The Psychological Benefits of Forest Bathing in Individuals with Fibromyalgia and Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis: A Pilot Study

The Psychological Benefits of Forest Bathing in Individuals with Fibromyalgia and Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis: A Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Psychological Benefits of Forest Bathing in Individuals with Fibromyalgia and Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis: A Pilot Study Mayte Serrat, Estíbaliz Royuela-Colomer, Sandra Alonso-Marsol, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3088899/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background/Objectives. The main objective of the present study is to assess the short-term effects of Forest Bathing (FB) conducted in a Mediterranean forest on individuals with fibromyalgia (FM) and/or Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) on perceived pain, fatigue, state anxiety, positive and negative affect, mood states, and state mindfulness. Methods. A total of 44 participants with FM and/or CSF/ME agreed to participate in this study. The FB session consisted of a 3km silent walk, lasting three hours long and guided by a specialized psychologist and a mountain guide to guarantee the safety of the activity. Paired-sample t -tests were used to analyze the pre-post changes in perceived pain, fatigue, state anxiety, positive and negative affect, mood states and mindfulness. Results. All reported variables but self-reported pain showed statistically significant pre-post variations after the FB session. Particularly, large-to-very-large improvements in positive and negative affect, state anxiety, tension, depression, anger, and vigor were found. Small-to-moderate effect sizes for fatigue, friendliness and state mindfulness were also reported. Conclusions. This study provides preliminary evidence of the short-term benefits of FB in individuals with FM and/or CFS/ME, especially on state anxiety and negative affect. fibromyalgia chronic fatigue syndrome forest bathing shinrin-yoku forest therapy mindfulness Introduction In recent years, the role of forests in promoting and improving human health and well-being has been gaining scientific interest (Yi et al. 2022 ; Gobster et al. 2022 ; Piva et al. 2022 ; Shim et al. 2022 ; Qiu et al. 2022 ). In this regard, there are mounting studies supporting the beneficial effects of nature exposure in a broad range of health outcomes and populations across the globe with evidenced positive effects on life satisfaction, mental and general health, longevity, more regulated mood and emotional states, and cognitive processes (Herzog et al. 1997 ; Takano 2002 ; Maas 2006 ; Biedenweg et al. 2017 ; Kondo et al. 2018 ; Twohig-Bennett and Jones 2018 ; Bratman et al. 2019 ). It has also been reported that the effects of forest environment induce physiological relaxation with changes in stress hormones (i.e., cortisol) and the autonomic nervous system (Park et al. 2010 ; Lee et al. 2011 , 2014 ; Tsunetsugu et al. 2013 ; Song et al. 2019 ). Benefits of nature exposure have also been demonstrated for even brief contemplative outdoor activities, such as forest walks and outdoor mindfulness practices, showing a positive effect on mental health in reducing, for instance, depressive and anxiety symptoms(Morita et al. 2007 ; Hansen et al. 2017 ; Oh et al. 2017 ; Muro et al. 2022 ). Different theories exist regarding the association between nature and human health and well-being. For example, the Attention Restoration Theory proposes that spending time in nature can restore attention and prevent the mental fatigue associated with modern lifestyles (Kaplan 1995 ). Similarly, the Stress Reduction Theory hypothesizes that the connection with nature activates the parasympathetic nervous system and reduces autonomic arousal (Ulrich et al. 1991 ), which is related to stress. Similarly, the Biophilia hypothesis points out that humans naturally desire to interact with nature and all living things that belong to the natural world (Kellert and Wilson 1995 ). Finally, other explanations suggest that the benefits of nature rely on aspects that individuals encounter when they spend more time in nature, namely, an increase in levels of physical activity, a reduction in exposure to harmful environments (e.g., air pollution, noise, and artificial light), and an increase in exposure to sunlight and vitamin D(Stanhope et al. 2020 ; Jimenez et al. 2021 ; Yang et al. 2021 ). Among nature connection practices is the Japanese practice of Shinrin-Yoku , also known as Forest Bathing (FB). FB may have remarkable psychological benefits associated with nature immersion, which could help manage and reduce the reported modern “stress-state” (Hansen et al. 2017 ; Timko Olson et al. 2020 ). The FB practice consists of mindful walking in a natural setting, quietly aimed at promoting communication and contact with nature, and it is usually carried out by specialized guides (Hansen et al. 2017 ). FB is a form of “Nature Therapy”, defined by Song, Ikei and Miyazaki (2014; 2016 ) as “a set of practices aimed at achieving ‘preventive medical effects’ through exposure to natural stimuli that render a state of physiological relaxation and boost the weakened immune functions to prevent diseases”. Evidence suggests that FB has psychological and overall health benefits. A recent review indicates that FB may increase natural human killer cell activity, reduce blood pressure and heart rate, diminish stress hormones, balance the autonomic nervous system, improve sleep, reduce anxiety, depression, anger, fatigue, and confusion, and increase vigor (Li 2022 ). However, the majority of the studies in FB are performed in Asian countries, with small sample sizes, with an over-representation of young and healthy men, needing more evidence to confirm the therapeutic effects of forests on health in other countries around the world and, particularly, in heterogeneous clinical populations (Lee et al. 2011 ; Song et al. 2019 ; Muro et al. 2022 ). FM is a highly prevalent rheumatic syndrome (2–8% of the general population), usually diagnosed between 20 and 50 years old (Häuser et al. 2015 ). It is characterized by chronic, diffuse musculoskeletal pain, fatigue, sleep disorders, high levels of distress and comorbidity with anxiety and depressive disorders (Clauw 2014 ). FM has recently been considered a functional somatic disorder, evolving from a primary pain disorder with a neurobiological basis to a broader biopsychosocial disorder (Wolfe and Rasker 2021 ). Although there is no curative treatment for this disease, pain education, cognitive behavioral therapy and therapeutic exercise are considered adequate approaches to manage FM symptoms, with an evidence level of 1A(Malfliet et al. 2019 ). FM is usually comorbid with other central sensitization syndromes such as CFS/ME(Kato et al. 2006 ; Yunus 2007 ; Castro-Marrero et al. 2017 ) in over 50% of the cases(Faro et al. 2014 ). CFS/ME is a disabling and complex illness that affects approximately 1% of the population (Lim et al. 2020 )and is characterized by persistent post-exertional fatigue and substantial symptoms related to cognitive, immune and autonomic dysfunction, including sore throat, muscle pain, joint pain, weakness, sleep disturbance, memory loss, and poor concentration (Brurberg et al. 2014 ; Cortes Rivera et al. 2019 ). This medical condition negatively impacts individuals’ quality of life, including their psychological, emotional and social well-being (NICE 2021 ). FB seems to be a promising intervention for promoting better mental health and well-being; however, there is a scarcity of studies exploring its effects in clinical samples; mainly, as far as we know, only one study uses FB in patients with FM. In this pilot study conducted in Spain by López-Pousa et al. ( 2015 ), 30 individuals with FM were included and randomly allocated to a group of aerobic exercise-based program (i.e., 1.25-kilometre walks during six days in a time-frame of 2 weeks) in a mature ( n = 15) or in a young forest ( n = 15). Although both groups showed decreases in FM symptoms, the group that performed the walk in the mature forest showed greater improvements in terms of r in days with intense pain, insomnia and more days of well-being. Regarding the effects of nature exposure in individuals with CFS/ME, in a recent study including 24 participants with CFS/ME, who were randomly allocated to outdoor daily living activities (for 6 days, at least 3 hours each) in a waterfall forest environment or to activities in an urban context, noticed that this natural context compared to urban areas improved their psychological state and enhanced immunity (Zhu et al. 2021 ). The main objective of the present study is to assess changes in self-reported pain, fatigue, mental health and psychological well-being indicators after a 3-hour FB session conducted in a Mediterranean forest in a sample of individuals diagnosed with FM and/or CFS/ME. We hypothesize that compared to baseline, after the FB session, participants will report lower levels of state anxiety, negative affect, anger, fatigue, tension, depressive mood, perceived pain, and perceived fatigue and higher levels of positive affect, vigor, friendship, and state mindfulness. Materials and Methods Design A pre-post study design was used with self-report assessment at baseline and after a 3-hour FB session. Procedure All participants were recruited using social media posting (mainly through an inclusive hiking club association called CIM project - Associació Esportiva Projecte Inclusiu CIM -). The activity was free to all individuals with FM and CFS/ME and participation of their families was also encouraged. The FB session was carried out in the Barcelona surrounding area, on the 10th of October 2021, at 10h a.m. The route started at 41°25'12.3"N 2°05'49.2"E coordinates. This area corresponds to the “Baixador de Vallvidrera'' train station, which is very well-connected with Barcelona center (approx. 