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Posttraumatic Stress Disorder (PTSD) is a disorder associated with poor health outcomes including high rates of cardio-metabolic disease. Exercise and physical activity more broadly offer substantial promise as a feasible and effective component of care. Evidence to date demonstrates that exercise can improve both the physical and mental health of people with PTSD. Exercise should be included in the treatment of PTSD, across the spectrum from inpatients receiving treatment for severe PTSD, to trauma-exposed individuals living in the community with sub-syndromal symptomatology.
Exercise and Posttraumatic Stress
Simon Rosenbaum, Brendon Stubbs, Felipe Schuch und
Davy Vancampfort
Posttraumatic Stress Disorder (PTSD) is a dis-
order associated with poor health outcomes
including high rates of cardio-metabolic disease.
Exercise and physical activity more broadly
offer substantial promise as a feasible and effec-
tive component of care. Evidence to date
demonstrates that exercise can improve both
the physical and mental health of people with
PTSD. Exercise should be included in the treat-
ment of PTSD, across the spectrum from inpa-
tients receiving treatment for severe PTSD, to
trauma-exposed individuals living in the com-
munity with sub-syndromal symptomatology.
Exercise Posttraumatic stress PTSD Meta-
bolic syndrome
1 Introduction ...................................... 1
2 Current Treatment of PTSD .................... 2
3 Physical Health of People with PTSD .......... 2
4 Correlates of Physical Activity in PTSD ....... 4
5 Evidence of Exercise as an Intervention ....... 5
6 Methodological Considerations and Implications
for Future Research ............................. 9
7 Conclusion ........................................ 10
References ............................................ 10
1 Introduction
Posttraumatic stress disorder (PTSD) typically
occurs following exposure to a potentially trau-
matic event which may include war, torture, phy-
sical or sexual assault or natural disaster (Ameri-
can Psychological Association 2013). PTSD
has an estimated lifetime prevalence of 6.8%
(Kessler et al. 2005) and is particularly prevalent
Simon Rosenbaum is funded by an NHMRC Early Career
Fellowship (APP1123336) & a UNSW Sydney Scientia
S. Rosenbaum (*)
School of Psychiatry, University of New South Wales,
Sydney, Australia
Black Dog Institute, Prince of Wales Hospital, Sydney,
B. Stubbs
Institute of Psychiatry, Psychology and Neuroscience
(IoPPN), Kings College London, London, UK
Physiotherapy Department, South London and Maudsley
NHS Foundation Trust, London, UK
F. Schuch
Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
Universidade La Salle, Porto Alegre, Brazil
D. Vancampfort
Department of Rehabilitation Sciences, KU Leuven
University of Leuven, Leuven, Belgium
#Springer-Verlag GmbH Deutschland 2017
R. Fuchs, M. Gerber (Hrsg.), Handbuch Stressregulation und Sport, Springer Reference Psychologie,
DOI 10.1007/978-3-662-49411-0_16-1
among those working in professions who are
exposed to high rates of trauma including rst
responders (police ofcers, paramedics, re-
ghters) and combat veterans (Sayer et al. 2010).
For example, the estimated point-prevalence of
PTSD among combat veterans is as high as 23%
(Fulton et al. 2015). Although previously classi-
ed by the Diagnostic and Statistical Manual of
Mental Disorders (DSM) as an anxiety disorder,
PTSD is now classied under a stand-alone chap-
ter of the DSM 5 under trauma and stressor related
disorders (American Psychological Association
2013). PTSD is characterized by four symptom
clusters including (i) re-experiencing,
(ii) avoidance, (iii) negative cognitions and mood,
and (iv) arousal. In order for a diagnosis of PTSD to
be made, symptoms must cause a clinically signi-
cant level of distress or impairment in social inter-
actions, capacity to work or in other areas of psy-
chosocial functioning (American Psychological
Association 2013). People with PTSD may present
with symptoms of hyper-vigilance, difculty
debrieng following exposure to a traumatic expe-
rience, increased anxiety and depression, social
withdrawal, aggression, nightmares and substance
misuse (Ozer et al. 2008). PTSD is associated with
adverse outcomes not limited to severe impair-
ments in psychosocial functioning (Zatzick et al.
2002), signicantly increased risk of suicide and
suicidal ideation (Jakupcak et al. 2009) and sub-
stance abuse and dependence (Schnurr et al. 2005).
2 Current Treatment of PTSD
Current treatments for PTSD include pharmaco-
therapies such as paroxetine, sertraline, uoxe-
tine, risperidone, topiramate, and venlafaxine, in
addition to psychological therapies such as
trauma-informed cognitive behavioral therapy
(CBT), exposure therapy and Eye Movement
Desensitization and Reprocessing (EMDR)
(Watts et al. 2013). Recent guidelines for the
treatment of PTSD indicate that up to 12 sessions
of between 60 and 120 min duration of trauma
informed CBT or EMDR may be required, and
that many people experiencing PTSD will require
additional treatment sessions (Harvey et al. 2015).
Recent evidence has also demonstrated the benets
of non-traditional strategies including mindfulness-
based stress reduction (Polusny et al. 2015).
3 Physical Health of People
with PTSD
3.1 Cardio-Metabolic Health
People with PTSD experience an excess mortality
rate two to three times higher than the general
population (Boscarino 2006; Pietrzak et al. 2011)
with a growing body of evidence demonstrating the
links between PTSD and poor physical health (Bar-
toli et al. 2015; Pacella et al. 2013; Rosenbaum
et al. 2015b;Wolfetal.2016a,b). For example,
PTSD is associated with the presence and severity
of cardiovascular diseases (CVD), which predicts
mortality independent of age, gender, and conven-
tional risk factors (Ahmadi et al. 2011). The pooled
prevalence of metabolic syndrome (the cluster of
risk factors including central obesity, high blood
pressure, low high-density lipoprotein (HDL)
cholesterol, elevated triglycerides and hyperglyce-
mia (Alberti et al. 2005)) among people with PTSD
is 38.7% (95% CI =32.145.6%) with an almost
doubled increased risk compared to the general
population (RR =1.82; 95% CI =1.721.92; p
<0.001) (Rosenbaum et al. 2015b). Similarly, the
prevalence of type two diabetes (T2DM) among
people with PTSD has been determined at 10%
(95% CI =8.1%12.0%), with PTSD resulting
in a signicantly increased risk of developing
T2DM (RR =1.49, 95% CI =1.171.89, p
<.001) (Vancampfort et al. 2016d).The relation-
ship between PTSD and metabolic syndrome has
been further explored in a 2016 study demonstra-
ting that PTSD severity at baseline predicts a sub-
sequent increase in metabolic syndrome severity
over time (β=0.08, p =0.002). These ndings
were signicant after controlling for initial meta-
bolic syndrome severity, with the authors nding
that for every ten PTSD symptoms endorsed (based
on a structured clinical interview), the odds of a
subsequent metabolic syndrome diagnosis increa-
sed by 56%(Wolf et al. 2016a). Furthermore, PTSD
has been shown to act as a catalyst for the associa-
2 S. Rosenbaum et al.
tion between metabolic syndrome and broad
bilateral reductions of cortical thickness, primarily
in the temporal and parietal regions in a sample of
relatively young US military veterans (Wolf et al.
