# Exercise as it relates to Disease/Post Traumatic Stress Disorder: Can exercise help?

This fact sheet is a critique of the academic paper Aerobic Exercise Reduces Symptoms of Posttraumatic Stress Disorder: A Randomized Controlled Trial by Fetzner and Asmundson.

## Background

Posttraumatic Stress Disorder (PTSD) is a mental condition that can affect anyone, it generally arises from exposure to a potentially traumatic event. Prevalence data from the Australian Bureau of Statistics reveal that 12.0% of Australians will experience PTSD in their lifetime. Rates are higher amongst emergency response personnel and members of the defence force; a 2010 study of current Australian Defence Force (ADF) members indicated this rate to be 8.3%. Global figures from the World Health Organisation reports prevalence of PTSD to vary between 2.3-8.8%, with higher rates amongst countries with current or recent violent conflict.
The suffering inflicted from PTSD varies in duration from months, to years, or lifelong.

### Cause

Distressing events that can result in PTSD include, but are not limited to:
* Being the victim of sexual assault
* Witnessing or being the victim of a violent assault/crime
* Confronted with threatened or actual death (e.g. emergency response, war, or combat), and,
* Sudden accidental or violent death of a loved one or close friend

### Symptoms

A summary of the PTSD diagnostic criteria used in the United States of America, and Australia indicate the key components of the condition to be:
* Persistently re-experiencing the event in the form of recurrent unwanted memories, and/or nightmares
* Avoidance of reminders of the event
* The emergence or increase in negative thought processes and mood after the event

### Treatment

Current treatments for PTSD include specific counselling, and antidepressant medication. Some studies have reported aerobic exercise to reduce symptoms of PTSD. Until recently, the minimum duration, type, and intensity of exercise needed to reduce PTSD symptoms had not been established.

## PTSD and Exercise

Research by Fetzner and Asmundson, two academic staff from the University of Regina (Canada), attempted to assess the validity of a standardised aerobic exercise program as treatment for PTSD; standardised simply means that a set type of exercise, duration and intensity were prescribed. Furthermore, the research endeavoured to ascertain whether distraction, or, focussing on the physical manifestations (internal focus) that occur during exercise are the cause for reduction of PTSD symptoms rather than exercise alone. The exercise program was conducted over two weeks and comprised of six 20-minute sessions of moderate-high intensity cycling.
Rather than being selected, interested participants were directed to complete an online screening survey through advertisements in local media. After the initial screening, numerous factors resulted in exclusion from the study. These included: having insufficient PTSD symptoms; substance-abuse issues; or, having factors that placed them at imminent risk of injury, illness or death from beginning an exercise program. The remaining participants were further screened over the phone to reassess and measure the severity of their symptoms against establish guidelines and checklists.

### Type of research

The research method used by the investigators was a randomised controlled trial (RCT) which is highly regarded for producing legitimate unbiased results. The disadvantage of this research type has been addressed in regards to this study in the conclusion section of this page.

### Participant groups

Eligible participants were randomly divided into three groups:
* Exercising with a distraction: This group exercised while watching a nature documentary and were required to answer three question related to it every five minutes. The idea behind this was to divert attention away from the uncomfortable physical sensations associated with exercise. Correct responses to the questions was regarded as paying attention to the distraction material.
* Exercising while focussing on the physical sensations: These participants were provided with a real-time display of themselves exercising. Each five minutes participants were required to score (out of 10) the intensity of the tension they felt in their legs, tension in their upper body, and difficulty of their breathing.
* Exercise only. No distractions or internal focus.
All groups were asked to maintain the physical activity levels they had prior to the involvement in the exercise component of the study.

### Results

Severity of PTSD symptoms were measured and scored at the following nine time points:
* [1] - Pretreatment
* [2-7] - At the end of each exercise session
* [8] - 1 week after last exercise session
* [9] - 1 month after last exercise session
Score changes in measurements represented a change to the severity of PTSD suffered by the participant. At the conclusion of the last exercise session reductions in all measures where observed in all groups. The researchers also measured changes in anxiety and depressive symptoms; these also resulted in reduction in severity.
Of the three groups, it was the exercise only group reported a slightly larger, but insignificant, reduction in PTSD symptoms compared to the other two groups.
Unfortunately the research revealed an increase in PTSD symptoms for all groups at follow up.

### Conclusion

While Fetzner and Asmundson criticised previous studies for small sample sizes, the sample size of their study contained only 33 participants, as such, was capable of producing large errors$^*$. On a regional level, the analysed sample was unintentionally biased towards Caucasian ethnicity; a drawback of RCT research that may render very different results in another part of the world.
The study added further evidence of the therapeutic effects of exercise on PTSD, but failed to indicate a specific reason for the reduction in PTSD symptoms. It also established a stronger claim of the exercise intensity, time, and type required to elicit benefits for PTSD.
$^{*Basedonmarginoferrorof17.4%}$

## Practical advice

As little as three 20-minute moderate intensity running or cycling activities can lead to positive effects for sufferers of PTSD. However, it is always best to consult your GP or an accredited exercise professional before commencement of an exercise program.

## Further information/resources

* Phoenix Australia: Centre for Posttraumatic Mental Health
* Video: Understanding Trauma
* Picking Up the Peaces - An Australian-based awareness and education group
* Accredited Exercise Professionals: Exercise and Sports Science Australia
If you require help for PTSD please consult your GP, or call Life Line 13 11 14.

## References

* 1 2 Mathew G. Fetzner & Gordon J.G. Asmundson (2015). Aerobic Exercise Reduces Symptoms of Posttraumatic Stress Disorder: A Randomized Controlled Trial. Cognitive Behaviour Therapy (44:4), p301-313.
* ↑ Australian Bureau of Statistics (2008). National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Cat. no. (4326.0). Canberra: ABS.
* ↑ Department of Defence. Post-traumatic Stress Disorder. http://www.defence.gov.au/health/healthportal/PTSD.asp Accessed: 30-09-2016
* ↑ Atwoli L, Stein DJ, Koenen KC, McLaughlin KA. Epidemiology of posttraumatic stress disorder: prevalence, correlates and consequences. Current opinion in psychiatry. 2015;28(4):307-311.
* ↑ Creamer, Mark C.; Burgess, Philip; McFarlane, Alexander Cowell. Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being, Psychological Medicine, 2001; 31 (7):1237-1247.
* ↑ American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: American Psychiatric Association.
* ↑ Phoenix Australia. Treatment options for Trauma. http://phoenixaustralia.org/recovery/treatment-options/ Accessed: 30-09-2016
* ↑ Diaz, A. B., & Motta, R. (2007). The effects of an aerobic exercise program on posttraumatic stress disorder symptom severity in adolescents. International journal of emergency mental health, 10(1), 49-59.
* ↑ Manger, T. A., & Motta, R. W. (2005). The impact of an exercise program on posttraumatic stress disorder, anxiety, and depression. International journal of emergency mental health.
* ↑ Newman, C. L., & Motta, R. W. (2007). The effects of aerobic exercise on childhood PTSD, anxiety, and depression. International journal of emergency mental health, 9(2), 133.
* ↑ National Health and Medical Research Council (1998-11-16). A guide to the development, implementation and evaluation of clinical practice guidelines (PDF). Canberra: Commonwealth of Australia. p. 56. ISBN 1-86496-048-5. Retrieved 2010-03-28.