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Relief of Chronic Posterior Neck Pain Depending on the Type of Forest Therapy: Comparison of the Therapeutic Effect of Forest Bathing Alone Versus Forest Bathing With Exercise

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Objective: To compare the pain-reducing effect of forest bathing alone versus forest bathing in combination with stretching and strengthening exercises in patients with chronic posterior neck pain. Methods: Sixty-four subjects with posterior neck pain that had lasted more than 3 months were enrolled. They were randomly divided into a forest bathing alone (FBA) group and a forest bathing with exercise (FBE) group; each group included 32 subjects. All subjects from both groups walked every morning in the forest for about 2 hours for 5 days. In the afternoon, the FBE group did a stretching and strengthening exercise for about 4 hours; the FBA group had free time in the woods. Visual analog scale (VAS) on one day, VAS over the previous week, neck disability index (NDI), EuroQol 5D-3L VAS (EQ VAS) and index (EQ index), McGill pain questionnaire (MPQ), the number of trigger points in the posterior neck region (TRPs), and the range of motion of the cervical spine were evaluated on the first and last day of the program and compared between the two groups. Results: The number of TRPs were significantly reduced in the FBE group compared with the FBA group (p=0.013). However, the other scales showed no significant difference between the two groups. Conclusion: When patients with chronic posterior neck pain underwent a short-term forest bathing (less than 7 days) program, FBE was more effective in the reduction of the number of TRPs than FBA. However, all other pain measurement scales we evaluated showed no statistically significant difference between the two protocols.
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Annals of Rehabilitation Medicine
Original Article
Ann Rehabil Med 2015;39(6):957-963
pISSN: 2234-0645 • eISSN: 2234-0653
http://dx.doi.org/10.5535/arm.2015.39.6.957
Received May 14, 2015; Accepted July 1, 2015
Corresponding author: Si-Bog Park
Department of Rehabilitation Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, 222-1 Wangsimni-ro,
Seongdong-gu, Seoul 04763, Korea
Tel: +82-2-2290-9226, Fax: +82-2-2290-9231, E-mail: sibopark@hanyang.ac.kr
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2015 by Korean Academy of Rehabilitation Medicine
Relief of Chronic Posterior Neck Pain Depending
on the Type of Forest Therapy: Comparison of
the Therapeutic Effect of Forest Bathing Alone
Versus Forest Bathing With Exercise
Boram Kang, MD
1
, Taikon Kim, MD, PhD
1
, Mi Jung Kim, MD, PhD
1
, Kyu Hoon Lee, MD, PhD
1
,
Seungyoung Choi, MD
1
, Dong Hun Lee, MD
1
, Hyo Ryoung Kim
2
, Byol Jun, MA
2
,
Seen Young Park
2
, Sung Jae Lee, MD, PhD
2
, Si-Bog Park, MD, PhD
1
1
Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul;
2
Department of Integrative Medicine, Korea University College of Medicine, Seoul, Korea
Objective
To compare the pain-reducing effect of forest bathing alone versus forest bathing in combination with
stretching and strengthening exercises in patients with chronic posterior neck pain.
Methods
Sixty-four subjects with posterior neck pain that had lasted more than 3 months were enrolled. They
were randomly divided into a forest bathing alone (FBA) group and a forest bathing with exercise (FBE) group;
each group included 32 subjects. All subjects from both groups walked every morning in the forest for about 2
hours for 5 days. In the afternoon, the FBE group did a stretching and strengthening exercise for about 4 hours;
the FBA group had free time in the woods. Visual analog scale (VAS) on one day, VAS over the previous week, neck
disability index (NDI), EuroQol 5D-3L VAS (EQ VAS) and index (EQ index), McGill pain questionnaire (MPQ), the
number of trigger points in the posterior neck region (TRPs), and the range of motion of the cervical spine were
evaluated on the first and last day of the program and compared between the two groups.
Results
The number of TRPs were significantly reduced in the FBE group compared with the FBA group (p=0.013).
However, the other scales showed no significant difference between the two groups.
Conclusion
When patients with chronic posterior neck pain underwent a short-term forest bathing (less than 7
days) program, FBE was more effective in the reduction of the number of TRPs than FBA. However, all other pain
measurement scales we evaluated showed no statistically significant difference between the two protocols.
Keywords
Neck pain, Exercise therapy, Chronic pain, Musculoskeletal pain, Complementary therapies
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INTRODUCTION
Posterior neck pain is a common complaint; it affects
70% of individuals at some time in their lives [1,2]. In
many cases, it is difficult to pinpoint the cause of the
pain. In cases where the underlying disease is not diag-
nosed and treated in the early stages, pain often does
not respond well to general treatment and, as a result,
the medical and socioeconomic costs of treatment can
be very high. Indeed, the mechanism and role of chronic
pain is different from that of acute pain. The major role
of acute pain is the protection of the body from damage
by noxious stimuli present in the external environment.
On the contrary, chronic pain has more complex causes
such as central nervous system damage, injury, or psy-
chosocial problems, and it often has the characteristics of
a pathological state rather than those of a physiological
state [3]. Understanding of the importance of psychoso-
cial factors such as affective and cognitive problems as a
cause of chronic pain has gradually increased.
