---
title: "Kurort Health Walking in a Forest: Short-Term Physiological and Psychological Effects"
id: "plos-one-3-physiological-and-psychological-outcomes-of-a-community-based-kurort-health"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-3-physiological-and-psychological-outcomes-of-a-community-based-kurort-health"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733"
published_at: "2026-09-03T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Kurort Health Walking in a Forest: Short-Term Physiological and Psychological Effects
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-3-physiological-and-psychological-outcomes-of-a-community-based-kurort-health
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733)
- **Published At:** 2026-09-03T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This single-group before–after study evaluated short-term physiological and psychological changes in adults participating in a community-based **Kurort Health Walking** program conducted in forested courses in Saikai City, Nagasaki, Japan. - Ninety participants were enrolled between March 2024 and March 2025; 89 completed the walking session and were included in analyses of blood pressure, pulse rate, and mood. Autonomic data were available for 87 participants. - The two certified Kurort courses (Shihondo Park, 1.83 km, 74 m gain; Isanoura Park, 2.1 km, 73 m gain) used the same 120-minute protocol including warm-up, guided walking with target pulse monitoring, and cool-down. - Primary physiological outcomes: mean **systolic blood pressure** fell from 127.2 ± 15.9 mmHg to 120.6 ± 15.5 mmHg (mean difference −6.6 mmHg, p < 0.001); **diastolic blood pressure** fell from 81.2 ± 12.5 mmHg to 76.3 ± 13.8 mmHg (mean difference −4.9 mmHg, p < 0.001). Pulse rate did not change significantly. - Sensitivity analysis excluding participants on antihypertensive medication showed similar SBP and DBP reductions. Baseline values and principal outcome changes did not differ materially between the two courses, so data were pooled. - Autonomic measures (LF/HF ratio and **HF power**) recorded at four standing measurement points during the walk showed no significant changes across time points. Measurements used a non-contact RGB facial video application previously validated under controlled conditions. - Psychological outcomes improved: POMS2 T-scores showed significant decreases in negative mood subscales (anger-hostility, confusion-bewilderment, depression-dejection, fatigue-inertia, tension-anxiety, and total mood disturbance) and increases in vigor and friendliness. MCL-S.2 scores showed increased Pleasure and Relaxation and decreased Anxiety. - The authors note the absence of a control group, so the independent effects of the forest environment, physical activity, and contextual factors could not be separated. Other study details: ethics approvals, STROBE reporting, and open data availability were documented.
## Clinical Analysis & Structured Key Points
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[](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733) [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733) * 0 [Save](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#savedHeader) * 0 [Citation](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#citedHeader) * 22 [View](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#viewedHeader) * 0 [Share](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733#discussedHeader) Open Access Peer-reviewed Research Article # Physiological and psychological outcomes of a community-based Kurort Health Walking program: A before–after study * Saori Miura , Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing * E-mail: saori.m@nagasaki-u.ac.jp Affiliation Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto, Nagasaki, Japan [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0004-6203-3737 ](https://orcid.org/0009-0004-6203-3737 "ORCID Registry") ⨯ * Shinji Horikawa, Roles Investigation Affiliation Faculty of Nursing, St. Mary’s College, Kurume, Fukuoka, Japan ⨯ * Kana Morizono, Roles Investigation Affiliation Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto, Nagasaki, Japan ⨯ * Miyu Miyazaki, Roles Investigation Affiliation Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto, Nagasaki, Japan ⨯ * Hiroki Torii, Roles Investigation Affiliation Faculty of Health Sciences, Junshin Gakuen University, Minami-ku, Fukuoka, Japan ⨯ * Hiromi Kuroda, Roles Writing – review & editing Affiliation Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto, Nagasaki, Japan ⨯ * Emi Matsuura Roles Investigation, Methodology, Writing – review & editing Affiliation Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto, Nagasaki, Japan ⨯ # Physiological and psychological outcomes of a community-based Kurort Health Walking program: A before–after study * Saori Miura, * Shinji Horikawa, * Kana Morizono, * Miyu Miyazaki, * Hiroki Torii, * Hiromi Kuroda, * Emi Matsuura ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: September 3, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0357733) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357733) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357733) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0357733) * [Peer Review](https://journals.plos.org/plosone/article/peerReview?id=10.1371/journal.pone.0357733) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#abstract0) * [Introduction](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec005) * [Materials and methods](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec006) * [Results](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec018) * [Discussion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec022) * [Conclusions](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec026) * [Supporting information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec027) * [Acknowledgments](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#ack) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357733) * [Figures](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733) ## Abstract ### Objective