Revisiting therapeutic landscapes in the spa context: toward a multisensory, evidence-based framework for healing environments

Abstract

The therapeutic potential of spa landscapes represents an emerging intersection between environmental psychology, medical geology, health geography, and wellness tourism research. This narrative review synthesizes existing empirical findings and theoretical frameworks to examine how spa environments contribute to human health and well-being outcomes. Historically, European spa towns exemplify therapeutic landscapes, rooted in the use of natural healing resources such as mineral waters, gases, peloids, and climate. These environments are shaped not only by their physical resources but also by multisensory qualities, spatial aesthetics, and cultural traditions, which together create complex therapeutic settings. Drawing from landscape architecture, environmental psychology, therapeutic horticulture, and medical geography, this review explores the mechanisms through which natural and designed spa landscapes facilitate healing processes. Evidence suggests that benefits arise from interactions between environmental quality, embodied experiences, and social and cultural factors. Yet scientific understanding remains fragmented, and no unified typology of spa environments, whether medical or wellness-oriented, or across various global contexts, currently exists. This review highlights the need for interdisciplinary empirical studies and proposes a conceptual basis for future research bridging environmental science, health geography, and wellness studies.

Introduction

The therapeutic landscapes of European spa towns are rich tapestries woven from historical, cultural, and medical threads. These places have long been recognized for their healing abilities, primarily due to their natural healing resources, such as mineral water, gases and peloids, which have been utilized for therapeutic purposes for centuries. These elements are often rich in essential minerals and compounds that can alleviate various health conditions and disorders, ranging from musculoskeletal, cardiovascular, and endocrinological to respiratory or dermatological (Gutenbrunner et al. 2010). The application of natural resources in spas usually includes traditional treatments such as hydrotherapy and balneotherapy, which are designed to harness the body’s innate healing processes.

Unlike generic therapeutic environments (such as green spaces or hospitals), spa landscapes are multisensory, commercialized, and ritualized spaces with deep historical and cultural significance. The concept of spa towns as centers for health and wellness is deeply rooted in European history, with significant development occurring during the 18th and 19th centuries. This period involved the establishment of a network of spa resorts across Europe, each characterized by its unique composition of healing sources and therapeutic offerings, which catered to the dual purpose of healing and leisure (Porter 1990). Today, these spa towns continue to attract visitors seeking both relaxation and rejuvenation, offering a blend of traditional treatments and modern wellness practices that enhance the overall experience for health-conscious travelers (Smith and Dryglas 2020).

The sustainability and adaptive reuse of these historic spa towns are also crucial for their ongoing relevance. Research indicates that the valorization of cultural landscapes in these towns can foster interdisciplinary cooperation and innovation, contributing to sustainable urban development (Fabi et al. 2021). The preservation of historical architecture and the promotion of natural resources are essential for maintaining the unique character of these towns while ensuring that they meet modern tourists’ expectations (Walton 2012).

There is a heightened focus on integrating natural and cultural heritage into the experiences of individuals visiting spas, fostering activities that encompass both recreational enjoyment and elements of therapeutic programs alongside established medical methodologies (Dudek and Piegdoń 2021; Smith 2021). The need for interactions with nature was also heightened by the COVID-19 pandemic (Doughty et al. 2023). Even though clients still visit spas primarily for therapeutic treatment, the spa environment itself, including its sensory qualities, spatial aesthetics, and immersive atmosphere, has emerged as a critical secondary driver of perceived benefit and motivation for return visits (Plzáková and Crespo Stupková 2019).

Comprehensive spa treatment often involves various techniques, such as hydrotherapy, balneotherapy, climatotherapy, and other holistic treatments designed to rejuvenate the body and mind (Frost 2004).

However, the scientific understanding of how specific environmental and sensory variables within these spa settings relate to health and well-being remains fragmented and unevenly theorized. Existing empirical studies vary considerably in their focus, methodological approaches, and conceptual grounding, particularly regarding sensory qualities, spatial configurations, and environmental affordances of spa landscapes. Moreover, the extent to which this body of research engages with broader theories of therapeutic landscapes and public health remains inconsistent.