2016b). These data provide substantial evidence
for calls for new interventions that target not only
the psychological symptoms of PTSD, but also the
co-occurring cardio-metabolic conditions (Farr
et al. 2014; Rosenbaum and Steel 2016).
3.2 Factors Contributing to Poor
Physical Health of People
with PTSD
The pathophysiology underlying the association
between PTSD and cardio-metabolic disease is
complex and yet to be fully elucidated. Emerging
evidence suggests that both share pathophysiolo-
gical features, including hypothalamicpituita-
ryadrenal (HPA) and sympatho-
adrenomedullary dysfunction (Dedert et al.
2010), inammation (Eraly et al. 2014), and com-
mon genetic links and epigenetic interactions (Ne-
vell et al. 2014). Comparable to other mental dis-
orders, the contributing role of modiable lifestyle-
related factors is becoming increasingly clear. For
example, people with PTSD are more likely than
the general population to smoke, with rates of
4086% for clinical samples (Fu et al. 2007), be
alcohol dependent (Blanco et al. 2013), and con-
sume diets that are high in saturated fats and rened
sugars(Carmassi et al. 2015), while low in fruit
(Godfrey et al. 2013). Furthermore, PTSD sym-
ptoms and depression have also been shown to be
associated with binge eating (Hoerster et al. 2015),
further highlighting the importance of diet as a key
modiable risk factor. Sedentary behavior is also a
key risk factor contributing to overall poor physical
health (Zen et al. 2012).
3.3 Low Fitness
Low cardiorespiratory tness dened as the abi-
lity of the circulatory and respiratory systems to
supply oxygen to working muscles during sustai-
ned physical activity (Physical Activity Guideli-
nes Advisory 2008), is a strong and independent
predictor of cardiovascular and all-cause morta-
lity and is of comparable importance with diabetes
and other established risk factors (Kodama et al.
2009). For example, in the general population,
people with low cardiorespiratory tness have a
relative risk for all-cause mortality of 1.70 (95%
CI =1.511.92; p <0.001) and for cardiovascu-
lar events of 1.56 (95% CI =1.391.75; P
<0.001) compared with those with a high cardio-
respiratory tness (Kodama et al. 2009). In com-
parison to those with average cardiorespiratory
tness, those with low cardiorespiratory tness
have a relative risk for all-cause mortality of
1.40 (95% CI =1.321.48; p <0.001) and for
cardiovascular events of 1.47 (95% CI =
1.351.61; p <0.001) (Kodama et al. 2009).
Despite increasing evidence regarding the poor
tness of people with mental disorders including
schizophrenia (Vancampfort et al. 2015b) and
bipolar disorder (Vancampfort et al. 2015d,
2016e), in addition to evidence demonstrating an
increase in tness can be achieved in mental
health populations following specic intervention
(Stubbs et al. 2016b; Vancampfort et al. 2015c),
and that higher tness levels are associated with
decreased incident depression (Åberg et al. 2012),
relatively little is known regarding the relation-
ship between cardiorespiratory tness and PTSD.
In a 2014 study of soldiers completing basic trai-
ning in the US, the odds of soldiers reporting
depressive symptoms were 60% lower at the com-
pletion of basic combat training for soldiers in the
highest tness category compared to soldiers in
the lowest category (odds ratio, 0.40; 95% CI =
0.190.84, p <0.0xx) (Crowley et al. 2014),
with calls to target soldier cardiorespiratory t-
ness before basic combat training in order to
improve psychological health outcomes.
In a subsequent analysis of data from a clinical
trial investigating, the benets of aerobic exercise
for PTSD (Fetzner and Asmundson 2015), LeB-
outhillier et al. (2016) examined the role of car-
diorespiratory tness in predicting reductions in
PTSD symptoms and anxiety sensitivity follo-
wing participation in aerobic exercise, nding that
aerobic exercise is particularly effective in indivi-
duals with poorer levels of cardiorespiratory t-
Exercise and Posttraumatic Stress Disorder 3
ness. In addition, there is evidence suggesting that
veterans with PTSD have a worse performance on
submaximal exercise tests such as the 6-min walk
test (6MWT), on handgrip strength and the short
physical performance battery (SPPB) when com-
pared to veterans without PTSD (Hall et al. 2014).
However, the next step towards a more clear and
precise comprehension of the tness capacity of
people with PTSD requires assessing and compa-
ring maximal tness capacity among people with
PTSD and without PTSD (Vancampfort et al. 2016).
4 Correlates of Physical Activity
Comparable to other psychiatric populations, peo-
ple with PTSD are more likely than the general
population to endorse unhealthy lifestyle behavi-
ors, including high rates of sedentary behavior
(Zen et al. 2012). Sedentary behaviour is inde-
pendently associated with an increased risk of
cardiometabolic disease and mortality in the gene-
ral population (Biswas et al. 2015). Therefore,
understanding physical activity correlates is
essential to improve health outcomes and redu-
cing sedentary lifestyles. Hall et al. (2015) found
that the current literature regarding physical
activity in people with PTSD is somewhat incon-
sistent, with approximately half of the identied
studies reporting a signicant negative association
between PTSD and physical activity participation
with the others reporting no signicant associati-
ons between PTSD and physical activity at all.
Among the general population, correlates con-
sistently associated with increased physical
activity participation include male gender, higher
self-efcacy, previous physical activity, current
health status and the intention to be physically
active (Bauman et al. 2012), however, it is unclear
whether these factors are similarly associated with
physical activity behavior among people with
PTSD. Previous qualitative research among peo-
ple with PTSD found a lack of time (14% before
and 39% after PTSD onset) and lack of motivation
(24% before and 71% after PTSD onset) nega-
tively affected physical activity participation
(de Assis et al. 2008). In order to better understand
the barriers and facilitators of participation in
physical activity in people with PTSD,
Vancampfort et al. (2016b) conducted a systema-
tic review of the correlates of physical activity in
people with PTSD. Eight studies were identied
that were eligible for inclusion (Arnson et al.
