherapy master’s students, with another two students gathering data for the remaining studies. A Ph.D. student (Émilie Fortin) reviewed the data from all eight studies and standardized the tables for consistency.

3. Results

Out of the 618 studies, only 8 were selected for final analysis, based on inclusion and exclusion criteria. A total of 209 participants, aged 25 to 91 years old, with various physical chronic impairment conditions took part in these studies. Chronic diseases included health conditions such as cancer survivors (n = 68), active cancer (n = 22), chronic pain (n = 70), chronic heart failure (n = 33), and long COVID (n = 16).
Following the quality assessment, three studies were rated as high quality, one as moderate to high, three as moderate, and one as moderate to high (see Table 1).
After reviewing the studies, the measures were categorized into physical, psychosocial, and physiological to comprehensively address the aims of the study. Fatigue was included in physical measurements, while quality of life and pain related factors were included in psychosocial measurements.

3.1. Physical Health

Five of the studies examined the impact of NBIs on physical function.
Among the positive effects, an improvement has been shown for weekly physical activity, upper body strength, and hamstring and back flexibility over time for BCS practicing a home-based mentored gardening intervention [56]. In terms of aerobic capacity, the same program showed improvement for BCS and older cancer survivors [56,57]. These results were from high-quality studies. Online guided forest bathing was shown to be effective to reduce fatigue and brain fog and improve sleep quality for women living with long COVID, and in the same way, integrated medicine therapy (i.e., forest therapy, horticultural therapy, yoga, meditation, and supportive group therapy) showed improvement in physical, affective, and total fatigue in a population living with either breast or lung cancer [58,59]. These studies were rated high and moderate quality, respectively.

3.2. Psychosocial Health

Psychosocial measures were collected in seven of the eight studies.
  • Mood and well-being:
Depressive symptoms, anxiety, reassurance of worth (defined as a feeling of added value or deserving a place in society), confusion, rumination, functional well-being, and spiritual well-being were improved in different chronic conditions after an NBI program [58,59,60,61,62]. These studies were rated moderate to high.
  • Pain:
Regarding pain, NBIs such as forest therapy (i.e., forest therapy, horticultural therapy, yoga, meditation, and supportive group therapy) and horticultural therapy combined with a pain management program have been shown to be effective to reduce pain intensity [60,62], emotional distress, and interference of pain with life and to improve pain-related behaviors and life control [62] for people living with chronic pain. This evidence is linked to moderate- to high-quality studies.
  • Social:
An online forest bathing program seems to be effective for improving social connection among women living with long COVID, according to a high-quality article [58].
  • Quality of life:
NBIs such as forest therapy programs for chronic widespread pain [60], integrated medicine programs for breast and lung cancer [59], and horticultural therapy combined with pain management programs for chronic pain [62] have shown improvement regarding quality of life. These studies were rated moderate to high quality.

3.3. Physiological Measures

Six of the eight selected studies assessed physiological measures in various populations, including those who survived cancer [56,57] or are living with active cancer (breast or lung) [59], chronic pain [60,62], and CHF [61,63].
Among the positive effects, NBIs seem to improve the autonomic nervous system via increased Standard Deviation of Normal to Normal interval (SDNN) and Total Power (TP) on ECG in chronic widespread pain (moderate to high quality) [60]. It also seems to improve the immune response (via higher NK cell activity) for the same population and for people living with active cancer (moderate to high quality) [59,60]. For individuals living with CHF, a four-day forest therapy program has been shown to be effective for improving cardiac health via the reduction in the CHF biomarker BNP and pro-inflammatory cytokines (IL-6), along with improvement in certain CVD-associated factors (ET-1 and AT-2) and oxidative stress levels (↑T-SOD and ↓MDA) [61]. These results are linked to a moderate-quality article.

4. Discussion

The aim of this systematic review was to explore the effects of NBIs on physical, psychosocial, and physiological functioning regarding individuals living with a chronic disease affecting their physical function.
The impact of nature on chronic diseases is an emerging topic in the literature, and this review has allowed the selection of eight intervention studies conducted from 2012 to 2022. It has also identified the need for further research on the subject, considering the positive outcomes found and the lack of homogeneity and number of studies regarding this field. The main significant improvements compared with the control groups were found in: physical measures: Time of moderate physical activity, upper body strength and aerobic capacity for BCS individuals, cancer and long COVID-related fatigue and sleep quality and brain fog for people living with long COVID; psychosocial measures: Anxiety for people living with CHF, long COVID and musculoskeletal pain, rumination and depression for people living with long COVID, depression and confusion for people living with CHF, quality of life and pain-related behaviors for people living with musculoskeletal pain, reassurance of worth for older cancer survivors and social connection for people living with long COVID; physiological measures: Autonomic nervous system activity and immune system for people living with chronic widespread pain and CHF biomarkers, pro-inflammatory cytokines, CVD associated factors and oxidative stress for people living with CHF. Moreover, compared with baseline, there was a significant improvement in the experimental groups regarding: physical measures, such as the upper body, hamstring, and back flexibility for BCS individuals and aerobic capacity for older cancer survivors; functional and spiritual well-being, mood state, and anxiety for individuals living with breast or lung cancer and quality of life for people living with generalized chronic pain and breast or lung cancer.
The implication of this literature review is that it highlights the potential of NBIs among individuals with chronic diseases affecting their physical function regarding their physical, psychosocial, and physiological health.

