Teaching prompts to get you started with planetary health, environmental, and sustainability education in physiotherapy. No matter what subject you teach.
The teaching prompts on this page are meant to provide physiotherapy educators around the world with simple starting points to integrate planetary health, environmental, and sustainability education into their teaching, with a focus on one of their most fundamental learning dimensions identified in the majority of leading education and competency frameworks for planetary health, environmental and sustainability education: the interconnections between health, environment, society, and, in our case, physiotherapy.
Identifying such starting points across all subjects taught in physiotherapy curricula, also lays the foundation for further implementation of environmental physiotherapy across curricula and the integration of other key competencies for sustainability. As such, these teaching prompts will also be the central output of the EPT Agenda 2027, which aims at the transversal implementation of environmental physiotherapy across curricula.
How to use these teaching prompts
These EPT teaching prompts are only meant to give you starting ideas and supporting literature to begin the integration of planetary health, environmental and sustainability education into whichever subject you are teaching in a physiotherapy curriculum.
Each teaching prompt is accompanied by a bullet point list with background information, supporting literature, and the name of the contributing author. To access this information, click on the plus (+) sign to the right side of the bar to each teaching prompt.
Feel free to copy, paste and adapt the content into your presentations or use them as inspiration for your explorations of the intersections between physiotherapy, health, society and the environment. Where it seems reasonable please acknowledge this resource in your presentation by including the EPA and ENPHE logos and the name of the contributing author of each respective teaching prompt.
Anatomy and Physiology
Human anatomy is fundamentally shaped by the environment
Background information
- All aspects of human anatomy and function are fundamentally shaped by our relationship to the environment
- Minerals are essential elements and building blocks of the large parts of human bodies and our bones are shaped through constant interaction with gravity
- The function of our muscles and nervous system depends on energy absorbed from the environment via food, air, and other sources
- The primary function of our joints is to set us in relation to the environment around us, whether it is to reach a place we want to get to, shake somebody’s hand, or lead a spoon to our mouth
- This can be acknowledged in teaching about human anatomy and function to provide a broader perspective on the body
Supporting literature
Gomes, C., & Rautureau, M. (Eds.)(2021). Minerals latu sensu and Human Health. Springer. https://doi.org/10.1007/978-3-030-65706-2
Richter, R., & Maric, F. (2022). Ecological Bodies and Relational Anatomies: Toward a Transversal Foundation for Planetary Health Education. Challenges, 13(2), 39. https://doi.org/10.3390/challe13020039
Ruggiu, A., & Cancedda, R. (2015). Bone mechanobiology, gravity and tissue engineering: effects and insights. Journal of Tissue Engineering and Regenerative Medicine, 9(12), 1339–1351. https://doi.org/10.1002/term.1942
Contributing author
For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway.
Thermoregulation and climate change are deeply connected
Background information
- In many countries, climate change is resulting in greater levels of heat strain for workers and other people undertaking physical activity during hot and humid months
- This is particularly so in natural environments where the ambient temperature and humidity are not controlled. In such contexts, core temperature and sweat loss in humans can rapidly rise and exceed safe levels, necessitating strategies to address these concerns and so manage risks of heat illness, heat injuries and, in worst-case scenarios, heat-related deaths
- Simply taking a break from physical activity and resting in the shade is unlikely to reduce high core temperatures to safer levels within acceptable time frames. In some instances, core temperatures continue to rise despite such rest breaks
- Human thermoregulatory mechanisms, alone, are frequently unable to adequately reverse core temperature rises in conditions of high heat stress, which are becoming more common with climate change
- Active cooling and preventive strategies are therefore becoming more important to manage risks to health and to worker productivity and athletic performance
Supporting literature
Brearley, M., Berry, R., Hunt, A. P., & Pope, R. (2023). A Systematic Review of Post-Work Core Temperature Cooling Rates Conferred by Passive Rest. Biology, 12(5), 695. https://doi.org/10.3390/biology12050695
Hall, A., Horta, A., Khan, M. R., & Crabbe, R. A. (2022). Spatial analysis of outdoor wet bulb globe temperature under RCP4. 5 and RCP8. 5 scenarios for 2041–2080 across a range of temperate to hot climates. Weather and Climate Extremes, 35, 100420. https://doi.org/10.1016/j.wace.2022.100420
Hunt, A.P., Brearley, M., Hall, A., & Pope R. (2023). Climate change effects on the predicted heat strain and labour capacity of outdoor workers in Australia. International Journal of Environmental Research and Public Health, 20, 5675. https://doi.org/10.3390/ijerph20095675
Contributing author
For questions about the content in this specific set please contact Prof Rod Pope, Charles Sturt University, Australia.
Thinking about breathing facilitates a different future for the human body and the physiotherapy profession
Background information
- Oxygen makes up 60% of our body mass – far more than carbon – and our ability to obtain oxygen from the atmosphere means we are intrinsically connected to our local environment and the wider ecosystem that maintains the conditions conducive to organic life
- Because breathing is a process of exchange, it dissolves the fictional boundary between what we think of as ‘inside’ the body, and what is ‘outside’. After all, when does an oxygen molecule actually become part of ‘me’?