This review synthesizes existing empirical and conceptual research across different categories of spa environments, with a primary focus on traditional European medical spas, situating their environmental and sensory characteristics within broader spa typologies. In doing so, it aims to clarify current research trajectories, identify conceptual and empirical gaps, and contribute to the development of an evidence-informed foundation for future research and policy applications.

Review methodology

This article is structured as a narrative literature review aimed at synthesizing current knowledge on therapeutic spa landscapes by integrating findings across environmental, architectural, and psychosocial domains. The goal is to provide a theoretical foundation for future interdisciplinary, evidence-based research. Narrative review methodology has been used for its ability to include a wide variety of studies and provide an overall summary, with interpretation and critique (Green et al. 2006). The search was carried out in four distinct steps: identification, screening, eligibility, and inclusion. Searches were conducted in three scientific databases, Web of Science, Scopus, and PubMed, with the search terms stated in Table 1. The search dates were restricted to 1992, when Gesler’s therapeutic landscape definition was published.

Table 1.

Search terms, fields and combinations

Search terms combinations with Boolean operators					Database search fields
“therapeutic mobility” OR		“spa” OR		“healing” OR	In Web of Science “Topic”
“therapeutic landscape*” OR		”spas” OR		“wellbeing” OR	In Scopus “Author, Title and Abstract”
“forest*” OR		“balneo*” OR		“health”	In Pubmed “Author, Title and Abstract”
“park*” OR	AND	“health resort medicine”	AND
“blue space” OR
“green space” OR
“negative air ions” OR
“volatile compounds” OR
“natural healing source” OR
”nature therapy”

The initial search was conducted in September 2024, and the final search was conducted in December 2024. In total, 232 sources were retrieved. After duplicates were discarded, 173 studies were forwarded to eligibility testing via inclusion criteria on the basis of the modified PICo framework (Hosseini et al. 2024): studies involving (P) individuals using spa facilities for therapeutic, rehabilitative, or wellness purposes; (I) investigations into the environmental, sensory, or cultural features of spa landscapes and their influence on health and well-being; and (Co) settings explicitly identified as spa environments, including medical spas, health resorts or hot and mineral springs. Both qualitative and quantitative studies were considered, as were reviews and theoretical papers contributing to the conceptualization of therapeutic spa landscapes, and the exclusion criteria were as follows:

• Studies in languages other than English.

• studies in which the term “therapeutic landscape” refers to medical/pharmaceutical treatment.

• Studies not discussing the therapeutic landscape or therapeutic potential of a place.

• Studies that use the term “spa” as an abbreviation of a term unrelated to health resorts.

• Studies discussing solely the touristic, not the therapeutic, aspects of spas.

• reviews (however, a set of relevant reviews was used for better contextual information).

The final number of original studies included was 22. To enhance thematic depth and context, we also included relevant conceptual sources identified through manual citation tracking. While this may introduce narrative selection bias, the approach aligns with best practices in exploratory reviews aiming to map the conceptual terrain and identify gaps in emerging fields.

Owing to the interdisciplinary nature of the topic and the diverse distribution of findings across environmental, sensory, and social dimensions, the results are integrated thematically throughout the manuscript rather than reported in a separate results section.

Therapeutic landscape

According to the European landscape convention (Council of Europe 2000), landscape is defined as a part of the land, as perceived by local people or visitors, which evolves through time as a result of being acted upon by natural forces and human beings. The therapeutic landscape is then seen as a combination of this physical environment, social interactions and human perceptions combined to produce an atmosphere that is conducive to healing. The definition of this concept was originally articulated by health geographer Wilbert Gessler in 1992 in his work, he explores the intersection of health and place, emphasizing how geographical and cultural contexts influence health outcomes and medical practices. He argues that landscapes are not merely backdrops for health-related activities but are integral to the therapeutic process itself (Gesler 1992, 1993, 1998). The intersection of holistic medicine and therapeutic landscapes highlights the importance of understanding how various elements, such as community engagement and cultural beliefs, interact with physical environments to shape health outcomes and patient well-being (Williams 1998). In addition, the therapeutic landscape concept extends beyond physical spaces to include the social and cultural dimensions of health. Andrews explored how therapeutic geographies can influence treatment practices and suggested that both physical and nonphysical aspects of healthcare environments play crucial roles in patients’ experiences (Andrews 2004). Similarly, Conradson (2005) suggested that it is helpful in analytical terms to distinguish between a ‘therapeutic landscape’ and a ‘therapeutic landscape experience’. As a relational analysis indicates, the attribute ‘therapeutic’ is often more precisely assigned to particular forms of self-landscape encounter rather than to the landscape itself.

