Pilot randomized controlled trial of exercise training for older veterans with PTSD

Elder abuse victimization, mental health, and protective factors

OBJECTIVES

This study investigated the association between elder abuse and depressive symptoms, as well as protective factors against adverse mental health outcomes from elder abuse.

METHODS

Participants were drawn from the 5928 graduates of the WLS, Wave 3 study (age range 70-73) who completed both in-person and telephone interviews. From this large group, 975 (16.4%) participants reported having experienced elder abuse and were included in the sample. Path analysis using Mplus was employed.

RESULTS

Elder abuse victimization was significantly associated with depressive symptoms, and those who had suffered multiple types of elder abuse experienced more severe mental health outcomes. However, both light physical activity conducted alone and having a friend as a confidant were negatively associated with depressive symptoms among older adults who had experienced elder abuse.

CONCLUSION

Given the significant association between elder abuse and negative mental health outcomes among older survivors, screening and prevention programs are recommended. Older adults who have experienced elder abuse may benefit from programs designed to increase physical activity and help older adults build and maintain close relationships with friends and confidants.

Is exercise a viable therapy for anxiety? Systematic review of recent literature and critical analysis

OBJECTIVES

Exercise has been promoted as a treatment for a variety of psychiatric conditions. The benefits of exercise for depression are widely recognized, but the benefits of exercise for anxiety are uncertain. Although several reviews promoted exercise as a treatment for anxiety, concerns about the quality of studies prompted us to provide a critical review of the recent literature to re-assess the value of exercise for treating anxiety.

METHODS AND MATERIALS

We conducted a systematic review of all peer-reviewed randomized clinical trials (RCTs) among adults, published between January 2014 and December 2021, with an exercise intervention and anxiety as the a priori primary outcome. Two reviewers independently extracted data from studies meeting inclusion criteria, including sample characteristics, exercise intervention, control conditions, primary anxiety measure, relevant findings, and methodological quality quantified by PEDro scores.

RESULTS

7240 published studies from CINAHL, EMBASE, MEDLINE, and PsycINFO were screened in April 2022, with 1831 participants across 25 eligible RCTs, of which 13 included elevated anxiety at study entry as an eligibility criterion. Only two of these 13 studies, and five of 12 studies of non-anxious individuals, found anxiety to be reduced unequivocally with exercise. Most studies suffered from significant methodological limitations including concurrent therapies and lack of intention-to-treat analyses.

CONCLUSION

There remains considerable uncertainty about the value of exercise in reducing symptoms of anxiety, particularly among anxious individuals. The paucity of methodologically sound studies of patients with anxiety represents a significant gap in our knowledge and calls for more research in the area. Word count: 249.

Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review

This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.

Perceived Barriers and Benefits of Exercise Among Men with Histories of Sexual Violence: Impact of PTSD and Physical Activity Status

This study reported on perceived benefits and barriers of exercise among men with histories of sexual violence (SV) and compared these perceptions by activity level and post-traumatic stress disorder (PTSD) status. An online, cross-sectional, survey of men with histories of SV (N = 198) was completed using Amazon Mechanical Turk. Inclusion criteria were identifying sex at birth as male, age between 18 and 65 years, self-reported history of SV, and living in the United States (U.S.). A total of 1,260 men were screened for the study, of which 316 met the inclusion criteria, and 198 met all data quality requirements and were included in the study. Sociodemographic information, exercise behavior, PTSD symptoms, and perceived exercise barriers/benefits were collected. Comparisons by activity and PTSD status were analyzed. Additionally, two open-ended qualitative research questions were included to provide nuance to perceived barriers/benefits of exercise. The most salient benefits included physical performance, psychological outlook, and preventative health. Open-ended responses also noted the mental and physical benefits of exercise. The most salient barrier was physical exercise, with open-ended responses emphasizing lack of time, chronic pain and health concerns, and poor mental health and lack of motivation as impediments to exercise. Significant differences were found in benefits (psychological outlook, physical performance) and barriers (exercise environment, high time expenditure, and family discouragement) between active and insufficiently active men with histories of SV (ps < .05; Cohen's ds = 0.32-0.57). Significant differences were found by PTSD status on benefits (physical performance, social interaction, and preventative health) and barriers (exercise milieu, time expenditure, hard physical exercise, family discouragement) (ps < .05; Cohen's ds = 0.40-1.10). Findings provide new gender-specific strategies for promoting exercise among men with histories of SV: integrating exercise physiologists into trauma recovery programs, psychoeducation, engaging friends and family members, peer-support, and building self-efficacy.

Aerobic exercise improves sleep in U. S. active duty service members following brief treatment for posttraumatic stress disorder symptoms

Introduction

Physical exercise is a lifestyle intervention that can positively impact aspects of physical and psychological health. There is a growing body of evidence suggesting that physical exercise, sleep, and PTSD are interrelated. This study investigated possible relationships. Three research questions were posed: (1) Did randomization to an aerobic exercise intervention reduce insomnia more than being randomized to an intervention without exercise, (2) Did change in sleep predict change in PTSD symptoms, and (3) Did change in sleep impact the relationship between exercise and PTSD symptom reductions?

Methods

Data were collected from 69 treatment-seeking active duty service members with PTSD symptoms randomized into one of four conditions; two conditions included aerobic exercise, and two conditions did not include exercise. Participants in the exercise groups exercised five times per week keeping their heart rate > 60% of their heart rate reserve for 20-25 min.