4.1. Impact on Physical Function

Five studies were included in the final analysis of physical function. An improvement in the weekly time of moderate physical activity was observed in the study by Bail et al. [56] after a one-year mentored home vegetable gardening program for BCS. This increase could be partly explained by the fact that gardening can be considered a moderate-intensity physical activity for older adults during tasks involving the upper and lower body (e.g., digging, fertilizing, weeding, raking, and tying plants to stakes) [64]. Furthermore, as demonstrated by Pudkasam et al. [65], supervised home-based programs have shown success in promoting physical activity among BCS, which could also help explain the observed increase in weekly moderate physical activity. The same program showed improvement in upper body strength. This could be explained by the fact that gardening involves repeated movements involving the upper limbs, such as lifting, carrying, or digging, which contribute to muscle strengthening [66]. The improvement in upper body, hamstring, and back flexibility in the same group can also be explained by the fact that upper and lower body movements are involved in gardening. A similar conclusion was reached in a 2022 study examining how gardening influences both physical and mental health [66]. The increased aerobic capacity observed in the same home-based gardening intervention for BCS and older cancer survivors (compared with baseline) can also be explained by the fact that this therapy is considered a low- to high-intensity aerobic activity, depending on the tasks [64,67]. The improvement in fatigue and fatigue symptoms for individuals living with long COVID and those living with active cancer corroborates some evidence suggesting that nature exposure may help reduce fatigue [68].
On the other hand, there were no positive effects of mentored home gardening regarding time of weekly moderate physical activity, upper body strength, gait speed, and balance for older cancer survivors. This could be partly explained by the fact that with aging, there is a decline in physical function, including balance, mobility, and muscle strength [69], that can make it more difficult for them to engage in a physical activity like gardening. This activity may not be sufficient in intensity or variety of tasks to counteract this physical decline. In the pilot study by Verra et al. [62], the addition of horticultural therapy to a pain-management program for individuals living with musculoskeletal pain did not result in larger improvement than in the control group regarding functional performance and aerobic endurance. This could be explained by the short duration of the experiment (four weeks), which is likely too brief to show a more significant difference. In addition, the pain-management program already included exercise therapy, which can also explain the non-significant difference between the groups, with an increased aerobic capacity in both groups.
Even if home-based gardening, guided forest bathing, and integrated medicine interventions showed some improvement regarding physical function, the studies included in this review were unable to validate our hypotheses regarding the impact of nature interventions for specific populations, such as cancer survivors, individuals living with long COVID, and those living with musculoskeletal chronic pain, such as fibromyalgia or non-specific back pain. This was due to a lack of homogeneity, number of evidence, and detailed descriptions of the different therapies (e.g., tasks involved in gardening and type of terrain during walking, etc.). This limitation restricts the scope of conclusions on this matter.
However, it is conceivable that improvement in these aspects of physical function will depend on the specific context of therapy, in line with the principle of exercise specificity. For instance, movements involved in horticulture may recruit certain muscles in the upper and lower body, stimulate balance, and train aerobic endurance, based on the intensity and duration of the specific tasks performed [66]. Similarly, forest walking may stimulate various aspects of physical function, such as dynamic balance, with the level of difficulty varying depending on factors like the type of terrain. Furthermore, it is possible to consider that nature therapy could contribute to improving aerobic endurance in a population suffering from a chronic disease. If we examine the physiological perspective of the effects of nature, the fact that heart rate and blood pressure decrease during a forest stay [12,19] would, therefore, lessen the strain on the heart, reduce the demand for oxygen, and enhance tissue oxygenation for the same physical demand [70]. This would consistently lead to an improvement in endurance during physical exertion. Likewise, the two studies by Mao et al. [61,63] also underscore the significance of forest stays on physiological markers of heart failure. Nature exposure could thus enhance cardiovascular function by reducing biomarkers of heart failure, oxidative stress indicators, and inflammatory factors. Finally, it is well established that innate immune cells (“NK cells”) play a crucial role against tumors and metastases [71]. Consequently, the observed increase in their activity in nature could have a preventive effect against the development or progression of cancer, which is often associated with significant consequences for physical function. These observations have been further elucidated in Section 3.3, regarding significant results on the physiological dimension.

4.2. Impact on Psychosocial Health

4.2.1. Pain

According to the findings of this mixed systematic review, forest therapy helped reduce pain in individuals suffering from generalized chronic pain [60]. Moreover, the addition of horticultural therapy to a pain management program showed an improvement in pain-related behaviors compared with the C group, as well as a decreased impact of pain on the participant’s life compared with baseline [62,72]. Indeed, the connection between nature exposure and pain is well-established in the literature. Several factors could explain this relationship, including reduced stress, anxiety, and inflammation, mood enhancement, activation of the parasympathetic system, and sensory stimulation [73].
The reduction in cortisol levels seen with interventions in nature could partially explain their positive effect on pain perception. Indeed, cortisol dysfunction (seen when there is a maladaptive response to stress) is implicated in a variety of chronic pain conditions [74]. This dysfunction can lead to inflammation, which can contribute to pain [75]. In addition, the comorbidity of depression and anxiety is common in chronic pain [76]. Moreover, being in nature increases serotonin levels, generates a state of well-being, and improves mood [54,77]. Improved mood can positively influence the perception of pain [78]. Furthermore, the natural environment provides a multitude of sensory stimuli that could divert attention away from pain, such as the different sounds (e.g., birds and river), smells (e.g., conifers and flowers), feelings (e.g., wind on the face), and sights (e.g., colors and elements of nature). This could result in a reduction in pain perception. Finally, contact with nature generally promotes the activation of the parasympathetic system, leading to a decrease in heart rate and blood pressure. This nervous system response promotes a state of relaxation and could contribute to a reduction in pain [79].

4.2.2. Quality of Life

Firstly, it is important to mention that optimal well-being is considered to be governed by various dimensions such as physical, emotional, interpersonal, social, intellectual, environmental, and spiritual well-being, which are all closely linked with quality of life [80].
In this review, well-being and quality of life were extensively discussed. Five studies measured quality of life, with three demonstrating improvement following diverse nature interventions, including forest therapy (for a population experiencing generalized chronic pain), integrated medicine (for individuals living with breast or lung cancer), and horticultural therapy (for individuals living with chronic musculoskeletal pain). This could be explained by the significant improvement in various aspects of psychosocial well-being, certain aspects of physical function, and a certain relief of pain burden.
Physical, psychosocial, and physiological factors, as well as quality of life, play a significant role in the rehabilitation and treatment process for individuals living with a chronic disease. Indeed, an optimal state of well-being and quality of life can result in increased motivation and engagement, reduced stress and anxiety, enhanced pain tolerance, optimized recovery, and more confidence, as well as an improvement in treatment adherence.
Beyond improvements in symptoms and quality of life, it is also relevant to consider whether NBIs could affect the clinical course of chronic diseases.

4.3. Possible Influence of NBIs on Chronic Disease Progression and Prognosis

Although the current evidence remains preliminary, some findings suggest that NBIs could positively influence the course of chronic diseases. For example, improved immune responses in cancer [59] and reduced biomarkers in heart failure [61,63] indicate mechanisms that may support better prognosis. These results open the door to considering NBIs not only as supportive therapies but also as potential contributors to long-term disease management, warranting further investigation through larger longitudinal trials.

4.4. Strengths and Limitations

This review stands out by specifically addressing the underexplored impact of NBIs on physical function in chronic diseases. Methodological rigor was ensured in respect to PRISMA guidelines and systematic searches across multiple databases. By synthesizing outcomes across physical, psychosocial, and physiological domains, the review highlights the multidimensional benefits of NBIs and their potential as complementary strategies in rehabilitation.
This review has some limitations. Firstly, environmental contexts differ, as studies were conducted in different countries (i.e., Switzerland, England, China, South Korea, Japan, the USA, Taiwan, Singapore, and Italy). Indeed, the environmental context differs from one country and region to another. For example, vegetation, colors, temperature, and air quality vary greatly. Also, the studies used were particularly heterogeneous. Indeed, the designs, measures, measurement tools, interventions, and populations varied from one study to another. Therefore, it is challenging to compare study results and draw solid conclusions for a wider generalization. Moreover, the review is limited by searching only three databases, which may have excluded relevant studies indexed elsewhere. Finally, several included studies had small sample sizes and variable methodological quality, and most interventions were short-term, limiting the ability to assess long-term effects.

4.5. Perspectives

This review highlights the immense lack of studies exploring the effects of nature on chronic diseases affecting physical function. Given the positive results obtained in the studies mentioned in this review, as well as the numerous hypotheses derived from theory and the proven overall health benefits of nature in the existing literature, future research in this field is both necessary and promising. This could benefit specific populations, such as those living with a chronic disease affecting physical function, as well as professionals, by providing clearer guidelines for nature prescriptions.