2007; Babson et al. 2015; Davidson et al. 2013;
Harte et al. 2013; Rosenbaum et al. 2016; Rutter
et al. 2013; Vujanovic et al. 2013), with a total of
1368 (994 males) people with PTSD (age range
1870 years). The review found no evidence of
signicant demographic correlates, however, con-
sistent evidence was found that older age was not
a barrier to physical activity participation (Van-
campfort et al. 2016b). Biological correlates
including body mass index, waist circumference
and the presence of bromyalgia were investiga-
ted and only the presence of bromyalgia was
associated with less physical activity participation
(n =1), although evidence was limited to a single
study (Arnson et al. 2007). Better sleep quality
was found to be associated with higher physical
activity levels (Vancampfort et al. 2016b). This is
of particular clinical interest given that sleep dis-
turbances are common, debilitating symptoms of
PTSD and the benecial effect of exercise on
improving sleep quality both in the general popu-
lation and among those with PTSD (Lamarche
and De Koninck 2007).
Strong consistent evidence was found that
PTSD symptom severity, and in particular sym-
ptoms of hyper-arousal are a negative correlate of
physical activity participation among people with
PTSD (Vancampfort et al. 2016b). It is possible
that the inverse association between physical
activity and hyper-arousal is due to a lower like-
lihood of more anxious individuals to engage in
physical activity. For example, those with an
increased trait/state anxiety may avoid participa-
ting in physical activity to avoid physiological
reactions including hyperventilation, tachycardia,
dizziness, or sweating, which are also common
signs and symptoms of panic (Knapen et al.
2015). However, given that physical activity has
demonstrated anxiolytic effects via repeated
exposure to anxiety-related somatic sensations
(Knapen et al. 2015), it has been argued that
increased physical activity among patients with
4 S. Rosenbaum et al.
PTSD may lead to decreased hyper-arousal sym-
ptoms (Vancampfort et al. 2016b).
5 Evidence of Exercise as an
Evidence for the role of exercise in the treatment
of PTSD has increased signicantly over the past
decade. The rst Cochrane Collaboration review
in this area broadly assessed the effect of sports
and games on PTSD and highlighted the lack of
available evidence for exercise as a treatment or
co-treatment option at the time of publication
(Lawrence et al. 2010). At the time (2010), no
RCTs were identied as eligible for inclusion,
although some studies were found that evaluated
exercise and/or sports based interventions
for PTSD.
The generalizability of the ndings was limited
due to considerable methodological weaknesses,
including a lack of randomization, small sample
sizes, and the inclusion of interventions evalua-
ting play-based therapy, considered a psychologi-
cal intervention (Chapman et al. 2001; Diaz and
Motta 2008; Schreier et al. 2005; Walker 1983).
Some of the initial and preliminary evidence of
the potential benet of exercise on PTSD sym-
ptoms came from a 2008 study by Diaz and Motta
(Diaz and Motta 2008) who conducted a
non-randomized study involving twelve female
adolescents diagnosed with PTSD. Their results
showed that 91% of participants showed a signi-
cant reduction in PTSD symptoms on the Child-
hood PTSD Symptom Scale, following participa-
tion in a walking program. The study had a
number of limitations including the use of a low
intensity exercise protocol, which did not include
progressive overload training, and failed to meet
basic principles of exercise prescription.
Between 2010 and 2016, there has been gro-
wing recognition of physical activity as an impor-
tant component of treatment for other mental dis-
orders including depression (Schuch et al. 2016a,
c; Stanton and Reaburn 2013) and schizophrenia
(Firth et al. 2015). Similarly, since the 2010 sports
and games for PTSD Cochrane Review, a number
of randomized controlled trials have been publis-
hed regarding the efcacy of exercise as a com-
ponent of treatment. A 2015 meta-analysis identi-
ed four unique RCTs, encompassing a total of
n=200 participants with a mean age of 3452
years (Rosenbaum et al. 2015c). One key metho-
dological difference between the 2015 review and
the 2010 Cochrane Collaboration review was the
use of physical activityas dened by Caspersen,
Powell, and Christenson (Caspersen et al. 1985),
as opposed to the more restricted and structured
subset of exercise and/or sports. Applying this
inclusion criterion allowed for pragmatic inter-
ventions such as physical activity counseling and
yoga to be potentially eligible, better reecting
clinical practice. The meta-analysis revealed con-
siderable heterogeneity regarding study design,
methodological quality, exercise intervention
variables and choice of control conditions. Results
revealed that physical activity was signicantly
more effective compared to control conditions at
decreasing symptoms of PTSD and depression
symptoms among people with a diagnosis of
PTSD. The review concluded that physical
activity may be a useful adjunct to usual care to
improve the health of people with PTSD and
despite the relative paucity of data, clinicians
should be optimistic regarding the inclusion of
physical activity as an intervention for people
with PTSD. Details of the identied trials, incor-
porating structured aerobic and resistance exer-
cise, yoga and treadmill-based aerobic exercise
are summarized below (see Table 1).
5.1 Structured Exercise and PTSD
Two trials have determined the efcacy and effec-
tiveness of exercise as an intervention strategy for
PTSD (Powers et al. 2015; Rosenbaum et al.
2015a). The trial of Powers et al. recruited parti-
cipants from the community in Dallas, USA, who
were screened positive for PTSD, and were ran-
domized to receive either 12 weeks of prolonged
exposure therapy (90 min, one weekly session) or
prolonged exposure in addition to exercise. The
exercise intervention involved 30 min of moderate
intensity (70% of age-predicted maximum heart
rate) treadmill exercise supervised by a clinician.
Exercise and Posttraumatic Stress Disorder 5
Table 1 Description of PTSD and physical activity RCTs (n =4)
Age mean (SD) Intervention Diagnostic criteria Control
(s) Setting Methodological quality
Exp Con
12 sessions Kripalu (Hatha)
yoga (1/wk for 12 weeks or
2/wk for 6-weeks)
Presence of at least one
symptom in each DSM
criterion cluster or meeting
criteria for at least two
symptom clusters
PSS-I Advertisement
at Veteran
Affairs medical
No No
34 (11.8) 12 sessions of moderate-
intensity aerobic exercise
(stationary cycling; 70% age
predicted max heart rate); in
addition to prolonged
exposure therapy
DSM Prolonged
PSS-I Online
No Yes
12 weeks of supervised,
individualised combined
aerobic/resistance exercise in
addition to usual care
DSM Usual-care PCL-C Inpatients Yes Yes
van der
Kolk, 2014
10 weeks 1x weekly 60 min
trauma-informed yoga
DSM Supportive
CAPS Community
No Yes
DSM diagnostic and statistical manual mental disorders, CAPS clinician administered PTSD scale, PSS-I PTSD symptom scale-interview (Rosenbaum et al. 2015c)
6 S. Rosenbaum et al.
The exercise intervention employed a 5-min
warm-up and used increasing speed until the
pre-determined target heart rate was achieved.
