GREEN Walk: A Nature-based Gait Training to Improve the Quality of Life Among Chronic Stroke Survivors

This study examined the effects of a structured, nature-based gait rehabilitation program titled GREEN Walk (Guided Recovery Engaging in Environment Walk) on physical, mental, social, and health-related quality of life outcomes among chronic stroke survivors. Chronic stroke is often associated with long-term impairments in mobility, emotional health, social participation, and overall functioning. Although conventional rehabilitation improves recovery in the early stages, many individuals reach a plateau in the chronic phase, where gains become limited despite ongoing deficits. This study explored whether integrating gait training with natural and functionally meaningful environments could provide additional benefits beyond traditional clinic-based approaches.

GREEN Walk was designed based on the understanding that walking is a complex activity requiring not only muscle strength and balance, but also attention, environmental awareness, emotional engagement, and adaptive motor control. Unlike conventional treadmill or indoor gait training, this program exposed participants to varied walking environments that simulate real-world conditions. These included level and uneven surfaces, ramps, curbs, stairs, and obstacle-based pathways that required continuous adjustment of posture, step strategy, and balance control. The progressive structure of the program aimed to challenge participants safely while promoting functional movement relevant to daily community ambulation.

The primary objective of the study was to determine the effects of GREEN Walk on four key domains of recovery: physical function, mental well-being, social participation, and overall health-related quality of life (HRQoL) in individuals with chronic stroke.

For physical outcomes, the intervention focused on improving gait performance, balance, lower extremity strength, coordination, and endurance. Chronic stroke survivors often experience reduced confidence in walking due to instability and fear of falling, leading to compensatory movement patterns and limited community mobility. Through repeated exposure to progressively challenging walking tasks, GREEN Walk promoted neuromuscular adaptation, improved postural control, and enhanced functional mobility. These improvements are essential for independence in daily activities such as walking outdoors, navigating uneven terrain, and performing community-based tasks.

In terms of mental health outcomes, the study assessed changes in emotional well-being, including stress, anxiety, mood, and motivation. Stroke survivors commonly experience psychological challenges such as reduced confidence, emotional distress, and frustration related to long-term disability. The integration of natural or nature-like environments was intended to reduce psychological stress and enhance emotional engagement during rehabilitation. Although some participants initially experienced increased emotional awareness during early sessions, likely reflected in short-term changes in DASS scores, continued participation led to improved psychological adaptation, reduced distress, and enhanced motivation by the end of the intervention period.

Regarding social participation, the study evaluated changes in the ability and willingness of participants to engage in social and community activities. Stroke-related mobility limitations often lead to social withdrawal and reduced interaction with others. While GREEN Walk showed a positive trend toward improved social participation, changes were not statistically significant within the six-week period. This suggests that while physical gains and increased confidence may begin to support social reintegration, longer intervention durations may be required to produce measurable improvements in this domain.

The study also assessed health-related quality of life (HRQoL) as a composite outcome reflecting physical, mental, and social well-being. Improvements were observed across multiple SF-36 domains, particularly after six weeks of intervention. Early gains were seen in physical role functioning, while more comprehensive improvements emerged later in areas such as physical functioning, energy and fatigue, emotional well-being, social functioning, general health, and perceived health change. These findings suggest that sustained exposure to nature-based gait training can produce cumulative benefits that extend beyond physical recovery to influence overall life satisfaction and daily functioning.

The intervention was implemented over a six-week period, with participants attending structured sessions three times per week. Each session lasted approximately 60 minutes and included warm-up exercises, a progressive walking program, and a cool-down phase. The walking activities were systematically advanced across weeks, starting from level surface walking and progressing toward more complex tasks such as obstacle negotiation, curb walking, ramp navigation, zigzag pathways, and stair climbing. This progression allowed participants to gradually adapt to increasing physical and environmental demands while maintaining safety under supervision. All sessions were conducted by licensed physical therapists who monitored performance, ensured safety, and adjusted activities according to participant capacity.

Outcome measures were assessed at multiple time points, including baseline and follow-up evaluations across the intervention period. Standardized tools were used to measure physical performance (Short Physical Performance Battery or SPPB), mental health status (Depression Anxiety Stress Scale or DASS-21), social skills and participation (Social Skills Inventory Scale or SSIS), and health-related quality of life (SF-36). Data analysis showed significant improvements in physical function at all time points, with the greatest gains observed at six weeks. Mental health outcomes showed an initial increase in distress followed by significant improvement by the end of the intervention. Social outcomes demonstrated positive but non-significant changes. HRQoL showed significant and multidimensional improvements at six weeks, indicating a cumulative effect of the intervention.

Overall, the findings suggest that GREEN Walk is an effective nature-based rehabilitation approach that significantly improves physical function and health-related quality of life in chronic stroke survivors, while also contributing to gradual improvements in mental well-being. Social participation, although positively influenced, may require longer intervention duration to achieve statistically significant changes. The study supports the idea that rehabilitation should extend beyond clinic-based settings and incorporate real-world, environment-driven movement experiences that address both physical and psychosocial aspects of recovery.

In conclusion, GREEN Walk demonstrates that structured gait training within natural and varied environments can provide a holistic rehabilitation approach for chronic stroke survivors. The integration of physical challenges with environmental stimulation supports not only mobility recovery but also emotional resilience and improved quality of life. Future studies with larger sample sizes, control groups, and longer follow-up periods are recommended to further validate these findings and explore long-term outcomes, including community participation, adherence, and sustainability of improvements.

Inclusion criteria

• have provided informed consent

Exclusion criteria

• with other comorbidities