5. Conclusions

This literature review highlights the positive impact of NBIs on physical, psychosocial, and physiological functioning in individuals living with chronic diseases that affect their physical functioning. Notably, no negative effects were reported across the studies reviewed. Despite differences in modalities, interventions such as forest therapy, forest bathing, and horticultural therapy share the following common features: they combine physical activity with sensory engagement in natural environments, promote psychophysiological regulation, and foster motivation by offering meaningful and enjoyable experiences. As such, these interventions can be considered complementary to traditional rehabilitation approaches, reinforcing conventional strategies while adding the unique holistic benefits of contact with nature. The effectiveness of these interventions appears to be influenced by several factors, including the type of intervention, the duration of the program, and the characteristics of the targeted population. These findings also point to broader implications for urban planning, underscoring the integration of accessible natural spaces—such as open spaces, greenways, forest patches, and community gardens—to promote health and well-being across the population, regardless of chronic disease status. Further research is necessary to deepen our understanding of these effects for specific chronic conditions and to develop guidelines for these populations.

Author Contributions

Conceptualization, É.F. and R.A.d.S.; methodology, É.F. and R.A.d.S.; software, É.F.; validation, É.F. and R.A.d.S.; formal analysis, É.F. and R.A.d.S. writing—original draft preparation, É.F.; writing—review and editing, R.A.d.S., M.-È.L., and G.L.; visualization, É.F., R.A.d.S., and M.-È.L.; supervision, R.A.d.S., M.-È.L., and G.L.; project administration, R.A.d.S. All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the Centre Intersectoriel en Santé Durable (CISD) from Université du Québec à Chicoutimi (UQAC) as part of a broader project entitled “Nature-based interventions to improve physical and mental health of older adults with chronic low-back pain” (funded from 2024 to 2026). R.A.d.S. is funded by CNPq Agency (Brazil) and G.L. received salary support from the Fonds de Recherche du Québec—Santé (FRQS). The funders had no role in any of the processes involved in this study, including study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data are available upon request to the corresponding author.

Acknowledgments

The authors gratefully acknowledge the contribution of the physical therapy students for their assistance with data collection and article analysis.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A

Table A1. Keyword’s Query on CINALH Plus with Full Text (EBSCOHost).
Table A1. Keyword’s Query on CINALH Plus with Full Text (EBSCOHost).
Query# of Results
#1TI (Forest* OR “Green spaces” OR greenspaces OR “outdoor spaces” OR wilderness OR “Shirin-yoku” OR Ecotherapy OR Biophilia)30,521
#2AB (Forest* OR “Green spaces” OR greenspaces OR “outdoor spaces” OR wilderness OR “Shirin-yoku” OR Ecotherapy OR Biophilia)98,741
#3((MH “Nature”) OR (MH “Forests+”) OR (MH “Parks, Recreational”) OR (MH “Wilderness”) OR (MH “Horticultural Therapy”) OR (MH “Trees”))30,521
#4#1 OR #2 OR #3124,377
#5(“Chronic disease*” OR “chronic illness*” OR “Metabolic syndrome” OR “Chronic pain” OR (MH “Chronic Disease+”) OR (MH “Chronic Pain”) OR (MH “Metabolic Syndrome”))849,180
#6TI “Quality of life” OR pain OR Function* OR Balance OR strength OR mobility OR “physical endurance”6,322,909
#7AB “Quality of life” OR pain OR Function* OR Balance OR strength OR mobility OR “physical endurance”6,464,488
#8MH “Quality of Life”) OR (MH “Pain+”) OR (MH “Physical Functional Performance+”) OR (MH “Postural Balance+”) OR (MH “Muscle strength”) OR (MH “Physical endurance”) 771,019
#9#6 OR #7 OR #8 6,597,846
#4 AND #5 AND #9333
2012–2023 (05)292
ANG/FRA = 290
Adults: 124
Table A2. Keyword’s Query on Cochrane.
Table A2. Keyword’s Query on Cochrane.
Query# of Results
#1Title Abstract Keyword (Forest* OR “Green spaces” OR greenspaces OR “outdoor spaces” OR wilderness OR “Shinrin-yoku” OR Ecotherapy OR Biophilia) OR MeSH descriptor: [Forests] explode all trees OR MeSH descriptor: [Nature] explode all trees OR MeSH descriptor: [Parks, Recreational] explode all trees OR MeSH descriptor: [Wilderness] explode all trees OR MeSH descriptor: [Horticultural Therapy] explode all trees OR MeSH descriptor: [Trees] explode all trees2077
#2(“Chronic disease*” OR “chronic illness*” OR “Metabolic syndrome” OR “Chronic pain” OR MeSH descriptor: [Chronic Disease] explode all trees OR MeSH descriptor: [Chronic Pain] explode all trees OR MeSH descriptor: [Metabolic Syndrome] explode all trees 68,659
#3Title Abstract Keyword (“Quality of life” OR pain OR Function* OR Balance OR strength OR mobility OR “physical endurance”) OR MeSH descriptor: [Quality of Life] explode all trees OR MeSH descriptor: [Pain] explode all trees OR MeSH descriptor: [Physical Functional Performance] explode all trees OR MeSH descriptor: [Postural Balance] explode all trees OR MeSH descriptor: [Muscle Strength] explode all trees OR MeSH descriptor: [Physical Endurance] explode all trees 623,594
#1 AND #2 AND #3 47
Cochrane reviews = 8
Trials: 39
ANG/FRA + Adults + 2012–2023 (05):
Cochrane reviews = 7
Trials: 39
Table A3. Keyword’s Query on PubMed.
Table A3. Keyword’s Query on PubMed.
RecherchesQuery# of Results
2012–2023
#1(Forest*[Title/Abstract] OR “Green spaces”[Title/Abstract] OR greenspaces[Title/Abstract] OR “outdoor spaces”[Title/Abstract] OR wilderness[Title/Abstract] OR “Shinrin-yoku”[Title/Abstract] OR Ecotherapy[Title/Abstract] OR Biophilia[Title/Abstract])76,746
#2((chronic disease[MeSH Terms]) OR (chronic diseases[MeSH Terms]) OR (metabolic syndrome x[MeSH Terms]) OR (chronic pain[MeSH Terms]) OR (“chronic disease*”) OR (“chronic illness”) OR (“metabolic syndrome”) OR (“chronic pain”))386,865
#3“Quality of life”[Title] OR pain[Title] OR Function*[Title] OR Balance[Title] OR strength[Title] OR mobility[Title] OR “physical endurance”[Title] 612,189
#4“Quality of life”[Title/Abstract] OR pain[Title/Abstract] OR Function*[Title/Abstract] OR Balance[Title/Abstract] OR strength[Title/Abstract] OR mobility[Title/Abstract] OR “physical endurance”[Title/Abstract] 3,167,258
#5(quality of life[MeSH Terms]) OR (pain [MeSH Terms]) OR (pain perception [MeSH Terms]) OR (physical functional performance[MeSH Terms]) OR (balance, postural [MeSH Terms]) OR (muscle strength [MeSH Terms]) OR (physical endurance[MeSH Terms]) 402,687
#6#3 OR #4 OR #53,238,618
#1 AND #2 AND #6238
ANG/FRA = 88
Adults: 73