15 minutes by train). “Baixador de Vallvidrera '' is part of the Serra de Collserola, a mountain range of more than 8,000 hectares, that is part of the Catalan Coastal Range and located between the rivers Besòs and Llobregat. The vegetation in Collserola is predominantly Mediterranean, consisting of a mix of evergreen and deciduous tree species. It contains many Mediterranean natural environments, especially forests, although low vegetation formations (maquis) also abound. Over a thousand major plants and around thirty plant communities have been catalogued, including forests of aleppo pines and nut pines, evergreen oaklands, riverside copses, maquis and scrublands, brush, and savannah grasslands. The original forest is the coastal holm oak grove (holm oak tree layer with a second shrub layer of common laurustine); however, due to human action (e.g., fires, grassland), most of the mountain range is also covered by aleppo pines. The forest also features dense undergrowth with various herbaceous plants, including wildflowers, grasses, and ferns. In addition to its natural features, the Collserola forest also serves as a recreational area for outdoor activities such as hiking, mountain biking, and nature observation. A masked unipersonal code was given to each participant, and then a link to an online questionnaire was sent by email. Participants answered the baseline questionnaire approximately 1h before starting the FB and in the first 24 hours after the FB session. Description of the FB Session The session was guided by one specialized psychologist with expertise in FB (A.M.), a specialized psychologist and physiotherapist in fibromyalgia (M.S.), and three mountain guides to guarantee the safety of the activity. The FB activity consisted of a 3km silence walk in 3 hours, with the realization of three 10-minute stops (i.e., before starting the walk, in the middle and at the e it) with practices of deep breathing and mindful awareness of the five senses in nature. A similar FB protocol was used in the study by Muro et al. ( 2022 ). Sample A total of 44 participants with FM and/or CSF/ME agreed to participate in this study. The inclusion/exclusion criteria were: to be diagnosed with FM, SFC/ME, or both syndromes by a rheumatologist, to have more than 18 years of age, to be able to understand Spanish and to be able to provide written informed consent. All participants consented to collaborate voluntarily and provided informed consent before participating in the study. The ethics committee of the Autonomous University of Barcelona approved the study in advance (reference code UAB5339). Instruments The survey was designed to gather data about the following: Sociodemographic and clinical characteristics age, body mass index (BMI), educational level, site of residence (urban or rural), illness self-perceived start (ISPS), and incapacity certificate. Furthermore, physical exercise habits (i.e., weekly amount of practice, exercise intensity and type of physical exercise) were also recorded. The Depression Anxiety Stress Scales-21 (DASS-21; Lovibond and Lovibond 1995 ) was administered to assess depressive, anxiety and stress symptoms of the sample at baseline. The DASS-21 is a 21-item self-reported scale that assesses symptoms of depression, anxiety and stress (7 items each) in non-clinical and clinical, including chronic pain, samples (Taylor et al. 2005 ). Each item is scored from 0 (d id not apply to me at all over the last week ) to 3 ( applied to me very much or most of the time over the past week ) and asks for symptoms presented over the previous week. Total scores in each subscale may range from 0 to 21, with higher scores indicating a more severe status. The Spanish adaptation of the DASS-21 has an adequate internal consistency (with Cronbach’s alphas of 0.84, 0.70, and 0.82 for depression, anxiety and stress, respectively (Bados et al. 2005 ). The 20-item subscale for assessing state anxiety levels (“right now”) from the State-Trait Anxiety Inventory- State (STAI; Spielberger 1972 ; Riquelme and Buela-Casal 2011 ) was used. It is a 4-point Likert scale ranging from 1 ( not at all ) to 4 ( very much so ). High scores correspond to altered states related to anxiety; low scores suggest an absence of stress and emotional stability. The Spanish version of the STAI state showed an internal consistency of Cronbach’s α = 0.94 (Riquelme and Buela-Casal 2011 ). The Positive Affect and Negative Affect Scale (PANAS; Watson and Tellegen 1985 ; López-Gómez et al. 2015 ) was used. It consists of two subscales of 10 items each for assessing positive and negative affect using a 5-point scale from 1 (v ery slightly or not at all ) to 5 ( extremely ). Scores of each subscale can range from 10–50, with higher scores meaning higher positive and negative affect levels. The scale has shown good psychometric properties in Spanish samples (Díaz-García et al. 2020 ) with internal consistency indexes (Cronbach’s alpha) of 0.92 for the Positive Affect Scale and 0.88 for Negative Affect Scale. The State Mindfulness Scale (SMS; Tanay and Bernstein 2013 ) consists of 21 items with a 5-point response scale that ranges from 1 ( not at all ) to 5 ( very well ) to evaluate the degree of conformity with the proposed assertions related to their experiences in the last 15 minutes. It is focused on two dimensions: mindfulness state of mind (related to thoughts) and mindfulness state of body (related to physical sensations). Higher scores represent a higher level of state mindfulness. In this study sample, this test showed an optimal internal consistency of Cronbach’s α = 0.97, consistent with data obtained by Tanay and Bernstein (Tanay and Bernstein 2013 ), who reported internal solid consistency reliabilities (α = .90–.95). The Profile of Mood States (POMS; McNair et al. 1971 ; Andrade et al. 2010 ) consists of 30 items measuring six mood states (anger, fatigue, vigor, friendship, tension, and depressive symptoms). Participants are requested to rate each item using a 5-point Likert Scale from 0 ( not at all ) to 4 ( extremely ). Higher scores indicated higher levels of that mood state. POMS subscales of the Spanish validation showed Cronbach’s αs between 0.78 (friendship) and 0.87 (fatigue). A Visual Analog Scale for rating pain intensity in the present moment ( VAS PAIN ; Hayes and Patterson 1921 ), with extremes from 0 ( no pain ) to 10 ( unbearable pain ), was used. Similarly, a VAS for assessing fatigue ( VAS FATIGUE ; Hayes and Patterson 1921 ) with extremes from 0 (i.e., lots of energy ) to 10 (i.e., no energy ) was used. Statistical Analyses Descriptive statistics such as means (with standard deviations) and frequencies were calculated for the sociodemographic and clinical characteristics. Paired-sample t -tests were used to analyze the pre-post changes in outcome measures before and after the FB. For a more precise interpretation of the relevance of the results in each assessed domain, effect sizes for pre-post changes were also calculated using Cohen’s d (rule of thumb for Cohen’s d : 0.2 = small, 0.5 = medium, and 0.8 = large effect sizes). All the statistical analyses were made using the SPSS 21.0 program, assuming a statistical significance level of 5%. Results Most of the participants were diagnosed with both FM and CFS/ME ( n = 37, 80.4%). Three participants had only an FM diagnosis (6.5%), and five had only a CFS/ME diagnosis (10.9%). All participants were women, with a mean age of 54 years, ranging from 26 to 69, with a BMI of 28.31 ± 6.46. Most (93.2%) lived in urban areas and achieved secondary or higher education (61.4%). They had an average of 11–13 years of self-perceived illness start/duration (in years) and showed moderate-to-high levels of pain (scoring 6–7 out of 10) and fatigue (scoring 7–8 out of 10). More than half (56.8%) had a recognized disability degree of 33% or more. According to the DASS-21 standard cut-offs (Lovibond and Lovibond 1995 ), 47.7% of the sample rated severe or highly severe for Depression, 53.5% for Anxiety, and 31.8% for Stress. In addition, participants reported that they were not very physically active individuals, as 84.1% of the participants used to practice light exercise (such as walking) twice a week (see Table 1 ). Table 1 Sociodemographic and Clinical Characteristics of the Study Sample Total sample ( n = 44) Sociodemographics Age (years) , M ± SD 53.82 ± 8.57 Women, n (%) 44 (100) Only fibromyalgia 3 (6.80) Only CFS/ME 4 (9.10) Fibromyalgia and CFS/ME diagnosis 36 (81.80) BMI , M ± SD 28.31 ± 6.45 Educational level, n (%) Primary Education 13 (29.50) Secondary Education 16 (36.40) Higher Education 11 (25.00) Other 4 (9.10) Residence , n (%) Urban area 41 (93,20) Rural area 3 (6.80) Clinical characteristics VAS Pain , M ± SD 6.64 ± 1.88 VAS Fatigue , M ± SD 7.48 ± 1.42 Fibromyalgia ISPS (years) , M ± SD 13.49 ± 10.89 CFS/ME ISPS (years) , M ± SD 10.93 ± 10.01 Incapacity certificate , n (%) No 12 (27.30) Requested 7 (15.90) Between 33% and 66% 21 (47.70) More than 66% 4 (9.10) DASS Depression* , n (%) Normal 0–9 15 (34.10) Mild 10–13 4 (9.10) Moderate 14–20 4 (9.10) Severe 21–27 7 (15.90) Extremely severe + 28 14 (31.80) DASS Anxiety* , n (%) Normal 0–9 12 (27.30) Mild 10–13 2 (4.50) Moderate 14–20 6 (13.60) Severe 21–27 7 (15.90) Extremely severe + 28 17 (38.60) DASS Stress , n (%) Normal 0–9 14 (31.80) Mild 10–13 7 (15.90) Moderate 14–20 9 (20.50) Severe 21–27 8 (18.20) Extremely severe > 28 6 (13.60) Physical exercise habits The weekly amount of physical exercise, n (%) 3 hours per week 8 (18.20) No exercise 3 (6.80) The intensity of weekly exercise sessions, n (%) Very light 14 (31.80) Mild 18 (40.90) Moderate 8 (18.20) Physical exercise type, n (%) Walking 37 (84.10) Yoga 1 (2.30) Nordic Walking 1 (2.30) Other 3 (6.80) Note: *Levels according to DASS-21 standard cut-offs (Lovinbond & Lovibond, 1995 ). Most psychological indicators showed statistically significant pre-post variations after the intervention (see Table 2 ). More precisely, there was a statistically significant decrease in negative affect ( p < 0.001; d = 0.84), state anxiety ( p < 0.001; d = 1.31), anger ( p < 0.001; d = 0.84), fatigue ( p = 0.009; d = 0.40), tension ( p < 0.001; d = 1.05), and depression ( p < 0.001; d = 1.21). Moreover, a significant increase in positive affect ( p < 0.001; d = 0.85), vigor ( p < 0.001; d = 0.84), friendship ( p = 0.001; d = 0.44), mindfulness of body ( p < 0.001; d = 0.48) and mindfulness of mind ( p < 0.001; d = 0.64) was noted. There was also a significant decrease in fatigue levels ( p = 0.003; d = 0.46) after the FB. There were no significant differences in pain intensity ( p = 0.421; d = 0.14). Table 2 Observed Changes after Forest-Bathing Practice. M ( SD ) Pre ( n = 44) M ( SD ) Post ( n = 42) Pre-post diff. M ( SD ) 95% CI t p d VAS Pain 6.64 (1.88) 6.31 (2.62) 0.33 (2.63) − .48, 1.13 0.813 0.421 0.14 VAS Fatigue 7.48 (1.42) 6.36 (2.76) 1.12 (2.31) .41, 1.83 3.167 0.003 0.46 PANAS Positive affect 25.52 (8.91) 34.07 (9.56) -7.98 (6.72) -10.05, -5.91 -7.779 < 0.001 0.85 PANAS Negative affect 22.84 (10.00) 14.80 (6.73) 7.49 (8.60) 4.84, 10.13 5.713 < 0.001 0.84 STAI Anxiety state 31.59 (14.54) 13.47 (11.71) 17.63 (12.62) 13.74, 21.51 9.162 < 0.001 1.31 POMS Anger 5.11 (5.40) 1.23 (2.78) 4.09 (5.34) 2.45, 5.74 5.022 < 0.001 0.84 POMS Fatigue 12.18 (5.21) 9.85 (6.07) 2.35 (5.62) .62, 4.08 2.739 < 0.01 0.40 POMS Vigour 6.36 (4.57) 10.69 (4.97) -4.09 (4.33) -5.43, -2.76 -6.198 < 0.001 0.84 POMS Friendliness 14.54 (4.52) 16.69 (3.78) -1.93 (3.55) -3.02, − .84 -3.567 0.001 0.44 POMS Tension 