pubs.acs.

org/est Critical Review

Benefits to Performance and Well-Being of Nature-Based Exercise: A

Critical Systematic Review and Meta-Analysis
Henrique S. Brito,* Eliana V. Carraça, António L. Palmeira, José P. Ferreira, Veronica Vleck,
and Duarte Araújo
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ABSTRACT: Prior reviews point to the superior benefits of

exercising in nature vs in conventional indoor venues, particularly in
terms of well-being. However, physical exercise performance,
neither in terms of efficacy nor efficiency, has not been sufficiently
addressed by past reviews of this topic. Therefore, we conducted
both a systematic review and meta-analysis of the experimental
literature that relates to differences in exercise performance and
well-being between exercising in nature and in conventional indoor
venues. Forty-nine relevant studiesthe outcome data of which
were used for the systematic reviewwere located within the Web
of Science, PubMed, and Scopus databases. The meta-analyses,
using data from twenty-four of the relevant studies, revealed no
significant overall environmental effect on task performance efficacy
outcomes (p = 0.100). For nature-based exercise, however, marginally positive cognitive performance outcomes (p = 0.059), lower
ratings of perceived exhaustion (p = 0.001), and higher levels of vigor (p = 0.017) were observed, indicating higher performance
efficiency. As for the effects of environment on well-being, positive affect was significantly higher for nature-based exercise (p =
0.000), while perceived stress was significantly higher for indoor exercise (p = 0.032). These results must, however, be interpreted
with caution. High levels of bias and between-study heterogeneity were observed. Nonetheless, given several noticeable trends in the
results, it may be that exercising in nature enhances the efficiency of exercise task performance to a greater extent than does indoor
exercise.
KEYWORDS: nature-based exercise, indoor exercise, exercise performance, efficacy, efficiency, well-being

1. INTRODUCTION environments, directly placating environmental justice issues

The question of the effects of human exposure to natural
environments, which for the purpose of this review are defined
as “any outdoor spaces that retain noticeable elements of
nature, ranging from pristine or semi-natural areas to urban
green or blue spaces, including green infrastructure” (Silva et
al.,1 p 9547) is becoming of increasing research interest. Access
to nature-based environments is directly affected by physical
and psychological factors, irrespective of where the population
that is under investigation is located. Socioeconomic status,
sociocultural constraints, gender, age, individual preferences,
occupation, and experience also influence access.1−3 Uneven,
inequitable, distribution of nature settings between different
local communities may then compound the disparities in
general health that generally occur across socio-demographic
boundaries.4,5 The promotion and development of exposure to
nature-based environments may, through accompanying
increases in physical activity levels, counteract this issue to
some extent, however. The implementation of such measures
at a local level will increase worldwide exposure to natural
across a variety of populations.1,6
Interaction with nature has widely been associated with
greater levels of (mental and physical) health and well-
being.3,7−9 Several pathways via which nature settings may be
linked to better physical and/or mental health have been
proposed.3 For example, living near nature settings may
engender an increase in physical activity.10,11 When routes are
made more green and attractive, the use of activeas opposed
to passivetransport to a given destination (e.g., walking to
work) may increase. Nature settings can also offer the
opportunity to practice a wide range of low-cost, physical-
activity-based, leisure activities. Such physical activity can then
decrease the risk for noncommunicable disease.12,13 Moreover,
Received: August 1, 2021
Revised: December 3, 2021
Accepted: December 6, 2021
Published: December 17, 2021

