Exercise as it relates to Disease/Group exercise treatment for military veterans with post-traumatic stress disorder

This WikiBook is a critical analysis of the research article "Veterans Group Exercise: A randomised pilot trial of an Integrative Exercise program for veterans with post-traumatic stress" by Goldstein et al., (2018)

This analysis was conducted as an assessment for Health Disease and Exercise (8340) at the University of Canberra.

Research Background
Post-Traumatic Stress Disorder (PTSD) can be defined as a chronic psychological condition developed following exposure to a traumatic event or experience, that involves actual or threat of death or serious injury. The prevalence of PTSD amongst military veterans has increased in the last decade following the Middle Eastern conflicts in Iraq and Afghanistan, with current estimates ranging from 15% in Vietnam War veterans, to 5-20% of those who served in Iraq and Afghanistan. These figures also don't take into account approximately 20% of returning servicemen and women who don't receive Post-Deployment Health Assessments. Estimations are often disputed and vary largely, due to the rate of underreporting and failure to seek treatment, as well as difficulty establishing a firm diagnosis.

Veterans suffering from PTSD often experience symptoms of functional impairment and an overall decreased quality of life. PTSD has been associated with higher lifetime prevalence of other negative health outcomes, in particular, circulatory, digestive, musculoskeletal, nervous system, respiratory and infectious diseases, and is also a major risk factor for cardiovascular disease. Aside from physiological health outcomes, PTSD is known to increase the prevalence of other psychological conditions with sufferers 3-5 times more likely to also suffer from depression. Anxiety, sleep disturbance and substance abuse/dependence are also more commonly associated with PTSD. Based on statistics, returned veterans in the United States account for 20% of suicide figures, with those in the 18–24 years age bracket are now 4x more likely than their non-serving peers, further highlighting the need for greater intervention into Veteran PTSD

Traditional treatments of Post-Traumatic Stress Disorder typically include either pharmacotherapy or psychotherapy, or a combination of both. Medicated intervention is most commonly through the use of anti-depressants, or similar, to treat the patient. Cognitive-behaviour therapy is the most commonly utilised from of psychotherapy when treating PTSD, and has been shown to be more effective than any other method of non-drug treatment. Published in 2007, the Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and PTSD state that exercise may be helpful in managing the symptoms of Post-Traumatic Stress Disorder, and are an effective part of a general self-care program

Where is this research from?
This research was a randomised pilot study conducted to assess the effects of a group exercise program on symptom severity and quality of life in Military Veterans suffering from Post-Traumatic Stress Disorder. As this is a relatively small sample size (n=47), and the nature of the research, the primary intention is to assess the protocols for validity for further research.

Participants in this study were determined to have met the criteria for current or partial PTSD, as outlined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. The Diagnostic and Statistical Manual of Mental Disorders is considered to be the gold standard in diagnosing mental health conditions including PTSD.

The primary author of this research, Lizabeth A. Goldstein, is an Assistant Professor at the University of California, San Francisco. She is extensively published in Post-Traumatic Stress Disorder, Cognitive Behaviour Therapies, as well as a range of other psychological conditions. The research was overseen by Dr. Thomas Neylan, resident professor of the Department of Psychiatry at the University of California, San Francisco. Amongst his other roles, Dr. Neylan is the Director of the Post-Traumatic Stress Disorders (PTSD) Clinic and the Stress and Health Research Program at the San Francisco Veterans Affairs Medical Centre.