9.29 (6.70) 2.71 (4.00) 6.35 (5.33) 4.71, 7.99 7.816 < 0.001 1.05 POMS Depression 9.63 (6.30) 2.80 (3.76) 6.53 (6.34) 4.58, 8.49 6.762 < 0.001 1.21 SMS Mindf. body 23.22 (5.38) 25.80 (4.37) -2.40 (4.11) -3.66, -1.13 -3.820 < 0.001 0.48 SMS Mindf. mind 55.13 (13.09) 63.42 (11.35) -8.02 (9.12) -10.83, -5.22 -5.766 < 0.001 0.64 Discussion The main aim of this study was to assess if a FB session could improve several outcomes in individuals with FM and/or SFC, with a particular focus on mental health and well-being. These results are strengthened given the notable clinical severity of the individuals included, with moderate-to-high reported levels of pain and fatigue (cardinal symptoms of FM and CFS/ME), a high rate of recognized disability degree and high depressive and anxious symptomatology. Furthermore, regarding the generalizability of the findings, more than 80% of the participants reported only performing light exercise (such as walking) twice a week, so we can ascertain that they are not only very physically active (a behavioral pattern not usually seen in these conditions) individuals were enrolled in this study. Overall, the results obtained in this pilot study align with previous studies in Asian and Mediterranean forests and show how FB may help in fostering mental well-being (Hansen et al. 2017 ; Wen et al. 2019 ; Timko Olson et al. 2020 ; Muro et al. 2022 , 2023 ). The current study found a decrease in negative affect, state anxiety, anger, fatigue, tension, and depression and an increase in positive affect, vigor, friendship, and mindfulness state in a clinical sample of individuals showing FM and/or SFC/ME. However, contrary to expectations, this study did not find a significant improvement in self-reported pain following the FB session. This study's results also align with previous studies that reported increased well-being after contact with nature, especially following a FB session (Antonelli et al. 2019 ; Yang et al. 2021 ; Gobster et al. 2022 ; Shim et al. 2022 ). As these studies suggest, FB might produce its benefits because it would increase exposure to nature, which is related to normalizing the stress-response system. In addition, our results also indicated an increase in state mindfulness, consistent with the Attention Restoration Theory (Kaplan 1995 ). According to this theory, spending time in nature has health benefits since it decreases attentional fatigue caused by the modern lifestyle. Therefore, the mindful state generated by the FB practice might have enabled individuals to enjoy the present moment and focus on the environment, the exercise or the silent company of other people instead of on their distressing internal states or engaging in ruminating tendencies. Furthermore, our results showed increased friendliness following the FB practice, previously documented in some studies (Jimenez et al. 2021 ; Muro et al. 2022 ; McEwan et al. 2022 ). In other words, FB may provide a shared experience with a space for socialization in which new bonds and connections may be created, which might increase social support. These findings highlight the potential of FB as a holistic intervention that promotes physical and mental health through exposure to nature and fosters mindfulness and social connection, contributing to overall well-being. It is important to note that most of the studies mentioned above have been conducted with healthy populations, often composed of young men and in Asia. Therefore, our results allow us to extend the positive effects of FB to a more specific population: patients with somatic functional syndromes such as FM and CFS/ME from the Mediterranean area. In this sense, our results are consistent with data obtained in the study of Muro et al. ( 2023 ) in which they concluded that FB in a Mediterranean forest increases psychological well-being in a sample of healthy adults compared to a control hiking group. To our knowledge, only one study explored the benefits of walking in a Mediterranean forest among patients with FM. Unlike our study, which lasted only one session and was conducted in a relatively young forest (i.e., due to recent human action (e.g., fires, grassland), most of the mountain range is covered by aleppo pine forests and not by its original coastal holm oak grove forest), the López-Pousa et al. ( 2015 ) study explored a two-week intervention in two types of Mediterranean forests (mature and young) among FM patients López-Pousa et al. ( 2015 ) concluded that an aerobic exercise program consisting of walking through a forest could reduce FM symptoms. But, only in the mature forest did participants experience a subjective perception of having fewer days of pain and insomnia and more days of wellness. Unlike them, we did not find differences in terms of pain. It could be because our FM session only lasted 3 hours, and perhaps more time is needed to obtain results in this highly resistant clinical outcome. Therefore, the duration of the nature exposure could be a significant factor influencing the effectiveness of the intervention, as it has been previously suggested by (Antonelli et al. 2019 ) Regarding the pain outcome, contrary to our results, Han et al. ( 2016 ) reported changes in pain perception following forest therapy among a sample of adults who suffered from chronic pain. Several differences between our study and the study of Han et al. ( 2016 ) could explain the discrepancy in the results. The intervention of Han et al. lasted for two days and included other components apart from FB, such as psychoeducation or time for socialization. It is assumed that the FB intervention is more beneficial when combined with other types of activities and when it has a longer duration. Another promising result observed after FB was the significant improvement in the CFS/ME core symptom of fatigue (moderate effect size) and, parallelly, the opposite aspect of vigor (large effect size). This result is in line with other research on the benefits of walking in the woods to reduce fatigue in FM and CFS/ME (López-Pousa et al. 2015 ; Zhu et al. 2021 ) Forest bathing, by providing a sensory-rich environment that engages multiple modalities of perception within a natural context in the forest has been shown to stimulate the parasympathetic nervous system and reduce sympathetic activity, resulting in a state of greater well-being and vitality (Siah et al. 2023 ) Limitations and Future Directions The present study has some strengths that deserve to be stated. Mainly, the sample size ( n = 44) was larger than the other study conducted on individuals with FM ( n = 30, López-Pousa et al. 2015 ) and the evaluation protocol included a thorough evaluation of the impact of the FB session at the mental health and well-being level. Furthermore, a multidisciplinary team conducted the intervention, including two specialized psychologists and a mountain guide. However, the present study presents limitations that should also be acknowledged. The first one is not having a control group which impedes establishing causality. The inclusion of a control group (e.g., a psychoeducative control group) will be considered in future studies to assess the intervention's effectiveness. Another consideration was the short duration of the FB protocol (only one session) and the lack of a follow-up assessment to evaluate the stability of the observed improvements. Furthermore, further studies should also consider potential moderators (e.g., gender, age, physical fitness) and mediators (e.g., self-efficacy, self-esteem, nature connectedness) in explaining the beneficial effects of FB. In addition, the sample included only women. Although our results are interesting to generalize those of previous studies that only included males, future studies should extend and compare the benefits of FB in a clinical sample of men and women. In conclusion, FB seems an affordable practice that may be useful for managing symptomatology in patients with FM and CFS/ME. Further research is needed to evaluate its effectiveness compared to other therapeutic approaches and to investigate further mechanisms of change associated with FB benefits. Conclusions The current study aimed to explore nature's benefits on individuals with FM and/or CFS/ME. The results from this study indicated that a 3-hour session of FB, conducted in a Mediterranean forest in patients with chronic pain and FM, could be beneficial for improving mental health and psychological well-being. FB could be an accessible and low-cost add-on therapeutic program which could be integrated into standard treatments for chronic pain and increase its efficacy and improve psychological distress in chronic pain patients. Further randomized controlled trials will be welcome comparing the effects of FB with other recognized therapeutic approaches for FM and/or CFS/ME (e.g., cognitive behavioral therapy, indoor therapeutic exercise). Furthermore, moderators (e.g., session duration) and mediators of change (e.g., changes in state mindfulness) of FB would be explored in future studies. Declarations Acknowledgements AF-S and AM acknowledge the funding from the Serra Húnter program (UAB-LE-8015 and UAB-LE-603, respectively). The project has been funded in part by the Spanish Ministry for Science and Innovation (MCIN) State R + D + I Program Oriented to the Challenges of Society (ref. PID 2020-117667RA-I00) and co-financed with European Union ERDF funds. We are grateful to the CIBER of Epidemiology and Public Health (CIBERESP CB22/02/00052; ISCIII) for its support. References Andrade E, Arce C, Torrado J, et al (2010) Factor Structure and Invariance of the POMS Mood State Questionnaire in Spanish. 