Outdoor experiences and outdoor-based activities and interventions for individuals with spinal cord injury: A systematic scoping review

Abstract

Study design: Systematic scoping review. Objectives: The aim was to identify and synthesize empirical studies exploring outdoor experiences, activities, and interventions in people with spinal cord injury (SCI). Methods: Systematic searches were performed in 7 bibliometric databases. Unique records were independently screened by 2 authors. Peer-reviewed studies on outdoor experiences, activities, or interventions in adults with SCI were included. This was supplemented by Google Scholar searches and citation tracking. Data from included studies were extracted and analysed in a narrative synthesis. Results: A total of 89 studies were included. Study findings were catalogued into 9 categories and grouped into 3 themes. Theme 1 covered findings related to the experiences and outcomes of outdoor recreational activities and nature exposure. Theme 2 covered findings on facilitators and barriers related to outdoor recreational activities and nature exposure. Theme 3 covered findings related to outdoor testing of equipment and tools. Conclusion: People with SCI mainly report positive experiences from engaging with the natural environment and pursuing outdoor activities, but also experienced a range of barriers that need to be considered in both research and clinical practice. Future studies need to explore the effects of outdoor-based rehabilitation, also employing high-quality methods.

Full text

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Journal of Rehabilitation Medicine
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REVIEW ARTICLE
2025 ©Author(s). Published by MJS Publishing, on behalf of the Foundation for Rehabilitation Information. This is an Open Access article distributed under the terms
of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).
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Study design: Systematic scoping review.
Objectives: The aim was to identify and synthesize
empirical studies exploring outdoor experiences,
activities, and interventions in people with spinal
cord injury (SCI).
Methods: Systematic searches were performed
in 7 bibliometric databases. Unique records were
independently screened by 2 authors. Peer-revie-
wed studies on outdoor experiences, activities, or
interventions in adults with SCI were included.
This was supplemented by Google Scholar sear-
ches and citation tracking. Data from included stu-
dies were extracted and analysed in a narrative
synthesis.
Results: A total of 89 studies were included. Study
ndings were catalogued into 9 categories and
grouped into 3 themes. Theme 1 covered ndings
related to the experiences and outcomes of outdoor
recreational activities and nature exposure. Theme
2 covered ndings on facilitators and barriers rela-
ted to outdoor recreational activities and nature
exposure. Theme 3 covered ndings related to out-
door testing of equipment and tools.
Conclusion: People with SCI mainly report posi-
tive experiences from engaging with the natural
environment and pursuing outdoor activities, but
also experienced a range of barriers that need to
be considered in both research and clinical prac-
tice. Future studies need to explore the effects of
outdoor-based rehabilitation, also employing high-
quality methods.
OUTDOOR EXPERIENCES AND OUTDOOR-BASED ACTIVITIES AND INTERVENTIONS
FOR INDIVIDUALS WITH SPINAL CORD INJURY: A SYSTEMATIC SCOPING REVIEW
Anders O. AABY, PhD
1
, Samuel D. WILLIAMSON, MSc
1,2
, Louise S. MADSEN, PhD
3,4
, Thomas MARIBO, PhD
3,5
and
Sophie L. RAVN, PhD
1,2
From the
1
Specialized Hospital for Polio and Accident Victims, Rødovre,
2
Department of Psychology, University of Southern Denmark,
3
DEFACTUM, Central Denmark Region,
4
National Rehabilitation Marselisborg Centre, and
5
Department of Public Health, Aarhus
University, Denmark
LAY ABSTRACT
This systematic scoping review examined outdoor
activities and interventions among people with spi-
nal cord injury. By analysing 89 peer-reviewed stu-
dies, the research catalogued ndings into 9 catego-
ries under 3 themes. The rst theme highlighted the
varied experiences and outcomes of engaging in out-
door recreational activities and nature exposure. The
second theme focused on the facilitators and barriers
encountered. The third theme examined outdoor tes-
ting of specialized equipment and tools. Participants
reported generally positive experiences with outdoor
activities and nature, though they faced several obsta-
cles. The ndings suggest the need for future research
to further investigate outdoor-based rehabilitation
and improve methodological quality. Promoting varied
outdoor activities could support recovery by providing
physical, psychological, and social health benets.
However, successful implementation requires overco-
ming numerous barriers with strong commitment from
health professionals and policymakers. Future studies
should explore transitioning indoor rehabilitation to
outdoor settings to better understand and enhance
health outcomes.