The therapeutic landscape model is rooted in both humanist and structuralist traditions, allowing for a nuanced understanding of how landscapes can be perceived and experienced differently by individuals on the basis of their cultural and social contexts (Kearns and Milligan 2020). Since its initial conception, positioned by Gesler, the concept has developed in various empirical and theoretical directions and has evolved as individual and social perceptions change over time (Bell et al. 2015, 2018; Taheri et al. 2021). Therapeutic landscapes not only facilitate physical healing but also enhance mental and emotional well-being (Finlay 2018).

While the concept of therapeutic landscapes provides a well-established theoretical framework for understanding the interplay between environment, perception, and health, its application within empirical spa research remains uneven. In many studies, the concept functions primarily as a descriptive or contextual reference rather than as an explicit analytical framework guiding study design, variable selection, or interpretation of findings.

Therapeutic spa landscape

The term “therapeutic spa landscape” was initially mentioned during the nomination of eleven European spa towns into the World Heritage List of UNESCO (2024). The therapeutic landscape is described as a beautiful natural landscape setting in which healing mineral waters are found. The great spa towns of Europe represent settlements with exceptionally well-preserved historical urban structures and a purposefully landscaped urban environment connected to the surrounding nature.

When we look back at the roots of therapeutic landscape theory, the foundational studies discussing this concept have been bound to specific locations with a reputation for healing, e.g., Epidauros, Bath or Lourdes (Gesler 1993, 1996, 1998). These studies emphasized that health transcends biological or medical issues and is deeply intertwined with the environments where we live and heal.

The example of Bath illustrates the evolution of the spa town, initially linked to Roman and pagan healing narratives. The place evolved through chemical analysis of mineral springs, medical endorsement, calculated commodification of health, social prestige, and fashion (Gesler 1998). Spa towns Lisdoonvarna (Ireland) and Te Aroha (New Zealand) underwent similar progress over time (Foley et al. 2011), similar to European spa towns, when health practices in spa towns transitioned from simple immersion and drinking of mineral water to more complex, medicalized hydrotherapy treatments, driven by advancements in technology and medical knowledge. This evolution underscores that humans (visitors) are not isolated entities but rather beings that are deeply connected to their environments (Gesler 1993).

The reputation of spa towns as healing places is deeply intertwined with their historical geographies, which influence how visitors perceive and experience these environments. This historical significance adds another layer to the therapeutic landscape, as the cultural narratives associated with these towns can enhance the psychological benefits of visitors (Foley et al. 2011).

It is generally known that common features of spa towns include mineral water springs or other natural healing sources, along with infrastructure such as inns, hotels and bathhouses surrounded by forests and parks designed to host visitors and patients. According to Gesler’s (1998) theory of the therapeutic landscape, in addition to this physical environment, it also involves the social and spiritual environment. The social environment here is represented by a reputation for healing, the historical context, social relations and shared activities, and the spiritual environment is represented by symbolism, visitors’ beliefs, expectations and perceptions. However, Dryglas and Salamaga (2023) investigated the therapeutic spa landscape as a value added to touristic products and reported that among visitors to European spa towns, the therapeutic landscape is currently associated mostly with the natural environment.

Although many studies have been conducted on the effects of these environments on health and well-being, there is still a gap in both theoretical and empirical research that focuses on the detailed composition or definition of the therapeutic spa landscape and its therapeutic potential. In this study, we explored how various elements, such as water features, vegetation diversity, and spatial organization, can influence and possibly enhance the therapeutic effects of spa therapeutic procedures.

