Post-traumatic stress disorder (PTSD) in U.K. Military veterans and exercise rehabilitation. By Alan Lofthouse

Hi Everyone


I hope all is well


This is the first post of July 2020. it is from my good friend and colleague Alan Lofthouse all around PTSD in UK Military Veterans and their Exercise Rehab. 


Hope all my readers you find this useful :)


Enjoy!


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1.0 Introduction

What is Post-traumatic stress disorder (PTSD), and how does it affect Veterans? According to the NHS England, (2018), PTSD is a psychological conditioning that sometimes makes the subject relive traumatic events through nightmares and flashbacks, which could be triggered by a particular smell, sound or even location. Furthermore, the subjects may experience a feeling of isolation, irritability and guilt on top of many other emotions. According to Zen, et al., (2012) PTSD can also lead to physiological problems such as excess sympathetic activity and disruption of the hypothalamic-pituitary-adrenal axis that may directly damage the cardiovascular system and cause atherosclerosis. The pooled prevalence of metabolic syndrome, including central obesity, high blood pressure, low high-density lipoprotein cholesterol, elevated triglycerides, and hyperglycaemia (Zimmet, et al., 2005). People who have been diagnosed with PTSD are twice as likely to develop a metabolic condition than people without PTSD (Vancampfort, et al., 2017).

According to the MOD, U.K. Armed Forces Mental Health: Annual Summary & Trends over Time. (2018), the most common age to get PTSD in the Royal Marines is 25-39 years old, this highlights that PTSD is a hidden psychological trauma and may affect a subject at any point later in life. Also, the same report summarised that non-commission officer is more likely to get PTSD than commission officers, and, Females are again more likely to get PTSD than some Male counterparts. The recent conflicts (2004-2018) that the British Armed Forces have been engaged in has been correlated with the rise of combat-related PTSD, (MOD, 2018). From 2004 to 2014, there was a 17% increase in the number of British military veterans with a form of combat-related PTSD (MOD, 2018). Mental welfare project figures highlight the need for improving prevention programs and rehabilitation programs for British veterans with PTSD. It is interesting to note that different joining requirements for the various branches of the British armed forces have a correlated effect on combat-related PTSD figures. For example, the "Royal Marines had a significantly lower rate of mental illness" this could be because of the "rigorous training that Royal Marines have to go through". (MOD, 2018), however, could this information be due to the fitness level required to join or is this data because of the recruitment and retention number of the Royal Marines. This essay is going to explore the question could the use of exercise therapy that has been previously highlighted that physical fitness level could help prevent or reduce the effects of PTSD, so, can physical activity help prevent or rehabilitate PTSD clients.

While planning an exercise intervention program for treating a client with PTSD, one of the primary consideration is the psychological side conditions which could be brought on by PTSD. According to Cohen & Shamus (2009), some subjects with PTSD could have other mental health conditions such as depression or substance abuse, physical injuries caused by the original traumatic event; for example, debilitating injuries, traumatic brain injury, cardiovascular disease, diabetes and other chronic illnesses. The MOD, (2018), has identified that mostly in veterans with PTSD the most common substance abuse is alcoholism, this has been hypothesised to be due to the nature of social activities or culture in the Armed forces.

Some of the more common physiological side effects for veterans with PTSD are; cardiovascular disease generally refers to any conditions that involve narrowed or blocked blood vessels that can lead to a heart attack, chest pain or a stroke (NHS, 2018). Another side condition of PTSD could be diabetes or obesity. Obesity affects one in four adults in the United Kingdom (NHS, 2018). However, there is a discrepancy in how obesity is measured in the U.K. Obesity in PTSD could be because of the psychological effects of group training and the subject may be in able to go outside the door.