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Public Health 121:54–63. https://doi.org/10.1016/j.puhe.2006.05.024 Muro A, Feliu-Soler A, Canals J, et al (2022) Psychological benefits of Forest Bathing during the COVID-19 pandemic: a pilot study in a Mediterranean forest close to urban areas. Journal of Forest Research 27:71–75. https://doi.org/10.1080/13416979.2021.1996516 Muro A, Mateo C, Parrado E, et al (2023) Forest bathing and hiking benefits for mental health during the COVID-19 pandemic in Mediterranean regions. Eur J For Res. https://doi.org/10.1007/s10342-023-01531-6 NICE (2021) Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. https://www.nice.org.uk/guidance/ng206 Oh B, Lee KJ, Zaslawski C, et al (2017) Health and well-being benefits of spending time in forests: systematic review. Environ Health Prev Med 22:71. https://doi.org/10.1186/s12199-017-0677-9 Park BJ, Tsunetsugu Y, Kasetani T, et al (2010) The physiological effects of Shinrin-yoku (taking in the forest atmosphere or forest bathing): evidence from field experiments in 24 forests across Japan. Environ Health Prev Med 15:18–26. https://doi.org/10.1007/s12199-009-0086-9 Piva G, Caruso L, Gómez AC, et al (2022) Effects of forest walking on physical and mental health in elderly populations: a systematic review. Rev Environ Health. https://doi.org/10.1515/reveh-2022-0093 Qiu Q, Yang L, He M, et al (2022) The Effects of Forest Therapy on the Blood Pressure and Salivary Cortisol Levels of Urban Residents: A Meta-Analysis. Int J Environ Res Public Health 20:458. https://doi.org/10.3390/ijerph20010458 Riquelme A, Buela-Casal G (2011) Actualización psicométrica y funcionamiento diferencial de los ítems en el State Trait Anxiety Inventory (STAI). Psicothema 23:510–515 Shim SR, Chang J, Lee J, et al (2022) Perspectives on the Psychological and Physiological Effects of Forest Therapy: A Systematic Review with a Meta-Analysis and Meta-Regression. Forests 13:2029. https://doi.org/10.3390/f13122029 Siah CJR, Goh YS, Lee J, et al (2023) The effects of forest bathing on psychological well-being: A systematic review and meta‐analysis. Int J Ment Health Nurs. https://doi.org/10.1111/inm.13131 Song C, Ikei H, Kagawa T, Miyazaki Y (2019) Effects of Walking in a Forest on Young Women. Int J Environ Res Public Health 16:229. https://doi.org/10.3390/ijerph16020229 Song C, Ikei H, Miyazaki Y (2016) Physiological Effects of Nature Therapy: A Review of the Research in Japan. Int J Environ Res Public Health 13:781. https://doi.org/10.3390/ijerph13080781 Spielberger CD (1972) Review of Profile of Mood States. Stanhope J, Breed MF, Weinstein P (2020) Exposure to greenspaces could reduce the high global burden of pain. Environ Res 187:109641. https://doi.org/10.1016/j.envres.2020.109641 Takano T (2002) Urban residential environments and senior citizens’ longevity in megacity areas: the importance of walkable green spaces. J Epidemiol Community Health (1978) 56:913–918. https://doi.org/10.1136/jech.56.12.913 Tanay G, Bernstein A (2013) State Mindfulness Scale (SMS): Development and initial validation. Psychol Assess 25:1286–1299. https://doi.org/10.1037/a0034044 Taylor R, Lovibond PF, Nicholas MK, et al (2005) The Utility of Somatic Items in the Assessment of Depression in Patients With Chronic Pain A Comparison of the Zung Self-Rating Depression Scale and the Depression Anxiety Stress Scales in Chronic Pain and Clinical and Community Samples. Clin J Pain 21:91–100 Timko Olson ER, Hansen MM, Vermeesch A (2020) Mindfulness and Shinrin-Yoku: Potential for Physiological and Psychological Interventions during Uncertain Times. Int J Environ Res Public Health 17:9340. https://doi.org/10.3390/ijerph17249340 Tsunetsugu Y, Lee J, Park B-J, et al (2013) Physiological and psychological effects of viewing urban forest landscapes assessed by multiple measurements. Landsc Urban Plan 113:90–93. https://doi.org/10.1016/j.landurbplan.2013.01.014 Twohig-Bennett C, Jones A (2018) The health benefits of the great outdoors: A systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res 166:628–637. https://doi.org/10.1016/j.envres.2018.06.030 Ulrich RS, Simons RF, Losito BD, et al (1991) Stress recovery during exposure to natural and urban environments. J Environ Psychol 11:201–230. https://doi.org/10.1016/S0272-4944(05)80184-7 Watson D, Tellegen A (1985) Toward a consensual structure of mood. Psychol Bull 98:219 Wen Y, Yan Q, Pan Y, et al (2019) Medical empirical research on forest bathing (Shinrin-yoku): a systematic review. Environ Health Prev Med 24:70. https://doi.org/10.1186/s12199-019-0822-8 Wolfe F, Rasker JJ (2021) The Evolution of Fibromyalgia, Its Concepts, and Criteria. Cureus. https://doi.org/10.7759/cureus.20010 Yang B-Y, Zhao T, Hu L-X, et al (2021) Greenspace and human health: An umbrella review. The Innovation 2:100164. https://doi.org/10.1016/j.xinn.2021.100164 Yi Y, Seo E, An J (2022) Does Forest Therapy Have Physio-Psychological Benefits? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int J Environ Res Public Health 19:10512. https://doi.org/10.3390/ijerph191710512 Yunus MB (2007) Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes. Semin Arthritis Rheum 36:339–356. https://doi.org/10.1016/j.semarthrit.2006.12.009 Zhu Z, Zhao X, OuYang Q, et al (2021) Waterfall Forest Environment Regulates Chronic Stress via the NOX4/ROS/NF-κB Signaling Pathway. Front Neurol 12:. https://doi.org/10.3389/fneur.2021.619728 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3088899","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":211834215,"identity":"d0899bbc-e561-466b-99ba-d509e437793b","order_by":0,"name":"Mayte Serrat","email":"","orcid":"","institution":"Hospital de la Vall d’Hebron, Universitat Autònoma de Barcelona","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mayte","middleName":"","lastName":"Serrat","suffix":""},{"id":211834217,"identity":"4f5bee71-afa6-4048-8b87-16fa72ec4b87","order_by":1,"name":"Estíbaliz Royuela-Colomer","email":"","orcid":"","institution":"Hospital de la Vall d’Hebron, Universitat Autònoma de Barcelona","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Estíbaliz","middleName":"","lastName":"Royuela-Colomer","suffix":""},{"id":211834219,"identity":"8c037861-392d-434b-b031-1ba13cd5f826","order_by":2,"name":"Sandra Alonso-Marsol","email":"","orcid":"","institution":"Hospital Del Mar","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Alonso-Marsol","suffix":""},{"id":211834220,"identity":"79d3d346-168d-4b25-8d44-71bcfb4cef96","order_by":3,"name":"Sònia Ferrés","email":"","orcid":"","institution":"Escoles Universitaries Gimbernat","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sònia","middleName":"","lastName":"Ferrés","suffix":""},{"id":211834221,"identity":"e1dd5522-3e8e-4208-9402-7ff081437c71","order_by":4,"name":"William Auer","email":"","orcid":"","institution":"Universitat Autònoma de Barcelona","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"William","middleName":"","lastName":"Auer","suffix":""},{"id":211834222,"identity":"e9f02116-8acc-4cc9-bf65-a4bd641d095a","order_by":5,"name":"Anna Muro","email":"","orcid":"","institution":"Universitat Autònoma de Barcelona","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Muro","suffix":""},{"id":211834223,"identity":"00e428ee-ea67-40b5-8ae8-47aee2cf3cde","order_by":6,"name":"Ruben Nieto","email":"","orcid":"","institution":"Universitat Oberta de Catalunya","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ruben","middleName":"","lastName":"Nieto","suffix":""},{"id":211834224,"identity":"087e2903-6bcc-4091-b1f8-f9ccafe7ddc5","order_by":7,"name":"Albert Feliu-Soler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3PsQrCMBCA4QsBs0SzXhH0FdpFEaq+SkVwUkEEQQQNFOKiex/DV5AMXcTZUXFw1U03UxXcUkeH/EtuyMclAC7XP8b46xDAiIQrQJRPaEYi8CQlkiRvYvBv5D3nExEXt+fpHVBQqspN1RoC05ejjaAudYNdBOjFRJUHqjsG3gvsD9O85skI5r5+EdqRCHZS1bz+MATbGWmohSHsZiW+2UIy4lNDiNKGcPuWwPzFkz1E1CRurPbpuMD7o8RGKul6e5NhiGK5PB3uk9lQsHRztZFP+B0LP1x3uVwuV05PFN8/yYKQEOYAAAAASUVORK5CYII=","orcid":"","institution":"Universitat Autònoma de Barcelona","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Albert","middleName":"","lastName":"Feliu-Soler","suffix":""}],"badges":[],"createdAt":"2023-06-20 19:44:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3088899/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3088899/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":39672405,"identity":"6d26c9e6-2795-44c8-bef1-8066577ced67","added_by":"auto","created_at":"2023-07-07 06:14:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":413751,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3088899/v1/43d6946f-a1a5-4ae3-9a39-170bd5ba183c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Psychological Benefits of Forest Bathing in Individuals with Fibromyalgia and Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis: A Pilot Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years, the role of forests in promoting and improving human health and well-being has been gaining scientific interest (Yi et al. \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Gobster et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Piva et al. \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Shim et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Qiu et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In this regard, there are mounting studies supporting the beneficial effects of nature exposure in a broad range of health outcomes and populations across the globe with evidenced positive effects on life satisfaction, mental and general health, longevity, more regulated mood and emotional states, and cognitive processes (Herzog et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Takano \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Maas \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Biedenweg et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Kondo et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Twohig-Bennett and Jones \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Bratman et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). It has also been reported that the effects of forest environment induce physiological relaxation with changes in stress hormones (i.e., cortisol) and the autonomic nervous system (Park et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Lee et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Tsunetsugu et al. \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Song et al. \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Benefits of nature exposure have also been demonstrated for even brief contemplative outdoor activities, such as forest walks and outdoor mindfulness practices, showing a positive effect on mental health in reducing, for instance, depressive and anxiety symptoms(Morita et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Hansen et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Oh et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Muro et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDifferent theories exist regarding the association between nature and human health and well-being. For example, the \u003cem\u003eAttention Restoration Theory\u003c/em\u003e proposes that spending time in nature can restore attention and prevent the mental fatigue associated with modern lifestyles (Kaplan \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Similarly, the \u003cem\u003eStress Reduction Theory\u003c/em\u003e hypothesizes that the connection with nature activates the parasympathetic nervous system and reduces autonomic arousal (Ulrich et al. \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e1991\u003c/span\u003e), which is related to stress. Similarly, the \u003cem\u003eBiophilia hypothesis\u003c/em\u003e points out that humans naturally desire to interact with nature and all living things that belong to the natural world (Kellert and Wilson \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Finally, other