Nature-based rehabilitation to reduce post-stroke fatigue is not effective: A randomized controlled trial

Abstract

We have performed the first randomized controlled study on a nature-based intervention for patients with post stroke fatigue. Nature Based Interventions are performed in outdoor environment especially suitable/ adopted for supporting treatment and rehabilitation programs. A total of 101 patients were randomized into a two-armed study: 1) treatment as usual, and 2) nature-based intervention. There were no statistical differences confirmed between the treatments, which may be partly explained by several methodological issues. However, participants showed good compliance with the nature-based intervention; thus, this study contributes with new knowledge to the field of stroke rehabilitation and is ground for further studies on how nature can support recovery from post-stroke fatigue. Objective: To determine whether nature-based rehabilitation, as an add-on to standard care, has a longterm influence on post-stroke fatigue, perceived value of everyday occupations, disability, healthrelated quality of life, anxiety, and depression at follow-up 8 and 14 months after randomization. Design: Single-blinded, 2-armed, randomized controlled trial. Methods: Stroke survivors, identified through routine 3-month follow-up visit (sub-acute) or medical records (chronic stroke > 1 year previously), were randomized to standard care + nature-based rehabilitation (intervention group) or standard care alone (control group). Blinded evaluations were conducted at follow-up 8 and 14 months after randomization, for the following outcomes: post-stroke fatigue (Mental Fatigue Scale; MFS), perceived value of everyday occupations (Occupational value instrument with predefined items), disability (modified Rankin Scale; mRS), health-related quality of life (Euro-QoL-5 Demension Questionnaire), anxiety (Hospital Anxiety and Depression Scale; HAD) and depression (HAD). Results: Approximately one-quarter of the screened patients were eligible for inclusion in the study; of these, half agreed to participate; a final total of 101 patients were randomized (mean age 67 years, 60% female). The patients with sub-acute stroke were highly compliant with the intervention. The participants in both the intervention and control groups improved, However, no statistically significant differences in improvement were found between the intervention and control groups for any of the outcome measures. Fatigue decreased to a value below the suggested cutoff for mental fatigue (< 10.5) in the intervention group, but not in the control group. Conclusion: Nature-based rehabilitation is feasible and well tolerated. A larger randomized controlled trial is warranted.

The effects of forest bathing on psychological well‐being: A systematic review and meta‐analysis

“…Twelve studies reported depression as an outcome, of which seven used the Beck Depression Inventory (Bang et al, 2016, 2017; Cho et al, 2008; Chun et al, 2017; Han et al, 2016), two used Zung's Depression Scale (Choi & Ha, 2014; You et al, 2014), two used Hospital Anxiety and Depression Scale (Kim et al, 2015; Pálsdóttir et al, 2020) and one used Geriatric Depression Scale—Korea Version (Lim et al, 2014). Data from 10 studies were included in the meta‐analysis, providing no intervention in the control group.…”

“…The pooled SMD was −0.67 (95% CI −0.99, −0.35, p < 0.001), and moderate heterogeneity was observed ( χ 2 = 29.31, p < 0.001, I 2 = 69%) (See Figure 2). Two studies (Pálsdóttir et al, 2020; Shin et al, 2012) were not included in the meta‐analysis since no standard deviations were reported, but both studies reported significantly lower scores for those in their intervention groups.…”

“…Nine studies reported anxiety as an outcome, of which six used the State–Trait Anxiety Inventory (Cho et al, 2008; Chun et al, 2017; de Brito et al, 2019; Koselka et al, 2019; Sin & Lee, 2018b; Song et al, 2019) and two used Hospital Anxiety and Depression Scale (Kim et al, 2015; Pálsdóttir et al, 2020). Data from the seven studies (Cho et al, 2008; Chun et al, 2017; de Brito et al, 2019; Kim et al, 2015; Park et al, 2015; Sin et al, 2018; Song et al, 2019) were included in the meta‐analysis.…”

“…No subgroup differences were detected ( p = 0.87). Three studies (Koselka et al, 2019; Pálsdóttir et al, 2020; Song et al, 2018) were not included in the meta‐analysis since no standard deviations were reported, but all three reported lower mean anxiety scores for their intervention groups (See Figure 3).…”

Migrants’ experiences of a nature-based vocational rehabilitation programme in relation to place, occupation, health and everyday life

“…The study was conducted at Swedish University of Agricultural Sciences (SLU) Alnarp Rehabilitation Garden, a living lab, where researchers, garden members, and community partners collaborate around nature-based interventions. Several nature-based rehabilitation projects targeting diverse groups have previously been hosted by SLU Alnarp rehabilitation garden (Pálsdóttir, Stigsdotter et al, 2018;Pálsdóttir et al, 2020). The 1.5 ha SLU Alnarp Rehabilitation Garden is divided into two major areas: 1) the formal and cultivation area and 2) the informal nature area (Pálsdóttir, 2016).…”