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Lee S. Cross-Lagged Associations Between Physical Activity, Self-Rated Health, and Psychological Resilience Among Older American Adults: A 3-Wave Study. J Phys Act Health 2023:1-8. [PMID: 37185450 DOI: 10.1123/jpah.2022-0455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 05/17/2023]
Abstract
The current study examined the reciprocal association between psychological resilience, physical activity, and self-rated health in older America adults. A 3-wave cross-lagged panel design was employed using data sampled from the Health and Retirement Study 2010, 2014, and 2018. In total, 8380 older adults, age ranged between 56 and 95 years at the baseline (mean age = 68.06, SD = 7.77), were analyzed. Using structural equation modeling, standardized path coefficients were estimated to determine the relationship between physical activity, self-rated health, and psychological resilience across 2 follow-up points. Cross-lagged analysis revealed that higher levels of physical activity at T1 and T2 were significantly associated with higher levels of self-rated health at T2 and T3, respectively. Self-rated health at T1 and T2 were significantly associated with physical activity at T2 and T3, respectively. Self-rated health and psychological resilience were positively related to one another at each time point. However, relationship between physical activity and psychological resilience was complex across time. Study findings support reciprocal prospective relationship between physical activity and self-rated health and the relationship between self-rated health and psychological resilience.
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Affiliation(s)
- Sunwoo Lee
- Faculty of Physical Culture, Palacký University Olomouc, Olomouc,Czech Republic
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2
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Prior short-term exercise prevents behavioral and biochemical abnormalities induced by single prolonged stress in a rat model of posttraumatic stress disorder. Behav Brain Res 2022; 428:113864. [DOI: 10.1016/j.bbr.2022.113864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/27/2022] [Accepted: 03/27/2022] [Indexed: 11/21/2022]
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3
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Relationship Between Mental Health, Resilience, and Physical Activity in Older Adults: A 2-Year Longitudinal Study. J Aging Phys Act 2021; 30:73-81. [PMID: 34407504 DOI: 10.1123/japa.2020-0264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/24/2020] [Accepted: 02/03/2021] [Indexed: 11/18/2022]
Abstract
The aim of this study was to longitudinally investigate the association between resilience and mental health in older adults and to determine the influence of physical activity on this relationship. A total of 291 older adults were included in a 2-year follow-up study. Adjusted linear regression models evaluated the association between resilience at baseline and mental health after 2 years in sufficiently and insufficiently physically active older adults. A negative correlation was found between resilience at baseline and depression, anxiety, and stress after 2 years for the overall sample. This association changed after stratifying the group. Sufficiently physically active individuals made greater use of the resilience components "Self-Sufficiency" and "Perseverance," whereas insufficiently physically active individuals made greater use of "Meaning of Life" and "Existential Singularity." Physical activity can influence the relationship between resilience and mental health. These results can help guide the devising of more effective interventions for this age group.
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4
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Gilson ND, Papinczak ZE, Mielke GI, Haslam C, McKenna J, Brown WJ. Stepped-down intervention programs to promote self-managed physical activity in military service veterans: A systematic review of randomised controlled trials. J Sci Med Sport 2021; 24:1155-1160. [PMID: 34246553 DOI: 10.1016/j.jsams.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 04/28/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES A stepped-down program is one where clients transition from the care of a health professional to self-managed care. This study reviewed the effectiveness of stepped-down interventions to promote self-managed physical activity for health in military service veterans. DESIGN Systematic review. METHODS Literature searches of 11 electronic databases were performed (up to 28th April 2020) to identify randomised controlled trials that assessed self-managed physical activity interventions in military service veterans. Data were extracted on study characteristics, intervention programs (with strategies mapped against a taxonomy of behaviour change techniques), and physical activity outcomes; secondary outcomes were physical fitness/function, psychosocial health, and cost effectiveness. Study quality was assessed using a 15-item checklist adapted from the TESTEX scale. RESULTS Searches identified 26 studies (all from the United States; N = 45 to 531 participants) representing 17 intervention programs. Studies were of good quality (M = 10.7; SD = 2.3). More than half (54%) reported positive between-group intervention effects for physical activity outcomes (mean increase of 80 min/week in self-reported physical activity at 10-12 months). Physical fitness/function outcomes improved in 38% of studies, but no studies found significant intervention effects for psychosocial health or cost effectiveness outcomes. Behaviour change techniques most frequently used to elicit physical activity changes were education, goal setting, goal review and self-monitoring. CONCLUSIONS Stepped-down programs that include specific behaviour change techniques have the potential to promote self-management of physical activity in military service veterans. Multi-national randomised controlled trials that use objective physical activity measures are needed to further build the evidence base.
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Affiliation(s)
- Nicholas D Gilson
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia.
| | - Zoe E Papinczak
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
| | - Gregore I Mielke
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
| | | | - James McKenna
- Active Lifestyles Research Centre, Leeds Beckett University, United Kingdom
| | - Wendy J Brown
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
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5
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Hoerster KD, Tanksley L, Sulayman N, Bondzie J, Brier M, Damschroder L, Coggeshall S, Houseknecht D, Hunter-Merrill R, Monty G, Saelens BE, Sayre G, Simpson T, Wong E, Nelson K. Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial. Contemp Clin Trials 2021; 107:106487. [PMID: 34144246 DOI: 10.1016/j.cct.2021.106487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.