Key words: nature; outdoor; greenspace; recreation; neurore-
habilitation; SCI, spinal cord injury; neurological disorders.
Submitted May 3, 2024. Accepted after revision Dec 27, 2024.
Published Jan 21, 2025. DOI: 10.2340/jrm.v57.40705.
J Rehabil Med 2025; 57: jrm40705.
Correspondence address: Dr Anders O Aaby, Specialized Hospital for
Polio and Accident Victims, Rødovre, Denmark. E-mail: aaa@special-
hospitalet.dk
For people living with spinal cord injury (SCI),
rehabilitation is crucial for optimizing function
across life areas (1, 2). While rehabilitation typically
occurs in health facilities, outdoor and greenspace
environments can also support people with SCI in eve-
ryday life (3). Expanding rehabilitation contexts may
encourage people to strive for improvement and learn
new strategies beyond the limitations of disability (4).
In recent decades, research linking health and
greenspaces has increased and formed an interdisci-
plinary research eld (5–11). The effort to understand
the nature-health connection has been aided by the
development of Attention Restoration Theory (12) and
Stress Reduction Theory (13). Attention Restoration
Theory highlights nature’s capacity to restore mental
energy depleted by urban environments (12), while
Stress Reduction Theory suggests that unthreatening
natural environments activates several emotional and
physiological stress-reduction responses (13). Indeed,
studies have shown benets of getting away from
hospital settings, appreciating nature, and engaging in
outdoor activities like kayaking or shing (3, 14–16).
Despite extensive research, synthesizing ndings
is challenging due to methodological and contextual
diversity. An early review from 2004 explored outdoor

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experiences of people with SCI but lacked a rigorous
approach to searching, screening, and data extraction,
relying partly on anecdotal evidence such as personal
correspondence and news media stories (3). Later, a
2017 systematic review explored health-promoting
nature access for people with mobility impairments,
including 3 SCI studies (8) but omitted ndings from
man-made parks and outdoor community facilities
as well as studies on non-health-related outcomes
and perspectives on barriers and facilitators. A 2019
systematic review on nature’s psychosocial impact on
neurological disability reported no SCI-specic stu-
dies, identifying this as an under-researched area (10).
A systematic scoping review is necessary to sum-
marize these diverse ndings and guide future research
and practice. The aim of this study was therefore to
identify and synthesize studies exploring outdoor expe-
riences and outdoor-based activities or interventions
among adults living with SCI.
METHODS
This systematic scoping review follows PRISMA guideline
extension for scoping reviews (17), with a pre-registered proto-
col in the Open Science Framework on 7 April 2022 (available
via https://doi.org/10.17605/OSF.IO/5W3ZQ).
Search strategy
Two search blocks were developed. Block 1 contained outdoor-
related terms such as nature, outdoor, outside, greenspace, forest,
garden, and more. Block 2 contained terms related to SCI such
as spinal cord lesion, spinal trauma, tetraplegia, paraplegia, and
more. Search terms were based on the literature and indexes,
tested in pilot searches, and used at title/abstract/keyword level
or similar. Search terms available as a subject heading were
searched as subject headings without explosion and as free text.
No database restrictions were used. The literature search was
performed as uniformly as possible across databases. The full
electronic search string is provided as supplementary informa-
tion (see Appendix S1).
Final searches were performed in 7 databases, i.e., PubMed,
PsycINFO (via OVID), Embase (via OVID), Web of Science,
Scopus, Cochrane Library, and CINAHL (added after consulta-
tion with a research librarian as not all volumes of Therapeutic
Recreation Journal were indexed in the other databases). The
main databases were searched on 7 April 2022, and CINAHL
on 22 April 2022. Additionally, backward citation tracking
and unsystematic searches in PEDro and Google Scholar were
conducted using various combinations of the search terms.
Eligibility criteria
Eligibility criteria were developed prior to screening. Studies
were included if they were peer-reviewed; published in English,
Danish, Swedish, or Norwegian; based on an adult SCI popula-
tion (≥ 18 years); and explored or evaluated outdoor experiences
or outdoor-based activities or interventions in any form or set-
ting. Studies with mixed samples needed either at least 50% SCI
participants or SCI-specic results. Studies merging indoor and
outdoor activities were excluded unless outdoor-specic results
were reported. No restrictions were imposed on study method or
design. Reviews, dissertations, letters, editorials, book chapters,
protocols, online registration of interventions, and conference
abstracts were excluded as ineligible formats, and studies noted
as unavailable were those we could not access, even with the
assistance of university research librarians.
