Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

The Effect of Physical Activity on PTSD

Lauren M. Oppizzi & Reba Umberger

To cite this article: Lauren M. Oppizzi & Reba Umberger (2018) The Effect of
Physical Activity on PTSD, Issues in Mental Health Nursing, 39:2, 179-187, DOI:
10.1080/01612840.2017.1391903

To link to this article: https://doi.org/10.1080/01612840.2017.1391903

Published online: 10 Jan 2018.

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ISSUES IN MENTAL HEALTH NURSING
, VOL. , NO. , –
https://doi.org/./..

The Effect of Physical Activity on PTSD

Lauren M. Oppizzi, MSN, RNa and Reba Umberger, PhD, RN, CCRN-Kb
a
PhD Student, College of Nursing, University of Tennessee, Knoxville, Tennessee, USA; b Assistant Professor, College of Nursing, Department of Acute
and Tertiary Care, The University of Tennessee Health Science Center, Memphis, Tennessee, USA

ABSTRACT
Although physical activity (PA) is known to reduce anxiety and depression, less is known about the
effects of PA on post-traumatic stress disorder (PTSD). The author examined the state of the science
regarding the effect of PA on PTSD. Three themes emerged: PA characteristics, added benefits of PA as
a PTSD intervention, and theories on the method of action. Physical activity seems to be an effective
adjunct therapy to reduce PTSD symptom severity. Findings are inconsistent between observational and
controlled studies. More research is needed to identify the most effective type, dose, and duration of
exercise.
The primary author is responsible for review, synthesis, and analysis of the literature as well as preparation
of the manuscript. The corresponding author is responsible for reviewing and editing the manuscript.
All authors have reviewed the submitted manuscript and approve the manuscript for submission.

SUMMARY STATEMENT
Why is this review needed?
r Post-traumatic stress disorder is a debilitating condition that is growing in prevalence and, if untreated
or undertreated, can have significant impact on individuals, families, and ultimately the society at
large.
r Traditional treatment includes psychotherapy and pharmacotherapy; however, many who suffer from
post-traumatic stress disorder have limited access to these treatment modalities.
r The Institute of Medicine has called for research into cost-effective, complementary treatments to
potentiate the traditional method of combined psychotherapy and pharmacotherapy.
What are the key findings?
r Physical activity has been shown to reduce symptoms of post-traumatic stress disorder in persons
with subsyndromal symptoms and persons resistant to standard treatment.
r Physical activity has also been shown to improve health conditions that may accompany PTSD (e.g.,
anxiety, depression, sleep disturbances, and cardiovascular disease).
How should the findings be used to influence policy/practice/research/education?
r Clinicians should include patient-specific exercise prescriptions in their plan of care for treating those
with PTSD (e.g., walking program, aerobic activity, or yoga).
r Interventions for persons with PTSD should extend beyond the relationship with the clinician, and
include methods that motivate continued exercise.
r Research should focus on the type and amount of activity that is most effective for treat-
ing persons with PTSD, including the length of time needed for optimal improvements to be
maintained.

Introduction four defining components of PTSD: negative thoughts, avoid-

ance or numbing, re-experiencing, and hyperarousal.
Post-traumatic stress disorder (PTSD) is a debilitating psycho-
logical condition that occurs after exposure to a single or a
series of traumatic events that include military combat, ter-
rorism, abuse, rape, childhood neglect, natural disasters, and Background
witnessing injury or death. Traumatic events can also occur Negative thoughts include persistent guilt or shame, fear, lack of
indirectly, such as when someone hears details regarding the trust, and/or a general lack of interest in activities or relation-
death or injury of a loved one (American Psychiatric Associa- ships they once enjoyed (APA, 2017). The term avoidance is the
tion [APA], 2017; Newman & Motta, 2007). The DSM-5 defines deliberate effort to avoid experiences, senses, people, or loca-
PTSD as the development of characteristic symptoms (following tions that provoke memories of the traumatic event; this also
one or multiple traumatic events) that persist for months, years, includes emotional desensitization to avoid feelings associated
or decades (American Psychiatric Association, 2017). There are with the traumatic event. This can lead to isolation and makes

CONTACT Lauren M. Oppizzi [email protected] University of Tennessee, College of Nursing, Knoxville, TN,  Volunteer Blvd Knoxville, TN , USA.
©  Taylor & Francis Group, LLC
180 L. M. OPPIZZI AND R. UMBERGER