Water

In the vast majority of spas, the healing potential is primarily based on minerals or hot springs. The term “spa” itself has its origins, probably rooted in the Latin phrase “salus per aqua,” which translates to “health through water” (Frost 2004). This etymology reflects the historical association of spas with therapeutic water treatments, a practice that dates back to ancient civilizations. Additionally, the name “spa” is believed to have been influenced by the town of Spa in modern-day Belgium, renowned for its mineral springs. This town became synonymous with the healing properties of its waters, further cementing the connection between the term and health-related water treatments (Smith 2009).

From a health geography and environmental medicine perspective, water in spa settings is conceptualized as a “blue space,” known for its capacity to promote psychological restoration, reduce stress, and facilitate sensory immersion (Foley and Kistemann 2015; Smith et al. 2022). These effects have been observed not only through drinking or full-body immersion (Bell et al. 2015; Severin et al. 2022) but also through visual engagement with water or even proximity to aquatic environments (Foley and Kistemann 2015; Takeda et al. 2023; Costa-Pinto 2024).

A substantial body of empirical research has already demonstrated the clinical benefits of mineral water therapies, particularly in the treatment of musculoskeletal, gastrointestinal, dermatological, and metabolic conditions. Spa-based drinking cures (Di Marco et al. 2020) and mineral water baths (Huber et al. 2019) are typically grounded in these localized empirical findings, with each spa locality offering unique mineral compositions tailored to specific indications. The therapeutic identity of each location is shaped by its distinctive spring characteristics, which are already medically codified and regulated in many countries.

The symbolic and sensory presence of water is almost universally perceived as beneficial, contributing to an atmosphere of calm, immersion, and healing. This experiential dimension of water reinforces its role as both a physical and symbolic driver of wellness. Hot spring baths also hold cultural and symbolic significance, functioning as ritualized landscapes that integrate spiritual, recreational, and therapeutic values for local communities and visitors alike (Serbulea and Payyappallimana 2012; McIntosh et al. 2021).

The physical setting surrounding spas, such as promenades, forested trails, and parklands, is not merely aesthetic; it also contributes physiologically through the release of bioactive compounds, similar to other natural healing resources (Moore 2015). In this context, the therapeutic value of spa water must be understood within a larger system of environmental coexposure, requiring a shift toward multivariable, integrative research models.

Geology and hydrogeology

In spa locations, healing sources are frequently aligned with active fault structures in the Earth’s crust that facilitate the ascent of geothermally heated, mineralized waters to the surface. These geostructural features not only shape the hydrogeochemical profile of spring waters but also may enable the emission of naturally occurring substances, including both harmful and potentially beneficial elements, from deep within the Earth’s crust (Krcmár and Vylita 2001). The negative health effects of geogenic elements, such as radon, arsenic, and lead, have been widely studied, particularly in relation to chronic exposure through groundwater or “geogas” in residential areas. Elevated levels of these elements have been linked to increased risk of cancer, neurological dysfunction, and developmental toxicity, leading to strict regulatory limits in drinking water and building environments (Ernst 2012).

In contrast, there is a notable lack of empirical research investigating the positive health effects of naturally emanated biogenic elements from geological sources, such as magnesium, calcium, and sodium ions, or trace elements such as boron and selenium, especially when they are present in the form of airborne “geoaerosols” near mineral springs or thermal vents. For example, a study conducted in the Slovak Republic demonstrated that higher levels of calcium and magnesium in drinking water were associated with improved public health indicators among the population (Rapant et al. 2017). These findings support the idea that geologically derived elements may exert a positive influence on human physiology.

It has been hypothesized that these biogenic particles or aerosols, which may diffuse into the lower atmosphere along fault zones, could contribute to neuroendocrine balance, immune function, and psychomotor restoration, particularly in natural spa settings where individuals are exposed during therapeutic walks.

