Exercise as it relates to Disease/Health benefits of sport and exercise on PTSD survivors

This is a critique of the research article: Ley C, Rato Barrio M, Koch A. “In the Sport I Am Here”: Therapeutic Processes and Health Effects of Sport and Exercise on PTSD. Qualitative Health Research. 2018;28(3):491-507 (1).

What is the background to this research?
Post Traumatic Stress Disorder (PTSD), defined as “a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event” (2) will affect ~7-8% of the U.S population during some stage of their lives (3). Types of PTSD can generally be categorised into three classifications: Uncomplicated PTSD, Complex PTSD and Comorbid PTSD. The former and easiest to treat is resultant of one traumatic event in contrast to Complex PTSD which is linked to multiple traumatic events. Comorbid PTSD is attributable to co-occuring mental disorders and is often the most difficult to treat (4). With stress being an inevitable common denominator at some point of most people’s lives, it is necessary to explore methods for stress alleviation in PTSD victims. The study presented aimed to contribute to a more holistic understanding of how exercise facilitates positive health benefits on PTSD symptoms (1).

Where is the research from?
Ley, Rato Barrio and Koch conducted their research at the University of Vienna, Austria in conjunction with Vienna based care centre for torture and war survivors - Hemayat. Their work was first published in Sage Journals, a leading independent academic publisher with a highly credible reputation which is reflected in their impact factor of 0.92 (5)(6). Despite the research being conducted in Vienna, the study and its findings remain relevant to Australians. Clemens Ley is a highly regarded and experienced author having contributed to over 90 publications in the health field through a variety of universities in several countries. María Rato Barrio has extensive experience in the health field also, having contributed to many publications often centered around the link between physical activity and health betterment. The remaining author, Andreas Koch has many credible publications often focussing on the influences of health at a molecular level.

What kind of research was this?
Despite the subject being selected from a pool of 14 participants, this research is classified as a holistic single-person case study due to the singular subject being the primary focus.

What did the research involve?
The research was completed in conjunction with the Movi Kune Project (7) which provided a foundation for this investigation to build upon, however to streamline the analysis, only the subsequent case study of PTSD victim Rashid will be critiqued. The processes and methods implemented were based upon three themes; “(a) a motivational–restorative, (b) a distraction, and (c) an exposure effect” (1). Through a variety of independent and group exercises/activities, Rashid’s pain sensations (both positive and negative) along with his improvement of awareness of body and self, were analysed by his therapist, who in turn would report the feedback to the researchers. The participant feedback was directed through Rashid’s therapist who had gained his trust as demonstrated through Rashid’s statement, “You are the only one I know here [in Austria] and I do not know [any other] good persons” (1). This inevitably improved accuracy and reliability in communication. Researchers also conducted observational analysis to develop descriptions of results such as “social interactions, task performance, skills, levels of activation and participation, attentional focus, and affective response” (1).

What were the basic results?
The image below demonstrates the potential for health benefits to occur and effectively depicts the intertwining relationships of various cognitive developments.

All results gained in this case study were based upon subjective observations and assessments of personal reflections facilitated by Rashid’s therapist. Through data analysis it was deduced that many of the subjects' positive affective states often had a distinct correlation to mastery experiences and accomplishments, an attentional focus on playing and positive group experiences. Additionally, positive pain sensations were frequently reported during exercising, allowing the subject to distinguish between positive and negative experiences of self. The progression of the intervention also saw a continuous increase in how often Rashid “showed [positive] emotions”(1) in situations such as scoring or catching in basketball. An associate trauma-expert was said to be amazed at the positive change demonstrated by Rashid. A further testament to the positive change initiated by the intervention was noted in Rashid’s final interview where he stated that he “only felt happy 2 days a week, either when he came to therapy or to the sport program”(1).

What conclusions can we take from this research?
This study provides a great demonstration of the potential health benefits obtainable through sport and exercise for PTSD survivors. A direct link between physical activity and improvements in various departments of cognitive health was established. Whilst the findings gained from this investigation are positive, the reliability and accuracy of the study are questionable, largely due to the unique circumstances of PTSD victims and the barriers in communication often present.

Practical advice
The single-person case study is effective in gaining sufficient data with adequate attention to detail, the study needs comparative data and repetition to improve reliability. This could be done through performing multiple single-person case studies, or alternatively widening the investigation to make it a cross-sectional study between large populations with an enhanced research team. Additionally, as is typical of most case studies, there is a lack of scientific rigour along with significant potential for researcher bias influenced data. In turn, generalisations for the wider population cannot be accurately produced, only hypothesised. In order to minimise such limitations, objective measures and multiple observers can be implemented to reduce researcher bias. The production of quantitative data through objective measures will enhance the repeatability of the investigation and also provide numerical data to be used for comparisons with normative data.

Further information/resources
For further information regarding PTSD and the influence of exercise in relation to this chronic disease, refer to the readings below.

The impact of sport and physical activity on the well-being of combat veterans

Evaluation of physical activity habits in patients with posttraumatic stress disorder

The effects of aerobic exercise on childhood PTSD, anxiety, and depression

14 CrossRef citations to date 8 Altmetric Articles The Role of Exercise in Reducing Childhood and Adolescent PTSD, Anxiety, and Depression

Exercise Intervention in PTSD

PTSD & Exercise: What every exercise professional should know

Post-traumatic stress disorder (PTSD)