Vol. 2, No.

3, Page 169-182
Copyright 2008, TSI Press Printed in the USA. All rights reserved

Horticultural Therapy has Beneficial Effects on Brain Functions in Cerebrovascular Diseases

Yuko Mizuno-Matsumoto *,1, Syoji Kobashi 2, Yutaka Hata 2, Osamu Ishikawa 3, and Fusayo Asano 4
University of Hyogo, Graduate School of Applied Informatics, Kobe, JAPAN University of Hyogo, Graduate School of Engineering, Himeji, JAPAN 3 Ishikawa Hospital, Himeji, JAPAN 4 Tokyo University of Agriculture, Department of Bio-therapy, Faculty of Agriculture, Tokyo, JAPAN
2 1

Received 15 May 2008; accepted 30 June 2008

Abstract Horticultural therapy (HT) is gaining attention as a form of rehabilitations in medical fields especially such as occupational therapy and nursing care, although its effectiveness has not been proven yet. This paper uses a strictly medical point of view to assess whether or not HT is effective for improvement of functional activities in the brains of brain-damaged patients. Five patients in Ishikawa Hospital with cerebrovascular diseases were invited to participate in HT for a month in addition to their routine medication and physical therapy (PT). The HT program was designed by horticultural therapists. The original purpose of the HT program was to monitor its effects on mental healing, cognitive re-organization, and training of sensory-motor function. The Functional Independence Measure (FIM) and the Self-Rating Depression Scale (SDS) were performed before and after HT to assess the patients physical activities of daily living (ADL) and to determine the patients mental changes in depressive states, respectively. Functional magnetic resonance imaging (fMRI) during recognition tasks was also measured before and after HT. The ADL of all patients significantly improved after HT; however, the depressive states in all patients did not change remarkably after the HT. fMRI examinations showed that the visual area, the inferior temporal area, the fusiform gyrus, and the supramarginal gyrus (SMG), in addition to the motor area, the supplementary motor area (SMA), the sensory area, and the cerebellum were activated after HT. These findings suggest that HT can accelerate an improvement of activities in the visual and color processing areas and the association areas as well as the sensory-motor areas of the brain in the patients with cerebrovascular diseases. HT, therefore, stimulates parts of brain, that are not always evoked through routine physical rehabilitation. HT can complement the routine physical rehabilitation and help to improve damaged brain function.

Corresponding author information: Yuko Mizuno-Matsumoto, M.D., Ph.D. (Medicine & Engineering) Graduate School of Applied Informatics, University of Hyogo Kobe Harborland Center Bldg. 22F, 1-3-3 Higashi-Kawasakichou, Chuo-ku, Kobe, Hyogo 650-0044, JAPAN, TEL/FAX: +81-78-367-8616/+81-78-362-0651, yuko@ai.u-hyogo.ac.jp

Keywords Horticultural therapy (HT), fMRI, Supramarginal gyrus (SMG), Visual area, Cerebrovascular disease, Functional independence measure (FIM)

1. INTRODUCTION
Horticulture is defined as the art and science of growing flowers, fruits, vegetables, and trees and shrubs resulting in the development of the minds and emotions of individuals and the enrichment and health of communities civilization [1]. Horticultural therapy (HT) is a remedial process in which plants and gardening activities are used to improve the body, mind, and spirits of people [2]. HT is thought to be an effective and beneficial treatment for people of all ages, backgrounds, and abilities. The therapeutic benefits of peaceful garden environments have been understood since ancient times. In the 19th century, Dr. Benjamin Rush, a signer of the Declaration of Independence considered to be the Father of American Psychiatry, reported that garden settings held curative effects for people with mental illness [2]. Soderback reviewed the literature on HT and described its use in rehabilitation following brain damage [3]. He showed that HT affected emotional, cognitive and/or sensory motor functional improvement and increased social participation, health, well-being and satisfaction with life. Jones and Haight reviewed articles on the use of the natural environment in the form of plants or plant material as therapeutic interventions [4]. They showed that there was a beneficial relationship between humans and the natural environment in the current therapeutic uses. Although HT has been strongly advocated, its effect is less established. Most papers on HT have been reported from the view of occupational therapy and nursing care. Therefore, the effectiveness of these interventionist approaches from the medical point of view remains to be proved, and it would have been desirable to perform subjective assessment of the approaches.