However, direct evidence for these effects remains scarce. This represents a research gap at the intersection of medical geology, environmental medicine, and health geography. While the health risks of toxic geogenic exposures are well documented, the potential therapeutic effects of beneficial lithospheric emissions remain largely unexplored.

Air quality

Spa resorts must adhere to exceptionally high standards for air quality. Even minor air pollution, which might be considered acceptable elsewhere, is perceived as an adverse factor in spas. In most spa towns, air quality is controlled by legal regulations (e.g., quality criteria of the European Spas Association - ESPA (2012)). These regulations ensure that the environment remains conducive to relaxation and healing, allowing clients to immerse themselves fully in the therapeutic experience without the stressors of urban pollution.

On the other hand, pollution (Pitt 2018; Mei et al. 2021) can have completely opposite effects, as can the presence of an unpleasant odor (Bignante 2020) or visual proximity to industrial zones or busy roadways, where even noncontact exposure can diminish the perceived therapeutic value of the landscape (Valenti and Mi 2010).

The presence of negative air ions, which are molecules that have gained one or more electrons, resulting in a negative charge, has been associated with various environmental and health benefits, particularly with improved air quality (Yan et al. 2015). These ions are naturally abundant in environments such as forests, waterfalls, and mineral springs (Kurt Kung and Pollack 2014) and are clearly perceived by visitors in spa towns such as Bad Gastein (Austria). Their concentration is particularly high near open-air inhalatoria and salt towers, such as those in Ciechocinek and Inowrocław (Poland), where negative ions have been linked to a reduction in airborne pathogens, including bacteria and viruses (Burkowska-But et al. 2014).

High concentrations of negative air ions contribute to a cleaner, fresher atmosphere by binding to airborne pollutants such as dust and allergens, thus potentially improving respiratory comfort and overall well-being for spa clients (Lazzerini et al. 2018; Jiang et al. 2018).

Nonetheless, studies have demonstrated that areas with high vegetation cover, such as parks and forests, tend to have relatively high concentrations of negative ions, which correlate with improved air quality. Forests, in particular, are known to generate negative ions through the photoelectric effect on leaf tips during photosynthesis, making them continuous natural generators of ion-rich air (Tammet et al. 2006).

Experimental studies under laboratory conditions have suggested that direct repeated exposure to negative air ions can reduce symptoms of psychological illness and enhance mental health (Pino 2013). However, more recent reviews have reported insufficient or inconclusive evidence of consistent health benefits from negative air ion exposure in humans (Bailey et al. 2018).

Despite the acknowledged importance of air quality in spa settings, several research gaps remain. One of them is microclimatic monitoring, which is often limited to general urban stations and lacks the spatial resolution needed to capture air quality at key treatment zones, such as forest paths, spring zones, or inhalatoria.

This highlights the need for spa-specific air monitoring protocols for localized, high-resolution air quality assessment in the designated treatment and leisure zones of spa towns (Fig. 1).

Fig. 1.

Conceptual framework of the therapeutic spa landscape

Vegetation

In addition to the negative ions mentioned above, vegetation also emits various volatile compounds called phytoncides, which are involved in plant growth, reproduction, defense, and even communication (Laothawornkitkul et al. 2009). One class of volatile organic compounds produced by trees that play important roles in their ecology and interactions with other organisms are monoterpenes. Among other compounds, the most common are α-pinene and β-pinene, which are found in the resin of coniferous trees (Ghirardo et al. 2010).

Research under laboratory conditions indicates that pinens exhibit anti-inflammatory (Rufino et al. 2014; Nam et al. 2014), anticancer (Matsuo et al. 2011; Kusuhara et al. 2012; Chen et al. 2015) and neuroprotective properties (Porres-Martínez et al. 2016). Li’s (2010) research suggested that the inhalation of phytoncides during forest bathing can increase the immune system through increased levels of natural killer activity. This enhancement occurs both directly, through inhalation of organic compounds such as α-pinene and limonene, which stimulate the number of perforin-, granzyme A-, and granulysin-expressing lymphocytes in the blood, and indirectly, by reducing stress hormones such as cortisol and adrenalin.