- Thinking about oxygen, air and breathing as more than just anatomical, physiological and biomedical issues allows us to imagine a broader role for physical therapies that might follow the path of air into questions about things like urban pollution, deforestation and algal blooms, as well as the meaning of breath in different world cultures. Clearly, it is more than just about pulmonary function and the treatment for chronic lung disease
- So breathing also offers a critique of the traditional belief that physical therapies should be confined to narrow Western biomedical ideals; opening a door to thinking radically about a different future for the profession
Supporting literature
Maric, F., & Nicholls, D. A. (2022). Environmental physiotherapy and the case for multispecies justice in planetary health. Physiotherapy Theory and Practice, 38(13), 2295–2306. https://doi.org/10.1080/09593985.2021.1964659
Nicholls, D. A. (2019). What’s real is immaterial: What are we doing with new materialism? Aporia: The nursing journal, 11(2), 3-13. http://hdl.handle.net/10292/13056
Richter, R., & Maric, F. (2022). Ecological Bodies and Relational Anatomies: Toward a Transversal Foundation for Planetary Health Education. Challenges, 13(2), 39. https://doi.org/10.3390/challe13020039
Contributing author
For questions about the content in this specific set please contact Prof David Nicholls, AUT University Auckland, New Zealand.
Assessment and Analysis
Considering environmental factors in physiotherapy management for structure, function, activity and participation
Background information
- The International Classification of Function (ICF) compartmentalised the patient together with the patient’s condition into the multiple factors that impact the overall wellbeing of the patient
- The ICF is used when evaluating disability and health and it considers the patient’s body structures and function, activities and participation, environmental and personal factors in the holistic management of the patient’s condition
- Climate and other environmental change may be considered in the context of ICF environmental factors that facilitate or inhibit patients function, activity and participation to improve physiotherapy management plans
Supporting literature
Gaskin, C. J., Taylor, D., Kinnear, S., Mann, J., Hillman, W., & Moran, M. (2017). Factors Associated with the Climate Change Vulnerability and the Adaptive Capacity of People with Disability: A Systematic Review. Weather, Climate, and Society, 9(4), 801–814. https://doi.org/10.1175/wcas-d-16-0126.1
Humpel, N. (2002). Environmental factors associated with adults’ participation in physical activity A review. American Journal of Preventive Medicine, 22(3), 188–199. https://doi.org/10.1016/s0749-3797(01)00426-3
Noreau, L., & Boschen, K. (2010). Intersection of Participation and Environmental Factors: A Complex Interactive Process. Archives of Physical Medicine and Rehabilitation., 91(9), S44–S53. https://doi.org/10.1016/j.apmr.2009.10.037
Contributing author:
For questions about the content in this specific set please contact Mahitsonge Nomusa Ntinga, University of Cape Town, South Africa.
Expanding clinical reasoning to include environmental concerns
Background information
- Clinical reasoning (CR) is an essential skill of physiotherapists and refers to the conscious and unconscious cognitive operations to integrate information pertaining to a patient’s unique circumstances
- CR can include diagnostic, therapeutic or narrative and tends to relate to the biopsychosocial model. It should incorporate wider holistic and contextual factors which include environmental considerations as these have significant potential to be implicated as causes of adverse health and barriers to improvement, they may coincide with factors relating to health inequalities
- Novice and experienced clinicians may use different models of CR but should strive for personalised, prioritised problem lists and shared decision making unique to the situation
- Tools to support clinical reasoning, for example concept maps and vector diagrams might help prompt clinicians to consider environmental contextual factors and support people to reflect on the impact and influence of environmental concerns and factors related to their health condition, activity, participation and QoL, more research is needed in this area
Supporting literature
Montpetit-Tourangeau, K., Dyer, J.-O., Hudon, A., Windsor, M., Charlin, B., Mamede, S., & Van Gog, T. (2017). Fostering clinical reasoning in physiotherapy: comparing the effects of concept map study and concept map completion after example study in novice and advanced learners. BMC Medical Education, 17(1). https://doi.org/10.1186/s12909-017-1076-z
Cruz, E. B., Caeiro, C., & Pereira, C. (2014). A narrative reasoning course to promote patient-centred practice in a physiotherapy undergraduate programme: a qualitative study of final year students. Physiotherapy Theory and Practice, 30(4), 254–260. https://doi.org/10.3109/09593985.2013.863415
Huhn, K., Gilliland, S.J., Black, L.L., Wainwright, S.F., Christensen, N. (2018) Clinical reasoning in physical therapy: A concept analysis. Physical Therapy, 99(4):440-456. https://doi.org/10.1093/ptj/pzy148
Contributing author
For questions about the content in this specific set please contact Dr Katherine Cook, University of Winchester, UK.
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Musculoskeletal Physiotherapy
Using active transport to promote physical activity and reduce carbon emissions
Background information
- Active transport can be a powerful means to achieve the WHO physical activity recommendations
- At scale and in combination with public transport, it can also significantly reduce greenhouse gas emissions in urban transport
- Active transport should be recommended for all commutes under 5km
- Teaching about physical activity and exercise prescription can easily include knowledge and skills relevant to the promotion of active transport as a clinical planetary health intervention.
Supporting literature
Bull, F. C., Al-Ansari, S. S., Biddle, S., Borodulin, K., Buman, M. P., Cardon, G., Carty, C., Chaput, J.-P., Chastin, S., Chou, R., Dempsey, P. C., Dipietro, L., Ekelund, U., Firth, J., Friedenreich, C. M., Garcia, L., Gichu, M., Jago, R., Katzmarzyk, P. T., … Willumsen, J. F. (2020). World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine, 54(24), 1451–1462. https://doi.org/10.1136/bjsports-2020-10295
Salvo, D., Garcia, L., Reis, R. S., Stankov, I., Goel, R., Schipperijn, J., Hallal, P. C., Ding, D., & Pratt, M. (2021). Physical Activity Promotion and the United Nations Sustainable Development Goals: Building Synergies to Maximize Impact. Journal of Physical Activity and Health, 18(10), 1163–1180. https://doi.org/10.1123/jpah.2021-0413
Toner, A., Lewis, J. S., Stanhope, J., & Maric, F. (2021). Prescribing active transport as a planetary health intervention – benefits, challenges and recommendations. Physical Therapy Reviews, 26(3), 159–167. https://doi.org/10.1080/10833196.2021.1876598
Contributing author
For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway.
