Physical Environment & Health

It is well documented that the physical environment influences population health, has an impact on chronic diseases and could have a preventative role on human’s health and wellbeing by promoting physical activity (Sallis et al., 2016). At the same time, there are physical, mental and social health problems associated with the environment and behaviours, as a result of our modern way of living. With the majority of the population living in urban environments, the importance of reconnecting with nature is more urgent than ever. Natural environments are connected with restorative experiences that improve mental health and social wellbeing, while therapeutic landscapes could stimulate greater activation in the brain regions responsible for visual attention (Olszewska, 2015).

There are a variety of nature-based interventions considered as green prescribing, including therapeutic horticulture, biodiversity conservation activities, farming, nature walk and forest bathing (Robinson et al., 2020). It is therefore crucial to make accessible, inclusive and high quality greenspaces as a primary goal of health-centric urban policies. From a landscape design and management perspective, however, there is limited evidence on which spatial characteristics can encourage mental and physical wellbeing most effectively (Stigsdotter, Sidenius & Grahn, 2020), and how different green spaces and design qualities could benefit or prevent specific chronic diseases.


Chronic Pain & Nature

Many studies have attempted to explore the potential effect of nature in pain. Most people will feel pain at some point in their lives, however, on some occasions this pain may persist due to a number of processes. Chronic pain rarely represents the actual condition of our body’s tissues, but is often influenced by a range of psychosocial issues (Moseley, 2007). Therefore, the benefits of nature on mental and social health, could be associated with the improvement of chronic pain as well (Stanhope, Breed & Weinstein, 2020).

In musculoskeletal conditions such as osteoarthritis, fibromyalgia or chronic low back pain, which are usually associated with persistent pain, mental and social well-being may play an important role in how people experience their symptoms. By performing activities in nature, body and mind could be benefited through physiological changes associated with physical activity, as well as changes in mental and social well-being resulting from the type of environment this physical activity is taking place in. Therefore, it would be interesting to understand the physiological responses of chronic pain when the body is exposed to different surrounding environments. 

Nafsika Michail (Dip.Arch, MA, PhD candidate)

Nafsika Michail (Dip.Arch, MA, PhD candidate)

Healthy street designer, Sustrans North

Nafsika is an Architect & Landscape Architect and she is researching the role of the physical environment in shaping healthy behaviours and encouraging physical activity. She has experience in participatory research, behaviour change and public health interventions.

Charalampos Harris Kelesidis (BSc, MSc MMACP)

First Contact Physiotherapist, Leeds GP practices

Harris is a Physiotherapist & Manual Therapist and he is keen on preventing and treating chronic pain related to musculoskeletal conditions. He has worked in a variety of practices including musculoskeletal private practices, private and public sector hospitals.

Health-related landscape research focuses on the mental health benefits of nature. Pain-related research suggests the connection between chronic pain and mental health. It would be intriguing then to explore the links between landscape architecture and chronic pain.

Possibilities for future research and clinical practice

Poor communication between the two disciplines makes research findings hard to apply. Landscape researchers may not understand various health conditions, while health professionals understand nature under the abstract term ‘greenspaces’. There is a need to actively connect the two disciplines and establish transdisciplinary collaborative pathways (Robinson et al. 2020), in order to develop a common vocabulary in nature-based interventions. 

Collaborations between physiotherapists and landscape architects could explore how specific design qualities of landscapes affect physiological responses of chronic pain. Transdisciplinary research could consider both health conditions (e.g. various musculoskeletal disorders) and design characteristics (e.g. path scale, materiality, vegetation, topography etc). Starting a dialogue between physiotherapy and landscape architecture could inform frameworks on which measurements should be taken both in biopsychosocial level and landscape design level, considering potential associations. Such an exploration demands a deep understanding of both disciplines and an active cooperation between physiotherapists, landscape architects and professionals from other fields. Physiotherapists and other health professionals, as well as patients must be part of a collaborative design process for therapeutic landscapes that could be used as clinical places and could benefit clinical practice and patient’s health.

Testing different design characteristics for various physiological responses could bring new knowledge on which landscapes may benefit different disorders. This explorative process could then inform the best possible design of clinical nature-based places. Moving further, this knowledge could eventually inform the design and management of everyday greenspaces and landscapes for the benefit of public health. 

An emerging collaboration

We’re a Physiotherapist and a Landscape Architect, both passionate about our fields, constantly seeking how our professions could be better practiced. From our experience so far, work conditions common to our respective professions do not correlate with how we believe our professions should be practised. Usual physiotherapy sessions take place in indoor settings, and in some instances even without natural light, thus presenting an unhealthy environment for practitioners and patients alike that deprives them of the health-benefits they may experience from greenspaces. At the same time, landscape architects design outdoor places for people and communities while working in offices without exposure to an immersive understanding of the needs of local people and the special circumstances of a landscape. All of the above led us to discussions around healthy working environments and the potential connection between natural landscapes and clinical practice

 We’re currently planning to use a piece of land with various landscapes and vegetation, which will be capable of accommodating both indoor and outdoor physiotherapy sessions. The selection of the location will depend on the accessibility for the local community and most importantly what type of community we would like to target (urban, semi-urban, rural). Our objective is to gradually develop an outdoor therapyscape as a result of participatory action research with chronic-pain patients. Physiotherapy sessions will feed in the designing of the landscape, based on the experience of both patients and physiotherapists. When the co-design process will eventually result in specific landscapes, we’re aiming to understand the effect of outdoor physiotherapy in chronic-pain patients. However, we are still developing a methodology framework for this action research, based on both chronic pain and therapeutic landscape literature.


Moseley, L. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews. 12. 169-178. 10.1179/108331907X223010.

Olszewska, A. (2015). Contemplative values of urban parks and gardens: Applying neuroscience to landscape architecture. PhD Thesis, University of Porto, Porto, Portugal.

Robinson, J.M., Jorgensen, A., Cameron, R., & Brindley, P. (2020). Let Nature Be Thy Medicine: A Socioecological Exploration of Green Prescribing in the UK, Int. J. Environ. Res. Public Health 2020, 17(10), 3460;

Sallis, J.E., et al. (2016). Physical activity in relation to urban environments in 14 cities worldwide: a cross-sectional study. Lancet, 387 (10034), 2207–2217. doi:10.1016/S0140-6736(15)01284-2

Stanhope, J., Breed, M., F, Weinstein, P., (2020). Exposure to greenspaces could reduce the high global burden of pain. Environmental Research, Volume 187,109641, ISSN 0013-9351,

Stigsdotter, U., K., Sidenius, U., and  Grahn, P., (2020). From research to practice: Operationalisation of the eight perceived sensory dimensions into a health-promoting design tool. Alam Cipta 13 (Special Issue 1), May 2020: Pathways to Urban Sustainability