Quality of Life Improved in PTSD Victims via Exercise
Recent research shows that a combination of regular resistance training and walking can enhance the usual treatments for post-traumatic stress disorder (PTSD). PTSD will affect about 1 out of 10 Canadians in their lifetime. In the news it is most often associated with those serving in the military or first responders (police, fire fighters and paramedics). However, anyone can experience PTSD.
On January 1st, new legislation in Manitoba finally recognizes PTSD as a work-related condition. This legislation gives workers of all occupations access to better care under the Workers Compensation Board, even if PTSD doesn't manifest from a single event.
Injuries leave their psychological imprints (residual memories) even once the physical trauma has healed. A dysfunctional emotional and physical healing process can lead to PTSD and depression if those injured are not resilient enough. Injured clients who seek physical rehabilitation also need to address the emotional memory for long-term success.
We have seen clients with whiplash from a car accident who have constant neck tension. Clients in motor vehicle collisions can end up suffering from PTSD. Another example is someone who has fallen, fractured a hip and is scared of getting on a bicycle because they fear falling and re-fracturing. Sometimes chronic pain and lack of ability to function well leads to depression.
What is Post-Traumatic Stress?
In their recent update to the Diagonstic and Statistical Manual of Mood Disorders (DSM-IV) the American Psychiatric Association reclassified post-traumatic stress from an anxiety disorder to a Trauma and Stressor-Related Disorder.
Post-Traumatic Stress Disorder Defined
"PTSD is the exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:
- directly experiences the traumatic event;
- witnesses the traumatic event in person;
- learns that the traumatic event occurred to a close family member of close friend (with the actual or threatened death either violent or accident;
- experiences first-hand repeated or extreme exposure to adversive details of the traumatic event (not through media, pictures, television or movies unless work-related)"
Regardless of the cause, it results in a great deal of suffering and significantly impacts an individual's ability to function socially, it reduces their work capacity as well as their ability to complete daily activities. PTSD is often also associated with depression and when not treated properly can lead to suicide.
How the Body Responds Physically to Stress
The somatic nervous system is responsible for sending external stimuli from our environment to our central nervous system so we can respond appropriatly. When there is danger there is a natural "flight or fight" response which is called upon. We become vigilant during this situation by automatically changing our breathing rate, heart rate and neuromuscular tension so that we can respond appropriately - freezing or running. In someone who is resilient these are transient and reverse once the danger has passed.
Importantly, this research shows that exercise programmes have the potential to improve the physical and mental health of PTSD patients
Rosenbaum et al., Acta Psychiatr Scand 2015: 131: 350–359
Response in PTSD Patients
One symptom of PTSD is arousal or hyper-vigilance, where the defense mechanism is activated with non-dangerous events such a car backfiring, smells or other environmental cues which in someone with an healthy response are non-events. With PTSD patients the somatic nervous system is on overdrive. In the clinic we have seen this constant turned-on mode lead to chronic pain, fatigue, dizziness, stiffness, lack of appetite, weakness and difficulty sleeping. Sleep is a very important for healing.
How PTSD is Usually Treated
The usual care for post-traumatic stress disorder is a combination of medicine and counselling, psychiatry or visits with a psychologist. There are several types of counselling including cognitive behaviour therapy, eye movement and desensitization (EMDR) and reprogramming and and exposure therapy (WebMD). There is also Somatic Experiencing.
Dr. Peter A Levine, the developer of Somatic Experiencing believes that exposure therapy does more harm than good. His book "Trauma and Memory: Brain and Body in Search for the Living Past," is an excellent read that explains how our brain and body respond to trauma and how we can recover from it.
Exercise Improves Quality of Life for PTSD Patients
There isn't a lot of research available that has studied how exercise can augment traditional PTSD treatment. We have had success by closely paying attention to how our clients' bodies respond during and after each session as well how they quickly they recover and progress from each exercise intervention. Clinically, it is important to communicate verbally while paying attention to non-verbal cues such as increased breathing rates, heart rates, changes in blood pressure and dizziness.
What we've found what has worked clinically is to base the exercise program on the client's daily capacities. Some days they might have more energy while on other days they will have less. Fatigue accumulates during the session and week. Physical and social activities can be very taxing for someone who also may be deconditioned due to previous physical injuries and/or lack of physical activity.
- Begin to exercise in an environment with few stimuli (music, lights, people)
- Walking orother gentle cardiovascular exercise. Start with 5 minutes and build tolerance. Walk up to the store or find a favourite outdoor route and gradually increase the distance
- Body weight exercises that are semi-supported
- 3-6 repetitions to build strength, rest between sets as needed 2-3 minutes
- Move in multiple directions - Tai Chi, dance, cross-body movements
- Use exercises that build movement confidence and are functional: squats, push-pull and agility drills that are multi-directional
- Strength training sessions two times per week for 45 minutes with a 10 - 15 min warm-up on a total body trainer
- Move from body weight to weight loaded exercises gradually
- Monitor intensity with a heart rate monitor, blood pressure
- Stop exercise and rest when symptoms increase (rapid breathing, dizziness, pain). Resume when they subside. Some exercises may trigger more symptoms than others
- Regular self-stretching and Fascial Stretch Therapy to calm the nervous system and improve range of motion
We've also noticed that clients with greater levels of hope and strong beliefs that they will recover have better outcomes.
Research into Treating PTSD with Exercise
In the May 2015 issue of Acta Psychiatrica Scandinavica researchers compared usual care for post-traumatic stress disorder with a 12-week exercise program and usual care. They studied 81 primarily men (84%) with a mean age of 47.8 years and a diagnosis of DSM-IV-TR PTSD. While they were focused on symptoms of PTSD they also assessed secondary outcomes that "included symptoms of depression, anthropometry (body fat and measurements), physical activity, mobility, strength, and sleep quality" (Rosenbaum S, Sherrington C, Tiedmann A, 2015).
Usual treatment included pharmaceuticals, group therapy and psychotherapy. The exercise group was given a 30 minute resistance training program three days per week based on the American Council on Sports Medicine's guidelines: 3 sets of 10 repetitions for 6 exercises. Intensity was increased by 10% when they were able to complete the exercise with 1-2 reps above desired. They were also given a pedometer with a goal of achieving 10,000 steps per day. Their programs were adjusted for each individual to account for severity of PTSD and to gain more adherence.
What they found was that there was a moderate difference between the exercise group and the usual care group post intervention for the PTSD checklist. There were no differences in grip strength and cardiorespiratory fitness. Improvements in other secondary outcomes such as reduction in PTSD sleep disturbances, body measurements and symptoms of depression and anxiety were also significant for the exercise group compared to those with only usual care.
Exercise Should Be Part of Post-Traumatic Stress Care
This study is believed to be the first to directly investigate exercise and PTSD. They're many which positively associate physical activity and the reduction of mood disorder symptoms.
Rosenbaurm et al.'s conclusion is that combining a structured exercise program of resistance training and walking with usual care will improve symptoms for people with post-traumatic stress disorder beyond usual care on its own. Also, "exercise improves symptoms of depression and cardiometabolic risk in people with PTSD."
Rosenbaum S, Sherrington C, Tiedemann A. Exercise Augmentation Compared to Usual Care for Post-Traumatic Stress Disorder: A Randomized Controlled Trial. Acta Psychiatr Scand 2015: 131: 350–359