Ulrich [5] reported the positive influence of nature on patients in the hospital. Surgical patients assigned to rooms with windows looking out on a natural scene had shorter postoperative hospital stays, received fewer negative evaluative comments in nurses notes, and took fewer potent analgesics than patients in similar rooms with windows facing a brick wall. Ulrich et al. showed that influences of nature could reduce the emotional, attentional, and physiological aspects of stress using the Zuckerman Inventory of Personal Reactions (ZIPERS), which is questionnaire using affects (subjective aspects of feeling or emotion) to assess feelings [6]. Ulrich et al. also measured physiological reactions using an electrocardiogram (ECG), pulse transit time, spontaneous skin conductance response, and frontalis muscle tension using an electromyogram (EMG), and documented physiological changes related to recovering from stress, including low blood pressure, reduced muscle tension, and differences in cardiac responses. Soderback indicated that HT could categorize four different intervention approaches: virtual, viewing, interaction, and action [3]. In the routine occupational or physical therapies, a patient executes actions only according to the therapists instruction. On the other hand, in HT the patient can objectively imagine the growth of vegetation in his or her own way, actually see that the vegetation is growing and simultaneously perform his/her own activities as rehabilitations. Ulrich suggested that the benefits of nature such as trees and other vegetations were positive influences on emotional and physiological states of the people, and the benefits came from visual encounters with nature from urban planning point of view [7].

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We have investigated the effectiveness of HT on the hypotheses that (1) imagination, observation, and participation in growing vegetation makes a positive effect on a patients actual activities, and (2) viewing colorful vegetation in nature under sunlight improves the visual abilities in the brain. To prove these hypotheses, we designed experimental fMRI protocols that reveal visual, recognitional, motor, and emotional functions/abilities. In addition, we used the questionnaires to measure the activities of daily living (ADL) and the mental mood of the patients. The aim of this paper is to assess whether horticulture therapy is effective for improvement of brain functional activity in brain-damaged patients from the medical point of view.

126 as a perfect independent. There are 13 motor items ranging from 13 to 91 (eating, grooming, bathing, dressing the upper body, dressing the lower body, toileting, bladder and bowel management, transfers to bed/chair, toilet and tub/shower, walking/wheelchair, and stair climbing) and 5 cognitive items ranging from 5 to 35 (comprehension, expression, social interaction, problem-solving, and memory). Each patients FIM was scored at the beginning and ending of the HT to assess levels of ADL. All patients were evaluated as to whether or not they suffered from depression, based on the DSM IV-TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition TR) criteria. A medical doctor also evaluated mental status using indicators such as mood, motivation, communication, and expression with an observational study. Moreover, the Self-Rating Depression Scale (SDS) was used to evaluate not only depression but also the patients depressive states influenced by their mental mood. All patients were rated using the SDS in scoring only 20 items of the questionnaire. The relationship between mean SDS score of patients and diagnosis of major depression was reported [9]. This report showed that the SDS had a sensitivity of 80 percent and specificity of 88 percent for detecting patients with major depression. The SDS was performed before and after the HT to assess changes in depressive state. The SDS score ranged from 20 to 80. A score of more than 50 is supposed to show the possibility of a severe depressive state (possibility of severe major depression is high), and a score of 40-50 is supposed to show a moderate depressive state (possibility of a moderate depression is high). Five patients were invited to participate in HT designed by horticultural therapists for a month in addition to the routine medical and physical treatment given in Ishikawa Hospital. The purpose of HT program was to bring about effects in mental healing, cognitive re-organization, and training of sensory motor function. The HT consisted of three steps: imagining nature, designing a flowerbed, and

2. METHODS
Case #1 was a 75-year-old right-handed male patient who had suffered a right internal carotid artery occlusion and had left hemiplegia and dysarthria. Case #2 was a 42-year-old right-handed male patient who had suffered a left cerebral infarction and had right hemiplegia and aphasia. Case #3 was a 60-year-old right-handed female patient who had suffered a right anterior cerebral artery occlusion and had left hemiplegia. Case #4 was a 56-year-old right-handed male patient who had suffered right thalamic bleeding and had left hemiplegia. Case #5 was a 68-year-old right-handed female patient who had suffered bleeding in the right frontal lobe and had left hemiplegia and dysarthria. Written informed consent was obtained from all subjects and patients after a detailed briefing of the experimental purposes and protocol. The functional independence measure (FIM) is an evaluation tool used to quantify the ability of patients to enter rehabilitation treatment and to chart their progress until discharged into the community or to another facility [8]. The FIM is an assessment instrument rating a patients level of function in 18 physical and mental tasks that represent the basic ADL. The total score rage is from 18 as a perfect dependent to

