Christina Pozerskis

MSc Sport and Exercise Psychology

State of the Science Report

State of the Science

CAN

EXERCISE

MANAGE

PTSD?

Loughborough University

c.pozerskis-16@student.lboro.ac.uk

1

INTRODUCTION ........................................ 3

HOW EXERCISE CAN HELP ......................... 5

PTSD & PHYSICAL ACTIVITY ....................... 6

INACTIVITY CONSEQUENCES ..................... 7

FACTORS TO CONSIDER ............................ 8

WHAT DOES THE RESEARCH SHOW? ......... 9

EXERCISE FOR MILITARY VETERANS ........ 14

MOVING FORWARD ................................ 17

REFERENCES ........................................... 19

APPENDIX ............................................... 25

CONTENTS

2

The aim for the report is to inform on what we currently know about exercise as a form

of treatment for Post-Traumatic Stress Disorder (PTSD). This will include an objective

overview of evidence for the benefits of exercise; the underlying mechanisms in

explaining how exercise produces benefits; and how exercise should best be

promoted/prescribed for this high-risk population. The report does not necessarily

conclude that exercise is beneficial, and instead, reflects the current ‘state of the science’.

Note. Expanded keys for tables and figures are presented in the Appendix.

PREFACE

3

PTSD is an anxiety disorder that can occur in people who have experienced or witnessed a traumatic event such as a loss of a relative, sexual abuse, mass conflict, physical injury, or other violent personal assaults [1].

Of the 223.4 million U.S adults who experience a traumatic event at

least once in their lives, 20% develop PTSD.

8% - 24.4 million Americans have PTSD at any given time.

PTSD statistical sources [2, 3]

INTRODUCTION

1/9 women develops PTSD (about twice as likely as men).

15% of Vietnam Veterans and 12% of Gulf War Veterans

experience PTSD each year.

PTSD Statistics

4

Diagnosis

PTSD diagnosis is characterized by four broad symptom clusters [1]: Symptoms must cause clinically significant levels of impairment or distress in areas of psychosocial functioning and persist for more than a month and sometimes years.

A high prevalence of comorbid conditions is apparent among PTSD sufferers and may contribute to premature mortality [4]. These include chronic pain [5], major depressive disorder [6], substance use disorders [6], diabetes [7] and cardiometabolic diseases (CMD) [8]. For example, pooled prevalence of metabolic syndrome among people with

PTSD is 38.7% (doubled increased risk compared to general population) [8]. Also, for

every 10 PTSD symptoms endorsed, the odds of a subsequent metabolic syndrome

diagnosis increase by 56% [9].

PTSD Treatment

The UK’s National Institute for Health and Care Excellence (NICE) recognize two forms of therapy as primary PTSD treatments [10]:

• Trauma-Focused Cognitive Behavioral Therapy (CBT)

• Eye Movement Desensitization and Reprocessing (EMDR)

Intrusive thoughts

Avoiding reminders

Negative thoughts and feelings

Arousal and reactive symptoms

INTRODUCTION

These therapies typically involve weekly sessions lasting 60 to 90-min that are delivered by clinicians over a course of 8-12 weeks.

5

Many who suffer from PTSD face several barriers to treatment initiation, including perceived stigma attached to mental health treatment, low expectations of positive outcomes, accessibility, and cost of treatment [11]. Thus, the need for cost-effective and less stigmatized methods of coping are required. Exercise is now recognized as a complementary treatment to potentiate the traditional method of psychotherapy. Due to the association between PTSD, depression and anxiety, promoting exercise may act as an invaluable coping method in treating individuals with PTSD [1].

Strengths of exercise treatment [12]

include:

✓ Accessibility

✓ Low-cost

✓ No negative connotations

A 2015 meta-analysis review [13]

evaluated the effectiveness of physical

activity (PA) interventions in treating or

managing PTSD and found:

PA more effective at reducing PTSD

symptoms and depressive symptoms

than control conditions.

HOW EXERCISE

CAN HELP

‘Conventional

treatment for

PTSD can benefit

from the addition

of physical activity

interventions as

complementary

treatments’ [13].

