**1. Introduction: the effect of exercise on posttraumatic stress disorder (PTSD)**

In the early days of research on the impact of exercise on negative emotional states, there was fairly consistent evidence of its beneficial impact [1, 2]; but there was virtually no evidence of its utility in managing PTSD. The reasoning behind the lack of evidence for the utility of exercise in reducing PTSD was that PTSD is a far more complex and enduring problem than many of the more transitory disorders such as anxiety and depression. PTSD literally transforms the individual sufferer on virtually all levels. It is not as simple as fear of driving on highways but involves an alteration of one's sense of self and one's view of the environment. PTSD sufferers report that they are no longer the person they once were and they no longer see the world in the same way. It seemed that exercise could not have a real impact on such a pervasive and enduring disorder as PTSD. I was somewhat taken by surprise when one of my doctoral students was able to prove otherwise [3].

In her study Dr. Manger obtained a sample of individuals from the community who had experienced a variety of traumatic events including the tragic death of a loved one or friend, a sexual or physical assault, serious accident (most common were automobile accidents), combat, severe illness or disease, or injury. Study participants reported experiencing between two and six traumatic events and on average were 48 years of age. Participants were then required to walk or jog on a treadmill at a moderate intensity level for 30 minutes and then engage in a cool down for 10 minutes. Moderate intensity exercise was defined as 60–80% of maximum heart rate for half an hour. Heart rate monitors were provided. Participants agreed to exercise two to three times per week for 10 weeks. Overall results showed significant reductions in PTSD, anxiety and depression following the exercise intervention. These results were maintained during the one-month follow-up period. In the exercise intervention presented here there was no need for those involved to deal with traumatic experiences other than, that which may have been encountered in filling out paper and pencil measures of trauma, and answering questions during initial interview. The reductions in negative emotional states that followed the exercise intervention cannot be attributed to any traditional form of therapeutic intervention as none was offered in this study. It appeared that exercise alone was responsible for the reductions in PTSD, anxiety and depression. This of course begs the question, which may be unanswerable: why does exercise have a beneficial effects noted here. To date there seems to be no universally agreed upon answer.

#### **1.1 Additional empirical studies of exercise and PTSD**

Another more recent study of adults, focusing specifically on women veterans of childbearing age, was conducted to determine if exercise in and of itself could positively impact PTSD [4]. The protocol involved brisk walking at a rate of 3 miles/hour for 30–40 minutes, 4 days a week for a total of 12 weeks. The exercise duration was gradually increased upward in the first 3 weeks to a full duration of 30–40 minutes per session by the end of week 3. Exercise sessions had a 3–5 minute warm up before advance the walking speed to its targeted intensity level. Results again showed significant reductions in PTSD and depression, and increases in quality of life measures and pain reduction. The authors state: "Finally, for patients with prominent avoidance related to their traumatic events, exercise many provide a safe and structured activity than can address social isolation and promote recovery" (p. 1813).

Avoidance is a major problem in treating PTSD with traditional treatments that require the patient to re-confront and reprocess their trauma experiences. If interventions, such as exercise can be effective in reducing this disorder and do not place a heavy emphasis on re-confronting prior trauma, they have an important place in our treatment choices. No study is without its limitations including this one which did not have a comparison group that was diagnosed PTSD but was not receiving exercise. Nevertheless, the overall thrust of existing empirical investigations certainly seems to point toward exercise as an effective intervention for PTSD.

The majority of research studies on exercise and PTSD, including those presented to this point use a cross-sectional approach whereby a group of individuals, most often adults, with PTSD are enrolled in an exercise program for a specific period and are given pre and posttest measures to see if there have been reductions in negative emotional states. In contrast an online longitudinal study involving 182 individuals who screened positive for PTSD [5] was conducted. In addition to a measure of PTSD participants completed online assessments of exercise behavior, psychological distress, sleep quality, pain, and alcohol/substance abuse. Findings were that there was a significant and direct effect of exercise on avoidance/numbing symptoms of PTSD. This is of no small significance as avoidance is one of the major difficulties in treating those who are traumatized. Numbing refers to emotional dampening and lack of engagement. However, for those who engaged in strenuous intensity exercise, which was defined as vigorous running or cycling, there was significantly less avoidance/numbing and hyperarousal. Those who engaged in strenuous exercise activity also reported better sleep quality, reduced substance abuse, less pain, and a reduction in overall PTSD symptoms than those who were less active.