it difficult for the individual to relate to loved ones. The third retained for analysis. Articles that examined the effect of physi-
defining component, re-experiencing, occurs when the individ- cal activity on other mental disorders and not specifically PTSD
ual relives the traumatic event through a reminder (e.g., when were excluded.
a veteran hears a firework explode in the sky, it may trigger a
memory of a traumatic combat experience). The memories may
Data abstraction
seem so real that they experience similar feelings of horror that
they had when the initial trauma occurred. The final defining Content from each article was abstracted and entered into a
component, hyperarousal, is when the individual is constantly matrix table to allow for appraisal of the relationship between
emotionally heightened. This can lead to problems such as anx- PA and PTSD. Select variables describing the articles included
iety, insomnia, and difficulty with concentration. These symp- are shown in Table 1 .
toms contribute to substantial social and occupational impair-
ment and poor physical health (Rosenbaum, Sherrington, &
Synthesis
Tiedemann, 2015a).
Common treatments for PTSD include psychotherapy (e.g., Three common themes emerged throughout the analysis: phys-
cognitive behavioral therapy, exposure therapy) and pharma- ical activity characteristics, the added benefits of utilizing PA
cotherapy. However, many who suffer from PTSD have limited as a PTSD intervention, and current theories on the method of
access to these treatments, and scientists within the Institute of action.
Medicine have recognized the need for adjunct, complemen-
tary, and cost-effective therapies to increase efficacy of current
Results
treatment (Babson et al., 2015; Institute of Medicine [IOM],
2012; Mitchell et al., 2014; Newman & Motta, 2007; Van der Some authors from these studies explored the effect of PA on
Kolk et al., 2014). It is well established that PA has an alleviating PTSD, while others sought to understand what type and length
effect on anxiety and depression (Babson et al., 2015, Fetzner of physical activity intervention is needed to achieve a reduc-
& Asmundson 2015, Newman & Motta 2007, Rosenbaum et al., tion in PTSD symptoms. This relates to the most effective “dose”
2015a). Though PTSD was once classified by the DSM IV as an or type of activity and the most effective “duration” or length
anxiety disorder (Newman & Motta 2007), it is now classified of activity. The study measures, along with primary outcome
as a trauma-and-stressor-related disorder (APA 2013). Anxiety measures used to evaluate the effectiveness of the intervention
and PTSD share common clinical characteristics and are closely in each study are shown in Table 1. Lastly, a summary of cur-
affiliated, yet, they are now recognized as two distinct classifi- rent theories on the methods of action were included by some
cations of psychological disorders; thus, how PA impacts PTSD authors.
is not well established. These factors warrant an exploration of
current literature on the effect of PA on PTSD symptom severity
Physical activity characteristics
to inform future research efforts on this topic.
The studies included various types and lengths of PA, including
The review
aerobic exercise (e.g., bicycling, walking), yoga, and resistance
or strength training.
Aim
Aerobic exercise. Newman & Motta’s (2007) intervention
This paper provides a critical analysis of the research literature included various aerobic activities of moderate intensity, such
related to the effect of PA on PTSD symptoms. It will conclude as jump rope and jogging. They defined moderate intensity as
with a summary of what is known and not known about the 60–80% of the target heart rate for 30 minutes at a time. The
effect of PA on PTSD and identify areas for future research. authors recruited 15 adolescents from a treatment facility who
met PTSD criteria; however only 11 were compliant with the
entire exercise intervention, and thus 11 were reported in the
Design
findings. Changes in pre-post intervention measures within sub-
This is a state of the science review. jects over time had a large effect in reducing PTSD symptoms.
Paired sample comparisons using both the Children’s PTSD
Inventory (CPTSDI) and the UCLA Post-Traumatic Stress Dis-
Search methods
order Reaction Index for DSM-IV, Revision 1: Adolescent Ver-
The first author searched Web of Science, Psych Info, Pubmed, sion (PTSD-RI) scales suggested a significant reduction in PTSD
and CINAHL using a university library database system. Article symptoms in baseline versus post-intervention scores (CPTSDI
abstracts and titles were searched for the following keywords: baseline M = 19.00, post M = 5.90, p < .001; PTSD-RI baseline
physical exercise, physical activity, exercise, post traumatic stress M = 31.31, post M = 10.27, p < .001). Based on the CPTSDI,
disorder, and PTSD. Results were limited to literature published all study participants met full criteria for PTSD diagnosis; post
within 10 years and in English language. Manual searches were intervention, only one (9%) participant did. The score differ-
also conducted using reference lists from publications. ences for PTSD-RI indicate a reduction in PTSD severity post
intervention. Study findings are significant but limited due to a
small sample size (N = 11).
Search outcome
Babson et al. (2015) also found improvements in PTSD
The total number of articles retrieved was 94. The titles and symptoms after an intervention that included aerobic activity.
abstracts were screened for relevance, and 13 publications were Study participants were male veterans who were in a 60–90 day
Table . Selected variables describing the articles in included in the state of the science Review.

Concurrent
First Author, Year Purpose Population Design/Method Sample Size Activity Type Treatment Activity Length PTSD Measure∗ Findings