Following the exercise session, speed was gra-
dually reduced for 5 min followed by a period of
stretching as a form of cool-down (Powers et al.
2015). In addition to a reduction in PTSD sym-
ptoms, the investigators found a signicant and
large impact of the exercise intervention on levels
of brain derived neurotropic factor (BDNF)
(Cohensd=1.08, SE =0.72), which has pre-
viously been implicated as a factor in the relation-
ship between exercise and improved mental
health (Schuch et al. 2016a).The authors conclu-
ded that exercise as an augmentation strategy to
exposure therapy may have the potential to
enhance psychological outcomes and holds pro-
mise for those who have a sub-optimal response to
routine treatment, via the promotion of synaptic
plasticity. While these data are encouraging regar-
ding the efcacy and potential moderating role of
BDNF in response to an exercise intervention for
people with PTSD, certain limitations should be
considered including the sample size (n =9),
which was too small to allow for between-group
signicance testing. In addition, these data pro-
vide useful evidence regarding the mechanism of
action and augmentative benets of specically
aerobic exercise, however, as acknowledged by
the study authors, the augmentation effects of
exercise are likely not limited to bouts of acute
aerobic exercise, and considering other exercise
modalities in combination with patient preferen-
ces and barriers, is likely to facilitate the design
and delivery of best-practice, evidence-based
exercise programs. In another study of n =33
participants with PTSD and sub-syndromal
PTSD, Fetzner and Asmundson (2015) also
demonstrated the benecial effect of aerobic exer-
cise, with clinically signicant improvements in
symptoms following a brief (2-week/6-session)
intervention, in which participants were randomi-
zed into one of three groups: (i) exercise plus
cognitive distraction (n =11), (ii) exercise plus
interoceptive prompts (n =11), or (iii) exercise
only (n =11). The overwhelming majority of the
sample (89%) experienced clinically signicant
reductions in PTSD symptom severity following
the 2-week intervention. While the lack of a con-
trol group presents a methodological limitation,
the authors argue that given the ease of implemen-
tation, aerobic exercise should be considered in
the treatment of PTSD-affected individuals (Fetz-
ner and Asmundson 2015). Interestingly, baseline
aerobic capacity may moderate the effects of exer-
cise on anxiety sensitivity based on recent data
demonstrating that participants with lower base-
line levels of cardiorespiratory tness, experien-
ced greater reductions in PTSD symptoms inclu-
ding avoidance and hyper-arousal, as well as total,
physical, and social symptoms of anxiety sensiti-
vity following an exercise intervention
(LeBouthillier et al. 2016). Investigating modera-
tors of response in exercise trials in people with
mental health disorders should be a priority for
future research because such evidence may help in
identifying subgroups that are more likely to
benet from exercise interventions (Schuch et al.
The largest trial to date of structured exercise
for people with PTSD was conducted in Sydney,
Australia, among n =81 in patients receiving
treatment for PTSD (Rosenbaum et al. 2015a).
Similar to the trial of Powers et al. (2015), the
study aimed to investigate the impact of adding a
structured exercise intervention to usual care,
comprising of a combination of pharmacotherapy,
group therapy and psychotherapy (e.g. trauma
informed cognitive behavioral therapy). Partici-
pants received either usual care (n =42), or usual
care in addition to the exercise program (n =39)
for a period of 12 weeks. Participants were inpa-
tients for a total period of 3 weeks and were
recruited during their second week of treatment.
Those randomized to the exercise intervention
(n =39) were provided with a 12-week exercise
program, involving one supervised exercise ses-
sion per week (supervised by an exercise physio-
logist with mental health experience), and were
asked to complete a minimum of two home-based,
unsupervised sessions. The intervention was a
pragmatic design, reecting clinical practice.
Supervised sessions focused on increasing patient
autonomous motivation towards exercise
(Vancampfort et al. 2015a,2016a), education
and goal setting. Participants were provided with
Exercise and Posttraumatic Stress Disorder 7
a pedometer and encouraged to record their daily
step count in an exercise diary. Participants were
also provided with elastic exercise bands in order
to perform recommended resistance training exer-
cises. Resistance exercises focused on multi-joint
(compound) exercises targeting the major muscle
groups including squats, chest press and seated/
standing rows. Participants were asked to record
all exercises including sets and repetitions in the
exercise diaries provided. These were reviewed at
the weekly supervised sessions and goals adjusted
accordingly. Results revealed a clinically signi-
cant impact of adding the exercise intervention to
usual care, with a between group difference of
5.4 (10.5 to 0.3), p =0.04 on the Posttrau-
matic Stress Disorder Checklist Civilian scale
(range =1785). Similarly, in line with evidence
demonstrating an anti-depressive effect of exer-
cise on symptoms of depression among people
with various mental illness (Rosenbaum et al.
2014a), a signicant between group difference
on the Depression Anxiety and Stress Scale
(DASS) was found 17.4 (28.9 to 6.0),
p=0.004 (Rosenbaum et al. 2015a). Physical
health was also assessed via the 6-min walk test
and through basic anthropometric assessments
including waist circumference and body weight.
Overall, a reduction in cardio-metabolic risk was
observed as determined by a reduction in waist
circumference, body fat percentage and trend for a
reduction in body weight. Of interest, the control
group experienced a mean increase in body
weight of 1.1 kg from baseline to follow-up, high-
lighting a potential preventative effect of the inter-
vention regarding cardio-metabolic health.
Several potential explanations for this increase in
control group body weight can be hypothesized,
namely an increase in sedentary behavior coupled
with a change in dietary habits including increase
in calorie consumption. The results of the trial,
while promising, should be interpreted in light of
methodological limitations. Firstly, the potential
impact of extra time and attention that the inter-
vention group received should be considered as a
potential mediating factor explaining the relation-
ship between the exercise intervention and impro-
ved symptoms. Although a possibility, the effects
of the intervention on objectively assessed cardio-
metabolic risk and self-reported walking and
moderate-vigorous physical activity levels
(as assessed by the International Physical Activity
Questionnaire (Rosenbaum et al. 2014b)) suggest
a direct impact of the exercise intervention. Se-
condly, no changes were reported in measures of
exercise capacity (cardiorespiratory tness and
grip strength). A potential explanation for this
lack of change is due to the selection of assess-
ments used. For example the 6-min walk test,
although validated for use in other psychiatric
populations such as schizophrenia (Bernard et al.