**71**

*The Role of Exercise in Reducing PTSD and Negative Emotional States*

Overall results of this study point to beneficial effects of aerobic activity particularly for those who exercise vigorously. However, this should not be interpreted to mean that moderate levels of exercise are not of value. The general message from the research literature is that even moderate levels of exercise are effective in reducing both anxiety and depression. Given that anxiety and depression are key components of PTSD, it should be clear that encouraging patients to exercise is

There are those who claim that the beneficial effects of exercise may be due to changes in brain morphology, chemistry, and function. These beneficial effects include improved learning and memory, anti-depressant and anti-anxiety effects, reduced cognitive decline related to aging, and improvements in symptoms of neurodegenerative diseases. Exercise appears to improve mood and cognition and to have its greatest effects on the hippocampus where both neurogenesis (nerve cell growth), angiogenesis (increase blood availability through the growth of new blood vessels) have been shown. Although the exact molecular mechanisms responsible for the exercise-induced neuroplasticity needs to be further researched, progress is continuing in this area especially regarding studies of neurotransmitter systems. Another study [6] examined active and inactive adolescent and adult twins between the ages of 14–24 with diagnosable anxiety disorders. Results showed that exercise reduced anxiety, PTSD, agoraphobia, and other specific phobias in the physically active twin. Twins not engaging in exercise did not have reductions in these disorders. The value of this study is that it helps to nullify genetic explanations as to why individuals may benefit from exercise. The authors kept the genetic factor relatively constant and continued to find that exercise alone benefited the active twin.

Having found positive results for the impact of aerobic exercise on PTSD in adults, the next step was to determine if the same outcome would occur in an adolescent sample. We recruited participants from a residential treatment center who were female, who had primarily been physically abused, sexually abused, maltreated or some combination of those, were between the ages of 14–17, and who had a diagnosis of PTSD based upon standardized measures [7]. Participants engaged in a structured group aerobic exercise program for 40 minutes, three times per week for a total of 8 weeks. The form of exercise varied with some girls jogging and some doing kickboxing but all of which produced an aerobic effect. Measures of PTSD, anxiety, and depression were taken twice during the beginning and end of a baseline period in which no intervention took place, at the end of the exercise intervention, and at a one-month follow up. Once again, results provided support for the positive effects of aerobic exercise on reducing PTSD, anxiety, and depression. Fewer youngsters met the criteria for PTSD and the end of the study than at the beginning and overall, significant reduction in anxiety and depression were shown. One of the major values of the exercise intervention is that it achieved positive therapeutic outcomes without the need for the adolescents to engage in formal therapy, which they were reluctant to do. It is easy to see that adolescent females may have been immensely troubled by their abuse and avoidant as far as sharing information in a formal therapeutic setting. If significant symptom reduction can be attained by a simple aerobic exercise activity, such activity should become part of

Finding that PTSD could be reduced through simple aerobic exercise interventions within adult and adolescent samples, another study [8] was conducted with youngsters 14–17 years of age at a private residential treatment facility, but this time the attempt was made to use only moderate intensity walking as the form of

*DOI: http://dx.doi.org/10.5772/intechopen.81012*

generally excellent practice.

**1.2 Exercise and PTSD in adolescents**

the formal structure of interventions for these youngsters.