2.0 Common treatment plans for PTSD

            According to the NHS (2018), the three most popular common ways in the U.K. to treat PTSD is cognitive behaviour therapy, eye movement desensitisation and reprocessing, finally group therapy. It has been noted by Smith, et al., (2015) that some subjects with PTSD will not include themselves in group therapy due to fear of being judged or not being able to control themselves in the situation. The American national centre for PTSD published an information leaflet and suggested that 53 out of 100 people will no longer have PTSD after three months of trauma-focused psychotherapy, 42 out of 100 people will again no longer have PTSD after three months of medication treatment (Sertaline, Paroxetine, Fluoxetine, Venlafaxine). Although, there is a lack of long term studies to support the information suggested by the American national centre for PTSD, so can they confirm that a subject will be symptom-free after a possible 3month intervention. The information in the leaflet is based solely on the American military information and lifestyle; this could be different for the British military veterans. 

Finally, the leaflet suggests that approximately 9 out of 100 people will no longer have PTSD if they do not use any treatment intervention. Although, as indicated by Rosenbaum, et al., (2015), there may be social barriers to exercise for clients whose symptoms include avoidance or withdrawal. For these clients, using one-on-one in a private setting may be the best strategy. As they build confidence, they can make the transition into a small-group environment, where positive social interactions will contribute to their mental wellbeing. Interestingly, the United Kingdom military has launched a wellbeing scheme that helps identify PTSD symptoms, which have been found to dramatically increases the number of military personal with PTSD. Again, this now highlights that more and more people can have PTSD and not know what the symptoms are, or, they do not want to talk about their mental wellbeing.

Produced by the U.S. national PTSD centre if the client takes medication or takes part in CBT/ Eye movement desensitisation and reprocessing (EMDR) within three months, the client would be PTSD free. However, the investigation that was conducted was very vague about the meaning of symptom-free. It is the author understanding that symptom-free mean the client has not had night terrors, loss of sleep, and prevention of hypersensitivity. Furthermore, due to the complexity and lack of long term research with treatment intervention (Vancampfort, et al., 2017), can we be confident that clients will be symptom-free long term.

As mentioned earlier, one intervention for PTSD is medication. Sertraline is an antidepressant known as a selective serotonin reuptake inhibitor (SSRI); it can take four to six week to affect the subjects (NHS, 2018). It has been suggested the on one in 100 people get one of the side effects that may come with this medication. However, a study by Babyak, et al., (2001) has identified that in a long term study, physical exercise was more effective than Sertraline in producing Serotonin. Although, this study was conducted on subjects aged 55-77 years old and according to the MOD, (2018) mental health report the most common age for veterans to start showing symptoms of PTSD was 30-40 years old. Furthermore, producing Serotonin artificially is more effective and sustainable than creating it naturally.

2.1 How Can Physical Activity Help?

Tsatsoulis & Fountoulakis, (2006), has suggested that PTSD has no known cure. The information above contradicts the three-month theory concluded by the American PTSD Centre, (2012) the evidence is emerging that exercise can be a valuable component of a comprehensive PTSD treatment plan (Tsatsoulis & Fountoulakis 2006). It has been suggested that low- to moderate-intensity activity can elevate mood, reduce anxiety (Cohen & Shamus 2009) and act as an overall stress-buffer (Tsatsoulis & Fountoulakis 2006). More specifically, exercise, particularly mind-body and low-intensity aerobic exercise has been shown to have a positive impact on the symptoms of depression and PTSD (Cohen & Shamus 2009). It is essential to recognise the psychological and physiological barriers to exercise for people living with PTSD.

●     The presence of other mental health conditions such as depression or substance abuse

●     Physical conditions caused by the original traumatic event; for example, debilitating injuries, including traumatic brain injury

●     Cardiovascular disease, diabetes and other chronic illnesses.

Because subjects with PTSD has very different needs, it is essential to individualise instruction and emphasise communication. One key consideration in designing an exercise program for clients with PTSD is to include low to moderate intensity and body awareness movement activities, which can reduce symptoms of anxiety and depression and have produced positive results in people with PTSD (Netz & Lidor 2003). Yoga has been used to help reduce symptoms of PTSD and improve physical activity levels (Mitchell, et al., 2014). Furthermore, Skaar, et al., (2018) and Reinhardt, et al., (2018) have both summarised data that all yoga styles will have a positive effect on PTSD symptoms. The investigation seems to believe that this is due to the controlled breathing element and the psychological effects that come with yoga exercises. Furthermore, it should be noted that yoga can help physiological. However, the study by Brurberg, et al., (2016) highlights that the mental aspect of PTSD is more difficult to the condition than the physiological perspective. 