6

Despite beneficial effects evidenced, people with PTSD show declines in PA over time

(Figure 1) [14]:

Following the onset of PTSD, substantial changes

in PA occur (Figure 2 and 3)

[15]:

Inadequate PA is the

fourth-leading risk factor

for mortality [16] and a

dominant risk factor for

CMD [17].

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.06

0.08

0.1

1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Ph

ysic

al A

ctiv

ity

Z-sc

ore

Study Year

Figure 1. Age-adjusted predicted physical activity trajectory over time by Trauma/PTSD group in full sample

No trauma

No PTSD

1-3 PTSD sm

4-5 PTSD sm

6-7 PTSD sm

PTSD & PHYSICAL

ACTIVITY

0

10

20

30

40

50

60

% d

eem

ph

ysic

ally

act

ive

Before PTSD After PTSD

0

10

20

30

40

50

60

% p

hys

ical

act

ivit

y p

arti

cip

atio

n

Before PTSD After PTSD

7

INACTIVITY

CONSEQUENCES

Unhealthy lifestyle behaviors

place people with PTSD at a

greater risk for developing

CMD [18] (Figure 4).

More importantly, reduced

levels of PA after PTSD onset

may be a route in which

severe PTSD symptoms affect

chronic disease risk [19].

Despite the evidence, focus

of clinical research on PTSD

populations has been on

minimizing adverse health

behaviors such as eating

disorders and tobacco use.

We should acknowledge

prime health results from

minimizing adverse health

behaviors AND addressing

health-promoting

behaviors (Figure 5) [20].

8

Multiple factors act as PA barriers that must be considered when forming PA

interventions (Figure 6). The majority reported by those suffering from PTSD appear

to be individual-related…

FACTORS TO

CONSIDER

Table 1. Factors negatively

affecting PA participation in PTSD

population [15]:

o Fibromyalgia (chronic pain

and tiredness)

o Sleep disruption

o Hyperarousal symptoms

o Anxiety

o Low mental and physical

quality of life

Systematic review of studies reporting

association between low PA

participation among PTSD sufferers

and [21]:

…Addressing

barriers through

modified PA

programs could

enable people

with PTSD to

improve long-

term physical

health trajectories

and quality of life

[21]. Despite these barriers, people with PTSD highly rate,

and feel prepared to adopt a healthier lifestyle.

9

AEROBIC EXERCISE

WHAT DOES THE

RESEARCH SHOW?

• Indirect effects via improved sleep

quality is of clinical value considering

insomnia co-occurs with PTSD and

persists even after successfully

treating PTSD symptoms.

• Exercise intensity is an important

factor in producing benefits.

KEY FINDINGS

Longitudinal research shows individuals diagnosed

with PTSD who engage in strenuous intensity exercise

(i.e. vigorous running and cycling), show significantly

less avoidance/numbing and hyperarousal symptoms

via improved sleep quality; reduced substance abuse;

less pain, compared to less active subjects [22].

Randomized controlled trials demonstrate the role of

the endocannabinoid (eCB) system that might

mediate positive outcomes in PTSD treatment

involving aerobic activity.

30 minutes of moderate intensity aerobic activity

activated the eCB system in individuals with and

without chronic PTSD [23], suggesting the eCB system

is dysregulated in PTSD [24]. Aerobic activity elicited

greater improvements in mood and reductions in pain

in individuals with PTSD (Figure 7). A later study

found, unlike in controls, one main eCB (2-

arachidonylglycerol) did not increase in response to

exercise or psychosocial stress in those with PTSD

(Figure 8) [25]. This may suggest adults with PTSD

have a blunted eCB response upon exposure to

different forms of stress compared to healthy

controls.

Additional research is needed if exercise is used to

treat mental health outcomes among individuals with

PTSD, because adults with PTSD show a blunted

mobilization of 2-AG in response to aerobic exercise.

10

WHAT DOES THE

RESEARCH SHOW?

AEROBIC EXERCISE

• Quick onset of mental health

benefits precipitated by aerobic

exercise.