Results

At baseline, 58% of participants reported moderate or severe insomnia. PTSD symptom severity decreased following treatment for all groups (p < 0.001). Participants randomized to exercise reported greater reductions in insomnia compared to those in the no exercise group (p = 0.47). However, change in insomnia did not predict change in PTSD symptoms nor did it significantly impact the relationship between exercise and PTSD symptom reductions.

Discussion

Adding exercise to evidence-based treatments for PTSD could reduce sleep disturbance, a characteristic of PTSD not directly addressed with behavioral therapies. A better understanding of exercise as a lifestyle intervention that can reduce PTSD symptoms and insomnia is warranted.

Adding physical activity to intensive trauma-focused treatment for post-traumatic stress disorder: results of a randomized controlled trial

Introduction

This randomized controlled trial examined the effectiveness of physical activity added to an intensive trauma-focused treatment (TFT) for post-traumatic stress disorder (PTSD) in comparison to adding non-physical control activities.

Methods

A total of 119 patients with PTSD were randomly assigned to a physical activity condition (PA; n = 59) or a non-physical activity control condition (nPA; n = 60). The 8-day intensive TFT programme consisted of daily prolonged exposure, EMDR therapy, and psychoeducation, which was complemented with physical activities versus controlled mixtures of guided (creative) tasks. As a primary outcome, the change in clinician and self-reported PTSD symptoms from pre-to post-treatment and at 6 months follow-up were measured.

Results

Intent-to-treat linear mixed-effects models showed no significant differences between the PA and nPA conditions on change in PTSD severity. Clinician and self-reported PTSD symptoms significantly decreased for both conditions, with large effect sizes (e.g., CAPS-5 dpre-post = 2.28). At post-treatment, 80.0% in the PA, and 82.7% in the nPA condition no longer met the diagnostic criteria for PTSD. Regarding the loss of Complex PTSD diagnoses this was 92.5% and 95.0%, respectively.

Conclusion

Either with additional physical or non-physical activities, intensive TFT is very effective for the treatment of (Complex) PTSD, as reflected by large effect sizes and loss of diagnostic status in both groups.

Clinical trial registration

Trialregister.nl Identifier: Trial NL9120.

Sleep timing, chronotype, and posttraumatic stress disorder: An individual participant data meta-analysis

Sleep disturbance is a major component of posttraumatic stress disorder (PTSD). The role of circadian disruption is largely overlooked, though many PTSD studies collect proxy markers of circadian timing. This individual participant data (IPD) meta-analysis examined the correlation between sleep timing / chronotype and PTSD severity among individuals diagnosed with PTSD, the standardized mean difference in sleep timing / chronotype for individuals with and without PTSD, and moderators of these relationships. A systematic search was conducted; authors provided IPD for 27 studies and aggregate data for 16 studies (3,011 participants with PTSD; 2,703 participants without PTSD). Two-step meta-analyses were conducted using a random-effects multivariate approach with robust variance estimation. Bedtime and wake time were not significantly associated with PTSD symptoms or diagnosis. Less total sleep time / time in bed was weakly associated with greater PTSD symptoms. Moderator analyses revealed that effect sizes were stronger in certain populations and when using wrist actigraphy to measure sleep timing; however, gap maps revealed few studies in moderator categories with the strongest effects. Only two studies measured chronotype, prohibiting strong conclusions. Our findings indicate that the relationship between sleep timing and PTSD is weak; however, key gaps in the literature warrant further study.

Relationship between physical activity and individual mental health after traumatic events: a systematic review

Background: Traumatic events can cause social tension, anxiety, panic and other psychological crises, and can even cause post-traumatic stress disorder (PTSD) and suicide. Physical activity has a good role in promoting mental health, and has a great application prospect in individual psychological intervention after traumatic events. However, no systematic review of the relationship between physical activity and individual mental health after traumatic events affecting many people has been published so far, which makes it impossible for people to understand the research status in this field from a holistic perspective.Objective: This review explores the relationship between physical activity and individual psychology, physiology, subjective quality of life and well-being after traumatic events, so as to provide some valuable clues or enlightenment for individual psychological intervention after traumatic events.Method: Relevant literature was searched in five databases, summarised, sorted and studied.Results: Thirty-three study papers were included in this review, the main study findings include: (1) Physical activity is positively correlated with individual mental resilience and subjective well-being after traumatic events, and negatively correlated with anxiety, depression, tension and PTSD. (2) Individuals with higher levels of physical activity have better mental health status after traumatic events than those who do not regularly engage in physical activity. (3) Physical activity can promote sleep quality, self-efficacy, subjective quality of life and various physiological functions of those experiencing traumatic events. (4) Physical activity (including exercise) is regarded as one of the preferred nursing measures to buffer against mental stress and maintain physical and mental health for those experiencing traumatic events.Conclusion: The level of physical activity is positively correlated with individual physical and mental health before and after traumatic events. Physical activity can be used as one of the effective measures to improve individual mental health after traumatic events.

