Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2015, Article ID 614783, 9 pages
http://dx.doi.org/10.1155/2015/614783
Research Article
Sense of Well-Being in Patients with Fibromyalgia:
Aerobic Exercise Program in a Mature Forest—A Pilot Study
Secundino López-Pousa,1 Glòria Bassets Pagès,2 Sílvia Monserrat-Vila,3
Manuel de Gracia Blanco,4 Jaume Hidalgo Colomé,5 and Josep Garre-Olmo3
1 Neurology Service, Health Care Institute, C/ Dr. Castany, s/n, Salt, 17190 Girona, Spain
2Besalu´ and Olot Primary Care Team, Catalan Institute of Health, Girona, Spain
3Research Unit, Health Care Institute, Girona, Spain
4Psychology Department, University of Girona, Spain
5Se`lvans Project, Accio´natura, Girona, Spain
Correspondence should be addressed to Secundino Lo´pez-Pousa; secundino.lopez@ias.scs.es
and Manuel de Gracia Blanco; manuel.gracia@udg.edu
Received 8 May 2015; Accepted 27 July 2015
Academic Editor: Martin O enbaecher
Copyright © 2015 Secundino Lo´pez-Pousa et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background and Objective. Most patients with bromyalgia bene t from di erent forms of physical exercise. Studies show that
exercise can help restore the body’s neurochemical balance and that it triggers a positive emotional state. So, regular exercise can help
reduce anxiety, stress, and depression. e aim of this study was to analyze the bene ts of moderate aerobic exercise when walking in
two types of forests, young and mature, and to assess anxiety, sleep, pain, and well-being in patients with bromyalgia. Secondary
objectives included assessing (i) whether there were di erences in temperature, sound, and moisture, (ii) whether there was an
improvement in emotional control, and (iii) whether there was an improvement in health (reduction in pain) and in physical and
mental relaxation. Patients and Methods. A study involving walking through two types of forests (mature and young) was performed.
A total of 30 patients were randomly assigned to two groups, mature and young forests. e participants were administered the
following tests: the Spanish version of the Revised Fibromyalgia Impact Questionnaire (FIQR) at baseline and the end-point of
the study, the State-Trait Anxiety Inventory (STAI) a er each walk, and a series of questions regarding symptomatic evolution.
Several physiological parameters were registered. Results. FIQR baseline and end-point scores indicated a signi cant decrease in
the symptomatic subscale of the FIQ (SD = 21.7; = −2.4; = 0.041). e within-group analysis revealed that di erences were
signi cant with respect to days of intense pain, insomnia, and days of well-being only in the group assigned to the mature forest, not
in the group assigned to the young forest. No di erences were found with respect to anxiety. Conclusions. Although the main aim
of this research was not achieved, as the results revealed no di erences between the groups in the two forest types, authors could
con rm that an aerobic exercise program consisting of walking through a mature forest can provide the subjective perception of
having less days of pain and insomnia and more days of wellness, in patients with bromyalgia.
1. Introduction
In recent years, in Japan, the practice of recreational and
relaxation activities conducted in forested environments
and extensive green spaces for therapeutic purposes has
increased considerably. is approach is called forest therapy
or “shinrin-yoku” (forest-air bathing and forest-landscape
watching/walking) and represents a popular form of natural
therapy for the many people looking to reduce stress [1].
Preventive medicine and complementary and alternative
medicine have investigated the therapeutic e ects of this
therapy [2]. Some physiological studies support the hypoth-
esis that walking in the woods has positive e ects on the
central nervous system, autonomic nervous system, and
endocrine system [3–6], increasing the immune response [7,
8], a ecting hypertension [9], and positively in uencing non-
insulin-dependent diabetic patients [10, 11]. Physical activity
in forests can have a positive e ect on the cardiovascular
response of young people [12]. In clinical practice, there
already exists some evidence, although heterogeneous, of
2
Evidence-Based Complementary and Alternative Medicine
the positive impact of natural scenery on human health.
Similarly, psychological studies indicate that there is a posi-
tive emotional response to forest environments because these
environments e ectively reduce stress and attentional fatigue,
help relieve depression, and improve psychological relaxation
[13]. Recent studies have indicated that walking through
a forest can improve the perception of health conditions
and tends to decrease stress in healthy people [13, 14].
