Impact of physical exercise on PTSD: a review
This review intends to collect and analyse previous studies on the influence of physical activity on PTSD. Although the number of studies currently dealing with this issue is expanding, important lines of scientific research have not examined it thoroughly. This is disappointing considering the strong repercussions of PTSD on the human body, which scholars have clearly illustrated.
The following article will list and group the most relevant scientific studies on the preventative role played by regular physical exercise against the chronification of PTSD and the need to combine it with psychotherapy.
The aims of the present work are to raise sensitivity among the scientific community on the body’s pivotal role when taking charge of a PTSD and to hypothesize a combined intervention through psychotherapy and daily workout.
Review: The Existing Literature
The literature in the psycho-traumatologic field reporting strict data on the impact of physical activity on PTSD is expanding, yet still scant in terms of standard protocols and detailed guidelines on what can benefit PTSD patients.
The impact of PTSD on the body is known – it has been highlighted in multiple studies published in authoritative magazines and well explained by scholars who have led the way, such as Bessel Van der Kolk in The Body Keeps The Score.
Magazines including the American Journal of Psychiatry and the Journal of Clinical Psychology, reference recent studies involving PTSD patients for whom standardised protocols of physical exercise were applied. These studies evidence the generic importance of aerobic physical activity, aimed at developing “muscle endurance,” to mitigate the somatic effects of PTSD.
Main contributions, listed in chronological order:
Fetzner & Asmundson (2014) investigated the benefits of regular aerobic activity (specifically, 6 sessions of 20 minutes in two weeks, i.e. 3 weekly sessions of 20 minutes) on a sample group of 33 PTSD patients. The researchers divided the group into 3 different sub-populations: the first of these was provided, during the exercises, with a “cognitive distraction” aimed at inducing the subjects to focus on other than the exercise itself or their own bodies. The second group was given the task of focusing on interoceptive aspects (i.e., to concentrate on the inner sensations stimulated by the exercise itself). The third group was simply asked to engage in the ongoing physical activity. The aim was to understand the ways in which a standardised and regular set of exercises may impact the symptoms of an heterogeneous group of PTSD patients: in particular, the investigation on the interoceptive subgroup focused on the causes – not only the presence – of sport’s benefits on PTSD. The results, however, showed few, if not no, differences, among the various subgroups. This may suggest a positive intergroup experience of aerobic exercise in the treatment of PTSD. The researchers argued that exercise in general could have enabled a process of “interoceptive exposition,” i.e. have promoted an active confrontation with body sensations stimulated by physical exercise itself. As we know, one of the key strategies – if not the main one – of PTSD management is the good handling of the somatic activation triggered by the emerging trauma. In this respect, the confrontation with the somatic sensations induced by regular aerobic exercise might prove a strong act of exposure to what comes from the body, regardless how much attention is paid to it.
Rosenbaum et al. (2014) published a randomised study, in Acta Psychiatrica Scandinavica, which investigated the difference between two types of treatment (with or without physical exercise) provided to a group of 81 patients with primary PTSD (diagnosed according to the criteria of the DSM IV, excluding those cases better defined by complex trauma and those suffering from chronicle physical pathologies, both likely to spread confusion in the process of analysis). The conclusions showed a higher improvement in the conditions of those who had been treated with physical exercise (specifically, 30 weekly minutes of cardio fitness in hospital, two sessions at home and a controlled program of minimum walk – up to 10,000 steps per day – for each subject).
Vancampfort et al. (2016) carried out a review on a sample of about 1,400 people with PTSD, highlighting a correlation between hyper-arousal and physical activity. They argued that one of the benefits of physical activities for PTSD patients might lie in their very process of habituation to the states of hyper-arousal, which are in fact better tolerated and managed with regular exercise.
Wolf Mehling et al. (2017) observed, in the Journal of Clinical Psychology, how a sample of 47 veterans subjected to physical training and mindfulness-based techniques for 12 weeks had experienced a general reduction of the dysregulative effects of PTSD-typical hyper-arousal states, thus experiencing a general improvement in their quality of life.
Vancampfort et al. (2017) published a meta-analysis carried out in five studies on a total of 192 PTSD patients, who had been treated with psychotherapeutic rehabilitation in combination with physical training. The authors evidenced the presence of certain psycho-physical benefits and reduced symptoms of hyper-arousal and avoidance, which led them to generically encourage the adoption of twice weekly resistance-training sessions together with 150 minutes of moderate exercise (or two 75 minute sessions of vigorous exercise) per week.