Precision-based exercise in people with anxiety and stress related disorders: Are there interindividual differences in anxiolytic effects? An ancillary meta-analysis of randomized controlled trials

Interest in the individualized responses to exercise has been growing within mental health care and psychiatry. This meta-analysis examined if true interindividual differences (IIDs) in anxiolytic effects of exercise exist among adults with anxiety- and stress-related disorders. Data were extracted from a previous meta-analysis of randomized controlled trials (RCTs) and searches in CINAHL, Embase and Medline were updated (8 arms from 7 original studies, n participants=322). Change outcome standard deviations treated as point estimates for anxiety were extracted to calculate true IIDs. Inverse variance heterogeneity and restricted maximum likelihood models were used. Aerobic exercise and resistance training showed significant anxiolytic effects. No significant pooled IIDs were found for aerobic exercise nor resistance training demonstrating that there is currently a lack of convincing evidence to support the notion that true IIDs exist for the anxiolytic effects of exercise among adults with anxiety- and stress-related disorders. Consequently, clinical practice can focus on general population physical activity guidelines for patients with anxiety- and stress-related disorders rather than aiming for highly specific, individualized recommendations. Future research could prioritize investigating how to motivate patients with anxiety- and stress-related disorders to meet general population physical activity guidelines.

Comparative Effectiveness of Multiple Exercise Interventions in the Treatment of Mental Health Disorders: A Systematic Review and Network Meta-Analysis

BACKGROUND

The efficacy of exercise interventions in the treatment of mental health disorders is well known, but research is lacking on the most efficient exercise type for specific mental health disorders.

OBJECTIVE

The present study aimed to compare and rank the effectiveness of various exercise types in the treatment of mental health disorders.

METHODS

The PubMed, Web of Science, PsycINFO, SPORTDiscus, CINAHL databases, and the Cochrane Central Register of Controlled Trials as well as Google Scholar were searched up to December 2021. We performed pairwise and network meta-analyses as well as meta-regression analyses for mental health disorders in general and each type of mental health disorder, with alterations in symptom severity as the primary outcome.

RESULTS

A total of 6456 participants from 117 randomized controlled trials were surveyed. The multimodal exercise (71%) had the highest probability of being the most efficient exercise for relieving depressive symptoms. While resistance exercise (60%) was more likely to be the most effective treatment for anxiety disorder, patients with post-traumatic stress disorder (PTSD) benefited more from mind-body exercise (52%). Furthermore, resistance exercise (31%) and multimodal exercise (37%) had more beneficial effects in the treatment of the positive and negative symptoms of schizophrenia, respectively. The length of intervention and exercise frequency independently moderated the effects of mind-body exercise on depressive (coefficient = 0.14, p = .03) and negative schizophrenia (coefficient = 0.96, p = .04) symptoms.

CONCLUSION

Multimodal exercise ranked best for treating depressive and negative schizophrenic symptoms, while resistance exercise seemed to be more beneficial for those with anxiety-related and positive schizophrenic symptoms. Mind-body exercise was recommended as the most promising exercise type in the treatment of PTSD. However, the findings should be treated with caution due to potential risk of bias in at least one dimension of assessment and low-to-moderate certainty of evidence. Trial Registration This systematic review was registered in the PROSPERO international prospective register of systematic reviews (CRD42022310237).

Exercise and Escitalopram in the Treatment of Anxiety in Patients Coronary Heart Disease: One Year Follow-Up of the UNWIND Randomized Clinical Trial

Anxiety is common among patients with coronary heart disease (CHD) and is associated with a worse prognosis. UNWIND was a 12-week randomized clinical trial comparing exercise and escitalopram to placebo on measures of anxiety, depression, and CHD biomarkers. Primary results of the trial reported that treatment with escitalopram, but not exercise, was associated with significant reductions in anxiety and depression. At 1-year follow-up, participants completed the Hospital Anxiety-Depression Scale-Anxiety (HADS-A) along with the HADS-Depression (HADS-D), the Beck Depression Inventory-II (BDI-II), and the Godin Leisure Time Exercise survey to assess physical activity. Results showed that those patients randomized to escitalopram had lower scores on the HADS-A compared to those randomized to exercise (P = 0.006) and had less depression compared to exercise on the HADS-D (P = 0.004) and BDI-II (P = 0.004). Participants randomized to exercise reported higher levels of physical activity at 1-year compared to those randomized to Placebo (P = 0.039). However, despite reporting being more physically active, those randomized to exercise did not have less anxiety or depression compared to placebo controls. Escitalopram appears to be a safe and effective treatment for anxiety; exercise has many health benefits, but does not appear to be effective in treating anxiety.

Is exercise/physical activity effective at reducing symptoms of post-traumatic stress disorder in adults — A systematic review

Background

Exercise has been used to manage symptoms of post-traumatic stress disorder (PTSD). The effect of exercise on PTSD outcomes has been previously explored in several studies. However, it still remains unclear what type of exercise/physical activity, intensity and duration is most effective for reducing symptoms of PTSD. A systematic review was conducted to determine which forms of exercise or physical activity have the greatest effect on PTSD outcome scores including an evaluation of exercise frequency and volume.

Methods

The following electronic databases were systematically searched from January 1980 to June 2021: MEDLINE, PsycINFO, PubMed and Web of Science. Inclusion criteria were studies investigating adults aged 18 or over, reporting the effect of exercise and physical activities on PTSD symptom outcome scores. Two reviewers independently extracted information on study characteristics, exposure and outcomes. In total of 3,217 articles were screened and 23 full text articles further assessed, with 13 RCT's included in the review, covering seven exercise/physical activity interventions. The study protocol was registered prospectively with PROSPERO (CRD42021255131).