Although medication, surgical treatment, physical mo-
dalities, cervical traction, epidural injection, etc. have
been applied for the purpose of treating posterior neck
pain, there is seldom an optimal treatment, except in the
case of surgical treatment for patients with specific con-
ditions [4,5]. Because of the limitations of existing treat-
ments, many complementary treatments have been sug-
gested and researched. For instance, one study addressed
pain reduction and increase in cervical range of motion
(C-ROM) following dry needling and acupuncture in 36
patients with chronic neck pain [4]; another examined
the pain-reducing effect of botulinum toxin A injection in
50 chronic neck pain patients [6]. However, no comple-
mentary treatments have been shown to be superior to
existing medical interventions.
Recently, many studies on the therapeutic effects of the
forest have been reported. A study in Japan showed an
increase of natural killer cell activity after 3 days of forest
bathing which lasted for a month [7]. A study comparing
the physiological and psychological effects of forest ver-
sus urban environments on young male adults showed
positive effects of forest bathing on physical and psy-
chological health [8]. Several studies about the effects of
forest bathing have been also reported in South Korea.
Forest bathing was reported to have a positive impact
on blood pressure and salivary cortisol level in elderly
patients with hypertension [9] and therapeutic effects in
patients with psychological problems such as anxiety, de-
pression, and stress [10-12]. As far as we knew, however,
a therapeutic effect of forest bathing on musculoskeletal
pain had not yet been reported. Therefore, we previously
conducted a preliminary study to address whether for-
est bathing may ameliorate chronic posterior neck pain
and showed significantly reduced pain in a forest bathing
group compared with a group going about daily life in a
city. On the basis of this result, we hypothesized that for-
est bathing plus stretching and strengthening exercises
targeted to the muscles in the cervical and shoulder re-
gions would have a superior therapeutic effect compared
with forest bathing alone; it has been shown that stretch-
ing and strengthening exercises are helpful for relieving
posterior neck pain [13]. The therapeutic effect of exer-
cise on neck pain is most likely because posterior neck
pain may result in reflexive protective muscle spasms and
decreased ROM, regardless of the primary cause of pain
[14].
To test our hypothesis, we herein compare the pain-re-
ducing effects of forest bathing alone versus forest bath-
ing plus stretching and strengthening exercises targeted
to the muscles of the cervical and shoulder regions.
MATERIALS AND METHODS
For one month in May 2013, 70 subjects who visited the
Department of Rehabilitation Medicine of Hanyang Uni-
versity Medical Center and met certain inclusion criteria
were recruited through a notice in the hospital, by phone,
or by e-mail. Of these 70, 6 dropped out for personal rea-
sons, so 64 subjects were finally included in this study.
Subjects all gave voluntary informed consent prior to the
beginning of the study.
Inclusion criteria were adults over the age of 20 with
posterior neck pain graded more than 4 using the visual
analog scale (VAS) that had lasted more than 3 months.
Exclusion criteria were acute inflammation findings in
blood tests, limitation of C-ROM because of cervical spi-
nal fixation operations, inability to walk for more than an
hour because of knee problems, or if residing in a forest
for more than a week was a hardship for any reason in-
cluding the presence of underlying disease.
Screening tests included simple radiographs of the cer-
vical spine and both knee joints, routine blood tests, and
Therapeutic Effect of Forest Therapy on Chronic Neck Pain
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VAS of cervical neck pain. On the first day of the experi-
ment in the forest, 2 rehabilitation medicine physicians
evaluated VAS on that day, VAS over the previous week,
neck disability index (NDI), EuroQol 5D-3L VAS (EQ VAS)
and index (EQ index), McGill pain questionnaire (MPQ),
the number of trigger points in the posterior neck region
(TRPs), and C-ROM. All the same tests were performed
by the same physicians on the last day of the experiment.
The VAS was developed for evaluating factors that are
difficult to objectively assess; it is commonly used for
evaluating pain levels [15]. In general, patients are pre-
sented with a 10-cm horizontal line anchored by ‘no
pain’ on one end and ‘pain as bad as it could be’ on the
other end; subjects mark the point on the line that they
feel represents their pain level. The VAS score is deter-
mined by measuring length (cm) on the line between the
no pain’ anchor and the subjects’ mark. Authors defined
VAS on one day’ as the level of posterior neck pain on
that day and ‘VAS over the previous week’ as an average
pain level of the posterior neck region during the preced-
ing week.
The NDI is a questionnaire developed in 1991 for the
purpose of helping to understand how neck pain affects
one’s ability to manage everyday activities. It consists of
10 sections with 6 multiple choice questions per section
[16].
The EQ VAS and index were developed by the EuroQol
Group. They are standardized measurement tools that
assess an individual’s health status [17]. EQ VAS is evalu-
ated in a similar manner as is VAS. Subjects mark their
status on a vertical line anchored by 0 and 100 at either
end to indicate ‘Your own health state today.’ A score of 0
means ‘Worst imaginable health state’ and a score of 100
means ‘Best imaginable health state.’ The EQ index has
5 sections, which are mobility, self-care, usual activities,
pain/discomfort, and anxiety/depression, and each sec-
tion has 3 possible answers.