Integrating outdoor exercise prescription for MSK prevention and rehabilitation
Background information
- Outdoor exercise and exposure to green and blue spaces can add many benefits to physical activity and its prescription for prevention and rehabilitation
- Variable surfaces and environments can give diverse challenges and stimulation that can contribute to the development of strength, endurance, proprioception, coordination, and overall physical health
- In addition to physical health, outdoor exercise has proven benefits for mental health and is increasingly showing potential to reduce the global burden of pain
- Teaching about physical activity and exercise prescription can easily include knowledge and skills relevant to the promotion of outdoor exercise as a planetary health intervention
Supporting literature
Kondo, M. C., Oyekanmi, K. O., Gibson, A., South, E. C., Bocarro, J., & Hipp, J. A. (2020). Nature Prescriptions for Health: A Review of Evidence and Research Opportunities. International Journal of Environmental Research and Public Health, 17(12), 4213. https://doi.org/10.3390/ijerph17124213
Stanhope, J., Breed, M. F., & Weinstein, P. (2020). Exposure to greenspaces could reduce the high global burden of pain. Environmental Research, 187, 109641. https://doi.org/10.1016/j.envres.2020.109641
Stanhope, J., Maric, F., Rothmore, P., & Weinstein, P. (2023). Physiotherapy and ecosystem services: improving the health of our patients, the population, and the environment. Physiotherapy Theory and Practice, 39(2), 227–240. https://doi.org/10.1080/09593985.2021.2015814
Contributing author
For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway.
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PulMonary Physiotherapy
Antenatal air pollution exposure and chronic obstructive lung disease
Background information
- Severe and prolonged heat waves, temperature variability, forest fires, consequent air pollution and floods are clear signs of climate changes
- Besides harming the planet these also put respiratory health at risk and increase morbidity and mortality among patients with chronic health diseases
- An even more alarming impact concerns antenatal air pollution exposure
- Maternal exposure to tobacco or fossil fuel-generated air pollutants causes in-utero growth retardation, lung remodelling and immune cell activation increasing the risk of developing asthma or respiratory infections, which seems to contribute to childhood origins of chronic obstructive lung disease by changing the ability for normal lung development and repair
Supporting literature
Voynow, J. A., & Auten, R. (2015). Environmental Pollution and the Developing Lung. Clinical pulmonary medicine, 22(4). https://doi.org/10.1097/cpm.0000000000000095
Bernstein, A. S., & Rice, M. B. (2013). Lungs in a Warming World. Chest., 143(5), 1455–1459. https://doi.org/10.1378/chest.12-2384
Shah, P. S., & Balkhair, T. (2011). Air pollution and birth outcomes: A systematic review. Environment International, 37(2), 498–516. https://doi.org/10.1016/j.envint.2010.10.009
Contributing author
For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal.
Air pollution, COPD and acute exacerbations
Background information
- Environmental factors such as exposure to biomass, fossil fuels, metals and indoor and outdoor air pollution, have a key role on the development of COPD and acute exacerbations
- These pollutants damage the airways by increasing bronchial activity, airway oxidative stress and inflammation
- Additionally exposure to these pollutants has also been found to increase hospital admission due to acute exacerbations
- Addressing air pollution is therefore an indispensable healthcare measure related to COPDs and acute exacerbations
Supporting literature
Dransfield, M., Stolz, D., & Kleinert, S. (2019). Towards eradication of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet , 393(10183), 1786–1788. https://doi.org/10.1016/S0140-6736(19)30950-X
Ko, F. W. S., & Hui, D. S. C. (2012). Air pollution and chronic obstructive pulmonary disease. Respirology, 17(3), 395–401. https://doi.org/10.1111/j.1440-1843.2011.02112.x
Souto-Miranda, S., Gonçalves, A.-C., Valente, C., Freitas, C., Sousa, A. C. A., & Marques, A. (2020). Environmental Awareness for Patients with COPD Undergoing Pulmonary Rehabilitation: Is It of Added Value? International Journal of Environmental Research and Public Health, 17(21), 7968. https://doi.org/10.3390/ijerph17217968
Contributing author
For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal.
Good indoor environments are essential for pulmonary health
Background information
- People spend most of the time in confined environments, such as home, offices among others
- In indoors environments, the concentration of air pollutants may be too high due to thermal insulation to reduce heat loss and also due to scarce ventilation, thus reducing indoor air quality
- Studies have reported associations between asthma symptoms and indoor sources of chemical pollutants among others, such as volatile organic compounds, gas appliances or even exposure to tobacco smoke
- This makes it ever more important to address indoor environments to ensure good pulmonary health
Supporting literature
Hahad, O., Daiber, A., & Münzel, T. (2023). Physical activity in polluted air: an urgent call to study the health risks. The Lancet Planetary Health, 7(4), e266–e267. https://doi.org/10.1016/s2542-5196(23)00055-4
Hulin, M., Simoni, M., Viegi, G., & Annesi-Maesano, I. (2012). Respiratory health and indoor air pollutants based on quantitative exposure assessments. European Respiratory Journal, 40(4), 1033–1045. https://doi.org/10.1183/09031936.00159011
Li, J., Sun, S., Tang, R., Qiu, H., Huang, Q., Mason, T., & Tian, L. (2016). Major air pollutants and risk of COPD exacerbations: a systematic review and meta-analysis. International Journal of Chronic Obstructive Pulmonary Disease, Volume 11, 3079–3091. https://doi.org/10.2147/copd.s122282
Contributing author
For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal.
