Elsevier

Journal of Affective Disorders

Volume 227, February 2018, Pages 345-352
Journal of Affective Disorders

Research paper
Veterans Group Exercise: A randomized pilot trial of an Integrative Exercise program for veterans with posttraumatic stress

https://doi.org/10.1016/j.jad.2017.11.002Get rights and content

Highlights

  • We developed an integrative exercise (IE) intervention for veterans with PTSD.

  • Veterans receiving IE demonstrated reduction of PTSD symptom severity.

  • Veterans receiving IE demonstrated improvements in quality of life.

  • Treatment completers rated the intervention as both feasible and acceptable.

Abstract

Background

Posttraumatic stress disorder (PTSD) is prevalent among military veterans and is associated with significant negative health outcomes. However, stigma and other barriers to care prevent many veterans from pursuing traditional mental health treatment. We developed a group-based Integrative Exercise (IE) program combining aerobic and resistance exercise, which is familiar to veterans, with mindfulness-based practices suited to veterans with PTSD. This study aimed to evaluate the effects of IE on PTSD symptom severity and quality of life, as well as assess the feasibility and acceptability of IE.

Methods

Veterans (N = 47) were randomized to either IE or waitlist control (WL). Veterans in IE were asked to attend three 1-h group exercise sessions for 12 weeks.

Results

Compared with WL, veterans randomized to IE demonstrated a greater reduction in PTSD symptom severity (d = −.90), a greater improvement in psychological quality of life (d = .53) and a smaller relative improvement in physical quality of life (d = .30) Veterans’ ratings of IE indicated high feasibility and acceptability.

Limitations

The sample was relatively small and recruited from one site. The comparison condition was an inactive control.

Conclusions

This initial study suggests that IE is an innovative approach to treating veterans with symptoms of PTSD that reduces symptoms of posttraumatic stress and improves psychological quality of life. This approach to recovery may expand the reach of PTSD treatment into non-traditional settings and to veterans who may prefer a familiar activity, such as exercise, over medication or psychotherapy.

Introduction

Posttraumatic stress disorder (PTSD) is prevalent among military veterans, with estimates ranging from 15% among Vietnam War veterans (Schlenger et al., 1992) to 5–20% among those deployed to Iraq and Afghanistan (Ramchand et al., 2010). Given the symptoms associated with PTSD, such as avoidance of activities, negative emotions, and poor sleep, veterans with PTSD face functional impairment and decreased quality of life in several domains (Erbes et al., 2007, Magruder et al., 2004, Pittman et al., 2012, Zatick et al., 1997). Patients with PTSD are also at increased risk of negative health outcomes, including cardiovascular disease, obesity, and even early mortality (Ahmadi et al., 2001; Bartoli et al., 2015; Boscarino, 2006; Jordan et al., 2013; Kubzansky et al., 2009, Kubzansky et al., 2007; Turner et al., 2013; Vaccarino et al., 2013).

Unfortunately, many veterans do not pursue mental health care, and among those who do, there is substantial lag time from end of deployment to initiation of mental health care (Maguen et al., 2012). In fact, less than ten percent of veterans attend a minimally recommended number of mental health appointments within the first year since PTSD diagnosis (Seal et al., 2010). Veterans who screen positive for mental health disorders endorse barriers to treatment and concerns about stigma at a far higher rate than those who screen negative, thus impeding care for those who need treatment the most (Hoge et al., 2004). Accordingly, the development of new acceptable treatments for PTSD may be necessary to overcome these substantial barriers to care.

Exercise is emerging as a potential intervention for the treatment of PTSD. Aerobic exercises are familiar to military veterans, as they are a part of daily life of all military personnel during their service, and lack the stigma often associated with more traditional mental health interventions. Individuals with PTSD report exercising at a lower rate than those without PTSD (Zen et al., 2012). Combined with the data suggesting that PTSD is associated with negative cardiac outcomes, exercise may be a particularly salient intervention for the veteran population.