Screening procedure
The search outputs were combined, duplicates removed, and
all unique studies were independently screened by 2 authors
using Covidence (18). Titles and abstracts were rst screened,
and non-excludable studies were then full-text screened with
exclusion reasons registered for publication purposes. Disa-
greements were resolved through discussion, with co-authors
consulted when necessary. Screening of PEDro and Google
Scholar records was conducted by the rst author.
Data extraction and synthesis
Data extracted included author(s), year of publication, country,
study setting, outdoor setting and activity, study aim, study
design, outcome(s), sample size (N), sample characteristics
(age and sex), injury characteristics (injury level, injury com-
pleteness, and time since injury), and key ndings relevant to
this review’s aim. The extracted data were tabulated and are
provided as supplementary information (see Appendix S2 for
study details and Appendix S3 for main ndings). Data extrac-
tion was performed independently by 2 authors, and disagre-
ements were resolved by checking the original paper. A third
author was consulted when necessary. Two student assistants
aided the data extraction process for the descriptive data (i.e.,
not results). They provided 1 part of the data extraction, while
1 of the authors provided the other part. The rst author cross-
veried the extractions tables. In 7 cases, corresponding authors
were contacted to clarify SCI proportions; 5 of these studies
were then included (19–23).
A narrative synthesis was performed to synthesize key n-
dings. This was deemed the most appropriate technique due to
methodological heterogeneity in the research eld. After fami-
liarization with the data, 1 author initially organized ndings into
coherent categories and themes, and performed a preliminary
narrative synthesis. This was rened by the review team through
iterative discussion until consensus was reached.
RESULTS
Systematic search results
The systematic searches identified 6,208 unique
records. Of these, 5,853 were excluded in title and
abstract screening, and 278 were excluded in full-text
screening, leaving 77 eligible studies. With 12 addi-
tional eligible studies identied through other sources
(i.e., backward citation tracking and Google Scholar),
a total of 89 studies were included in this review (see
PRISMA Flowchart in Fig. 1).
Study characteristics of the included studies
Most studies were conducted in North America
(n = 62), followed by Western Europe (n = 14), and
Australia (n = 4). Sample sizes ranged from case studies
(n = 1) to large surveys (n = 920 with approximately
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half having fewer than 20 participants. In terms of
sex, 94% included more than 50% men, while 77%
included more than two-thirds male participants.
Mean age was not reported consistently, but for the 68
studies that did, the mean age ranged from 24.5 years
to 64 years. There was considerable variation in how
injury characteristics were reported, so a summary is
not pertinent. Most studies were quantitative (n = 45),
followed by qualitative (n = 36), and mixed-methods
(n = 8). A complete list of all the extracted study cha-
racteristics is provided as supplementary information
(see Appendix S2).
Narrative synthesis
The 89 included studies explored a wide range of
outdoor contexts and activities, employed various
methodological approaches, and focused on different
aspects or effects of outdoor experiences. Findings
were organized into 9 categories and grouped into
3 overarching themes. For a visual overview of the
categorization, see Fig. 2.
This categorization was based on ndings, so many
of the included studies are represented across multi-
ple themes and categories. The 3 themes and the 9
categories are described below. A complete list of the
extracted main ndings is provided as supplementary
information (see Appendix S3).
Multifaceted experiences and perceived outcomes of
outdoor recreational activities and nature exposure
(theme 1). This theme synthesizes positive and nega-
tive experiences of engaging in outdoor recreational
activities and nature exposure. The rst category,
“outdoor recreational activities”, covers experiences in
outdoor recreational activities such as hiking, skiing,
gardening, kayaking, and more. The second category,
“nature exposure”, includes experiences of walking/
wheeling or simply being outdoors and in nature. The
third category, “living near green and open spaces”,
covers health outcomes related to living close to green
and open spaces.
Outdoor recreational activities. This category was
the most prominent with 30 studies (14–16, 20, 21,
24–48). This included degree of participation, gene-
ral experiences, perceived physical and psychosocial
benets, and negative experiences.
People with SCI were generally interested in parti-
cipating in outdoor recreational activities (24), and 1
study found that 26% set outdoor-related rehabilitation
Fig. 1. PRISMA owchart of the
systematic search and screening
process, including reasons for
exclusion. Final search was
performed on 7 April 2022.
