Content » Vol 52, Issue 2

Original report

The nature stroke study; NASTRU: A randomized controlled trial of nature-based post-stroke fatigue rehabilitation

Anna María Pálsdóttir, Kjerstin Stigmar, Bo Norrving, Ingemar F. Petersson, Mikael Åström, Hélène Pessah-Rasmussen
Swedish University of Agricultural Sciences (SLU), Department of Work Sciences, Business Economics and Environmental Psychology (AEM), 23053 Alnarp, Sweden. E-mail:
DOI: 10.2340/16501977-2652


Objective: To determine whether nature-based rehabilitation, as an add-on to standard care, has a long-term influence on post-stroke fatigue, perceived value of everyday occupations, disability, health-related quality of life, anxiety, and depression at follow-up 8 and 14 months after randomization.
Design: Single-blinded, 2-armed, randomized controlled trial.
Methods: Stroke survivors, identified through routine 3-month follow-up visit (sub-acute) or medical records (chronic stroke > 1 year previously), were randomized to standard care + nature-based rehabilitation (intervention group) or standard care alone (control group). Blinded evaluations were conducted at follow-up 8 and 14 months after randomization, for the following outcomes: post-stroke fatigue (Mental Fatigue Scale; MFS), perceived value of everyday occupations (Occupational value instrument with pre-defined items), disability (modified Rankin Scale; mRS), health-related quality of life (Euro-QoL-5 Demension Questionnaire), anxiety (Hospital Anxiety and Depression Scale; HAD) and depression (HAD).
Results: Approximately one-quarter of the screened patients were eligible for inclusion in the study; of these, half agreed to participate; a final total of 101 patients were randomized (mean age 67 years, 60% female). The patients with sub-acute stroke were highly compliant with the intervention. The participants in both the intervention and control groups improved, However, no statistically significant differences in improvement were found between the intervention and control groups for any of the outcome measures. Fatigue decreased to a value below the suggested cut-off for mental fatigue (< 10.5) in the intervention group, but not in the control group.
Conclusion: Nature-based rehabilitation is feasible and well tolerated. A larger randomized controlled trial is warranted.

Lay Abstract

We have performed the first randomized controlled study on a nature-based intervention for patients with post stroke fatigue. Nature Based Interventions are performed in outdoor environment especially suitable/adopted for supporting treatment and rehabilitation programs. A total of 101 patients were randomized into a two-armed study: 1) treatment as usual, and 2) nature-based intervention. There were no statistical differences confirmed between the treatments, which may be partly explained by several methodological issues. However, participants showed good compliance with the nature-based intervention; thus, this study contributes with new knowledge to the field of stroke rehabilitation and is ground for further studies on how nature can support recovery from post-stroke fatigue.


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