Other mechanisms of action

evidenced:

• Strategies to maintain exercise

motivation are needed as PTSD

individuals are at risk of

discontinuing exercise post-

intervention.

KEY FINDINGS

Whether an individual with PTSD is accentuated

or distracted from somatic arousal during aerobic

exercise, implicit interoceptive exposure is likely

to augment beneficial effects [26]:

33 PTSD-affected patients were randomized into

three exercise groups each with a different

attentional focus

Towards

somatic

arousals

Distraction

from

somatic

arousal

No distraction/

interoceptive

prompts

Significant improvements in:

✓ Total PTSD symptom severity

✓ PTSD symptom clusters

✓ Anxiety sensitivity

All groups completed two weeks of six, 20-

minute aerobic exercise sessions

SENSE OF

ACHIEVEMENT

REPRIEVE

FROM

EVERYDAY

ANXIETY

MEANINGFUL

ACTIVITY RE-

ENGAGEMENT

INCREASED

ENDORPHIN

PRODUCTION

INTEROCEPTIVE EXPOSURE

Hyperventilation

Rapid heart rate

Muscular tension

Sweating

Exercise?

Panic attack?

Exposing patients to feared physiological

symptoms in the context of PA increases

tolerance for such symptoms.

Repeated exposure reinforces that

sensations may be discomforting but do

not pose a threat.

11

KEY FINDINGS RESISTANCE TRAINING

WHAT DOES THE

RESEARCH SHOW?

Resistance training (RT) serves as an alternative

when aerobic exercise is undesired and may

produce a net therapeutic effect on PTSD.

✓ A randomized controlled feasibility trial

[27] supported the anxiolytic effects of 3

weeks of RT for individuals with PTSD

(Table 2).

Research cataloging the effects of exercise dose

(i.e., intensity, frequency, and duration) on PTSD

and other psychological outcomes are necessary

before any optimal exercise prescription

recommendations can be made.

12

WHAT DOES THE

RESEARCH SHOW?

KEY FINDINGS AUGMENTATION PROGRAMS

Given the high prevalence of CMD among

people with PTSD, augmentation programs

may be a promising tool to elicit a dual-health

impact.

A 12-week exercise intervention (three 30-

minute resistance-training sessions/week and a

pedometer-based walking program) in addition

to usual care, compared to usual care alone,

demonstrated significant between-group

differences favoring the intervention group for

mental and physical health outcomes in in-

patients diagnosed with PTSD (Table 3) [28].

Exercise as an augmentation to exposure

therapy also has the potential enhance

psychological outcomes.

A small-scale randomized study testing the

efficacy of exercise in aiding exposure therapy in

adults suffering from PTSD, found greater

reductions in PTSD symptoms, and a large

impact on levels of brain-derived neurotropic

factor (BDNF) compared to prolonged exposure

alone (Figure 9) [29]. (Higher BDNF is associated

with enhanced learning, cognition, and

improved exposure-based treatment outcomes).

Exercise can therefore act as a cognitive

enhancer, particularly for those who have sub-

optimal response to routine treatment, via

promotion of synaptic plasticity.

13

WHAT DOES THE

RESEARCH SHOW?

INTERVENTION: 8 weeks of 1-hour trauma yoga

intervention classes for people with PTSD [38].

MEASURES: PTSD symptoms, depression, anxiety, stress

and interoceptive awareness assessed at baseline, week 2,

4, 6, 8, and week 2 and 8 post-intervention using

quantitative and qualitative measures.

FINDINGS:

• Significant increases in interoceptive awareness

(attention-regulation, self-regulation, and body-

listening) and significant decreases in PTSD

symptoms, depression, anxiety, and stress pre to

post yoga.

CONCLUSION:

Improving interoceptive awareness through yoga helps

trauma survivors regain mind-body connection that is

commonly lost following traumatic events and assist in

effective regulation of emotions and behaviours.

Large randomized control studies are needed to identify

the direct interaction effects and mediating relationships.

KEY FINDINGS YOGA

Yoga interventions has proven to treat a number of

trauma populations including war veterans [30],

tsunami survivors [31] and those with current full or

subthreshold PTSD symptoms [32]. Findings show

improvements for…

Changes in interoceptive awareness is proposed as a

mechanism behind the reductions in PTSD

symptoms and increases in well-being [33].