explanations suggest that the benefits of nature rely on aspects that individuals encounter when they spend more time in nature, namely, an increase in levels of physical activity, a reduction in exposure to harmful environments (e.g., air pollution, noise, and artificial light), and an increase in exposure to sunlight and vitamin D(Stanhope et al. \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Jimenez et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yang et al. \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong nature connection practices is the Japanese practice of \u003cem\u003eShinrin-Yoku\u003c/em\u003e, also known as Forest Bathing (FB). FB may have remarkable psychological benefits associated with nature immersion, which could help manage and reduce the reported modern \u0026ldquo;stress-state\u0026rdquo; (Hansen et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Timko Olson et al. \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The FB practice consists of mindful walking in a natural setting, quietly aimed at promoting communication and contact with nature, and it is usually carried out by specialized guides (Hansen et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). FB is a form of \u0026ldquo;Nature Therapy\u0026rdquo;, defined by Song, Ikei and Miyazaki (2014; \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) as \u0026ldquo;a set of practices aimed at achieving \u0026lsquo;preventive medical effects\u0026rsquo; through exposure to natural stimuli that render a state of physiological relaxation and boost the weakened immune functions to prevent diseases\u0026rdquo;.\u003c/p\u003e \u003cp\u003eEvidence suggests that FB has psychological and overall health benefits. A recent review indicates that FB may increase natural human killer cell activity, reduce blood pressure and heart rate, diminish stress hormones, balance the autonomic nervous system, improve sleep, reduce anxiety, depression, anger, fatigue, and confusion, and increase vigor (Li \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, the majority of the studies in FB are performed in Asian countries, with small sample sizes, with an over-representation of young and healthy men, needing more evidence to confirm the therapeutic effects of forests on health in other countries around the world and, particularly, in heterogeneous clinical populations (Lee et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Song et al. \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Muro et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFM is a highly prevalent rheumatic syndrome (2\u0026ndash;8% of the general population), usually diagnosed between 20 and 50 years old (H\u0026auml;user et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). It is characterized by chronic, diffuse musculoskeletal pain, fatigue, sleep disorders, high levels of distress and comorbidity with anxiety and depressive disorders (Clauw \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). FM has recently been considered a functional somatic disorder, evolving from a primary pain disorder with a neurobiological basis to a broader biopsychosocial disorder (Wolfe and Rasker \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although there is no curative treatment for this disease, pain education, cognitive behavioral therapy and therapeutic exercise are considered adequate approaches to manage FM symptoms, with an evidence level of 1A(Malfliet et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFM is usually comorbid with other central sensitization syndromes such as CFS/ME(Kato et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Yunus \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Castro-Marrero et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) in over 50% of the cases(Faro et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). CFS/ME is a disabling and complex illness that affects approximately 1% of the population (Lim et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)and is characterized by persistent post-exertional fatigue and substantial symptoms related to cognitive, immune and autonomic dysfunction, including sore throat, muscle pain, joint pain, weakness, sleep disturbance, memory loss, and poor concentration (Brurberg et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Cortes Rivera et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This medical condition negatively impacts individuals\u0026rsquo; quality of life, including their psychological, emotional and social well-being (NICE \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFB seems to be a promising intervention for promoting better mental health and well-being; however, there is a scarcity of studies exploring its effects in clinical samples; mainly, as far as we know, only one study uses FB in patients with FM. In this pilot study conducted in Spain by L\u0026oacute;pez-Pousa et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), 30 individuals with FM were included and randomly allocated to a group of aerobic exercise-based program (i.e., 1.25-kilometre walks during six days in a time-frame of 2 weeks) in a mature (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15) or in a young forest (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15). Although both groups showed decreases in FM symptoms, the group that performed the walk in the mature forest showed greater improvements in terms of r in days with intense pain, insomnia and more days of well-being. Regarding the effects of nature exposure in individuals with CFS/ME, in a recent study including 24 participants with CFS/ME, who were randomly allocated to outdoor daily living activities (for 6 days, at least 3 hours each) in a waterfall forest environment or to activities in an urban context, noticed that this natural context compared to urban areas improved their psychological state and enhanced immunity (Zhu et al. \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main objective of the present study is to assess changes in self-reported pain, fatigue, mental health and psychological well-being indicators after a 3-hour FB session conducted in a Mediterranean forest in a sample of individuals diagnosed with FM and/or CFS/ME. We hypothesize that compared to baseline, after the FB session, participants will report lower levels of state anxiety, negative affect, anger, fatigue, tension, depressive mood, perceived pain, and perceived fatigue and higher levels of positive affect, vigor, friendship, and state mindfulness.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eA pre-post study design was used with self-report assessment at baseline and after a 3-hour FB session.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eAll participants were recruited using social media posting (mainly through an inclusive hiking club association called CIM project -\u003cem\u003eAssociaci\u0026oacute; Esportiva Projecte Inclusiu CIM\u003c/em\u003e-). The activity was free to all individuals with FM and CFS/ME and participation of their families was also encouraged. The FB session was carried out in the Barcelona surrounding area, on the 10th of October 2021, at 10h a.m. The route started at 41\u0026deg;25'12.3\"N 2\u0026deg;05'49.2\"E coordinates. This area corresponds to the \u0026ldquo;Baixador de Vallvidrera'' train station, which is very well-connected with Barcelona center (approx. 15 minutes by train). \u0026ldquo;Baixador de Vallvidrera '' is part of the Serra de Collserola, a mountain range of more than 8,000 hectares, that is part of the Catalan Coastal Range and located between the rivers Bes\u0026ograve;s and Llobregat. The vegetation in Collserola is predominantly Mediterranean, consisting of a mix of evergreen and deciduous tree species. It contains many Mediterranean natural environments, especially forests, although low vegetation formations (maquis) also abound. Over a thousand major plants and around thirty plant communities have been catalogued, including forests of aleppo pines and nut pines, evergreen oaklands, riverside copses, maquis and scrublands, brush, and savannah grasslands. The original forest is the coastal holm oak grove (holm oak tree layer with a second shrub layer of common laurustine); however, due to human action (e.g., fires, grassland), most of the mountain range is also covered by aleppo pines. The forest also features dense undergrowth with various herbaceous plants, including wildflowers, grasses, and ferns. In addition to its natural features, the Collserola forest also serves as a recreational area for outdoor activities such as hiking, mountain biking, and nature observation.\u003c/p\u003e \u003cp\u003eA masked unipersonal code was given to each participant, and then a link to an online questionnaire was sent by email. Participants answered the baseline questionnaire approximately 1h before starting the FB and in the first 24 hours after the FB session.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the FB Session\u003c/h2\u003e \u003cp\u003eThe session was guided by one specialized psychologist with expertise in FB (A.M.), a specialized psychologist and physiotherapist in fibromyalgia (M.S.), and three mountain guides to guarantee the safety of the activity. The FB activity consisted of a 3km silence walk in 3 hours, with the realization of three 10-minute stops (i.e., before starting the walk, in the middle and at the e it) with practices of deep breathing and mindful awareness of the five senses in nature. A similar FB protocol was used in the study by Muro et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eA total of 44 participants with FM and/or CSF/ME agreed to participate in this study. The inclusion/exclusion criteria were: to be diagnosed with FM, SFC/ME, or both syndromes by a rheumatologist, to have more than 18 years of age, to be able to understand Spanish and to be able to provide written informed consent.\u003c/p\u003e \u003cp\u003e All participants consented to collaborate voluntarily and provided informed consent before participating in the study. The ethics committee of the Autonomous University of Barcelona approved the study in advance (reference code UAB5339).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cp\u003eThe survey was designed to gather data about the following:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSociodemographic and clinical characteristics\u003c/strong\u003e \u003cp\u003eage, body mass index (BMI), educational level, site of residence (urban or rural), illness self-perceived start (ISPS), and incapacity certificate. Furthermore, physical exercise habits (i.e., weekly amount of practice, exercise intensity and type of physical exercise) were also recorded.