The MPQ is a self-reported measure of pain level. It is
composed of 78 words in 20 categories; for each category,
subjects choose the word that best represents their feel-
ing of pain. Scores are calculated by summing the values
associated with each word and a higher score means
more severe pain [18].
A TRP is defined as a hyperirritable spot and is diag-
nosed if a subject feels pain when weak pressure (less
than 4 kg/cm
2
) is applied with a pressure algometer [19].
In this study, the researchers examined bilateral cervical
paraspinal, upper trapezius, and infraspinatus muscles,
which are related to posterior neck pain, and counted the
number of TRPs in these 6 muscles.
The C-ROM was evaluated by summating measures of
cervical flexion, extension, right lateral bending, left lat-
eral bending, right rotation, and left rotation.
Sixty-four subjects (11 males, 53 females) were ran-
domly divided into a forest bathing alone (FBA) group
(n=32) and a forest bathing with exercise (FBE) group
(n=32). Both groups participated in a program consist-
ing of 2 hours of walking in the forest every morning
for 5 days. For 2 hours each afternoon, the FBE group
did additional stretching and strengthening exercises
targeting muscles in the cervical and shoulder regions.
This exercise program was developed and organized by
a committee composed of four physicians specializing
in rehabilitation medicine and three physical therapists
after a literature review. The exercise program consists
of a 10-minute warm-up followed by 30 minutes of main
Fig. 1. Flow chart showing the
schedule and plan of this study.
Screening
(7-10 days before
the program
was started)
The first day of
the program
The last day of
the program
Forest bathing alone for7days
Forest bathing with exercise for7days
Comparison
Boram Kang, et al.
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exercise and a 10-minute cool down. Subjects rest for 10
minutes and then repeat the exercise program, so the
total exercise time is 2 hours. The warm-up exercise is
composed of light stretching; not only the cervical and
shoulder regions but the whole body is included. In the
main exercise, exercise intensity is gradually increased
and stretching and strengthening exercises are focused
on the cervical and shoulder regions. Although the cool
down exercise is composed of only stretching, the inten-
sity is higher than that of the main exercise. In contrast
with the FBE group, the FBA group did not do the exer-
cise program in the afternoon and instead had free time
in the forest. After dinner, the FBE group did another 2
cycles of the same exercise program and the FBA group
again had free time in the forest (Fig. 1).
Pain levels pre-intervention and post-intervention were
compared between the FBA and FBE groups using the
Mann-Whitney U test. The Wilcoxon signed-rank test was
used to compare pre-intervention versus post-interven-
tion outcomes in each group. The p-value for significance
was set at 0.05.
RESULTS
There was no significant difference in age, sex, height,
or weight between the FBA and FBE groups. VAS on the
day of screening and the first day of the forest program
showed no significant difference between the two groups
(p=0.779 and p=0.767) (Table 1). Most subjects were un-
employed or students; only 5 subjects in the FBE group
and 4 subjects in the FBA group had jobs. Of the em-
ployed subjects in the FBE group, 2 were office clerks, one
Table 1. Subject characteristics
Variable Forest bathing alone (n=32) Forest bathing with exercise (n=32) p-value
a)
Age (yr) 50.0±14.93 54.8±9.78 0.828
Sex (male:female) 5:27 6:26 0.515
Height (cm) 160.1±6.20 160.7±6.81 0.669
Weight (kg) 58.4±10.17 59.9±9.45 0.985
VAS at screening 5.9±1.26 6.4±1.33 0.779
VAS on the first day 5.2±1.61 5.3±1.64 0.767
Values are presented as mean±standard deviation or number.
VAS, visual analog scale.
a)
p-values were calculated using the independent t-test (p<0.05, statistically significant).
Table 2. Difference between the two types of forest therapy program (n=64)
Forest bathing alone (n=32) Forest bathing with exercise (n=32) p-value
c)
VAS on one day
a)
–2.7±1.69 –2.9±1.93 0.559
VAS over the previous week
a)
–2.8±1.40 –3.1±1.77 0.485
NDI
a)
–15.1±8.45 –11.3±11.73 0.181
EQ VAS
b)
28.7±15.12 21.8±20.97 0.165
EQ index
b)
0.28±0.192 0.22±0.154 0.129
MPQ
a)
–13.5±10.75 –13.3±13.39 0.652
TRPs
a)
–1.0±1.49 –2.1±1.66 0.013*
C-ROM
b)
74.7±60.69 85.2±58.46 0.667
Values are presented as mean±standard deviation.
VAS, visual analog scale; NDI, neck disability index; EQ VAS, EuroQoL 5D-3L VAS; EQ index, EuroQol 5D-3L index;
MPQ, McGill pain questionnaire; TRPs, trigger points in the posterior neck region; C-ROM, cervical range of motion.
a)
Negative change indicates improvement.
b)
Positive change indicates improvement.
c)
p-values were calculated using the Mann-Whitney U test.
*p<0.05, statistically significant.
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was self-employed, one worked as a translator, and one
was a lecturer; in the FBA group, 2 were office clerks and
2 were self-employed.
Of all the pain assessment methods used to compare
the two groups post-intervention, only the number of
TRPs was significantly different; it was lower in the FBE
group than in the FBA group (p=0.013). The other scales
showed no significant differences between the two
groups (Table 2).