Babson,  Assess the impact Male veterans, Non-experimental,  Aerobic (cycling: CBT† Variable, PCL-M No difference in PTSD by PA.
of sleep and – y/o pre/post test total days and – day However, there was a
exercise on inpatient with design miles cycled program difference in those with poor
PTSD severity PTSD during baseline sleep quality
nonresponsive treatment)
to treatment
Diaz,  Evaluate PA on Females, Non-experimental,  Aerobic-(walking- Residential PTSD  weeks CPSS Significant reduction in PTSD
PTSD symptom – y/o, single group, moderate treatment symptoms post intervention.
severity in inpatient‡ pre/post test intensity:
adolescents design and  min sessions
repeated x/week)
measures
Fetzner,  Evaluate if PA has Civilians, mostly RCT, pre/post test ,  groups of Aerobic (cycling, No psychotherapy or  weeks PCL-C All groups reported decreased
anxiolytic aerobically design with   six -minute new PTSD symptoms over time but
effects on “untrained”; equal groups sessions plus psychopharma- no differences were detected
PTSD and if full and (distraction, any existing therapy in the between the groups. High
attentional sub-syndromal interoceptive pretreatment past  months loss-to-follow-up at one
focus has an PTSD prompts, and PA PA) month required data
influence alone) imputation for almost % of
the sample.
LeardMann,  Evaluate U.S. service Non-experimental, , Moderate, Unknown Variable, PCL-C Odds for developing PTSD or
association of members Retrospective vigorous, and self-reported persistent PTSD decreased
type/amount analysis of survey strength annual survey with activity
of PA on PTSD data from the training ranked over a  year
Mellennium by  categories period.
cohort study. (very active,
active, slightly
active, inactive,
or cannot be
physically
active).
LeBouthillie,  To quantify Secondary Hierarchical linear  Aerobic (cycling) See Fetzer,   weeks PCL-C Aerobic exercise reduced PTSD
reduction of analysis of modeling symptoms regardless of
PTSD as a Fetzer’s  baseline cardiovascular
function of RCT. fitness level.
cardiovascular
fitness level.
Mitchell,  Evaluate effect of Females, RCT, pre/post test  Yoga ( minute Psychotherapy  or  weeks PC-PTSD; PSS-I; Both groups experienced a
yoga on PTSD – y/o; full design groups:  session once or (.%), any recent PCL clinical and significant
and Yoga,  control twice per change in decrease in PTSD symptoms
subthreshold week) psychotropic (change in total PCL) but
PTSD medication was there was not a significant
an exclusion difference between groups.
criteria.
Newman,  Evaluate PA on Females, Longitudinal study,  Mixed moderate Individual or group  weeks CPTSDI; PTSD-RI Significant reduction in PTSD
PTSD, anxiety, – y/o, Single group aerobic (three therapy (all), symptoms from baseline to
and depression Inpatient with pre/post test -minutes psychotropic post intervention by CPTSDI
in adolescents PTSD-RI score repeated group medication (%) and PTSD-RI with a large
ISSUES IN MENTAL HEALTH NURSING

of at least  measures exercises per effect.

week)
(Continued on next page)
181
Table . Continued 182

Concurrent
First Author, Year Purpose Population Design/Method Sample Size Activity Type Treatment Activity Length PTSD Measure∗ Findings

Powers,  Evaluate if PA Females, Pilot RCT, pre/post  Aerobic (treadmill Prolonged exposure  weeks PSS-I Large between group effect size
plus exposure – y/o test design Small  minutes (PE) therapy for increase in BDNF levels
therapy groups: PE with prior to each ( minutes per and decrease in PTSD
increases BDNF exercise vs PE PE session) week ×  weeks) symptoms.
levels and alone
enhances
improvement
in PTSD
Price,  Evaluate Females, Nonrandomized,  Weekly, one-hour Psychotherapy,  weeks CAPS DTS DES Significant reduction in PTSD