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actually planting a tree. The therapists instructed the patients in all these processes. Table 1 shows an example of the HT program for each session in Case #2. The subject was able to experience the whole process of growing flowers including designing a garden,

creating a planting plan, preparing a flowerbed for seeding, seeding, watering, and making pressed flowers from his/her own flowers from the flowerbed. It took about a month to complete this process. Figure 7 in the Appendix shows some pictures of scenes from HT programs in Table 1.

Session 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Table 1. Horticultural Therapy Program for Case #2. Description of Programs Flowerbed preparation (weeding) Flowerbed preparation (weeding) Readying the soil Creating a planting plan for flowerbeds Briefing on future activities and selecting seedling Cultivating Terrarium making Planting to the flowerbed according to plan Planting seedling to flowerbed Soil readying, watering, and dividing seedling Watering, and picking up withered flowers Doing crafts using moss, and watering Watering Planting vegetables, weeding, dividing Making name plates for the flowerbeds Watering and weeding Watering, weeding, and appreciating other patients flowerbeds Making a container garden Making pressed flowers Working in the garden and a healthy forest landscape (pleasant) or a dying forest (unpleasant) in task 2. Each trial involved the consecutive presentation of the photos for 2 seconds proceeded by a crosshair image for 20-30 seconds (Figure 1). Subjects were instructed to fixate on a photo, and judge whether or not the photo was pleasant by moving their right index finger, or unpleasant by moving both the right index and middle fingers. Each task consisted of 20 blocks, half of which were pleasant, and half of which were unpleasant. Photos were randomly ordered within each task. The duration of each task was 516 seconds. In the study, five patients performed this experimental protocol using the fMRI scanner before and after HT.

Functional magnetic resonance imaging (fMRI) under recognition tasks was measured before and after HT. The experimental fMRI protocols were designed to reveal the hypotheses on the effectiveness of HT as we mentioned in Introduction. In the other words, viewing, recognition, movement, and the emotional functions/abilities of the patients were trying to be clarified. Subjects performed two kinds of tasks, in which they fixated on an image and categorized it into a pleasant image or an unpleasant image based on the previous instructions for each trial. Images included two kinds of emotional photos: a girls smiling facial expression (pleasant) or an angry facial expression (unpleasant) in task 1,

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1 block 20 blocks (516 sec)

Figure 1. Schematic diagram of fMRI measurement task. MR images were acquired on a 1.5 Tesla SIGNA CV/i scanner (GE Medical Systems, Milwaukee, WI). After initial acquisition of T1 structural images, echo planar imaging (EPI) was used to acquire data sensitive to the BOLD signal at a repetition time (TR) of 2000 ms and an echo time (TE) of 40 ms. High-resolution T1 images were acquired to aid in anatomic normalization. The spatial resolution of BOLD images was set by a 64 by 64 voxel matrix covering 260 260 mm2 with a 5 mm slice thickness. The image gave an in-plane resolution of 4.06 by 4.06 mm2. Twenty axial slices with 5 mm thickness were acquired to cover the whole brain. During the data acquisition, 258 images (phases) per slice were obtained in 516 seconds (= 258 x 2.0 sec). This produced a 4-D dataset consisting 64 64 20 258 voxels, in which a voxel is referred to as (x, y, z, t). Data analysis was performed with the Statistical Parametric Mapping analytic package (SPM5, Wellcome Department of Cognitive Neurology, London, UK). In the first step, we identified regions that showed significant activation during the pleasant or unpleasant images compared to those during the crosshair image. Activations were reported if they exceeded p < 0.05 (uncorrected) on the single voxel level in each patient. We showed images of the activation areas before and after HT. In the next step, the differences between the images before and after HT were calculated using the t-statistic, and contrast maps were generated for each patient. We extracted the increased areas in activity after HT compared to those before HT in each patient (p < 0.1). In the figures the areas in which activation decreased or did not change after HT were omitted.

3. RESULTS
The doctors clinical observations of the whole process left the impression that all the patients expressions and motivation had improved after the HT.