Although it has been suggested that fatigue is a common symptom of clients with depression or PTSD, it is more predominant in those who take antidepressants—knowing what medications each subject is taking, and adjusting the intensity and duration of the activity to avoid overtiring the client. A structured exercise program can give some people living with PTSD a sense of control they lack in other aspects of their lives. This information supports the facts that Verterns struggles to re-integrate into civilian society due to the difference in personal ethics and lifestyle; this is due to no structure in their life anymore (MOD, 2018). There is a risk these clients could develop unhealthy or unsafe approaches to exercise, so make sure exercise does not become excessive behaviour. An investigation by Brurberg, et al., (2016) has identified that exercise may not hinder chronic fatigue disorders but could help improve the subjects fatigue level. It has also been suggested that exercise therapy will help with the following; sleep, physical function and self-perceived general health, although, there has not yet been a correlation between exercise therapy and the improvement of quality of life, anxiety and depression.

PTSD has been linked closely with depression, according to the MOD, (2017) mental welfare report. It has been reported by Stanton and Reaburn, (2014) and Ranjbar, et al., 2015, that exercise has an apparent positive effect on depression. However, this investigation only uses supervised aerobic exercise three times a week for a nine-week intervention protocol. As the research form Vancampfort, et al., (2017) has been advised that a person with PTSD should exercise up to 150 minutes per a week of moderate exercise or 75 minutes vigour's exercise while maintaining a two times a week resistance exercise program. However, this study does not identify as to what classes as moderate or vigour exercise or what resistance exercise program the subjects followed. However, Brurberg, et al., (2016) has highlighted that there is no positive correlation between exercise therapy and depression, which contradicts what has been reported by Stanton and Reaburn, (2014); Ranjbar, et al., 2015 and Vancampfort, et al., (2017), which all have suggested that exercise will improve depression symptoms.

Furthermore, it has been suggested by Helgadottir, et al., (2017), that the long term effects of exercise therapy have depressed the depression symptoms. The above paragraph has highlighted that there is evidence both for and against the use of exercise therapy, however, due to the psychological effect of PTSD it is possible that exercise could have a positive effect on decreasing the symptoms. There is also a lack of supporting evidence around; time, frequency and program length concerning gaining a definite reduction in PTSD symptoms.

Furthermore, the type of exercise, only aerobic exercise Yoga have been investigated (Stanton and Reaburn, 2014; Ranjbar, et al., 2015 and Vancampfort, et al., 2017) to have a positive effect on the symptoms of PTSD, further research is needed into this area and more longitude study into the effects of exercise on mental health. Finally, the only time resistance exercise programs have been used in PTSD cases is for one of the secondary conditions, loss of limbs, however, the study by Wasser, et al., (2017) did not include monitoring of PTSD symptoms, but found that the mental welfare of limb lost victims was found to have a positive effect when exercising to their mental wellbeing.

2.2 PTSD side symptoms and exercise therapy

2.2.1 Loss of limbs

According to the MOD, (2018) veterans who have conducted the most operational tour and have lost of a body part will be 70% more likely to develop PTSD. The most common limbs lost in operation deployment or arms and legs. A program suggested by Wasser, et al., (2017) that consisted of Plank Seated back extension, truck rotary stability, leg extensions, monster walk, posture reset, adduction resistance and superman exercise has been suggested to help improve the quality of life for unilateral amputees. However, this study only used 40 subjects, and each subject did not undergo the same surgical procedure, which could have affected the biomechanical and physiological outcomes of the study. Another major factor to acknowledge the loss of a limb is the metabolic effect of the change of gait. Therefore, a change in nutritional advice must be acknowledged due to the effect of this, and how it affects physical interventions to help the subject achieve a higher quality of life. Keogh and Beckman, (2019) have suggested that an increase in protein or fat to help counter the increases of the subjects energy needs. In both of the studies, they did not look at psychological interventions that could of help the limb loss victim to optimising the rehabilitation program. 

