horticultural therapy has beneficial effects on brain functions in cerebrovascular diseases

8/4/2019 Horticultural Therapy has Beneficial Effects on Brain Functions in Cerebrovascular Diseases

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Vol. 2, No. 3, Page 169-182Copyright 2008, TSI Press

Printed in the USA. All rights reserved

Horticultural Therapy has Beneficial Effectson Brain Functions in Cerebrovascular

DiseasesYuko Mizuno-Matsumoto

*,1, Syoji Kobashi

2, Yutaka Hata

2, Osamu Ishikawa

3, and

Fusayo Asano4

1University of Hyogo, Graduate School of Applied Informatics, Kobe, JAPAN

2University of Hyogo, Graduate School of Engineering, Himeji, JAPAN

3Ishikawa Hospital, Himeji, JAPAN

4Tokyo University of Agriculture, Department of Bio-therapy, Faculty of Agriculture, Tokyo,

JAPAN

Received 15 May 2008; accepted 30 June 2008

AbstractHorticultural therapy (HT) is gaining attention as a form of rehabilitations in medical fields

especially such as occupational therapy and nursing care, although its effectiveness has not been

proven yet. This paper uses a strictly medical point of view to assess whether or not HT is effective

for improvement of functional activities in the brains of brain-damaged patients. Five patients in

Ishikawa Hospital with cerebrovascular diseases were invited to participate in HT for a month in

addition to their routine medication and physical therapy (PT). The HT program was designed by

horticultural therapists. The original purpose of the HT program was to monitor its effects on mental

healing, cognitive re-organization, and training of sensory-motor function. The Functional

Independence Measure (FIM) and the Self-Rating Depression Scale (SDS) were performed before

and after HT to assess the patients physical activities of daily living (ADL) and to determine the

patients mental changes in depressive states, respectively. Functional magnetic resonance imaging

(fMRI) during recognition tasks was also measured before and after HT. The ADL of all patientssignificantly improved after HT; however, the depressive states in all patients did not changeremarkably after the HT. fMRI examinations showed that the visual area, the inferior temporal area,

the fusiform gyrus, and the supramarginal gyrus (SMG), in addition to the motor area, thesupplementary motor area (SMA), the sensory area, and the cerebellum were activated after HT.

These findings suggest that HT can accelerate an improvement of activities in the visual and colorprocessing areas and the association areas as well as the sensory-motor areas of the brain in the

patients with cerebrovascular diseases. HT, therefore, stimulates parts of brain, that are not alwaysevoked through routine physical rehabilitation. HT can complement the routine physical

rehabilitation and help to improve damaged brain function.

*Corresponding author information:

Yuko Mizuno-Matsumoto, M.D., Ph.D. (Medicine & Engineering)

Graduate School of Applied Informatics, University of Hyogo

Kobe Harborland Center Bldg. 22F, 1-3-3 Higashi-Kawasakichou, Chuo-ku, Kobe, Hyogo 650-0044, JAPAN,

TEL/FAX: +81-78-367-8616/+81-78-362-0651, [email protected]


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KeywordsHorticultural therapy (HT), fMRI, Supramarginal gyrus (SMG), Visual area, Cerebrovascular

disease, Functional independence measure (FIM)

1. INTRODUCTIONHorticulture is defined as the art and science ofgrowing flowers, fruits, vegetables, and trees

and shrubs resulting in the development of the

minds and emotions of individuals and the

enrichment and health of communities

civilization [1]. Horticultural therapy (HT) is a

remedial process in which plants and

gardening activities are used to improve the

body, mind, and spirits of people [2]. HT is

thought to be an effective and beneficial

treatment for people of all ages, backgrounds,

and abilities. The therapeutic benefits of

peaceful garden environments have beenunderstood since ancient times. In the 19th

century, Dr. Benjamin Rush, a signer of theDeclaration of Independence considered to be

the Father of American Psychiatry, reportedthat garden settings held curative effects for

people with mental illness [2].