However, while the therapeutic effects of monoterpenes are well supported by experimental data, their ambient concentrations in spa environments, particularly in urban spa parks or landscaped forests, are rarely measured. This represents a research gap in understanding actual visitor exposure to these compounds in real-world spa settings.

However, the therapeutic potential of spa greenery is not limited to the substances emitted by vegetation. It is also species diversity which is perceived by visitors. The feeling of visitor satisfaction is higher the higher the species diversity is (He et al. 2022). Methorst et al. (2021) and Kučera et al. (2015) support this by their research on the species diversity of spa greenery followed by bird diversity, creating a “soundscape” that has a positive impact on mental health and overall well-being. During walks in parks and forests, one can “plug-in” all five senses, which is the main principle of Japanese shinrin-yoku, a practice that encourages individuals to immerse themselves in nature and engage with their surroundings through sight, sound, touch, smell, and even taste. Such quality encounters and their therapeutic effects have been studied by many researchers (Li 2010; Koga and Iwasaki 2013; Yau and Loke 2020; Peterfalvi et al. 2021; He et al. 2022; Bell et al. 2023).

The positive perception of natural encounters is rooted in our natural affinity for life. Wilson (Wilson 1986) described this phenomenon in his book as biophilia, the very essence of our humanity. In addition to its soothing effect (Doughty et al. 2023), nature-based therapy influences physical health. For example, Peterfalvi et al. (2021) reported that participants had lower blood pressure after 2-hour leisure forest walks. Immersion in nature promotes connectivity with surrounding vegetation, animals or other people, which resonates with the supposed therapeutic role of exposure to the natural environment (Lea 2008).

Although forest walks have positive impacts on human health throughout the year (Peterfalvi et al. 2021), it is also important to consider seasonal variations (Strauss-Blasche et al. 2002; Yin et al. 2024) and the potential adverse effects of such walks under unfavorable weather conditions (Oomen-Welke et al. 2022). Nature can act therapeutically even indirectly through virtual reality (Depledge et al. 2011; Reese et al. 2022) or just by looking at scenic photographs (Bao 2023). This can play a role for those who are physically unable to access nature.

We must not forget the role of spa greenery as a sound barrier, protecting spa visitors from unsolicited noise. This acoustic benefit not only enhances the tranquility of the environment but also contributes to a more immersive and restorative experience for individuals seeking relaxation and rejuvenation. Spatial organization, including the division of zones for healing, silencing, and recreation, further enhances therapeutic outcomes by ensuring functional and sensory harmony in spa parks (Sztubecka et al. 2022). Although fully planted aromatic plants can enrich these parks with additional sensory experience, they have been proven to be beneficial for therapeutic purposes (Marcus and Sachs 2014). Spa parks can also contribute to visual therapy through their aesthetic features and landscape composition (Krisantia et al. 2021).

Architecture and aesthetics

The architecture and aesthetics of spa towns play pivotal roles in shaping visitors’ experiences and reinforcing the therapeutic character of these landscapes (Dryglas and Salamaga 2023). Elements such as historic colonnades, pavilions, fountains, and garden architecture contribute to an environment that evokes tranquility, dignity, and continuity. Thoughtful spatial composition, including axial paths, symmetry, secluded zones, and visual openings, supports a sense of order and harmony. These features, often inherited from the landscape traditions of the 19th and early 20th centuries, foster place identity and emotional bonding for spa visitors (Foley et al. 2011).

Structural design also contributes to the formation of therapeutic environments by integrating physical and built elements with social conditions and human perceptions. The sensual qualities of architectural environments can enhance the therapeutic experience (McIntosh et al. 2021).

However, spa environments are rarely evaluated for their aesthetic qualities and the extent to which these qualities contribute to therapeutic outcomes. This stands in contrast to healthcare settings such as hospitals, where although research on aesthetics and healing remains relatively shallow, some studies have examined the role of design, color, light, and spatial layout in patient recovery and well-being (Gesler et al. 2004; Dijkstra et al. 2006). Such investigations are far less common in spa contexts, leaving a significant gap in understanding how architectural beauty and sensory harmony may amplify the health benefits of the spa environment.