References

  1. Nolte, E.; Knai, C.; Saltman, R.B. Assessing Chronic Disease Management in European Health Systems: Concepts and Approaches; World Health Organization: Copenhagen, Denmark, 2014; Volume 37. [Google Scholar]
  2. Public Health Agency of Canada. Prevalence of Chronic Diseases and Risk Factors Among Canadians Aged 65 Years and Older. Available online: https://www.canada.ca/en/services/health/publications/diseases-conditions/prevalence-chronic-disease-risk-factors-canadians-aged-65-years-older.html (accessed on 27 December 2023).
  3. Statistics Canada. Pain or Discomfort that Prevents Activities. Available online: https://www150.statcan.gc.ca/n1/pub/82-229-x/2009001/status/pdl-eng.htm (accessed on 27 December 2023).
  4. Wong, S.L.; Gilmour, H.; Ramage-Morin, P.L. Parkinson’s disease: Prevalence, diagnosis and impact. Health Rep. 2014, 25, 10–14. [Google Scholar] [PubMed]
  5. Canadian Cancer Society. Physical Symptoms of Advanced Cancer. Available online: https://cancer.ca/en/living-with-cancer/advanced-cancer/physical-symptoms-of-advanced-cancer (accessed on 20 January 2024).
  6. Statistics Canada. Arthritis. Available online: https://www150.statcan.gc.ca/n1/pub/82-229-x/2009001/status/art-eng.htm (accessed on 24 January 2024).
  7. Public Health Agency of Canada. Report from the Canadian Chronic Disease Surveillance System: Asthma and Chronic Obstructive Pulmonary Disease (COPD) in Canada. 2018. Available online: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018.html (accessed on 24 January 2024).
  8. Winfield, J.B. Pain and arthritis. N. C. Med. J. 2007, 68, 444–446. [Google Scholar] [CrossRef] [PubMed]
  9. Public Health Agency of Canada. Aging and Chronic Diseases: A Profile of Canadian Seniors. Available online: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/aging-chronic-diseases-profile-canadian-seniors-report.html (accessed on 24 January 2024).
  10. Kotera, Y.; Richardson, M.; Sheffield, D. Effects of shinrin-yoku (forest bathing) and nature therapy on mental health: A systematic review and meta-analysis. Int. J. Ment. Health Addict. 2022, 20, 337–361. [Google Scholar] [CrossRef]
  11. Martyn, P.; Brymer, E. The relationship between nature relatedness and anxiety. J. Health Psychol. 2016, 21, 1436–1445. [Google Scholar] [CrossRef]
  12. Farrow, M.R.; Washburn, K. A Review of Field Experiments on the Effect of Forest Bathing on Anxiety and Heart Rate Variability. Glob. Adv. Health Med. 2019, 8, 2164956119848654. [Google Scholar] [CrossRef]
  13. Berman, M.G.; Kross, E.; Krpan, K.M.; Askren, M.K.; Burson, A.; Deldin, P.J.; Kaplan, S.; Sherdell, L.; Gotlib, I.H.; Jonides, J. Interacting with nature improves cognition and affect for individuals with depression. J. Affect. Disord. 2012, 140, 300–305. [Google Scholar] [CrossRef]
  14. Nisbet, E.K.; Zelenski, J.M.; Murphy, S.A. Happiness is in our nature: Exploring nature relatedness as a contributor to subjective well-being. J. Happiness Stud. 2011, 12, 303–322. [Google Scholar] [CrossRef]
  15. White, M.P.; Elliott, L.R.; Grellier, J.; Economou, T.; Bell, S.; Bratman, G.N.; Cirach, M.; Gascon, M.; Lima, M.L.; Lõhmus, M. Associations between green/blue spaces and mental health across 18 countries. Sci. Rep. 2021, 11, 8903. [Google Scholar] [CrossRef]
  16. Mason, L.; Ronconi, A.; Scrimin, S.; Pazzaglia, F. Short-term exposure to nature and benefits for students’ cognitive performance: A review. Educ. Psychol. Rev. 2022, 34, 609–647. [Google Scholar] [CrossRef]
  17. Norwood, M.F.; Lakhani, A.; Fullagar, S.; Maujean, A.; Downes, M.; Byrne, J.; Stewart, A.; Barber, B.; Kendall, E. A narrative and systematic review of the behavioural, cognitive and emotional effects of passive nature exposure on young people: Evidence for prescribing change. Landsc. Urban Plan. 2019, 189, 71–79. [Google Scholar] [CrossRef]
  18. Schertz, K.E.; Berman, M.G. Understanding nature and its cognitive benefits. Curr. Dir. Psychol. Sci. 2019, 28, 496–502. [Google Scholar] [CrossRef]
  19. Ideno, Y.; Hayashi, K.; Abe, Y.; Ueda, K.; Iso, H.; Noda, M.; Lee, J.-s.; Suzuki, S. Blood pressure-lowering effect of Shinrin-yoku (Forest bathing): A systematic review and meta-analysis. BMC Complement. Altern. Med. 2017, 17, 409. [Google Scholar] [CrossRef]
  20. Yao, W.; Zhang, X.; Gong, Q. The effect of exposure to the natural environment on stress reduction: A meta-analysis. Urban For. Urban Green. 2021, 57, 126932. [Google Scholar] [CrossRef]
  21. Hunter, M.R.; Gillespie, B.W.; Chen, S.Y.-P. Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers. Front. Psychol. 2019, 10, 722. [Google Scholar] [CrossRef] [PubMed]
  22. Opdahl, E.; Demps, K.; Heath, J.A. Decreased cortisol among hikers who preferentially visit and value biodiverse riparian zones. Sci. Rep. 2021, 11, 848. [Google Scholar] [CrossRef] [PubMed]
  23. Kobayashi, H.; Song, C.; Ikei, H.; Kagawa, T.; Miyazaki, Y. Analysis of individual variations in autonomic responses to urban and forest environments. Evid.-Based Complement. Altern. Med. 2015, 2015, 671094. [Google Scholar] [CrossRef]
  24. Andersen, L.; Corazon, S.S.; Stigsdotter, U.K. Nature exposure and its effects on immune system functioning: A systematic review. Int. J. Environ. Res. Public Health 2021, 18, 1416. [Google Scholar] [CrossRef]
  25. Ong, A.D.; Cintron, D.W.; Fuligni, G.L. Engagement with nature and proinflammatory biology. Brain Behav. Immun. 2024, 119, 51–55. [Google Scholar] [CrossRef]
  26. Hu, J.; Shen, P.; Mao, Y.; Qiu, J.; Xu, L.; Wu, Y.; Wang, Y.; Ding, Y.; Lin, H.; Shui, L. Association of fine particulate matter and residential green space with rheumatoid arthritis. Environ. Res. 2024, 263, 120151. [Google Scholar] [CrossRef]
  27. Hartley, K.; Ryan, P.; Brokamp, C.; Gillespie, G.L. Effect of greenness on asthma in children: A systematic review. Public Health Nurs. 2020, 37, 453–460. [Google Scholar] [CrossRef]
  28. Galitskaya, P.; Luukkonen, A.; Roslund, M.I.; Mänttäri, M.; Yli-Viikari, A.; Tyrväinen, L.; Sinkkonen, A.; Laitinen, O. Green space quantity and exposure in relation to the risk of immune-mediated diseases: A scoping review. BMC Public Health 2024, 24, 3358. [Google Scholar] [CrossRef] [PubMed]
