Close your eyes for a minute and visualize one of your favorite moments in nature. What feelings arise in you?

Have you ever felt the need to integrate the natural environment in your therapy? During my breaks in the internships I tried to expose myself to as much sun and fresh air as possible to stay energized on a full day inside the clinic. No matter how bad the day was, my walking break always felt good to me. When I was asked about my bachelor thesis, I reflected on my internships and felt the need to enable patients to take energizing walks in nature. It was challenging to put my, by now, “anecdotal evidence based thoughts” into practice. Questions like the following floated in my head:

Why do we often choose technologies when it comes to innovation instead of looking at health innovations from an evolutionary approach? What is the purpose of a health innovation? Why do we often look at humans separate from the environment? Why have we forgotten to see ourselves as a part of nature?

I was quite indecisive about how to start, but I found interesting research about forest therapy that excited me to dive deeper into the health benefits of natural environments. I asked myself, why we are not making extensive use of the health benefits provided by our natural environment in therapy. After exploring the forest with all its species-appropriate potential for human health, I began to develop tasks designed for using the forest in a therapeutic context.

Just take time for yourself right now and explore the task. When was the last time you watched the clouds?

While demands on healthcare are increasing due to the rise and complexity of chronic diseases, physiotherapy is in need to further design interventions that are based on sharing the responsibility of health between patient and physiotherapists through self-management and patient empowerment (7–9). A recent systematic review has advocated that policy makers and health professionals should integrate frequent nature-based interventions in clinical settings to have a long-lasting effect on quality of life (10).

On this basis, the aim of my case-study bachelors project was to investigate the feasibility of a nature-based homework program (NBHP) to teach a patient with a chronic disease how to improve their quality of life using nature’s health benefits at Gesundheitszentrum Deubener.

The patient in this case study was a 33 year-old female diagnosed with multiple sclerosis in 2009. After several lighter relapses she suffered a severe relapse in March 2019. She was on sick leave since her last relapse and worried about not being able to work anymore. She complained of a constant increase of her stress levels and a wide range of physical complaints typical for MS.

The NBHP was an 8 week program based on nature-based homework and guided reflections with the physiotherapist. The physiotherapeutic management consists of 40 minutes weekly. It starts with formulating a SMART goal and educating the patient about the function of our brain, senses and pain in relation to nature’s health benefits. After the first session the 40 minutes are split in two sessions. First, a 20 minutes reflection session to encourage patient reflection, find implementation strategies and guide self-management. Second, a 20 minutes physiotherapy session which focused mostly on improving gait steadiness in this case.

The nature based homework consisted of being in a forest environment and completing one task each walk. It was required to be in a forest environment for 5 days per week for at least 20 minutes each time. The patient was able to freely choose 10 of 20 tasks that were provided on little paper cards. The tasks were based on enhancing the human-nature relationship by describing the interaction with the natural environment and educational advice about its health benefits. Each task is subdivided in either body perception, mindfulness or our senses to set a therapeutic focus to the task in nature. Additionally, the patient received one of three basis tasks each 2 weeks that focus on integration of healthy routines in daily life (for example: Heaven’s door). Another reflection tool is a small empty notebook. It is provided for the patient to voluntarily write down thoughts, experiences on forest walks or whatever she likes. The notebook doesn’t need to be shown to any therapist, but rather had the purpose to be used as the patient’s own personal diary.

Two questionnaires were used to measure quantitative data about quality of life and nature relatedness. The health related quality of life questionnaire (SF-36) showed a significant change in social function from 50 to 100 points. Bodily pain and vitality improved by 35 points from baseline. The nature relatedness scale (NR-6) improved from 2.33 to 3.66 (Total: 5). It is considered a predicator of happiness, environmental concern, and nature relatedness. Strong nature relatedness is associated with greater happiness and ecologically sustainable behavior (11).

Qualitative measures were collected with a semi-structured interview of the executive director Steffen Deubener and the patient. The executive director explained that the focus on the environment gives the patient the feeling of doing something valuable for their health regardless of how they execute it. For the patient the environment that offered sensory experiences, trees to balance on, animals to watch and stillness to relax, was a motivation to repeat the walk almost every day. She felt more balanced mentally from being in the forest daily and equated the improvements of her gait steadiness in the forest with being able to go out more often.

“Now that I make it up to 2 hours through the forest without any problems, I go to the disco again in the evenings.”

The patient experienced a wide range of positive effects on behavioral change that consisted of trying out yoga, meditation and cooking more vegetables. She reflected that she can rely on her senses, take a forest walk to relieve her headache instead of taking a pill, relax when reading or being alone in the forest.

“As soon as you interact with the forest, you also deal with other things about how you can make your life better and healthier.”