Additionally, cognitive and a ective improvements have been
observed in people with major depressive disorder who
performed therapeutic walks in the forest [15]. However,
existing evidence on the e ects of forest therapy on people’s
health is limited. A recent systematic revision of randomized
clinical studies on the healing and health-improving e ects
of forest therapy [16] did not nd su cient evidence of such
e ects due to the poor methodological quality of the trials and
the heterogeneous and incomparable protocols employed.
Nonetheless, the authors propose a series of strategies and
methodological improvements that would make studies of
forest therapy viable and would consolidate the limited
existing evidence. Following the recommendations proposed
by the aforementioned study (e.g., appropriate comparisons
in order to explain why forest therapy is better than other
types of interventions) [16], the overall objective of this
research is to assess the short-term e ects of walking through
the woods in two natural conditions (primary forest versus
secondary forest) on bromyalgia symptoms and to provide
scienti c evidence of the results on the health of patients with
FM a er walking through these woods.
Fibromyalgia (FM) is a rheumatic syndrome of unknown
etiology characterized by chronic, di use musculoskeletal
pain, fatigue, sleep disorders, and morning sti ness and
is associated with psychological disorders, mainly anxiety
and depression. is condition also exhibits hypersensitivity
along with veri able pain in speci c anatomical points [17]
and a ects 2% to 8% of the population, mostly women [18].
Currently, there is no e ective treatment to control FM symp-
toms, although there is growing evidence of the symptomatic
bene t of certain pharmacological treatments (tricyclic
antidepressants, inhibitors of serotonin, and norepinephrine
and gabapentinoid reuptake modulators) and of certain
nonpharmacological therapies (physical exercise, cognitive
behavioral therapy, and health education) [18], as well as a
balanced diet [19].
e main objective of the study was to assess the short-
term e ects of walking through the woods in natural con-
ditions on bromyalgia symptoms and to demonstrate that
people with FM performing moderate exercise in therapeutic
forests exhibit a signi cant improvement in their clinical
symptoms when compared with the same type of exercise
in younger forests. Secondary objectives included assessing
(i) whether there are signi cant di erences in temperature,
sound, and moisture between mature and young therapeutic
forests; (ii) whether people who exercise in therapeutic forests
signi cantly improve emotional control, have a sense of
improved health, and observed a reduction in pain; (iii) and
whether the therapeutic forest provides patients with greater
physical and mental relaxation.
2. Patients and Methods
2.1. Design and Participants. A randomized single-blind
clinical trial of two groups, with individuals 20 to 70 years
old who were diagnosed with FM, was designed. People
with FM, belonging to the Garrotxa Association of Chronic
Fatigue and Fibromyalgia, were invited to participate. People
with Chronic Fatigue Syndrome were excluded. Information
study documents about the project were sent by mail to
the association and potential participants were contacted
by telephone to enroll and schedule a meeting prior to
starting the study. All patients met the diagnostic criteria
of the American College of Rheumatology [17, 20, 21]. A
sample size of 15 participants per group (young and mature
forest) was selected to provide, with a power of 78.2%, a
di erence equal to or greater than 30 points in the FIQR
scale between both groups, assuming a standard deviation
of 30 points and a con dence level of 95%. e study was
approved by the Institutional Review Board of the Institut
d’Assiste`ncia Sanita`ria in Girona. All participants signed
informed consent.
2.2. Procedure. Participants were assigned to each group
using a list of random numbers. Each group took 1.25-
kilometer walks in the evenings between 5 and 6 pm during
six days. During the walks, participants were accompanied
by two nurses trained in interviewing. ese nurses were
blinded to the type of forest and ensured that the walks
were performed in a homogeneous manner. Additionally,
the nurses were responsible for managing the data collection
notebooks.