© 2021 American Chemical Society https://doi.org/10.1021/acs.est.1c05151

62 Environ. Sci. Technol. 2022, 56, 62−77
Environmental Science & Technology
the perception and experience of a nature setting can have a
positive effect on mental health. Views of green places have, for
example, been associated with lower levels of stress.14 Long-
term interaction with nature settings may promote restora-
tion15 and regeneration,16 improve sleep quality, and have a
positive influence on major risk factors for mental illness.17
Finally, the cleaner air and water, the noise reduction benefits,
and the biodiversity that are associated with a green ecosystem
may improve health, through their effect on respiratory,
cardiovascular, and other functions.3
Exercising while interacting with nature is known as nature-
based exercise or green exercise. A range of cognitive and well-
being benefits have been attributed to it. These benefits
include reduced anxiety, improved attention, high(er) self-
esteem, and improved mood. They have been reported even
for short exercise bouts.18−20 Crucially, various groups have
suggested that these health benefits of nature-based exercise
outweigh those that are accrued when the same type of
exercise is conducted indoors.21−23 Some studies, however,
have not demonstrated significant differences between the
physical activity related benefits of nature-based exercise and
those of indoor exercise. Others have reported greater acute
health benefits (such as lower systolic and diastolic blood
pressure) to be associated with indoor, as opposed to outdoor
physical activity.24,25 To date, no consensus has been reached
by the literature as regards the relative benefits of indoor vs
nature-based exercise.
A key way to clarify this state of affairs and to formally
identify the main findings of published experimental research,
is the Systematic Review and Meta-Analysis (SR-MA). The
Systematic Review approach uses clearly defined, systematic
methods to collect together the empirical evidence from
experimental studies, precisely evaluate their experimental
quality, and both review and synthesize their results.
Systematic Review is a precondition of Meta-Analysis.26 The
process of Meta-Analysis uses the estimates of multiple studies
to arrive at a weighted, pooled, estimate of the clinical
effectiveness of the intervention in question. Moreover, SR-MA
can primarily be used as a lens to appraise how the studies of
every design are being applied (i.e., cohort, randomized
controlled trial, case control).27 Thus, in addition to providing
the most comprehensive possible overview of research and
evidence on a given topic, the process of SR-MA can enable
researchers to make an informed, balanced, decision on how to
improve the design of future studies.28
To date, several systematic reviews of the benefits of indoor
vs nature-based exercise have been published.7,29 Bowler et
al.30 reviewed the benefits to well-being of different activities in
natural and synthetic environments. These environments
included indoor, outdoor built, and outdoor natural land-
scapes. They concluded that nature environments may have a
greater positive impact on well-being than do synthetic
environments. Similarly, Coon et al.7 compared the mental
health and well-being of exercising within nature-based vs
indoor environments. They indicated that there was evidence
for greater improvements in mental health and well-being
when the participants exercised in nature. However, the
combination of methodological failings and insufficient
experimental data in the studies that were surveyed meant
that the latter authors were unable to continue to a meta-
analysis. Their review7 was updated in the light of more recent
evidence, and the SR-MA process completed for nature vs
indoor based exercise, by Lahart et al.29 In contrast to other
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authors, Lahart et al. suggested that the benefits to well-being
of nature-based exercise may not differ from those accruing to
indoor exercise. To our knowledge, theirs is the only
systematic review to date to have assessed outcome variables
that relate to performance efficiency of the metabolic response
to a given exercise task (through variables such as heart rate
and blood lactate concentration), and to the performance
efficacy of said exercise task (via indicators such as the power
output that was achieved during, and the completion time, for
said task). Unfortunately, however, their meta-analysiswhich
involved the data from three longitudinal studiesonly
assessed exercise performance efficiency related outcomes,
that is, heart rate and blood pressure related changes. Lahart et
al. did not include any crossover studies of the acute effects of
nature-based vs indoor exercising on well-being and perform-
ance efficacy of an exercise task within their meta-analysis. This
is despite the fact that such studies form the majority of the
academic literature on the subject.
Exercise performance can itself be subcategorized into both
performance efficacy and performance efficiency.31 Perform-
ance efficacy is synonymous with performance outcome. It may
be expressed as the total number of repetitions done, the total
distance covered, the speed, or the work rate32 during an
exercise task. Navalta et al.,33 for example, reported that during
a 30 min walk at a self-selected pace, the participants covered a
greater distance when walking in natural environments, than
when walking indoors or in outdoor urban environments.
Reich et al.34 reported that for young male endurance runners
who were instructed to run at specific intensities, the speeds
that were attained during a forest trail run exceeded those that
were observed for indoor treadmill running. A longitudinal
study in postmenopausal women, comparing nature-based with
indoor strength training, showed that the nature-based group
improved upper-body muscle strength significantly more than
did the indoor group.22 Contrastingly, performance efficiency
refers to the processes that are used to achieve the same
outcome. Higher efficiency means that the same outcome is
achieved with less effort and better use of resources. Such
processes include cognitive processes (e.g., working memory
and attention) and perceived exertion or heart rate when
exercise is conducted in a given environment. For example,
Anandh et al.35 showed that attention was improved in the
outdoor environment as opposed to the indoor environment in
elderly people after completing the same exercise load. In
another case, Jang and So36 showed that the outdoor group
considered taekwondo training to be less tiresome than did the
indoor group during similar intensity classes.
Inevitably, the merging of individual measures into general
outcomes, for the purposes of meta-analysis, requires both
discussion and clinical judgment. Clearly, therefore, when the
results of analyses that use different but related measures are
combined into an overall effect, or results are generalized to
wider population groups (as has been done across many
disciplines37−39), a rationale must be presented for this.
Although the goal of meta-analysis is to generate a
dichotomous outcome, the finding of an umbrella effect across
outcomes, when it is correctly interpreted, may provide a
useful contribution to both research and to policy decisions.
The systematic reviews7,29 that have been published to date
on the effect of nature-based vs indoor exercise on
psychological state refer to results that were obtained on
numerous affective variables from scales and questionnaires,
such as the Exercise-Induced Feeling Inventory, the Profile of
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Environmental Science & Technology
Mood States, the Activation−Deactivation Adjective Checklist,
and the State Trait Anxiety Inventory. These instruments have
been shown to share constructs,40 a necessary condition for
meta-analysis,41 within the affective outcomes such as pleasure,
displeasure, arousal, stress, and tiredness. The same systematic
reviews7,29 analyzed other variables such as attentional focus
and memory, which are interdependent cognitive processes
and have been the main cognitive outcomes that have been
examined. The theoretical existence of a general attention factor,
which is itself associated with cognitive executive function, has
been postulated.42 This justifies the joint analysis of cognition
related measures in the studies that involve nature-based
exercise.
The mechanisms by which nature-based experience may
influence health and well-being are under debate. Various
theoretical explanations for why or how nature-based exercise
could be more beneficial for this than indoor exercise are
currently under discussion (see Araújo et al.43 for an in-depth
review). It has been postulated, for example, that the fact that it
is conducted within a nature-based setting may impact the
extent to which the (normally positive) effect of exercise on
mental and physical health is experienced. Such impacts of
both exercise activity and nature environment could be
synergistic.2 Logically, the combined effect of both exposures
may best be clarified through the analysis of exercise
performance44 and not uniquely via the analysis of well-being.
Therefore, the aim of this study was to assess the magnitude
of the effects on both performance efficacy and performance
efficiency, as well as on well-being, of exercising in natural vs
indoor settings, using the process of systematic review followed
by meta-analysis.
2. METHODS
For the purposes of transparency, the methods and primary/
secondary outcomes of the systematic review were agreed in
advance. The protocol that was set at the planning stage was
then registered with PROSPERO (https://www.crd.york.ac.
uk/PROSPERO), with the review identification number of
CRD42018097194. The “Preferred Reporting Items for
Systematic Reviews and Meta-Analyses” (PRISMA) guide-
lines45 were followed throughout the review process. No
changes to the registered protocol were made while the
systematic review was underway. If they had been: when, why,
and how this was done would have been disclosed both to the
reviewers and to the readers of this paper, in accordance with
the PRISMA guidelines.
2.1. Data Sources and Literature Search. For evidence-
based research to be adequate, it is essential that it be based on
as broad a search of the literature, including as many studies
that meet the inclusion and exclusion criteria, as possible. The
Web of Science, PubMed, and Scopus databases are among the
databases that are recommended for the efficient searching of
online scientific resources with a view to conducting a
systematic review.46 They were therefore selected for that
purpose. The search encompassed records published from
inception up until and including April 2021. We note that
MEDLINE47 is one of the multiple other databases that are
included within the Web of Science database, but that PubMed
has a broader reach and more entries than MEDLINE. The
search covered English language papers, abstracts, and theses,
that is, papers written in the language in which the majority of
academic evidence is couched, but also Portuguese language
publications, given that all the authors are fluent Portuguese
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speakers. However, only English language papers proved to be
eligible for the SR-MA.
The keywords that were to be used in the search strategy
were based on three main topics: physical activity, outdoor
nature-based environments, and indoor environments. They
enabled two of the authors to independently perform a
thorough search for comparative experimental trials of outdoor
nature-based exercise and indoor exercise. They did this using
a combination of three keywords: one of which was physical
activity related, one of which was related to nature environ-
ments, and one of which was indoor exercise related (Table 1).
Each of the keywords that were used itself consisted of a
minimum combination of two words. The keywords were
culled from the abstracts of relevant literature related to
outdoor and indoor physical activity, identified from previous
systematic reviews.7,29 The keywords were designed to reduce
ambiguity and thus increase search efficiency in accordance
with the PICO (population, intervention, control, outcome)
framework for bringing clarity to the formulation of research
question(s) and deciding on the eligibility of studies for
systematic review. The research question in this case being “in
exercising individuals (population), how effective are nature-
based environments (intervention) vs indoor environments
(control) for improved performance efficiency, performance
efficacy, and well-being (outcome).” We did not, therefore, use
keywords that were related to the outcome of the intervention
(i.e., performance efficacy, efficiency and well-being) in the
initial search. This is because doing so could have reduced the
recall of the search, which would then have risked the exclusion
of potentially relevant studies that utilized measures which
would not have been patent in the keywords. The
bibliographies of previous relevant reviews7,29 were also
hand-searched for additional relevant studies.
2.2. Eligibility Criteria. The eligibility criteria for a study
to be selected for the systematic review were set according to
the PICO framework,48 as follows: (Population) it involved
any group of participants, of any description; (Intervention) It
involved physical activityfor which exercise intensity,
volume, and frequency was reportedwithin either an
outdoor, nature-based environment or within a virtual reality
simulation of an outdoor nature-based environment; (Com-
parison) the study had to have compared indoor physical
activity to similar (either actual or simulated) outdoor, nature-
based activity. If the outdoor task was a 30 min self-paced
outdoor walk, for example, the suitable indoor counterpart to it
could be 30 min of self-paced walking on an indoor track or
indoor treadmill; (Outcome) at least one of the reported
outcome(s) of the exercise task was performance efficacy,
performance efficiency, and or well-being related. Examples of
suitable performance efficacy outcomes (i.e., outcomes related
to how well participants performed the task) include running
speed, work rate, power output, and distance achieved.
Directed attention scores, working memory scores, perceived
exertion scores and arousal scores, and heart rate numbered
among applicable performance efficiency related outcomes
(i.e., measures that were related to cognitive, psychological,
and physiological functioning during the exercise task). The
well-being related outcomes that were considered suitable
included any self-reported measures that were related to
positive and negative mental states (such as affect, happiness,
tension, and or stress). Moreover, the study had to be
randomized or nonrandomized, to assess longitudinal or acute
effects, and to either involve independent groups (one of which
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Environmental Science & Technology pubs.acs.org/est Critical Review