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Affiliation(s)
- Katherine D Hoerster
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; University of Washington, Department of Psychiatry and Behavioral Sciences, 100 NE 45(th) Street, Suite 300, Seattle, WA 98105; United States.
| | - Lamont Tanksley
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States.
| | - Nadiyah Sulayman
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Juliana Bondzie
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Moriah Brier
- VA Puget Sound Healthcare System, Anesthesiology Service, 1660 South Columbian Way, Seattle, WA 98108, United States.
| | - Laura Damschroder
- VA Ann Arbor Center for Clinical Management Research, 2800 Plymouth Rd. NCRC Bldg 16 (152), Ann Arbor, MI 48105, USA.
| | - Scott Coggeshall
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Dakota Houseknecht
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Rachel Hunter-Merrill
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Gillian Monty
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Brian E Saelens
- Seattle Children's Research Institute, 1920 Terry Avenue, Seattle, WA 98101, United States of America; University of Washington, Department of Pediatrics, 1959 NE Pacific Street, Seattle, WA 98195, United States of America.
| | - George Sayre
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Tracy Simpson
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Edwin Wong
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Karin Nelson
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States; University of Washington, Department of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States.
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6
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Hoerster KD, Tanksley L, Simpson T, Saelens BE, Unützer J, Black M, Greene P, Sulayman N, Reiber G, Nelson K. Development of a Tailored Behavioral Weight Loss Program for Veterans With PTSD (MOVE!+UP): A Mixed-Methods Uncontrolled Iterative Pilot Study. Am J Health Promot 2020; 34:587-598. [PMID: 32162528 DOI: 10.1177/0890117120908505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Veterans with post-traumatic stress disorder (PTSD) lose less weight in the Veterans Affairs (VA) weight management program (MOVE!), so we developed MOVE!+UP. DESIGN Single-arm pre-post pilot to iteratively develop MOVE!+UP (2015-2018). SETTING Veterans Affairs Medical Center. PARTICIPANTS Overweight Veterans with PTSD (5 cohorts of n = 5-11 [N = 44]; n = 39 received ≥1 MOVE+UP session, with cohorts 1-4 [n = 31] = "Development" and cohort 5 [n = 8] = "Final" MOVE!+UP). INTERVENTION MOVE!+UP weight management for Veterans with PTSD modified after each cohort. Final MOVE!+UP was coled by a licensed clinical psychologist and Veteran peer counselor in 16 two-hour in-person group sessions and 2 individual dietician visits. Sessions included general weight loss support (eg, behavioral monitoring with facilitator feedback, weekly weighing), cognitive-behavioral skills to address PTSD-specific barriers, and a 30-minute walk to a nearby park. MEASURES To inform post-cohort modifications, we assessed weight, PTSD, and treatment targets (eg, physical activity, diet), and conducted qualitative interviews. ANALYSIS Baseline to 16-week paired t tests and template analysis. RESULTS Development cohorts suggested improvements (eg, additional sessions and weight loss information, professional involvement) and did not lose weight (mean [M] = 1.8 lbs (standard deviation [SD] = 8.2); P = .29. Conversely, the final cohort reported high satisfaction and showed meaningful weight (M = -14 pounds [SD = 3.7] and 71% lost ≥5% baseline weight) and PTSD (M = -17.9 [SD = 12.2]) improvements, P < .05. CONCLUSIONS The comprehensive, 16-week, in-person, cofacilitated Final MOVE!+UP was acceptable and may improve the health of people with PTSD. Iterative development likely produced a patient-centered intervention, needing further testing.
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Affiliation(s)
- Katherine D Hoerster
- Health Services Research and Development Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA.,Mental Health Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Lamont Tanksley
- Mental Health Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA
| | - Tracy Simpson
- Mental Health Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA
| | - Brian E Saelens
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Seattle Children's Research Institute, Seattle, WA, USA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Marissa Black
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA
| | - Preston Greene
- Health Services Research and Development Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA
| | - Nadiyah Sulayman
- Health Services Research and Development Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA
| | - Gayle Reiber
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.,Health Services Research Center of Innovation, Salt Lake City, UT, USA
| | - Karin Nelson
- Health Services Research and Development Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA.,General Internal Medicine Service, VA Puget Sound Health Care System, Seattle Division, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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7
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Pebole MM, Hall KS. Insights Following Implementation of an Exercise Intervention in Older Veterans with PTSD. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2630. [PMID: 31340588 PMCID: PMC6678353 DOI: 10.3390/ijerph16142630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Michelle M Pebole
- Geriatric Research, Education and Clinical Center, Durham VA Health Care System, Durham, NC 27705, USA
| | - Katherine S Hall
- Geriatric Research, Education and Clinical Center, Durham VA Health Care System, Durham, NC 27705, USA.
- Department of Medicine, Duke University, Durham, NC 27710, USA.