2.3. Variables and Instruments. Each participant’s informa-
tion regarding age and approximate date of bromyalgia
diagnosis was gathered and self-referential comorbidity was
recorded before beginning the study using a standardized
questionnaire. Participants’ weights and heights were mea-
sured on the rst and last day of intervention. Blood pres-
sure, heart rate, oxygen saturation, and temperature of the
participants were determined at the beginning and end of
each walk. In conjunction with the Spanish version of the
Revised Fibromyalgia Impact Questionnaire (FIQR) [22] and
the Spanish version of State-Trait Anxiety Inventory (STAI)
[23] that were administered on the rst and last day of
intervention, participants completed an ad hoc questionnaire
on the symptomatic progression of bromyalgia during the
last 15 days of the trial, specifying the days of generalized
discomfort, the days of intense pain, the presence of insom-
nia, and the number of days during which they experienced
well-being. A questionnaire including a self-assessment of the
study bene ts composed of 9 items with a 0 (negative)–10
(positive) points range was administered the last day of the
study. Measures relating to environmental conditions of the
forests, such as temperature (in degrees Celsius), luminosity
(in lux), noise (in decibels), and atmospheric pressure (in
hectopascals), were recorded thirty minutes prior to each
session.
2.4. Description of the Independent Variable. A young forest
is one that presents only rst age classes species. Usually, it is
Evidence-Based Complementary and Alternative Medicine
3
a forest with a homogeneous dense or very dense structure
and impenetrable undergrowth [24–26].
A mature forest, regardless of its location, urban areas or
natural, is one in which the absence of timber exploitation
during at least the last 4 or 5 decades has allowed reaching
a more advanced and complex structure, with a wider range
of age groups, including old trees with a large diameter
(usually over 100 years). e closure of the crowns of the trees
causes little undergrowth. is composition allows a wide
biodiversity and an ecosystem that includes many more types
of lichens, fungi, mosses, invertebrates, and their predators,
that is, all the ora and fauna in the natural evolution of a
forest [24–26].
We refer to a therapeutic forest when the structure of the
forest has relatively mature trees, or at least components of
maturity (trees), and it is accessible to be visited.
e two forests are located in the Garrotxa Volcanic Zone
Natural Park, speci cally between Olot and the beech forest
in Jorda` (Northeast of Girona, Spain). e topography of this
area is characterized by rolling hills and small mountains,
corresponding to volcanoes of reduced dimensions that
emerged approximately 17,000 years ago from lava ow. e
forests are mainly composed of wet oak groves of sessile oak
(Quercus robur), typical of the valley bottoms and quaternary
plains that were successively lled by volcanic materials and
lacustrine deposits. ese forests grow in a middle-European
sub-Atlantic climate, in the biogeographic mountain region,
speci cally the submontane area, and are very rare in the
south of the Pyrenees. e walks were performed through at
areas in these woods.
e “Can Serra” mature forest (mature forest group) has
many centenarian trees with large and irregular shaped trunk
and big roots above the ground. e dominant species is
sessile oak, with a harmoniously irregular high mountain
structure and a considerable density of old trees with siz-
able treetops. is area presents rare and very penetrable
undergrowth, with su cient space to accommodate a group
of people on a therapeutic walk through the existing trails
(Figure 2).
e young forest “Les Llongaines” (young forest group)
consists of a more regular and dense woodland with an age
range of 5–35 years, without any tree exceeding 50 years.
e dominant species is sessile oak, although there is a small
sector with beech trees. is is a large open area inhabited
by species such as bramble (Rubus ulmifolius), hawthorn
(Crataegus monogyna), or broom (Cytisus scoparius). e
vegetation is homogeneous, compact, closed, and less pen-
etrable (Figure 3).
2.5. Statistical Analysis. We described all the study vari-
ables by means of central tendency (mean) and dispersion
(standard deviation) measures for quantitative variables.
Descriptive data was calculated for the overall sample and
strati ed according the type of forest (mature and young).
In order to assess the e ect of forest type in the FIQR
scores and in the secondary outcomes we conducted an
inferential analysis using a between-group comparison of the
di erences between baseline and the end of the study scores
with the nonparametric Mann-Whitney test. Additionally,
Table 1: Characteristics of the participants (mean (SD)).