2015), has not been validated specically among
people with PTSD, and use of a sub-maximal
cycle ergometer protocol such as the Åstrand-
Rhyming test would have provided increased spe-
cicity and reliability (American College of
Sports Medicine 2013). This is particularly rele-
vant given the relatively young mean age of par-
ticipants (between 47 and 52 years).
While evidence for the effect of structured exer-
cise on PTSD is in its infancy, current evidence
base suggests that augmenting usual care with
structured exercise may provide signicant clinical
benets for those affected. Future research should
consider building on the previous studies through
programs targeting those receiving treatment in the
community as well as imbedding clinical exercise
programs within routine treatment.
5.2 Yoga
Yoga and the impact on psychiatric disorders
including PTSD is the focus of increasing acade-
mic investigation. Two 2014 RCTs investigated
the impact of yoga on people with PTSD (Kolk
et al. 2014; Mitchell et al. 2014), nding evidence
of a benecial effect on psychiatric symptomato-
logy, in line with previous reviews investigating
the effect of yoga on other psychiatric conditions.
Given that yoga cannot be classied as either
strictly a cardiorespiratory or resistance-based
activity, the promising results demonstrate that
both types of activity are likely benecial for
people with PTSD. The trial of Mitchell et al.
8 S. Rosenbaum et al.
utilized 12 sessions Kripalu (Hatha) yoga, with
one session per week for a total of 12 weeks, or
two sessions per week for a total period of
6 weeks. The trial of Kolk et al. used one 60-min
session of trauma informed yoga for a total of
10 weeks. The authors described trauma-informed
yoga as incorporating the central elements of ha-
tha yoga (breathing, postures, and meditation)
while simultaneously emphasizing curiosity about
bodily sensations (Kolk et al. 2014).
In another RCT of yoga for n =38 women
with PTSD symptoms recruited from Veteran
Affairs hospital, those randomized to the yoga
intervention received 75-min yoga classes weekly
for 12 weeks, or twice weekly for 6 weeks, depen-
ding on the participants preference (Martin et al.
2015). In contrast to the hypothesis that partici-
pants randomized to receive the yoga intervention
(in comparison to a wait-list control group), no
increase in self-reported leisure-time physical
activity was observed despite a positive trend.
Changes in self-efcacy and motivational regula-
tion for exercise were found, with those in the
yoga group showing evidence of a signicant
decrease in external regulation. Given the esta-
blished importance of increasing autonomous
motivation towards physical activity in order to
achieve long term and sustainable lifestyle change
(Vancampfort et al. 2015e,2016a), these ndings
offer promise regarding the optimal method of
delivering interventions for people with PTSD
and maximizing adherence.
6 Methodological Considerations
and Implications for Future
Interpreting the evidence base regarding the
impact of exercise on PTSD should be undertaken
in light of signicant progress that has been made
regarding exercise and the treatment of other men-
tal health conditions. For example, recent reviews
have found that the analysis of the exercise and
depression literature has repeatedly and systema-
tically underestimated the impact of exercise on
both depressive symptoms and major depression
due in part to publication bias and a large control
group response in clinical trials (Schuch et al.
2016c; Stubbs et al. 2016a). The exercise and
PTSD literature is at risk of similar interpretations,
and future trials should, as a priority, be designed
with these caveats in mind.
Similarly, drawing on the depression and schi-
zophrenia literature, trials utilizing trained profes-
sionals with clinical training in exercise prescrip-
tion (such as physiotherapists and exercise
physiologists) have repeatedly been shown to
reduce drop-out and maximize adherence to
exercise-based interventions (Stubbs et al.
2016c; Vancampfort et al. 2016c). Furthermore
and somewhat unsurprisingly, among people with
major depressive disorder, greater baseline sym-
ptom severity predicts greater drop-out from exer-
cise interventions highlighting the importance of
addressing motivation as a key component of
exercise interventions (Stubbs et al. 2016c).
Given recent data indicating that people with
PTSD highly value, are preparing for and feel
ready to engage in healthier lifestyles (Klingaman
et al. 2015), ensuring that interventions maximize
external validity by including a motivational com-
ponent is of key importance.
In order to justify the inclusion of exercise
programs as a routine component of treatment
for PTSD, cost-benet analysis are required in
order to determine and quantify the nancial
implications of diverting resources or investing
funds into such initiatives. Such economic ratio-
nales must aim to include cost-savings associated
with prevention in the context of the treatment of
physical health comorbidities and ideally poten-
tial benets regarding preventing future episodes
of poor mental health.
While evidence of the efcacy of exercise and
physical activity interventions in the treatment of
PTSD is increasing, effectiveness research capa-
ble of driving practice change, along with policy
level research is urgently required. Such an argu-
ment has been made for physical activity research
more broadly (Rutten et al. 2016), yet is particu-
larly pertinent in a condition such as PTSD where
the prevalence, cost of treatment and overall bur-
den is increasing.
Exercise and Posttraumatic Stress Disorder 9
7 Conclusion
PTSD is a pervasive condition associated with
poor health outcomes including high rates of
cardio-metabolic disease. Exercise and physical
activity more broadly (including yoga-based
interventions) offer promise as accessible, feasi-
ble, and effective components of care. The evi-
dence to date overwhelmingly support inclusion
of structured exercise as a component of standard
care. Given the established impacts of exercise on
improving cardio-metabolic health, tness and
symptoms of other mental health conditions inclu-
ding depression, failing to provide access to sup-
ported exercise programs, should be considered as
a failure to provide best-practice, evidence- based
care for people with PTSD.
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Exercise and Posttraumatic Stress Disorder 13
... Physical activity is one type of alternative intervention that has been shown to improve symptoms among individuals with either PTSD (Fetzner & Asmundson, 2015;Greer & Vin-Raviv, 2019;Hegberg, Hayes, & Hayes, 2019;Oppizzi & Umberger, 2018;Powers et al., 2015;Rosenbaum, Sherrington, & Tiedemann, 2015;Rosenbaum, Vancampfort, et al., 2015;Rosenbaum, Stubbs, Schuch, & Vancampfort, 2017) or MDD (Babyak et al., 2000;Craft & Landers, 1998;Mota-Pereira et al., 2011;Schuch et al., 2016;Silveira et al., 2013), suggesting that it may be an effective intervention option for those with both disorders. However, research examining the effects of exercise on psychological comorbidities is limited. ...