Oppizzi and Umberger (2018) carried out a deep meta-analysis of the pre-existing literature publishing one of the most exhaustive contributions to the research on the topic. The key points of this meta-analysis may be synthesized as follows:
a) higher impact of aerobic activity – such as brisk walking, rope skipping, jogging, cycling – on PTSD;
b) increasing evidence of the significant benefits of Yoga practice on PTSD symptoms;
c) importance of constant physical training and
d) centrality of sleep quality, which is improved by physical activity, as a therapeutic element in relation to PTSD.
Furthermore, some hypotheses were made about the mechanisms underlying the benefits of physical exercise on PTSD:
a) expositive hypothesis – some reasoned exercise would allow PTSD patients to slowly familiarize themselves with the somatic sensations triggered by traumatic experiences;
b) regulative hypothesis – exercise would help to decrease the hyper-arousal states and escape the hypo-arousal ones and
c) physiological hypothesis – regulation of the hormones released by post- traumatic stress, liberation of endorphins, increased brain neurotrophic factor.
Hegberg et al. (2019) exhaustively examined 19 studies carried out on PTSD-diagnosed subjects. This explored the correlation between the use of aerobic exercise only (thus excluding Yoga and other practices) and PTSD levels. The results showed evident links between aerobic activity and decreased PTSD symptoms; nonetheless, the authors called for further research (namely RCT studies) in order to evaluate a possible causality between the two events. This article sets a series of hypotheses about the mechanisms of action of physical exercise in terms of benefits for PTSD. Specifically, the authors mention:
desensitization and exposure: A subject exposed to aerobic (including vigorous) exercise stimulating an hyper-arousal condition is likely to interpret that very physiological alteration as non-pathological in context of non-exercise (for instance, in case of an intense tachycardia due to vigorous exercise, that very tachycardia will be ideally interpreted as less “dangerous” also in daily life);
cognitive impairment: The authors noted the absence of studies relating physical exercise and better cognitive performances in subjects suffering from PTSD. However, a vast quantity of studies about improvement of some cognitive functions in the elderly and the young (in particular executive functions and episodic memory) suggested that the same improvements could be detected in PTSD patients, Those very cognitive functions – episodic memory and executive functions – being the most compromised in the PTSD;
anatomic functions and altered brain structures: Here also the authors evidenced the absence, upon publication, of studies examining the morphology (altered or not) of specific brain areas following a period of specific training. However, they noted that various studies showed a positive impact of aerobic exercise and “cardio-respiratory fitness” on the morphology of many brain areas in elderly patients – the same areas which are altered following the development of PTSD;
hypothalamus-pituitary-adrenal axis (HPA): Studies on healthy subjects show how physical activity helps keep HPA functioning. The authors suggest that physical activity could benefit HPA regulation in PTSD patients. In this population, in fact, the impact of post-traumatic stress on the HPA circuit, due to an alteration of its feedback mechanism, had been observed.The authors pointed out that the studies on the HPA axis in correlation with PTSD are too scarce to provide reliable data.
Finally, the authors observed how multiple sources referred to the correlation between alterations of the immune system and the presence of prolonged stress, in particular in relation to the concept of inflammation. The de-inflammatory effects of physical activity and its beneficial effects on various aspects of life, including sleep quality, are well documented in literature. The authors noted the core importance of sleep in the recovery from PTSD as a significant processing of the mnestic data (cognitivization) takes place during sleep. (Pagani et al., 2017)
Neurocognitive and neurophysiological aspects: some speculative assumptions
The work of Hegberg et al. represents the most exhaustive contribution in literature so far. In general terms there are different theories regarding the mechanisms which make aerobic physical activity a potential for integration to the standard treatment of PTSD. These theories are attributable to four hypotheses.
Using the body for regulatory purposes can be considered a mastery strategy, meaning an active behaviour promoting the recovery of mastery status in terms of emotional regulation. There are different ways to recover the mastery. The body represents an often effective, although primal, way to fall into line with what Daniel Siegel calls the “window of tolerance.” Physical activity creates the ability to soothe states of neurophysiological dysregulation when these are excessively upward in tendency (hyper-arousal) or to promote a “return to life” against states of seemingly invincible de-activation (hypo-arousal). It is understood that PTSD determines dysregulations of both hyper and hypo-arousal.