There is preliminary evidence to support exercise as an effective intervention for PTSD in civilian adults (Manger and Motta, 2005, Kim et al., 2013, Fetzner and Amundson, 2015, Rosenbaum et al., 2015), but research in this area may not be generalizable to the typical outpatient, veteran population. Manger and Motta (2005) evaluated a 12-session aerobic exercise program among nine adults with PTSD, with no comparison group, finding a significant reduction in symptoms of PTSD. Kim et al. (2013) observed superior reduction in PTSD symptoms among 11 female nurses with PTSD who participated in a 16-session mindfulness-based stretching and deep breathing exercise program compared to 11 female nurses with PTSD participating in a control condition. The nature of the control condition was not specified. Fetzner and Amundson (2015) evaluated 33 participants (76% female) with PTSD who completed 6 sessions of stationary biking. The participants were divided into three groups with varying attentional focus (i.e., attention to somatic arousal, distraction from somatic arousal, and no attentional prompting). All groups demonstrated significant reduction in PTSD symptom severity. Rosenbaum et al. (2015) assessed change in PTSD symptom severity among 81 participants with PTSD attending an inpatient program. They found that participants randomized to usual care (individual and group psychotherapy, medication) plus 3 30-min resistance training sessions per week and a pedometer-based walking program had significantly reduced PTSD symptoms compared to participants randomized to usual care alone. Though exercise is ubiquitous in the military experience, only one study of exercise for veterans with PTSD was found in the literature: One study of Australian Vietnam veterans demonstrated high acceptance of exercise therapy (Otter and Currie, 2004), however, only five veterans were diagnosed with PTSD, and quantitative outcome data were not reported. This literature also lacks reporting of functional outcomes, which are particularly important in the case of PTSD.

In recent years, military settings have increasingly adopted mindfulness-based practices (Crawford et al., 2013). Trials of Mindfulness-Based Stress Reduction (MBSR) for veterans with PTSD have shown promise for this approach in reducing PTSD symptom severity, but the effect of treatment has varied (Kearney et al., 2012, Kearney et al., 2013, Niles et al., 2012, Polusny et al., 2015). The investigators of one trial raised the question as to whether the MBSR should be modified or tailored for veterans with PTSD, particularly due to frequent manifestations of veterans’ posttraumatic symptoms, such as intrusive thoughts, during mindfulness practice (Kearney et al., 2013). Another consideration is that mindfulness-based interventions include attitudinal principles that are well-suited for incorporation with other activities, allowing patients to benefit from these skills while engaging in their daily lives.

Given the promise of exercise- and mindfulness-based interventions for PTSD, we developed an Integrative Exercise (IE) program combining aerobic and resistance exercise, as well as yoga poses, movements, and breathing, within the context of mindfulness-based principles, such as nonjudgmental attitude and acceptance. The aim of the current study was to evaluate the efficacy, feasibility, and acceptability of the IE intervention compared with a waitlist control among military veterans with PTSD. Primary treatment outcomes were PTSD symptom severity and quality of life.

Section snippets

Participants

Study participants included veterans age 18–69-years-old who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) criteria for current PTSD or partial PTSD. Exclusion criteria were: (1) lifetime history of any psychiatric disorder with psychotic features, bipolar disorder, or mania, (2) alcohol or substance dependence in past year, (3) prominent suicidal or homicidal ideation, (4) pregnancy, (5) clinically significant neurological disorder

Results

Fig. 1 illustrates participant flow through the study. Participants included 47 veterans, with 42 veterans meeting DSM-IV diagnostic criteria for PTSD and 5 meeting criteria for partial PTSD. Twenty-one veterans were randomly assigned to IE and 26 to WL. Baseline demographic and diagnostic data are presented in Table 1. The sample was mostly male (81%) and racial or ethnic minority (60%). Age ranged from 24- to 69-years-old (M = 46.80, SD = 14.93). The mean CAPS score at baseline was 61 (SD =

Discussion

This randomized pilot study evaluated the effect of IE on PTSD symptom severity and quality of life among veterans with PTSD. Participants in the IE group demonstrated greater improvement in PTSD symptom severity and psychological quality of life compared with participants randomized to WL. These results, combined with similar dropout to waitlist and high participant ratings of feasibility and acceptability, demonstrate promise for this intervention as a less stigmatizing and more familiar

Acknowledgments

The authors wish to acknowledge Gary Agcaoili, Chris Geronimo, Allegra Hirschman, and Timothy Riel for their work on this project. The Embarcardero YMCA generously donated space for the exercise classes. This work was supported by: the Veterans Health and Integration Program; private donations to the Osher Center for Integrative Medicine at the University of California San Francisco (major donors included Alexsis de Raadt-St. James and Mark B. Hoffman, Michelle and Robert Friend Foundation,

Contributions

GJC, LST, MAC, and TCN obtained funding. WEM, TJM, BEC, DEB, LST, MAC, and TCN designed the study. LAG, WEM, TJM, AS, LST, JAH, MAC, and TCN collected and managed the data. LAG, WEM, TJM, BEC, DEB, SM, MAC, and TCN analyzed and interpreted the data. LAG, WEM, TJM, BEC, DEB, LST, SM, MAC, and TCN drafted and assisted with revisions of the manuscript. All authors approved the final manuscript.

Role of funding source

The funding sources did not have any role in the conduct of the research or the preparation of this

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