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe \u003cem\u003eDepression Anxiety Stress Scales-21\u003c/em\u003e (DASS-21; Lovibond and Lovibond \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) was administered to assess depressive, anxiety and stress symptoms of the sample at baseline. The DASS-21 is a 21-item self-reported scale that assesses symptoms of depression, anxiety and stress (7 items each) in non-clinical and clinical, including chronic pain, samples (Taylor et al. \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Each item is scored from 0 (d\u003cem\u003eid not apply to me at all over the last week\u003c/em\u003e) to 3 (\u003cem\u003eapplied to me very much or most of the time over the past week\u003c/em\u003e) and asks for symptoms presented over the previous week. Total scores in each subscale may range from 0 to 21, with higher scores indicating a more severe status. The Spanish adaptation of the DASS-21 has an adequate internal consistency (with Cronbach\u0026rsquo;s alphas of 0.84, 0.70, and 0.82 for depression, anxiety and stress, respectively (Bados et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 20-item subscale for assessing state anxiety levels (\u0026ldquo;right now\u0026rdquo;) from the \u003cem\u003eState-Trait Anxiety Inventory- State\u003c/em\u003e (STAI; Spielberger \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e1972\u003c/span\u003e; Riquelme and Buela-Casal \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) was used. It is a 4-point Likert scale ranging from 1 (\u003cem\u003enot at all\u003c/em\u003e) to 4 (\u003cem\u003every much so\u003c/em\u003e). High scores correspond to altered states related to anxiety; low scores suggest an absence of stress and emotional stability. The Spanish version of the STAI state showed an internal consistency of Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.94 (Riquelme and Buela-Casal \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe \u003cem\u003ePositive Affect and Negative Affect Scale\u003c/em\u003e (PANAS; Watson and Tellegen \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e1985\u003c/span\u003e; L\u0026oacute;pez-G\u0026oacute;mez et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) was used. It consists of two subscales of 10 items each for assessing positive and negative affect using a 5-point scale from 1 (v\u003cem\u003eery slightly or not at all\u003c/em\u003e) to 5 (\u003cem\u003eextremely\u003c/em\u003e). Scores of each subscale can range from 10\u0026ndash;50, with higher scores meaning higher positive and negative affect levels. The scale has shown good psychometric properties in Spanish samples (D\u0026iacute;az-Garc\u0026iacute;a et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) with internal consistency indexes (Cronbach\u0026rsquo;s alpha) of 0.92 for the Positive Affect Scale and 0.88 for Negative Affect Scale.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eState Mindfulness Scale\u003c/em\u003e (SMS; Tanay and Bernstein \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) consists of 21 items with a 5-point response scale that ranges from 1 (\u003cem\u003enot at all\u003c/em\u003e) to 5 (\u003cem\u003every well\u003c/em\u003e) to evaluate the degree of conformity with the proposed assertions related to their experiences in the last 15 minutes. It is focused on two dimensions: mindfulness state of mind (related to thoughts) and mindfulness state of body (related to physical sensations). Higher scores represent a higher level of state mindfulness. In this study sample, this test showed an optimal internal consistency of Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.97, consistent with data obtained by Tanay and Bernstein (Tanay and Bernstein \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), who reported internal solid consistency reliabilities (α\u0026thinsp;=\u0026thinsp;.90\u0026ndash;.95).\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eProfile of Mood States\u003c/em\u003e (POMS; McNair et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e1971\u003c/span\u003e; Andrade et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) consists of 30 items measuring six mood states (anger, fatigue, vigor, friendship, tension, and depressive symptoms). Participants are requested to rate each item using a 5-point Likert Scale from 0 (\u003cem\u003enot at all\u003c/em\u003e) to 4 (\u003cem\u003eextremely\u003c/em\u003e). Higher scores indicated higher levels of that mood state. POMS subscales of the Spanish validation showed Cronbach\u0026rsquo;s αs between 0.78 (friendship) and 0.87 (fatigue).\u003c/p\u003e \u003cp\u003eA \u003cem\u003eVisual Analog Scale\u003c/em\u003e for rating pain intensity in the present moment (\u003cem\u003eVAS PAIN\u003c/em\u003e; Hayes and Patterson \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1921\u003c/span\u003e), with extremes from 0 (\u003cem\u003eno pain\u003c/em\u003e) to 10 (\u003cem\u003eunbearable pain\u003c/em\u003e), was used. Similarly, a VAS for assessing fatigue (\u003cem\u003eVAS FATIGUE\u003c/em\u003e; Hayes and Patterson \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1921\u003c/span\u003e) with extremes from 0 (i.e., \u003cem\u003elots of energy\u003c/em\u003e) to 10 (i.e., \u003cem\u003eno energy\u003c/em\u003e) was used.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eDescriptive statistics such as means (with standard deviations) and frequencies were calculated for the sociodemographic and clinical characteristics. Paired-sample \u003cem\u003et\u003c/em\u003e-tests were used to analyze the pre-post changes in outcome measures before and after the FB. For a more precise interpretation of the relevance of the results in each assessed domain, effect sizes for pre-post changes were also calculated using Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e (rule of thumb for Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e: 0.2\u0026thinsp;=\u0026thinsp;small, 0.5\u0026thinsp;=\u0026thinsp;medium, and 0.8\u0026thinsp;=\u0026thinsp;large effect sizes). All the statistical analyses were made using the SPSS 21.0 program, assuming a statistical significance level of 5%.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMost of the participants were diagnosed with both FM and CFS/ME (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;37, 80.4%). Three participants had only an FM diagnosis (6.5%), and five had only a CFS/ME diagnosis (10.9%). All participants were women, with a mean age of 54 years, ranging from 26 to 69, with a BMI of 28.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.46. Most (93.2%) lived in urban areas and achieved secondary or higher education (61.4%). They had an average of 11\u0026ndash;13 years of self-perceived illness start/duration (in years) and showed moderate-to-high levels of pain (scoring 6\u0026ndash;7 out of 10) and fatigue (scoring 7\u0026ndash;8 out of 10). More than half (56.8%) had a recognized disability degree of 33% or more. According to the DASS-21 standard cut-offs (Lovibond and Lovibond \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), 47.7% of the sample rated severe or highly severe for Depression, 53.5% for Anxiety, and 31.8% for Stress. In addition, participants reported that they were not very physically active individuals, as 84.1% of the participants used to practice light exercise (such as walking) twice a week (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and Clinical Characteristics of the Study Sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal sample\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e, \u003cb\u003eM\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.82\u0026thinsp;\u0026plusmn;\u0026thinsp;8.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWomen, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOnly fibromyalgia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOnly CFS/ME\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFibromyalgia and CFS/ME diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (81.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e, \u003cb\u003eM\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (29.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (36.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (25.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e, \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (93,20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS Pain\u003c/b\u003e, \u003cb\u003eM\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS Fatigue\u003c/b\u003e, \u003cb\u003eM\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFibromyalgia ISPS (years)\u003c/b\u003e, \u003cb\u003eM\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.49\u0026thinsp;\u0026plusmn;\u0026thinsp;10.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCFS/ME ISPS (years)\u003c/b\u003e, \u003cb\u003eM\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncapacity certificate\u003c/b\u003e, \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (27.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRequested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (15.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween 33% and 66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (47.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDASS Depression*\u003c/b\u003e, \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal 0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (34.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild 10\u0026ndash;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate 14\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere 21\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (15.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely severe\u0026thinsp;+\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (31.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDASS Anxiety*\u003c/b\u003e, \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal 0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (27.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild 10\u0026ndash;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate 14\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (13.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere 21\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (15.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely severe\u0026thinsp;+\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (38.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDASS Stress\u003c/b\u003e, \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal 0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (31.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild 10\u0026ndash;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (15.