  29. Velarde, M.D.; Fry, G.; Tveit, M. Health effects of viewing landscapes—Landscape types in environmental psychology. Urban For. Urban Green. 2007, 6, 199–212. [Google Scholar] [CrossRef]
  30. Alvarsson, J.J.; Wiens, S.; Nilsson, M.E. Stress recovery during exposure to nature sound and environmental noise. Int. J. Environ. Res. Public Health 2010, 7, 1036–1046. [Google Scholar] [CrossRef] [PubMed]
  31. Weber, S.T.; Heuberger, E. The impact of natural odors on affective states in humans. Chem. Senses 2008, 33, 441–447. [Google Scholar] [CrossRef]
  32. Ratcliffe, E. Sound and soundscape in restorative natural environments: A narrative literature review. Front. Psychol. 2021, 12, 570563. [Google Scholar] [CrossRef]
  33. Franco, L.S.; Shanahan, D.F.; Fuller, R.A. A review of the benefits of nature experiences: More than meets the eye. Int. J. Environ. Res. Public Health 2017, 14, 864. [Google Scholar] [CrossRef]
  34. Bentley, P.R.; Fisher, J.C.; Dallimer, M.; Fish, R.D.; Austen, G.E.; Irvine, K.N.; Davies, Z.G. Nature, smells, and human wellbeing. Ambio 2023, 52, 1–14. [Google Scholar] [CrossRef]
  35. Sumitomo, K.; Akutsu, H.; Fukuyama, S.; Minoshima, A.; Kukita, S.; Yamamura, Y.; Sato, Y.; Hayasaka, T.; Osanai, S.; Funakoshi, H.; et al. Conifer-Derived Monoterpenes and Forest Walking. Mass Spectrom. 2015, 4, A0042. [Google Scholar] [CrossRef]
  36. Yamada, A.; Sato, Y.; Horike, T.; Miyanaga, M.; Wang, D.H. Effects of a Forest Walk on Urinary Dityrosine and Hexanoyl-Lysine in Young People: A Pilot Study. Int. J. Environ. Res. Public Health 2020, 17, 4990. [Google Scholar] [CrossRef]
  37. Li, Q.; Kobayashi, M.; Wakayama, Y.; Inagaki, H.; Katsumata, M.; Hirata, Y.; Hirata, K.; Shimizu, T.; Kawada, T.; Park, B.J.; et al. Effect of Phytoncide from Trees on Human Natural Killer Cell Function. Int. J. Immunopathol. Pharmacol. 2009, 22, 951–959. [Google Scholar] [CrossRef]
  38. Li, Q.; Morimoto, K.; Kobayashi, M.; Inagaki, H.; Katsumata, M.; Hirata, Y.; Hirata, K.; Suzuki, H.; Li, Y.J.; Wakayama, Y.; et al. Visiting a forest, but not a city, increases human natural killer activity and expression of anti-cancer proteins. Int. J. Immunopathol. Pharmacol. 2008, 21, 117–127. [Google Scholar] [CrossRef]
  39. Li, Q.; Morimoto, K.; Kobayashi, M.; Inagaki, H.; Katsumata, M.; Hirata, Y.; Hirata, K.; Shimizu, T.; Li, Y.J.; Wakayama, Y.; et al. A forest bathing trip increases human natural killer activity and expression of anti-cancer proteins in female subjects. Biol. Regul. Homeost. Agents 2008, 22, 45–55. [Google Scholar]
  40. Tischer, C.; Kirjavainen, P.; Matterne, U.; Tempes, J.; Willeke, K.; Keil, T.; Apfelbacher, C.; Täubel, M. Interplay between natural environment, human microbiota and immune system: A scoping review of interventions and future perspectives towards allergy prevention. Sci. Total Environ. 2022, 821, 153422. [Google Scholar] [CrossRef]
  41. Zhang, Y.-D.; Fan, S.-J.; Zhang, Z.; Li, J.-X.; Liu, X.-X.; Hu, L.-X.; Knibbs, L.D.; Dadvand, P.; Jalaludin, B.; Browning, M.H. Association between residential greenness and human microbiota: Evidence from multiple countries. Environ. Health Perspect. 2023, 131, 087010. [Google Scholar] [CrossRef] [PubMed]
  42. Hillsdon, M.; Thorogood, M.; Anstiss, T.; Morris, J. Randomised controlled trials of physical activity promotion in free living populations: A review. J. Epidemiol. Community Health 1995, 49, 448–453. [Google Scholar] [CrossRef] [PubMed]
  43. Sugiyama, T.; Giles-Corti, B.; Summers, J.; du Toit, L.; Leslie, E.; Owen, N. Initiating and maintaining recreational walking: A longitudinal study on the influence of neighborhood green space. Prev. Med. 2013, 57, 178–182. [Google Scholar] [CrossRef] [PubMed]
  44. Jennings, V.; Bamkole, O. The relationship between social cohesion and urban green space: An avenue for health promotion. Int. J. Environ. Res. Public Health 2019, 16, 452. [Google Scholar] [CrossRef]
  45. Rigolon, A.; Browning, M.H.; McAnirlin, O.; Yoon, H. Green space and health equity: A systematic review on the potential of green space to reduce health disparities. Int. J. Environ. Res. Public Health 2021, 18, 2563. [Google Scholar] [CrossRef]
  46. Anguluri, R.; Narayanan, P. Role of green space in urban planning: Outlook towards smart cities. Urban For. Urban Green. 2017, 25, 58–65. [Google Scholar] [CrossRef]
  47. Douglas, O.; Lennon, M.; Scott, M. Green space benefits for health and well-being: A life-course approach for urban planning, design and management. Cities 2017, 66, 53–62. [Google Scholar] [CrossRef]
  48. Balsas, C.J. Making Hidden Sustainable Urban Planning and Landscape Knowledge Visual and Multisensorial. Land 2024, 14, 1. [Google Scholar] [CrossRef]
  49. Shanahan, D.F.; Astell–Burt, T.; Barber, E.A.; Brymer, E.; Cox, D.T.; Dean, J.; Depledge, M.; Fuller, R.A.; Hartig, T.; Irvine, K.N. Nature–based interventions for improving health and wellbeing: The purpose, the people and the outcomes. Sports 2019, 7, 141. [Google Scholar] [CrossRef] [PubMed]
  50. Chun, H.-r.; Choi, Y.-Y.; Cho, I.; Nam, H.-k.; Kim, G.; Park, S.; Cho, S.-i. Indicators of the psychosocial and physiological effects of forest therapy: A systematic review. Forests 2023, 14, 1407. [Google Scholar] [CrossRef]
  51. Jimenez, M.P.; DeVille, N.V.; Elliott, E.G.; Schiff, J.E.; Wilt, G.E.; Hart, J.E.; James, P. Associations between nature exposure and health: A review of the evidence. Int. J. Environ. Res. Public Health 2021, 18, 4790. [Google Scholar] [CrossRef] [PubMed]
  52. Taylor, E.M.; Robertson, N.; Lightfoot, C.J.; Smith, A.C.; Jones, C.R. Nature-based interventions for psychological wellbeing in long-term conditions: A systematic review. Int. J. Environ. Res. Public Health 2022, 19, 3214. [Google Scholar] [CrossRef]
  53. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, n71. [Google Scholar] [CrossRef]
  54. Lin, Y.; Lin, R.; Liu, W.; Wu, W. Effectiveness of horticultural therapy on physical functioning and psychological health outcomes for older adults: A systematic review and meta-analysis. J. Clin. Nurs. 2022, 31, 2087–2099. [Google Scholar] [CrossRef]
  55. Harrison, R.; Jones, B.; Gardner, P.; Lawton, R. Quality assessment with diverse studies (QuADS): An appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies. BMC Health Serv. Res. 2021, 21, 144. [Google Scholar] [CrossRef]
