Nature-based interventions - State of the art and future research. Patrik Grahn Professor, SLU Alnarp

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1 Nature-based interventions - State of the art and future research Patrik Grahn Professor, SLU Alnarp

2 State of the art Evidence from eleven recent systematic research reviews with clear inclusion and exclusion criteria, as well as some adjacent studies that are missing in the reviews Theories regarding Nature Based Interventions

3 NBI reviews, regarding the function in general Annerstedt M, Währborg P. 2011: does any kind of NBI have any effect on any health outcome? Jang et al 2010 Meta analysis of HT effect. Kamioka et al 2014; RCT studies of HT: Positive results regarding mental disorders (depression, anxiety, PTSD, schizophrenia, ADHD); social problems (substance abuse, antisocial behavior); somatic diseases (heart failure, stroke); intellectual capacity (cognitive impairment). Effect size=0.71, higher regarding children (especially,special needs) and elderly people (especially dementia). Best group size, about 5 participants, with sessions or 31+ sessions. Cognitive capacity, social problems, effects on physical capacity and emotional stability. Annerstedt M, Währborg P. Nature assisted therapy: systematic review of controlled and observational studies. Scand J Publ Health 2011; 39: ; Jang EJ, Han GW, Hong JW, Yoon SE, Pak CH. Meta-analysis of research papers on horticultural therapy program effect. Korean J Horticult Sci Technol 2010; 28: ; Kamioka H, Tsutani K, Yamada M, Park H, Okuizumi H, Honda T, Okada S, Park SJ, Kitayuguchi J, Abe T, Handa S, Mutoh Y. Effectiveness of horticultural therapy: a systematic review of randomized controlled trials. Complement Ther Med Oct;22(5):930-43

4 NBI - mental disorders Significant decrease in depression and anxiety (not in control group) and increase in attentional capacity and self-esteem In addition, better psychological well-being, lower stresslevels, higher coping capacity, better sleep quality, less agitation and better social behavior Positive results regarding dementia: affect and engagement Clatworthy, J., Hinds, J., Camic, P.M Gardening as a mental health intervention: a review. Mental Health Review Journal, 18 (4): ; Cipriani, J., Benz, A., Holmgren, A., Kinter, D., McGarry, J., Rufino, G A systematic review of the effects of horticultural therapy on persons with mental health conditions. Occupational Therapy in Mental Health. DOI: / X

5 NBI for elderly people Promotes overall health; QoL, physical capacity, cognitive ability and socialization. Lower stress hormones, and depression, improved gross motor capacity, cognitive capacity, language and ADL functions. Depended on professionalism of therapists. Dementia: Higher emotional health, perceived selfidentity and levels of engagement Wang, D; MacMillan, T. The Benefits of Gardening for Older Adults: A Systematic Review of the Literature. Activities, Adaptation & Aging, 37, 2013: ; Blake M., Mitchell G Horticultural therapy in dementia care: a literature review. Nursing Standard. 30: 41-47: a narrative review on the use of NBI in dementia care. Kim JH, Kwon SB, Kim HJ, Choi GH, Lee HM Effects of Horticultural Therapy for the Korean Elderly: A Systematic Literature Review. J Korean Biol Nurs Sci 18(3):

6 Animal assisted interventions and care farming Kamioka H, Okada S, Tsutani K, Park H, Okuizumi H, Handa S, Oshio T, Park SJ, Kitayuguchi J, Abe T, Honda T, Mutoh Y. Effectiveness of animal-assisted therapy: A systematic review of randomized controlled trials. Complement Ther Med Apr;22(2): Iancu SC, Hoogendoorn AW, Zweekhorst MB, Veltman DJ, Bunders JF, van Balkom AJ. Farm-based interventions for people with mental disorders: a systematic review of literature. Disabil Rehabil. 2015;37(5):379-88; Gorman R, Cacciatore J. Cultivating our humanity: A systematic review of care farming & traumatic grief. Health Place Sep;47:12-21

7 Animal assisted interventions and care farming: Results Most evidence regarding Mental and behavioral disorders. Types of animal intervention were dog, cat, dolphin, bird, cow, rabbit, ferret, and guinea pig. In a study environment limited to the people who like animals, AAT may be an effective treatment for mental and behavioral disorders such as depression, schizophrenia, and alcohol/drug addictions, and is based on a holistic approach through interaction with animals in nature. Favorable effects on clinical status (eg depression) but conflicting effects regarding rehabilitative effects (functioning and quality of life).

