Exercise as it relates to Disease/The impact of exercise on hyperarousal in veterans diagnosed with PTSD

This is a critical review of "The interactive role of exercise and sleep on veteran recovery from symptoms of PTSD."

What is the background to this research?
PTSD or Post Traumatic Stress Disorder is defined as the inability to recover from a stress reaction following exposure to a traumatic event. The inability to recover after an estimated given time (1 month~), becomes the onset of PTSD and its symptoms. According to US findings on PTSD, military veterans are most at risk of developing PTSD. The Veterans Health Administration (VHA), has estimated that since 2001, there has been a 60% increase to military veterans diagnosed with PTSD. The background of this research has strong foundations, as not only do serving and the veteran population suffer from PTSD- it is increasingly prevalent in civilian society. PTSD has many negative effects on physical health problems, functional impairment including but not limited to marital difficulties, unemployment , financial constraints and separate psychological disorders. There are effective interventions in place, but these can be time consuming, require specialised clinicians and are not always effective in combating PTSD. This research aims to assess the impacts of sleep and exercise to limit hyperarousal in military veterans suffering PTSD. With extensive research going into similar psychological disorders, little has gone into PTSD. This research is based on veterans who have served in Operation Iraqi Freedom or Operation Enduring Freedom.

Where is the research from?
The research is based on military veterans who have served in Operation Iraqi/Enduring Freedom with the US Armed Forces with the study being conducted in the US. The median age of veterans in the study is 52.18 with a range of 24-70. Although there is little evidence to suggest symptoms of PTSD decrease with exercise, the study was only conducted with US veterans in the Iraqi War. The study does not include veterans from Vietnam (pre-Iraq) or Afghanistan (post-Iraq Freedom). The participants of the study did not include veterans from Commonwealth countries, Iraqi or forces or enemy soldiers. Therefore, limiting the research to one country and one war.

What kind of research was this?
The research revolved around military veterans incorporating exercise and sleep on a bike-exercise program. The aim of the study was to incorporate both sleep patterns and exercise to find a degree of relief for PTSD sufferers. The main concept of the study was to limit contributing factors that engaged hyperarousal of suffering veterans. Ethnicity played an important role of this kind of the research as its displacement of ethnicity was comparatively accurate to the US Armed Forces. However, it does not accurately represent PTSD or veterans as a whole.

What did the research involve?
The research involved a few control measures- they were abstinent for the program. This involved toxicology reports before the testing started. A Pittsburgh Sleep Quality questionnaire was completed, a PTSD checklist determining severity of symptoms and the bike program which incorporated total amount of kilometres travelled over the course of the study. There is a margin of error in interpreting questionnaires that have been conducted individually and not professionally. This entails the veterans perceived health and not their actual health. The exercise program did not incorporate different methods of exercise and intensity, it only measured kilometres travelled. Varying intensity levels of exercise can significantly impact on mood. The error and intensity limiting variables significantly decrease the outcome of the research as it does not include a broader exercise study, nor does it have many control measures.

What were the basic results?
The main results of the study indicated that the group who engaged in the bike-exercise program reported lower hyperarousal levels. Importantly, exercise and sleep did not directly contribute to the overall symptoms decreasing, it merely interacted with only hyperarousal symptoms of PTSD. The veterans that had poor sleep and high hyperarousal were impacted more by the exercise program and limiting hyperarousal; whereas those who slept well had little effect of their hyperarousal levels. Those who participated in the bike-exercise program did drop in hyperarousal levels as shown in Fig 1.

What conclusions can we take from this research?
Hyperarousal is a key symptom of PTSD; it is also a negative symptom leading to poor sleep quality. Although this study was limited, there are signs that exercise can improve hyperarousal levels, which in turn can lead to better sleep quality and ultimately improving chronic health disorders in veteran and PTSD suffering populations. Associations between exercise and engaging in treatment are a barrier for veterans, with veterans choosing exercise over the latter. It is important to note that exercise interventions are much cheaper than behavioural or pharmaceutical interventions. The research does have limitations, it is unknown for how long hyperarousal levels are maintained pre/during/post exercise and what happens in between exercise bouts. Intensity and type of exercise limits this study as it does not account for their response- only riding a bike. Overall, the study does show promise in incorporating exercise with PTSD sufferers as hyperarousal levels decrease. However, more and broader research is needed in understanding underlying factors to promote a better and broader foundation for research.

Practical advice
This research concluded with positive findings, yet limited and narrow control measures/assessments. Veterans suffering PTSD from Iraqi Freedom/Enduring understand the importance of exercise post-military, however, the resources to continue exercise are either limited, expensive or shadowed by chronic disorders including PTSD. The study would show more practicality in broadening the participant parameters, exercise type and intensity and objective sleep assessments e.g. sleep study. Exercise interventions are medication free, low cost and more importantly, can be easily accessed. Veterans associations not only in the US, but any veteran worldwide, should have access either free or for a small price to access exercise programs. From this study, it has proven to be highly beneficial in limiting PTSD symptoms which will overall improve chronic health disorders in PTSD populations. Australia has a Veterans Program run by Exercise Physiologists and other Allied Health Professionals called VIDA. However, this program is only accessible for war veterans with a white or gold card and does not incorporate peace time efforts or general service. There are steps in the right direction, but there is still a long way to go to ensure military veterans and PTSD sufferers can access exercise interventions to improve overall health and limit chronic health disorders.

Further information/resources

 * Vida Wellness
 * Arent, D. Landers and J. Etnier Journal of Aging and Physical Activity, 8 (2000), pp. 407-430 Retrieved via PubMed
 * Department of Veteran's Affairs - Health and Wellbeing