The Impact of Green Exercise on Cardiovascular and Musculoskeletal Health in Middle-Aged and Older Adults: A Scoping Review.

Growing urbanization has significantly contributed to the global burden of cardiovascular and musculoskeletal diseases. Green exercise, defined as structured physical activity in natural environments, has emerged as a potential intervention to address these health outcomes. This scoping review aims to synthesize the current scientific evidence on the cardiovascular and musculoskeletal benefits of green exercise among middle-aged (35-64 years) and older adults (≥65 years), examining potential mechanisms, intervention characteristics, and practical implications. A systematic search was conducted across PubMed, Web of Science, Scopus, and Google Scholar databases. Methodological quality was assessed to contextualize the strength of the findings. The available evidence suggests potential cardiovascular benefits, particularly in blood pressure regulation and heart rate variability, supported by both high and moderate-quality studies. Regarding musculoskeletal health, high-quality evidence appears to show improvements in muscle strength, lean mass and functional capacity, as well as reductions in fat mass. While green exercise appears to offer additional psychophysiological advantages over indoor exercise, results remain mixed regarding the clinical superiority of natural versus urban outdoor settings. Notably, significant benefits were observed across diverse frequencies and durations, suggesting that a strictly optimal dose-response remains elusive due to study heterogeneity. Consequently, green exercise appears to be a promising, evidence-informed strategy for healthy aging. While it is associated with improvements in cardiovascular and musculoskeletal health, its added value over traditional settings should be viewed as a complementary factor for adherence. Future research should prioritize high-quality mechanistic trials and standardized protocols to refine clinical prescriptions.