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goals (25). The most popular outdoor recreational
activities were wheeling, hand-cycling, kayaking, and
sit-skiing (24), but the included studies showed that
people with SCI engaged many other activities like
hunting and shing (14, 15, 26, 27), scuba diving (28),
horseback riding (24), sailing (29, 30), and more. One
study showed an 86% decrease in outdoor activities
post-SCI (31), and 2 studies showed reduced or lack of
participation in outdoor recreational activities (16, 21).
In terms of effects of participation in outdoor
recreational activities, 1 intervention study showed
general satisfaction as well as a decrease in barriers
and increased positive affect and self-efcacy among
participants in a 3-day cottage programme compared
with a non-randomized control group (16). The dif-
ferences in self-esteem and negative affect were not
signicant (16).
Across studies exploring the experience of different
outdoor recreational activities, participants expressed
joy, pleasure, well-being, or enthusiasm when they
engaged in skiing (20,32), water-skiing (33), kayaking
(21, 34–36), sailing (29,30), hunting and shing (26,
27), hiking (37, 38), and hand-cycling (21, 32, 33,
35). Participants also regularly experienced a sense
of achievement, self-esteem, or competence (20, 29,
34, 39). Participation in outdoor recreational activities
was also closely related to recovery, re-integration, and
identity reconstruction (24, 26, 40, 41). In addition to
these positive experiences, 1 study noted that people
with SCI were frustrated with the patronizing com-
ments they received (24). Findings from some studies
(20, 21, 29, 30, 37, 39) were derived from evaluations
of specic programmes, while the remaining ndings
reect the experiences of individuals with SCI enga-
ging in these activities within their everyday lives.
Focusing rst on land-based activities, 2 studies
evaluating skiing programmes (20, 39) and 1 study
exploring experiences with prior use of sit-skiing (42)
showed that participants experienced increased quality
of life (42), improved physical condition, self-worth,
and satisfaction with their body (39), in addition to
feeling less anxious, more prepared, and empowered
(20). While participants in 1 study found skiing to be
daunting (20), another study reported that participants
Fig. 2. Overview of the
categorization of findings in
the narrative synthesis. Nine
meaningful categories were
developed, which were grouped
into 3 overarching themes.
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felt safe (42). Like skiing, hand-cycling made partici-
pants nervous, and some were hesitant to try it out in a
study describing a 10-session recreational programme
(21). However, with encouragement all participants
tried it and found it enjoyable (21). Another study
found hand-cycling to be the most popular activity on
offer (43). In other studies where participants reec-
ted on their use of hand-cycling, it was described as
providing a sense of freedom and independence (33,
41). Furthermore, people with SCI preferred biking
outside (44), and it was viewed as a way of getting
back into the woods (32). Getting back into nature was
also appreciated during a skiing programme (20) and
a hiking programme (37), as well as when reecting
on previous hiking experiences (41).
Gardening was one of the activities in which people
with SCI were most likely to experience changed
performance when reecting on leisure activities (27),
and only around 8% had engaged in gardening in the
previous 3 days (46). In reecting on leisure activities,
gardening was found in 1 study to be therapeutic and
relaxing (28). Similar to gardening, when reecting on
hunting and shing, people with SCI described having
challenges in performance or at least in getting the full
experience (45), but also as a way to relax (26), a diver-
sion from worry (47), and a source of well-being (27).
In terms of water-based activities, similar sentiments
of appreciating the natural scenery and the calming
atmosphere on the water were expressed when reec-
ting on water skiing and kayaking (34, 36, 43), as well
as during sailing programmes (29, 30). In 3 studies,
participants reected on their participation in sea kaya-
king expeditions provided by an outdoor experience
organization and described it as a means of immersing
oneself in the natural world (34, 36, 48). Participants
in 1 study expressed feeling safe during kayaking
(36), while they expressed fears of capsizing and
bad weather in another study (34). This was the only
negative experience reported. Kayaking was described
as an equalizer because participants felt on the same
level as their able-bodied peers (34, 36, 48). It further
provided a sense of freedom, supported their adjust-
ment process and mental health, and offered physical
health benets like strength, stamina, and balance (34,
36, 48). A sense of freedom was also described when
reecting on swimming and during sailing program-
mes (24, 29, 30). Participants also experienced that
independent sailing challenged stigmas concerning
their abilities (29).