Soderback reviewed the literature on HT and

described its use in rehabilitation followingbrain damage [3]. He showed that HT affected

emotional, cognitive and/or sensory motor

functional improvement and increased social

participation, health, well-being andsatisfaction with life. Jones and Haight

reviewed articles on the use of the natural

environment in the form of plants or plant

material as therapeutic interventions [4]. They

showed that there was a beneficial relationship

between humans and the natural environment

in the current therapeutic uses.

Although HT has been strongly advocated, its

effect is less established. Most papers on HT

have been reported from the view of

occupational therapy and nursing care.

Therefore, the effectiveness of theseinterventionist approaches from the medical

point of view remains to be proved, and it

would have been desirable to perform

subjective assessment of the approaches.

Ulrich [5] reported the positive influence of

nature on patients in the hospital. Surgicalpatients assigned to rooms with windows

looking out on a natural scene had shorter

postoperative hospital stays, received fewer

negative evaluative comments in nurses notes,

and took fewer potent analgesics than patients

in similar rooms with windows facing a brick

wall.

Ulrich et al. showed that influences of nature

could reduce the emotional, attentional, and

physiological aspects of stress using the

Zuckerman Inventory of Personal Reactions

(ZIPERS), which is questionnaire using affects(subjective aspects of feeling or emotion) toassess feelings [6]. Ulrich et al. also measured

physiological reactions using anelectrocardiogram (ECG), pulse transit time,

spontaneous skin conductance response, andfrontalis muscle tension using an

electromyogram (EMG), and documented

physiological changes related to recovering

from stress, including low blood pressure,

reduced muscle tension, and differences in

cardiac responses.

Soderback indicated that HT could categorizefour different intervention approaches:

virtual, viewing, interaction, and

action [3]. In the routine occupational or

physical therapies, a patient executes actions

only according to the therapists instruction.

On the other hand, in HT the patient can

objectively imagine the growth of vegetation in

his or her own way, actually see that the

vegetation is growing and simultaneously

perform his/her own activities as

rehabilitations. Ulrich suggested that the

benefits of nature such as trees and other

vegetations were positive influences on

emotional and physiological states of the

people, and the benefits came from visualencounters with nature from urban planning

point of view [7].


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We have investigated the effectiveness of HT

on the hypotheses that (1) imagination,

observation, and participation in growing

vegetation makes a positive effect on a

patients actual activities, and (2) viewing

colorful vegetation in nature under sunlight

improves the visual abilities in the brain. Toprove these hypotheses, we designed

experimental fMRI protocols that reveal

visual, recognitional, motor, and emotional

functions/abilities. In addition, we used the

questionnaires to measure the activities of

daily living (ADL) and the mental mood of thepatients.

The aim of this paper is to assess whetherhorticulture therapy is effective for

improvement of brain functional activity inbrain-damaged patients from the medical point

of view.

2. METHODSCase #1 was a 75-year-old right-handed male

patient who had suffered a right internal

carotid artery occlusion and had left

hemiplegia and dysarthria. Case #2 was a

42-year-old right-handed male patient who had

suffered a left cerebral infarction and had right

hemiplegia and aphasia. Case #3 was a

60-year-old right-handed female patient who

had suffered a right anterior cerebral artery

occlusion and had left hemiplegia. Case #4 was

a 56-year-old right-handed male patient who

had suffered right thalamic bleeding and had

left hemiplegia. Case #5 was a 68-year-old

right-handed female patient who had suffered

bleeding in the right frontal lobe and had left

hemiplegia and dysarthria. Written informed

consent was obtained from all subjects and

patients after a detailed briefing of the

experimental purposes and protocol.