CARDIOVASCULAR PHYSIOTHERAPY
Cardiovascular diseases and climate change
Background information
- All aspects of the cardiovascular system are affected by the relationship to the environment, including climate change.
- As climate change makes heat waves more frequent and more intense, cardiovascular morbidity and mortality rates increase.
- Potential pathophysiological mechanisms underlying heat impact include increased cardiac load, reduced blood pressure, prothrombotic conditions and systemic inflammatory responses.
- Physiotherapists have a crucial role in cardiac rehabilitation, helping patients to avoid the impacts of heat waves as best as possible, and preparing them to face climate change through personal and structural interventions.
Supporting literature
Liu, J., Varghese, B. M., Hansen, A., Zhang, Y., Driscoll, T., Morgan, G., Dear, K., Gourley, M., Capon, A., & Bi, P. (2022). Heat exposure and cardiovascular health outcomes: a systematic review and meta-analysis. The Lancet Planetary Health, 6(6), e484–e495. https://doi.org/10.1016/s2542-5196(22)00117-6
Gostimirovic, M., Novakovic, R., Rajkovic, J., Djokic, V., Terzic, D., Putnik, S., & Gojkovic-Bukarica, L. (2020). The influence of climate change on human cardiovascular function. Archives of environmental & occupational health, 75(7), 406-414. https://doi.org/10.1080/19338244.2020.1742079
Peters, A., & Schneider, A. (2021). Cardiovascular risks of climate change. Nature Reviews Cardiology, 18(1), 1–2. https://doi.org/10.1038/s41569-020-00473-5
Contributing author:
For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal and Mathijs Wicherson, Hogeschool Utrecht, Netherlands
Air pollution impacts cardiovascular health
Background information
- Short-term exposure to increased concentrations of air pollutants, such as fine inhalable particles from construction sites, unpaved roads, fields, smokestacks or fires, can trigger severe cardiovascular-related problems such as heart attacks.
- Longer-term exposure can lead to increased risk of cardiovascular mortality and decreases in life expectancy or even death.
- Understanding the role of air pollution in cardiovascular disease is essential for physiotherapists wishing to improve the prevention and rehabilitation of cardiovascular problems.
Supporting literature
Brook, R. D., Franklin, B., Cascio, W., Hong, Y., Howard, G., Lipsett, M., Luepker, R., Mittleman, M., Samet, J., Smith, S. C., & Tager, I. (2004). Air Pollution and Cardiovascular Disease. Circulation, 109(21), 2655–2671. https://doi.org/10.1161/01.cir.0000128587.30041.c8
Berg, Z. K., Rodriguez, B., Davis, J., Katz, A. R., Cooney, R. V., & Masaki, K. (2019). Association Between Occupational Exposure to Pesticides and Cardiovascular Disease Incidence: The Kuakini Honolulu Heart Program. Journal of the American Heart Association, 8(19). https://doi.org/10.1161/jaha.119.012569
Zeliger, H. I. (2013). Lipophilic chemical exposure as a cause of cardiovascular disease. Interdisciplinary Toxicology, 6(2), 55–62. https://doi.org/10.2478/intox-2013-0010
Contributing author
For questions about the content in this specific set please contact Andrea Ribeiro, ISAVE Instituto Superior de Saúde, Portugal
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Paediatric Physiotherapy
The environment plays a central role in facilitating or limiting motor skills development in children
Background information
- Physical, social, symbolic, and cultural characteristics of an environment may invite, permit, or inhibit a reciprocal transaction between the immediate environment and the active child’s engagement in diversified motor behaviours (walking to school, performing a motor task, practising a sports activity, etc.).
- These child–environment interactions result from the emergence of diversified types of affordances, such as those in the motor category.
- Physiotherapists must consider the central role of the environment in facilitating or limiting motor skills development in children.
Supporting literature
Helldén, D., Andersson, C., Nilsson, M., Ebi, K. L., Friberg, P., & Alfvén, T. (2021). Climate change and child health: a scoping review and an expanded conceptual framework. The Lancet Planetary Health, 5(3), E164-E175. https://doi.org/10.1016/s2542-5196(20)30274-6
Flores, F. S., Rodrigues, L. P., Copetti, F., Lopes, F., & Cordovil, R. (2019). Affordances for motor skill development in home, school, and sport environments: A narrative review. Perceptual and Motor Skills, 126(3), 366-388. https://doi.org/10.1177/0031512519829271
Ward, J. S., Duncan, J. S., Jarden, A., & Stewart, T. (2016). The impact of children’s exposure to greenspace on physical activity, cognitive development, emotional wellbeing, and ability to appraise risk. Health & Place, 40, 44-50. https://doi.org/10.1016/j.healthplace.2016.04.015
Contributing author
For questions about the content in this specific set please contact Vilma Dudoniene. Lithuanian Sports University and Maria do Rosário Martins, ISAVE, Portugal
Urban natural environments and motor development in early life
Background information
- Youth growing up in places with more greenspaces have better developmental outcomes.
- Early childhood development is a strong predictor of health and wellbeing throughout the life course.
- Neighbourhood public green and blue spaces are related to lower motor development deficits and decreased motor development deficits
- Physiotherapists should stimulate a clinical approach in green spaces improving social interaction and better developmental outcomes.