... Although research broadly supports the utility of physical activity for mental health symptoms (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014;Stubbs et al., 2017), evidence suggests that beneficial effects of physical activity on psychological health may be enhanced under specific conditions. For example, benefits of physical activity appear to be enhanced if the activity occurs in a natural environment (Barton & Pretty, 2010;Bowler, Buyung-Ali, Knight, & Pullin, 2010;Thompson Coon et al., 2011), especially one near water (Barton & Pretty, 2010). ...
... Physical activity is one type of alternative intervention that has been shown to improve symptoms among individuals with either PTSD (Fetzner & Asmundson, 2015;Greer & Vin-Raviv, 2019;Hegberg, Hayes, & Hayes, 2019;Oppizzi & Umberger, 2018;Powers et al., 2015;Rosenbaum, Sherrington, & Tiedemann, 2015;Rosenbaum, Vancampfort, et al., 2015;Rosenbaum, Stubbs, Schuch, & Vancampfort, 2017) or MDD (Babyak et al., 2000;Craft & Landers, 1998;Mota-Pereira et al., 2011;Schuch et al., 2016;Silveira et al., 2013), suggesting that it may be an effective intervention option for those with both disorders. However, research examining the effects of exercise on psychological comorbidities is limited. ...
... Although research broadly supports the utility of physical activity for mental health symptoms (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014;Stubbs et al., 2017), evidence suggests that beneficial effects of physical activity on psychological health may be enhanced under specific conditions. For example, benefits of physical activity appear to be enhanced if the activity occurs in a natural environment (Barton & Pretty, 2010;Bowler, Buyung-Ali, Knight, & Pullin, 2010;Thompson Coon et al., 2011), especially one near water (Barton & Pretty, 2010). ...
... Physical activity is one type of alternative intervention that has been shown to improve symptoms among individuals with either PTSD (Fetzner & Asmundson, 2015;Greer & Vin-Raviv, 2019;Hegberg, Hayes, & Hayes, 2019;Oppizzi & Umberger, 2018;Powers et al., 2015;Rosenbaum, Sherrington, & Tiedemann, 2015;Rosenbaum, Vancampfort, et al., 2015;Rosenbaum, Stubbs, Schuch, & Vancampfort, 2017) or MDD (Babyak et al., 2000;Craft & Landers, 1998;Mota-Pereira et al., 2011;Schuch et al., 2016;Silveira et al., 2013), suggesting that it may be an effective intervention option for those with both disorders. However, research examining the effects of exercise on psychological comorbidities is limited. ...
... Although research broadly supports the utility of physical activity for mental health symptoms (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014;Stubbs et al., 2017), evidence suggests that beneficial effects of physical activity on psychological health may be enhanced under specific conditions. For example, benefits of physical activity appear to be enhanced if the activity occurs in a natural environment (Barton & Pretty, 2010;Bowler, Buyung-Ali, Knight, & Pullin, 2010;Thompson Coon et al., 2011), especially one near water (Barton & Pretty, 2010). ...
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Together, posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are debilitating and commonly comorbid; however, the effects of this comorbidity on psychological outcomes during exercise programs, such as surf therapy, have not been examined. This study compared changes in depression/anxiety and positive affect during surf therapy sessions between active duty service members with comorbid PTSD and MDD and those with either disorder alone. The study applied DSM-5 criteria to baseline self-report measures to assign probable disorder status, and used a longitudinal design involving repeated measurements to assess outcomes within 6 weekly sessions. Service members completed validated self-report questionnaires using the Patient Health Questionnaire-4 and the Positive Affect Schedule before and after each session. Within surf therapy sessions, both the comorbid and single disorder groups reported significant improvements in symptoms of depression/anxiety and positive affect. However, those with comorbid PTSD and MDD experienced significantly greater reductions in depression/anxiety (β = −1.22, p = .028) and significantly greater improvements in positive affect (β = 3.94, p = .046) compared with the single disorder group. Surf therapy appears to have global effects on psychological symptom reduction and may be a useful adjunctive intervention for the treatment of comorbid PTSD and MDD in both clinical and community health settings.
... Exercise and sport have been successfully employed to treat a wide range of psychiatric disorders [13], and are considered essential to human wellbeing [14]. Although the UNHCR (United Nations High Commissioner for Refugees, Geneva, Switzerland) recognizes the potential of exercise and sport as a peace-building measure in refugee camps [15], and reviews have shown that increased physical activity has positive effects on traumatized individuals [16,17], very limited evidence is available regarding the potential of exercise and sport as part of the treatment of refugees suffering from PTSD symptoms [18]. In a study with 36 refugees with PTSD symptoms living in Germany and Switzerland, Liedl et al. [19] showed that, following the intervention, refugees who participated in 12 weeks of biofeedback-based cognitive behavioral therapy (CBT-BF) in combination with physical activity (including mixed activities such as endurance, strength, and flexibility training) reported an improved capacity to cope with pain compared to CBT-BF alone or a waiting-list control condition. ...
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Objective: Refugees have a particularly high prevalence of psychopathological disorders. Despite this, little attention has been paid to the treatment of traumatized refugees, and research on the effects of exercise and sport among refugees is still in its infancy. Thus far, no randomized controlled trials have been carried out in a refugee camp setting, most likely because such trials are complicated by multiple organizational and methodological issues. We highlight some major challenges when carrying out experimental research in a refugee camp. Method: This report of professional practice is based on systematic observations, individual and focus group interviews and experiences made in a pre-experimental study, implemented in a refugee camp on the Greek mainland. Results: The report provides background information about how refugees generally come to Greece, how transit camps are typically managed, which institutions are involved in the camp management, which rules need to be followed by people working in a camp, which countries refugees generally come from, and conditions in which they live in the camp. We also identify general factors that complicate experimental research in such a setting, and highlight specific issues pertaining to sport and exercise-based intervention trials. Conclusions: Currently, more people are fleeing their home regions than after the end of the Second World War. This situation calls for a change in the understanding of humanitarian aid. Pure material and technical support must be complemented by public health measures, including exercise and sport programs. Researchers who want to enter this field of research can learn important lessons from our observations.
... Je nach Outcome scheint die Stresspufferwirkung des Sports auf ganz unterschiedliche Weise zustande zu kommen. Im vorliegenden Buch wird ein spezifisches Augenmerk auf die Themen Gehirnaktivität (Ludyga 2017), Schlafqualität (Brand 2017), Adipositas (Holmes 2017), Gefäßsteifigkeit (Deiseroth und Hanssen 2017), Burn-out (Wunsch und Gerber 2017) und Posttraumatische Belastungsstörungen (Rosenbaum et al. 2017) gelegt. Der wohl am häufigsten genannte Mechanismus, der zur Erklärung der Stresspufferwirkung des Sports herangezogen wird, ist jedoch die sogenannte Cross-Stressor Adaptations-Hypothese (Sothmann 2006). ...