All evaluated scales (VAS on a particular day, VAS
over the previous week, NDI, EQ VAS and index, MPQ,
the number of TRPs, and C-ROM) showed significant
improvement after 7 days of the forest program in both
groups (Table 3).
DISCUSSION
When we analyzed VAS on one day, VAS over the pre-
vious week, MPQ, and NDI, which reflect intensity of
posterior neck pain, there were no significant differences
between individuals in the two types of forest program.
These results could be interpreted to mean that adding
an exercise program to forest bathing is not an effective
way to reduce posterior neck pain. EQ VAS and index,
which reflect general health status, also showed no sig-
nificant differences according to the type of forest pro-
gram.
As mentioned above, posterior neck pain results in
muscle spasms and decreased C-ROM in most cases
regardless of the primary cause of pain. Therefore, we
thought that evaluating the number of TRPs and C-ROM
could be helpful for verifying pain intensity in the poste-
rior neck region. C-ROM showed no significant difference
between the two groups, like all other scales mentioned
above. However, the number of TRPs was significantly
reduced in the FBE group compared with the FBA group,
which suggests that adding a stretching and strengthen-
ing exercise to forest bathing is more effective in reducing
the number of TRPs than forest bathing alone.
It is unclear why intensity of pain, health status, and
C-ROM were not significantly better in the FBE group in
spite of a significant reduction in the number of TRPs.
The authors’ opinions about this issue are as follows. 1)
The measurement method for detecting TRPs used in this
study was a test for ‘latent TRPs,’ which are spots where
pain is felt after applying weak pressure; these could be
Table 3. Scores of each group on the first and last days of the forest program
Forest bathing alone (n=32) Forest bathing with exercise (n=32)
The first day of
the program
The last day of
the program
p-value
c)
The first day of
the program
The last day of
the program
p-value
c)
VAS on one day
a)
5.2±1.61 2.5±1.58 <0.001* 5.3±1.64 2.4±1.24 <0.001*
VAS over the previous week
a)
5.7±1.55 2.9±1.45 <0.001* 5.8±1.52 2.7±1.48 <0.001*
NDI
a)
33.2±10.82 18.1±8.72 <0.001* 30.0±10.36 18.6±9.84 <0.001*
EQ VAS
b)
47.3±16.89 75.9±14.74 <0.001* 50.8±16.92 72.6±15.72 <0.001*
EQ index
b)
0.59±0.212 0.87±0.071 <0.001* 0.64±0.176 0.86±0.079 <0.001*
MPQ
a)
26.4±13.48 12.9±10.81 <0.001* 22.7±11.45 9.4±8.02 <0.001*
TRPs
a)
4.5±1.46 3.5±1.68 0.001* 4.3±1.49 2.3±1.32 <0.001*
C-ROM
b)
261.6±68.40 336.3±71.58 <0.001* 254.3±73.09 339.4±84.19 <0.001*
Values are presented as mean±standard deviation.
VAS, visual analog scale; NDI, neck disability index; EQ VAS, EuroQol 5D-3L VAS; EQ index, EuroQol 5D-3L index; MPQ, McGill pain questionnaire;
TRPs, trigger points in the posterior neck region; C-ROM, cervical range of motion.
a)
Lower value indicates better status.
b)
Higher value indicates better status.
c)
p-values were calculated using the Wilcoxon signed-rank test.
*p<0.05, statistically significant.
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different from ‘active TRPs,’ which reflect pain subjects
feel in the absence of any external pressure. Therefore,
it is possible that, although the number of ‘latent TRPs
was significantly reduced in the FBE group compared to
the FBA group, the number of ‘active TRPs’ was not. 2)
Because on average more than 2 TRPs still remained in
patients in the FBE group, intensity of pain, health sta-
tus, and C-ROM might not be affected. In addition, in
this study, identifying the pain threshold of the remain-
ing TRPs was impossible because a TRP was diagnosed
if subjects felt pain less than 4 kg/cm
2
but other pres-
sures were not tested. 3) TRPs do not necessarily reflect
the main source of pain. Not only muscle but also bone,
ligament, disc, nerve, etc. could be the focus of posterior
neck pain. Likewise, C-ROM may remain limited because
muscle pain is not the only cause of muscle spasms and
limitations in ROM.
When comparing outcomes pre-intervention versus
post-intervention, all scales showed significant improve-
ment in both groups. This result suggests that forest bath-
ing is effective in relieving pain and improving the health
status of subjects with posterior neck pain. However, this
conclusion has limitations because it is impossible to ex-
clude the effect of simply resting on pain relief and health
status improvement given the design of this study.
This study has several limitations. First, the duration
of forest bathing was one week and the duration of the
program was 5 days, which are short periods of time.
Although the authors set the duration based on the dura-
tion of previous studies, most of which were 3 to 7 days,
such short durations might be a cause of the insignificant
effect of the stretching and exercise program. However,
this short duration could be meaningful in respect to
real life, in which many people spend from 2 or 3 days to
about 7 days forest bathing during their weekends or va-
cations. In a follow-up study, we plan to compare the ef-
fect of the exercise program in longer-term forest bathing.
