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Figure 1
The Danderyd Hospital Horticultural Therapy Garden (DHHTG). A—H are plant-grounds with various heights; A
¼
ground level,
B
¼
variable level 20–75 cm, C
¼
68 cm, D
¼
60 cm, E
¼
40 cm, G
¼
85 cm, H
¼
70 cm, I
¼
water pond with a waterfall, J
¼
a garden tool shed,
K
¼
15 m
2
greenhouse and L
¼
water reservoir.
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and are slightly inclined to avoid slippery surfaces,
(c) there is enough space between the plant beds to
allow two wheelchairs to meet easily.
In one corner of the garden is a long, 108-square-foot
tool-shed with a sedum covered roof and two compost
bins. The tool-sheds are well stocked with gardening
tools and other material. The placing of each tool is
marked with symbols, for easy finding and replacement,
and at a height reachable by all users. The hooks for
hanging the tools on are designed for ease of handling.
Another part of the garden is screened off by a
robust, 2 metre-high, 6 metre long trellis, serving as an
aid to standing. A 160-square-foot round greenhouse
allows cultivation experiments protected from the
Nordic climate. A pond and a waterfall heighten the
natural impression. Nearby garden furniture invites
one to relax, calm down and be sociable. A boule
track encourages activity.
The bedding areas and flowerbeds have five different
working heights allowing various working positions
(e.g. standing up, bending or sitting). The highest bed-
ding areas are tables, which a wheelchair user can drive
beneath and round. A wooden bench for sitting and
resting and for putting material down on surrounds
the larger bedding areas. There is an electric point on
the shed wall. Watering is performed from a tap on the
shed or from a covered water tank with a tap [28].
Design of gardening tools for the DHHTG
Ergonomically [98], the DHHTG seeks (a) to use the
most ergonomical garden tools for the various elements:
digging, cultivating, sowing, planting, watering, raking,
loosening or breaking up weeds, trimming or cutting,
cutting faded or fresh flowers and vegetables, mowing
grass, moving garden material, tools and oneself about,
covering new plants [25] and (b) the most appropriate
ergonomical body positions.
Most DHHTG garden tools (the plant/beds out, try or
tables, mini-garden-house-boxes; watering cans, various
types of spade, rake, pitchfork, pruning shears, wheel-
barrow, carts or baskets and/or aprons with big pockets
for tools and material and for protection gloves) were
available on the market. However, the selections were
based on principles of occupational-therapy ergonomics
[98] and adapted for use among patients with neuromus-
culoskeletal and movement-related impairments.
The ergonomics included the principles that [24, 28]:
(a) all tools were as light as possible (figure 2a),
(b) tools with separate handles are used to facilitate
the adaptation of exchangeable handles. This
allows adaptation to the individual patient’s need
for purposeful training (figure 2b),
(c) the tool allows optimal biomechanical body posi-
tions (e.g. suitable handle lengths for sitting or
standing working positions) (figure 2c),
(d) the design permits the lowest possible workload
(e.g. less muscle strength is required when both
hands and one foot are used for making holes in
hard earth and with a curved rake handle) (figure
2d),
(e) the tools useable with a two-hand-grip by people
with a weak or paretic arm and hand (figure 2e),
(f) the angle between the tool head, e.g. spade and
handle allows optimal work functions—a neutral
body position in the forearm when gripping (figure
2f), and
(g) wooden tool-handles designed to suit various grip
functions and functional use and in neutral hand
positions (figure 2g).
Cultivating in the DHHTG
Different methods and materials are used for
cultivating, where possible at different heights and
reachable from some distance. Examples are (a) the
use of raised cultivation beds, (b) movable mini-hot-
houses and hot-beds, (c) square-foot cultivation in
frames or (d) cultivation directly in a sack at ground
level near the trellis, (e) in a box, (f) in pots arranged
in a rotation system or (g) in a hanging pipe or
basket [28].
Seeds for the DHHTG
Seeds and plants were chosen to reflect the various
therapeutic approaches described in table 1.
Participants in and organization of DHHTG gardening
Participants
. The patients, aged 18–65 years, taking
part in the Danderyd hospital horticultural therapy
rehabilitation suffered from pain- or movement-related
impairments (hemiparesis or paraplegia) and/or cogni-
tive (speaking, reading spatial orientation, memory
dysfunction, attention, concentration and logical
reasoning difficulties) and/or were depressed. Disabil-
ities ranged from major to minor insufficiency. Thus,
some patients were wheelchair users, but others had a
major memory disability with no movement-related
disability. Patients’ families and friends and staff were
also welcome to participate.