Young forest ( = 16)
Mature forest ( = 14)
Age
60.6 (8.4)
64.4 (6.5)
Weight
73.3 (18.1)
67.8 (6.9)
Height
159.1 (6.6)
157.3 (3.1)
BMI
SBP∗
28.9 (6.9)
140.4 (19.0)
27.4 (3.1)
121.3 (17.6)
DBP
79.8 (8.6)
77.1 (9.3)
HR
SaO2∗
BT
74.7 (10.2)
95.3 (2.2)
35.7 (0.5)
75.7 (10.2)
97.4 (1.6)
35.9 (0.4)
BMI: body mass index; SBP, systolic blood pressure; DBP: diastolic blood
pressure; HR:
∗ < 0.05.
heart
rate;
SaO2:
oxygen
saturation;
BT:
body
temperature;
we assessed the within-group di erences between baseline
and the end of the study scores in the FIQR and in the
secondary outcomes for each forest group using the Wilcoxon
Signed Ranks Test for paired data.
3. Results
Initially, 34 participants who were randomized in two groups
enrolled in the study. Nonetheless, only 30 of them took
part in the research because four dropped out by choice,
alleging time incompatibility before the start of the study.
All participants were women, and 14 and 16 participants
were assigned to the mature forest and to the young forest,
respectively. e average age of all participants was 62.3 years
(SD = 7.7) with an average weight of 70.7 kg (SD = 14.1) and
height of 158.3 cm (SD = 28.2). At baseline systolic blood
pressure was of 131.4 mm Hg (SD = 20.4), diastolic blood
pressure of 77.2 mm Hg (SD = 9.1), heart rate of 74.4 bpm
(SD = 9.2), oxygen saturation of 96.2% (SD = 2.1), and
body temperature of 35.4∘C (SD = 0.4). Table 1 presents
the baseline characteristics of the participants strati ed by
group. e comparison of baseline characteristics between
the two groups revealed signi cant di erences in systolic
blood pressure, which was higher in the participants assigned
to the young forest (140.4 versus 121.3; Mann-Whitney U =
−2.55; = 0.009), and oxygen saturation, which was higher
in participants assigned to the mature forest (95.3 versus 97.4;
Mann-Whitney U = −2.92; = 0.003).
With respect to the environmental features during the
study, no signi cant di erences were observed between the
two forests (light ( = 0.083), atmospheric pressure ( =
0.673), sound ( = 0.656), temperature ( = 0.371), and
moisture ( = 0.816)) (Figure 1).
At baseline, the mean score of all participants in the FIQR
scale was 58.7 points (SD = 20.5). e breakdown of the FIQR
score on its three subscales was 16.6 points (SD = 6.7) for the
functional disability subscale, 10.1 points (SD = 6.6) for the
overall impact of the disease subscale, and 32.0 (10.7) points
for the subscale of clinical symptoms, without exhibiting sta-
tistically signi cant di erences between participants assigned
to either group.
Date
Group
Les Llongaines, young forest
Can Serra, mature forest
Figure 1: No signi cant di erences were observed between the two forests.
15
20
25
30
35
Temperature
Date
Date
4
1000
800
600
400
200
0
70
60
50
40
30
20
Date
Atmospheric pressure
1000
995
990
985
980
975
970
Date
Humidity
Sound
40
38
36
34
32
30
Light
Evidence-Based Complementary and Alternative Medicine
Evidence-Based Complementary and Alternative Medicine
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Table 2: Di erences in the FIQR symptom score for all participants between baseline and end-point: within-group (pre-post) analysis.
FIQR total score
FIQR functional disability subscale
FIQR general impact subscale
FIQR symptoms subscale
FIQR individual symptoms
FIQR pain
FIQR energy
FIQR sti ness
FIQR sleep quality
FIQR depression
FIQR memory problems
FIQR anxiety
FIQR tenderness
FIQR balance problems
FIQR sensitivity to noise, light, odors, and cold
∗ < 0.05.
Baseline
59.0 (20.6)
16.6 (6.6)
10.1 (6.6)
32.0 (10.7)
6.5 (2.3)
6.7 (3.2)
6.2 (2.9)
7.7 (2.6)
5.1 (3.7)
6.1 (3.1)
6.3 (3.5)
7.2 (2.8)
5.3 (3.2)
6.9 (3.3)
End-point
55.1 (23.8)
17.9 (6.2)
9.2 (6.2)
27.8 (12.4)
5.6 (2.6)
5.8 (3.1)
5.0 (3.3)
6.3 (3.3)
4.7 (3.5)
6.1 (3.3)
4.3 (3.6)
5.8 (3.2)
5.2 (3.1)
6.5 (3.6)
Di erence
3.8 (22.9)
1.3 (8.0)
0.9 (7.9)
4.2 (7.9)
−0.9 (2.3)
−0.9 (4.1)
−1.2 (3.1)
−1.4 (3.6)
−0.4 (4.2)
0.03 (2.1)
−1.9 (3.7)∗
−1.4 (3.0)∗
−0.03 (2.8)
−0.5 (3.7)
Figure 2: Mature forest “Can Serra.” E(X): 457051/N(Y)4667801.