 2.2.2 Traumatic brain injury

A possible side effect of PTSD could be traumatic brain injuries, according to Levin and Arrastia, (2015), early diagnoses is crucial to help reduce brain swelling and further injuries, after the acute phase it has been advised not to return to sport or work till symptoms free. However, a possible effect way of reducing the concussion effect is by following England RFU, concussion return to play guide. The investigation by Levin and Arrastia, (2015), has suggested the following plan post-acute injury (Below). Working alongside this, it could be possible to follow the RFU guidelines for RTP for concussion (below). However, significant brain injury would require more physical and neurological observation. The world of ruby has placed much current research into brain trauma, and concussion in rugby players and the joining of the two worlds could help return veterans to work.

Figure 1 - Levin and Arrastia, (2015), Post-acute treatment plan.

Figure 2- RFU return to play concussion guide.

           

2.2.3 Cardiovascular disease (CVD)

According to the NHS, (2018), the most advised why of preventing CVD is by conducting on average 150 minutes of moderate physical activity? This information is supported by an investigation conducted by Alves, et al., (2016). A review of CVD and exercise published by Eijsvogels, et al., (2016), has presented that exercise intervention for CVD has a positive effect on prevention and helping to improve the symptoms of CVD. The information provides highlights that physical interventions help prevents and could improve symptoms of CVD. Therefore, the information provided could help to reduce the side conditions of PTSD, which in turn could help prevent the hypersensitivity of the subject to certain situations.

2.2.4 Diabetes

The treatment plan for diabetes is to achieve and stabilise optimal blood glucose, lipid and blood pressure level. (Balducci, et al., 2014). Exercise intervention has been shown to help optimise the blood glucose level, lipid level and will also help blood pressure (ACSM, 2018). One side effect of the condition diabetes is overweight, which leads to correct gait and limits movement. According to Francia, wt al.,(2015), Exercise intervention has been shown to have a positive correlation on movement skills and gait in subjects who have been clinically diagnosed to have diabetes. Concerning PTSD, diabetes only occurs in one out of 30 veterans (Boyko, et al., 2010). However, this investigation was conducted on U.S. military veterans and not on U.K. veterans, and different lifestyle factors will affect the diabetes rating in veterans in the U.K. and the U.S. it has been suggested that yoga can help to decreases the symptoms diabetes (Cui, et al., 2017).

2.2.5 Obesity

The NHS, (2017) have suggested a definition for obesity is if your body mass index (BMI) is over 24.9 then you could be classed as obese, also if male waist circumference is higher than 94cm for males and 80cm for females then again you are on the scale for being obese. However, because the formula for BMI is based on height and weight, how can it be accurate for sport or people who have a physically active lifestyle? Is has been suggested by Rothman, (2008) that BMI is a simple but not accurate enough for people who have a physically active lifestyle. "Obesity is a result from excessive adipose tissue in relation of fat free mass", (Peterlin, et al., 2012), with this definition clearly outlined the requirements for the classification of obesity, and would be a far better protocol to use to measure obesity; however, this protocol can be expensive.

Obesity in subjects with PTSD could be classed as a psychological condition; this is because the subject is replacing his poor mental pain status with something that symbolises pleasers somewhere in his psyche (Weinberg and Gould, 2018). PTSD subjects have been suggested to have an elevated risk of metabolic syndromes (Rosenbaum, et al.,2015). This is supported by Wolf, et al., (2017), who claims that PTSD subjects have two times more likely to develop a metabolic condition like obesity, the study suggests that veterans who were deployed to Afghanistan and Iraq are two times more likely to become obese than thou deployed else were, although, this study information all came from American soldiers and veterans. Therefore, the information could be inaccurate for British soldiers and veterans. This is because of the welfare and education the soldiers receive on nutrition and post PTSD care from the military. American soldiers have to seek this information out where British soldiers have a care system in place through the NHS for education guidance is on PTSD.