Zu unterscheiden sind zwei Perspektiven auf das Thema „Stressregulation und Sport“: Zum einen die eher gesundheitsbezogene Perspektive „Stressregulation durch Sport“ (Wie können Sport und Bewegung dazu beitragen, mit Stress und Belastung im Alltag besser umzugehen, sodass die Gesundheit davon möglichst wenig beeinträchtigt wird?) und zum anderen die eher leistungsbezogene Perspektive „Stressregulation im Sport“ (Wie können Athleten im Wettkampf mit Stress und Druck so umgehen, dass ihre Leistungsfähigkeit davon möglichst wenig beeinträchtigt wird?). Beide Blickwinkel werden im Überblick kurz vorgestellt und hinsichtlich ihres empirischen Gehalts bewertet. Darüber hinaus werden einzelne Themen und Entwicklungen, die für die zukünftige Forschung in diesem Bereich vielversprechend erscheinen, kurz angerissen.
Für die Wiedererlangung und Stärkung der Stabilität ist jegliche Form von Bewegung hilfreich. Bei einem traumatischen Erlebnis mobilisiert unser Körper alle Kräfte, um zu kämpfen oder zu fliehen, oder er erstarrt, wenn beides nicht möglich ist. Wenn unsere instinktiven Verteidigungsreaktionen nicht ausgeführt oder abgeschlossen werden und die Erstarrung sich nicht lösen kann, dann bleibt die enorme Aktivierung in unserem Körper bestehen. So ist es naheliegend, dass nach einem traumatischen Erleben jegliche Form der Bewegung und sportlichen Aktivität unseren Körper unterstützt, diese enorme Aktivierung und u. a. die ausgeschütteten Stresshormone wieder abzubauen. Dies ist umso wichtiger, wenn eine „zeitnahe Wiederherstellung der autonomen Homöostase“ ausbleibt und sich in unserem autonomen Nervensystem „immer mehr Streß“ ansammelt (Levine 2019, S. 40). Das ist im Besonderen bei wiederholten oder chronischen Traumatisierungen der Fall. Langfristig kann dies unsere Gesundheit beeinträchtigen und verschiedene Symptome wie z. B. Bluthochdruck, Herzrhythmusstörungen oder Migräne hervorrufen und u. a. zu gastrointestinalen und Autoimmunerkrankungen führen (McLeay et al. 2017).
Das Thema Stressregulation und Sport kann aus zwei unterschiedlichen Perspektiven betrachtet werden. Aus Sicht des Gesundheitssports geht es primär um Stressregulation durch Sport. Es stellt sich die Frage, inwieweit sich durch körperliche und sportliche Aktivität die Belastungen des Alltags besser bewältigen lassen, so dass Gesundheitsbeeinträchtigungen vermieden oder reduziert werden können. Aus Sicht des Leistungssports geht es um Stressregulation im Sport. Mit anderen Worten: Wie können Athleten und Athletinnen mit hohen Trainingsbelastungen und psychischem Druck umgehen, ohne dass dabei die Leistungsfähigkeit beeinträchtigt wird oder psychische Beschwerden entstehen? Hier geht es also um Faktoren, die dazu beitragen, dass Personen im Leistungs- und Spitzensport auch unter Druck ihre besten Leistungen abrufen können. Nachdem im ersten Teil dieses Kapitels die theoretischen Grundlagen erarbeitet werden, wird im zweiten Teil auf diese beiden Perspektiven eingegangen.
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Background: People with posttraumatic stress disorder (PTSD) are more likely than the general population to be physically inactive. The present review systematically evaluated correlates of physical activity across the socio-ecological model for people with PTSD. Methods: Two independent reviewers searched Embase, PubMed, PsycARTICLES and CINAHL from inception until June 2015, combining the medical subject heading 'post-traumatic stress disorder' or 'PTSD', with 'physical activity' or 'exercise'. Data were extracted by the same independent researchers and summarized according to the socio-ecological model. Results: Eight papers involving 1,368 (994♂) participants (age range=18-70years) were eligible and enabled evaluation of 21 correlates. The only correlate consistently (n≥4) associated with lower physical activity participation in persons with PTSD were symptoms of hyperarousal. No consistent facilitators were identified. Conclusions: Hyperarousal symptoms are associated with lower physical activity participation among people with PTSD and should be considered in the design and delivery of individualized exercise programs targeting this population. The role of social, environmental and policy factors on physical activity participation among people with PTSD is unknown and should be addressed by future research.
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Objectives: This paper presents a typology of available evidence to inform physical activity policy. It aims to refine the distinction between three types of evidence relating to physical activity and to compare these types for the purpose of clarifying potential research gaps. Methods: A scoping review explored the extent, range and nature of three types of physical activity-related evidence available in reviews: (I) health outcomes/risk factors, (II) interventions and (III) policy-making. A six-step qualitative, iterative process with expert consultation guided data coding and analysis in EPPI Reviewer 4. Results: 856 Type I reviews, 350 Type II reviews and 40 Type III reviews were identified. Type I reviews heavily focused on obesity issues (18 %). Reviews of a systematic nature were more prominent in the Type II (>50 %). Type III reviews tended to conflate research about policy intervention effectiveness and research about policymaking processes. The majority of reviews came from the United States, United Kingdom, Australia and Canada. Conclusions: Although evidence gaps exist regarding evidence Types I and II, the most prominent gap regards Type III, i.e. research pertaining to physical activity policymaking. The findings presented herein will be used to inform physical activity policy development and future research.
Purpose: People with posttraumatic stress disorder (PTSD) have an increased risk of cardiovascular diseases (CVD). Physical fitness is a key modifiable risk factor for CVD and associated mortality. We reviewed the evidence-base regarding physical fitness in people with PTSD. Methods: Two independent reviewers searched PubMed, CINAHL, PsycARTICLES, PEDro, and SPORTDiscus from inception until May 2016 using the key words "fitness" OR "exercise" AND "posttraumatic stress disorder" OR "PTSD". Results: In total, 5 studies involving 192 (44 female) individuals with PTSD met the inclusion criteria. Lower baseline physical fitness are associated with greater reductions in avoidance and hyperarousal symptoms, as well as with total, physical, and social symptoms of anxiety sensitivity. Rigorous data comparing physical fitness with age- and gender matched general population controls are currently lacking. Conclusions: The research field regarding physical fitness in people with PTSD is still in its infancy. Given the established relationships between physical fitness, morbidity and mortality in the general population and the current gaps in the PTSD literature, targets for future research include exploring: (a) whether people with PTSD are at risk of low physical fitness and therefore in need of intensified assessment, treatment and follow-up, (b) the relationships among physical fitness, overall health status, chronic disease risk reduction, disability, and mortality in individuals PTSD, (c) psychometric properties of submaximal physical fitness tests in PTSD, (d) physical fitness changes following physical activity in PTSD, and (e) optimal methods of integrating physical activity programs within current treatment models for PTSD. Implications for Rehabilitation People with PTSD should aim to achieve 150 minutes of moderate or 75 minutes vigorous physical activity per week while also engaging in resistance training exercises at least twice a week. Health care professionals should assist people with PTSD to overcome barriers to physical activity such as physical pain, loss of energy, lack of interest and motivation, generalized fatigue and feelings of hyperarousal.
