Posttraumatic stress disorder (PTSD) is an anxiety disorder triggered by witnessing or experiencing a traumatic event. Although it is commonly associated with combat veterans, it also frequently affects survivors of violent personal assaults (rape, mugging or domestic violence), childhood abuse, natural disasters, accidents and life-threatening illnesses.
Cohen et al. (2009) note that 8%–12% of all adults, and 13%–31% of military veterans, will suffer from PTSD at some point in their lives. These statistics make it very likely that exercise professionals will encounter clients who have PTSD. Understanding how PTSD influences physical and mental health can be critical to developing a successful exercise program for these clients.
Understanding More About PTSD
PTSD is fundamentally a dysfunction of the body’s stress-coping system, resulting in serious health effects (see Figure 1). A complex cluster of PTSD symptoms can be divided into three general categories:
- Intrusive memories or flashbacks. Recalling a traumatic event arouses intense emotions like terror or panic.
- Emotional numbing. Traumatic stress blunts or impairs normal emotional functioning. This may lead to drug or alcohol abuse.
- Anxiety and increased arousal. Worrisome thoughts cause a person to overreact to even minor stimuli, leading to excessive alertness and startle reactions.
PTSD clients may feel helpless and experience a diminished sense of self-control. Symptoms vary in severity from person to person and can be chronic or intermittent. Without intervention, PTSD can increase the chances of a person developing severe depression, substance abuse and suicidal thoughts.
How Can Exercise Help?
While PTSD has no known cure to date, evidence is emerging that exercise can be a valuable component of a comprehensive PTSD treatment plan (Tsatsoulis & Fountoulakis 2006). Low- to moderate-intensity exercise 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).
Designing an Exercise Program for PTSD Clients
It is essential to recognize the barriers to exercise for PTSD sufferers. These include
- 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; and
- cardiovascular disease, diabetes and other chronic illnesses.
The skilled exercise professional should promote the benefits of exercise and help turn these potential “barriers” into a source of motivation for the client to overcome.
Because each client with PTSD has very different needs, it is important to individualize instruction and emphasize communication. One key consideration in designing an exercise program for clients with PTSD is to include low- to mod-erate-intensity body-awareness movement activities (such as Pilates, yoga, Nia®, therapeutic dance, tai chi or qigong), which can reduce symptoms of anxiety and depression and have produced positive results in PTSD sufferers (Netz & Lidor 2003). Diaphragmatic (or pranayama) breathing and muscle relaxation exercises, which have a natural calming effect, should also be a regular part of the program.
Unique Training Concerns
When working with PTSD clients, remember that their symptoms can vary from day to day and may be triggered by seemingly innocuous situations, such as loud noises or crowds. Try to learn each client’s triggers and symptom severity, as this information will be critical to success, not only in designing an exercise program, but also in ensuring client compliance in the long term. Be sure to provide a safe environment where clients can relax and focus on their health and well-being during the exercise session.
Fatigue is a common symptom of clients with depression and/or PTSD, particularly those who take antidepressants. Know what medications each client is taking, and adjust the intensity and duration of the activity to avoid overtiring the client. Be aware that a structured exercise program can give some PTSD sufferers a sense of control they lack in other aspects of their lives. There is a risk these clients could develop unhealthy or unsafe approaches to exercise, so make sure exercise does not become an excessive behavior.
Finally, there may be social barriers to exercise for clients whose symptoms include avoidance or withdrawal. For these clients, exercising 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 setting, where positive social interactions will contribute to their mental well-being.
PTSD: Final Thoughts
Exercise can play an important role in helping clients with PTSD recover and regain confidence. Exercise also addresses many of the health problems commonly associated with chronic PTSD, including cardiovascular disease and depression. While there may be challenges to beginning an exercise program for those suffering from PTSD, exercise professionals are in a unique position to provide the motivation and tools that will promote favorable change and improve quality of life for these clients.
Pranayama (abdominal or diaphragmatic) breathing has been shown to improve immune function, hypertension, asthma, autonomic nervous system imbalances and psychological or stress-related disorders (Jerath et al. 2006).
Have a client place one hand on the abdomen above the navel to feel it being pushed outward during the inhalations. Next, let the breathing focus include expansion of the rib cage during the inhalation. Have the client place the edge of the hands alongside the rib cage (at the level of the sternum) to learn this; correct diaphragmatic breathing will elicit a noticeable lateral expansion of the rib cage.
1. Have the client take a comfortable position.
2. Encourage the client to breathe slowly and relax.
3. Tell the client that he or she is safe.
4. Let the client know you are there to help.
5. Address the client by name.
6. Ask questions to reorient the client (What is today’s date? How many children do you have?)
7. Slowly bring the client back to the present place.
8. If necessary, refer the client to a qualified health provider.
Keep these key points in mind when designing an exercise program for clients with PTSD:
1. Be repetitive. Repetition helps clients to eventually master the exercises, which builds confidence and self-efficacy.
2. Be predictable. Predictability assists in reducing anxiety-arousal symptoms that trigger PTSD episodes.
3. Be noncompetitive. Competitive environments can activate the sympathetic nervous system, triggering undesirable increases in stress levels. Exercise should ease pressure on PTSD clients, not increase it.
4. Be reflective. Coaching clients to develop an internal awareness of the body’s response to the mild stress of exercise can help them handle daily-life stress more effectively.
5. Be patient. Each PTSD client calls for an individually paced exercise strategy that lets the client acquire skills, learn self-control and improve quality of life.
6. Be realistic. Clients need honest and attainable fitness goals.
7. Be flexible. Planning how you will adapt to the unexpected is important. For example, when facing a surprising situation with a PTSD client (such as getting a flat tire on an outdoor cycling exercise session), you must remain calm so the client feels secure.
8. Be nonjudgmental. PTSD clients may not respond to instructions and exercise cues in the way that other clients would.
9. Be prepared. Some PTSD clients will experience mood alternations. Stop, talk and listen to the client when that happens.
10. Be knowledgeable. Staying informed about a client’s health status and medication changes will help you more readily adapt an exercise program to meet the client’s needs.
Cohen, B.E., et al. 2009. Posttraumatic stress disorder and health-related quality of life in patients with coronary heart disease: Findings from the Heart and Soul Study. Archives of General Psychiatry, 66 (11), 1214–20.
Cohen, G.E., & Shamus, E. 2009. Depressed, low self-esteem: What can exercise do for you? The Internet Journal of Allied Health Sciences and Practice, 7 (2).
Jerath, R., et al. 2006. Physiology of long pranayamic breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. Medical Hypotheses, 67 (3), 566–71.
Netz, Y., & Lidor, R. 2003. Mood alterations in mindful versus aerobic exercise modes. The Journal of Psychology, 137 (5), 405–19.
Pole, N. 2007. The psychophysiology of posttraumatic stress disorder: A meta-analysis. Psychological Bulletin, 133 (5), 725–46.
Tsatsoulis, A., & Fountoulakis, S. 2006. The protective role of exercise on stress system dysregulation and comorbidities. Annals of the New York Academy of Sciences, 1083, 196–213.
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