  56. Bail, J.R.; Frugé, A.D.; Cases, M.G.; De Los Santos, J.F.; Locher, J.L.; Smith, K.P.; Cantor, A.B.; Cohen, H.J.; Demark-Wahnefried, W. A home-based mentored vegetable gardening intervention demonstrates feasibility and improvements in physical activity and performance among breast cancer survivors. Cancer 2018, 124, 3427–3435. [Google Scholar] [CrossRef]
  57. Demark-Wahnefried, W.; Cases, M.; Cantor, A.; Fruge, A.; Smith, K.; Locher, J. Pilot randomized controlled trial of a home vegetable gardening intervention among older cancer survivors shows feasibility, satisfaction, and promise in improving vegetable and fruit consumption, reassurance of worth, and the trajectory of central adiposity. J. Acad. Nutr. Diet. 2017, 118, 689–704. [Google Scholar] [CrossRef]
  58. McEwan, K.; Collett, H.; Nairn, J.; Bird, J.; Faghy, M.A.; Pfeifer, E.; Jackson, J.E.; Cook, C.; Bond, A. The Feasibility and Impact of Practising Online Forest Bathing to Improve Anxiety, Rumination, Social Connection and Long-COVID Symptoms: A Pilot Study. Int. J. Environ. Res. Public Health 2022, 19, 14905. [Google Scholar] [CrossRef] [PubMed]
  59. Nakau, M.; Imanishi, J.; Imanishi, J.; Watanabe, S.; Imanishi, A.; Baba, T.; Hirai, K.; Ito, T.; Chiba, W.; Morimoto, Y. Spiritual care of cancer patients by integrated medicine in urban green space: A pilot study. Explore 2013, 9, 87–90. [Google Scholar] [CrossRef] [PubMed]
  60. Han, J.W.; Choi, H.; Jeon, Y.H.; Yoon, C.H.; Woo, J.M.; Kim, W. The Effects of Forest Therapy on Coping with Chronic Widespread Pain: Physiological and Psychological Differences between Participants in a Forest Therapy Program and a Control Group. Int. J. Environ. Res. Public Health 2016, 13, 255. [Google Scholar] [CrossRef] [PubMed]
  61. Mao, G.; Cao, Y.; Wang, B.; Wang, S.; Chen, Z.; Wang, J.; Xing, W.; Ren, X.; Lv, X.; Dong, J.; et al. The Salutary Influence of Forest Bathing on Elderly Patients with Chronic Heart Failure. Int. J. Environ. Res. Public Health 2017, 14, 368. [Google Scholar] [CrossRef] [PubMed]
  62. Verra, M.L.; Angst, F.; Beck, T.; Lehmann, S.; Brioschi, R.; Schneiter, R.; Aeschlimann, A. Horticultural Therapy for Patients With Chronic Musculoskeletal Pain: Results of a Pilot Study. Altern. Ther. Health Med. 2012, 18, 44–50. [Google Scholar]
  63. Mao, G.X.; Cao, Y.B.; Yang, Y.; Chen, Z.M.; Dong, J.H.; Chen, S.S.; Wu, Q.; Lyu, X.L.; Jia, B.B.; Yan, J.; et al. Additive Benefits of Twice Forest Bathing Trips in Elderly Patients with Chronic Heart Failure. Biomed. Environ. Sci. 2018, 31, 159–162. [Google Scholar] [CrossRef]
  64. Park, S.-A.; Lee, K.-S.; Son, K.-C. Determining exercise intensities of gardening tasks as a physical activity using metabolic equivalents in older adults. HortScience 2011, 46, 1706–1710. [Google Scholar] [CrossRef]
  65. Pudkasam, S.; Polman, R.; Pitcher, M.; Fisher, M.; Chinlumprasert, N.; Stojanovska, L.; Apostolopoulos, V. Physical activity and breast cancer survivors: Importance of adherence, motivational interviewing and psychological health. Maturitas 2018, 116, 66–72. [Google Scholar] [CrossRef]
  66. Beavers, A.W.; Atkinson, A.; Varvatos, L.M.; Connolly, M.; Alaimo, K. How Gardening in Detroit Influences Physical and Mental Health. Int. J. Environ. Res. Public Health 2022, 19, 7899. [Google Scholar] [CrossRef]
  67. Hawkins, J.; Smith, A.; Backx, K.; Clayton, D. Exercise intensities of gardening tasks within older adult allotment gardeners in Wales. J. Aging Phys. Act. 2015, 23, 161–168. [Google Scholar] [CrossRef]
  68. Park, B.-J.; Furuya, K.; Kasetani, T.; Takayama, N.; Kagawa, T.; Miyazaki, Y. Relationship between psychological responses and physical environments in forest settings. Landsc. Urban Plan. 2011, 102, 24–32. [Google Scholar] [CrossRef]
  69. Nakano, M.M.; Otonari, T.S.; Takara, K.S.; Carmo, C.M.; Tanaka, C. Physical performance, balance, mobility, and muscle strength decline at different rates in elderly people. J. Phys. Ther. Sci. 2014, 26, 583–586. [Google Scholar] [CrossRef] [PubMed]
  70. Guenette, J.A. Clinical Exercise Pathophysiology for Physical Therapy: Examination, Testing, and Exercise Prescription for Movement-Related Disorders. Physiother. Can. 2015, 67, 394–395. [Google Scholar] [CrossRef]
  71. Chan, I.S.; Ewald, A.J. The changing role of natural killer cells in cancer metastasis. J. Clin. Investig. 2022, 132, e143762. [Google Scholar] [CrossRef]
  72. Kerns, R.D.; Turk, D.C.; Rudy, T.E. The west haven-yale multidimensional pain inventory (WHYMPI). Pain 1985, 23, 345–356. [Google Scholar] [CrossRef]
  73. Stanhope, J.; Breed, M.F.; Weinstein, P. Exposure to greenspaces could reduce the high global burden of pain. Environ. Res. 2020, 187, 109641. [Google Scholar] [CrossRef]
  74. Blackburn-Munro, G.; Blackburn-Munro, R. Pain in the brain: Are hormones to blame? Trends Endocrinol. Metab. 2003, 14, 20–27. [Google Scholar] [CrossRef]
  75. Hannibal, K.; Bishop, M. Chronic stress, cortisol dysfunction, and pain: A psychoneuroendocrine rationale for stress management in pain rehabilitation. Phys. Ther. 2014, 94, 1818–1825. [Google Scholar] [CrossRef]
  76. O’Reilly, A. La dépression et l’anxiété dans la douleur chronique: Une revue de travaux. J. Ther. Comport. Cogn. 2011, 21, 126–131. [Google Scholar] [CrossRef]
  77. Park, B.J.; Shin, C.S.; Shin, W.S.; Chung, C.Y.; Lee, S.H.; Kim, D.J.; Kim, Y.H.; Park, C.E. Effects of Forest Therapy on Health Promotion among Middle-Aged Women: Focusing on Physiological Indicators. Int. J. Environ. Res. Public Health 2020, 17, 4348. [Google Scholar] [CrossRef]
  78. Goli, Z.; Asghari, A.; Moradi, A. Effects of Mood Induction on the Pain Responses in Patients with Migraine and the Role of Pain Catastrophizing. Clin. Psychol. Psychother. 2016, 23, 66–76. [Google Scholar] [CrossRef]
  79. Anheyer, D.; Haller, H.; Barth, J.; Lauche, R.; Dobos, G.; Cramer, H. Mindfulness-Based Stress Reduction for Treating Low Back Pain: A Systematic Review and Meta-analysis. Ann. Intern. Med. 2017, 166, 799–807. [Google Scholar] [CrossRef]
  80. Fahey, T.; Insel, P.; Roth, W.; Wong, L. Fit and Well: Core Concepts And Labs in Physical Fitness and Wellness, 6th ed.; Ryerson, M.H., Ed.; Mayfield Publishing Company: California City, CA, USA, 2022. [Google Scholar]