Supporting literature
Kabisch, N., Alonso, L., Dadvand, P., & van den Bosch, M. (2019). Urban natural environments and motor development in early life. Environmental research, 179, 108774. https://doi.org/10.1016/j.envres.2019.108774
Kabisch, N., Haase, D., & Annerstedt Van Den Bosch, M. (2016). Adding Natural Areas to Social Indicators of Intra-Urban Health Inequalities among Children: A Case Study from Berlin, Germany. International Journal of Environmental Research and Public Health, 13(8), 783. https://doi.org/10.3390/ijerph13080783
Sprague, N. L., Bancalari, P., Karim, W., & Siddiq, S. (2022). Growing up green: a systematic review of the influence of greenspace on youth development and health outcomes. Journal of exposure science & environmental epidemiology, 32(5), 660–681. https://doi.org/10.1038/s41370-022-00445-6
Contributing author
For questions about the content in this specific set please contact Vilma Dudoniene. Lithuanian Sports University and Maria do Rosário Martins, ISAVE, Portugal
Playgrounds to include children with disabilities
Background information
- Public play spaces are designed for children to develop their social and physical abilities and enrich their experience.
- Through play, children can learn various cognitive skills in a relaxing environment.
- Play is an important component in the social, emotional, intellectual, and physical development of all children.
- Although playgrounds are designed to support children’s play, children with disabilities are often unable to fully participate in playgrounds, however, all children should have the same right to play in play spaces.
- Evidence supports that greenspaces are an important environmental influence on physical activity and emotional wellbeing for children and that these can be used by physiotherapists to improve children’s development and socialization.
Supporting literature
Fernelius, C. L., & Christensen, K. M. (2017). Systematic review of evidence-based practices for inclusive playground design. Children, Youth and Environments, 27(3), 78-102. https://doi.org/10.7721/chilyoutenvi.27.3.0078
Ward, J. S., Duncan, J. S., Jarden, A., & Stewart, T. (2016). The impact of children’s exposure to greenspace on physical activity, cognitive development, emotional wellbeing, and ability to appraise risk. Health & Place, 40, 44-50. https://doi.org/10.1016/j.healthplace.2016.04.015
Siu, K. W. M., Wong, Y. L., & Lam, M. S. (2017). Inclusive play in urban cities: a pilot study of the inclusive playgrounds in Hong Kong. Procedia engineering, 198, 169-175. https://doi.org/10.1016/j.proeng.2017.07.080
Contributing author
For questions about the content in this specific set please contact Vilma Dudoniene. Lithuanian Sports University and Maria do Rosário Martins, ISAVE, Portugal
Women’s Health
Physiotherapy and the environmental footprint of menstruation management
Background information
- Menstrual hygiene products generate a significant amount of waste and economic costs associated with their destruction.
- Physiotherapists could play an important role in reducing this impact by developing different strategies, such as advising on the use of reusable menstrual hygiene products, managing menstrual pain through different physiotherapy techniques, and facilitating active strategies for coping with pain.
- More research is needed to identify data about the generated waste.
Supporting literature
Anand, U., Vithanage, M., Rajapaksha, A. U., Dey, A., Varjani, S., & Bontempi, E. (2022). Inapt management of menstrual hygiene waste (MHW): An urgent global environmental and public health challenge in developed and developing countries. Heliyon, 8(7), e09859. https://doi.org/10.1016/j.heliyon.2022.e09859
Babbar K, Martin J, Ruiz J, Parray AA, Sommer M. Menstrual health is a public health and human rights issue. Lancet Public Health 2021;2667:9–10. https://doi:10.1016/s2468-2667(21)00212-7
Kaur, R., Kaur, K., & Kaur, R. (2018). Menstrual Hygiene, Management, and Waste Disposal: Practices and Challenges Faced by Girls/Women of Developing Countries. Journal of Environmental and Public Health, 2018, 1–9. https://doi.org/10.1155/2018/1730964
Contributing author
For questions about the content in this specific set please contact Zeltia Naia Entonado, Universidade da Coruna, Spain.
Women face unique health risks due to climate change
Background information
- Women face unique climate change risks based on their gender for a variety of reasons, including their frequent marginalisation.
- Different forms of violence against women (emotional, physical, sexual, etc.) during and after extreme events could be related to a range of factors (patriarchal attitudes, societal norms, social dislocation, economic difficulties, and disaster reduction efforts) that could worsen during extreme weather events.
- Physiotherapists must increasingly consider how gender affects health risks, which are now further exacerbated by climate change.
Supporting literature
Natterson-Horowitz, B., Boddy, A. M., & Zimmerman, D. (2022). Female Health Across the Tree of Life: Insights at the Intersection of Women’s Health and Planetary Health. PNAS Nexus. https://doi.org/10.1093/pnasnexus/pgac044
Van Daalen, K. R., Kallesøe, S. S., Davey, F., Dada, S., Jung, L., Singh, L., Issa, R., Emilian, C. A., Kuhn, I., Keygnaert, I., & Nilsson, M. (2022). Extreme events and gender-based violence: a mixed-methods systematic review. The Lancet Planetary Health, 6(6), e504-e523. https://doi.org/10.1016/s2542-5196(22)00088-2
Van Daalen, K., Jung, L., Dhatt, R., & Phelan, A. L. (2020). Climate change and gender-based health disparities. The Lancet Planetary Health, 4(2), e44–e45. https://doi.org/10.1016/s2542-5196(20)30001-2
Contributing author
For questions about the content in this specific set please contact Zeltia Naia Entonado, Universidade da Coruna, Spain.
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PHYSIOTHERAPY in Mental Health
Greenspace exposure improves mental health
Background information
- Greenspace exposure is related to less severe symptoms and lower incidence of psychopathology in children, adolescents and adults.
- Built environments lacking greenspace are predictors for depressive moods across age groups.
- Urban greenspace levels (or greenspace intervention) are positively associated with mental well-being.
- The implementation of physiotherapy should take into account the environment where physiotherapy is carried out, allowing the use of green spaces (for example yards, parks, forests).
- Home and school visits by a physiotherapist can make use of green spaces to support the mental health of rehabilitated people.