The improvement of mental health during the NBHP aligns with existing literature, which shows that more frequent active visits in nature facilitate more positive thoughts (12). The subjective improvement of the patient’s senses could be related to the quality of the stay in the forest, which was enhanced by the tasks focusing on sensory experiences in nature (13). The improvements in her gait steadiness could be related to the amount of walking through the challenging terrain of the forest and the focus on gait training during physiotherapy. The significant increase from 20 minutes up to 2 hours walking capacity might be facilitated by the rapid increase of parasympathetic tone in forests, which she felt through lower levels of perceived exertion (14, 5). Another unexpected effect was the regeneration of her sweat response. She was positively shocked when she felt the sweat during sports, because the last time she sweat was eight years ago.

The patient increased her connection to nature, which helped her a great deal to comply with the program and to benefit from the additional effects of physical activity in return. The patient identified the following factors as important for her compliance: becoming aware of her positive progress, being in nature, concentrating on herself, controlling the therapy at her own pace, not wanting to write down or report negative things. A systematic review concluded that an increased compliance in self-management programs for chronic conditions was linked to individual sessions in a clinical setting, which aligns with our findings about the importance of the reflection session with the physiotherapist (15). The teaching of self efficacy during the program was ensured by guiding the patient towards the process of self-exploration when choosing the task, the natural environment and the content of the notebook herself. The preferences of the patient were respected to put her in control of the level of interaction with nature. The patient was on sick leave and lived only 5 minutes walking from a forest, which can be seen as an advantage for the implementation of the NBHP, but also shows the feasibility and demand of a homework program in this case.

Another factor for compliance was the perceived simplicity of the NBHP. But when all the resulting behavior changes are considered, the phrasing of simplicity might even seem contradictory. The question should be, why did she perceive the implementation of the homework program as simple and why did she decide to spend more and more time in nature? The design of the NBHP and the role of the natural environment on the human body might offer explanations for the extraordinary effects of the NBHP.

“There is rarely a day when I don’t go (into the forest) because I feel like my body really calls for it.”

This finding might be evoked by the continuous reflections. Yet explained by the Supportive Environment Theory (SET), which argues regarding the scope of meaning that when a person becomes ill or is in a life crisis, she is more dependent on the non-human environment. The reason for this is that our most complex relations are to other people and the simplest relations are to inanimate objects such as water, stones and trees (16, 17). A better nature connectedness would therefore translate into a stable relationship with the natural elements, which helps the patient to reduce anxiety and pain, spark creative processes, restore the sense of self, improve our perceptions for reality and promote tolerance and understanding (18).

The triangle of the SET illustrates the stages of engagement that the patient might have gone through during the 8 weeks of the NBHP (19). The patient was facilitated to self-regulate by searching for environments she perceived as supportive and secure. According to SET the NBHP might have led to the patient selecting the supportive environment based on the sensory impulses that initiated salutogenic effects regarding, e.g., senses, hormones, emotions and cognition, which affect function, feelings and behaviour (20). Therefore the key learning of the patient was to become aware of supportive environments and use them for the rise of her physical and mental health. This made the NBHP a powerful tool to facilitate various ways of behavior change up to the point of social reintegration and returning back to work.

Figure 1. Triangle of supporting environments (from Bengtsson & Grahn, 2014). The lower a person is in the triangle, the greater is the need for a supportive non-human environment and vica versa.

The patient described how the NBHP has helped her with the following statement:

“The cool thing is that at work I can look out of the window towards the forest. Then I can get the pictures back in my head and I often say to myself, everything is fine, take it easy”

Building on this Bachelor thesis project, I am inclined to think that NBHPs have the potential to give physiotherapists the ability to help patients with a chronic disease to improve their health in a previously unconsidered way. Through an NBHP as I developed, patients might learn a stress management tool that enables them to  find supportive environments to improve their quality of life. A re-established connection to nature in a therapeutic context opens the door for salutogenic interventions in the rehabilitation of patients with chronic health problems. Furthermore, the natural environment might be one of the most important contributors to the effect and feasibility shown by this case-study. Physiotherapy could benefit greatly by further researching and implementing nature based interventions for the management of chronic health problems.

Nature-based interventions also open possibilities towards research questions that reach beyond benefits for human health. We might start asking if nature-based interventions produce co-benefits for biodiversity and climate change? If yes, could nature based therapeutic interventions not also be thought of as nature-based solutions? How can we better link nature-based interventions with nature-based solutions to let patients experience the reciprocal relationship between their health and the health of our planet?

Please feel free to comment here, or contact me on twitter, Linkedin or instagram anytime. I would really love to hear your thoughts, so we can start a discussion about all this right here and now. Lastly, I want to thank Steffen Deubener for enabling this case study at Gesundheitszentrum Deubener in Germany.

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