Therefore, there is a need for closer cooperation among spa operators, urban planners, architects, and landscape designers to ensure that future development or renovation projects preserve not only the historical and aesthetic values of spa environments but also their therapeutic function.

Social interactions and emotional perception

The social dynamics inherent to spa towns significantly enhanced their appeal, as the leisure activities offered in these settings often facilitated meaningful social interactions among visitors. These interactions are widely regarded as contributing positively to mental well-being.

The therapeutic landscape concept emphasizes the importance of social and cultural contexts in shaping health experiences. For example, in traditional healing landscapes, the interactions among patients, physicians, and the environment contribute significantly to the healing process (Gesler 1993).

Foley (2011) also described therapeutic landscapes as being as much about social opportunities as they are medicinal. Social interactions influence both individual experiences of healing and the broader cultural contexts that shape these experiences. The interplay between social dynamics and environmental factors is essential for understanding how places can promote health and well-being (Doughty 2018). Conradson’s (2005) theory of the therapeutic landscape experience, as an encounter between the self and the landscape, offers an important framework for understanding how individuals engage with and interpret the therapeutic environment on a deeply personal level. This approach highlights the need to consider the subjective, embodied experience of place, where the encounter between oneself and the landscape fosters reflection, identity formation, and emotional restoration. The therapeutic landscape experience is often described as important as the therapeutic environment itself (Andrews et al. 2014).

During their therapeutic stay in spa, visitors can escape from everyday life and stress (Little 2013). This retreat allows individuals to disconnect and help them rejuvenate mentally (Lea 2008; Edwards 2022). Subjective therapeutic perception can also be amplified by the presence of sacred places in the spa landscape. The relational dimensions of these sites allow for individual interpretations and quests for healing, accommodating traditional religious practices while also providing alternatives for those who may find conventional places of worship less inviting (Perriam 2015).

A longer stay in a medical spa can also contribute to improving quality of life in the domain of social relations, especially in older patients (Zwolińska et al. 2018). Interplay between social engagement and physical activity not only enhances the quality of life for older adults but also encourages a sense of community, reducing feelings of isolation and loneliness that are often prevalent in this demographic.

Doughty (2013) described how engaging in shared activities creates opportunities for communication and bonding, enhancing the overall social atmosphere. The same conclusion was reached in their research by Grant et al. (2017). When they describe how social interaction during communal walks can contribute to overall well-being, especially in older people. His findings are considered against the therapeutic landscape and therapeutic mobility theories. This is supported by Gatrell (2013), who considers the integration of movement in therapeutic activities important, particularly through activities such as walking, which has been shown to foster social connections and promote physical health.

Research on social experiences within spa environments remains limited and has focused predominantly on short-term outcomes, whereas potential long-term social benefits remain underexplored. Notably, the influence of digital communication technologies (e.g., smartphones or social media platforms) on restorative social interactions in spa settings has yet to be thoroughly investigated. The extent to which digital engagement facilitates or impedes social connectedness in these therapeutic contexts remains ambiguous and represents an important gap in the current literature.

Physical activity in the therapeutic spa landscape

Physical activity is associated with favorable neurobiological changes, such as increased oxygen to the brain and improved neural plasticity, which may alleviate symptoms of mental disorders such as depression and anxiety (Cotterill and Kotera 2023).

Frühauf et al. (2020) emphasized that engaging in physical activity in natural settings can amplify its benefits, providing a greater impact on the immune system and mental health than other environments do. These findings are in agreement with the findings of Olafsdottir et al. (2020). Physical activity in therapeutic environments combined with balneological treatments can even increase therapeutic outcomes [36].

It has been proven that easy access to green and blue spaces can significantly influence physical activity levels (Bell et al. 2014; White et al. 2016; Pasanen et al. 2019). Marques et al. (2021) also argued that outdoor spaces designed with accessibility in mind can help overcome barriers to rehabilitation, thereby promoting greater participation in physical activities.