was indoor-based and one of which was nature-based), or be a

”indoor* settings” OR “natural versus indoor” OR “dance room” OR “exercise environments” OR “exercise setting” OR “control conditions” OR “visual environment*” OR “indoor group” OR “indoor treadmill” OR “indoor
“outdoor versus indoor” OR “green outdoors” OR “walking in the forest” OR “outdoor green” OR “outdoor environment*” OR “nature-based environments” OR “outdoors and indoors” OR “green-outdoor” OR “outdoor

environments” OR “exercising in laboratory” OR “laboratory treadmill” OR “indoor and outdoor” OR “indoor exercise-setting” OR “indoor* exercise” OR “indoor training” OR “outdoor versus indoor” OR “walking in the
intervention” OR “physical fitness” OR “exercise intensity” OR “during exercise” OR “laboratory cycling” OR “outdoor cycling” OR “track runners” OR “effect* of exercise” OR “outdoor walking” OR “brief walk” OR

“exercise session*” OR “exercise program” OR “circuit strength training” OR “indoor training” OR “outdoor training” OR “resistance training” OR “high-intensity exercise” OR “treadmill running” OR “walking session” OR

“outdoor environment” OR “indoor and outdoor activities” OR ″outdoor training” OR “outdoor vs laboratory” OR ″outdoor session” OR ″laboratory vs outdoor” OR “outdoor trial” OR “field and laboratory settings” OR
“indoor, outdoor” OR “outdoor and laboratory environments” OR “outdoor run” OR “indoor and outdoor″ OR “outdoors in a green/nature area” OR “nature group” OR “exercis* in nature” OR “outdoor exercise” OR

and outdoor activities” OR “indoor training” OR “compared to control” OR “outdoor vs laboratory” OR “laboratory vs outdoor” OR “field and laboratory settings” OR “indoor, outdoor” OR “outdoor and laboratory
”natural versus indoor” OR “natural environment*” OR “natural settings” OR “exercise environments” OR “green exercise” OR “visual environment*” OR “visual nature” OR “nature condition” OR “outdoor trail” OR
“exercise-induced” OR “effects of running” OR “physical exercise” OR “exercise experiments” OR “indoor and outdoor walks” OR “exercise-based intervention” OR “biking bout” OR “circuit-strength sequence” OR
crossover trial.
”physical activity” OR “green exercise” OR “exercise bout*” OR “controlled exercise” OR ”postexercise” OR “responses to exercis*” OR “running session” OR “outdoor running” OR “mountain hiking” OR “exercise
2.3. Study Screening and Data Extraction. The
selection of the studies was performed in two phases. In
Phase One, potentially relevant studies were screened, on the
basis of their title and abstract, by two of the authors (HB, EC)

gymnasium” OR “gym setting*” OR ″indoor gym” OR “walking indoors” OR “outdoors and indoors” OR “indoor taekwondo” OR “indoor condition” OR “in a gym” OR “virtual environment*”
independently. If any doubt existed as regards whether or not
to include or exclude an article in the analysis, it was selected
for the next evaluation phase. In Phase Two, the full texts of
the articles were reviewed according to the eligibility criteria. If
HB and EC disagreed over the inclusion of articles, the
mediation of a third reviewer (DA) was required to proceed
“training program” OR “training intervention” OR “indoor cycling” OR “indoor track” OR “cycling outdoors” OR “fitness test” OR “sprint running” OR “running exercise”

any further. The two authors who were involved in the

selection of the studies then, again working independently,
extracted the data from the studies that fulfilled the eligibility
criteria for inclusion in the systematic review into Microsoft
Excel. In the cases where additional data to those that were
available in the paper were warranted, they were requested
from the author(s). Most such data were pairwise data from
crossover trials.
2.4. Risk of Bias Assessment. The risk of bias in
randomized independent groups trials was assessed via the
Cochrane Collaboration’s Tool for assessing Risk of Bias in
randomized trials.49 Crossover trials were assessed for risk of
bias as suggested by Ding et al.50 Both such tools have
previously been employed for the purpose of systematic
review.29
2.5. Summary Measures and Synthesis of Results.
keywords