This study aimed to evaluate short-term physiological and psychological changes associated with participation in a community-based Kurort Health Walking program conducted in a forest environment. ### Patients and methods This study was conducted as part of a public health program in Saikai City, Nagasaki, Japan. A total of 90 participants who attended certified Kurort Health Walking courses between March 2024 and March 2025 were included. Physiological parameters, including systolic and diastolic blood pressure and pulse rate, and psychological status were assessed before and after the walking session. Autonomic nervous activity was evaluated using heart rate variability indices, including the low-frequency/high-frequency ratio and high-frequency power, measured at four time points before, during, and after the walk. Mood states were assessed using validated questionnaires. ### Results Systolic and diastolic blood pressure decreased significantly after the walking session (p < 0.001). Neither the low-frequency/high-frequency ratio nor high-frequency power showed significant changes across the measurement points. Negative mood states decreased significantly, whereas positive mood states, including vigor, friendliness, pleasure, and relaxation, increased, and anxiety decreased after walking (p < 0.001). ### Conclusion Participation in the community-based Kurort Health Walking program was associated with short-term changes in physiological and psychological measures. However, because this study did not include a control group, the independent contributions of the forest environment, physical activity, and other contextual factors could not be distinguished. ## Figures ![Fig 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g004) ![Table 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t004) ![Table 5](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t005) ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g002) ![Fig 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g003) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t002) ![Table 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t003) ![Fig 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g004) ![Table 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t004) ![Table 5](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.t005) ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g002) ![Fig 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g003) **Citation:** Miura S, Horikawa S, Morizono K, Miyazaki M, Torii H, Kuroda H, et al. (2026) Physiological and psychological outcomes of a community-based Kurort Health Walking program: A before–after study. PLoS One 21(9): e0357733. https://doi.org/10.1371/journal.pone.0357733 **Editor:** Hidetaka Hamasaki, Japanese Academy of Health and Practice, JAPAN **Received:** June 10, 2026; **Accepted:** August 20, 2026; **Published:** September 3, 2026 **Copyright:** © 2026 Miura et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** The minimal dataset underlying the findings of this study is provided as [Supporting information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#sec027) ([S1 Data](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.s003)). **Funding:** The author(s) received no specific funding for this work. **Competing interests:** The authors have declared that no competing interests exist. ## Introduction Currently, more than half of the global population resides in urban areas, and this trend is projected to continue [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref001)]. Urbanization has exposed individuals to chronic overstimulation and hectic lifestyles, raising concerns about its impact on mental health and cardiovascular disease [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref002),[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref003)]. Simultaneously, in rural areas, decreased physical activity due to automobile dependence has been linked to obesity and an increased risk of lifestyle-related diseases [[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref004)]. In this context, contact with nature is recognized as an essential means of stress recovery and health maintenance [[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref005),[6](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref006)]. Thus, supporting health maintenance and promotion through natural environments is essential across populations in contemporary societies. Activities in forest environments have been shown to improve cardiovascular function, such as lowering blood pressure and stabilizing heart rate, as well as to reduce stress, depressive symptoms, and anxiety [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref007),[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref008)]. In Germany, naturopathy, including forest therapy, is integrated into the public medical system and is implemented within an internationally advanced framework [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref009),[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref010)]. In Japan, “Kurort Health Walking,” based on the German Kurort system but adapted to the Japanese climate, culture, and national character, has gained significant attention [[11](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref011)]. Kurort is derived from the German words _kur_ (cure, recuperation, or stay for health) and _ort_ (place or region). Kurort Health Walking differs from typical walking in its emphasis on walking on sloped or sandy terrain, maintaining a sensation of slight coolness (cold air), avoiding excessive increases in heart rate, and experiencing natural elements such as wind and light [[12](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref012),[13](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref013)]. Previous studies have suggested that Kurort Health Walking significantly reduces systolic blood pressure (SBP) and diastolic blood pressure (DBP) [[14](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref014),[15](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref015)] and improves