Jal 05 00035 g001
Figure 1. PRISMA Flow diagram from all articles in selection and in analysis.
Figure 1. PRISMA Flow diagram from all articles in selection and in analysis.
Jal 05 00035 g001
Table 1. Quality assessment of the included studies based on the Quality Assessment for Diverse Studies (QuADS) table.
Table 1. Quality assessment of the included studies based on the Quality Assessment for Diverse Studies (QuADS) table.
* Criteria[56][57][58][59][60][61][62][63]
1. Theoretical or conceptual underpinning to the research33323212
2. Statement of research aim/s33332231
3. Clear description of research setting and target population23222321
4. The study design is appropriate to address the stated research aim/s33332322
5. Appropriate sampling to address the research aim/s23332111
6. Rationale for choice of data collection tool/s33222121
7. The format and content of data collection tool/s is appropriate to address the stated research aim/s33333231
8. Description of data collection procedure33223222
9. Recruitment data provided22113121
10. Justification for analytic method selected33003010
11. The method of analysis was appropriate to answer the research aim/s33012323
12. Evidence that the research stakeholders have been considered in research design or conduct00000000
13. Strengths and limitations critically discussed32303230
** Overall qualityHighHighHighModerateModerate to highModerateModerateLow to moderate
The chosen criteria have been indicated in bold in the table. * Each criterion was rated on a 0–3 scale, where 0 = no mention, 1 = very limited description, 2 = some description, and 3 = detailed description. ** High = ≥4 criteria rated 3 and ≥3 criteria rated 2; moderate to high = 3 criteria rated 3 and ≥4 criteria rated 2; moderate = majority of criteria rated 2; low to moderate = 3 criteria rated 2 and ≥4 criteria rated 1 or 0; low = majority of criteria rated 1 or 0.
Table 2. Description of the eight included articles.
Table 2. Description of the eight included articles.
Author (Year)Study DesignPopulationGroupsInterventionOutcomes
(i.e., Physical, Psychosocial, and Physiological)
[56]Randomized waitlist controlled feasibility trialCaucasian and African American breast cancer survivors (BCS) aged from 32 to 84 yearsE Gr: n = 44 *
C Gr: n = 38 *
* No mention of sex		1 year-long mentored home vegetable gardening (spring, summer and fall garden) every week (daily or several times weekly)Physical:
Self-reported physical activity (GL-TE-Q)
Physical performance: 2-Minute Step Test, 8-Foot Get-up and Go, 30-sec Chair Stand, Sit and Reach, Back Scratch, Arm Curl, Hand Grip Strength
Psychosocial:
Quality of life (HRQOL)
Physiological:
Biomarkers: Cortisol (stress level), telomerase (healthful aging), IL-6 (inflammation level) (via blood samples)
[57]Randomized waitlist controlled feasibility trialOlder cancer survivors aged from 60 to 91 yearsE Gr: n = 24 (6 M; 18 W)
C Gr: n = 22 (8 M; 14 W)		1 year-long mentored home vegetable gardening (spring, summer and fall garden) every week (from once/week to several times/day)Physical:
Physical activity (GL-TE-Q)
Physical performance (SFB)
Psychosocial:
Perceived stress (PSS)
Reassurance of worth (SPS)
Quality of life (SF-36)
Self-Efficacity (from SCT)
Social support (items from Sallis and colleagues)
Physiological:
Biomarkers: cortisol, telomerase, IL-6 (blood samples)
[60]Nonrandomized controlled trial Building and facility management professionals experiencing chronic widespread pain, aged from 25 to 49 yearsE Gr: n = 33 (16 M; 17 W)
C Gr: n = 28 (10 M; 18 W)		2 days of supervised forest therapy (various indoor and outdoor activities: Indoor music therapy and psychoeducation on coping with pain; walking, therapeutic activities, bodily exercises, and mindfullness-based meditation in the forest)Psychosocial:
Pain (VAS Pain)
Depression level (BDI)
Quality of life (EQ-VAS)
Physiological:
Immunological marker (NK cells) (blood samples)
Cardiovascular parameters (via ECG)
[61]Randomized controlled trialElderly with chronic heart failure (NYHA class 1 to 3) and hypertension, aged from 65 to 80 yearsE Gr: n = 23 (12 M; 11 W)
C Gr: n = 10 (7 M; 3 W)		4 days forest bathing program, consisting of two walks per day on flat terrain, each lasting 1.5 h (3 h in total per day)Psychosocial:
Mood state (POMS)
Physiological:
Blood samples: BNP, NT-ProBNP, ET-1, AGT, Ang II, AT1, AT2, IL-6, TNF-α, HCRP, T-SOD, serum MDA
[63]Randomized controlled trialElderly with chronic heart failure (NYHA class 1 to 3) and hypertension, aged from 65 to 80 yearsE Gr: n = 10 *
C Gr: n = 10 *
* From the E Gr of [61]		Addition of a second 4-day forest bathing, 4 weeks later (from [61])Physiological:
Blood samples: BNP, IL-6, TNF-α, T-SOD and MDA
[58]Pilot study:
Waitlist controlled, repeated measures		Adult women living with long COVID, aged from 24 to 61 yearsE Gr: n = 16 (16 W)One session per week of 1 h of guided online forest bathing, either at home or in a green space, for 4 weeksPhysical:
Symptoms of long COVID
Psychosocial:
Anxiety (POMS)
Rumination (qualitative)
Social connection (IOS)
Symptoms of long COVID
[59]Pilot studyIndividuals living with breast or lung cancer at various stages, aged from 45 to 67 yearsE Gr: n = 22
(4 M; 18 W)		1 day/week of integrated medicine for 12 weeks: forest therapy (walk), horticultural therapy, yoga exercises (everyday), meditation, and supportive group therapyPhysical:
Cancer related fatigue (CFS)
Psychosocial:
Well-being (FACIT-Sp)
Quality of life (SF-36)
Mood State (POMS-SF)
Anxiety (Spielbergers’s STAI)
Cancer related fatigue (CFS)
Physiological:
Immunological marker (NK cells)
[62]Pilot Study: Prospective, nonrandomized, controlled studyIndividuals suffering from fibromyalgia or nonspecific back pain, aged from 20 to 76 yearsE Gr: n = 37
C Gr: n = 42
No mention of gender		7 horticulture group sessions lasting 1 h, twice a week for 4 weeks, added to a daily pain management program (including: (1) Medical care including adapted drug therapy, (2) exercise therapy, and (3) psychotherapy, mainly cognitive, and operant behavior therapy)Physical:
Functional performance and aerobic endurance (BPS and 6MWT)