First, a qualitative analysis of the performance and well-being

related results of the studies was undertaken. Higher work
rate(s), higher levels of concentration, better memory ratings,
faster completion of tasks, lower physiological work and lower
exertion to achieve the task were considered to be synonymous
Table 1. Search Strategy for the Web of Science, PubMed, and Scopus Databases

with improved performance. Similarly, higher well-being was

considered to have been attained when higher scores on the
measures that were related to self-reported joy and or self-
esteem; and lower scores on sadness and tension etc. were
observed.
Then, seven meta-analyses were conducted, using Compre-
hensive Meta-analysis software (CMA, Version 3, Borenstein,
M., Hedges, L., Higgins, J., & Rothstein, H., Biostat,
Englewood, NJ 2013, as follows: For the outcomes of
performance efficacy: task output; for performance efficiency:
cognitive performance, heart rate, fatigue/exhaustion, arousal/
route” OR “outdoor condition” OR “outdoor track”

energy, and, finally, for well-being: positive affect as well as

stress/anxiety. We meta-analyzed the most frequent outcomes
of interest in the studies, or similar constructs of outcomes.
Thus, different measures of positive emotions, mood, and
affect were considered together if they were considered to fall
within one construct in the study. Paired statistics (such as the
intraindividual mean differences between the outdoor and
indoor conditions, as well as standard error of the difference)
were used for the analysis of crossover studies. Means, sample
numbers and standard deviations were among the data that
were used for the studies that involved independent groups.
2.6. Data Extraction and Quantitative Analysis. Data
from pre-to-post intervention about the effects of exercising in
AND

AND

nature and indoor settings were used for the meta-analyses.

These data allowed for the analysis of the acute effects of one
physical activ-

outdoor envi-

single exposure to either the indoor or the outdoor nature-

indoor envi-
ronment

ronment
topic

based exercise environment on performance efficacy, perform-

ance efficiency and well-being. In CMA, retrieved data were
ity

computed using the continuous (means) data entry formats

65 https://doi.org/10.1021/acs.est.1c05151
Environ. Sci. Technol. 2022, 56, 62−77
Environmental Science & Technology
Figure 1. Flow Diagram of the process of study selection for the SR-MA.
from unmatched groups (post data only), one group (prepost),
and computed effect sizes. The analyses were conducted using
the random effects method. The effect size was the
Standardized Difference in Means (SDM). That is, standard
deviations (SD) were used both to standardize the mean
differences of different scales according to a single scale, and to
apportion weights to the results of individual studies. Studies
with small SD led to relatively higher estimates of SMD and
vice versa.51 The use of this method in meta-analysis allows for
mean differences between treatments to be combined, even
when the different studies have assessed outcomes using
different rating scales.52 Significance level was set at p ≤ 0.05.
Between-study heterogeneity was assessed using the I2 statistic.
This was considered as the variance of the observed effects
percentage that reflects the variance of the true effects in each
outcome analysis. I2 values of 25%, 50%, and 75% were taken
to reflect low, moderate, and high between-study hetero-
geneity, respectively.53
3. RESULTS
The results of the SR-MA are presented in three sections. First,
we present the results of the searches of the Web of Science,
PubMed, and Scopus databases. Second, we present the
qualitative analysis of the studies that were selected for the
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systematic review (including any statistically significant data
performance and well-being outcomes that they reported).
Finally, we describe the results of the meta-analyses that were
conducted of the effects of an indoor vs outdoor/simulated
outdoor, nature-based, environment on exercise performance
efficacy and efficiency, as well as on well-being.
3.1. Study and Data Selection. Overall, 559 undupli-
cated records were identified from the combination of the Web
of Science, PubMed, and Scopus databases and the
bibliographies of previous reviews on the topic of nature-
based vs indoor exercise7,29 (Figure 1). After the screening of
titles and abstracts, 90 records remained. The full texts of these
studies were then carefully read by the same individuals (HB
and EC), so as to select the ones that were of interest to this
review. The final 49 studies (17 of which were independent
groups studies and 32 of which were crossover trials), which
were all in the English language, were then qualitatively
screened. Risk of bias was assessed in all included studies by
two reviewers (AP, JPF). None of the data were deemed
unsuitable for exclusion because of risk of bias. Quantitative
data were then extracted, for the purposes of meta-analysis,
from 24 of said studies. Additional relevant unpublished data
were also provided, for the meta-analysis, by the author(s) of
nine of the 24 selected studies.
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Environmental Science & Technology
Figure 2. Degree of bias (expressed as a percentage) of the 17 independent groups studies that were selected for systematic review, according to the
Cochrane Collection Tool for Assessing Risk of Bias.
3.2. Systematic Analysis. 3.2.1. Study Characteristics.
The 49 studies that were selected for the systematic review had
implemented a similar exercise task at least on one occasion
within both the outdoor nature-based and the indoor built
environments. These tasks were dancing, running, walking,
hiking, cycling, aerobic and resistance training, circuit-based
exercise, taekwondo, and/or cognitive-motor task activities.
Walking, running, and cycling were the most commonly
utilized exercise modes. Four studies were longitudinal. They
involved multiple exercise sessions over a three month
period.22,54−56 The remainder of the studies (nine of which
involved treadmill running or cycle ergometry while the
participants were immersed in a simulated natural environ-
ment57−65) examined the acute effects of a single exercise
intervention. Some nuances in the study interventions (e.g.,
hearing sounds such as birdsongs, car traffic, or music while
exercising in an indoor vs within a nature-based environ-
ment23,64,66) may have confounded the effects of the physical
environment to some extent.
3.2.2. Participant Characteristics. A total of 1832
individuals participated in the trials, of whom 897 were
identified as female (49%). Five trials, accounting for
approximately 15% of the pooled sample from all 49 studies,
did not disclose their participants genders. The participants
represented a fairly diverse population. They included children,
adolescents, dancers, university students and staff, postmeno-
pausal women, elderly persons, recreational and competitive
runners, cyclists, orienteers, triathletes, marathon runners,
office employees, regular exercisers, taekwondo players, rugby
union and other team sport players, as well as individuals who
had been diagnosed with depression or obesity. The study
sample sizes ranged from eight to 154 individuals. The
approximate pooled mean age of the 1468 participants of the
44 papers, abstracts, and theses that provided age data was 29.9
years.
3.2.3. Exercise Environments. The outdoor environments
that were in the trials encompassed rural areas situated amidst
trees and fields,54 nature parks and forests that were
occasionally located near bodies of water,25,34,36,56,67−75 city
parks with trees and some built features,21,76−80 university
campuses with plants and trees within view, outdoor athletic
tracks,23,65,66,81−86 and mountain trails.24,33 Nine studies
simulated an outdoor, nature-based environment in the
laboratory by showing video footage of nature reserves,61
botanical gardens,64 rural fields with cattle nearby and
woods,59 or a forest58,60,62,63 to their participants. Two
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studies57,65 used a head mounted display to create a “virtual
nature” environment.
As regards the indoor environments, studies often used
standard rooms21,56,79 or indoor corridors not exposed to
greenery,54 room viewing blank screens,60,58,59,76,62,63 gyms
and fitness centers,23,24,34,36,64,67−69,72,74,78,80,81,84,87,75,88 phys-
iology laboratories,25,33,65,66,71,77,82,83,85 a shopping center,73
and underground hallways.86
3.2.4. Measures. In terms of performance efficacy, the most
prevalent measures that were used were self-selected exercise
intensity, distance covered, time to completion of set distances,
time elapsed until voluntary exhaustion was reached, self-
selected speed, cycling power output, and muscle endurance
(assessed via the number of repetitions done). In addition, the
most prevalent performance efficiency measures in the studies
were arousal and perceived exertion (assessed by the Felt
Arousal Scale and via Rating of Perceived Exertion,
respectively), as well as heart rate and blood lactate
concentration. Finally, the most oft-reported well-being-related
measures were self-reported affect and mood states, self-
esteem, and anxiety. The scales that were used were the
Feeling Scale, the Physical Activity Affect Scale, the Mood
Survey Scale, the Exercise-induced Feeling Inventory, the
Profile of Moods States, and the Positive and Negative Affect
Scales for affect and mood states; the Rosenberg Self-esteem
Scale for self-esteem, and the State Trait Anxiety Inventory for
anxiety. Cognitive performance-related was scored according
to the Thoughts During Running Scale, the Attentional Focus
Questionnaire, the Stroop Test, the Backward Digit Span Task,
and/or the Trail Marking Test (see Supporting Information
(SI) for a review of all the included studies outcomes and
results, SI Table S1).
3.2.5. Risk of Bias. Most of the 17 independent groups
studies reported that the participants were randomized into
groups. In many cases, no additional information on how such
randomization was accomplished was provided, however
(Figure 2). Nor did 13 of the 32 crossover studies report
how their study participants were split into treatment order
groups. Just six of the 17 studies were deemed, on the basis of
the Cochrane Collaboration’s Tool for assessing Risk of Bias49
in randomized trials, to possess a low risk of bias.
Any blinding of the participants and collectors to their
assigned intervention that occurred went largely unreported.
Fourteen of the 32 crossover studies24,59,62,63,68,70,80,81,89−94
may have incorporated insufficient recovery time between the
exercise interventions (Figure 3). Depending on their fitness
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Figure 3. Degree of bias of the 32 crossover trials that were selected for systematic review, assessed via the method of Ding et al.50