✓ PTSD symptoms

✓ Sleep quality

✓ Stress

✓ Positive affect

✓ Resilience

✓ Anxiety

…via enhanced

interoceptive

awareness

“I felt grounded and in

my body. I focused on

myself unlike other

classes where I just

follow instructions”.

“I found a calm during

practice where anxiety

and depression can be

put aside”.

14

Exercise-based interventions are considered a viable form of ‘alternative

medicine’ for veterans’ mental health.

• Less than 10% of veterans attend recommended

number of mental health appointments within first

year of PTSD diagnosis [34].

• Veterans generally have blunted responses to

traditional therapies compared to nonveteran

populations [35].

• Perceptions of stigma and institutional-related

barriers to care stop veterans with PTSD from

seeking treatment (Table 3) [36].

EXERCISE FOR

MILITARY VETERANS

PTSD symptom severity and avoidance symptoms

hold unique positive associations with barriers to

care, highlighting the impact of psychopathology

on veterans’ experiences and perceptions with

seeking help.

Exercise can reduce barriers to

treatment by:

✓ Requiring minimal supervision or can

be done at home;

✓ Being familiar to veterans;

✓ Naturally lending itself to the logistic

barriers i.e. cost of treatment,

scheduling, transport issues [37].

Table 4. Unadjusted Means and Standard

Deviations of Perceived Barriers to Care Subscales

15

EXERCISE FOR

MILITARY VETERANS

Participants in IE evidenced:

✓ More exercise activity and greater

reduction in PTSD symptom severity than

WL (Table 5).

✓ Greater improvement in psychological

quality of life among IE group, but smaller

relative improvement in physical quality of

life.

✓ High levels of satisfaction with

intervention i.e. less stigmatizing and

more practical, learning new skills,

distraction from negative experiences

(lowering hypervigilance).

KEY FINDINGS STRUCTURED PROGRAMS

Veterans (18-69y) meeting DSM-IV criteria for

current PTSD [38]

Waitlist control

condition (WL) (n=26)

Group-based Integrative

Exercise (IE): combining

aerobic, resistance and

mindfulness-based exercise

for 12 weeks (n=21)

Measurements (baseline, week 4, 8, 12)

PTSD symptoms (CAPS), quality of life, intervention

feasibility & acceptability, leisure-time exercise

The feasibility and efficacy of structured exercise programs

have also been evidenced among overweight veterans in

addressing the constellation of CMD risk [39], and in

women veterans [40]; an often-underrepresented group

within exercise and mental health research [41].

Authors state:

“Finally, for patients with

prominent avoidance related

to their traumatic events,

exercise may provide a safe

and structured activity that

can address social isolation

and promote recovery”

16

EXERCISE FOR

MILITARY VETERANS

KEY FINDINGS NATURE-BASED EXERCISE

16 war veterans with PTSD took part in a study

investigating how surfing may influence veterans’

psychological health beyond the medical emphasis on

treating symptoms and disorder [42].

Using interviews and participant observation,

psychological well-being increased via two main

mechanisms (Figure 7).

RESPITE FROM PTSD SYMPTOMS

RELATIONSHIPS WITH OTHER VETERANS

Valuable time in the present

Sense of absorption in activity

Keeping the chaos of PTSD at bay

Collectively challenging stigma

Sense of belonging and camaraderie

Reconnection with people

These findings exemplify how exercise can add to life -

through positive experiences - rather than eliminating

problems. Still, longitudinal research is required to examine

changes in veterans’ mental health after their engagement

with exercise-based approaches.

17

Given the strength and consistency of the emerging evidence, we suggest that exercise and PA

broadly, offers hope as feasible, safe and effective components of care. However, exercise-

based intervention research is still maturing, so we refrain from making damaging claims about

exercise as a ‘miracle cure’ for PTSD. Instead, we recognise the impact of exercise on improving

cardio-metabolic health, symptoms and well-being in PTSD sufferers, whilst acknowledging

areas that warrant further attention.