Results

Thirteen studies from four countries involving a total of 531 patients were selected for inclusion. Individual forms of exercise/physical activity examined showed some effect on reducing PTSD symptoms but combined exercises (resistance training, aerobic, strength and yoga) administered over a 12 week period, three times a week for 30–60 min showed greater effects on PTSD symptoms.

Conclusion

The limited evidence suggests that a combined exercise intervention has the best evidence for a having a beneficial effect on PTSD symptoms.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255131.

Mapping the network biology of metabolic response to stress in posttraumatic stress disorder and obesity

The co-occurrence of stress-induced posttraumatic stress disorder (PTSD) and obesity is common, particularly among military personnel but the link between these conditions is unclear. Individuals with comorbid PTSD and obesity manifest other physical and psychological problems, which significantly diminish their quality of life. Current understanding of the pathways connecting stress to PTSD and obesity is focused largely on behavioral mediators alone with little consideration of the biological regulatory mechanisms that underlie their co-occurrence. In this work, we leverage prior knowledge to systematically highlight such bio-behavioral mechanisms and inform on the design of confirmatory pilot studies. We use natural language processing (NLP) to extract documented regulatory interactions involved in the metabolic response to stress and its impact on obesity and PTSD from over 8 million peer-reviewed papers. The resulting network describes the propagation of stress to PTSD and obesity through 34 metabolic mediators using 302 documented regulatory interactions supported by over 10,000 citations. Stress jointly affected both conditions through 21 distinct pathways involving only two intermediate metabolic mediators out of a total of 76 available paths through this network. Moreover, oxytocin (OXT), Neuropeptide-Y (NPY), and cortisol supported an almost direct propagation of stress to PTSD and obesity with different net effects. Although stress upregulated both NPY and cortisol, the downstream effects of both markers are reported to relieve PTSD severity but exacerbate obesity. The stress-mediated release of oxytocin, however, was found to concurrently downregulate the severity of both conditions. These findings highlight how a network-informed approach that leverages prior knowledge might be used effectively in identifying key mediators like OXT though experimental verification of signal transmission dynamics through each path will be needed to determine the actual likelihood and extent of each marker’s participation.

Exercise to Reduce Posttraumatic Stress Disorder Symptoms in Veterans

BACKGROUND

Physical exercise offers benefits for treating psychological disorders, particularly depression. Exercise is associated with reduction of posttraumatic stress disorder (PTSD) symptoms in civilians. Given the comorbidities and unique trauma experiences of the veteran population, the current work aims to estimate the effect of exercise on PTSD symptoms in veteran samples.

OBSERVATIONS

A systematic review identified 6 single-arm studies and 3 randomized controlled trials (RCTs) using exercise as an interventional treatment among veteran samples with full or subsyndromal PTSD. Most single-arm studies used yoga-based interventions, whereas RCTs showed more variety and included yoga, aerobic activity, and resistance exercises. Data synthesis of study results revealed a medium standardized mean difference for the single-arm trials (Hedges g, -0.60, P = .03) and a small-to-medium standardized mean difference for the RCTs (Hedges g, -0.40, P = .06). Single-arm studies were all rated at serious risk of bias. Only 1 RCT was rated at high risk of bias, although the remaining RCTs showed some concern of elevated bias.

CONCLUSIONS

There is preliminary evidence that exercise may be a useful treatment option for PTSD symptom reduction in veterans. Our review also highlights the need for additional high-quality randomized trials to confirm the benefits of exercise for PTSD symptom reduction in veterans.

Augmenting PTSD treatment with physical activity: study protocol of the APPART study (Augmentation for PTSD with Physical Activity in a Randomized Trial)

BACKGROUND

New intensive trauma-focused treatment (TFT) programmes that incorporate physical activity have been developed for people with post-traumatic stress disorder (PTSD). However, the unique contribution of physical activity within these intensive TFT programmes has never been investigated in a controlled manner.

OBJECTIVES

This randomized controlled trial will investigate the effectiveness of physical activity added to an intensive TFT programme. In addition, the study aims to investigate the underlying mechanisms of the effects of physical activity on the change in PTSD symptoms.

METHODS

Individuals with PTSD (N = 120) will be randomly allocated to two conditions: a physical activity or a non-physical active control condition. All participants will receive the same intensive TFT lasting eight days within two consecutive weeks, in which daily prolonged exposure and EMDR therapy sessions, and psycho-education are combined. The amount of physical activity will differ per condition. While the physical activity condition induces daily physical activities with moderate intensity, in the non-physical active control condition no physical activity is prescribed; but instead, a controlled mixture of guided (creative) tasks is performed. The two primary outcome measures are change in PTSD symptoms from pre- to post-treatment and at six months follow-up, measured with the Clinician-Administered PTSD Scale (CAPS-5), and the PTSD Checklist for DSM-5 (PCL-5). Additionally, self-reported sleep problems, depressive symptoms, emotion regulation, dissociation symptoms and anxiety sensitivity will be measured as potential underlying mechanisms.

CONCLUSIONS

This study will contribute to the research field of augmentation strategies for PTSD treatment by investigating the effectiveness of physical activity added to intensive TFT.

TRIAL REGISTRATION

This trial is registered in the Netherlands Trial Register (Trial NL9120).