level, this could have meant that the participants underwent based exercise participants exhibited more energy,65 arousal,82
the second exercise intervention when they were insufficiently and vigor;66,76 reported lower fatigue,66,36,93 tiredness,65
recuperated from the first exercise task. Moreover, and as exhaustion,87 and perceived exertion.36,87,96 However, two
expected, in some cases it was not possible to replicate the studies reported that nature exercisers felt more exhausted21
exercise task in the two environments as closely as the authors and reported higher levels of perceived exertion80 than did
might have wished. For example, in biomechanical terms indoor based exercisers. In addition, four studies34,71,93,94
outdoor running and running on a treadmill are not strictly observed higher heart rates while exercising in nature than
comparable.95 Finally, 11 studies21,35,65,73,75,77,83,84,86,90,92 were observed for indoor exercise.
provided insufficient details of the statistical methods that Regarding well-being, 14 studies reported that nature
they employed to arrive at their results. exercisers had higher positive affect,69,72,80,82,87,35 mood,23
3.2.6. Results of the Longitudinal Studies. One22 out of the happiness,74 pleasantness, and delight;23 higher feelings of
four longitudinal studies that were included in the systematic comfort and calmness;33 greater vitality,36,86 restorativeness,80
review showed that, on average, over three-months of nature- and revitalization;82 higher levels of pride83 and self-esteem;73
based exercise their participants performed a higher number of lower anxiety, depression, and anger;66,36 lower total mood
bench press repetitions than did indoor exercisers, that is, disturbance;73 and less distress80 than did indoor exercisers.
participants in the nature-based exercise condition presented a Finally, one59 out of nine simulation and virtual reality
higher performance efficacy. As regards well-being, in one studies57−63,65,97 observed that nature simulation exercisers
study56 the nature-based exercise participants exhibited greater had higher positive affect and lower perceived exertion, while
positive affect and tranquility during almost the entirety of the indoor exercisers showed diminished affect. A second study57
intervention, while positive engagement and tranquility were reported that the nature-based simulation caused greater
diminished in the indoor exercisers. Another study54 observed calmness than did the indoor environment. A third study61
that participants in nature-based exercise showed greater levels reported that exercisers in simulated nature showed lower
of self-efficacy and motivation than did indoor based exercisers. mood disturbance and stress than did indoor exercisers.
Finally, another study55 showed improved depressive symp- 3.3. Meta-Analyses. The performance efficacy outcomes,
toms after exercising in nature as opposed to indoors. None of performance efficiency outcomes, and well-being related
the longitudinal studies addressed exercise performance outcomes of the meta-analyses are illustrated in Table 2. The
efficiency. observed positive effect sizes (SDM) mean a pooled higher
3.2.7. Results of the Acute Effect Studies. Regarding effect in the direction of nature-based exercise.
performance efficacy, six out of 45 acute effect studies reported
that their nature-based exercise participants engaged in Table 2. Effect Sizes and Statistics of the Meta-Analysis
dancing more vigorously,21 exhibited greater power output in 95% CIb 95% CIb
cycling (and took less time to complete the trial),71 ran outcome SDMa lower upper p-value
faster,34,91 demonstrated higher levels of cycling endurance,67 performance task 0.32 −0.06 0.71 0.100
and covered more distance running96 than did their indoor efficacy performance
counterparts. In contrast, one study77 reported nature-based performance cognitive 0.68 −0.03 1.38 0.059
exercise participants exhibited lower cadence within a cycling efficiency performance
task than indoor exercisers. Another study78 reported that heart rate 0.12 −0.11 0.34 0.306
nature exercisers ran slower than indoor exercisers did. fatigue/ −0.52 −0.84 −0.21 0.001
exhaustion
As for performance efficiency, one study79 reported that arousal/energy 0.42 0.08 0.77 0.017
participants in nature-based exercise had lower heart rates and well-being positive affect 0.51 0.27 0.76 0.000
oxygen consumption levels (for a comparable exercise task) stress/anxiety −0.36 −0.69 −0.03 0.032
than did indoor exercisers. Another study36 reported that
a
nature exercisers performed better on attention (assessed via SDM, Standardized difference in means. bCI, Confidence interval;
the Trail Making Test) than indoor exercisers did. Nature- significance if p ≤ 0.05.