Figure 3: Young forest “Les Llongaines.” E(X): 457216/
N(Y)4666983.
In the total sample, the within-group analysis (pre-post)
revealed a di erence score of 3.8 points (SD = 22.9) for the
total FIQR, 1.3 points (SD = 8.0) for the subscale of functional
disability, −0.9 points (SD = 7.9) for general impact subscale,
and −4.2 points (SD = 11.0) for the clinical symptoms
subscale, which was statistically signi cant (32.0 versus 27.7;
Wilcoxon Signed Ranks Test = −2.04; = 0.41). Table 2
presents the scores for individual clinical symptoms, where
a signi cant decrease in the severity of symptoms, such as
anxiety (Wilcoxon Signed Ranks Test = −2.86; = 0.004)
and tenderness (Wilcoxon Signed Ranks Test = −2.30;
= 0.021), was observed.
e between-group analysis comparing FIQR total and
subscale scores revealed no statistically signi cant di erences
between the two groups of forests. e group assigned to
the mature forest had a score di erence in the total FIQR
of −6.1 points (SD = 21.3), 0.5 points (SD = 9.0) in the
subscale of functional disability, −2.6 points (SD = 6.7) in
general impact, and −4.1 points (SD = 11.8) in the clinical
symptoms. In the group assigned to the young forest, the
di erence in the total FIQR was −1.7 points (SD = 24.6), 2.2
points (SD = 7.2) for the subscale of functional disability, 0.6
(SD = 8.6) points for overall impact, and −4.3 points (SD =
11.8) for clinical symptoms. Table 3 presents the di erences
in individual symptoms of the FIQR between the two groups.
With respect to anxiety, the mean score for the overall
sample of trait anxiety scale of the STAI was 4.9 points
(SD = 8.3) and 34.9 points for the STAI-state subscale (SD
= 9.5). At baseline, no signi cant di erences were observed
in any of the STAI subscales among the participants in both
groups. State and trait anxiety STAI subscales did not show
statistically signi cant di erences between the baseline and
the end of the study scores among the groups (di erences
were not detected within-group analysis nor between-group
analysis). Similarly, no di erences were found in any of
the recorded physiological parameters (blood pressure, heart
rate, and body temperature and oxygen saturation) between
the start and end of the study.
With respect to subjective assessments on the number
of days of perceived well-being/discomfort between baseline
and end-point, a decrease in the number of days with
symptoms was observed. However this di erence was not
statistically signi cant, either for the entire sample or between
groups. e within-group analysis revealed that only the
mature forest group and not the young forest group exhibited
signi cant di erences in the days of intense pain, insomnia,
and sense of well-being (Table 4).
Table 5 presents the nal scores on the self-assessment of
the study bene ts. Results indicate that the participants that
6
Evidence-Based Complementary and Alternative Medicine
Table 3: Di erences in the FIQR symptom score for all participants between baseline and end-point: between-group analysis.
FIQR total score
FIQR functional disability subscale
FIQR general impact subscale
FIQR symptoms subscale
FIQR individual symptoms
FIQR pain
FIQR energy
FIQR sti ness
FIQR sleep quality
FIQR depression
FIQR memory problems
FIQR anxiety
FIQR tenderness
FIQR balance problems
FIQR sensitivity to noise, light, odors, and cold
Young forest ( = 16)
−6.1 (21.3)
0.5 (9.0)
−2.6 (6.7)
−4.1 (11.8)
−1.0 (2.6)
−0.7 (3.3)
−1.5 (3.4)
−0.9 (3.19)
−0.3 (3.6)
−0.1 (2.1)
−1.0 (3.7)
−1.1 (3.0)
−0.1 (2.1)
−1.6 (2.9)
Mature forest ( = 14)
−1.7 (24.6)
2.2 (7.2)
0.6 (8.6)
−4.3 (11.8)
−0.7 (2.0)
−1.0 (4.9)
−0.9 (2.7)
−1.8 (4.1)
−0.4 (4.9)
0.1 (2.0)
−2.9 (3.4)
−1.6 (3.0)
0.1 (3.4)
0.9 (4.0)
Table 4: Days of perceived well-being/discomfort at baseline and
end-point and di erences strati ed by the type of forest: within-
group (pre-post) analysis.
