Using Natural Environments as Clinical Settings
Original Editor - Environmental Physiotherapy Project
Top Contributors - Alexandra Stead
Introduction
For decades, the physiotherapy clinic has remained within four walls, utilising synthetic treatment areas and exercise equipment. While these treatment areas are safe for the patient, they often lack the ecological validity to allow patients to experience true functional recovery. As the Environmental Physiotherapy gains more momentum around the world, physiotherapists are beginning to view the natural world as a treatment area in itself.[1] By utilising both Green areas (forests and parks) and Blue areas (rivers and oceans), patients are challenged in ways which are limited within a traditional clinic setting.[2]
River-Based Hydrotherapy in Natural Spaces
Many physiotherapy clinics utilise hydrotherapy treatment areas in which the water parameters are regulated. However, natural rivers offer patients the benefit of varying hydrostatic pressures and currents.[3] By entering a natural water environment, patients are required to exhibit constant postural sway to accommodate the natural movement of the water. Additionally, natural sounds, like flowing water and birdsong, have been shown to reduce mental stress.[4] Although these findings were reported upon healthy populations, but they can provide the necessary foundational data to determine whether these natural waterscape treatments may be beneficial for populations with chronic pain or other health conditions.
Suspension Training using Natural Prop Roots
In some regions of the world, mature vegetation contains natural prop roots that can be used as an exercise alternative to traditional suspension trainers. Exercising in such natural, outdoor settings has been associated with additional physiological and psychological benefits compared with indoor exercise environments.[2] Unlike traditional suspension trainers that use a bar of uniform diameter, the prop roots have varying girths that may require the user to continuously adjust their hand position.[5] This varying girth may help provide a means to challenge fine motor control in upper limb injuries, though the application remains unexplored.
Proprioceptive Training on Natural Rough Surfaces
The flatness of the clinic floor can lead to sensory laziness of the lower limb. The environment contains an infinite variety of different textures that provide the CNS(Central Nervous System) with the proprioceptive signals that necessitates nervous system to maintain balance and function appropriately.[6]
The instability of different natural textures requires the body to activate the muscles and mechanoceptors of the feet to provide stability when walking. For instance, running on loose sand requires 1.5 times more energy than walking on firm ground.[7] Thus, it trains intrinsic muscles of feet and ankle stabilisers without any significant high impact forces.
Fine Motor Training Through Foraging and Therapeutic Gardening
The natural environment provides a diverse ‘sensory enrichment’ for patients with fine motor deficits, which often exhibit repetitive behaviours with artificial materials like peg boards or putty. Tasks like therapeutic gardening or & ‘foraging’ for specific natural materials like seeds, stones or leaves has been utilised as a treatment for mental health and general well being.[8]
Weeding gardens or picking specific plants requires the patients to exhibit fine motor skills like pincer grasp and hand-eye coordination. Additionally, gardening as a physical activity has been shown to aid in their neurological recovery.[9] These activities provide motivation for patients to participate in their therapy, and ultimately improve neural plasticity.
Economic Availability and Sustainability of Natural Clinical Settings
One of the main arguments for the use of natural clinical settings is its economic sustainability.[10] Traditional physical clinics have high costs associated with their operation like rent, electricity and purchasing necessary medical equipment.
Reduced Capital Expenditure
Locations like a community park or the beach are locations that do not require a therapist to spend money on maintaining the location. Thus, this ‘free’ infrastructure required for the clinics to function allows therapists with limited resources to continue to provide physical therapy for their patients.[11]
Furthermore, patients are more likely to adhere to a treatment protocol if it is a leisure activity instead of a therapy protocol. Thus, reducing the economic burden that results from patients not adhering to their therapy program. Additionally, activities and exercises can be held with group of patients rather than individually with each patient, meaning that one therapist can attend multiple patients at once improving the economic efficiency of the physical therapist.[10]
Clinical Safety Considerations
When using natural environments for physiotherapy, it is important to learn what’s safe for each patient. Look at their balance, cognitive ability, and whether their health is stable enough for the setting. Check out any risks around, like rough ground, fast water, or even lousy weather. Acquaint the patient with new surroundings, and closely supervise them, therapist at all times should be prepared for any unpredictable situations.[2]
Summary
The natural environment is nothing but an extension of clinical setting with proper patient safety measures. While the available evidence is promising, more recent research is needed to understand the role of natural environments in physiotherapy practice. Nonetheless, by viewing a river as a hydrotherapy tank and a forest floor as a proprioceptive gym, we offer therapy that is evidence-backed, economically sustainable, and fundamentally synced with human evolution.[1]
Open Online Resources
Environmental Physiotherapy Association (EPA)
References
- ↑ 1.0 1.1 Maric F, Nicholls DA. Environmental physiotherapy and the case for multispecies justice in planetary health. Physiotherapy theory and practice. 2022 Nov 18;38(13):2295-306.
- ↑ 2.0 2.1 2.2 Gladwell VF, Brown DK, Wood C, Sandercock GR, Barton JL. The great outdoors: how a green exercise environment can benefit all. Extreme physiology & medicine. 2013 Jan 3;2(1):3.
- ↑ Roviello V, Gilhen-Baker M, Roviello GN, Lichtfouse E. River therapy. Environmental chemistry letters. 2022 Oct;20(5):2729-34.
- ↑ Liu C, Jing X, Shi J, Li J, Zhang Y, Gao W. Effects of natural sound on human stress recovery based on EEG techniques. Journal of Environmental Psychology. 2024 Aug 1;97:102365.
- ↑ Watts PB. Physiology of difficult rock climbing. European journal of applied physiology. 2004 Apr;91(4):361-72.
- ↑ Hatton AL, Dixon J, Rome K, Martin DJ. Standing on textured surfaces: effects on standing balance in healthy older adults. Age Ageing. 2011;40(3):363–368. doi:10.1093/ageing/afr009.
- ↑ Pinnington HC, Dawson B. The energy cost of running on grass compared to soft dry beach sand. Journal of science and medicine in sport. 2001 Dec 1;4(4):416-30.
- ↑ Kamioka H, Tsutani K, Yamada M, Park H, Okuizumi H, Honda T, Okada S, Park SJ, Kitayuguchi J, Abe T, Handa S. Effectiveness of horticultural therapy: a systematic review of randomized controlled trials. Complementary therapies in medicine. 2014 Oct 1;22(5):930-43.
- ↑ Lentoor AG. Effect of gardening physical activity on neuroplasticity and cognitive function. Exploration of Neuroprotective Therapy. 2024 Jun 5;4(3):251-72.
- ↑ 10.0 10.1 Busk H, Sidenius U, Kongstad LP, Corazon SS, Petersen CB, Poulsen DV, Nyed PK, Stigsdotter UK. Economic evaluation of nature-based therapy interventions—A scoping review. Challenges. 2022 May 30;13(1):23.
- ↑ Walters G, Dring KJ, Williams RA, Needham R, Cooper SB. Outdoor physical activity is more beneficial than indoor physical activity for cognition in young people. Physiology & Behavior. 2025 Jun 1;295:114888.