3.0 Reflective summary

I think the above information supports the use of exercise intervention that could help with supporting symptom reduction in subjects with PTSD, however, with the multiple of factors that is associated with PTSD not just the physiological would exercise therapy work for long terms. I think further studies into the effect of different type and duration of exercise should be conducted into this field as this will help maybe shorten the 3-month recovery timeframe that has been suggested by the MOD, (2018) and The American national post-traumatic stress centre for veterans. In conjunction with CBT or eye movement desensitisation therapy could help shorten the therapy time for veterans with PTSD. It has been noted that most secondary symptoms and primary symptoms have had decrees in symptoms with the intervention of yoga, can it be hypnotised that movement and breathing training effect PTSD, this is a possible route for further research.

To summarise the essay above PTSD in my point of view is a joint rehabilitation mission between the psychological and physiological departments. This is due to the information in the essay; people with PTSD have different physiological conditions even from traumatic injury or other mental scares. Therefore, exercise should help to improve symptom and overall help to control the condition due to the body physiological response to exercise. Also, the psychological effects of exercise can help to improve the condition. Further investigation into the selection process of troops who are frontline may need to be addressed as it seems, the more robust the training and selection, the less possibility of developing PTSD is. Finally, I think a greater understanding of the physiological conditions can help optimise the rehabilitation program so the therapist can then help prevent the secondary conditions.

           

4.0 References

●     Alves, A.J., Viana, J.L., Cavalcante, S.L., Oliveira, N.L., Duarte, J.A., Mota, J., Oliveira, J. and Ribeiro, F., 2016. Physical activity in primary and secondary prevention of cardiovascular disease: Overview updated. World journal of cardiology, 8(10), p.575.

●     American College of Sports Medicine, 2013. ACSM's guidelines for exercise testing and prescription. Lippincott Williams & Wilkins.

●     Babyak, M., Blumenthal, J.A. and Herman, S., 2001. Exercise was more effective in the long term than Sertraline or exercise plus Sertraline for major depression in older adults.(Therapeutics). Evidence-Based Mental Health, 4(4), pp.105-106.

●     Balducci, S., Sacchetti, M., Haxhi, J., Orlando, G., D'errico, V., Fallucca, S., Menini, S. and Pugliese, G., 2014. Physical exercise as therapy for type 2 diabetes mellitus. Diabetes/metabolism research and reviews, 30(S1), pp.13-23.

●     Boyko, E.J., Jacobson, I.G., Smith, B., Ryan, M.A., Hooper, T.I., Amoroso, P.J., Gackstetter, G.D., Barrett-Connor, E., Smith, T.C. and Millennium Cohort Study Team, 2010. Risk of diabetes in U.S. military service members in relation to combat deployment and mental health. Diabetes Care.

●     Cui, J., Yan, J.H., Yan, L.M., Pan, L., Le, J.J. and Guo, Y.Z., 2017. Effects of yoga in adults with type 2 diabetes mellitus: A meta‐analysis. Journal of diabetes investigation, 8(2), pp.201-209.

●     Eijsvogels, T.M., Molossi, S., Lee, D.C., Emery, M.S. and Thompson, P.D., 2016. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. Journal of the American College of Cardiology, 67(3), pp.316-329.

●     Francia, P., Paternostro, F., Anichini, R., De Bellis, A., Seghieri, G., Lazzeri, R., Gulisano, M. and Marini, M., 2015. Musculoskeletal manifestations of diabetes mellitus: the role of exercise therapy in the treatment of limited joint mobility, muscle weakness and reduced gait speed. Italian Journal of Anatomy and Embryology, 120(1), p.201.