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Figure 4. Task performance outcomes meta-analysis comparing nature-based exercise vs indoor exercise; PA, physical activity; m, meters; km/h,
kilometers per hour; min, minutes; sec, seconds; SDM, standardized difference in means.

Figure 5. Cognitive performance outcomes meta-analysis of studies comparing nature-based exercise vs indoor exercise; MAAS, mindful attention
awareness scale; BDST, backward digit span task; TMT, trail making test; TAFS, Tammen Attentional Focus Scale; CNT, Cambridge
Neuropsychological Test; SCM/ECM, self-caught method/experimenter-classified method; SDM, standardized difference in means.

Figure 6. Heart rate outcomes (in beats per minute and expressed as a percentage of maximum heart rate) meta-analysis of studies comparing
nature-based exercise vs indoor exercise; SDM, standardized difference in means.

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Figure 7. Perceived exertion, exhaustion, fatigue, and tiredness outcomes meta-analysis of studies comparing nature-based exercise vs indoor
exercise; EIFI, exercise induced feeling inventory; RPE, rating of perceived exertion; POMS, profile of mood states; ADACL, activation deactivation
adjective checklist; SDM, standardized difference in means.

Figure 8. Arousal and energy meta-analysis of studies comparing nature-based exercise vs indoor exercise; POMS, profile of mood states; FAS, felt
arousal scale; ADACL, activation deactivation adjective checklist; SAC, stress arousal checklist.

3.3.1. Performance Efficacy. No significant overall differ-
ence in task performance outcomes was found when
comparing nature-based exercise with indoor (dancing, cycling
and running) exercise (SDM = 0.32, 95% CI: −0.06; 0.71, p =
0.100, Figure 4). However, out of the nine sources (including
one nature simulation study58) from which the data were
extracted for this analysis all but one favored nature-based
exercise. High levels of heterogeneity between studies (I2 =
75.1%) were, nonetheless, observed.
3.3.2. Performance Efficiency Based on Cognitive Out-
comes. There was a marginally significant overall positive
effect of nature-based (as opposed to indoor-based) exercise
on cognitive performance outcomes (Figure 5). These
outcomes included working memory and attention (SDM =
70
0.68, 95% CI: −0.03; 1.38, p = 0.059). One of the studies that
was used for this meta-analysis involved a simulated, rather
than an actual, nature-based environment.58 This analysis,
again, revealed high heterogeneity between studies (I2 =
94.7%).
3.3.3. Performance Efficiency Based on Heart Rate. No
significant differences were observed in cardiac output related
outcomes of exercising in an indoor as opposed to an outdoor/
simulated outdoor, nature-based, environment (SDM = 0.12,
95% CI: −0.11; 0.34, p = 0.306) (Figure 6), including data
from one nature simulation study.58 In this case the
heterogeneity between studies was low (I2 = 19%)
3.3.4. Performance Efficiency Based on Perceived Fatigue.
There was a significant overall positive effect of nature-based
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Figure 9. Positive affect outcomes meta-analysis of studies comparing nature-based exercise vs indoor exercise; PAS, positive affect scale; EIFI,
exercise induced feeling inventory; PAAS, physical activity affect scale; FS, feeling scale; HIK, Happiness Index Korea; SDM, standardized
difference in means.

Figure 10. Tension, stress, anxiety outcomes meta-analysis comparing nature-based exercise vs indoor exercise; POMS, profile of mood states;
STAI, state trait anxiety inventory; ADACL, activation deactivation adjective checklist; SS, stress scale developed for this specific study; SAC, stress
arousal checklist; PSS, perceived stress scale; SDM, standardized difference in means.

