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.