●     Helgadóttir, B., Forsell, Y., Hallgren, M., Möller, J. and Ekblom, Ö., 2017. Exercise for depression: What are the long-term effects of different exercise intensities? Björg Helgadóttir. European Journal of Public Health, 27(suppl_3).

●     Keogh, J.W. and Beckman, E., 2019. Exercise and nutritional benefits for individuals with a spinal cord injury or amputation. In Nutrition and Enhanced Sports Performance (pp. 175-188). Academic Press.

●     Larun, L., Brurberg, K.G., Odgaard‐Jensen, J. and Price, J.R., 2016. Exercise therapy for chronic fatigue syndrome. Cochrane Database of Systematic Reviews, (2).

●     Ministry of Defence. (2017). U.K. Armed forces mental health: annual summary & Trends over time, 2007/08 - 2016/17. U.K. armed forces mental health. 1 (1), p1-41.

●     Mitchell, K.S., Dick, A.M., DiMartino, D.M., Smith, B.N., Niles, B., Koenen, K.C. and Street, A., 2014. A pilot study of a randomised controlled trial of yoga as an intervention for PTSD symptoms in women. Journal of Traumatic Stress, 27(2), pp.121-128.

●     MOD. (2018). U.K. Armed Forces Mental Health: Annual Summary & Trends Over Time, 2007/08 - 2017/18. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/717033/20180621_Mental_Health_Annual_Report_17-18_O.pdf. Last accessed 1st December 2018.

●     NHS. (2018). Cardiovascular disease. Available: https://www.nhs.uk/conditions/cardiovascular-disease/. Last accessed 1st November 2018.

●     NHS. (2018). Obesity. Available: https://www.nhs.uk/conditions/obesity/. Last accessed 1st November 2018.

●     NHS. (2018). Sertraline. Available: https://beta.nhs.uk/medicines/sertraline/. Last accessed 1st December 2018.

●     Peterlin, B.L., Calhoun, A.H. and Balzac, F., 2012. Men, women, and migraine: the role of sex, hormones, obesity, and PTSD. J Fam Pract, 61(4), pp.7-11.

●     Ranjbar, E., Memari, A.H., Hafizi, S., Shayestehfar, M., Mirfazeli, F.S. and Eshghi, M.A., 2015. Depression and exercise: a clinical review and management guideline. Asian journal of sports medicine, 6(2).

●     Reinhardt, K.M., Noggle Taylor, J.J., Johnston, J., Zameer, A., Cheema, S. and Khalsa, S.B.S., 2018. Kripalu yoga for military veterans with PTSD: a randomised trial. Journal of clinical psychology, 74(1), pp.93-108.

●     Rosenbaum, S., Stubbs, B., Ward, P.B., Steel, Z., Lederman, O. and Vancampfort, D., 2015. The prevalence and risk of metabolic syndrome and its components among people with post-traumatic stress disorder: a systematic review and meta-analysis. Metabolism, 64(8), pp.926-933.

●     Rosenbaum, S., Vancampfort, D., Steel, Z., Newby, J., Ward, P.B. and Stubbs, B., 2015. Physical activity in the treatment of post-traumatic stress disorder: a systematic review and meta-analysis. Psychiatry Research, 230(2), pp.130-136.

●     Rothman, K.J., 2008. BMI-related errors in the measurement of obesity. International journal of obesity, 32(S3), p.S56.

●     Skaare, J., 2018. A Systematic Review: Examination of Yoga-Based Interventions to Determine their Benefits and Effectiveness in Treating PTSD in Women.

●     Stanton, R. and Reaburn, P., 2014. Exercise and the treatment of depression: a review of the exercise program variables. Journal of Science and Medicine in Sport, 17(2), pp.177-182.v

●     Vancampfort, D., Stubbs, B., Richards, J., Ward, P.B., Firth, J., Schuch, F.B. and Rosenbaum, S., 2017. Physical fitness in people with post-traumatic stress disorder: a systematic review. Disability and Rehabilitation, 39(24), pp.2461-2467.