Background Physiotherapy can improve the health of people with serious mental illness (SMI) but many are inactive. Adopting theoretically-based evidence considering the motivational processes linked to the adoption and maintenance of an active lifestyle can assist physiotherapists in facilitating lifestyle changes in people with SMI. Purpose Within the Self-Determination Theory (SDT) and the Trans-Theoretical Model (TTM) (stages of change) frameworks, we investigated differences in motives for physical activity between different diagnostic SMI groups. Methods All participants with SMI from 15 different centers completed the Behavioral Regulation in Exercise Questionnaire 2 (BREQ-2), the International Physical Activity Questionnaire (IPAQ) and the Patient-centered Assessment and Counseling for Exercise (PACE) questionnaire. Results Overall 294 persons with SMI (190♀) (43.6 ± 13.6years) agreed to participate. People with affective disorders had higher levels of introjected regulations than people with schizophrenia. No significant differences were found for other motivational regulations. Moreover, no significant differences were found according to gender, setting and educational level. Multivariate analyses showed significantly higher levels of amotivation and external regulations and lower levels of identified and intrinsic regulations in the earlier stages of change. Strongest correlations with the IPAQ were found for motivational regulations towards walking. Conclusions Our results suggest that in all people with SMI the level of identified and intrinsic motivation may play an important role in the adoption and maintenance of health promoting behaviours. Implications The study provides a platform for future research to investigate the relationships between autonomy support, motivational regulations and physical and mental health variables within physiotherapy interventions for this population.
Background: Posttraumatic stress disorder (PTSD) is associated with elevated risk for metabolic syndrome (MetS). However, the direction of this association is not yet established, as most prior studies employed cross-sectional designs. The primary goal of this study was to evaluate bidirectional associations between PTSD and MetS using a longitudinal design. Methods: 1,355 male and female veterans of the conflicts in Iraq and Afghanistan underwent PTSD diagnostic assessments and their biometric profiles pertaining to MetS were extracted from the electronic medical record at two time points (spanning ~2.5 years, n = 971 at time 2). Results: The prevalence of MetS among veterans with PTSD was just under 40% at both time points and was significantly greater than that for veterans without PTSD; the prevalence of MetS among those with PTSD was also elevated relative to age-matched population estimates. Cross-lagged panel models revealed that PTSD severity predicted subsequent increases in MetS severity (β = .08, p = .002), after controlling for initial MetS severity, but MetS did not predict later PTSD symptoms. Logistic regression results suggested that for every 10 PTSD symptoms endorsed at time 1, the odds of a subsequent MetS diagnosis increased by 56%. Conclusions: Results highlight the substantial cardiometabolic concerns of young veterans with PTSD and raise the possibility that PTSD may predispose individuals to accelerated aging, in part, manifested clinically as MetS. This demonstrates the need to identify those with PTSD at greatest risk for MetS and to develop interventions that improve both conditions.
Abstract Background Patients with bipolar disorder (BD) are approximately twice as likely to die prematurely due cardiovascular diseases (CVD) than the general population. Cardiorespiratory fitness (CRF) is an important health outcome measure, predictive for CVD and premature mortality. Aims The aim of the current study was to compare the CRF of outpatients with BD versus age-, gender-, and body mass index (BMI)-matched healthy controls (HC). A secondary aim was to assess potential correlates of CRF. Methods All participants underwent a maximal incremental exercise test to measure the maximum oxygen uptake (VO2max, the golden standard assessment of cardiorespiratory fitness), wore a Body Sensewear Armband for 5 subsequent days to assess their physical activity behavior and completed the Positive-and-Negative-Affect-Schedule (PANAS). Results Outpatients with BD (n=20; 47.8±7.6years) had a significantly lower VO2max compared with HC (n=20; 47.8±7.6years) (26.0±7.3 versus 30.4±6.5 ml/min/kg, P=0.047). A higher VO2max was correlated with younger age, higher active energy expenditure, higher PANAS positive and lower PANAS negative affect scores and a lower antipsychotic medication dose. Limitations The limited sample and cross-sectional design preclude definitive conclusions. Conclusions Compared with HC, outpatients with BD have reduced CRF levels of approximately 4.4 ml/min/kg. In the general population such reductions are associated with a 20% increased premature mortality risk. Interventions targeting CRF in BD are required. Although more research is needed, clinicians should consider the utility of objective assessments of CRF for risk stratification in outpatient settings.
Objective: To present a critical review of the literature and research on sleep difficulties in adults with posttraumatic stress disorder (PTSD), more specifically the existing treatment options, and to formulate recommendations regarding future treatment approaches and research related to sleep and PTSD. Data sources: The following databases were consulted: PsycInfo (1872-2006) and MEDLINE (1966-2006). The search was conducted using the following key terms: PTSD and sleep, PTSD and nightmares, PTSD and dreams, PTSD and insomnia, PTSD and periodic limb movement disorder, and PTSD and sleep disordered breathing. Only studies examining sleep disturbance among adults with PTSD were included, and only articles written in English were consulted. Study selection: Studies and reviews related to the prevalence, causes, and treatments of sleep disturbance among adults with PTSD, as well as those examining the relationship between sleep and PTSD, were selected. Conclusions: Promising treatment options are available for treating sleep difficulties among adults with PTSD. In particular, cognitive-behavioral therapy including a component for nightmares (imagery rehearsal therapy) and insomnia has been found to significantly improve sleep disturbance among these individuals. It is proposed that with the inclusion of other components, such as a screening for other sleep disorders, relaxation exercises, positive self-talk, imagery rehearsal related to recurring images before bed, and a daytime nap, sleep-related symptoms may improve to a greater degree, which may then lead to a significant decrease in other PTSD symptoms and overall PTSD severity. The inclusion of sleep medicine specialists should also be considered for sleep medicine treatment of individuals with PTSD. Collaboration between mental health professionals and sleep medicine specialists is therefore recommended for treatment of sleep-related difficulties among individuals with PTSD.