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate 14\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (20.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere 21\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (18.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely severe\u0026thinsp;\u0026gt;\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (13.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical exercise habits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eThe weekly amount of physical exercise, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 hour per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 hours per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (29.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3 hours per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 hours per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (18.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eThe intensity of weekly exercise sessions, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery light\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (31.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (40.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (18.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical exercise type, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (84.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYoga\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNordic Walking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote: *Levels according to DASS-21 standard cut-offs (Lovinbond \u0026amp; Lovibond, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1995\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost psychological indicators showed statistically significant pre-post variations after the intervention (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). More precisely, there was a statistically significant decrease in negative affect (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.84), state anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.31), anger (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.84), fatigue (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.40), tension (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.05), and depression (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.21). Moreover, a significant increase in positive affect (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.85), vigor (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.84), friendship (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.44), mindfulness of body (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.48) and mindfulness of mind (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.64) was noted. There was also a significant decrease in fatigue levels (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.46) after the FB. There were no significant differences in pain intensity (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.421; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.14).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObserved Changes after Forest-Bathing Practice.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e) Pre\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e) Post\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePre-post diff.\u003c/p\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ed\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.64 (1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.31 (2.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33 (2.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.48, 1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.48 (1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.36 (2.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.12 (2.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e.41, 1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePANAS Positive affect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.52 (8.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.07 (9.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-7.98 (6.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-10.05, -5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-7.779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePANAS Negative affect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.84 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.80 (6.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.49 (8.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.84, 10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTAI Anxiety state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.59 (14.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.47 (11.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.63 (12.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.74, 21.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOMS Anger\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.11 (5.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.23 (2.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.09 (5.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.45, 5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOMS Fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.18 (5.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.85 (6.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.35 (5.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e.62, 4.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOMS Vigour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.36 (4.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.69 (4.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.09 (4.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-5.43, -2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-6.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOMS Friendliness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.54 (4.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.69 (3.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.93 (3.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.02, \u0026minus;\u0026thinsp;.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-3.567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOMS Tension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.29 (6.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.71 (4.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.35 (5.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.71, 7.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.816\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOMS Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.63 (6.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.80 (3.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.53 (6.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.58, 8.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMS Mindf. body\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.22 (5.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.80 (4.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.40 (4.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.66, -1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-3.820\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMS Mindf. mind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.13 (13.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.42 (11.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-8.02 (9.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-10.83, -5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-5.766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main aim of this study was to assess if a FB session could improve several outcomes in individuals with FM and/or SFC, with a particular focus on mental health and well-being. These results are strengthened given the notable clinical severity of the individuals included, with moderate-to-high reported levels of pain and fatigue (cardinal symptoms of FM and CFS/ME), a high rate of recognized disability degree and high depressive and anxious symptomatology. Furthermore, regarding the generalizability of the findings, more than 80% of the participants reported only performing light exercise (such as walking) twice a week, so we can ascertain that they are not only very physically active (a behavioral pattern not usually seen in these conditions) individuals were enrolled in this study.\u003c/p\u003e \u003cp\u003eOverall, the results obtained in this pilot study align with previous studies in Asian and Mediterranean forests and show how FB may help in fostering mental well-being (Hansen et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wen et al. \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Timko Olson et al. \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Muro et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The current study found a decrease in negative affect, state anxiety, anger, fatigue, tension, and depression and an increase in positive affect, vigor, friendship, and mindfulness state in a clinical sample of individuals showing FM and/or SFC/ME. However, contrary to expectations, this study did not find a significant improvement in self-reported pain following the FB session. This study's results also align with previous studies that reported increased well-being after contact with nature, especially following a FB session (Antonelli et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Yang et al. \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Gobster et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Shim et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As these studies suggest, FB might produce its benefits because it would increase exposure to nature, which is related to normalizing the stress-response system. In addition, our results also indicated an increase in state mindfulness, consistent with the \u003cem\u003eAttention Restoration Theory\u003c/em\u003e (Kaplan \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). According to this theory, spending time in nature has health benefits since it decreases attentional fatigue caused by the modern lifestyle. Therefore, the mindful state generated by the FB practice might have enabled individuals to enjoy the present moment and focus on the environment, the exercise or the silent company of other people instead of on their distressing internal states or engaging in ruminating tendencies. Furthermore, our results showed increased friendliness following the FB practice, previously documented in some studies (Jimenez et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Muro et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; McEwan et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In other words, FB may provide a shared experience with a space for socialization in which new bonds and connections may be created, which might increase social support. These findings highlight the potential of FB as a holistic intervention that promotes physical and mental health through exposure to nature and fosters mindfulness and social connection, contributing to overall well-being.