●     Vancampfort, D., Stubbs, B., Richards, J., Ward, P.B., Firth, J., Schuch, F.B. and Rosenbaum, S., 2017. Physical fitness in people with post-traumatic stress disorder: a systematic review. Disability and Rehabilitation, 39(24), pp.2461-2467.

●     Wasser, J.G., Herman, D.C., Horodyski, M., Zaremski, J.L., Tripp, B., Page, P., Vincent, K.R. and Vincent, H.K., 2017. Exercise intervention for unilateral amputees with low back pain: study protocol for a randomised, controlled trial. Trials, 18(1), p.630.

●     Weinberg, R.S. and Gould, D.S., 2018. Foundations of sport and exercise psychology. Human Kinetics.

●     Wolf, E.J., Bovin, M.J., Green, J.D., Mitchell, K.S., Stoop, T.B., Barretto, K.M., Jackson, C.E., Lee, L.O., Fang, S.C., Trachtenberg, F. and Rosen, R.C., 2016. Longitudinal associations between post-traumatic stress disorder and metabolic syndrome severity. Psychological medicine, 46(10), pp.2215-2226.

●     Wolf, E.J., Miller, D.R., Logue, M.W., Sumner, J., Stoop, T.B., Leritz, E.C., Hayes, J.P., Stone, A., Schuchman, S.A., McGlinchey, R.E. and Milberg, W.P., 2017. Contributions of polygenic risk for obesity to PTSD-related metabolic syndrome and cortical thickness. Brain, behaviour, and immunity, 65, pp.328-336.

●     Zen, A.L., Whooley, M.A., Zhao, S. and Cohen, B.E., 2012. Post-traumatic stress disorder is associated with poor health behaviours: findings from the heart and soul study. Health Psychology, 31(2), p.194.

●     Zimmet, P., Magliano, D., Matsuzawa, Y., Alberti, G. and Shaw, J., 2005. The metabolic syndrome: a global public health problem and a new definition. Journal of atherosclerosis and thrombosis, 12(6), pp.295-300.

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Thank you Alan for this insightful post!

I am sure the readers have enjoyed this topic and given them plenty food for thought.

Andrew Richardson, Founder of Strength is Never a Weakness Blog

I have a BSc (Hons) in Applied Sport Science and a Merit in my MSc in Sport and Exercise Science and I passed my PGCE at Teesside University. 

Now I will be commencing my PhD into "Investigating Sedentary Lifestyles of the Tees Valley" this October 2019. 

I am employed by Teesside University Sport and WellBeing Department as a PT/Fitness Instructor.  

My long term goal is to become a Sport Science and/or Sport and Exercise Lecturer. I am also keen to contribute to academia via continued research in a quest for new knowledge.

My most recent publications: 

https://www.sciencedirect.com/science/article/pii/S1752928X19300216

https://www.sciencedirect.com/science/article/abs/pii/S1752928X19301076 

https://link.springer.com/article/10.1007/s40279-020-01323-7 

My passion is for Sport Science which has led to additional interests incorporating Sports Psychology, Body Dysmorphia, AAS, Doping and Strength and Conditioning. 

Within these respective fields, I have a passion for Strength Training, Fitness Testing, Periodisation and Tapering. 

I write for numerous websites across the UK and Ireland including my own blog Strength is Never a Weakness. 

I had my own business for providing training plans for teams and athletes. 

I was one of the Irish National Coaches for Powerlifting, and have attained two 3rd places at the first World University Championships, 

in Belarus in July 2016.Feel free to email me or call me as I am always looking for the next challenge. 

Contact details below; 

Facebook: Andrew Richardson (search for)

Facebook Page: @StrengthisNeveraWeakness

Twitter: @arichie17 

Instagram: @arichiepowerlifting

Snapchat: @andypowerlifter 

Email: a.s.richardson@tees.ac.uk

Linkedin: https://www.linkedin.com/in/andrew-richardson-b0039278 

Research Gate: https://www.researchgate.net/profile/Andrew_Richardson7