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Organization
. The patients gardened as one of several
self-chosen activities during the sessions. These were
organized in groups whose composition changed at
intervals during the term. The organization and
participants are shown in table 2. From February to
mid-November 2003, 72 patients (23 men) suffering
from brain damage (e.g. stroke, haemorrhage, brain
trauma), aged 18–65 years, participated in one of
three gardening groups. Each patient participated as a
group member, but was prescribed individual garden-
ing work: his or her ‘therapeutic tonic’. This
individual work was intended to be done at other
times than the group meetings.
All the gardening tasks were performed in a neutral
way. They were graded from easiest to most difficult.
For example, the patient was asked to plan a flowerbed
with only one plant species. The degree of difficulty of
this activity increased when the same flowerbed was to
be planned for year-round flowering with spring tulips,
early summer herbs, summer flowers and finally autumn
flowers for drying.
Therapeutic use of the DHHTG
. As indicated above,
the DHHTG gardening concept was used as a tonic.
The therapeutic purposes were individualised to one
or a combination of (a) mental healing, (b) recreation,
(c) social interaction, (d) sensory stimulation, (e)
cognitive re-organization, (f) sensorymotor function,
(g) assessment of pre-vocational skills and (h) teaching
of ergonomical body positions.
The DHHTG as a place for mental healing
. It was pre-
sumed that time regularly spent in the DHHTG may
positively influence visitors’ minds and may cure or
alleviate physical illness [99], especially among those
with severe brain damage. The DHHTG was a
favourable place frequently visited for resting, medita-
tion and relaxing relief; or for meeting family and
friends in a non-hospital environment. There are many
fragrances in a garden regardless of season, affording
topics for conversation and prompting memories.
Grass and dew, flowers and berries, these things are
Figure 2
a. Lightweight garden tools are required, e.g. from the left: Lightweight (3.8 kg) wheelbarrow in cloth, with raised handles for optimal
ergonomic standing or walking position; Medium-weight (about 9 kg) ‘easy wheelbarrow’ can be pushed or pulled with one hand (in hemiparesis);
Standard weight (about 12 kg) wheelbarrow shown for comparison. b. Garden tools with detachable handles allow individual adaptation. c. Suitable
tool lengths facilitate optimal biomechanical body positions such as standing and sitting. Marks for easy lengthening or shortening of telescopic
handle. d. Garden tools should facilitate as low a work load as possible. For example digging is facilitated when both hands and one foot. e. Garden
tools adapted for use with a two-hand-grip. Slings can be added to afford a useful grip for weak arm and hand muscles. f. Garden tools for work in a
neutral body position are recommended, for example gripping the handle of this cultivator. g. The handles of these garden tools are enlarged with
soft plastic, decreasing the grip muscle strength required.
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often connected to events of long ago. For a while
these environmental perceptions may help the patients
to forget his/her disabilities and concern about the
future.
The DHHTG garden and gardening for recreation
.
These were used for patients undergoing a transition
from working life to a life with decreased oppor-
tunities to carry on with previous leisure activities.