effectiveness – y/o single-group Trauma pharmacotherapy symptoms
of extended feasibility study, sensitive yoga
L. M. OPPIZZI AND R. UMBERGER

yoga pre/post test class, home

intervention design practice
on chronic x/week
PTSD
symptoms
Rosenbaum, a Evaluate RCTs to Adults >  Mean Meta-analysis of   Yoga, aerobic, varies – weeks PSS-I PCL-C Pooled date from all  RCTs
date for the ages – y/o RCT resistance CAPS showed reduction in PTSD
effect of PA on training symptoms with PA
PTSD
Rosenbaum, b Evaluate impact % male, % RCT, assessor  Aerobic, walking Psychotherapy,  weeks PCL-C Significant decrease in PTSD
of exercise female, blinded Groups: plus three group therapy, symptoms for participants
program on – y/o, Usual care (n =  minutes pharmacotherapy with PA versus usual care
PTSD inpatient ) vs usual care resistance alone
symptoms plus PA (n = ) sessions each
week
Rosenbaum,  To assess the % male, % Retrospective  Aerobic Inpatient therapy as  weeks (check) PCL-C Significant & negative
relationship female, . ± pooled analysis of (self-reported reported above correlation with walking &
with PTSD . years, prior RCT PA PTSD
severity and inpatient questionnaire-
other variables IPAQ-SF§ )
on time spent
in moderate PA
and walking
Van der Kolk,  Yoga compared Females, RCT Groups: Trauma  Yoga (one hour Pharmacotherapy  weeks CAPS Greater PTSD decline in exercise
to education in – y/o with Informed Yoga (n per week) group
reducing PTSD PTSD, = ) vs
nonresponsive Supportive
to treatment women’s health (n
= )
∗ Post-Traumatic Stress Disorder (PTSD) is operationally defined in these studies by using the following instruments: The Clinician administered PTSD Scale for DSM- (CAPS-) is the “Gold standard” for the general population, since
it is a structured clinical interview versus a self-report measure. The PTSD Checklist-Military Version (PCL-M) is a revised version of the PTSD checklist for DSM- (PCL-), which is a  item self-report measure that is used to monitor,
screen, and make a provisional diagnosis of PTSD based on DSM- symptoms. Variants of the military version include changes in the rating scale, in instructions, and wording when referring to the index event. The PTSD Checklist-
civilian (PCL-C) is a  item self-report measure that correlates with the DSM- symptoms criteria, and does have differences in the rating scale and is not interchangeable with the PCL-. The Children’s PTSD inventory (CPTSDI)
is a clinician administered scale that can be utilized in children aged – years, and is based on the DSM-IV criteria. The UCLA Post-Traumatic Stress Disorder-Reaction Index (PTSD-RI) is a self-report measure that assesses PTSD
symptoms based on DSM-, and can be used in people aged  years and older. The Child PTSD symptom scale (CPSS) is a  item self-report instrument that assesses PTSD symptom severity in children aged – years and is based
on DSM-IV, and the PTSD Symptom Scale-Interview (PSS-I) is a  item measure and is a semi-structured interview that can be administered by a lay person. It assesses for the presence and severity of PTSD based on DSM-IV. The
Davidson Trauma Scale for PTSD (DTS) is a self-reported measure that asseses severity and frequency of PTSD symptoms based on DSM- criteria. The Dissociative Experiences Scale (DES) is also self-reported and measures the level
of dissociation (Price et al., , Steinberg & Beyerlein, , U.S. Department of Veterans Affairs, ).
† Cognitive behavioral therapy is abbreviated CBT.
‡ The term inpatient indicates a PTSD treatment facility.
§ The International Physical Activity Questionnaire Short Form (IPAQ-SF) is an instrument that is used to assess physical activity.
 ISSUES IN MENTAL HEALTH NURSING 183