Psychosocial:
Quality of life (SF-36)
Anxiety and depression (HADS)
Pain (MPI)
Coping strategies (CSQ)
6MWT: 6—Minute Walk Test, AGT, Ang II, AT1, and AT2: Components of the renin-angiotensin system playing a protective role in cardiovascular diseases, BCS: Breast Cancer Survivors, BDI: Beck Depression Inventory, BNP: Brain Natriuretic Peptide/biomarker of CHF, BPS: Back Performance Scale, C Gr: Control Group, CFS: Cancer Fatigue Scale, CHF: Chronic Heart Failure, CSQ: Coping Strategy Questionnaire, ECG: Electrocardiogram, EQ-VAS: EuroQo Visual Analog Scale, E Gr: Experimental Group, ET-1: Endothelin-1/biomarker of cardiovascular diseases, FACIT-Sp: Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale, GL-TE-Q: Godin Leisure-Time Exercise Questionnaire, HADS: Hospital Anxiety and Depression Scale, HR: Heart Rate, HRQOL: Health-Related Quality of Life questionnaire, IL-6, TNF-α, and HCRP: Pro-inflammatory cytokines, IOS: Inclusion of Others in the Self scale, M: Men, MPI: Multidimensional Pain Inventory, NK cells: Natural Killer cells, NT-ProBNP: N-terminal pro b-type natriuretic peptide/biomarker of CHF, POMS: Profile Of Mood State, POMS-SF: Short-form of the Profile Of Mood State questionnaire, PWBI: Personal Well-being Index, SDNN: Standard Deviation of Normal to Normal intervals, SCT: Social-Cognitive Theory, SFT: Senior Fitness Battery, SF-36: Short-Form Health Survey to assess Quality of Life, SPS: Social Provision Scale, Spielberger’s STAI: State-Trait Anxiety Inventory, T-SOD: Antioxidant enzyme, TP: Total Power, VAS Pain: Visual Analog Scale for Pain, WHO: World Health Organization, W: Women.
Table 3. Physical, psychosocial and physiological results from the studies.
Table 3. Physical, psychosocial and physiological results from the studies.
Author (Year)InterventionResults (Statically Significant)Overall Quality of the Study
Population/Chronic DiseasePhysicalPsychosocialPhysiological
[56]Mentored home vegetable gardening (1 year)↑ Time of moderate physical activity (in E Gr vs. C Gr)
↑ aerobic capacity (in E gr vs. C Gr)
↑ upper body strength
(in E Gr vs. C Gr)
↑ flexibility of hamstrings and lower back (in E Gr only)
↑ grip strength (in E Gr and C Gr) 		No significant resultNo significant resultHigh
BCS
[57]Mentored home vegetable gardening (1 year)↑ aerobic capacity (in E Gr only)
↑ gait speed and balance
(in E Gr C Gr)		↑ Reassurance of worth
(in E Gr vs. C Gr)		↓ telomerase activity (in E Gr)*
* No mention of comparison between groups		High
Older cancer survivors
[60]Supervised forest therapy (2 days) ↓ Pain level (in E Gr *)
↑ Quality of life (in E Gr *)
↓ Depression level
(in E Gr and C Gr *)
* No comparison between groups		↑ NK cells (in E Gr)
↑ ANS function (via ↑ SDNN and TP) (in E Gr)
↓ HR and SDNN (in C Gr) 		Moderate to high
Chronic widespread pain
[61]Forest bathing program
(4 days)		 ↑ mental state (anxiety, depression and confusion)
(in E Gr vs. C Gr)		↓ CHF markers, pro-inflammatory cytokines and oxydative stress levels
(in E Gr vs. C Gr)
↑ AT2 (protective role in cardiovascular diseases)
(in E Gr)		Moderate
Elderly with CHF
[63]Second forest bathing program (4 days) Additive benefits from [61]:
↓ CHF markers, pro-inflammatory cytokines and oxydative stress levels
(in E Gr)		Low to moderate
Elderly with CHF
[58]Guided online forest bathing (4 weeks)↓ long COVID symptoms (fatigue, brain fog and sleep quality)
(in E Gr vs. the waitlist-controlled period)		↓ anxiety *
↓ rumination *
↓ long COVID symptoms
(depression and anxiety) *
↑ social connection *
* (in E Gr vs. waitlist-controlled period)		 High
Long COVID
[59]Integrated medicine (12 weeks)↓ Cancer related fatigue (physical, affective and total fatigue)↑ functional and spiritual well-being
↑ quality of life
↑ mood state
↑ anxiety		↑ Immunological marker activity (NK cells) Moderate
Breast or lung cancer
[62]Horticultural therapy (4 weeks)↑ functional performance and
aerobic endurance
(in E Gr and C Gr) 		↑ quality of life
(role physical and mental health of the SF-36)
(in E Gr vs. C Gr)
↓ anxiety (in E Gr vs. C Gr)
↓ pain related behaviors
(in E Gr vs. C Gr);
↓ pain severity, interference with pain, affective distress and life control (from MPI)
(in E Gr) 		Moderate
Fibromyalgia or non specific back pain
ANS: Autonomic Nervous System, AT2: Components of the renin-angiotensin system playing a protective role in cardiovascular diseases, BCS: Breast Cancer Survivors, C Gr: Control Group, CHF: Chronic Heart Failure, E Gr: Experimental Group, HR: Heart Rate, HRQOL: Health-Related Quality of Life questionnaire, IL-6, TNF-α, and HCRP: Pro-inflammatory cytokines, IOS: Inclusion of Others in the Self scale, M: Men, MPI: Multidimensional Pain Inventory, NK cells: Natural Killer cells, SDNN: Standard Deviation of Normal to Normal intervals, SF-36: Short-Form Health Survey to assess Quality of Life, TP: Total Power, W: Women,↑: Increased, ↓: Decreased.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Fortin, É.; Langelier, M.-È.; Léonard, G.; da Silva, R.A. The Impact of Nature-Based Interventions on Physical, Psychosocial, and Physiological Functioning for Physical Chronic Diseases: A Systematic Review. J. Ageing Longev. 2025, 5, 35. https://doi.org/10.3390/jal5030035

AMA Style

Fortin É, Langelier M-È, Léonard G, da Silva RA. The Impact of Nature-Based Interventions on Physical, Psychosocial, and Physiological Functioning for Physical Chronic Diseases: A Systematic Review. Journal of Ageing and Longevity. 2025; 5(3):35. https://doi.org/10.3390/jal5030035

Chicago/Turabian Style

Fortin, Émilie, Marie-Ève Langelier, Guillaume Léonard, and Rubens A. da Silva. 2025. "The Impact of Nature-Based Interventions on Physical, Psychosocial, and Physiological Functioning for Physical Chronic Diseases: A Systematic Review" Journal of Ageing and Longevity 5, no. 3: 35. https://doi.org/10.3390/jal5030035

APA Style

Fortin, É., Langelier, M.-È., Léonard, G., & da Silva, R. A. (2025). The Impact of Nature-Based Interventions on Physical, Psychosocial, and Physiological Functioning for Physical Chronic Diseases: A Systematic Review. Journal of Ageing and Longevity, 5(3), 35. https://doi.org/10.3390/jal5030035

Article Metrics

Back to TopTop