Baseline
Young forest
Days of discomfort
12.4 (3.0)
Days of intense pain
8.9 (5.4)
Days of insomnia
7.4 (6.5)
Days with no anxiety
2.9 (5.0)
Days of perceived well-being 1.4 (2.2)
Mature forest
Days of discomfort
8.6 (5.0)
Days of intense pain
7.9 (5.9)
Days of insomnia
7.9 (6.6)
Days with no anxiety
6.1 (5.5)
Days of perceived well-being 2.2 (2.5)
∗ < 0.05.
End-point
9.4 (5.4)
6.1 (5.7)
5.6 (6.7)
1.3 (2.1)
2.9 (4.4)
4.8 (6.5)
2.5 (4.1)
3.7 (5.3)
6.8 (6.8)
7.0 (4.7)
Di erence
−3.3 (3.9)
−2.1 (7.0)
−1.9 (6.4)
−2.1 (6.0)
1.5 (3.0)
−3.8 (7.4)
−5.9 (7.0)∗
−4.7 (6.4)∗
1.0 (7.3)
5.0 (4.8)∗
walked through the mature forest had a better self-assessment
of the bene ts of the study regarding the degree of relaxation
during the walks and will be more prone to recommend this
therapy.
4. Discussion
e main aim of this research, which was to demonstrate that
the clinical bene t of moderate exercise would be superior
in mature forests than in younger forests, was not achieved,
as the results revealed no di erences in the FIQ score
between groups. However, participants who walked in the
mature forest, unlike those who did so in the young forest,
reported signi cant di erences between baseline and nal
scores with respect to the number of days of intense pain,
days of insomnia, and days of well-being. Other controlled
studies with FM patients that used di erent types of activity
(moderate exercise, stretching, and educational therapies)
reported improvements with respect to pain, functional
status, and life quality as well [27, 28]. Our results are very
similar to those observed by Arcos-Carmona et al. [29],
through a combined program of aerobic exercises and pro-
gressive relaxation techniques, given that the bene ts of this
therapy consisted mainly of improvements in night’s rest,
pain, and quality of life.
ere is a bene t associated with the intervention because
the scores in the FIQR subscale for symptoms revealed a
global decrease in intensity, speci cally pointing to signi cant
di erences in anxiety and pain items. Other studies showed
similar ndings of patient improvement a er conducting
di erent types of physical exercises [30–32]. However, the
progress observed in our study cannot be attributed to phys-
ical exercise in the forest, given that all participants per-
formed the same activity. In our study, participants in the
mature forest group, unlike the young forest group, reported
improvements in pain, insomnia, and wellness compared
with baseline.
Although anxiety is one symptom that typically improves
in most studies on exercise and FM, no signi cant di erences
in anxiety were found between groups in our study. e
lack of response could be attributed to the short duration
of the study, which only lasted two weeks. Studies of longer
duration, usually more than eight weeks, have obtained better
results [33, 34].
Phytoncides are antimicrobial allelochemic volatile
organic compounds derived from plants. Some plants give
o very active substances which prevent them from rotting
or being eaten by some insects and animals or degraded by
bacteria and fungi [35]. Due to greater diversity, complexity,
and longevity of mature forests, these have more intense and
varied phytoncides. In this sense, the immense wealth of
volatile components of natural forests structures gives them
a huge healing capacity.
When comparing both groups (young/mature forest), the
group that walked through the mature forest reported feeling
Evidence-Based Complementary and Alternative Medicine
7
Table 5: Assessment at the end of the study (mean (SD)).
I think this therapy was good for me.
During the walks, I have been more relaxed than usual.
I would recommend this therapy to others.
My sleep problems have improved.
I feel less tired.
I feel less pain.
I feel less anxious.
As days went by, I felt greater discomfort.