Diet quality and exercise in older veterans with PTSD: a pilot study

Older veterans with posttraumatic stress disorder (PTSD) are at increased risk of obesity and cardiometabolic disease. Physical activity and healthy eating are two behaviors that impact health, functional independence, and disease risk in later life, yet few studies have examined the relationship between PTSD and diet quality. This secondary analysis aimed to: (a) characterize the diet quality of older veterans with PTSD in comparison to U.S. dietary guidelines and (b) explore if participation in a supervised exercise intervention spurred simultaneous changes in dietary behavior. Diet quality was assessed with the Dietary Screener Questionnaire (DSQ), which measures daily intake of fiber, calcium, added sugar, whole grain, dairy, and fruits/vegetables/legumes. The sample included 54 military veterans ≥ 60 years old with PTSD who participated in a randomized controlled pilot trial comparing 12 weeks of supervised exercise (n = 36) to wait-list usual care (n = 18). The DSQ was administered at baseline and 12 weeks. Consumption of added sugar exceeded U.S. dietary guideline recommendations and consumption of whole grains, fruits/vegetables/legumes, fiber, calcium, and dairy fell short. Participation in the supervised exercise intervention was not associated with changes in diet quality. Results revealed that the diet quality of older veterans with PTSD is poor, and while the exercise intervention improved health through exercise, it did not make veterans any more likely to adopt a more healthful diet. Interventions targeting diet, or diet + exercise, are needed to manage the increased risk of obesity and cardiometabolic disease present in older veterans with PTSD.

Sleep management in posttraumatic stress disorder: a systematic review and meta-analysis

OBJECTIVE

Post-traumatic stress disorder (PTSD) can lead to many negative secondary outcomes for patients, including sleep disturbances. The objective of this meta-analysis is (1) to evaluate the effect of interventions for adults with PTSD on sleep outcomes, PTSD outcomes, and adverse events, and (2) to evaluate the differential effectiveness of interventions aiming to improve sleep compared to those that do not.

METHODS

Nine databases were searched for relevant randomized controlled trials (RCTs) in PTSD from January 1980 to October 2019. Two independent reviewers screened 7176 records, assessed 2139 full-text articles, and included 89 studies in 155 publications for this review. Sleep, PTSD, and adverse event outcomes were abstracted and meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method for random effects.

RESULTS

Interventions improved sleep outcomes (standardized mean difference [SMD] -0.56; confidence interval [CI] -0.75 to -0.37; 49 RCTs) and PTSD symptoms (SMD -0.48; CI -0.67 to -0.29; 44 RCTs) across studies. Adverse events were not related to interventions overall (RR 1.17; CI 0.91 to 1.49; 15 RCTs). Interventions targeting sleep improved sleep outcomes more than interventions that did not target sleep (p = 0.03). Improvement in PTSD symptoms did not differ between intervention types.

CONCLUSIONS

Interventions for patients with PTSD significantly improve sleep outcomes, especially interventions that specifically target sleep. Treatments for adults with PTSD directed towards sleep improvement may benefit patients who suffer from both ailments.

Trauma-informed exercise for women survivors of sexual violence

Compared to their male counterparts, women experience alarmingly high rates of sexual violence (SV). Nearly 20% of women in the USA have been victims of SV, and prevalence of sexual assault among female service members is reported to be even higher, up to 50%. SV results in negative health outcomes like posttraumatic stress disorder, depression, obesity, poor body image, and pain-related disability. Exercise has been shown to positively impact both mental and physical health outcomes in populations experiencing posttraumatic symptoms, yet women survivors of SV are often excluded from exercise trials in trauma-affected populations. The purpose of this paper is to comment on the importance of incorporating women-specific trauma-informed principles in the content and delivery of exercise interventions in trauma-affected populations, particularly as it relates to SV. Researchers discuss the implications of female-specific and trauma-informed exercise considerations for SV survivors. This commentary highlights the need for trauma-informed implementation efforts and outcome measurements in exercise interventions involving women affected by SV. Researchers call for (a) increased qualitative work on trauma-specific implementation efforts across exercise intervention domains and (b) increased assessment of trauma-specific outcomes in exercise trials.

The anxiolytic effects of exercise for people with anxiety and related disorders: An update of the available meta-analytic evidence

Exercise as a treatment option for people with mental disorders is a field of growing interest. The increased number of published randomized controlled trials (RCTs) evaluating the effects of exercise in the treatment of anxiety and related disorders in recent years calls for an update of the available meta-analytic evidence. Electronic databases (PubMed, CINAHL, PSYCArticles, and Embase) were searched up to 17.2.2021, for RCTs evaluating the effects of exercise on anxiety and stress symptoms in adults with anxiety and related disorders. A random effects meta-analysis was conducted. A total of 13 RCTs comprising 731 adult participants (exercise n=376; control n=355) were included. Exercise had a small, bordering medium, but statistically significant effect on decreasing anxiety symptoms compared to control condition (standardized mean difference=-0.425, 95%CI -0.67 to -0.17; I² = 47.9%) in people with anxiety and related disorders. Our meta-analysis updates the existing evidence supporting exercise as an efficacious intervention for anxiety and related disorders. Although the updated meta-analytic evidence is less heterogenous than previously reported, future research is still needed to explore the factors moderating the effects of exercise on outcome such as frequency, intensity, duration of the sessions, and type of exercise and qualification of the provider in more detail.