2. The body dissipates the trauma
This expression, borrowed from one of the world leaders in the somatic approach to trauma, Peter Levine, expresses the sense of letting the traumatic experience out through the body. The studies of Pat Ogden focus on the development and the practice of “action tendencies” blocked during and after trauma. Levine carried out long studies on animal behaviour looking at trauma in both an aneural-biological and ethological sense.
Animals, when not marked by past traumatic experiences, respond effectively to single traumas by “shaking” them off their bodies, thus restoring the pre-trauma neuro-physiological state. Humans are not always able to do so. Despite the substantial inter-specific overlapping of the oldest brain parts observable in vertebrate animals, the human brain is equipped with some powerful tools of storage and problem solving regarding experienced reality, which paradoxically leads to an excessive and distorted storage of the trauma itself. Levine speaks about an excess of physical “energy” which, unable to develop in a biological sense because of the state of deep impotence experienced during the trauma, remains in the body perturbing it (post-traumatic stress). This aspect of Levine’s theory precedes and is comparable to the already mentioned “action tendencies” theorized by Pat Ogden, which should ideally be “taken out” through sensorimotor channels, i.e. through the body (first vehicle and natural site of the escape/attack reactions triggered by threats), with some semantic nuances. (Pat Ogden defines the action tendencies as a highly finalized movement, Levine as a “too full” that must be let out.) Sport, in this respect, might be conceived as a vehicle for letting out the action tendencies matured during trauma. Levine describes somatic effects of PTSD reactions as including tremors, excessive sweating and cold hands. According to him, such signs might tell us about an autonomous response of the central nervous system, blocked in an abnormal, prolonged “defence mode” as if expecting a new hypothetically forthcoming traumatic event. Levine, together with other scholars, interprets these signs and symptoms as bodily “spies” of something that needs to be evacuated or dissipated (e.g. an intense anger left unexpressed, an impossible escape from the body).
For example, when observing an animal emerging from a state of apparent death, we can see that the animal evacuates the state by means of trembling. Some animals – for example bears – tend to tremble more (they are shaken by intense tremors which then quiet down), others less. Tremor represents a natural response aimed at dissipating terror and anxiety with some psychotherapeutic schools of thought seeing its voluntary self-induction as an instrument to discharge the energies. The “discharge of fear” process following a strong shock or trauma seems, in fact, to naturally occur. We know that animal behaviour recapitulates, in a certain simplified sense, our own behaviour, and that sometimes we can learn from the observation of animals, that which we hardly manage to observe in ourselves. The work done by Peter Levine teaches us that the body must be “discharged” following a strong activation. Sport, in this respect, provides an ideal and modular container to successfully express such blocked tendencies.
The image above describes an ideal sequence which illustrates immobility to recovery of empowerment conditions through running. The running tool is used as a means for the development and achievement of the fight-or-flight response which was kept frozen by the trauma. Levine effectively explains how, in order for a trauma to settle, there must be an association between immobility and fear in order to dissociate and solve, in a clinical sense, these two aspects of the patient’s life experience to free him from the trap of the post-trauma.
3) Interoceptive exposure therapy
Exposure therapy is founded on the concept of rehearsal, i.e. repetition and habituation, which makes it an effective coping tool in those cases where the tendency would instead be “avoiding”. Rehearsing a public speech, attending places perceived as dangerous, indulging in the reading of inner states of fear and terror, are all examples of exposure strategies used to make those very stimuli (both inner and outer) less “activating”.
One of the consequences of PTSD is the continued inner and outer avoidance of all that concerns the trauma and the context in which it took place. The expression “phobia of interior states” is used to indicate the result of an individual’s total avoidance of that which might elicit a dysregulated body reactivation (inner triggers such as thoughts and images able to provoke a traumatic break-in are avoided). According to this hypothesis, physical activity would allow the re-appropriation of a higher sense of control, through exposure and habituation, on the bodily sensations induced by regular exercise.