Supporting literature
Tran, I. T., Sabol, O., & Mote, J. (2022). The relationship between greenspace exposure and psychopathology symptoms: A systematic review. Biological Psychiatry Global Open Science, 2(3), 206–222. https://doi.org/10.1016/j.bpsgos.2022.01.004
Yang, B., Zhao, T., Hu, L., Browning, M. H. E. M., Heinrich, J., Dharmage, S. C., Jalaludin, B., Knibbs, L. D., Liu, X., Luo, Y., James, P., Li, S., Huang, W., Chen, G., Zeng, X., Yu, Y., & Dong, G. (2021). Greenspace and human health: An umbrella review. The Innovation, 2(4), 100164. https://doi.org/10.1016/j.xinn.2021.100164
Yijun Zhang, Suzanne Mavoa, Jinfeng Zhao, Deborah Raphael and Melody Smith. (2020) The Association between Green Space and Adolescents’ Mental Well-Being: A Systematic Review. International Journal of Environmental Research and Public Health.17(18), 6640. https://doi.org/10.3390/ijerph17186640
Contributing author:
For questions about the content in this specific set please contact Maria Maljanen, Tampere University of Applied Sciences, Finland, and Monique Vroomen – van Zutphen, Fontys Hogeschoolen, Netherlands
Reducing loneliness through outdoor activity
Background information
- Physiotherapists have an important role in identifying and supporting lonely people or those at risk of becoming so.
- Being exposed to nature is hypothesized to decrease feelings of loneliness by helping to build relationships with people and nature that can reduce stress.
- Outdoor experiences may facilitate social involvement and shared learning.
Supporting literature
Leavell, M. A., Leiferman, J. A., Gascon, M., Braddick, F., Gonzalez, J. M., & Litt, J. S. (2019). Nature-Based Social Prescribing in Urban Settings to Improve Social Connectedness and Mental Well-being: a Review. Current Environmental Health Reports, 6(4), 297–308. https://doi.org/10.1007/s40572-019-00251-7
Astell-Burt, T., Hartig, T., Eckermann, S., Nieuwenhuijsen, M., Mcmunn, A., Frumkin, H., & Feng, X. (2022). More green, less lonely? A longitudinal cohort study. International Journal of Epidemiology, 51(1), 99–110. https://doi.org/10.1093/ije/dyab089
Contributing author:
For questions about the content in this specific set please contact Maria Maljanen, Tampere University of Applied Sciences, Finland, and Monique Vroomen – van Zutphen, Fontys Hogeschoolen, Netherlands
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Ethics and Professional Practice
Considering environmental ethics as a necessary part of healthcare professional ethics
Background information
- Professional ethics in physiotherapy has historically been focused on the relationship between the patient and therapist.
- Because of the significant health impacts of environmental degradation, it is now necessary to integrate an environmental perspective into our understanding of ethics in physiotherapy.
- Healthcare professionals also have an ethical duty to reduce the environmental footprint of healthcare systems and services to stay true to the fundamental ethical principle of “do no harm”.
- Environmental ethics can be included in all teaching about ethics in physiotherapy.
Supporting literature
Katz, C. (2022). The Ethical Duty to Reduce the Ecological Footprint of Industrialized Healthcare Services and Facilities. The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, 47(1), 32–53. https://doi.org/10.1093/jmp/jhab037
Maric, F., & Nicholls, D. A. (2022). Environmental physiotherapy and the case for multispecies justice in planetary health. Physiotherapy Theory and Practice, 38(13), 2295–2306. https://doi.org/10.1080/09593985.2021.1964659
Wardrope, A. (2020). Health justice in the Anthropocene: medical ethics and the Land Ethic. Journal of Medical Ethics, 46(12), 791–796. https://doi.org/10.1136/medethics-2020-106855
Contributing author
For questions about the content in this specific set please contact Filip Maric (PhD), UiT The Arctic University of Norway.
Health equity and access to physiotherapy in the face of climate change
Background information
- The health impacts of climate change will be different for every individual due to their differences in exposure, sensitivity and adaptive capacity.
- Exposure is high for those living in rural areas with harsh cold temperatures or those living at the top of a block of flats in a hot city centre.
- Sensitivity is raised due to age, pre-existing medical conditions, social deprivation, isolation and marginalisation.
- Adaptive capacity can be limited in our patients with restricted mobility or impaired communication skills.
- When high exposure, sensitivity and limited adaptive capacity align individuals are vulnerable to the health impacts of climate change.
- Physiotherapy educators may encourage students to reflect on how climate change will affect the health of vulnerable patients.
- This may lead to discussions around the potentially minimal carbon footprint of vulnerable patients and be followed with carbon literacy training.
Supporting literature
Fagliano, J. A., & Diez Roux, A. V. (2018). Climate change, urban health, and the promotion of health equity. PLOS Medicine, 15(7), e1002621. https://doi.org/10.1371/journal.pmed.1002621
Khanal, S., Ramadani, L., & Boeckmann, M. (2023). Health Equity in Climate Change and Health Policies: A Systematic Review. Sustainability, 15(13), 10653. https://doi.org/10.3390/su151310653
Smith, G. S., Anjum, E., Francis, C., Deanes, L., & Acey, C. (2022). Climate Change, Environmental Disasters, and Health Inequities: The Underlying Role of Structural Inequalities. Current Environmental Health Reports, 9(1), 80–89. https://doi.org/10.1007/s40572-022-00336-w
Contributing author
For questions about the content in this specific set please contact Danielle Munford, University of Plymouth, UK.
Climate and health advocacy are a healthcare professional responsibility
Background information
- Health professionals including physiotherapists have a responsibility to be key agents of change in climate and health issues due to our trusted voice globally.