Second, the ages of the subject did not show a normal
distribution; specific ages were overrepresented. Because
subjects had to make time to participate in a week-long
study, students in their 20s and adults older than 50 made
up the majority of the participants. As the effect of rest-
ing on pain relief and health status improvement could
be limited to some degree because most of these subjects
had no jobs, the result would be more meaningful if the
next study includes patients with normally distributed
ages and more patients who are employed. Third, as
mentioned above, the effect of resting was not controlled.
To solve this problem, in the next study, the FBA group
must be compared with a group of participants who take
a rest period in the city of the same duration.
In conclusion, when short-term forest bathing (less
than 7 days) was used to treat patients with chronic pos-
terior neck pain for the purposes of pain relief and health
status improvement, FBE is more effective in the reduc-
tion of the number of TRPs than FBA. However, all other
scales we evaluated showed no statistically significant
difference between the two protocols.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article
was reported.
ACKNOWLEDGMENTS
This research is supported by Ministry of Culture, Sports
and Tourism (MCST) and Korea Creative Content Agency
(KOCCA) in the Culture Technology (CT) Research & De-
velopment Program 2015 and Korea Forest Service.
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... tions and listening to music can improve depressive symptoms and pain (e.g., [19,[37][38][39][40][41][42][43][44] while also improving sleep [45][46][47][48]. It is noteworthy that all three-nature-based interventions, listening to music and quality sleep-can also positively impact immune functions [33,49,50]. ...
... Figure 1C illustrates the prospects of creating mutually beneficial interactions when integrating biophilic design and indoor environments supporting disease-specific self-care. The network of diverse physiological responses to such therapeutic interior environments is supported by accumulating studies showing that nature-based interventions and listening to music can improve depressive symptoms and pain (e.g., [19,[37][38][39][40][41][42][43][44] while also improving sleep [45][46][47][48]. It is noteworthy that all three-nature-based interventions, listening to music and quality sleep-can also positively impact immune functions [33,49,50]. ...
... It is noteworthy that perioperative exposure to music is associated with the reduced intake of analgesic drugs [91,92]. There is also a growing number of studies indicating that exposure to nature and natural light may provide analgesia and reduce the burden of pain [42,93]. A combination of music, relaxation and guided imagery reduces pain in fibromyalgia patients [106,107] • Exercise and meditation reduces lower back pain intensity [108] The therapeutic interior design concept for people with chronic pain includes biophilic elements and features supporting chronic pain self-care ( Figure 2B). ...
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The benefits of biophilic interior design have been recognized by healthcare facilities, but residential environments receive relatively less attention with respect to improving the health of people living with chronic diseases. Recent “stay-at-home” restrictions due to the COVID-19 pandemic further emphasized the importance of creating interior spaces that directly and indirectly support physical and mental health. In this viewpoint article, we discuss opportunities for combining biophilic interventions with interior design, fostering disease-specific self-care. We provide examples of designing residential spaces integrating biophilic interventions, light therapy, relaxation opportunities, mindfulness meditation, listening to music, physical activities, aromatherapy, and quality sleep. These modalities can provide the clinical benefits of reducing migraine headaches and chronic pain, as well as improving depressive symptoms. The disease-specific interior environment can be incorporated into residential homes, workplaces, assisted-living residences, hospitals and hospital at home programs. This work aims to promote a cross-disciplinary dialogue towards combining biophilic design and advances in lifestyle medicine to create therapeutic interior environments and to improve healthcare outcomes.
... A study conducted in South Korea evaluated the pain-reducing effect of forest therapy (Kang et al., 2015). The study involved 64 individuals who were suffering from posterior neck pain for more than three months. ...
... Therefore, the results showed that forest therapy could be used as a form of health promotion and prevention of diseases. However, just like the other two studies (Ohtsuka et al., 1998;Kang et al., 2015), the sustained effects were not evaluated. ...
... Some researchers believe that it is the activities employed in forest therapy that brings benefit, and not nature itself. For instance, light exercises, commonly in the form of walking or stretching exercises, can have a positive effect on the immune system (Smyth et al., 2002), reduce blood glucose levels (Ohtsuka et al., 1998) and even reduce chronic pain (Kang et al., 2015). Blood pressure on the other hand, can be reduced by better stress management (Rajoo et al., 2019). ...
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Studies have found that urban environments have a negative impact on physical and mental health. This is due to urban stressors such as increased noise levels, higher crime rates and rampant pollution. Moreover, living in building-dominant surroundings increases stress levels. There’s growing scientific evidence that forest therapy is a cost-effective method of stress management, and also has the ability to improve physical and mental wellbeing. The concept of forest therapy was first developed by the Japanese Forestry Agency in 1982, where it is known as “shinrin-yoku”. Over the years, there has been growing interest in forest therapy research. These studies usually focus on forest therapy’s effects on human health, from physiological and psychosocial perspectives, but there are also studies on its potential in treating specific illnesses such as hypertension and depression. By analysing current research frameworks, methodologies and research findings, we would gain a better insight and understanding of forest therapy; Allowing researchers, medical professionals and the general public to fully utilize this cost-effective form of preventative medicine. Therefore, the core objective of this review paper is to provide: a) An in-depth analysis of current forest therapy research, from physiological and psychosocial perspectives, b) To provide a systematic summary of current forest therapy research and c) To encourage healthcare professionals and the general public to fully utilize forest therapy as a form of preventive medicine. We reviewed current literature on forest therapy (2010 to 2020) using two electronic databases (ScienceDirect and PubMed), and selected 27 articles for this review. Based on the research data, we believe that forest therapy plays an important role in preventive medicine and stress management for all age groups. However, there is a need for more research on its sustained effects and for multi-disciplinary studies, especially with healthcare professionals.