Nature exposure. The appreciation of being outdoors
and in the natural environment was not just expressed
during outdoor recreational activities. A total of 13
studies were categorized as reporting ndings on the
experience of nature exposure while simply walking/
wheeling outside or just being in nature (14, 15, 27,
33, 49–57). For instance, some expressed a newfound
appreciation for nature following their injury (33, 54).
Furthermore, participants trying out an exoskeleton
outside commented on the positive effects of fee-
ling the sun and kicking leaves (53). Simply getting
outside was described as a much appreciated escape
from the hospital setting (14) and from feeling caged
(15). Lastly, outdoor activities (i.e., walking/wheeling,
camping, and being in nature) were among the 6 most
likely activities (out of 21 activities) for people with
SCI to be interested in and to endorse as a source of
well-being (27).
In addition to generally positive experiences, some
adverse effects and negative experiences associated
with nature exposure were expressed. A few studies
noted that outdoor wheeling was associated with
increased pain (55–57). Outdoor wheeling and being
in the garden or on the street were all found to be asso-
ciated with a higher risk of falling (50–52). This led to
worry and vigilance when scanning the environment,
which reduced their enjoyment of being outside (49).
Living near green or open spaces. Four studies investi-
gated whether living near greenspaces and open spaces
was related to greater participation, health, functio-
ning, and well-being for people with SCI (58–61).
Collectively, they showed inconsistent results. First,
living in areas with a large proportion of open spaces
approximately doubled the odds of reporting full par-
ticipation (61) and had approximately half the odds of
reporting poor health (58). Furthermore, proportion of
park space was associated with higher functioning (59).
Conversely, living in areas with moderate amounts
of greenspace and open spaces was associated with
greater depression and less positive affect compared
with living in areas with less greenspace and open
spaces (60).
Facilitators and barriers related to engaging in
outdoor recreational activities and nature exposure
(theme 2). In theme 2, factors that either promote or
hinder participation in outdoor recreational activities
and nature exposure were identied and grouped.
It consisted of 4 categories: physical environment,
adaptive equipment, social and personal factors, and
outdoor mobility.
Physical environment. This category included 18 stu-
dies (15, 19, 22, 35, 41, 62–74). These included lack
of or steep kerb cuts; lack of or poorly maintained
sidewalks; uneven, steep, soft, wet, or slippery terrain;
grass, mud, sand, stones and gravel; and stairs (15,
19, 35, 41, 63–69). Furthermore, climate and weather
were generally reported as barriers to participation
(64, 70). Winter conditions, specically, were found to
be a barrier due to slippery roads, increased pain, and
discomfort (63, 68, 69, 71–74). Conversely, summer
conditions were both a barrier and a facilitator (68,
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69). In addition to seasonal effects, rain was noted
in 3 studies as being an issue with mobility assistive
devices (15, 66, 67).
Adaptive equipment.
In total, 18 studies were catego-
rized here (14, 20, 24, 29, 32, 37, 48, 75–85). First,
it was highlighted as being of importance to be able
to pursue outdoor recreational activities (24, 75), and
specically in terms of skiing (20), shing (14, 32),
kayaking (48), sailing (29), and hiking (37). Three stu-
dies also highlighted high cost (24, 32), poor condition
(29), and reliance on other people’s assistance (24).
A range of studies showed the mitigating effects of
having mobility assistive devices that could traverse
difcult terrain (32, 37, 76–79). Specically in terms
of exoskeletons, the most common location of usage
was outside (81), and they enabled walking on various
outdoor terrain (82), increased outdoor walking speed
(83, 84), and signicantly improved outdoor 6-min
walking test (85).
Social and personal factors. A total of 10 studies were
included in this category (20, 21, 24, 28, 29, 37, 40, 41,
75, 86). First, social encouragement was a facilitator
of outdoor recreation (21, 24). Conversely, needing
assistance, lack of volunteers, health concerns, trans-
portation, and scheduling were highlighted as barriers
to outdoor recreation across studies (24, 28, 29, 37,
41). A personal barrier to pursuing outdoor recreatio-
nal activities was lack of knowledge on possibilities,
different kinds of adaptive equipment, and how to use
them (21, 75). Conversely, having someone to consult
was described as a vital social facilitator (75).
Volunteers were instrumental in a hiking excursion
programme, but, on a personal level, relinquishing
control and accepting dependence on volunteers was
difcult for some participants (37). Acceptance, in the
sense of being able to let go of the past self in develo-
ping a new identity, was found to be associated with
engagement in new outdoor activities (40). Similarly,
constructing the SCI in a “quest narrative” facilitated
engagement in sports and outdoor recreation compared
with the “restoration narrative” (86).