- Physiotherapists need to expand the therapeutic paradigm and recognize the impact of climate change as a key determinant of health and how it affects the most vulnerable first and hardest, but also develop a more just and climate-friendly health care system.
- It is our responsibility to communicate this to patients, our professional community, the public, and decision-makers and stakeholders at all levels.
- We must view this as a crucial part of our job and serve as role models, encourage patients to engage in healthy behaviours, help patients to navigate health care, redress health inequities, as well as, individually or as a professional group, engage in systems- and more political forms of advocacy, to improve individual health, influence leaders and develop policies that will help stabilize the climate and improve global human health.
Supporting literature
Luong, K. T., Kotcher, J., Miller, J., Campbell, E., Epel, E., Sarfaty, M., & Maibach, E. (2021). Prescription for healing the climate crisis: Insights on how to activate health professionals to advocate for climate and health solutions. The Journal of Climate Change and Health, 4. https://doi-org.proxy.kib.ki.se/10.1016/j.joclim.2021.100082
Duhaime, A.-C., Futernick, M., Alexander, M., Erny, B. C., Etzel, R. A., Gordon, I. O., Guinto, R., Hertelendy, A. J., Howard, C., Maki, L., Olagunju, A. T., Parker, E. R., Redvers, N., Sehgal, A., Shultz, J. M., Simidchiev, A., Torday, J. S., & Zhang, Y. (2021). Healthcare professionals need to be CCLEAR: Climate collaborators, leaders, educators, advocates, and researchers. The Journal of Climate Change and Health, 4, 100078. https://doi.org/https://doi.org/10.1016/j.joclim.2021.100078
Joel Charles, Abby N. Lois, Chirantan Mukhopadhyay, Edward Maibach, Jonathan A. Patz. (2021). Health professionals as advocates for climate solutions: A case study from Wisconsin. The Journal of Climate Change and Health, 4, 100052. https://doi.org/10.1016/j.joclim.2021.100052
Contributing author
For questions about the content in this specific set please contact Emma Swärdh, Karolinska Institute, Sweden.
Neurological rehabilitation
Nature-based therapy may be beneficial in the treatment of neurological disorders
Background information
- Nature-based therapy offers targeted benefits for individuals with neurological disorders.
- Preliminary research shows that exposure to natural environments can improve motor function, motor-sensory function, cognitive function, and fatigue in conditions like Parkinson’s disease, stroke, and traumatic brain injury.
- This can be acknowledged in teaching that nature-based therapy may be a valuable and holistic approach to complement traditional treatments in neurological rehabilitation, enhancing the well-being of those with neurological disorders.
Supporting literature
Corazon, S. S., Olsen, L. J., Olsen, A. M., & Sidenius, U. (2019). Nature-based therapy for people suffering from post-concussion syndrome – A pilot study. Health, 11(11), 1501. https://doi.org/10.4236/health.2019.1111113
Pálsdóttir, A. M., Andersson, G., Grahn, P., Norrving, B., Kyrö Wissler, S., Petersson, I. F., & Pessah-Rasmussen, H. (2020). The nature stroke study; NASTRU: A randomized controlled trial of nature-based post-stroke fatigue rehabilitation. Journal of Rehabilitation Medicine, jrm00020. https://doi.org/10.2340/16501977-2652
Vibholm, A. P., Christensen, J. R., & Pallesen, H. (2020). Nature-based rehabilitation for adults with acquired brain injury: A scoping review. International Journal of Environmental Health Research, 30(6), 661-676. https://doi.org/10.1080/09603123.2019.1620183
Contributing author:
For questions about the content in this specific set please contact Aki Rintala, LAB University of Applied Sciences, Finland.
Air pollution has negative impacts on neurodegeneration
Background information
- Air pollution above a certain level predicts a higher risk of developing neurological diseases, such as Alzheimer and Parkinson’s.
- Among all air pollutants, PM2.5 is one of the most important and is emitted from various outdoor sources, such as vehicular emissions, construction sites and indoor sources such as chimneys and cooking fires.
- It often leads to premature ageing of the brain via inducing neurodegeneration.
- Physiotherapists must understand how air pollution contributes to neurodegeneration to consider preventive actions and research in neurological pathologies.
Supporting literature
Craig, L., Brook, J. R., Chiotti, Q., Croes, B., Gower, S., Hedley, A., Krewski, D., Krupnick, A., Krzyzanowski, M., Moran, M. D., Pennell, W., Samet, J. M., Schneider, J., Shortreed, J., & Williams, M. (2008). Air pollution and public health: a guidance document for risk managers. Journal of toxicology and environmental health. Part A, 71(9-10), 588–698. https://doi.org/10.1080/15287390801997732
Kim, H., Kim, W. H., Kim, Y. Y., & Park, H. Y. (2020). Air Pollution and Central Nervous System Disease: A Review of the Impact of Fine Particulate Matter on Neurological Disorders. Frontiers in public health, 8, 575330. https://doi.org/10.3389/fpubh.2020.575330
Wang, J., Ma, T., Ma, D., Li, H., Hua, L., He, Q., & Deng, X. (2021). The Impact of Air Pollution on Neurodegenerative Diseases. Therapeutic Drug Monitoring : a Journal Devoted to Therapeutic Drug Monitoring and Clinical Drug Toxicology, 43(1), 69–78. https://doi.org/10.1097/FTD.0000000000000818
Contributing author
For questions about the content in this specific set please contact Sristhi Banerjee, LJ Institute of Physiotherapy, India.
To be developed... YOUR IDEA HERE!
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Acute and Intensive care
Reducing the environmental footprint of intensive and acute care units
Background information
- Intensive and acute care units (ICUs and ACUs) significantly contribute to the healthcare sector’s carbon footprint, primarily due to their round-the-clock operation, energy-intensive equipment, extensive use of disposable supplies, and waste generation.