inpatient cognitive behavioral therapy rehabilitation program center. Walking was measured by a pedometer and recorded in a
due to treatment resistance. They were invited to volunteer in walking diary by participants. The authors reported a significant
cycling intervention during their stay. The authors collected data improvement in PTSD symptoms (primary outcome measure)
on miles and number of days cycled, and evaluated the dose of as assessed by the PTSD checklist-civilian (PCL-C). There was
exercise by examining PSTD symptoms by three exercise groups a moderate post-intervention effect between the intervention
[none, moderate (<59.6 miles), and high (>59.6 miles)]. No dif- group as compared to the control (non-active) group (MD
ferences between baseline and discharge PTSD symptoms were = −5.4, 95% CI −10.5 to −0.3, p = .04). Poor adherence
detected among participants who did and did not exercise; how- (<20% turned in their walking diaries) to the full interven-
ever, interaction effects among sleep quality and exercise on tion prevented the authors from detecting a dose response of
a PTSD symptom cluster were detected. Those who had poor PA on PTSD. Results suggested that a walking program that
baseline sleep quality and exercised experienced a significant includes resistance training in addition to usual care signifi-
reduction in hyperarousal symptoms (β = −.24, p = .002). They cantly improved PTSD symptoms as compared to those who
concluded that cycling is a beneficial adjunct therapy to treating only had the usual treatment for PTSD (e.g., psychotherapy,
hyperarousal symptom of PTSD in those with poor sleep quality. pharmacological intervention, and group therapy).
Benefits from aerobic cycling were further confirmed by Fetzner Based on the above findings, aerobic activity, regardless of the
and Asmundson (2015), yet, general PTSD symptoms improved type, has demonstrated a reduction in PTSD symptom sever-
and were not isolated to any of its defining components. ity. Neither study that included cycling interventions demon-
Fetzner and Asmundson (2015) conducted a randomized strated strong evidence of a reduction in all PTSD symptoms;
controlled trial (RCT) to examine whether a cycling interven- however, both studies had significant limitations that impacted
tion has anxiolytic effects in PTSD and also explored whether internal validity of the study (e.g., self-selected groups, unreli-
or not a difference in attention and focus during the activity able measure of sleep quality, and no non-active control group)
would influence this. Civilians (N = 33) who were mostly aer- and potentially undermined results. Use of a walking interven-
obically untrained with full blown PTSD symptoms or subsyn- tion also demonstrated an improvement in general PTSD symp-
dromal PTSD were randomized into three groups: (1) PA plus toms, though one study sought to achieve aerobic capacity (Diaz
interoceptive prompts, (2) PA plus cognitive distraction, and (3) & Motta, 2008), while the other did not assess heart rate; instead,
PA alone. Interoceptive prompts meant that the instructor called these authors included steps taken as a data point (Rosenbaum
participants to focus on specific bodily sensations, such as the et al., 2015a). Statistically significant reduction in PTSD symp-
contraction of a certain muscle group every five minutes dur- toms in both cases suggest the need to distinguish whether or
ing the activity. Cognitive distraction meant participants were not there is a difference between aerobic PA and dose (e.g., steps
directed to view a nature show. They assessed changes in PTSD taken) in reducing symptom severity. Regardless, the studies
(total score and subscales) over time in the intervention group that include PA with more aerobic tendencies (i.e., jump roping,
using hierarchical models. Each intervention group contained walking, cycling) suggest that this type of PA can lessen PTSD
11 participants; however, almost half of the group participants symptom severity, whether it’s a targeted defining component,
were lost to follow-up at one month. The authors used impu- such as hyperarousal (Fetzner & Asmundson, 2015), or a reduc-
tation methods to account for missing data. The sample size tion in general PTSD symptoms over time (Babson et al., 2015;
was small; nevertheless, the use of repeated measures increased Diaz & Motta, 2008; Newman & Motta 2007; Rosenbaum et al.,
the power to detect differences. There was a significant reduc- 2015a).
tion (p < .01) in PTSD (total and all subscales) symptoms over Yoga. Though yoga is not an aerobic exercise, it has been
time within all intervention groups, yet no significant difference shown to be beneficial to mental and physical health and
in PTSD symptoms between intervention groups. Each group hypothesized to reduce PTSD symptom severity (Mitchell et al.,
engaged in PA, and participants self-reported clinically signifi- 2014; Rosenbaum et al., 2015b). Mitchell et al. (2014) and Van
cant reduction in PTSD symptom severity in all groups. der Kolk et al. (2014) conducted a pilot study that demon-
Walking has also been utilized as an aerobic PA intervention strated that the impact of the group (yoga intervention versus
in PTSD. According to Rosenbaum et al. (2016), it is easily assessment control) was not statistically significant to detect a
incorporated and translated across settings. Ease of use and relationship between the effect of yoga on PTSD symptoms. The
acceptance among various populations also enhances partic- authors report a clinically significant improvement in PTSD
ipation and sustainability. Diaz and Motta (2008) included a severity over time in the yoga group (measured weekly by PCL-
twenty-five-minute moderate-intensity walking intervention, C during the intervention). A clinically significant reduction in
where participants (N = 12) self-monitored and reported their PTSD is defined as a 10 to 20-point change in the PCL-C score
heart rates at select moments during the exercise to ensure (Fetzer & Asmundson, 2015); participants also self-reported
they were reaching the heart rate goal. The study was a pre- that the intervention was a beneficial, positive experience. They
test post-test design with no non-active control group. They did not report any worsening of PTSD symptoms over the
reported statistically significant improvements in PTSD and course of treatment.
trauma symptoms. This was further confirmed by Rosenbaum, Van der Kolk and colleagues (2014) conducted a study that
Sherrington, and Tidemann (2015a), who had similar find- included a weekly one-hour trauma-informed yoga class for
ings. They conducted an assessor-blinded RCT that included 10 weeks as an intervention. The authors assessed PTSD sever-
a walking program combined with thirty minutes of resistance ity and affect tolerance, which is the ability to tolerate stimuli
training three times per week. PA was used in addition to usual with appropriate rather than impulsive behavior. During the
care versus usual care alone at an inpatient PTSD treatment class, there was a focus on breathing, posture, meditation, and
184 L. M. OPPIZZI AND R. UMBERGER