The functional independence measure (FIM) is

an evaluation tool used to quantify the ability

of patients to enter rehabilitation treatment andto chart their progress until discharged into the

community or to another facility [8]. The FIMis an assessment instrument rating a patients

level of function in 18 physical and mentaltasks that represent the basic ADL. The total

score rage is from 18 as a perfect dependent to

126 as a perfect independent. There are 13

motor items ranging from 13 to 91 (eating,

grooming, bathing, dressing the upper body,

dressing the lower body, toileting, bladder and

bowel management, transfers to bed/chair,

toilet and tub/shower, walking/wheelchair, and

stair climbing) and 5 cognitive items rangingfrom 5 to 35 (comprehension, expression,

social interaction, problem-solving, and

memory). Each patients FIM was scored at the

beginning and ending of the HT to assess levels

of ADL.

All patients were evaluated as to whether or notthey suffered from depression, based on the

DSM IV-TR (Diagnostic and StatisticalManual of Mental Disorders Fourth Edition

TR) criteria. A medical doctor also evaluatedmental status using indicators such as mood,

motivation, communication, and expressionwith an observational study. Moreover, the

Self-Rating Depression Scale (SDS) was used

to evaluate not only depression but also the

patients depressive states influenced by

their mental mood. All patients were rated

using the SDS in scoring only 20 items of the

questionnaire. The relationship between mean

SDS score of patients and diagnosis of major

depression was reported [9]. This report

showed that the SDS had a sensitivity of 80

percent and specificity of 88 percent for

detecting patients with major depression. TheSDS was performed before and after the HT to

assess changes in depressive state. The SDS

score ranged from 20 to 80. A score of more

than 50 is supposed to show the possibility of a

severe depressive state (possibility of severe

major depression is high), and a score of 40-50

is supposed to show a moderate depressive

state (possibility of a moderate depression ishigh).

Five patients were invited to participate in HTdesigned by horticultural therapists for a month

in addition to the routine medical and physicaltreatment given in Ishikawa Hospital. The

purpose of HT program was to bring abouteffects in mental healing, cognitive

re-organization, and training of sensory motor

function. The HT consisted of three steps:

imagining nature, designing a flowerbed, and


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actually planting a tree. The therapists

instructed the patients in all these processes.

Table 1 shows an example of the HT program

for each session in Case #2. The subject was

able to experience the whole process of

growing flowers including designing a garden,

creating a planting plan, preparing a flowerbed

for seeding, seeding, watering, and making

pressed flowers from his/her own flowers from

the flowerbed. It took about a month to

complete this process. Figure 7 in the

Appendix shows some pictures of scenes from

HT programs in Table 1.

Table 1. Horticultural Therapy Program for Case #2.

Session Description of Programs

1 Flowerbed preparation (weeding)

2 Flowerbed preparation (weeding)

3 Readying the soil

4 Creating a planting plan for flowerbeds

5 Briefing on future activities and selecting seedling

6 Cultivating

7 Terrarium making

8 Planting to the flowerbed according to plan

9 Planting seedling to flowerbed10 Soil readying, watering, and dividing seedling

11 Watering, and picking up withered flowers

12 Doing crafts using moss, and watering

13 Watering

14 Planting vegetables, weeding, dividing

15 Making name plates for the flowerbeds

16 Watering and weeding

17 Watering, weeding, and appreciating other patients flowerbeds

18 Making a container garden

19 Making pressed flowers

20 Working in the garden

Functional magnetic resonance imaging

(fMRI) under recognition tasks was measured

before and after HT. The experimental fMRI

protocols were designed to reveal the

hypotheses on the effectiveness of HT as we

mentioned in Introduction. In the other words,

viewing, recognition, movement, and the

emotional functions/abilities of the patients

were trying to be clarified. Subjects performed

two kinds of tasks, in which they fixated on an

image and categorized it into a pleasant

image or an unpleasant image based on theprevious instructions for each trial. Imagesincluded two kinds of emotional photos: a

girls smiling facial expression (pleasant) or anangry facial expression (unpleasant) in task 1,