... Pain reduction is an emerging field of study in greenspace interventions [39], particularly the relationships between pain, stress, and the burden of chronic illness [40][41][42][43][44]. To date, several studies describe the pain-reducing effects of viewing nature (e.g., simulated greenspaces) in clinical settings for acute and chronic pain populations [37,41,[45][46][47][48][49]. ...
... Pain reduction is an emerging field of study in greenspace interventions [39], particularly the relationships between pain, stress, and the burden of chronic illness [40][41][42][43][44]. To date, several studies describe the pain-reducing effects of viewing nature (e.g., simulated greenspaces) in clinical settings for acute and chronic pain populations [37,41,[45][46][47][48][49]. ...
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Shinrin-yoku, forest bathing, may provide relief from chronic and breakthrough pain in patients with axial spondyloarthritis and improve immune function through increasing NK cell numbers and activity and their downstream effectors, perforin and granulysin, after chemo- or radiation therapy in breast and prostate cancer patients. The aim of this paper is to describe the study protocol for a simulated forest immersion therapy using virtual reality and atomized phytoncides, volatile organic compounds found in forested areas designed to effect positive change for these two patient populations. The setting, including the room set up and samples with inclusion/exclusion specific to this type of intervention, is outlined. Measures and calibration procedures pertinent to determining the feasibility of simulated forest immersion therapy are presented and include: ambient and surface room temperatures and relative humidity in real time, ambient ultrafine particulate matter, ambient droplet measurement that coincides with volatile organic compounds, specific phytoncides, and virtual reality and atomization of phytoncide set up. Particular lessons learned while training and setting up the equipment are presented. Simulated forest immersion therapy is possible with attention to detail during this early phase when development of methods, equipment testing, and feasibility in deploying the intervention become operational. The expected outcome of the development of the methods for this study is the creation of a standardized approach to simulating forest therapy in a controlled laboratory space.
... The positive benefits of exposure to nature have been reported for various health conditions. Studies have shown that contact with nature is effective for conditions related to stress [35,36], fatigue [37] and depression [38]. Among studies that have investigated pain management and alleviation, those on the psychological and physiological benefits of natural environments and the broader context of nature have reported no adverse effects [39]. ...
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This study aimed to investigate the effects of mindfulness-based mandala coloring made within nature on individuals with chronic widespread musculoskeletal pain (CWP). Thirty-six participants were randomly allocated. In the experimental group, identical interventions and procedures were administered for each experiment. The control group members were untreated and remained in an urban environment. Overall, the experiment showed significant improvements in tender points (f = 8.791, p = 0.006), total stress level (f = 14.570, p = 0.001), depressive symptoms (f = 15.205, p = 0.001), anger symptoms (f = 7.263, p = 0.011) and salivary cortisol (f = 10.619, p = 0.003) in the experimental group. The results reflect that MBMC within nature is effective in reducing pain, psychological stress responses, and cortisol levels in individuals with CWP. The positive results could be a product of the experimental design rather than the treatment itself. A rigorous experimental design provides better understanding of MBMC within nature.
... The intervention consisted of forest bathing in both the control group and the intervention group. The intervention group additionally performed stretching and strengthening exercises [54]. This, too, is an example of an inadequate control group, since this study design was used to investigate the effects of stretching and strengthening exercises rather than forest therapy. ...
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Background: The aim of this systematic review of systematic reviews was to identify, summarise, and synthesise the available evidence of systematic reviews (SRs) and meta-analyses (MAs) on the preventative and therapeutic psychological and physical effects of forest-based interventions. Methods: Both bibliographic databases and grey literature sources were searched for SRs and MAs published until May 2020. Eight databases were searched for relevant articles: MEDLINE, Embase, Web of Science, Cochrane Library, PsycInfo, CiNii, EBSCO, and Scopus. Grey literature was sourced from Google Scholar and other web-based search tools. SRs and MAs that included randomised controlled (RCT), non-randomised controlled (NRCT), and non-controlled trials (NCT) on health-related effects of forest-based interventions were eligible if they had searched at least two databases. The methodological quality of eligible reviews was assessed by AMSTAR-2. Results: We evaluated 11 systematic reviews covering 131 different primary intervention studies, mostly from Asian countries, three of which included supplementary meta-analyses. The quality assessment resulted in moderate confidence in the results of two reviews, low confidence in six, and critically low confidence in three. The results of the eight moderate and low-rated reviews indicated that forest-based interventions are beneficial to the cardiovascular system, immune system, and mental health (in the areas of stress, depression, anxiety, and negative emotions). Evidence for the effectiveness of forest-based interventions on metabolic parameters in adults, the severity of atopic dermatitis in children and adolescents, and social skills and sociality in healthy primary school children was weak. Discussion/Conclusions: Evidence suggests beneficial therapeutic effects of forest-based interventions on hypertension, stress, and mental-health disorders, such as depression and anxiety. Changes in immunological and inflammatory parameters after forest therapy should be verified in bio-geographically native forests. In the future, more attention should be paid to careful planning, implementation, and reporting of primary studies and to systematic reviews on the effects of forest-based interventions.