self-awareness. Participants (N = 64) made intentional choices an accessible and effective adjunct treatment (Babson 2015;
about themselves instead of desensitizing their feelings or acting Rosenbaum et al., 2016).
out of impulse, and the aim of this was to combat this tendency Poor sleep quality is a substantial concern for those with
in PTSD. Both groups had a significant decrease in PTSD symp- PTSD since its ramifications are cyclic in nature. Defining
toms, as measured by the Clinician-Administered PTSD scale components (such as hyperarousal) not only inhibit sleep, but
(CAPS), but the yoga group had a greater decline than the con- poor sleep quality is thought to compound PTSD symptom
trol group (yoga: b = −9.21, t = −2.34, p = .02 and the control: severity (Babson et al., 2015; Rosenbaum et al., 2015a). Babson
b = −22.12, t = −3.39, p = .001). Post intervention, 16 of et al. (2015) found an interaction effect between poor sleep
31 (52%) participants no longer met criteria for PTSD versus quality and PA with one defining component of PTSD. More
6 of 29 (21%) controls, and there was a significant difference specifically, those who had poor sleep quality at baseline experi-
between groups (n = 60, x2 = 6.17, p = .013). Even though enced a significant reduction in hyperarousal after participating
there was a lasting reduction throughout the intervention for in the PA intervention. This study suggests that PA may, in
the yoga group, it is not known if improvements in the yoga part, reverse the negative cycle of poor sleep and worsening
group persisted post intervention. symptoms. PA may directly improve sleep quality, thus reducing
Results of both studies evaluating the impact of yoga on hyperarousal symptoms; on the other hand, PA may alleviate
PTSD symptoms are inconsistent. This could be simply due to the hyperarousal component of PTSD, thereby improving sleep
the fact that one was a pilot study with too small of a sample size quality. Other studies have determined that an improvement in
to detect a significant difference (Mitchell et al., 2014), while the sleep quality is an important component of PTSD treatment,
second had a larger sample size and detected statistical signifi- and it is something that may be simultaneously addressed with a
cant changes in symptoms (Van der Kolk et al., 2014). Regard- PA intervention (Babson et al., 2015; Rosenbaum et al., 2015a).
less, both demonstrate some type of improvement in symptoms, However, the effect of PA on PTSD related sleep disturbances is
even if only clinically significant or patient-reported (Mitchell largely unexplored and in need of further research.
et al., 2014). This suggests that yoga as a PA may be beneficial In addition to improvements in mental health, activity
to alleviate PTSD symptoms; nevertheless, further research is has the added benefit of improving overall physical health
needed. (Rosenbaum et al., 2015a, 2016). Not only have studies shown
Activity Duration. There are mixed findings as to whether that PA alleviates PTSD symptom severity, but it is postulated
or not the length of an intervention has an influence on main- to be an intentional way to combat the substandard levels of PA
taining psychological benefits. Newman and Motta (2007) con- that those with PTSD typically exhibit (LeardMann et al., 2011;
ducted a 5-week intervention and found that improvements in LeBouthillier et al., 2016; Newman & Motta 2007; Rosenbaum
PTSD symptom severity were not maintained at one-month et al., 2015a, 2016). Rosenbaum et al. (2015a) recognized that
post-intervention. Fetzner and Asmundson (2015) conducted cardiovascular risk was a common problem in those with PTSD,
a 2-week intervention, and found similar results in their study and so they included measures to evaluate physical effects of
that explored whether or not aerobic activity had anxiolytic activity as a secondary outcome in their study. These included
effects in those with PTSD. Participants’ PTSD symptoms ini- a PA questionnaire, a 6-minute walk test to determine car-
tially improved, but worsened post-intervention at one week diorespiratory fitness, grip strength, body mass index (BMI),
and one month follow ups. Both studies support the claim that body fat percentage, waist circumference, resting heart rate,
a PA intervention should be continued to maintain benefits and blood pressure. This study was the first to include such
(LeBouthillier, Fetzner, & Asmundson, 2016, Newman & Motta measurements—although typical in many physical exercise
2007, Van der Kolk et al., 2014). trials—when evaluating the effect of activity on those with
More recently, Price et al (2017) utilized a 20-week yoga PTSD, and the study results demonstrated an overall improve-
intervention to treat women (N = 9) with chronic, treatment ment in physical health throughout the twelve-week exercise
resistant PTSD. Findings demonstrated a significant reduction program. Since the lack of PA leads to higher cardiovascular
in PTSD symptom severity, and treatment effects lasted two risk, PA can benefit both mental and physical health and should
months after the intervention ended. The former two studies be an important part of a plan of care
were much shorter in duration compared to the latter. Though
the sample size is small, findings suggest that there is an ideal
Theories on the method of action
intervention duration with potential lasting benefits of physical
activity after the intervention ceases. Further research is needed In addition to the perceived benefits of this type of intervention,
to distinguish the optimal length of time needed to maintain there are specific reasons why scientists hypothesize its efficacy
psychological benefits of physical activity. in treating PTSD due to the method by which it works. More
precisely, there are distinct avenues by which improvement is
said to occur.
Added benefits of PA as a PTSD intervention
Interoceptive exposure. Lower levels of PA are typically
Despite the type of PA, a common thread throughout the liter- seen among persons with PTSD (Rosenbaum et al., 2015a).
ature was the peripheral benefits of utilizing PA as part of the Consequently, there are lower levels of exposure to “distressing”
PTSD treatment regimen. Some suggest that PA simultaneously physical sensations that naturally accompany PA; these physical
improves sleep quality (Babson et al., 2015) and cardiovascular sensations are known as interoceptive exposure. LeBouthillier
health (Rosenbaum et al., 2015a, 2016). The literature also et al. (2016) theorized that this leads to a higher sensitivity
illuminates the cost-effectiveness of PA and suggests that it is to distressing physical sensations or emotions, as compared
 ISSUES IN MENTAL HEALTH NURSING 185