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Table 2 shows date information of subjects: onset of disorders, beginning of general rehabilitation, beginning of HT, first, before HT and second, after HT measurement of fMRI. HT began 6 months after the onset of

disorder in Case #1 and 2 years and 8 months after the onset in Case #2 although HT began 2-3 months after the onsets in Cases #3, #4, and #5.

Table 2. Date Information of subjects Case #1 Case #2 Case #3 Onset of disorder 12/6/2003 10/1/2001 6/28/2004 Beginning of rehabilitation 4/22/2004 4/2/2002 7/27/2004 Beginning of HT 6/8/2004 6/8/2004 9/25/2004 First trial 6/1/2004 6/1/2004 9/25/2004 fMRI Second trial 7/16/2004 7/16/2004 10/25/2004 Table 3 shows the total scores of FIM before and after the HT. The scores of motor and cognitive items are also shown in the table. The total scores of all the cases after HT are significantly larger than those before HT (paired T test: p < 0.03). The scores on motor items of all cases after HT are also significantly larger than those before HT (paired T test: p < 0.03), while there are no significant differences between the scores on cognitive items before and after HT (paired T test: p = 0.16).

Case #4 6/21/2004 8/14/2004 9/25/2004 9/25/2004 10/25/2004

Case #5 1/26/2005 3/11/2005 4/4/2005 4/4/2005 5/19/2005

The medical doctor ruled out all the patients except Case #2 as depression based on a diagnosis of DSM IV-TR criteria from the clinical point of view. Table 4 shows the scores of SDS before and after HT. Case #2 before and after HT is categorized into a severe depressive state, and Case #4 before and after HT and Case #5 after HT are categorized into a moderate depressive state as assessed by the SDS score. However, there are no significant differences between the SDS scores of all cases before and after HT (paired T test: p = 0.88). Case #3 86 53 33 116 81 35 Case #4 64 39 25 114 85 29 Case #5 59 33 26 104 75 29

Before HT

After HT
* p < 0.03

Total score Motor items Cognitive items Total score Motor items Cognitive items

Table 3. Scores of FIM Case #1 Case #2 62 91 38 72 24 19 92 89 68 71 24 18

* *

Before HT After HT
p = N.S.

Table 4. Scores of SDS Case #1 Case #2 Case #3 39 57 38 37 61 32

Case #4 47 45

Case #5 36 44

Figures 3 to 6 show the activated areas during the cognitive tasks before and after HT (p < 0.05), and the increased areas in activation after HT, compared to the level before HT (p < 0.1) in Cases #1 through #5, respectively.

Figure 3 shows that the bilateral visual areas (Brodmann areas: BAs 17 and 18), the right motor area (BA 4), and the left supplementary motor area (SMA) (BA 6), the right sensory areas (BAs 3 and 2), the right supramarginal

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gyrus (SMG) (BA 40), and the left cerebellum were activated after HT to compare to their activation level before HT in Case #1. Figure 3 shows that the bilateral visual areas (BAs 17 and 18), the left motor area (BA 4), left SMA (BA 6), the left sensory areas (BA 2), the bilateral temporal pole (BA 38), the right fusiform gyrus (BA 37), and the right cerebellum were activated in Case #2. Figure 4 shows that the bilateral visual areas (BAs 17 and 18) and the left cerebellum were activated

in Case #3. Figure 5 shows that the left visual areas (BAs 17 and 18) and the right prefrontal areas (BAs 10, 11, and 47), the sensory area (BA 1), the left SMG (BA 40), the bilateral middle temporal gyrus (BA 21), the right inferior temporal gyrus and fusiform gyrus (BA 20), the right temporal pole (BA 38), and the bilateral cerebellum were activated in Case #4. Figure 6 shows that the bilateral cerebellum was activated in Case #5.

Figure 2. Activated areas of Case #1 before HT (left) and after HT (middle) (p < 0.05), and increased areas in activation after HT, compared to the activation level before HT (right) (p < 0.1).

Figure 3. Activated areas of Case #2 before HT (left) and after HT (middle) (p < 0.05), and increased areas in activation after HT, compared to the activation level before HT (right) (p < 0.1).

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Figure 4. Activated areas of Case #3 before HT (left) and after HT (middle) (p < 0.05), and increased areas in activation after HT, compared to the activation level before HT (right) (p < 0.1).