- Health professionals, including physiotherapists, can play an important role in reducing this impact by adopting several strategies
- Strategies may include promoting energy efficiency, minimising waste, ensuring efficient use and maintenance of equipment, advocating for environmentally friendly practices, facilitating home-based therapy (tele-physiotherapy), and transitioning to digital platforms for documentation.
Supporting literature
Baid, H., & Damm, E. (2021). Reducing critical care’s carbon footprint with financial and social co-benefits. Intensive & Critical Care Nursing, 64, 103030. https://doi.org/10.1016/j.iccn.2021.103030
McGain, F., Muret, J., Lawson, C., & Sherman, J. D. (2020). Environmental sustainability in anaesthesia and critical care. British Journal of Anaesthesia, 125(5), 680–692. https://doi.org/10.1016/j.bja.2020.06.055
Muret, J., & Kelway, C. (2019). Why should anaesthesiologists and intensivists care about climate change? Anaesthesia, Critical Care & Pain Medicine, 38(6), 565–567. https://doi.org/10.1016/j.accpm.2019.10.014
Contributing author
For questions about the content in this specific set please contact António Alves Lopes, ESSAlcoitão, Portugal.
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Occupational Health and Ergonomics
Education about health in the future work environment
Background information
- Physiotherapists are important stakeholders in occupational health and ergonomics.
- Undergraduate students need education about work and the work environment.
- We expect employers will increasingly seek advice from health professionals, including occupational health physiotherapists, about managing the expected impact of climate change at the workplace.
- Active transport, e.g. getting to and from work, and working outdoors will prove challenging for employees and their employers. An initial starting point for class discussion is about work-related heat stress and occupational lung disease.
Supporting literature
Borg, M. A., Xiang, J., Anikeeva, O., Pisaniello, D., Hansen, A., Zander, K., Dear, K., Sim, M. R., & Bi, P. (2021). Occupational heat stress and economic burden: A review of global evidence. Environmental Research., 195. https://doi.org/10.1016/j.envres.2021.110781
Di Corleto, R. (2019) Physical Hazards: Thermal Environment. In HaSPA (Health and Safety Professionals Alliance), The Core Body of Knowledge for Generalist OHS Professionals. Tullamarine, VIC. Safety Institute of Australia. https://www.ohsbok.org.au/wp-content/uploads/2019/11/26-Thermal-Environment-1.pdf
Feary, J., Lindstrom, I., Huntley, C. C., Suojalehto, H., & De La Hoz, R. E. (2023). Occupational lung disease: when should I think of it and why is it important?. Breathe, 19(2), 230002. https://doi.org/10.1183/20734735.0002-2023
Contributing author
For questions about the content in this specific set please contact Rose Boucaut, University of South Australia, and Charlotte Gerner, University of South Australia.
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Health Promotion
Importance of sustainable transportation enhancing active lifestyle
Background information
- Active commuting (~45min/day) is associated with low levels of low-grade inflammation and more active leisure time
- Single-occupancy vehicles (SOV) transportations increase pollution, and congestion, and reduces physical activity
- People spend less time in physical activities which causes an economic burden in society by increasing the risks of type 2 diabetes and respiratory and circulatory system disorders (e.g., Finland 3,2 billion / year)
- New developments in sustainable SOV transportation (i.e., electric cars, scooters, and bikes) may provide sustainable access to long-distance environments, but they may also cause risks of less physical activity and mobility
- Physiotherapists are encouraged to support behaviour changes among citizens and persons with risks of diseases to stay active and find new ways to incorporate sustainable transportation and active lifestyle
Supporting literature
Allaouat, S., Halonen, J. I., Jussila, J. J., Tiittanen, P., Ervasti, J., Ngandu, T., … & Lanki, T. (2024). Association between active commuting and low-grade inflammation: a population-based cross-sectional study. European Journal of Public Health, 34(2), 292-298. https://doi.org/10.1093/eurpub/ckad213
Mundorf, N., Redding, C. A. & Bao, S. (2023). Sustainable transportation and health. International Journal of Environmental Research and Public Health, 15: 542. https://doi.org/10.3390/ijerph15030542
Mundorf, N., Redding, C. A., & Paiva, A. L. (2018). Sustainable transportation attitudes and health behavior change: Evaluation of a brief stage-targeted video intervention. International Journal of Environmental Research and Public health, 15(1), 150. https://doi.org/10.3390/ijerph15010150
Contributing author:
For questions about the content in this specific set please contact Aki Rintala, LAB University of Applied Sciences, Finland.
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Do you have ideas for teaching prompts that we can add?
The development of the EPT teaching prompts began at the 2023 European Network of Physiotherapy in Higher Education (ENPHE) seminar in Bergen, Norway following the formation of a new ENPHE subgroup on Environmental Physiotherapy. It now continues in close collaboration with EPT Agenda participating institutions, and we can always use more support.
If you would like to support the further development of these teaching prompts as a contributing author please contact us here.
Other projects and resources in environmental physiotherapy education
There are an increasing number of projects and resources surrounding planetary health, environmental and sustainability education. For published literature and relevant websites please visit our resources page.
PREP-IP Persons with Refugee experience Education Project – Interprofessional
The PREP-IP project addresses the mismatch between the competence of healthcare professionals and the complex rehabilitation needs of a growing population of refugees and migrants in Europe.
In partnership with physiopedia and Plus, the Environmental Physiotherapy Association has launched an Environmental Physiotherapy Content Development Project and a growing range of Environmental Physiotherapy Courses featuring a growing number of courses related to environmental physiotherapy.