Outdoor mobility. Outdoor mobility is a facilitator or
barrier to engaging in outdoor activities, and 4 of the
included studies explored outdoor mobility (87–90).
One study was able to improve walking ability in a
4-week training programme, but improvements were
not maintained at follow-up (87). Another study showed
that a walking speed of 0.59 m/s was able to distinguish
between people who were able to walk outdoors and
those who were not (88). Lastly, motor strength, light
touch sensation, and lower extremity motor scores were
key predictors of outdoor mobility (89, 90).
Empirical testing in outdoor settings (theme 3). This
theme included studies that used an outdoor setting to
perform empirical testing and validation of equipment
and assessment tools. In the rst category, studies that
explored energetics (i.e., energy use) of equipment or
activities were synthesized. In the second category,
studies that tested and validated non-wheelchair or
exoskeleton equipment in an outdoor setting or any
other assessment tools related to the outdoor context
were synthesized.
Energetics of equipment and activities.
Ten studies were
categorized as reporting ndings related to energetics
(91–100). These studies showed participants using less
physiological effort when wheeling than when walking
outside (92), when using ultralight wheelchairs (93),
when using 2-arm chairs compared with 1-arm chairs
(94), when using power-assisted compared with manual
wheelchairs (95), and when using a mobility assistance
dog (98). Further, propulsion forces were signicantly
higher when wheelchairs are propelled over grass,
pavement, and uphill (96), as well as across aggregated
outdoor terrain compared with smooth terrain (97). Two
studies used heart rate to indicate energy use during
outdoor tasks and found it was a reliable indicator when
propelling a wheelchair outdoors (99), but could not
reliably predict oxygen uptake (100).
Validation of equipment and assessment tools. Five
studies were categorized as testing and validating
equipment or assessment tools related to outdoor
contexts (23, 101–104). Three studies have developed
and validated equipment in outdoor setting: a fatigue
meter (101), a device to quantify physical activity using
wheel pushes (102), and a set of crutches to assess
load on upper extremities (23). In terms of assessment
tools, the outdoor 6-min walking test was more repre-
sentative of actual performance as the indoor version
tended to underestimate walking ability (103). Lastly,
the outdoor domain in a physical activity scale showed
poor reliability (104).
DISCUSSION
Summary of ndings
Overall, studies indicate frequent participation in
outdoor recreational activities like wheeling, hand-
cycling, kayaking, and sit-skiing among people with
SCI, offering positive experiences such as joy, self-
efcacy, and freedom. Being outdoors helped escape
hospital settings and appreciate nature, although
negative experiences like patronization, safety con-
cerns, and increased pain were noted. Proximity to
greenspaces correlated with better physical health and
activity levels but also with depression and reduced
positive affect.
For individuals with SCI, barriers to outdoor
activities and nature exposure included inaccessible
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environments, adverse weather, high costs, and lack of
adaptive equipment. Knowledge of adaptive equipment
and support from volunteers and family were crucial
facilitators, whereas needs for assistance, insufcient
volunteer availability, health issues, and transport
logistics posed signicant challenges.
Research showed that outdoor equipment demon-
strated distinct differences in energetics and propulsion
forces across various activities. Tools like fatigue
meters and wheel push counters were effectively vali-
dated outdoors. The 6-min walking test, administered
in a community setting, provided a more accurate per-
formance representation than when conducted indoors.
Study ndings in context
Positive experiences in outdoor recreation like joy,
freedom, and recovery align with the 2004 review on
SCI and outdoor experiences (3). This review adds
empirical weight, highlighting nuances related to
positive and negative experiences of outdoor activities,
nature exposure, and living near greenspaces. Barriers
like transportation, social support, and knowledge
noted in the 2004 review (3) are further detailed here
to include the physical environment, weather, cost and
availability of adaptive equipment, and social factors
like health concerns and acceptance. Additionally,
this review uniquely emphasizes the physical requi-
rements like walking speed and motor strength as
well as specialized equipment, such as ultralight and
power-assisted wheelchairs and mobility assistance
dogs, which enhance accessibility and reduce strain,
fostering independence. Outdoor-specic assessments,
like the 6-minute walking test, were validated for mea-
suring functional capacity in natural settings.
