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