to those who exercise, and thus make these sensations more may indicate that physical improvements that are associated
difficult to tolerate. In their study, those who had lower baseline with exercise are directly linked to mental improvements.
levels of cardiorespiratory fitness had the greatest benefit to the Physiological effects. Some scientists suggest that the under-
intervention, since they experienced unfamiliar sensations and lying mechanism by which PA is said to affect PTSD symptoms is
became more accustomed to them over time. They concluded through physiological processes (Mitchell et al., 2014; Newman
that the decrease in hyperarousal and anxiety symptoms were & Motta, 2007; Powers et al., 2015). One group of authors argued
attributed to intentional exposure to “distressing” physical the case of the neurophysiological impact of yoga and its effect
sensations associated with exercise, thus desensitizing them on buffering the body’s natural stress response, and thus, short-
to distressing sensations that accompany PTSD. Fetzner and and long-term cortisol and catecholamine regulation processes
Asmundson (2015) made a similar claim that exposure to such (Mitchell et al., 2014).
sensations helps decrease anxiety sensitivity towards otherwise Powers and colleagues (2015) conducted a study to test
feared somatic sensations. In fact, they hypothesized that par- brain-derived neurotropic factor (BDNF) as it relates to PTSD
ticipants who were prompted to notice interoceptive sensations treatment. BDNF is necessary for memory, long-term learn-
(i.e., they asked participants to notice the sensations in legs or ing, and fear extinction, yet those with anxiety disorders have
to any difficulty breathing) during exercise would experience an been shown to have low levels of this protein. The authors
even greater improvement than the group that simply exercised reviewed literature indicating that fifteen minutes of aerobic
without such prompting. This hypothesis was not supported by exercise raises BDNF levels; thus, they hypothesized that aerobic
the findings; in fact, those who were in the group with prompted activity directly prior to an exposure therapy intervention may
interoceptive exposure had less of a positive response in regards enhance outcomes with this current treatment for PTSD. Sig-
to PTSD symptoms, as compared to the other two groups. This nificance testing was limited by the small sample size (N = 9) in
could be attributed to their attempt to synthetically manipulate their pilot study, yet, effect sizes were calculated and interpreted
the attention to somatic sensation that naturally occurs in PA. using Cohen’s d. They found a very large effect between group
Emotional regulation. Two different studies included yoga pre-test and post-test, with an increase in plasma BDNF levels
as the intervention, with the theory that mindfulness specifically and a decrease in PTSD symptoms in the exercise intervention
targets the avoidance component of PTSD (Mitchell et al., 2014; plus exposure therapy group, as compared to the control group
Van der Kolk et al., 2014). Yoga involves stretching, meditation, with only exposure therapy. Although the findings were limited
and a focus on breathing and bodily sensations with movement. by the small sample size, they provide support—through a mea-
Rather than dissociating themselves emotionally or physically, surable biomarker—for the claim that PA is an effective adjunct
this activity was hypothesized to help participants learn to therapy for PTSD.
tolerate physical sensation as they are coached to become
self-aware during the yoga session. Learning to tolerate physical
Discussion
sensations, such as noticing a feeling of fear rather than avoid-
ing it, is said to help participants regulate emotions. Mitchell Overall, there is substantial support in the literature to sup-
et al. (2014) hypothesized that emotional regulation through port the benefit of PA on reducing PTSD symptom severity.
yoga would alleviate re-experiencing symptoms and avoidance. Moreover, this has been shown to positively affect conditions
Research findings are mixed regarding this. They found that that often go alongside PTSD, including anxiety, depression,
the impact of group allocation (non-active control group versus poor sleep quality, and cardiovascular risk. Intervention types
yoga intervention group) was not statistically significant when have ranged anywhere from yoga to aerobic exercises, which
evaluating scores for PTSD. The study may have been too includes activities such as brisk walking, bicycling, jogging, and
underpowered (N = 38) to detect a statistical difference. jumping rope. Length of time has ranged anywhere from 2–
Van der Kolk et al. (2014) also included yoga as an inter- 12 weeks. Findings have consistently demonstrated that PA is a
vention, and detected a statistically significant improvement in useful adjunct or complementary therapy to treatment for sub-
overall PTSD symptoms in the intervention group (b = −9.21, syndromal to treatment-resistant PTSD (Babson et al., 2015;
t = −2.34, p = .02) (Van der Kolk et al., 2014). The authors LeBouthillier et al., 2016; Mitchell et al., 2014; Van der Kolk et al.,
measured PTSD by the CAPS, and tested it at regular intervals 2014). Though, it is not determined what type or dose of exer-
throughout the study to ensure inter-rater reliability. However, cise is necessary for optimal results, the literature suggests that
the authors did not mention whether or not the CAPS evalu- PA should continue beyond the initial intervention to maintain
ated a specific breakdown in types of PTSD symptoms (negative results (LeBouthillier et al., 2016; Newman & Motta 2007; Van
thoughts, avoidance, re-experiencing, and hyperarousal). This der Kolk et al., 2014).
study would have been more informative if such a measure had The majority of the studies had small sample sizes (rang-
been used. It would have provided more insight into how yoga ing from 9 to 38) with the exception of a few (ranging from
impacts PTSD symptoms. 64 to 38,883). In addition, there were several studies that did
Though both of these studies contained interventions based not have a non-active control group or there were other reasons
on prior research, they would have been strengthened if sup- for study limitations; furthermore, most studies had gender bias
ported by a theoretical framework guiding their interventions. (Babson et al., 2015; Diaz & Motta, 2008; LeBouthillier et al.,
One type of theory that could have supported a yoga interven- 2016; Mitchell et al., 2014; Newman & Motta, 2007; Powers et al.,
tion that contains a therapeutic mindfulness component is a 2015; Rosenbaum et al., 2015b, 2016; Van der Kolk et al., 2014).
mind–body theory. Newman and Motta (2007) referred to lit- Despite this, there were nearly an equal amount of studies that
erature proposing that the mind and body are one entity, which were biased to either females or males with similar results. These
186 L. M. OPPIZZI AND R. UMBERGER