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Ahmadian AJ, Neylan TC, Metzler T, Cohen BE. Longitudinal association of PTSD symptoms and self-reported physical functioning among Veterans. J Affect Disord 2019; 250:1-8. [PMID: 30818050 DOI: 10.1016/j.jad.2019.02.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Few longitudinal studies have investigated the potentially dynamic relationship between Posttraumatic Stress Disorder (PTSD) and physical functioning, and the number of follow-up timepoints have been limited. We evaluated whether PTSD symptoms predicted future physical functioning and vice versa using five assessments over four years. METHODS Data was used from a longitudinal cohort of 695 participants recruited from Veteran Affairs medical outpatient clinics who experienced a traumatic event. PTSD symptom severity was assessed annually with the PTSD Checklist (PCL). Physical functioning was measured with the 10-item subscale of the SF-36. An autoregressive cross-lagged panel model was used to determine the temporal associations between PTSD and physical functioning, adjusting for age, sex, ethnicity, education and employment. Comorbidities and health behaviors were added to assess their roles in the relationship. RESULTS Greater PTSD symptom severity predicted worse physical functioning the following year (average β = -0.10, P <0.001), where a 10-point increase in PCL score predicted a 0.3-point decline in physical function score over one year. Similarly, better physical functioning also predicted reduced PTSD severity the following year, but to a smaller magnitude (average β = -0.04, P = .003). The pattern of effects was similar after controlling for comorbidities and health behaviors. LIMITATIONS Both primary variables relied on self-report, and generalizability may be limited by the mostly male Veteran sample. CONCLUSIONS Our results support a bidirectional, but unequal, relationship between PTSD and physical functioning over time. They also highlight the importance of long-term control of PTSD symptoms in preventing functional decline.
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Affiliation(s)
- Ashkan J Ahmadian
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA.
| | - Thomas C Neylan
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Thomas Metzler
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA
| | - Beth E Cohen
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Internal Medicine, University of California, San Francisco, CA, USA
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Hall KS, Morey MC, Beckham JC, Bosworth HB, Pebole MM, Pieper CF, Sloane R. The Warrior Wellness Study: A Randomized Controlled Exercise Trial for Older Veterans with PTSD. TRANSLATIONAL JOURNAL OF THE AMERICAN COLLEGE OF SPORTS MEDICINE 2018; 3:43-51. [PMID: 29632895 PMCID: PMC5889111 DOI: 10.1249/tjx.0000000000000056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Posttraumatic stress disorder (PTSD) affects up to 30% of military veterans. Older veterans, many of whom have lived with PTSD symptoms for several decades, report a number of negative health outcomes. Despite the demonstrated benefits of regular exercise on physical and psychological health, no studies have explored the impact of exercise in older veterans with PTSD. This paper describes the development, design, and implementation of the Warrior Wellness exercise pilot study for older veterans with PTSD. Veterans aged ≥60 with a Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnosis of PTSD will be recruited and randomized to (a) Warrior Wellness, a 12-week supervised, facility-based exercise intervention, or (b) usual care for 12 weeks. Warrior Wellness is a theory- and evidence-based behavioral intervention that involves 3 sessions per week of multi-component exercise training that targets strength, endurance, balance, and flexibility. Warrior Wellness focuses on satisfaction with outcomes, self-efficacy, self-monitoring, and autonomy. Factors associated with program adherence, defined as the number of sessions attended during the 12 weeks, will be explored. Primary outcomes include PTSD symptoms and cardiovascular endurance, assessed at baseline and 12 weeks. Compared to those in usual care, it is hypothesized that those in the Warrior Wellness condition will improve on these efficacy outcomes. The Warrior Wellness study will provide evidence on whether a short-term exercise intervention is feasible, acceptable, and effective among older veterans with PTSD, and explore factors associated with program adherence. ClinicalTrials.gov Identifier: NCT02295995.
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Affiliation(s)
- Katherine S Hall
- VA Durham Healthcare System, Geriatric Research, Education, and Clinical Center, Durham, NC.,Duke University, Department of Medicine, Durham, NC
| | - Miriam C Morey
- VA Durham Healthcare System, Geriatric Research, Education, and Clinical Center, Durham, NC.,Duke University, Department of Medicine, Durham, NC
| | - Jean C Beckham
- VA Durham Healthcare System, Mental Illness Research, Education, and Clinical Center, Durham, NC.,Duke University, Department of Psychiatry and Behavioral Sciences, Durham, NC
| | - Hayden B Bosworth
- Duke University, Department of Psychiatry and Behavioral Sciences, Durham, NC.,VA Durham Healthcare System, Health Services Research and Development, Durham, NC
| | - Michelle M Pebole
- VA Durham Healthcare System, Geriatric Research, Education, and Clinical Center, Durham, NC
| | - Carl F Pieper
- Duke University, Department of Biostatistics and Bioinformatics, Durham, NC
| | - Richard Sloane
- VA Durham Healthcare System, Geriatric Research, Education, and Clinical Center, Durham, NC.,Duke University, Department of Biostatistics and Bioinformatics, Durham, NC
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