\u003c/p\u003e \u003cp\u003eIt is important to note that most of the studies mentioned above have been conducted with healthy populations, often composed of young men and in Asia. Therefore, our results allow us to extend the positive effects of FB to a more specific population: patients with somatic functional syndromes such as FM and CFS/ME from the Mediterranean area. In this sense, our results are consistent with data obtained in the study of Muro et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) in which they concluded that FB in a Mediterranean forest increases psychological well-being in a sample of healthy adults compared to a control hiking group.\u003c/p\u003e \u003cp\u003eTo our knowledge, only one study explored the benefits of walking in a Mediterranean forest among patients with FM. Unlike our study, which lasted only one session and was conducted in a relatively young forest (i.e., due to recent human action (e.g., fires, grassland), most of the mountain range is covered by aleppo pine forests and not by its original coastal holm oak grove forest), the L\u0026oacute;pez-Pousa et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) study explored a two-week intervention in two types of Mediterranean forests (mature and young) among FM patients L\u0026oacute;pez-Pousa et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) concluded that an aerobic exercise program consisting of walking through a forest could reduce FM symptoms. But, only in the mature forest did participants experience a subjective perception of having fewer days of pain and insomnia and more days of wellness. Unlike them, we did not find differences in terms of pain. It could be because our FM session only lasted 3 hours, and perhaps more time is needed to obtain results in this highly resistant clinical outcome. Therefore, the duration of the nature exposure could be a significant factor influencing the effectiveness of the intervention, as it has been previously suggested by (Antonelli et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRegarding the pain outcome, contrary to our results, Han et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) reported changes in pain perception following forest therapy among a sample of adults who suffered from chronic pain. Several differences between our study and the study of Han et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) could explain the discrepancy in the results. The intervention of Han et al. lasted for two days and included other components apart from FB, such as psychoeducation or time for socialization. It is assumed that the FB intervention is more beneficial when combined with other types of activities and when it has a longer duration.\u003c/p\u003e \u003cp\u003eAnother promising result observed after FB was the significant improvement in the CFS/ME core symptom of fatigue (moderate effect size) and, parallelly, the opposite aspect of vigor (large effect size). This result is in line with other research on the benefits of walking in the woods to reduce fatigue in FM and CFS/ME (L\u0026oacute;pez-Pousa et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Zhu et al. \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) Forest bathing, by providing a sensory-rich environment that engages multiple modalities of perception within a natural context in the forest has been shown to stimulate the parasympathetic nervous system and reduce sympathetic activity, resulting in a state of greater well-being and vitality (Siah et al. \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThe present study has some strengths that deserve to be stated. Mainly, the sample size (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;44) was larger than the other study conducted on individuals with FM (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30, L\u0026oacute;pez-Pousa et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and the evaluation protocol included a thorough evaluation of the impact of the FB session at the mental health and well-being level. Furthermore, a multidisciplinary team conducted the intervention, including two specialized psychologists and a mountain guide. However, the present study presents limitations that should also be acknowledged. The first one is not having a control group which impedes establishing causality. The inclusion of a control group (e.g., a psychoeducative control group) will be considered in future studies to assess the intervention's effectiveness. Another consideration was the short duration of the FB protocol (only one session) and the lack of a follow-up assessment to evaluate the stability of the observed improvements. Furthermore, further studies should also consider potential moderators (e.g., gender, age, physical fitness) and mediators (e.g., self-efficacy, self-esteem, nature connectedness) in explaining the beneficial effects of FB. In addition, the sample included only women. Although our results are interesting to generalize those of previous studies that only included males, future studies should extend and compare the benefits of FB in a clinical sample of men and women.\u003c/p\u003e \u003cp\u003eIn conclusion, FB seems an affordable practice that may be useful for managing symptomatology in patients with FM and CFS/ME. Further research is needed to evaluate its effectiveness compared to other therapeutic approaches and to investigate further mechanisms of change associated with FB benefits.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe current study aimed to explore nature's benefits on individuals with FM and/or CFS/ME. The results from this study indicated that a 3-hour session of FB, conducted in a Mediterranean forest in patients with chronic pain and FM, could be beneficial for improving mental health and psychological well-being. FB could be an accessible and low-cost add-on therapeutic program which could be integrated into standard treatments for chronic pain and increase its efficacy and improve psychological distress in chronic pain patients. Further randomized controlled trials will be welcome comparing the effects of FB with other recognized therapeutic approaches for FM and/or CFS/ME (e.g., cognitive behavioral therapy, indoor therapeutic exercise). Furthermore, moderators (e.g., session duration) and mediators of change (e.g., changes in state mindfulness) of FB would be explored in future studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eAF-S and AM acknowledge the funding from the Serra H\u0026uacute;nter program (UAB-LE-8015 and UAB-LE-603, respectively). The project has been funded in part by the Spanish Ministry for Science and Innovation (MCIN) State R\u0026thinsp;+\u0026thinsp;D\u0026thinsp;+\u0026thinsp;I Program Oriented to the Challenges of Society (ref. PID 2020-117667RA-I00) and co-financed with European Union ERDF funds. We are grateful to the CIBER of Epidemiology and Public Health (CIBERESP CB22/02/00052; ISCIII) for its support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAndrade E, Arce C, Torrado J, et al (2010) Factor Structure and Invariance of the POMS Mood State Questionnaire in Spanish. Span J Psychol 13:444\u0026ndash;452. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S1138741600003991\u003c/span\u003e\u003cspan address=\"10.1017/S1138741600003991\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonelli M, Barbieri G, Donelli D (2019) Effects of forest bathing (shinrin-yoku) on levels of cortisol as a stress biomarker: a systematic review and meta-analysis. 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Front Neurol 12:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fneur.2021.619728\u003c/span\u003e\u003cspan address=\"10.3389/fneur.2021.619728\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"fibromyalgia, chronic fatigue syndrome, forest bathing, shinrin-yoku, forest therapy, mindfulness","lastPublishedDoi":"10.21203/rs.3.rs-3088899/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3088899/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Objectives.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main objective of the present study is to assess the short-term effects of Forest Bathing (FB) conducted in a Mediterranean forest on individuals with fibromyalgia (FM) and/or Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) on perceived pain, fatigue, state anxiety, positive and negative affect, mood states, and state mindfulness. \u003cstrong\u003eMethods.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A total of 44 participants with FM and/or CSF/ME agreed to participate in this study. The FB session consisted of a 3km silent walk, lasting three hours long and guided by a specialized psychologist and a mountain guide to guarantee the safety of the activity. Paired-sample \u003cem\u003et\u003c/em\u003e-tests were used to analyze the pre-post changes in perceived pain, fatigue, state anxiety, positive and negative affect, mood states and mindfulness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll reported variables but self-reported pain showed statistically significant pre-post variations after the FB session. Particularly, large-to-very-large improvements in positive and negative affect, state anxiety, tension, depression, anger, and vigor were found. Small-to-moderate effect sizes for fatigue, friendliness and state mindfulness were also reported. \u003cstrong\u003eConclusions.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study provides preliminary evidence of the short-term benefits of FB in individuals with FM and/or CFS/ME, especially on state anxiety and negative affect.\u003c/p\u003e","manuscriptTitle":"The Psychological Benefits of Forest Bathing in Individuals with Fibromyalgia and Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-23 02:34:05","doi":"10.21203/rs.3.rs-3088899/v1","editorialEvents":[{"type":"communityComments","content":3}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c4ae193c-b149-4a01-a9dc-693c4090fe89","owner":[],"postedDate":"June 23rd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-07-07T06:14:28+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-23 02:34:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3088899","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3088899","identity":"rs-3088899","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}