... Neck pain occurrence is affected by several factors, involving environmental, psychological, and social aspects. The absence of diagnosis and proper management of the underlying pathology can result in chronic conditions, as well as very high medical and socioeconomic costs [1]. ...
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Background Myofascial trigger point (MTrP) plays a major role in the genesis of mechanical neck pain, which may lead to chronic disorders. The purpose of the study is to investigate and compare the effect of ice massage plus integrated neuromuscular inhibition technique (INIT) versus INIT alone on active trigger points in the upper trapezius of persons having mechanical neck pain. Forty participants diagnosed as mechanical neck pain with upper trapezius active myofascial trigger points. They were randomized into two equal groups. Group A (experimental) received ice massage for 10 min plus INIT, while group B (control) received INIT alone. The treatment program continued for 2 weeks (3 sessions/week). The outcome measures are the pain intensity, pain pressure threshold, cervical lateral side bending and neck daily functions. Results The results showed that there were significant improvements in VAS at p = .899 and F = .78, PPT at p = .288 and F = .553, cervical side bending at p = .094 and F < 0.00001, and NDI at p = .164 and F = 0.00001 in both groups, while there were no statistically significant differences between both groups as p > 0.05. Conclusion Ice massage and INIT are effective methods in managing active trigger points in the upper trapezius of persons having mechanical neck pain without statistically significant difference.
... A forest walk with elevation gain or that is demanding in terms of physical exercise may increase physiological stress but is found to have positive effects in relieving mental stress and feeling uplifted [81]. Furthermore, one study tested the effectiveness of a combination of FB alone and FB with additional physical exercise on people with chronic posterior neck pain, showing a reduction in the number of trigger points after FB and exercise session [114]. In addition, an afternoon forest walk was found to be more effective in extending sleep duration than a forenoon walk in a sample of people with sleep complaints [102]. ...
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Research Highlights: This review gives an overview of existing literature on the emerging topic of human wellbeing-forest contact nexus and provides a preliminary framework linking forests to wellbeing by highlighting key variables affecting this relationship. Background and Objectives: Existing literature reveals the psychological, physiological and social wellbeing benefits of contact with forest ecosystems; however, the role of forests in this relationship remains largely unexplored. The objectives of this review are twofold: (i) to provide an overview of the contributions of forest experiences to human wellbeing and the related interplay with forest ecosystems and (ii) to identify knowledge gaps to inform future research and systematize information available for forest managers and planners to support the development of effective forest-based initiatives. Materials and Methods: A scoping review was performed with a five-phase method integrating a systematic approach on Scopus, Web of Science and PubMed databases and snowball search. Studies were analyzed using a descriptive-analytical method. Results: Overall, 93 papers were included in the review. These are mainly from health-related sciences providing limited information for forest managers, planners and practitioners. Four main underlying variables of the forest-wellbeing relationship are identified: interaction, forest features, sensorial dimension of the forest and individual traits and reactions. Conclusions: Forest-based initiatives provide good opportunities for supporting public health and time spent in contact with forests seems to have a “health-bonus”. Whether and to what extent forest management can contribute to this is still poorly investigated. There is the need to better study causal relationships between specific forest features, type of interactions, frequency and “dose” of experiences, individual reactions and needs and wellbeing effects to maximize benefits from forest-based initiatives.
Chapter
This chapter presents the relevant studies on the short- and long-term health effects of forest bathing and forest therapy. They are scientifically prepared and evaluated. A distinction is made between the relaxing and restorative effects as well as the psychological and physical effects, also on various disease patterns.
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This article aimed to develop the "forest therapy" program, which is a cognitive behavior therapy (CBT)-based intervention program using forest environment, and investigate its effects on blood pressure (BP), salivary cortisol, and quality of life (QoL) measures in patients with hypertension. A total of 56 men and women were enrolled for this study, being referred from local health centers in Republic of Korea, from April to October 2009. They were conveniently assigned to either "forest" group participating in the forest therapy program or control group doing self-monitoring of BP. Measurements of salivary cortisol level and QoL were done at initial visits and at 8-week final visits. Both groups did not differ significantly in baseline clinical characteristics. The BP change at week 4 and week 8 did not differ between the two groups. Salivary cortisol level reduction was significantly larger and QoL measures improved significantly more in the forest group at week 8 compared with the control group. The forest therapy program did not induce prolonged systolic blood pressure (SBP) reduction. However, considering the significant decrease in cortisol level and improvement in QoL measures, this may be a useful model of community hypertension management program.