I would use this therapy again.
∗ < 0.05.
Global
8.2 (1.8)
8.0 (2.0)
8.9 (2.1)
5.3 (2.9)
4.6 (2.8)
4.7 (2.6)
4.5 (3.6)
4.7 (3.6)
95.8%
Young forest
7.8 (1.8)
7.1 (2.1)
8.0 (2.7)
5.6 (2.6)
4.2 (1.7)
3.9 (1.8)
3.8 (2.0)
3.4 (3.0)
92.3%
Mature forest
8.5 (1.8)
9.0 (1.4)∗
9.7 (0.6)∗
5.0 (3.3)
5.1 (3.7)
5.6 (3.0)
5.2 (3.3)
5.9 (3.9)
100%
more relaxed than usual, in a statistically signi cant manner,
compared with those who performed the exercise in the
young forest. is subjective perception may be related to the
alleged bene ts of walks through mature woodland. Walking
through the forests implies contacting phytoncides produced
by trees, as well as enjoying the fresh air, pleasant scenery, and
mild climate.
Moreover, the health bene ts of activities undertaken
in forests can be explained by a better mental and breath
control, which involves the recovery of homeostasis [36].
“Natural” stimuli associated with walking in the forests
modify oxidative stress and hormonal stress reducing the
serum levels of oxidative stress markers such as nitric
oxide, malondialdehyde, and catalase, as well as the serum
level of cortisol, norepinephrine, and dopamine and signif-
icantly increasing serum epinephrine concentrations [37].
is bene t would be higher in patients with (FM) suf-
fering from acute in ammatory state because it could be
modi ed through exercise, inducing a decrease of systemic
concentration of IL-8, NA, and cortisol and producing and
releasing in ammatory cytokines from monocytic cells [38];
thus the recovery of immune function would be improved
[39].
ese physiological responses to the environment might
interact with each other, leading to positive health outcomes.
ese mechanisms could be explained with respect to the
results observed in other epidemiological studies that have
reported positive relationships between the environment and
health parameters. At present, there is little evidence on the
direct bene ts of walking through the woods in reducing
chronic pain and fatigue in patients with FM [3].
e study has several limitations. First, due to its
exploratory nature, it was underpowered to detect minor
di erences in the primary e cacy variable, which is the
FIQR score. Another limitation, as previously stated, was the
short duration of the study length. Perhaps greater di erences
could have been found if the forest had had therapeutic
features closer to those of older forest with more evolved
natural dynamics. However, such types of forest are very
scarce and valuable and are generally located at a considerable
distance from urban areas, which would have prevented
the study. Finally, phytoncides were not measured in this
study which prevents demonstrating their contribution in the
alleviation of symptoms in the FM.
Nonetheless, the results are encouraging and are consis-
tent with those observed in studies of healthy individuals.
As previously mentioned, walking in the woods among
phytoncide emanations in a pure environment surrounded by
landscapes of scenic quality is part of most forest therapy pro-
grams. Further research with programs of longer duration,
conducted in more mature forests, would clarify the potential
bene t of forests in people with FM. Perhaps these exercises
could be a complement to existing therapies.
Conflict of Interests
e study is funded by a grant from the Environmental
Agency of the Province of Girona with the support of the
Garrotxa Association of Chronic Fatigue and Fibromyalgia.
Acknowledgments
e authors thank the subjects whose participation made this
study possible. e authors thank the rest of the members
of the “Fibroscoterapi@” group [Bassets Page`s G.; Coll-Presa
C.; Caler Ruiz E.; Esser S; Fontseca Palome´ M.; Fraiz Mun˜oz
E.; Garre-Olmo J.; Giro´ Amigo´ F.; Gonza´lez Corominas F.; de
Gracia-Blanco M.; Hidalgo Colome´ J.; Keller D.; Lo´pez-Pousa
S.; Margel´ı Vo¨lp A.; Monserrat-Vila S.; Montserrat-Rose´s M.;
Mun˜oz Santiso M; Trabalon F.; Turro´-Garriga O.; Vila Subiro´s
J.] for technical assistance and comments and suggestions;
for helping during recruitment of the subjects; for assistance
with statistical analysis; for providing consultation to the
investigators on the study; and for carefully preparing the
paper and the illustrations.
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