Qualitative Analysis of a Supervised Exercise Program for Older Veterans With PTSD

OBJECTIVE

Older veterans with post-traumatic stress disorder (PTSD) experience substantial physical and mental health challenges. Given the well-known and wide-reaching benefits of exercise, exploring the impact of interventions designed specifically for this population would be valuable. As such, the present study explored perspectives from older veterans with PTSD who participated in Warrior Wellness, a 12-week supervised exercise intervention designed for older veterans with PTSD. This study was aimed at evaluating 1) facilitators of engagement, 2) perceived benefits from the intervention, and 3) recommendations about possible modifications to the intervention.

DESIGN

Qualitative study.

SETTING

Face-to-face semistructured interviews conducted after the Warrior Wellness trial was completed.

PARTICIPANTS

Fifteen veterans (100% male, 93% African American or Black, 100% non-Hispanic or Latinx, average age = 68.7 years) who completed the Warrior Wellness exercise program.

MEASUREMENTS

Semistructured interviews were conducted using an interview guide that assessed veterans' experience in Warrior Wellness and recommendations for future intervention modifications. Interviews were subsequently transcribed and analyzed by thematic analysis.

RESULTS

Shared experience, program features, camaraderie during workouts, and accountability emerged as facilitators of engagement. Perceived benefits spanned physical health, mental health, and behavioral domains. Finally, veterans provided several suggestions for modifying the intervention such as increasing its duration, adding a nutritional component, and including significant others in enrollment.

CONCLUSIONS

This study offers valuable insights into the intervention and interpersonal factors that veterans view as important for their engagement in exercise, the perceived benefits of exercise, and the ways in which interventions designed for this population can be refined.

Emotion regulation and the association between PTSD, diet, and exercise: a longitudinal evaluation among US military veterans

Background: Posttraumatic stress disorder (PTSD) is associated with premature onset of chronic health conditions such as cardiovascular disease. Diet and exercise are behavioural contributors to physical health, and research suggests they are influenced by psychiatric symptoms, including PTSD. Objectives: The aim of this study was to examine longitudinal associations between PTSD and exercise and diet quality and to test if emotion regulation strategies contribute to the link between PTSD and these health behaviours. Method: A representative sample of US military veterans (n = 860 at Time 1, n = 503 at Time 2, mean age = 63 years, 91.5% male) were assessed twice over the course of approximately three years. Results: Mediation models revealed that the association between baseline PTSD symptom severity and subsequent diet quality was mediated by emotion suppression (measured at Time 2; indirect B = -.03; 95% CI: -.059 to -.002). Trauma exposure also directly predicted diet quality (B = -.31; p = .003). There were no significant direct or indirect associations between PTSD severity or trauma exposure and exercise engagement. Conclusions: These results suggest that PTSD symptoms are associated with worse diet quality and that the consumption of unhealthy food may be driven by efforts to suppress emotion. This carries implications for understanding and treating medical comorbidities among those with traumatic stress.

Dropout from exercise randomized controlled trials among people with anxiety and stress-related disorders: A meta-analysis and meta-regression

OBJECTIVE

. Exercise has established efficacy in people with anxiety and stress-related disorders. Dropouts from randomized controlled trials (RCT's) pose a threat to the validity of the evidence, with dropout rates varying across studies. We conducted a meta-analysis to investigate the prevalence and predictors of dropout rates among adults with anxiety and stress-related disorders participating in exercise RCT's.

METHODS

. Two authors searched major electronic databases up to 07/2020. We included RCT's of exercise interventions in people with anxiety and stress-related disorders that reported dropout rates. A random effects meta-analysis and meta-regression were conducted.

RESULTS

. Fourteen RCT's involving 16 exercise interventions (n=369, mean age 20.7 to 67.7years; 38.4% male) were included. The trim-and-fill-adjusted prevalence of dropout across all studies was 22.4% (95%CI = 15.0% to 32.0%). Applying controlled motivation strategies (P<0.001) predicted higher dropout. Supervision during all sessions and by an expert in exercise prescription and applying autonomous motivation strategies predicted lower dropout (all P<0.001). Dropout was similar in exercise versus control conditions (OR = 0.84, 95%CI = 0.54 to 1.29, p = 0.42, I² = 0%; N=16).

LIMITATIONS

. Potentially important moderators of dropout, such as the severity of mental health symptoms and illness duration were insufficiently available.

CONCLUSIONS

. Exercise is well tolerated by people with anxiety and stress-related disorders and drop out in RCT's is comparable to control conditions. Thus, exercise is a feasible treatment, in particular when autonomous motivation strategies are included and when the intervention is delivered by healthcare professionals with expertise in exercise prescription.

Aerobic exercise reduces anxiety and fear ratings to threat and increases circulating endocannabinoids in women with and without PTSD

Reductions in state anxiety have been reported following an acute bout of aerobic exercise. However, less is known regarding anxiety and fear ratings to specific threatening stimuli following an acute bout of aerobic exercise in women with PTSD. Moreover, the mechanisms responsible for the anxiolytic effects of exercise are not fully understood, although recent studies suggest a role for the endocannabinoid (eCB) system. Thus, this study utilized a randomized, counterbalanced approach to examine anxiety and fear ratings to predictable or unpredictable electric shock administration and circulating concentrations of eCBs and mood states immediately following moderate-intensity aerobic exercise (30 min on treadmill at 70-75% maximum heart rate) and a quiet rest control condition in women with and without a history of trauma, and in women with PTSD (N=42). Results revealed that anxiety and fear ratings to unpredictable and predictable threats were significantly (p<.05) lower following exercise compared to quiet rest, with correlational analyses indicating those with greater increases in circulating eCBs had greater reductions in anxiety and fear ratings to unpredictable and predictable threats following exercise. Also, there were significant (p<.05) reductions in fatigue, confusion, total mood disturbance, and increases in positive affect following exercise for the entire sample. Non-trauma controls and PTSD groups reported significant (p<.05) increases in vigor, with additional mood improvements following exercise for the PTSD group (i.e., decreases in state anxiety, negative affect, tension, anger, and depression). Results from this study suggest that aerobic exercise exerts psychological benefits in women with PTSD, potentially due to exercise-induced increases in circulating concentrations of eCBs.