Gardening was presented as a new leisure activity,
available despite present disabilities. Any gardening-
associated activity was counted, such as sitting and
looking, walking, eating, talking, sunbathing, reading,
listen to music, playing games in the garden, which
the patients did for pleasure [3, 100]. It was presumed
that the patients’ participation in gardening would
Table 2
Organization of the DHHTG during a year (2003)
Time Group Participants
Meetings
per week
Total number
of meetings
5 February–15
November 2003
Morning group 12 men, 12 women
(wheelchair users=3)
One per week 30
16 April–27
August 2003
Afternoon group 7 men, 5 women
(wheelchair users=0)
One per week 13
30 June–15
August 2003
Summer group 7 men, 3 women
(wheelchair users=1)
Three per week 21
Table 1
Examples of the DHHTG seed or plant material, its purposes and main therapeutic usefulness
Main therapeutic use Purposes of the seed or plant material
Examples of seed or plant material
used (Latin names)
Mental healing, recreation,
cognitive re-organization
Good germinativeness Calendula officinalis
Suitable hardiness for the climate zone Tagetes
Well-known and therefore enables patients to
recognize the plants and flowers used for
square cultivation
Impatiens walleriania
Cognitive re-organization; memory
stimulation
Arouse childhood memories Tropaeolum pereqrinum
Antirrhinum majus
Raphanus satiuus
Mental healing, recreation, social
interaction
Beautiful colour Impatiens hawkeri (red, pink,
white, violet)
Sensory stimulation Wonderful scent Lathrus adoratus
Heliotropium arborescens
Nicotiana sylvestris
Matthiola
Teaching of ergonomic body
positions
Climbing plants and low height placing allows work
with different body positions at the same time
Nicotiana sylvestris
Ipomea tricolor
Cosmos bipinnatus
Helianthus annuus
Social interaction, cognitive
re-organization, training of
sensory-motor function,
teaching of ergonomical
body positions
Vegetables for use in the kitchen designed
for ADL training
Anethum gravealen
Petrose linum (Crispum
Lactuca (sativa)
Beta vulgaris
Sensory stimulation Seeds of various sizes, form, surface Pelargonium

hortorum
Senecio sineraria
Social interaction, pre-vocational
skills assessment
Fast-germinating seed for a new collection
every autumn
Tropaeolum
Calendula officinalis
Phaseoulus occineus
Tagets ‘Silvia’
Non-specific Seeds from exotic plants for use in the garden house Physalis peruriana
Citrus
Non-specific Seeds for Swedish cultural plant species Linum (usitatissimum)
Recreation, leisure activity According to patient’s wishes
Cognitive re-organisation Reading instructions and interpreting the pictures
on seed packets
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involve, amuse and satisfy them, give them pleasure
and promote their creativity and wellbeing. In addi-
tion, the garden flowers may inspire patients to try
other leisure activities such as painting or painting
therapy. Other patient groups aimed for transition of
new leisure activities using the flowers and harvest for
floral decoration and cooking.
DHHTG gardening for social interaction
. Participation
in a gardening group was also prescribed for its
associated psychosocial benefits. It was presumed that
patients’ interpersonal relations would be strengthened
through mutual communication about the DHHTG
work and observable in an increased sense of self-
worth, the release of hostility and aggression, shared
control of self and environment, the experience of
choice, increased socialization, practice in coping
skills, increased tolerance of other group members,
conscious intellectual stimulation [100], feelings of
togetherness and teamwork. For example, the thera-
pist gives the group members ‘garden-related home-
work’ to be performed. This task was often used for
patients with aphasia encouraging them to talk and
continue their interaction.
DHHTG gardening for sensory stimulation or integra-
tion
. Patients with severe brain damage and decreased
awareness were presumed to receive sensory stimula-
tion [101] through the reticular activating system, via
responses to different plant material [80, 83]. Sensory
stimulation was performed in a systematic way. The
therapist asked the patient questions related to
the plant material and the garden environment. The
patients’ tasks were to compare or identify variations
of the material. The flowers offered opportunities for
stimulation through smelling and seeing. Memories
connected to the sense of smell would increase arou-
sal. Butterflies and insects would trigger eyes to follow
them. Vegetables and spices grown in the garden
would stimulate taste. Leaves from different species,
with rough or smooth or hairy surfaces would stimu-
late touch in the hand. Sand, soil and water would sti-
mulate sensations in bare feet. Water, birds,
bumblebees and soils make sounds that stimulate
hearing and sound orientation. Bamboo and reeds
moving in the wind make music that may stimulate
auditive perception.
The DHHTG gardening for cognitive re-organization
.
Different gardening activities such as planning a
flowerbed, calculating the depth and distance between
plants, reading instructions on the seed packages or
listening to oral or written instructions for doing
gardening were used for patients’ cognitive re-organi-
zation therapy of attention, spatial, verbal, numerical,
praxis, memory and logical impairments. In this thera-
peutic approach, the patients systematically learn
strategies for a new way of performing the activity
[102]. For example, special education strategies for
planning the growing process in a flower bed gives
opportunities for the patient suffering from frontal
brain damage to re-organize his logical order ability.