#### *The Role of Exercise in Reducing PTSD and Negative Emotional States DOI: http://dx.doi.org/10.5772/intechopen.81012*

*Psychology of Health - Biopsychosocial Approach*

for 10 minutes. Moderate intensity exercise was defined as 60–80% of maximum heart rate for half an hour. Heart rate monitors were provided. Participants agreed to exercise two to three times per week for 10 weeks. Overall results showed significant reductions in PTSD, anxiety and depression following the exercise intervention. These results were maintained during the one-month follow-up period. In the exercise intervention presented here there was no need for those involved to deal with traumatic experiences other than, that which may have been encountered in filling out paper and pencil measures of trauma, and answering questions during initial interview. The reductions in negative emotional states that followed the exercise intervention cannot be attributed to any traditional form of therapeutic intervention as none was offered in this study. It appeared that exercise alone was responsible for the reductions in PTSD, anxiety and depression. This of course begs the question, which may be unanswerable: why does exercise have a beneficial effects noted here.

Another more recent study of adults, focusing specifically on women veterans of childbearing age, was conducted to determine if exercise in and of itself could positively impact PTSD [4]. The protocol involved brisk walking at a rate of 3 miles/hour for 30–40 minutes, 4 days a week for a total of 12 weeks. The exercise duration was gradually increased upward in the first 3 weeks to a full duration of 30–40 minutes per session by the end of week 3. Exercise sessions had a 3–5 minute warm up before advance the walking speed to its targeted intensity level. Results again showed significant reductions in PTSD and depression, and increases in quality of life measures and pain reduction. The authors state: "Finally, for patients with prominent avoidance related to their traumatic events, exercise many provide a safe and structured

activity than can address social isolation and promote recovery" (p. 1813).

Avoidance is a major problem in treating PTSD with traditional treatments that require the patient to re-confront and reprocess their trauma experiences. If interventions, such as exercise can be effective in reducing this disorder and do not place a heavy emphasis on re-confronting prior trauma, they have an important place in our treatment choices. No study is without its limitations including this one which did not have a comparison group that was diagnosed PTSD but was not receiving exercise. Nevertheless, the overall thrust of existing empirical investigations certainly seems to point toward exercise as an effective intervention for PTSD. The majority of research studies on exercise and PTSD, including those presented to this point use a cross-sectional approach whereby a group of individuals, most often adults, with PTSD are enrolled in an exercise program for a specific period and are given pre and posttest measures to see if there have been reductions in negative emotional states. In contrast an online longitudinal study involving 182 individuals who screened positive for PTSD [5] was conducted. In addition to a measure of PTSD participants completed online assessments of exercise behavior, psychological distress, sleep quality, pain, and alcohol/substance abuse. Findings were that there was a significant and direct effect of exercise on avoidance/numbing symptoms of PTSD. This is of no small significance as avoidance is one of the major difficulties in treating those who are traumatized. Numbing refers to emotional dampening and lack of engagement. However, for those who engaged in strenuous intensity exercise, which was defined as vigorous running or cycling, there was significantly less avoidance/numbing and hyperarousal. Those who engaged in strenuous exercise activity also reported better sleep quality, reduced substance abuse, less pain, and a reduction in overall PTSD symptoms than those who were

To date there seems to be no universally agreed upon answer.

**1.1 Additional empirical studies of exercise and PTSD**

**70**

less active.

Overall results of this study point to beneficial effects of aerobic activity particularly for those who exercise vigorously. However, this should not be interpreted to mean that moderate levels of exercise are not of value. The general message from the research literature is that even moderate levels of exercise are effective in reducing both anxiety and depression. Given that anxiety and depression are key components of PTSD, it should be clear that encouraging patients to exercise is generally excellent practice.

There are those who claim that the beneficial effects of exercise may be due to changes in brain morphology, chemistry, and function. These beneficial effects include improved learning and memory, anti-depressant and anti-anxiety effects, reduced cognitive decline related to aging, and improvements in symptoms of neurodegenerative diseases. Exercise appears to improve mood and cognition and to have its greatest effects on the hippocampus where both neurogenesis (nerve cell growth), angiogenesis (increase blood availability through the growth of new blood vessels) have been shown. Although the exact molecular mechanisms responsible for the exercise-induced neuroplasticity needs to be further researched, progress is continuing in this area especially regarding studies of neurotransmitter systems.