The Effects and Mechanisms of Exercise on the Treatment of Depression

Background: It is necessary to seek alternative therapies for depression, because side effects of medications lead to poor adherence and some patients do not achieve a clinical treatment effect. Recently the role of exercise as a low-cost and easy-to-use treatment for depression has gained attention with a number of studies showing that exercise is effective at reducing depressive symptoms and improving body functions such as cardiorespiratory system and cognitive function. Because of the heterogeneity of exercise therapy programs, there is no standardized and unified program. Few studies have summarized the specific properties of exercise programs (type, intensity, duration, and frequency) and clinical prescriptions for exercise are not mentioned in most articles. Aims: This study aimed to investigate the feasibility and efficacy of exercise therapy for patients with depression, in order to appraise the evidence and outline accepted guidelines to direct individualized treatment plans for patients with depression based on their individual situations. Methods: A systematic review of English language literature including papers published from 2010 to present in PubMed was performed. Given the feasibility of prescribing exercise therapy for patients with depression, nearly 3 years of clinical studies on the treatments of depressive symptoms with exercise were first reviewed, comparing the exercise programs utilized. Conclusions: Exercise has therapeutic effects on depression in all age groups (mostly 18-65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression. Moderate intensity exercise is enough to reduce depressive symptoms, but higher-dose exercise is better for overall functioning. Exercise therapy has become more widely used because of its benefits to the cardiovascular system, emotional state, and systemic functions. Recommendations: Aerobic exercise/mind-body exercise (3-5 sessions per week with moderate intensity lasting for 4-16 weeks) is recommended. Individualized protocols in the form of group exercise with supervision are effective at increasing adherence to treatment.

PTSD Improvement Associated with Social Connectedness in Gerofit Veterans Exercise Program

OBJECTIVE

Post-traumatic stress disorder (PTSD) is common in Veterans. Symptoms can perpetuate into late life, negatively impacting physical and mental health. Exercise and social support are beneficial in treating anxiety disorders such as PTSD in the general population, although less is known about the impact on Veterans who have lived with PTSD for decades. This study assessed associations between social connectedness, physical function and self-reported change in PTSD symptoms among older Veterans specifically participating in Gerofit.

DESIGN

Prospective clinical intervention.

SETTING

Twelve sites of Veterans Affairs (VA) Gerofit exercise program across the United States.

PARTICIPANTS

Three hundred and twenty one older Veteran Gerofit participants (mean age = 74) completed physical assessments and questionnaires regarding physical and emotional symptoms and their experience.

MEASUREMENTS

Measures of physical function, including 30-second chair stands, 10-m and 6-min walk were assessed at baseline and 3 months; change in PTSD symptoms based on the Diagnostic Statistical Manual-5 (DSM-5) assessed by a self-report questionnaire; and social connection measured by the Relatedness Subscale of the Psychological Need Satisfaction in Exercise scale (PNSE) were evaluated after 3 months of participation in Gerofit.

RESULTS

Ninety five (29.6%) Veterans reported PTSD. Significant improvement was noted in self-rated PTSD symptoms at 3 months (P < .05). Moderate correlation (r = .44) was found between social connectedness with other participants in Gerofit and PTSD symptom improvement for those Veterans who endorsed improvement (n = 59). All participants improved on measures of physical function. In Veterans who endorsed PTSD there were no significant associations between physical function improvement and PTSD symptoms.

CONCLUSION

Veterans with PTSD that participated in Gerofit group exercise reported symptom improvement, and social connectedness was significantly associated with this improvement. In addition to physical health benefits, the social context of Gerofit may offer a potential resource for improving PTSD symptoms in older Veterans that warrants further study.

Self-reported exercise frequency and PTSD: results from the National Health and Resilience in Veterans Study

OBJECTIVE

Physical exercise may serve as a protective factor for posttraumatic stress disorder (PTSD), but little is known about whether physical exercise is associated with PTSD in population-based samples of military veterans.

METHODS

We analyzed cross-sectional data on the relation between self-reported physical exercise frequency and the prevalence of probable PTSD in a nationally representative sample of 2832 U.S. military veterans who participated in the National Health and Resilience in Veterans Study.

RESULTS

A "U-shaped" association best explained the relation between self-reported exercise frequency and the prevalence of probable PTSD. Compared to veterans without probable PTSD, those with probable PTSD were nearly twice as likely to report no weekly exercise (52.3% vs. 29.3%) or daily (7 days/week) exercise (15.2% vs. 8.5%) and were nearly half as likely to report exercising a median of 3.5 days/week (32.6% vs. 62.1%). No exercise was associated with greater severity of emotional numbing and lower severity of anxious arousal symptoms, while daily exercise was associated with greater severity of re-experiencing symptoms.