The DHHTG gardening for training of sensory-motor
functions
. The various elements of gardening, used in
a neutral way and with increasing efforts, were
presumed suitable for training and improvement of
mobility, muscle strength and balance, fine, gross, bi-
lateral and eye-hand motor co-ordination, plus range
of motion. For example, a patient with a right hemi-
paresis may overcome and possibly improve muscle
weakness of arm and hand by using a high-geared
pair of pruning shears when harvesting tomatoes. In
addition, for patients with a hemiparesis, gardening
activities were used with the traditional sensorimotor
treatment strategies which are presumed to develop
the motor function and motor control, including the
application of sensory stimulation to muscles and
joints which would facilitate specific motor responses
[103]. For example, the patients stand and balance
when removing faded leaves from the climbing plants,
whereas the trellis give support and safety.
The patients had the opportunity to practice ways of
using adaptations and coping behaviour for performing
of the gardening elements [98]. These adaptations were
both physical and mental. For example, the next group
meeting was planned such that all group members were
involved and all were responsible for a task which was
compatible with their ability.
The DHHTG gardening for assessment of pre-
vocational skills and or pre-vocational training
.
Gardening was prescribed as a part of establishing the
patients’, with pain-related impairments, work toler-
ance. The patients’ ability to perform gardening
elements including lifting, reaching, carrying, pushing,
pulling, sitting and standing and work tolerance
was observed [98]. With these purposes, digging,
re-construction and repairing of paving, drawing the
lawn mower, moving or mounting shelves, carrying
boxes and moving sacks with soil were common work
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tasks. The observed results were presumed to contri-
bute to defining the individual patient’s capability
[104] to perform employed work.
DHHTG gardening for teaching ergonomic body
positions
. The various gardening occupations were used
for work-tolerance training. However, the emphasis
here was on the most appropriate ergonomic body
position and use of garden tools following anthropo-
metric principles. For example, during gardening, the
joints were in neutral positions; the gardener directly
facing the job without twisting his or her body, back,
neck or hips. The knees were preferably bent (when
possible) when picking up items from the ground [98].
Kneeling was avoided with the use of raised plant-
beds and a garden stool. Further, the gardeners were
taught to work in the most comfortable way [24].
It was presumed that this ergonomic approach would
prevent injuries to muscles and bones and might
afford pain relief. Teaching ergonomic body positions
was used for 45 minutes once a week individually or
to groups. The patients with Rheumatoid Arthritis
and Chronic Obstructive Lung Disease were given
information about suitable tools and working methods
but did not do gardening.
Educational use of the DHHTG
During a 3-day seminar, rehabilitation team staff
were taught about gardening and the design of a garden
for horticultural therapy. The members of these teams
were interested in starting their own horticultural
therapeutic gardening programmes. The results of
this training contributed to the introduction of

300
horticultural-therapeutic gardens throughout Sweden
today. The concept of
DHHTG
horticultural therapy
has spread and is now in use in nursing homes, rehabili-
tation clinics and acute care among people with infirmi-
ties, mental retardation, mental illness, neurological
diseases such as dementia, multiple sclerosis, stroke
and brain damage and musceloskeletal diseases such
as rheumatoid arthritis [24]. DHHTG has been further
adapted by agricultural training establishments in
Sweden. The ALNARP campus of the Swedish
University of Agricultural Sciences offers a half-term
university course ‘Tra
̈
dga
̊
rd och park som rehabiliter-
ing’ (Gardens and Parks as Rehabilitation) (http://
www.movium.slu.se) and the ULTUNA campus in
Uppsala a quarter-term course in ‘Skoltra
̈
dga
̊
rdskurs’
(Gardens in the Swedish School System).
Discussion
Restrictions in the literature search and the literature
available in the databases used made it difficult to detect
past and present trends in horticultural therapy.
However, the results of this historic review indicated
four different intervention approaches: (a) ‘
Virtual
’
elements from nature in the form of pictures, reading
or discussion [10], (b)
viewing
nature through films or
windows [12, 13], (c)
interacting
, i.e. visiting a hospital
healing garden and receiving impressions and experi-
ence [44, 80, 94], and (d)
action
through doing garden-
ing jobs [87, 94]. The latter approach was strongly
suggested [4, 87, 92, 105–107], but its use was sparsely
demonstrated, which justifies this description of garden-
ing in DHHTG related mainly to patients suffering
from brain damage. The literature suggests or describes
horticultural therapy as a mediator intended to affect
patients’ (a) emotional functions such as stress [75, 84,
93], increasing wellbeing [87,91] or influencing healing
[4], (b) sensory-motor functions and activities [48, 80,
83], (c) cognitive functions and activities [14] and
(d) promoting participation in social life, such as
prevocational training [14] or the avoidance of social
isolation [10] or the promotion of human habits [108].
