Exercise as it relates to Disease/PTSD: moving forward with exercise

Critique of Article: Exercise augmentation compared with usual care for post-traumatic stress disorder: a randomised controlled trial Rosenbaum S, Sherrington C, Tiedemann A.

What is the background to this research?
Post traumatic stress disorder (PTSD) is a psychiatric condition occurring with people who have witnessed or experienced a traumatic event including but not limited to, natural disasters, war, acts of terrorism, serious accidents or personal assault. Veterans are at the highest risk of developing PTSD with between 5-20% experiencing it at some stage, first responders are also at a high risk being placed above the general population PTSD rate of between 5-10%.

The symptomology of PTSD can be classed into four main categories with varying degrees of severity across sufferers:
 * Intrusive or unwanted thoughts can be shown through repeated unsolicited memories manifesting in the forms of dreams and flashbacks that can be vivid the individual feels as like they are reliving the trauma.
 * Avoidance of reminders may come in the form of avoiding people, places, objects and activities associated with the traumatic event, including avoidance of discussing the traumatic event.
 * Negative feelings and thoughts present with a focus on both the self and on those around individual, emotionally this can manifest in the forms of anger, guilt, shame and/or fear as well as lower propensity to feel joy and happiness through activities that previously elicited such responses.
 * The final symptomology category is arousal and reactive symptoms, this is can be demonstrated by changes to the individual’s behaviour often expressed through anger, irritability, recklessness, self-destructive behaviour, insomnia and concentration issues.

Until this article there had been no research into the effect of exercise on the physical health outcomes of PTSD. Due to positive effects of physical activity on cognition and overall mental health it was hypothesised that this study would prove exercise as a positive aspect of future care for PTSD sufferers.

Where is the research from?
This study was conducted in 2014 from the Musculoskeletal division, The George Institute for Global Health and School of Public Health, University of Sydney, Sydney, NSW and St John God of Health Care Richmond Hospital, Sydney, NSW, Australia.

Dr Simon Rosenbaum was funded by St John God of Healthcare, Richmond Hospital. Dr Tiedemann and Prof. Sherrington are supported by fellowships from the Australian National Health and Medical Research Council. There were no competing interests declared or any role played by the funders in the study design or conduct.

What kind of research was this?
This study was an assessor blinded randomised controlled trial which makes it the gold standard of study design. It consisted of a decent sized population with 81 participants who had been diagnosed with primary PTSD by the DSM-IV-TR. The intervention was 12 weeks in duration involved usual care for both groups as well as resistance training and walking programme for the group receiving the intervention.

What did the research involve?
The 81 participants in the study were randomly allocated into one of two groups, 42 were selected as the control receiving usual care while the remaining 39 received an exercise intervention of 3 30-minute resistance training sessions per week and a walking program. The resistance training session protocols consisted of 1 exercise physiologist supervised exercise session per week in the hospital gymnasium and 2 non-supervised home-based sessions. The protocol was designed within the guidelines of the ACSM and consisted of a 3x10 sets to repetitions protocol for up to 6 exercises with 30-60 second rest intervals. Intensity was determined by the IPAQ and the Borg RPE with the session intensity goal  being a rating of between 12-17. These protocols were employed to accommodate for hypothesised adherence issues with individuals presenting higher severity PTSD. The walking programme required the individuals to aim for a daily goal of 10,000 steps per day to be recorded in an exercise diary, however, this was adjusted for the individuals to make realistically achievable goals.

The usual care that both groups received was a combination of medication, psychologist led group therapy and psychotherapy. Access to these therapies was identical for both groups across the full intervention. The primary outcomes assessed were the PTSD symptoms as outlined by the PCL-C, secondary outcomes were symptoms of depression, physical activity, strength, mobility, anthropometry and sleep.

The methodology for this study was excellent however there were some issues. These flaws are largely regarding the high percentage of males and the geographical similarities between participants. The intervention group only consisted of 3 female participants (8%) and the usual care group contained 10 females (24%), this provided limited data as to the overall applicability of the study’s findings in regard to women. Another flaw in the study is in its geographical constraints. All the participants were residing in or near Sydney, making these findings potentially irrelevant to other populations. As part of the exclusion criteria, participants did not qualify if their trauma was from childhood, therefore making these findings irrelevant for PTSD sufferers whom fall into that category.

What were the basic results?
The study showed that the exercise intervention group improved significantly better in multiple assessments and approached statistical significance in several other categories. The primary outcome measure (PCL-C) showed a significant improvement when compared to the usual care group with 71% of participants completing follow up assessment for this outcome.

Furthering this many of the secondary outcomes displayed statistically significant improvements. This is evidenced primarily through the DASS combined measurements of depression, stress and anxiety. The intervention group greatly reduced their time spent sitting and sleep quality as measured by the PSQIA total score also demonstrated an improvement. Furthermore, the study found the reduction of BMI approached significance in the exercise intervention group. There were no significant differences in any of the following:
 * Cardiorespiratory fitness
 * Resting heart rate
 * Systolic blood pressure
 * Diastolic blood pressure
 * Grip strength
 * Total physical activity

What conclusions can we take from this research?
There are significant mental health and physical health outcomes that can be gained by patients with a PTSD diagnosis when compared to usual care alone. By including exercise in a treatment plan for individuals with PTSD there are potential benefits for reduced PTSD specific symptoms, lowered levels of depression and anxiety, lessened insomnia and improvements in BMI.

Practical advice
With the many benefits of exercise being shown to improve mental health across a range of conditions it should be a consideration for any mental health intervention. This study adds to the evidence and provides the first statistically relevant findings for PTSD specific exercise interventions.

Further information/resources
For further information on PTSD please see:
 * Beyond blue
 * Black dog institute
 * Health direct
 * Different brains

For those with someone afflicted with PTSD in their lives please see:
 * PTSD help guide
 * Mayo clinic - helping a loved one

For those in urgent need of assistance please contact:
 * Lifeline 13 11 14 (Australia)
 * The Samaritans 135 247 (Australia)
 * Suicide call back service 1300 659 467 (Australia)