Findings from related disability research reect
similar positive outcomes in outdoor activities such
as kayaking and sailing (105), paddling (106), skiing
(107), and hiking (108), alongside a sense of freedom
and relaxation in nature (109). Increased mood and
well-being, relaxation, sense of competence, self-
esteem, physical strength, and social connectedness
were also noted in 3 recent reviews focusing on enga-
gement with nature for people with physical disabilities
(8), brain injury (9), and neurological disability (10).
However, there were also notable differences. Cog-
nitive benets from nature engagement were observed
in other reviews (8–10) but not found here, possibly
due to the focus on different populations like those
with brain injuries (9) or neurological disabilities (10).
Additionally, while nature engagement often provided
pain relief for those with physical disabilities (110, 111),
it frequently resulted in increased pain for individuals
with SCI, likely because their pain arose from active
participation in outdoor activities such as wheeling.
The ndings align with Attention Restoration Theory
(12) and Stress Reduction Theory (13), suggesting
nature’s role in restoring attention and reducing stress,
illustrated through activities like sea kayaking. Other
studies within the SCI eld have shown a stress-redu-
cing response from visual stimulation with indoor bon-
sai trees (112) and increased mood and relaxation using
virtual reality to view natural scenery (113). Further-
more, living near greenspaces correlates with health
and participation outcomes, but also with depression
and less positive affect (58–61). This could be because
the areas are not accessible. This is underscored by
research suggesting that people with disabilities feel a
sense of exclusion and outsideness when greenspaces
are not accessible (114), highlighting the importance
of accessibility in greenspace design.
This review also suggests that recreational activities
themselves offer physical, psychological, and social
health benets. However, the outdoor setting could still
enhance these effects compared with an indoor envi-
ronment, as research suggests the natural environment
encourages physical activity, improves mental health,
and facilitates social cohesion (115–117).
Clinical implications
Given the positive experiences and noted barriers for
individuals with SCI engaging in outdoor activities,
this review underscores that rehabilitation should not
solely occur within the connes of indoor facilities
and points to several crucial implications for clinical
practice, rehabilitation, and policy formulation. Integra-
ting outdoor recreational activities such as kayaking,
hand-cycling, and gardening into routine rehabilitation
programmes could enhance physical, psychological,
and social well-being. As such, there is a clear need
for training healthcare providers on the benets and
logistics of implementing outdoor-based interventions.
This includes understanding the specic needs of people
with SCI and how to safely incorporate outdoor activi-
ties into therapeutic practices. Furthermore, addressing
physical, environmental, technical, personal, and social
barriers is essential for successful outdoor rehabilita-
tion. Clinics and rehabilitation centres should work
with local governments and organizations to improve
accessibility of parks, trails, and outdoor recreational
facilities. This includes ensuring accessible transport
and the availability of adaptive equipment. There is a
need for research institutions, manufacturers, and com-
munity organizations to continue the development and
distribution of cost-effective and sturdy adaptive equip-
ment that meets the practical needs of individuals with
SCI and enhances independence in outdoor settings.
The ndings on outdoor mobility offer essential
insights into the physical requirements for indepen-
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dent movement outdoors, including walking speed
and motor strength, which are predictive of outdoor
ambulation abilities in people with SCI. For example,
a minimum walking speed of 0.59 m/s was shown to
differentiate those who can walk outdoors from those
who cannot, while motor strength, light touch sensa-
tion, and lower extremity scores further predict outdoor
mobility, suggesting that rehabilitation professionals
should incorporate assessments of these physiologi-
cal indicators to tailor interventions effectively and
to set realistic mobility goals that facilitate outdoor
engagement.
This review also highlights the importance of equip-
ment validation for outdoor use. Studies on energy
expenditure and propulsion forces indicate that using
aids like ultralight wheelchairs, power-assisted devi-
ces, and mobility assistance dogs can reduce physical
strain during outdoor activities. Additionally, a com-
munity 6-min walking test offers a more accurate
assessment of actual outdoor mobility compared with
indoor tests, which tend to underestimate capacity in
real-world settings. These validated tools should be
integrated into clinical practice to ensure that the fun-
ctional abilities of individuals with SCI are accurately
represented and supported in outdoor contexts.
In terms of social barriers, building strong support
networks of peers, friends, family, and volunteers
could help facilitate participation in outdoor activities.