MOVING FORWARD

Exercise Prescription and Promotion: Using Current Evidence to

Inform Future Practice

Exercise frequency, intensity, mode,

and type

Current guidelines and research examining exercise

preferences for PTSD population [43, 44] suggest:

• 150min of moderate PA per week is unrealistic and

discouraging for PTSD patients. Instead, start at a

non-challenging level with something enjoyable (i.e.

walking, yoga) and progress to include vigorous-

intensity exercise (which appears effective in

coping with hyperarousal symptoms).

• One-to-one exercise in private setting may help

individuals suffering from avoidance symptoms

build confidence before transitioning to small group

settings (shown as helpful in addressing social

barriers and motivation to exercise).

• Preference in location and form of exercise meeting

the needs of PTSD individuals should be a guiding

factor (i.e. distraction from thoughts during

exercise using music or challenge of exercise;

activate feelings of enjoyment through group-based

exercise or exercising outdoors).

Adherence to exercise

Interventions should extend beyond the relationship with

the clinician and include techniques in Self-Determination

Theory to motivate continued exercise [45]. Promoting an

autonomy-supportive environment is key:

• Opportunities for self-direction and choices (e.g.

to opt-out/in during sessions).

• Participation in shaping sessions (e.g. proposing

exercises).

• Experiencing personal mastery together with

positive self and group experiences (e.g. feedback

and encouragement from trainers and other

participants, becoming aware of own skills and

coping abilities).

18

MOVING FORWARD

Non-medical promotion

Promoting a ‘non-medical approach’ rather than ‘exercise as medicine’ is crucial for PTSD

sufferers, and especially for veterans [46]. Benefits include:

• Positive associations of exercise with physical culture of military.

• Perceived distance from passive, clinically oriented approaches e.g. taking

medication.

• Avoidance in constructing exercise as something ‘obligatory’.

Individualized treatment

Patient-specific exercise prescriptions are essential

considering the medical complexities amongst the PTSD

population [47, 48]. Exercise-based interventions should:

• Understand each client’s triggers and symptom

severity to tailor instruction and activity

appropriately.

• Provide a safe environment where clients can

relax and focus on health and well-being during

exercise.

• Offer adaptations within exercise prescriptions to

address the diverse physical functioning needs

(i.e. daily fluctuations in pain or mobility may

mean rigid prescription is not feasible).

19

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25

Appendix 1: Expanded keys for tables

Table 2. Sleep quality and latency measured using Pittsburgh Sleep Quality Index; PTSD symptoms using

Post-Traumatic Diagnostic Scale for DSM-5; anxiety using State-Trait Anxiety Inventory; depression

using Centre for the Epidemiological Studies of Depression Short Form.

Table 3. PTSD symptoms measured using Post-Traumatic Stress Disorder Checklist-Civilian; depression,

anxiety and stress using Depression Anxiety and Stress Scale; PTSD related sleep quality by Pittsburgh

Sleep Quality Index Addendum for PTSD; body fat % obtained using a bio-impedance scale; waist

circumference defined as the point mid-way between iliac crest and costal margin; time spent sitting

per day assessed using the International Physical Activity Questionnaire-Short Form.

Table 4. Items were rated on a 4-point scale with 1=not at all, 2=slightly, 3=moderately, and 4=very

much.

Table 5. Leisure-time exercise activity measured using Godin Leisure-Time Exercise Questionnaire.

APPENDIX

26

Appendix 2: Expanded key for figures

Figure 1. Includes women with trauma/PTSD during follow-up, between 1989 and 2009 (n=15,353).

Predicted values of physical activity are plotted.

Figure 2 and 3. Includes Brazilian patients with PTSD (n=50).

Figure 7. Total Mood Disturbance scores obtained from Profile of Mood States (POMS) questionnaire;

pain measured using the McGill Pain Questionnaire-Short-Form (MPQ-SF).

Figure 9. Plasma BDNF analyzed by RayBiotech, Inc. (Norgross, GA) using a sandwich enzyme-linked

immunosorbent assay (ELISA) kit.

APPENDIX