8 What is actually described and discussed? Gaps to fill for translational research: from basic research to praxis 1. Good definition of NBI and the aim of the intervention; a clear hypothesis 2. Adequate description of the intervention: the intervention quality, including the place and its characteristics, activities and - in some cases - companion animals. Ne 3. Description of the intervention dose 4. Adequate description of research methodology (RCT, cohort study, qualitative interview): participants included and excluded (e.g. ICD diagnosis), randomization (if used), outcomes (validated protocols), cohort studies, registers, ethics 5. Description of adverse effects (e.g., allergy, infection) and withdrawals 6. Description of costs; health economics 7. Transferring the method to regular use

9 The Black Box What is the black box - the intervention? First: How should it be defined and named: The big umbrella and how the different parts connect to it: HT, AAT, NAI, wilderness therapy...

10 Second: What is included in the intervention? What is nature in NAI? A primeval forest, wood, urban park, big garden, small garden, or a rose in a flowerpot? Which animals are best? A horse, cow, sheep, dog, rat, chicken, wild animals, wild birds? Activities associated with NBI? Which necessary characteristics of the companion animal, the garden or the natural environment are needed, in order for a therapeutic activity to take place for a particular target group of patients Professional therapists or not? Which therapists are needed? OT, PT, psychologists? Or special NBI-therapists? Or any therapists at all?

11 Theories Attention Restoration Theory, Kaplan & Kaplan, about the best settings for restoring cognitive capacity Psycho-Evoutionary Theory, Ulrich, about recovery from high levels of stress: Biophobia biophilia Physical activity, reward system, dopamine Daylight, cortisol and melatonin, vitamin D Subliminal perception and priming facilitation; parallel thinking in multi-tasking (planning, routines, reflexes etc.) Enriched environments, affecting all fifteen senses, muscles, hormones, heart, stomach etc.; and restoring people's physical as well as mental energy and resources All of the above are about - supportive environments: physical environments (eg natural environments), social environments (eg fellow patients, therapists, companion animals), cultural environments (eg activities, values, languages)

12 Immunology Shinrin yoku forest bathing, aromatherapy, forest air with phytoncides, activating NK cells Li, Q Forest medicine. Nova publishers. Li, Q. Kobayashi, M. Kumeda, S. Ochiai, T. Takashi Miura, T. Takahide Kagawa, T. Michiko Imai, M. Wang, Z. Otsuka, T. and Kawada, T Effects of Forest Bathing on Cardiovascular and Metabolic Parameters in Middle-Aged Males. Evidence-Based Complementary and Alternative Medicine, Art ID

13 RCT-study in Alnarp Immune system (cytokines: Interleukin-2, Interferongamma). Intervention group was significantly affected regarding levels of the immune system, stabilizing the immune system. Important regarding too high (autoimmune disorders) as well as too low levels. IFN-gamma, killing virus, activating NK and NKT-cells, cytotoxic T-cells and immunoglobulin. Differens between intervention and control (p < 0.01) Interleukin 2, affecting all of the immune system, especially lymphocytes (p < 0.05).

14 Rehabilitation potential

15 Stress-related symptoms Palsdottir, Grahn, Persson 2013 Changes in Scand J Occ Ther online 80 SCI SCI Baseline Follow-up

16 Stress-related symptoms 6 SMBQ SMBQ Baseline Follow up1 Follow up2 Follow up3

17 Function OSA - F Baseline Follow up1 Follow up2 Follow up3 OSA - F

18 Return to work Job training Part time Full time Baseline Follow up

19 Dose-effect, percent return to work weeks 12 weeks 24 weeks

20 Reduced costs for primary care, one year after intervention

21 Reduced costs for beddays in psychiatric care, one year after intervention

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23 Alnarps Rehabiliteringsträdgård

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