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

The purpose of the study is to find out if a nature-based gait training program titled GREEN Walk can help people with chronic stroke improve their physical, mental, and social health, as well as their overall quality of life. The participants in this study are people with chronic stroke who are able to take-part in walking rehabilitation. they will take part in a structured walking program designed to simulate real-life outdoor movement.

Participants will:

1. Join GREEN Walk sessions that last about 60 minutes each.
2. Walk through different natural-like environments with different terrains and simple obstacles.
3. Perform guided walking tasks that challenge balance, strength, and coordination.
4. Complete assessment tests before and after the program to measure changes in movement, mood, social participation, and overall health related quality of life.

The GREEN Walk program uses nature-based and varied walking activities to help participants practice real-world movement in a safe and structured way. Researchers will use the results of this study to understand whether this type of rehabilitation can support recovery and improve daily life after stroke.

Study Overview

• Status: Completed
• Conditions: Chronic Stroke Survivors
• Intervention / Treatment: Other: GREEN Walk Training Program

Detailed Description

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.

• Study Type: Interventional
• Enrollment (Actual): 11
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Philippines
  • Ilocos Norte
    • Batac City, Ilocos Norte, Philippines, 2906
      • Mariano Marcos State University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• have provided informed consent

Exclusion Criteria:

• with other comorbidities

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Experimental Group; The study was a quasi-experimental study with only one group. All participants in the group received a 1 hr./day x 3 days/week x 6 weeks of progressing Guided Recovery Engaging in ENvironment Walk training (GREEN Walk) in the green spaces. The gait training includes the following: walking in even surfaces; walking in uneven surfaces; walking on curbs; walking on ramps; stair climbing

Other: GREEN Walk Training Program; The GREEN Walk training program emphasizes a nature-based gait training and environmental adaptability. The participants were exposed to grassy pathways, inclined surfaces, uneven grounds, natural slopes, and obstacle enriched environments that simulated real life community ambulation as the intervention primarily utilized naturally available environments and simple obstacles, making it practical for long term implementation beyond clinic-based care. This form of training more closely resembled daily mobility situations encountered outside the rehabilitation setting, making the intervention more task specific and functionally relevant. Specifically, all participants attended a 1 hr./day x 3 days/week x 6 weeks of progressing Guided Recovery Engaging in ENvironment Walk training (please see attached Study Protocol Appendix for the exercise protocol). No other interventions provided to the participants.; Other Names: GREEN Walk Exercise

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes From and Significant Difference in Participants' Health-Related Quality of Life (HRQoL) between Baseline and one-week and six weeks post-intervention.	Using the Short Form Health Survey (SF-36) with subscales on the following: general health; physical; mental; social; emotional Participants achieved a response if they scored a total health score ranging from 0 (worst health) to 100 (best health).	From enrollment to first and six weeks post-intervention.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes From and Significant Difference in Participants' Physical Ability between Baseline and one-week and six weeks post-intervention.	Participants' physical ability was assessed using the Short Physical Performance Battery (SPPB), which included the following test areas: balance,; gait speed, and; lower extremity strength Each test is scored 0-4, with a total score ranging from 0 (greater functional limitation) to 12 (better mobility). Note: Please see study protocol where the SPPB form was included for reference.	From enrollment to first and six weeks post-intervention.
Changes From and Significant Difference in Participants' Mental Capacity between Baseline and one-week and six weeks post-intervention.	Participants' mental capacity was measured using the DASS-21 form, which included the following scales: Depression; Anxiety; Stress The form utilized a 4-point likert scale in assessing depression, anxiety and stress and is classified into normal, mild, moderate, severe, and extremely severe. This study utilized the DASS-21. Higher total score indicates greater severity of depression, anxiety, and stress.	From enrollment to first and six weeks post-intervention.
Changes From and Significant Difference in Participants' Social status between Baseline and one-week and six weeks post-intervention.	This study utilized the Social Skills Inventory Scale (SSIS) to measure participants' social status, which includes the following sections of the form: Verbal and non-verbal communication; self-care,; self-control, and; relationship skills The outcome measurement used key scoring from 0-2. total accumulated score of on the identified sections, which was a total of 52 items. For the total score, lower score indicates strong social skills while higher scores suggest of needing improvement in social skills.	From enrollment to first and six weeks post-intervention.

Collaborators and Investigators

• Sponsor: Mariano Marcos State University
• Investigators: Principal Investigator: Mary Audrey D Viloria, MS in Rehabilitation Science, Mariano Marcos State University

Study record dates

Study Major Dates

• Study Start (Actual): March 28, 2025
• Primary Completion (Actual): May 10, 2025
• Study Completion (Actual): May 15, 2025

Study Registration Dates

• First Submitted: May 28, 2026
• First Submitted That Met QC Criteria: June 3, 2026
• First Posted (Actual): June 8, 2026

Study Record Updates

• Last Update Posted (Actual): June 8, 2026
• Last Update Submitted That Met QC Criteria: June 3, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: chronic stroke; gait training; environmental physical therapy
• Other Study ID Numbers: PT-002

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The data that will be shared will be the group data based on the statistical analysis method that will be utilized in the study.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No