and a healthy forest landscape (pleasant) or a

dying forest (unpleasant) in task 2. Each trial

involved the consecutive presentation of the

photos for 2 seconds proceeded by a crosshair

image for 20-30 seconds (Figure 1). Subjects

were instructed to fixate on a photo, and judge

whether or not the photo was pleasant by

moving their right index finger, or unpleasant

by moving both the right index and middle

fingers. Each task consisted of 20 blocks, half

of which were pleasant, and half of which were

unpleasant. Photos were randomly orderedwithin each task. The duration of each task was516 seconds. In the study, five patients

performed this experimental protocol using thefMRI scanner before and after HT.


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Figure 1. Schematic diagram of fMRI measurement task.

MR images were acquired on a 1.5 Tesla

SIGNA CV/i scanner (GE Medical Systems,

Milwaukee, WI). After initial acquisition of T1

structural images, echo planar imaging (EPI)

was used to acquire data sensitive to the BOLD

signal at a repetition time (TR) of 2000 ms andan echo time (TE) of 40 ms. High-resolution

T1 images were acquired to aid in anatomic

normalization. The spatial resolution of BOLD

images was set by a 64 by 64 voxel matrix

covering 260 260 mm2

with a 5 mm slice

thickness. The image gave an in-plane

resolution of 4.06 by 4.06 mm2. Twenty axial

slices with 5 mm thickness were acquired to

cover the whole brain. During the data

acquisition, 258 images (phases) per slice were

obtained in 516 seconds (= 258 x 2.0 sec). This

produced a 4-D dataset consisting 64 64 20 258 voxels, in which a voxel is referred to as

(x, y, z, t).

Data analysis was performed with the

Statistical Parametric Mapping analyticpackage (SPM5, Wellcome Department of

Cognitive Neurology, London, UK). In the

first step, we identified regions that showed

significant activation during the pleasant or

unpleasant images compared to those during

the crosshair image. Activations were reported

if they exceeded p < 0.05 (uncorrected) on thesingle voxel level in each patient. We showed

images of the activation areas before and after

HT. In the next step, the differences between

the images before and after HT were calculated

using the t-statistic, and contrast maps were

generated for each patient. We extracted the

increased areas in activity after HT compared

to those before HT in each patient (p < 0.1). In

the figures the areas in which activation

decreased or did not change after HT were

omitted.

3. RESULTSThe doctors clinical observations of the whole

process left the impression that all the patientsexpressions and motivation had improved after

the HT.

1 block

20 blocks (516 sec)


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Table 2 shows date information of subjects:

onset of disorders, beginning of general

rehabilitation, beginning of HT, first, before

HT and second, after HT measurement of

fMRI. HT began 6 months after the onset of

disorder in Case #1 and 2 years and 8 months

after the onset in Case #2 although HT began

2-3 months after the onsets in Cases #3, #4, and

#5.

Table 2. Date Information of subjectsCase #1 Case #2 Case #3 Case #4 Case #5

Onset of disorder 12/6/2003 10/1/2001 6/28/2004 6/21/2004 1/26/2005

Beginning of rehabilitation 4/22/2004 4/2/2002 7/27/2004 8/14/2004 3/11/2005

Beginning of HT 6/8/2004 6/8/2004 9/25/2004 9/25/2004 4/4/2005

First trial 6/1/2004 6/1/2004 9/25/2004 9/25/2004 4/4/2005fMRI

Second trial 7/16/2004 7/16/2004 10/25/2004 10/25/2004 5/19/2005

Table 3 shows the total scores of FIM before

and after the HT. The scores of motor and

cognitive items are also shown in the table. The

total scores of all the cases after HT aresignificantly larger than those before HT

(paired T test: p < 0.03). The scores on motor

items of all cases after HT are also significantlylarger than those before HT (paired T test: p

horticultural therapy has beneficial effects on brain functions in cerebrovascular diseases

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