The descriptions concerned people with mental [94, 106,
107, 109] or physical illness requiring vocational train-
ing [1, 14, 46].
However, there were very few descriptions of how
horticulture therapy has been used for people with
brain damage. Consequently, the present study may
contribute with its description of how horticultural
therapies are being organized at Danderyd Rehabili-
tation Clinic. The patients with brain damage
interacted
in the garden, mediating healing and social interactions.
They interacted by doing gardening jobs, mediating in
reaction the training of sensory stimulation, cognitive
re-organization, sensory-motor functions and pre-
vocational skills. The presentation is based on personal
communication and popular-science articles [23, 24,
26–28] in Swedish, combined with acknowledged
occupational therapy literature. However, it would
have been desirable to use direct observation or medical
records for analysis. Therefore, even if full identification
of this horticultural-therapeutic approach and its effec-
tiveness is still incomplete, it may be helpful to plan and
conduct such direct studies.
Many of the articles reviewed include recommenda-
tions for planning horticultural therapy [110], the
designing of a hospital healing garden [6, 75] in the
form of herb [111] or hospice [78] gardens, suggestions
for suitable plant material [112], methods and tools
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adapted for people with various disabilities [113]
and, finally, exploration of the importance of special
landscapes (adventure playgrounds, children’s farms,
ecological parks or landscaped school grounds) to
facilitate children’s learning [114].
Another value of the DHHTG was its use for training
in horticultural therapy for rehabilitation team mem-
bers. This has resulted in the establishment of new
hospital gardens in Sweden. A similar process has
been going on over the past 16 years in the UK,
where the project strongly promotes its health
benefits [115].
The articles used in this study for reviewing the
literature of horticultural therapy represent several
different disciplines: anthropology, environmental
psychology, horticulture, landscape architecture, medi-
cine [67] and occupational therapy. This in turn may
have influenced the selection of articles and restricted
the review. However, the findings presented above are
comparable to those of an integrative literature review
by Jones and Haight [108] published in 2002. These
authors reviewed 24 articles on the use of the natural
environment in the form of plants or plant material as
therapeutic interventions, either virtually or actually,
among resident patients with altered mental health
status or learning disabilities: older adults with altered
levels of impairment.
Although horticulture therapy was strongly advo-
cated, its effects were less established, except for the
envisaging and viewing
aspects. It was suggested
that the envisaging and viewing form of horticultural
therapy, based on the hypothesis of a beneficial rela-
tionship between humans and the natural environment
positively affects mood and provides mental restora-
tion. This tallies with Relf ’s [67] review (see above)
that ‘views of nature have positive, psychological
responses, physiological impacts (lower blood pressure,
reduced muscle tension), and a reduced need for
medical treatment occurs’.
The
interacting
form of horticulture was evaluated
[115] among 22 patients on a geriatric ward who had
access to an indoor conservatory garden connected
with an outdoor garden. The patients behaviour was
observed regarding their movements on the ward
1 month before the gardens were installed and 1 and 6
months thereafter. The results demonstrated positive
reactions and increased the number of visits to the
outdoor garden following installation of the indoor
conservatory.
Elderly people’s (
n
¼
24)
action
was assessed during a
3-month structured gardening intervention, showing a
significant improvement (
p
< 0.000) in wellbeing [87].
A study with an hermeneutic phenomenological
research approach [94] was conducted among people
with chronic mental illness (
n
¼
10) who were members
of a club. The aims were to explore the participants’
experiences of gardening.
When horticulture was used in this group-based
setting immediate and positive effects were observed in
terms of quality of life, well being and self-concept.
Summary
This article (a) gives a broad historic overview of
how horticultural therapy has been used; (b) describes
the design and organization of Danderyd Hospital
Horticultural Therapeutic Garden and (c) for patients’
with brain injuries, outlines how gardening as a tonic
offers a supplement to their rehabilitation, in terms of
mental healing, recreation, social interaction, sensory
stimulation, cognitive reorganization, training of
sensorimotor function, pre-vocational assessment and
the teaching of ergonomics. However, the effectiveness
of these intervention approaches remains to be proved.
Acknowledgements
Our deep thanks for financial support are due to the Rehabilitation
Clinic, Danderyd Hospital and to Stiftelsen Oskar Hirsch Minne (The
Oskar Hirsch Memorial Foundation).
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