exercise on perceived fatigue. Exercising in nature-based
environments led to lower levels of perceived exertion,
exhaustion, fatigue, and tiredness than were observed for
comparable indoor exercise (SDM = −0.52, 95% CI: −0.84;
−0.21, p = 0.001) (Figure 7). The analysis revealed high
heterogeneity between studies (I2 = 77.6%). We note that
negative SDM indicates greater performance efficiency.
3.3.5. Performance Efficiency Based on Arousal and
Energy. There was a significant overall effect of environment
on performance efficiency, as monitored via arousal and energy
level related measures. Exercising in nature-based environ-
ments incurred greater perceived arousal and vigor scores in
participants than did indoor exercise (SDM = 0.42, 95% CI:
0.08; 0.77, p = 0.017) (Figure 8). The analysis revealed high
heterogeneity between studies (I2 = 74.8%).
71
3.3.6. Well-Being Based on Positive Affect. There was a
significant overall effect of environment on positive affect. This
suggested that exercising in nature-based environments may
facilitate greater positive affect, mood, and feelings of pleasure
and happiness, as compared to indoor environments (SDM =
0.51, 95% CI: 0.27; 0.76, p = 0.000) (Figure 9). The analysis
revealed moderate levels of interstudy heterogeneity (I2 =
59.4%).
3.3.7. Well-Being Based on Perceived Stress. There was a
significant effect on perceived tension, anxiety, and stress
measures (SDM = −0.36, 95% CI: −0.69; −0.03, p = 0.032)
(Figure 10), with lower values in the nature-based exercise
participants. The analysis included data from two nature
simulation studies61,62 and revealed moderate heterogeneity
between studies (I2 = 56.4%).
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4. DISCUSSION
This systematic review and meta-analysis assessed the relative
effects on performance efficacy, performance efficiency, and
well-being related measures of exercising in nature/simulated
nature vs indoor environments. It revealed performance
efficiency and well-being to be higher when the exercise task
was performed within a nature-based setting than when it was
performed indoors. Performance efficacy did not differ,
however, significantly with exercise setting.
4.1. Systematic Review. The majority of the studies that
were included in the systematic analysis demonstrated greater
benefits to be associated with exercising in nature than with
exercising indoors. This increased benefit of nature-based
exercise included greater levels of affect,23,56,72,74,82,87,93,98
arousal, 65,76,82,93 restorativeness,80,82,86,87 and tranquil-
ity.33,56,57,81,87 Lower levels of fatigue,65,87,93 depression,66,73
anger, confusion,73 and distress80 were also associated with
exercising in nature. The aforesaid finding held across the
studies in question irrespective of study design, of the outcome
measures that were involved, and of participant characteristics
(i.e., the age, sex, and physical activity levels of the individuals
who were involved). Three out of 49 papers, however, reported
the opposite effect, namely that indoor exercise incurred lower
levels of exhaustion,21 tension, stress,83 and perceived
exertion80 than did nature-based exercise. Why this anomaly
occurred may be related to methodological issues with the
studies themselves. Byrka et al.,21 for example, reported greater
(levels of) exhaustion in their nature-based exercise group than
in their indoor exercise group, but exercise intensity was self-
selected and higher in the nature-based group. In the study of
Kerr et al.,83 the participants were accustomed to running
outdoors. The pretest familiarization session that the
researchers employed may have mitigated the tension and
stress that was expected to occur within a laboratory
environment. The novelty factor of said setting may also
have had a positive effect on the study participants. Finally, the
finding of Williams,80 that is, of higher levels of perceived
exertion for nature-based than for indoor exercise, may have
reflected the presence of hills in the outdoor, but not in the
indoor, environment.
Thus, the overall conclusion of our systematic review is that
exercising in nature-based environments may incur additional
well-being benefits to those that accrue with exercise that is
conducted indoors.7,18,30 Our results both agree with, and
extend on those of Coon et al.7 The latter authors concluded,
after reviewing 11 studies, that a natural, outdoor, environment
may have a synergistic effect on the effect of exercise on
selected measures of well-being. They contradict the later
findings of Lahart et al.,29 who reported that exercise in nature
may not favorably influence “emotion, perceived exertion,
exercise intensity, and biological markers” (p 1). Lahart et al.
hypothesized that the mental health benefits of nature-based
exercise may not be as evident as those that occur with indoor
based exercise. However, Lahart et al. mainly used harvest plots
for their quantitative analysis. Harvest plots neither provide
measures of effect magnitude, nor take study sizes into
account.99 These issues are taken into account by meta-
analyses. Moreover, our meta-analyses incorporated unpub-
lished data from multiple studies. Said data were directly
provided to ourselves by the authors of said studies. We were
consequently able to integrate the original individual data of
each study participant from multiple publications into our
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analyses, thereby enriching both the results, and the
interpretation of the results, of our systematic review.
4.2. Insights from the Meta-Analyses. To the authors’
knowledge, these are the first meta-analyses of the relative
effect of nature/simulated nature vs indoor environments on
the performance efficacy and efficiency of an exercise task to
have been conducted. The studies that reported exercise
performance efficacy data as their primary outcome were in the
minority of those that we examined. The effects of environ-
ment were not significant for performance efficacy (Figure 4)
and were marginally significant for cognitive performance
(efficiency) (Figure 5). Nonetheless, we observed that exercise
performance efficacy and efficiency as a whole tended to be
higher within a natural/simulated natural environment than
they were within an indoor environment, as shown by effect
sizes that generally favored nature-based exercise (even if these
were not significant).
Performance efficiency in the form of perceived exertion and
vigor was significantly favored by exercise being conducted
within a nature-based environment (Figure 7). Even though
performance efficacy tended to be greater (but not significantly
so) in outdoor nature-based exercise, perceived exertion
(which is highly correlated with task performance efficacy100)
was also clearly lower. Similar effects were present for task
efficiency related measures such as energy, vigor, and arousal
(Figure 8). Such findings were both as expected and support
the view that there is a tendency for individuals to feel
energized when they are in a nature-based environment.
As for well-being, positive affect was significantly favored
during nature-based exercise (Figure 9). Tension and stress
were significantly greater within an indoor setting than they
were when individuals exercised in a nature-based environment
(Figure 10). This finding is in agreement with the ecological
dynamics framework given that exploring and engaging in
nature affordances (possibilities for action offered by the
environment) promotes well-being.43 Interestingly, the results
of the meta-analyses of the effect of exercise on performance
efficiency (cognitive performance, heart rate, perceived
exertion58) and well-being (tension/stress61,62) for simulated-
and for actual nature-based environments were similar. The
predominantly green visuals of a nature/simulated nature
setting may play a role in the benefits that are attained from
exercising within it.101 Certainly, the exercise interventions that
were assessed were fairly diverse. They ranged from occupa-
tional exercise, through recreational exercise, to competitive
sport. The sample participants were also fairly diverse. This
wide applicability of the performance and well-being related
benefits of exercising within nature is encouraging.
4.3. Proposed Explanation for the Benefits of Nature-
Based Exercise. These mentioned beneficial effects may be
explained by the existence of a synergistic relationship between
the benefits of exercising and the benefits of interacting with a
nature-based environment.102 From an ecological dynamics
perspective, within nature environment possess more varied
affordances (i.e., possibilities for action presented to the
exerciser) than do indoor environments. Given that they
present unknown, slightly irregular environments,103,104
nature-based settings allow for greater variability and more
flexibility of behavior. Adjustments in movement can more
easily be made without goal attainment necessarily being
compromised. Manufactured environmentswith their safe,
predictable, and monotonous featuresare more likely to
elicit repetitive, “automatic-type” behavior. Nature’s affordan-
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Environmental Science & Technology
ces demand a continuous embodied and embedded engage-
ment of the exerciser in the task at hand. This promotes the
development of a deep interaction of the individual with his/
her environment. This in turn contributes to both skill learning
and performance.43
4.4. Strengths and Limitations. Notwithstanding the
above, it must be recognized that the studies that were
