Exercise and Posttraumatic Stress
Simon Rosenbaum, Brendon Stubbs, Felipe Schuch und
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-
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
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,
Black Dog Institute, Prince of Wales Hospital, Sydney,
Institute of Psychiatry, Psychology and Neuroscience
(IoPPN), King’s College London, London, UK
Physiotherapy Department, South London and Maudsley
NHS Foundation Trust, London, UK
Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
Universidade La Salle, Porto Alegre, Brazil
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,
among those working in professions who are
exposed to high rates of trauma including ﬁrst
responders (police ofﬁcers, paramedics, ﬁre-
ﬁghters) 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-
ﬁed by the Diagnostic and Statistical Manual of
Mental Disorders (DSM) as an anxiety disorder,
PTSD is now classiﬁed 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-
ﬁcant 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, difﬁculty
debrieﬁng 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), signiﬁcantly 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, ﬂuoxe-
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 beneﬁts
of non-traditional strategies including mindfulness-
based stress reduction (Polusny et al. 2015).
3 Physical Health of People
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 =32.1–45.6%) with an almost
doubled increased risk compared to the general
population (RR =1.82; 95% CI =1.72–1.92; 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 signiﬁcantly increased risk of developing
T2DM (RR =1.49, 95% CI =1.17–1.89, 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 ﬁndings
were signiﬁcant after controlling for initial meta-
bolic syndrome severity, with the authors ﬁnding
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
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 hypothalamic–pituita-
ry–adrenal (HPA) and sympatho-
adrenomedullary dysfunction (Dedert et al.
2010), inﬂammation (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 modiﬁable lifestyle-
related factors is becoming increasingly clear. For
example, people with PTSD are more likely than
the general population to smoke, with rates of
40–86% 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 reﬁned
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
modiﬁable 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 ﬁtness deﬁned 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 ﬁtness have a
relative risk for all-cause mortality of 1.70 (95%
CI =1.51–1.92; p <0.001) and for cardiovascu-
lar events of 1.56 (95% CI =1.39–1.75; P
<0.001) compared with those with a high cardio-
respiratory ﬁtness (Kodama et al. 2009). In com-
parison to those with average cardiorespiratory
ﬁtness, those with low cardiorespiratory ﬁtness
have a relative risk for all-cause mortality of
1.40 (95% CI =1.32–1.48; p <0.001) and for
cardiovascular events of 1.47 (95% CI =
1.35–1.61; p <0.001) (Kodama et al. 2009).
Despite increasing evidence regarding the poor
ﬁtness 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 ﬁtness can be achieved in mental
health populations following speciﬁc intervention
(Stubbs et al. 2016b; Vancampfort et al. 2015c),
and that higher ﬁtness levels are associated with
decreased incident depression (Åberg et al. 2012),
relatively little is known regarding the relation-
ship between cardiorespiratory ﬁtness 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 ﬁtness category compared to soldiers in
the lowest category (odds ratio, 0.40; 95% CI =
0.19–0.84, p <0.0xx) (Crowley et al. 2014),
with calls to target soldier cardiorespiratory ﬁt-
ness before basic combat training in order to
improve psychological health outcomes.
In a subsequent analysis of data from a clinical
trial investigating, the beneﬁts of aerobic exercise
for PTSD (Fetzner and Asmundson 2015), LeB-
outhillier et al. (2016) examined the role of car-
diorespiratory ﬁtness in predicting reductions in
PTSD symptoms and anxiety sensitivity follo-
wing participation in aerobic exercise, ﬁnding that
aerobic exercise is particularly effective in indivi-
duals with poorer levels of cardiorespiratory ﬁt-
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 ﬁtness capacity of
people with PTSD requires assessing and compa-
ring maximal ﬁtness 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 identiﬁed
studies reporting a signiﬁcant negative association
between PTSD and physical activity participation
with the others reporting no signiﬁcant 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-efﬁcacy, 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 identiﬁed
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
18–70 years). The review found no evidence of
signiﬁcant 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 ﬁbromyalgia were investiga-
ted and only the presence of ﬁbromyalgia 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 beneﬁcial 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 signiﬁcantly over the past
decade. The ﬁrst 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 identiﬁed as eligible for inclusion,
although some studies were found that evaluated
exercise and/or sports based interventions
The generalizability of the ﬁndings 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 beneﬁt 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-
ﬁcant 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 efﬁcacy of exercise as a com-
ponent of treatment. A 2015 meta-analysis identi-
ﬁed four unique RCTs, encompassing a total of
n=200 participants with a mean age of 34–52
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 activity’as deﬁned 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 reﬂecting
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 signiﬁcantly
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 identiﬁed 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 efﬁcacy 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
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
34 (11.8) 12 sessions of moderate-
intensity aerobic exercise
(stationary cycling; 70% age
predicted max heart rate); in
addition to prolonged
12 weeks of supervised,
aerobic/resistance exercise in
addition to usual care
DSM Usual-care PCL-C Inpatients Yes Yes
10 weeks 1x weekly 60 min
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 signiﬁcant and
large impact of the exercise intervention on levels
of brain derived neurotropic factor (BDNF)
(Cohen’sd=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 efﬁcacy 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
signiﬁcance testing. In addition, these data pro-
vide useful evidence regarding the mechanism of
action and augmentative beneﬁts of speciﬁcally
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 beneﬁcial effect of aerobic exer-
cise, with clinically signiﬁcant 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 signiﬁcant
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 ﬁtness, 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
beneﬁt 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, reﬂecting 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 signiﬁ-
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 =17–85). 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 signiﬁcant 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 ﬁtness 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 speciﬁcally among
people with PTSD, and use of a sub-maximal
cycle ergometer protocol such as the Åstrand-
Rhyming test would have provided increased spe-
ciﬁcity 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 signiﬁcant clinical
beneﬁts 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.
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), ﬁnding evidence
of a beneﬁcial effect on psychiatric symptomato-
logy, in line with previous reviews investigating
the effect of yoga on other psychiatric conditions.
Given that yoga cannot be classiﬁed as either
strictly a cardiorespiratory or resistance-based
activity, the promising results demonstrate that
both types of activity are likely beneﬁcial 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 participant’s 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-efﬁcacy and motivational regula-
tion for exercise were found, with those in the
yoga group showing evidence of a signiﬁcant
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 ﬁndings
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 signiﬁcant 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-beneﬁt analysis are required in
order to determine and quantify the ﬁnancial
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 beneﬁts regarding preventing future episodes
of poor mental health.
While evidence of the efﬁcacy 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
PTSD is a pervasive condition associated with
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cardio-metabolic disease. Exercise and physical
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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, ﬁtness 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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