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In Japan, a forest bathing trip, called "Shinrinyoku" in Japanese, is a short, leisurely visit to a forest; it is regarded as being similar to natural aromatherapy. This review focuses on the effects of forest bathing trips on human immune function. Beginning in 2005, adult Japanese individuals, both male and female, participated in a series of studies aimed at investigating the effect of forest bathing trips on human immune function. The subjects experienced a 3-day/2-night trip to forest areas, and blood and urine were sampled on days 2 (the first sampling during each trip) and 3 (the second sampling during each trip), and on days 7 and 30 after the trips. Natural killer (NK) activity, the numbers of NK, granulysin-, perforin-, and granzymes A/B-expressing lymphocytes in the blood, and the concentration of urinary adrenaline were measured. The same measurements were made before the trips on a normal working day as a control. The mean values of NK activity and the numbers of NK, granulysin-, perforin-, and granzymes A/B-expressing cells on forest bathing days were significantly higher than those on the control days, whereas the mean values of the concentration of urinary adrenaline on forest bathing days were significantly lower than that on the control days in both male and female subjects. The increased NK activity lasted for more than 30 days after the trip, suggesting that a forest bathing trip once a month would enable individuals to maintain a higher level of NK activity. In contrast, a visit to the city as a tourist did not increase NK activity, the numbers of NK cells, or the level of intracellular granulysin, perforin, and granzymes A/B. These findings indicate that forest bathing trips resulted in an increase in NK activity, which was mediated by increases in the number of NK cells and the levels of intracellular granulysin, perforin, and granzymes A/B.
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The present article describes VAS Generator (www.vasgenerator.net), a free Web service for creating a wide range of visual analogue scales that can be used as measurement devices in Web surveys and Web experimenta- tion, as well as for local computerized assessment. A step-by-step example for creating and implementing a vi- sual analogue scale with visual feedback is given. VAS Generator and the scales it generates work independently of platforms and use the underlying languages HTML and JavaScript. Results from a validation study with 355 participants are reported and show that the scales generated with VAS Generator approximate an interval-scale level. In light of previous research on visual analogue versus categorical (e.g., radio button) scales in Internet- based research, we conclude that categorical scales only reach ordinal-scale level, and thus visual analogue scales are to be preferred whenever possible.
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Rosalind Rabin, Frank de Charro, Agota Szende 1.1 Purpose of this booklet Governments and healthcare funders worldwide are making increasing use of economic evaluation to inform priority setting in health care. For various reasons, cost benefit analysis is usually rejected in favour of cost-effectiveness or cost-utility analyses, often involving the estimation of the incremental cost per Quality Adjusted Life Year (QALY) gained (Drummond et al, 2005). The estimation of QALYs gained requires valuations for all relevant health states on a scale anchored at 1 = Full health and 0 = Dead. The EQ-5D is widely used in this context and a number of value sets are available for all the health states generated by the EQ-5D descriptive system. These can be readily applied to health outcomes measured as EQ-5D profiles. EQ-5D has become one of the valuation approaches recommended by several reimbursement authorities and academic bodies in European countries (e.g. The Netherlands, Norway, Italy, Hungary, Poland, Portugal, UK), North America (e.g. Canada), and elsewhere (e.g. New Zealand). The EuroQol Group frequently receives requests for advice regarding EQ-5D valuation data. Those seeking to apply EQ-5D valuations in economic evaluation want to know about the availability of EQ-5D value sets and how they can obtain them. They also seek specific guidance about which of the available value sets they should use for their purposes.
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To provide scientific evidence supporting the efficacy of forest bathing as a natural therapy by investigating its physiological benefits using biological indicators in outdoor settings. Within-group comparisons were used to examine psychological and physiological responses to exposure to real forest and urban environments. Young Japanese male adults participated in a 3-day, 2-night field experiment. Physiological responses as well as self-reported psychological responses to forest and urban environmental stimuli were measured in real settings. The results of each indicator were compared against each environmental stimulus. Heart rate variability analysis indicated that the forest environment significantly increased parasympathetic nervous activity and significantly suppressed sympathetic activity of participants compared with the urban environment. Salivary cortisol level and pulse rate decreased markedly in the forest setting compared with the urban setting. In psychological tests, forest bathing significantly increased scores of positive feelings and significantly decreased scores of negative feelings after stimuli compared with the urban stimuli. Physiological data from this field experiment provide important scientific evidence on the health benefits of forest bathing. The results support the concept that forest bathing has positive effects on physical and mental health, indicating that it can be effective for health promotion. Despite the small sample size in this study, a very clear tendency towards positive physiological and psychological outcomes in forests was observed.
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The McGill Pain Questionnaire consists primarily of 3 major classes of word descriptors--sensory, affective and evaluative--that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically. This paper describes the procedures for administration of the questionnaire and the various measures that can be derived from it. The 3 major measures are: (1) the pain rating index, based on two types of numerical values that can be assigned to each word descriptor, (2) the number of words chosen; and (3) the present pain intensity based on a 1-5 intensity scale. Correlation coefficients among these measures, based on data obtained with 297 patients suffering several kinds of pain, are presented. In addition, an experimental study which utilized the questionnaire is analyzed in order to describe the nature of the information that is obtained. The data, taken together, indicate that the McGill Pain Questionnaire provides quantitative information that can be treated statistically, and is sufficiently sensitive to detect differences among different methods to relieve pain.