What did the research involve?
The research was conducted on a veteran population (n=47), aged 18–69 (M=46.8). The participants - mostly male (81%) - were first screened following the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)(DSM - IV) to establish the status of their PTSD - current (n=42) or partial (n=5). Participants were then randomised into their research groups - 21 to undertake the Integrated Exercise Program (IE) and the remaining 26 to remain in a monitor only Waitlist Control Group (WL). Participants from both groups underwent pre-screening through a number of methodologies, to establish baseline prior to the research commencing. Pre-screening included a previous medical history, completion of the Physical Activity Readiness Questionnaire and more targeted assessments to determine particular characteristics associated with each participants PTSD. Each of these assessments was then to be followed up at the conclusion of week 4, week 8 and week 12 - the end of the research period. Targeted assessments consisted of;


 * Structured Clinical Interview for DSM-IV - structured interview assessment used to determine participants diagnostic status, is considered to have good reliability and validity.
 * Clinician-Administered PTSD Scale (CAPs) - structured interview assessment used to assess the frequency and intensity of the participants PTSD-related symptoms. Severity scores are assigned to each symptom, and scores are then totalled 0 - 136 with a higher score indicative of more severe symptoms. The CAPs assessment has been established to provide good test-retest reliability and consistency.
 * World Health Organisation Quality of Life (WHOQOL - BREF) - self-reporting assessment determining quality of life in physical and psychological health, shown to have a good level of reliability and validity.
 * Feasibility and Acceptability Questionnaire - self-reporting assessment completed by IE participants following the conclusion of exercise program, based on overall treatment impression, content of intervention and length of intervention. Responses gathered on a scale of 1 - 5.
 * Godin Leisure-Time Exercise Questionnaire - self-reporting assessment completed by IE and WL participants weekly. Shows good reliability and validity, based on comparisons with maximum oxygen consumption (VO2Max) and body fat.

The Integrated Exercise (IE) participants began their research protocols following all of the pre-screening assessments. The IE protocols followed three-1 hour group training sessions per week, across a 12-week period for the entirety of the study. Exercise intervention consisted of a combination of aerobic training, strength training with free weights and resistance bands, as well as yoga movements conducted following one new mindfulness principle introduced on a weekly basis. Each exercise session was approached on a full-body basis, working all major muscle groups but through varying durations and intensities to reduce the effects of delayed onset muscle soreness (DOMs).

What were the basic results?
The research highlighted particular areas of effectiveness of the exercise intervention in its treatment of PTSD, its symptoms and the quality of life of participants. On average, IE participants recorded a reduction of 30.64 on the CAPs assessment, compared with an average of 14.77 in the WL group. This difference in CAPs scores indicates the successful reduction of symptoms in the IE group, when compared to WL. Based on the WHOQOL - BREF data, both physical and psychological, there is further reason to suggest validity of the group exercise intervention, as physical data was significantly greater, and psychological had also improved.

The participants that completed the entire exercise intervention reported high levels of satisfaction overall. Each participant reported perceived benefit from treatment, learning new skills and techniques, and overall the experience of the intervention in a group setting was engaging and enjoyable.

What conclusions can we take from this research?
Based on the research, there is evidence to suggest benefit in group exercise intervention as a treatment for Post-Traumatic Stress Disorder in Military Veterans. The improvements in symptom severity and quality of life amongst the participants indicates there is a need for further supporting research in this area, but the results of this pilot study show positive signs for its effectiveness as an alternative to traditional pharmacotherapy or psychotherapy. There is enough scope in this research to consider further study, in a larger population. Exercise in a group setting may help to breakdown barriers and stigma associated with PTSD.

Further research into the viability of group exercise as a treatment for PTSD in Veterans is required, in a larger population sample. As the research conducted was a pilot study, the small sample size only gives a brief indication as to the success of the intervention. Furthermore, heavy reliance on self reporting data, a lack of physiological testing, and comparison to an "inactive" group restricts the overall validity.

Practical Advice
Due to the lack of practical recommendations in the research, and the limited information regarding PTSD and exercise for Military Veterans available, the primary source of practical advice would be considered to follow Physical Activity Guidelines, as prescribed for general populations. The Integrated Exercise Program in the research, although briefly outlined, doesn't specify amount, modality and structure of each type of exercise so as such, recommendations for exercise based on the information provided cannot be concluded.

Further information / resources
For further information and reading on Post-Traumatic Stress Disorder in Veterans, please consider the links below;
 * PTSD Treatment for Veterans: What's Working, What's New and What's Next
 * Department of Veterans Affairs, Australia
 * Soldier On, Australia