examined by this systematic review and meta-analysis
possessed a considerable risk of methodological bias. This
bias mainly resulted from a dearth of details of the
randomization process of, the methodological design of, and
the extent to either single- or double-blinding took place
within the studies that were analyzed. The sociocultural
environment of the exercise task also varied between studies.
The individuals who took part in them were, or could have
been, sharing their exercise environments with friends, other
exercisers, and or pedestrians on occasion. It is also difficult to
maintain topographical conditions across nature-based and
indoor- environments. For example, Niedermeier et al.24
compared the responses of exercisers to an indoor treadmill
walk and a mountain hike. An exact simulation of the downhill
part of the hike on the indoor treadmill would not have been
possible. Thus, and as expected, all the meta-analyses that we
conducted invariably possessed medium-to-high levels of
between-study heterogeneity.
Of all the experimental variables that are involved in these
types of nature related experiment, the weather and pollution
levels to which participants are subjected may be the most
difficult to control. The season of the year, the environmental
temperatures, the humidity levels, the air quality, and the
cleanliness (level of pollution) of the environment can all affect
the effects of exercise within it (making them less predictable).
This is particularly so in the case of nature-based exercise,
where such effects are harder to control. It is, additionally,
regrettable that only a limited number of the studies that have
thus far been published have described the temperature and
humidity of their exercise environments.23,68,74,76−78,98 Of
those studies that did state such information, in one case the
temperature difference between the nature-based and indoor
setting exceeded 10 °C.69 Other ecosystem details that could
have a bearing on the exercise response that is displayed have
been raised within the academic literature. Jang et al.36
proposed that the benefits of exercising in nature may occur
due to sensory refreshment, since indoor air is more
contaminated than outdoor air. Shin et al.74 suggested that
had their experiment been conducted in an urban environ-
ment, their participants’ emotions would have been influenced
by air pollution and vehicle emissions. Such issues went largely
unassessed in the studies that we examined.
It was not possible to conduct posthoc analyses for sex, for
participant age, for exercise intensity, or for exercise mode. All
of these variables may have contributed to the high levels of
between-study heterogeneity that we observed in the present
meta-analyses. Subgroup analysis would only have been viable
had there been greater standardization of methods, such as
occurs in clinical trials, across studies. Simply put, there were
not enough factors in common across the studies for us to
merge them more than we did. We acknowledge, therefore,
that the effect sizes that we observed, and the high propensity
for bias in the studies, precludes the drawing of a definitive
conclusion from our results. Furthermore, although we
collected data from an acceptable number of studies, by no
means were we able to obtain all the data that was procured
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(not all of which was necessarily published) by the original
researchers.
We would contend that the use of a bigger pool of studies,
with improvement and better reporting of their methodologies,
is necessary for the benefits of nature-based exercise vs indoor
exercise on performance and well-being to become more clear.
This is particularly so as regards performance efficacy. We also
highlight that, because the findings are at high risk of bias due
to the design of the experiments, there is a tendency to avoid
conducting meta-analyses when bias, limited evidence,
incompletely reported outcomes, and different measures exist
across studies. However, according to McKenzie et al.,105
“meta-analysis methods should be considered in these
circumstances, as they may provide important insights if
undertaken and interpreted appropriately.” (Section 12-1).
These insights are particularly relevant for the design of future
studies.
Notwithstanding its limitations, this paper makes an
important contribution to the literature. The strengths of this
paper include that, first, it involved systematic review of the
data from 49 research articles, comparing a multitude of
performance efficacy and efficiency and well-being effects
between nature-based exercise and indoor exercise. Second, it
presents preliminary meta-analyses of concrete measures of
performance and well-being in the aforesaid exercise environ-
ments. If studies had been excluded from the review on the
basis of a high risk of bias, or the data from them had not been
merged into common outcome(s), it would not have been
possible to conduct meta-analyses of all the available data.
Notwithstanding the limitations of our SR-MA, its main
message is that there is a noticeable trend toward additional
benefits being accrued with exercising in nature, over those
that are accrued within an indoor environment.
It is clear from our results that, for experiment bias to be
reduced, future work in this field should follow strict
methodological guidelines. Due to the importance of
contextual clarity to readers and researchers, and its
implications in explaining the effects of interventions, authors
should extensively describe the exercise environment. Such
descriptions should include both the social context, and
environmental determinants of the locale in which the exercise
is taking place. Additionally, with a view to decreasing research
bias in research in this field, we recommend the implementa-
tion of independent group trials. Since the participants in
crossover trials may infer that it is expected of them to have
better results in the nature-based setting, it may be that,
despite the benefits of crossover study designs (i.e., using
participants as their own control), control is higher for
independent group trials. Furthermore, as the current lack of
longitudinal studies creates an important gap in the research
literature, large scale studiesof several months durationof
the effect of environment on exercise performance and well-
being of structured exercise or sport tasks should be
conducted.
4.5. Concluding Remarks. We consider this review to
have made an important step forward in the research literature.
Our work complements previous reviews7,29 vis a vis the
understanding of the role of exercise environment on
performance and well-being. We were able to find a larger
number of studies for the systematic analysis, and conduct
meta-analysis on a far larger data set, than previous reviews.
We conclude that the nature environment may help exercisers
and athletes to improve their performance through its
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facilitation of processes that are beneficial to task performance.
These processes include lower perceived exertion and
increased feelings of energy and arousal, in contrast to
exercising in indoor conventional venues. To the overall
population, nature-based exerciseinvolving inexpensive
physical activity, and affording increased feelings of energy
and lower exhaustion, as well as possible improvement in
cognitive functioning and overall efficiency and productivity in
their everyday activities may be a great possibility for
adopting and maintaining exercise behavior.
■
ASSOCIATED CONTENT
* Supporting Information
sı
The Supporting Information is available free of charge at
https://pubs.acs.org/doi/10.1021/acs.est.1c05151.
Table S1, Design, samples, interventions, settings,
outcomes, and results of the included studies (PDF)
■ AUTHOR INFORMATION
Corresponding Author
Henrique S. Brito − CIPER, Faculdade de Motricidade
Humana, Universidade de Lisboa, Cruz Quebrada −
Dafundo 1499-002 Lisbon, Portugal; orcid.org/0000-
0001-9387-5559; Email: hbrito@e-fmh.ulisboa.pt
Authors
Eliana V. Carraça − CIDEFES, Faculdade de Educaçaõ Física
e Desporto, Universidade Lusófona de Humanidades e
Tecnologias, Campo Grande 1749-024 Lisbon, Portugal
António L. Palmeira − CIDEFES, Faculdade de Educaçaõ
Física e Desporto, Universidade Lusófona de Humanidades e
Tecnologias, Campo Grande 1749-024 Lisbon, Portugal
José P. Ferreira − CIDAF, Faculdade de Ciências do Desporto
e Educaçaõ Física, Universidade de Coimbra, Estádio
Universitário de Coimbra, 3040-248 Coimbra, Portugal
Veronica Vleck − CIPER, Faculdade de Motricidade
Humana, Universidade de Lisboa, Cruz Quebrada −
Dafundo 1499-002 Lisbon, Portugal
Duarte Araújo − CIPER, Faculdade de Motricidade Humana,
Universidade de Lisboa, Cruz Quebrada − Dafundo 1499-
002 Lisbon, Portugal
Complete contact information is available at:
https://pubs.acs.org/10.1021/acs.est.1c05151
Author Contributions
All the authors contributed to, and approved, the final version
of the manuscript.
Notes
The authors declare no competing financial interest.
■
ACKNOWLEDGMENTS
We o thank the authors of the studies included in our meta-
analyses who sent us additional information and made their
original datasets available to us. Without their valuable
assistance, it would not have been possible to do this
review.21,23,96,24,33,58,68,71,73,78,93 D.A., H.B., and V.V. were
partly funded by the “Fundaçaõ para a Ciência e Tecnologia”
(grant number UIDB/00447/2020, awarded to CIPER−
“Centro Interdisciplinar para o Estudo da Performance
Humana” (unit 447).
74
■
pubs.acs.org/est Critical Review
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