The general benefits of movement in nature are well documented (Gladwell et al. 2013), but there is limited evidence regarding the optimal type, intensity, and duration of physical activity required to achieve maximal health benefits in spa settings.

Conclusions

In this review, we synthesize empirical and conceptual research on therapeutic spa landscapes, with a particular focus on traditional European medical spa contexts. The findings highlight the inherently complex and multidimensional nature of spa environments, which combine natural healing resources, sensory experiences, architectural and spatial design, and sociocultural interactions. While historical and theoretical foundations for spa environments are well established, empirical evidence linking specific environmental variables to measurable health outcomes remains limited and uneven.

Across the reviewed literature, several consistent patterns emerge. Environmental qualities of spa settings are frequently acknowledged as important contributors to therapeutic experience, yet they are rarely operationalized as independent variables within empirical study designs. Sensory dimensions, such as visual coherence, soundscapes, or atmospheric conditions are often described descriptively rather than measured systematically. Although the concept of therapeutic landscapes is widely cited, it is seldom employed as an explicit analytical framework guiding hypothesis formulation, methodological choices, or interpretation of findings. The absence of a unified typology of spa environments, spanning medical and wellness-oriented settings across diverse geographical contexts, further complicates comparative analysis and evidence synthesis.

From the authors’ perspective, this fragmentation appears to reflect a broader conceptual challenge rather than a lack of scholarly attention. Spa landscapes occupy an ambiguous position between medical treatment, leisure, cultural heritage, and commercial wellness, resulting in parallel research traditions that rarely intersect. Consequently, environmental and sensory dimensions are frequently treated as contextual background rather than as active components of therapeutic processes. This limits the field’s ability to articulate how, and under what conditions, spa environments contribute to health outcomes beyond the effects of specific treatments.

Future studies should address these gaps through standardized measurement protocols and interdisciplinary approaches. In particular, we propose empirical investigations into whether higher environmental quality is associated with improved clinical and self-reported well-being outcomes; how the aesthetic and multisensory qualities of spa settings mediate perceived therapeutic benefit; and the extent to which social and cultural factors enhance healing experiences and influence return visitation. Further research is needed to explore psychological and physiological mechanisms, such as stress reduction and cardiovascular or neuroendocrine responses, as well as the long-term behavioral impacts of spa visitation on physical activity and wellness habits.

By systematically testing these hypotheses through longitudinal and experimental designs, future research can strengthen the evidence base for integrating environmental quality, cultural heritage, and health promotion within spa landscapes. Such advances would support more nuanced public health strategies and inform the sustainable planning, preservation, and adaptive development of spa destinations.We acknowledge several limitations in this study. The review methodology identified only 22 original empirical studies that focused explicitly on therapeutic landscapes in spa settings, highlighting a significant gap in the existing evidence. This limited dataset may restrict the comprehensiveness and generalizability of the findings. Although an additional manual search was performed to supplement the database results, this step may have introduced a degree of selection bias, reflecting our interpretive judgment in source inclusion.

Furthermore, while this review aimed to explore a wide range of environmental and experiential elements relevant to therapeutic landscapes, it may not fully capture all variables that influence health outcomes in spa settings. Notably, many of these outcomes, such as perceived tranquility, emotional relief, or social connection, are inherently subjective and highly context dependent, which complicates efforts at standardized measurement. This subjectivity, while central to the therapeutic experience, poses challenges for empirical validation and underscores the need for methodological pluralism in future research.

Author contribution

Jana Walterová: Writing – original draft, Writing – review & editing, Methodology, Investigation, Conceptualisation. Tomáš Vylita: Writing – review & editing. Alina Huseynli: Writing – review & editing. Supervision, Funding acquisition, Conceptualization.

Funding

This work was supported by the “Spa Research Centre” project (CZ.10.01.01/00/22 001/0000261) supported by the Operational Programme Just Transition, European Just Transition Fund.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used AI for copy editing to improve the academic writing and readability of the study. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Competing interests

The authors have no competing interests to declare that are relevant to the content of this article.