components limit the generalizability of findings, yet, each study and have a negative impact on an individual, families, and ulti-
contributes valuable input to the early stages of developing the mately, society at large. Typical treatment involves combined
body of research on this subject. psychotherapy and pharmacotherapy, however, some are resis-
tant or have limited access to traditional treatment modalities
(Babson et al., 2015; Institute of Medicine [IOM], 2012; Mitchell
Future research
et al., 2014; Newman & Motta, 2007; Van der Kolk et al., 2014).
It is clear that PA has a positive effect on PTSD symptoms; how- The IOM has called for research into complementary treatments
ever, the optimal dose (type and duration of PA) is not clear. to enhance effectiveness and access to care.
How does PA affect PTSD—globally, or does it target the indi- Studies have shown that PA has significant alleviating effects
vidual symptoms? What type of PA is most effective? What is the on depression and anxiety symptoms (Babson et al., 2015;
underlying mechanism of action, and does it vary with different Fetzner & Asmundson 2015; Newman & Motta, 2007; Rosen-
populations? What are other potential confounding or interac- baum et al., 2015a), but little is known about its effects on PTSD
tive factors in addition to sleep that need to be explored? What symptom severity. This review of the current state of the science
is the impact of PA on PTSD symptom reduction in other at- demonstrated that PA also has an alleviating effect on PTSD
risk populations (e.g., refugee populations, survivors of critical symptom severity, although some findings are mixed. Most
illness)? Refugee populations are at high risk due to traumatic of the studies to date have been small and without standard
experiences associated with war and violence, and there are methodologies. We identified three major themes: PA character-
language and cultural barriers to PTSD treatment. Exercise is an istics, added benefits of PA as a PTSD intervention, and theories
intervention that can be used across cultures, is more accessible on the method of action by which PA impacts symptom severity.
than other treatments, and can be translated to various settings PA characteristics were broad. Studies included varying
and ethnicities (Diaz & Motta, 2008; Rosenbaum et al., 2016). ranges of intensities (e.g., yoga, walking, cycling, aerobic vigor-
Post intensive care syndrome (PICS) affects up to one-third of ous strength training) and intervention lengths (2–12 weeks).
intensive care unit (ICU) patients and includes anxiety, depres- Aerobic activity showed a reduction in symptom severity, but
sion, and PTSD (Davidson, 2013). PA can be an ideal inter- the dose (e.g., steps taken) of aerobic activity needed to reduce
vention that can bridge barriers to standard treatment. It can PTSD symptoms is unclear. Studies that utilized a yoga inter-
be applied to those who are unable to fully communicate their vention have inconsistent findings, though all demonstrated
thoughts and feelings due to language, cultural, or perhaps even improvement. Furthermore, it is unclear as to whether or not
cognitive barriers (such as in PICS). Research should be con- the intervention length as a moderating effect on reducing PTSD
ducted in these at-risk populations to determine if PA can reduce symptom severity. Further studies are needed to determine the
the PTSD disease burden in these ever-growing populations. optimal type, dose, and duration of activity needed to reduce
In future research, it is recommended that intervention PTSD symptom severity.
protocols and exercise doses are standardized to enhance study PA in general has added benefits as an intervention for the
rigor and strengthen findings (Diaz & Motta, 2008; Fetzner population, since PTSD is associated with poor sleep habits
& Asmundson, 2015). Studies should be carefully designed to and cardiovascular health (Babson et al., 2015; Rosenbaum,
include a non-active control group and assessment of other Sherrington, & Tiedermann 2015; Rosenbaum et al., 2016).
potential confounding and treatment factors (e.g., CBT inter- There is an association between sleep quality, PA, and PTSD
vention, social support). Loss to follow-up due to location, symptom severity; however, the relationship is unclear. Addi-
transportation, and inconvenience for participants has been tional research is needed to delineate this relationship. Further-
an issue in existing studies. Future studies need to include more, studies demonstrated an improvement in overall physical
interventions in a convenient location (Diaz & Motta, 2008; health, though few included the use of anthropometric measures
Rosenbaum et al., 2015a), and include effective strategies to to evaluate the effect of PA on physical health in this population.
prevent loss to follow-up (Robinson et al., 2015). Interventions We recommend that future studies include these non-invasive
should promote motivation to continue the exercise beyond the measures to evaluate physical effects of the intervention, since
program, since continuing PA is a necessary part of maintaining this is consistent with PA studies in the general population.
effects of treatment (Rosenbaum et al., 2015a). Finally, some scientists postulate methods by which improve-
Objective anthropometric measures should be included as an ments occur. So far, these include interoceptive exposure, emo-
outcome since this population is at high risk for cardiovascu- tional regulation, and physiological processes. Interoceptive
lar disease (Rosenbaum et al., 2015a, 2015b). Obtaining these exposure relates to the distressing sensations that naturally
measurements before and after the intervention is invaluable to accompany PA, and is suggested to help desensitize those with
determine the full picture of how PA benefits those with PTSD. PTSD to the distressing nature of their symptoms. Emotional
Perhaps this will help justify the use for non-pharmacological regulation is postulated to occur with PA through increasing
interventions as a method to not only improve mental health a sense of self-awareness and control. Physiological processes
but physical health as well. include neurochemical response to PA (e.g., yoga) that buffers
the body’s natural stress response. Further research is needed
to clarify the process by which PA impacts PTSD symptom
Conclusion
severity.
PTSD is a condition that is often associated with anxiety, depres- PA has beneficial effects on PTSD symptom severity and
sion, and poor physical heath that further compound its sever- overall health; however, recommendations for standardized
ity and consequences. If left untreated, it can be debilitating exercise prescriptions for PTSD in clinical practice are needed.
 ISSUES IN MENTAL HEALTH NURSING 187

Before these can be developed for this population, careful atten- LeBouthillier, D. M., Fetzner, M. G., & Asmundson, G. J. G. (2016).
tion to study design to allow for comparisons in meta-analysis Lower cardiorespiratory fitness is associated with greater reduc-
is needed. Until that time, nurse practitioners can at least rec- tion in PTSD symptoms and anxiety sensitivity following aer-
obic exercise. Mental Health and Physical Activity, 10, 33–39.
ommend PA in accordance with national guidelines (American doi:10.1016/j.mhpa.2015.11.001
Heart Association, 2016). Mitchell, K. S., Dick, A. M., DiMartino, D. M., Smith, B. N., Niles, B.,
Koenen, K. C., … Street, A. (2014). A pilot study of a randomized con-
trolled trial of yoga as an intervention for PTSD symptoms in women.
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Newman, C. L., & Motta, R. W. (2007). The effects of aerobic exercise
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that greatly improved the manuscript. Emergency Mental Health, 9(2), 133–158.
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