4) Antidepressant and anxiolytic effect of physical exercise
Multiple studies have valued and shown the positive impact of physical exercise on symptoms of depression and anxiety stemming from various life experiences. If we consider the “network” theory of mental disturbance promoted by Denny Borsboom, psycho-pathological symptoms are to be considered as horizontally located on the individual’s psychological scene, connected and interdependent. We can also see an indirect impact of physical activity on PTSD, including its impact on some of the side symptoms of post-traumatic stress itself, such as severe insomnia or general anxiety. In fact, the cognitive performances of a PTSD patient coping with the management of the disturbance generally improves with the improvement of sleep quality. It must be remembered that post-traumatic stress feeds on the constant adaptation to a reality which is perceived as threatening. To face it in a state of prostration from lack of sleep makes it even more threatening (Pierre Janet has described it as easier for a potentially traumatic event to take root in the mind of its victim in conditions of “psychic tiredness”). The same could be said about depressive experiences resulting from exhaustion. Regulating imbalances or decreases in mood by stimulating the production of endorphins through a prolonged session of aerobic exercise should be considered an attempt to generally improve life quality in the goal of liberation from primary PTSD.
The present review follows on from previous articles aimed at evidencing how the bodily channel can affect some core neuro-physiologic and somatic symptoms of PTSD. A reasoned use of a specific workout program, combined with triphasic psychotherapy, could accelerate the recovery time and induce a higher sense of grounding, stability and mastery. It has not been possible here, due to lack of resources, to undertake an in vivo trial path of the suggested training program on a suitable sample of subjects. I hope it will be undertaken in the future by experts interested in the topic. Ideally, research into PTSD would benefit from experts in athletic training specialized in the treatment of PTSD, who could merge with a specialist team – together with psychotherapists and psychiatrists – able to act in parallel.
Borsboom D. & Cramer A. O.J. (2013). Network Analysis: An Integrative Approach to the Structure of Psychopathology, Annual Review of Clinical Psychology, 9:1, 91-121
Hegberg, N. J., Hayes, J. P., & Hayes, S. M. (2019). Exercise Intervention in PTSD: A Narrative Review and Rationale for Implementation. Frontiers in psychiatry, 10, 133. doi:10.3389/fpsyt.2019.00133
Levine, P.A. (2014) Somatic Experiencing, casa Editrice Astrolabio, Roma
Mathew G. Fetzner & Gordon J.G. Asmundson (2015) Aerobic Exercise Reduces Symptoms of Posttraumatic Stress Disorder: A Randomized Controlled Trial, Cognitive Behaviour Therapy, 44:4, 301-313, DOI: 10.1080/16506073.2014.916745
Mehling, Wolf & Chesney, Margaret & Metzler, Thomas & Goldstein, Lizabeth & Maguen, Shira & Geronimo, Chris & Agcaoili, Gary & Barnes, Deborah & Hlavin, Jennifer & Neylan, Thomas. (2017). A 12-week integrative exercise program improves self-reported mindfulness and interoceptive awareness in war veterans with posttraumatic stress symptoms. Journal of Clinical Psychology. 74. 10.1002/ jclp.22549.
Ogden, P., Minton, K., Pain, C. (2006). Il trauma e il corpo. Manuale di psicoterapia sensomotoria. Tr.it. Istituto di Scienze Cognitive Editore, Sassari 2012
Pagani M, Amann BL, Landin-Romero R and Carletto S (2017) Eye Movement Desensitization and Reprocessing and Slow Wave Sleep: A Putative Mechanism of Action. Front. Psychol. 8:1935. doi: 10.3389/fpsyg.2017.01935
Philip & Rosenbaum, Simon. (2016). Physical Activity in People With PTSD: A Systematic Review of Correlates. Journal of Physical Activity and Health. 13. 910-918. 10.1123/jpah.2015-0436.
Rosenbaum, S, Sherrington, C, Tiedemann, A. (2014) Exercise augmentation compared to usual care for post-traumatic stress disorder: a randomized controlled trial, Acta Psichiatrica Scandinavica, Vol. 131, Issue 5, Pag. 350-359
Siegel, D. (2013). Il Terapeuta consapevole. Guida per il terapeuta al Mindsight e all’Integrazione neurale. Sassari: Istituto di Scienze Cognitive Editore
Vancampfort, Davy & Stubbs, Brendon & Richards, Justin & Ward, Philip & Firth, Joseph & Schuch, Felipe & Rosenbaum, Simon. (2016). Physical fitness in people with posttraumatic stress disorder: a systematic review. Disability and Rehabilitation. 39. 10.1080/09638288.2016.1226412.