Figure 5. Activated areas of Case #4 before HT (left) and after HT (middle) (p < 0.05), and increased areas in activation after HT, compared to the activation level before HT (right) (p < 0.1).

Figure 6. Activated areas of Case #5 before HT (left) and after HT (middle) (p < 0.05), and increased areas in activation after HT, compared to the activation level before HT (right) (p < 0.1).

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Table 5 shows a summary of the activated areas after HT in each patient (Cases #1 through #5). In the table, the letter A represents an increase of activation after HT, compared to the level before HT (p < 0.1). The letters O, F, P, T, and C represent occipital, frontal, parietal, temporal, and cerebellum, respectively. Each area number shows the Brodmann area in occipital, frontal, parietal, and temporal lobes. L and R show left and right hemispheres, respectively. The column in gray shows a disabled side in each patient.

The visual areas (BAs 17 and 18), the motor area (BA 4), SMA (BA 6), the prefrontal areas (BAs 10, 11, and 47), the sensory areas (BAs 3, 1, and 2), SMG (BA 40), the middle temporal gyrus (BA 21), the inferior temporal gyrus and fusiform gyrus (BAs 20 and 37), the temporal pole (BA 38), and the left cerebellum were activated after HT to compare to the activation level before HT. These events occurred in an unaffected side of cerebellum in all patients and the occipital area in all but one.

Table 5. Increased areas in activation after horticultural therapy in each patient (Cases #1 through #5). The letter A represents increased areas in activation after HT, compared to the level before HT (p < 0.1). The letters O, F, P, T, and C represent occipital, frontal, parietal, temporal, and cerebellum, respectively. Each area number shows the Brodmann area in occipital, frontal, parietal, and temporal lobes. L and R show left and right hemispheres, respectively. The column in gray shows a disabled side in each patient.
Case Area # 17 O 18 4 6 F 10 11 47 3 1 P 2 40 21 20 T 38 37 C p < 0.1 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A L A #1 R A L A #2 R A L A #3 R A L A #4 R L #5 R

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4. DISCUSSION
The effects of HT in the brain functions of cerebrovascular diseases were investigated using fMRI studies and questionnaires. The results in this paper show an increase of activations in the visual area, the motor area, SMG, sensory area, SMA, the prefrontal area, the inferior and middle temporal gyrus, the fusiform gyrus, the temporal pole, and the cerebellum. Recent fMRI studies reported that mainly recovered areas after the stroke using the routine rehabilitation were the sensory area, motor area, premotor area (PMA), cerebellum, SMA, and parietal areas[10, 11, 12]. Our results show that the visual area, the inferior temporal gyrus, the fusiform gyrus, and the SMG were activated in addition to the ordinarily recovering areas. HT could cause these differences in the process of recovering brain activities. The fusiform gyrus and the inferior temporal cortex are considered to be related to human color processing [13, 14, 15]. These color processing areas and visual areas increased their activities after HT. This result shows that processes of HT: virtual elements such as creating a planting plan (Figure 7-A), viewing nature (Figures 7-B to 7-G), interaction, and action through doing gardening jobs, under the sunlight, could have an effect on the color processing areas and visual areas in the brain. Our results show that viewing and concerning color processing might be essential in the effectiveness of HT. SMG is well known to play a roll in perception and discernment in the association area [16]. SMG might mediate a nonspatial attentional function, such as stimulus detection or alerting other areas to the appearance of a salient stimulus irrespective of a precise spatial location [17, 18]. The results presented here demonstrate that this kind of network area of the brain in addition to the motor, sensory, and visual areas increased its activities after HT. These findings suggest that the improved motor and sensory skills in the patients could be associated with reactivation or compensation of a physiological network such