CONCLUSIONS

Results of this study suggest a "U-shaped" association between self-reported exercise frequency and the prevalence of probable PTSD among U.S. veterans. Veterans with probable PTSD were more likely than those without probable PTSD to report not exercising at all or exercising every day and were less likely to report exercising 1-6 days per week. Clinical implications of these findings are discussed.

Warrior Wellness: A Randomized Controlled Pilot Trial of the Effects of Exercise on Physical Function and Clinical Health Risk Factors in Older Military Veterans With PTSD

BACKGROUND

Military veterans living with post-traumatic stress disorder (PTSD) face significant physical and functional health disparities, which are often aggravated over time and in the context aging. Evidence has shown that physical activity can positively impact age-related health conditions, yet exercise trials in older adults with mental disorders are rare. Our study was a tailored and targeted pilot exercise intervention for older veterans with PTSD.

METHODS

Fifty-four older veterans with PTSD (mean age = 67.4 years, 90.7% male, 85.2% non-white) were randomized to supervised exercise (n = 38) or wait-list usual care (n = 18) for 12 weeks. Physical activity (MET-min/wk) and aerobic endurance (assessed with the 6-minute walk test) were primary outcomes. Secondary outcomes were physical performance (strength, mobility, balance), cardiometabolic risk factors (eg, waist circumference), and health-related quality of life.

RESULTS

At 12 weeks, a large effect of the intervention on physical activity levels (Cohen's d = 1.37) was observed compared to wait-list usual care. Aerobic endurance improved by 69 m in the exercise group compared to 10 m in wait-list group, reflecting a moderate between-group effect (Cohen's d = 0.50). Between-group differences on 12-week changes in physical performance, cardiometabolic risk factors, and health-related quality of life ranged from small to large effects (Cohen's d = 0.28-1.48), favoring the exercise arm.

CONCLUSION

Participation in supervised exercise improved aerobic endurance, physical performance, and health-related clinical factors in older veterans with PTSD; a medically complex population with multiple morbidity. Group exercise is a low-cost, low-stigma intervention, and implementation efforts among older veterans with PTSD warrants further consideration.

A systematic review of factors associated with outcome of psychological treatments for post-traumatic stress disorder

OBJECTIVE

Psychological interventions for post-traumatic stress disorder (PTSD) are not always effective and can leave some individuals with enduring symptoms. Little is known about factors that are associated with better or worse treatment outcome. Our objective was to address this gap.

METHOD

We undertook a systematic review following Cochrane Collaboration Guidelines. We included 126 randomized controlled trials (RCTs) of psychological interventions for PTSD and examined factors that were associated with treatment outcome, in terms of severity of PTSD symptoms post-treatment, and recovery or remission.

RESULTS

Associations were neither consistent nor strong. Two factors were associated with smaller reductions in severity of PTSD symptoms post-treatment: comorbid diagnosis of depression, and higher PTSD symptom severity at baseline assessment. Higher education, adherence to homework and experience of a more recent trauma were associated with better treatment outcome.

CONCLUSION

Identifying and understanding why certain factors are associated with treatment outcome is vital to determine which individuals are most likely to benefit from particular treatments and to develop more effective treatments in the future. There is an urgent need for consistent and standardized reporting of factors associated with treatment outcome in all clinical trials.

Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review

Compelling evidence from animal and human research suggest a strong link between inflammation and posttraumatic stress disorder (PTSD). Furthermore, recent findings support compromised neurocognitive function as a key feature of PTSD, particularly with deficits in attention and processing speed, executive function, and memory. These cognitive domains are supported by brain structures and neural pathways that are disrupted in PTSD and which are implicated in fear learning and extinction processes. The disruption of these supporting structures potentially results from their interaction with inflammation. Thus, the converging evidence supports a model of inflammatory dysregulation and cognitive dysfunction as combined mechanisms underpinning PTSD symptomatology. In this review, we summarize evidence of dysregulated inflammation in PTSD and further explore how the neurobiological underpinnings of PTSD, in the context of fear learning and extinction acquisition and recall, may interact with inflammation. We then present evidence for cognitive dysfunction in PTSD, highlighting findings from human work. Potential therapeutic approaches utilizing novel pharmacological and behavioral interventions that target inflammation and cognition also are discussed.

Insights Following Implementation of an Exercise Intervention in Older Veterans with PTSD

Individuals with post-traumatic stress disorder (PTSD) face numerous barriers to exercise. Little is known about behavioral strategies to promote participation in this population. This is a secondary analysis of individual barriers and goals, exercise prescription characteristics, and patient perceptions of a 12-week, community-based, randomized controlled exercise trial targeting older adults with PTSD, (N = 45; mean age = 68; male = 91%). The most common cited goals for participating included weight loss (65%) and increasing strength (65%). Exercise mode varied among those who completed the program (n = 37), with 14 (38%) using exclusively treadmill; eight (22%) using only bike, and 15 (41%) utilizing a combination. Patient-reported exercise duration and intensity progressively increased over the 12 weeks, and duration differed by mode of exercise. We observed high rates of attendance (84%) and completion (88%) to the program. Patient-reported barriers to attendance most often included health problems (62%) and medical appointments (55%). Participant responses to a program evaluation revealed high levels of satisfaction, preferences for group-based programs, and insights about the acceptability of the exercise environment (physical and social). This study is the first to report on goals, barriers, exercise prescription needs, and individual responses to supervised exercise training in a unique population, that is, older veterans with PTSD. Results of this study can inform future health promotion programs targeting older veterans with PTSD.