Programmes designed to increase social interactions
and community bonding through group activities could
be especially benecial. As an overarching theme,
policymakers should be informed of the benets of
outdoor activities for people with SCI. This could
facilitate and promote the development of policies that
support and fund accessible greenspaces and outdoor
recreational areas.
Of note, the present study found only a few inter-
vention studies and no studies that applied more
rigorous methods to test the effect of outdoor-based
interventions. This lack of strong intervention studies
lessens the certainty of conclusions that can be drawn
to guide clinical practice. It remains unclear how chan-
ges in rehabilitation setting specically affect health
outcomes. This uncertainty is important to address in
future research. Furthermore, we found no studies that
explored the conversion of traditionally indoor reha-
bilitation activities (e.g., transfer training) to outdoor
settings, thereby also providing no strong evidence
base for clinical practice.
Limitations
The present study holds several strengths, like a broad
and rigorous search strategy, but also limitations. First,
we applied a broad search method to map studies of
outdoor experiences, activities, and interventions in
SCI. However, this still only identies studies that
mention the search words in the title, abstract, or key-
words, or were indexed accordingly. This meant that
there are likely studies that have a relevant outdoor
activity that have not appeared in our searches. We
have attempted to address this issue by conducting
thorough searches using Google Scholar, but there
are probably still records not identied. This could
be in participation research, but also specic outdoor
activities that we did not include in our search. This
could also be true of studies using mixed study samples
(e.g., mixed neurological disorders) or specic SCI
samples (e.g., spina bida), which were not included
in the search terms.
Furthermore, the literature search was concluded
over 2 years prior to publication, resulting in the exclu-
sion of potentially relevant studies published after April
2022. Given the current pace of research publication, it
would be advisable to conduct an updated systematic
review within the next 3–5 years to ensure the inclusion
of the most recent evidence.
Another limitation involves the language restrictions
applied. We included studies published in English,
Danish, Swedish, and Norwegian but excluded 6
records based on language. Although it is unknown
whether these studies would have met our eligibility
criteria, this remains a potential limitation.
A further limitation is related to the considerable
variation in the studies. SCIs are highly different in
terms of consequences for physical abilities, both due
to differences in level and completion of injury, but also
due to the large variations in associated symptoms such
as pain, spasticity, or gut issues (118). In this review,
we have not grouped ndings based on injury charac-
teristics or associated symptoms. Such characteristics
could potentially serve as an important difference
between the studies and related ndings in addition to
being an important factor in clinical decision-making.
Another limitation is the deviation from the protocol
regarding the assessment of risk of bias for the studies
included. We chose to ignore this due to the large num-
ber and diversity of the studies in the current study.
This decision after the fact means that the quality of
the studies and the associated risks of bias were not
evaluated systematically.
Future directions
It is crucial to advance our understanding of the spe-
cic role that the outdoor natural environment plays
compared with the recreational activity. Future studies
need to develop and employ rigorous methods and
measurement scales to begin teasing out these effects.
Furthermore, most research has focused on experiences
and perceived benets of physical activities, so studies
need to investigate outdoor pursuits such as horticul-
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A.O. Aaby et al. “Spinal cord injury and outdoor experiences” p. 9 of 12
tural therapy (119), forest bathing (120), and green care
farming (121). Similarly, future studies need to explore
the experiences and effects of transforming traditional
indoor rehabilitation practice to an outdoor context.
There could potentially be a set of novel barriers and
facilitators associated with this move. Lastly, most
research has been conducted in North America, which
has a strong culture of outdoor recreational pursuits
facilitated by private organizations and volunteers. In
the Scandinavian countries, this is much less pronoun-
ced as rehabilitation is largely organized within the
public health system. Additionally, policy contexts dif-
fer by region, with some countries enforcing legal fram-
eworks that secure access to public spaces like parks
and forests for people with disabilities. This highlights
the importance of examining how national policies and
public health infrastructures shape the strategies for
outdoor rehabilitation. Related disability research indi-
cated that Scandinavian health professionals express a
lack of experience and knowledge necessary to design
and implement outdoor rehabilitation programmes (4),
underscoring the need for research into interdisciplinary
training and knowledge-sharing to support high-quality,
outdoor-based rehabilitation services.
ACKNOWLEDGEMENTS
The authors would like to thank students Amalie Langesøe
Christiansen and Malthe Vinther Madsen for their help in the
data extraction process for the descriptive data. They would
also like to thank the research library at University of Southern
Denmark for feedback during the literature search.
The authors have no conicts of interest to declare.
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