as SMG in the brain. Our results show that HT contributes to their activations. HT can stimulate parts of brain not always evoked through routine physical rehabilitation. HT can compensate for routine physical rehabilitation and help to improve damaged brain function. Our results from one questionnaire showed that the daily activities in total score and motor items of FIM significantly improved. Compares with other therapies such as routine physical therapy, occupational therapy, music therapy, and animal therapy, HT has the following features: (1) a patient can objectively observe vegetation growing, (2) the patient can intervene in the process of growing vegetation from seeds, (3) the patient can actually see the results of his/her efforts when the vegetation has grown, (4) the patient can amicably share his/her achievements with other people. Spontaneous rehabilitation of the patient could be encouraged by repeated successful experiences of growing plants. We think that these features can help the patient improve his/her ADL. Our results from the other questionnaire, SDS, showed that mood was not changed remarkably in most patients. For mental mood or emotional improvement, a tailor-made program of HT during a long period would be needed. Another feature of HT is its beginning or onset time. Case #1 and Case #2 began 6 months and 2 years and 8 months, respectively after the onset (Table 2). In spite of the long time after the onset of disorders, Case #1s and Case #2s brain function activated after HT. This activation shows that HT can effectively improve brain function even if HT begins several months or years after the onset. The time of the onset of disorders therefore, might be irrelevant, because HT contains multifunctional elements, and the patient can move from fundamental activities to complex activities. We report here changes in brain function of five cases after HT. Now we are planning to

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target a larger number of patients who will participate in HT and we will investigate their brain activities through a quantitative statistical analysis in the future. We are also planning to compare patients given HT with patients not given HT. These five case studies proved the possibility that HT accelerates an improvement of activities in the visual and color processing area and the association area of brains in the patients with cerebrovascular diseases. Moreover, HT can

also help to contribute to improvement in the patients ADL. We think the research presented here is necessary to accomplish further studies.

ACKNOWLEDGEMENTS
This work is partially supported by a Grant-in-Aid from the Ministry of Education, Culture, Sports, Science and Technology, JP (19500393).

APPENDIX

A. Creating a planting plan

B. Selecting seedlings for flowerbeds

C. A flowerbed before weeding

D. A flowerbed soon after planting

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E. A flowerbed a month after planting

F. Flowerbeds and flowerpots planted by patient

G. Watering Figure 7. Scenes from Horticultural Therapy Programs

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AUTHOR INFORMATION
Yuko MizunoMatsumoto received the M.D. degree from Shiga University of Medical Science, Japan, in 1991, and Ph.D. degrees in Medical Science and Engineering from Osaka University, Japan, in 1996 and 2003, respectively. From 1999 to 2000, she was a Post-Doctoral

[10] Cramer S. C. (2004) Changes in motor system function and recovery after stroke. Restor. Neurol. Neurosci. 22 (3-5): 231-238 [11] Calautti C., Leroy F., Guincestre J. Y., et al. (2001) Sequential activation brain mapping after subcortical stroke: changes in hemispheric balance and recovery. Neuroreport 12 (18): 3883-3886

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Research Fellow in the Department of Neurology, Johns Hopkins University, Baltimore, MD. Since 2004, she has been an Associate Professor in the Graduate School of Applied Informatics, University of Hyogo, Kobe, Japan. She is a Certifying Physician of The Japanese Society of Psychiatry and Neurology, and a Certifying Physician & Electroencephalographer of Japanese Society of Clinical Neurophysiology.

Osamu Ishikawa is a Vice-President of Ishikawa Hospital, Japan. He is also the President of A Geriatric Health Services Facility, SEIYOU. His research interests are in medical imaging, surgery systems, and care systems for elderly persons.

Syoji Kobashi is an associate professor in Graduate School of Engineering, University of Hyogo, Japan. His research interests include soft computing approach to medical signal/image processing and human brain functions. He received the Joseph F. Engelberger Best Paper Award at the 2nd World Automation Congress in 2000, the IEEE EMBS Japan Young Investigators Competition from IEEE EMBS Japan Chapter in 2003.

Yutaka Hata is a professor in Graduate School of Engineering, University of Hyogo, Japan. He spent one year in BISC Group, University of California at Berkeley from 1995 to 1996 as a visiting scholar. He is the Founding Editor-in-Chief of the International Journal of Intelligent Computing in Medical Sciences and Image Processing, and the regional editor of Intelligent Automation & Soft Computing. He received Joseph F. Engelberger Best Paper Award and Best Paper Award at the WAC2000, USA. and WAC Contribution Award, at 2002, 2004 and 2006.

Fusayo Asano, Ph.D. in Agriculture, is a professor of Laboratory of Plant Assisted Therapy, Department of Bio- therapy, faculty of Agriculture, Tokyo University of Agriculture, Japan. She is a Horticultural Therapist Master at the American Horticultural Therapy Association and received Rhea McCandliss Professional Service Award in 2004 for her contribution to the field of horticultural therapy, especially in education. She is a founding director of the Japanese Society of People-Plant Relationships and Japanese Horticultural Therapy Association.

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