emotional states by reducing anger and depression while increasing vigor, pleasure, and relaxation [[14](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref014)–[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref017)]. Furthermore, while the highest efficacy is observed on sunny days, certain benefits, such as improved relaxation and reduced anxiety, are maintained even in rainy conditions [[18](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone.0357733.ref018)]. Although previous studies have reported improvements in blood pressure and psychological outcomes following Kurort Health Walking, little evidence is available regarding autonomic nervous system responses, particularly heart rate variability indices such as the low-frequency/high-frequency (LF/HF) ratio and high-frequency (HF) power in real-world community settings. Evaluating autonomic nervous activity during community-based Kurort Health Walking programs may provide additional objective evidence regarding physiological responses associated with participation in natural environments. Therefore, this study aimed to investigate short-term physiological and psychological changes associated with participation in a community-based Kurort Health Walking program conducted in forest environment. Specifically, physiological indices, including blood pressure, pulse rate, and autonomic nervous system activity, as well as psychological outcomes, were evaluated before and after the walking session. Evaluating these physiological and psychological changes may contribute to a better understanding of the short-term responses to community-based walking programs conducted in forest environments. ## Materials and methods ### Study design and participants This study was conducted as a single-group observational pre–post study within an existing public health program implemented by the local government. Participants were recruited through the Saikai City Public Relations Magazine, the official municipal website, and the Nagasaki Prefecture walking application. Adults who voluntarily participated in one of two certified Kurort Health Walking courses organized by Saikai City, Nagasaki Prefecture, between March 20, 2024, and March 30, 2025, were included in this study. Individuals who were unable to complete the walking course or who declined to participate were excluded from the study. No restrictions were placed on previous participation history, medication use, or underlying diseases. Participation was limited to one session per course for each participant. Prior to the start of the study, the objectives and procedures were explained to all participants both orally and in writing, and written informed consent was obtained. ### Study fields This study was conducted on two courses certified as “Kurort paths” by the Japan Kurort Research Institute in Saikai City. #### Shihondo Park course. The Shihondo Park course is 1.83 km long with a cumulative altitude gain of 74 m. It is characterized by its location at the tip of the peninsula, surrounded by the sea on three sides, offering an expansive view ([Fig 1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone-0357733-g001)). [![thumbnail](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g001)](https://journals.plos.org/plosone/article/figure/image?size=medium&id=10.1371/journal.pone.0357733.g001 "Click for larger image") Download: * [PNG larger image](https://journals.plos.org/plosone/article/figure/image?download&size=large&id=10.1371/journal.pone.0357733.g001) * [TIFF original image](https://journals.plos.org/plosone/article/figure/image?download&size=original&id=10.1371/journal.pone.0357733.g001) Fig 1. Map of the Shihondo Park course. The course has a total length of 1.83 km and a cumulative altitude gain of 74 m. Situated at the tip of a peninsula and surrounded by the sea on three sides, the course offers an expansive view. Base map and data from OpenStreetMap and OpenStreetMap Foundation. The walking route was added by the authors. [ https://doi.org/10.1371/journal.pone.0357733.g001](https://doi.org/10.1371/journal.pone.0357733.g001) #### Isanoura Park course. The Isanoura Park course is 2.1 km long with a cumulative altitude gain of 73 m. It passes through lush natural forests surrounding a dam lake upstream of the Isanoura River and features seasonal changes in scenery ([Fig 2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357733#pone-0357733-g002)). [![thumbnail](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357733.g002)](https://journals.plos.org/plosone/article/figure/image?size=medium&id=10.1371/journal.pone.0357733.g002 "Click for larger image") Download: * [PNG larger image](https://journals.plos.org/plosone/article/figure/image?download&size=large&id=10.1371/journal.pone.0357733.g002) * [TIFF original image](https://journals.plos.org/plosone/article/figure/image?download&size=original&id=10.1371/journal.pone.0357733.g002) Fig 2. Map of the Isanoura Park course. The course has a total length of 2.1 km and a cumulative altitude gain of 73 m. The route passes through lush, natural forests surrounding the dam lake upstream of the Isanoura River, offering attractive scenery that changes with the seasons. Base map and data from OpenStreetMap and OpenStreetMap Foundation. The walking route was added by the authors. [ https://doi.org/10.1371/journal.pone.0357733.g002](https://doi.org/10.1371/journal.pone.0357733.g002) ### Walking protocol The Kurort Health Walking sessions were conducted under the guidance of two certified health and exercise trainers. The same walking protocol was applied to both courses. Each session lasted approximately 120 minutes, including warm-up exercises, the walking session, and cool-down exercises after returning to the starting point. Participants monitored their pulse rate (PR) by manual palpation at designated points along the course to maintain the target exercise intensity. The target PR was set at “160 – age” (corresponding approximately to 55%–60% of the age-predicted maximal heart rate), with the target PR reduced by 10%–20% for those rec
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