Understanding potential of greenspace as a therapeutic intervention post-stroke: a rapid review of evidence

Introduction
Stroke is the leading cause of disability in the UK, and demand on stroke services is predicted to double in the next 15 years. In addition to having acquired a potentially long-term disability, stroke survivors are at risk of further stroke and cardiovascular events, even if they receive evidence-based secondary prevention. Additionally, many stroke survivors experience ongoing mood-related issues, which are often left unaddressed. Engaging with greenspace is known to have positive effect on physical and mental health in the general population, and it is possible that engaging with greenspace could play an important role in encouraging improved recovery from stroke.

Methods
We conducted evidence searches between June 2018 to March 2019 on databases including DORIS, PROPSERO, the NHS Knowledge Network, and a general online search for industry publications using the search terms ‘stroke’, ‘health and greenspace’, ‘greenspace’, ‘green space’, ‘natural environment’, ‘natural surroundings’, ‘greenness’. For inclusion in the review, literature had to refer to either health benefits relating to greenspace/being in nature, or a greenspace health intervention. 287 appropriate articles were identified. Following full-text screening, 27 articles were included in the final review. Data was synthesised and analysed using the rapid review framework.

Findings
We found limited evidence about greenspace and stroke, just 2 studies. Both indicated a positive effect, but highlighted the need for more research in this area. Greenspace was indicated improve outcomes for those with dementia, type 2 diabetes, mental health problems, and cardiovascular issues. Being exposed to greenspaces is associated with perceived improvement in general and mental health, better cognitive function in adults, lower risk of a number of chronic diseases (e.g. diabetes and cardiovascular conditions), and reduced mortality. Walking in nature was found to have positive effects on neural brain activity by encouraging a reduction in activity in the part of the brain associated with negative thinking (subgenual prefrontal cortex) in comparison to walking in an urban location. Since many stroke survivors experience these physical and mental health problems, exposure to nature could be hugely beneficial for this patient population.

Conclusions
Spending time in greenspace has positive effects on physical and mental health, and has been successfully tested as an intervention for psychiatric patients, cardiac issues, and type 2 diabetes. Access to greenspace could also prove beneficial for long-term recovery after stroke. More research, specifically focused on this topic would be useful, ahead of developing a suitable intervention.