Another study [6] examined active and inactive adolescent and adult twins between the ages of 14–24 with diagnosable anxiety disorders. Results showed that exercise reduced anxiety, PTSD, agoraphobia, and other specific phobias in the physically active twin. Twins not engaging in exercise did not have reductions in these disorders. The value of this study is that it helps to nullify genetic explanations as to why individuals may benefit from exercise. The authors kept the genetic factor relatively constant and continued to find that exercise alone benefited the active twin.

## **1.2 Exercise and PTSD in adolescents**

Having found positive results for the impact of aerobic exercise on PTSD in adults, the next step was to determine if the same outcome would occur in an adolescent sample. We recruited participants from a residential treatment center who were female, who had primarily been physically abused, sexually abused, maltreated or some combination of those, were between the ages of 14–17, and who had a diagnosis of PTSD based upon standardized measures [7]. Participants engaged in a structured group aerobic exercise program for 40 minutes, three times per week for a total of 8 weeks. The form of exercise varied with some girls jogging and some doing kickboxing but all of which produced an aerobic effect. Measures of PTSD, anxiety, and depression were taken twice during the beginning and end of a baseline period in which no intervention took place, at the end of the exercise intervention, and at a one-month follow up. Once again, results provided support for the positive effects of aerobic exercise on reducing PTSD, anxiety, and depression. Fewer youngsters met the criteria for PTSD and the end of the study than at the beginning and overall, significant reduction in anxiety and depression were shown. One of the major values of the exercise intervention is that it achieved positive therapeutic outcomes without the need for the adolescents to engage in formal therapy, which they were reluctant to do. It is easy to see that adolescent females may have been immensely troubled by their abuse and avoidant as far as sharing information in a formal therapeutic setting. If significant symptom reduction can be attained by a simple aerobic exercise activity, such activity should become part of the formal structure of interventions for these youngsters.

Finding that PTSD could be reduced through simple aerobic exercise interventions within adult and adolescent samples, another study [8] was conducted with youngsters 14–17 years of age at a private residential treatment facility, but this time the attempt was made to use only moderate intensity walking as the form of

intervention rather than using varied forms of more intense aerobic activity. In this study, participants completed a 5 week baseline and then an intervention which involved 25 minutes sessions of exercise which included: 1 minute of slow leisurely walking (warm up), 23 minutes of moderated intensity walking, and 1 minute of slow leisurely walking (cool down). Heart rates were maintained at 60–90% of maximum. By keeping the intervention unvaried and structured, the hope was to make the study more precise than earlier conducted investigations. The majority of participants showed statistically significant reductions in PTSD symptoms from baseline to post-intervention. There was also a reduction in trauma related stress. Results of anxiety and depression measures were not as clear cut as those from PTSD and this may have been due to the fact that initial levels were not overly high and therefore significant reductions were less likely to occur. Like previous studies, the reductions in PTSD were primarily maintained in follow-up and in some cases the reductions increased over time.

The authors concluded that aerobic exercise interventions might be appropriate for youngsters who demonstrate difficulty with expressing their emotions verbally as is required in traditional CBT type therapies. In addition, aerobic exercise as an intervention for PTSD may be more appropriate than exposure therapies, which is more likely to be tolerated in teens with concentration problems, self-control difficulty, and with histories of sexual-abuse and the avoidance of discussing their traumatic experiences that such abuse usually produces.

A study of adolescent females [9] suggested that peer pressures related to social acceptance significantly affect the high level of anxiety in this group. Issues such as wearing fashionable clothes, having a boyfriend, doing well in school, being popular etc. were factors upon which their peers judged their merit. In this study, individuals in the exercise group participated in 50 minute dance classes, four times a week, for 4 weeks. The classes followed a dance routine to elevate heart rate to 160 beats per minute and ended with a cool-down to bring the heart rate down to 100 beats per minute. Results of the study showed clear benefits in terms of anxiety reduction by engaging in the aerobic dance routine. Thus it appears that a variety of exercises from treadmills, to walking, to kickboxing to dance and others can have beneficial effects on negative emotional states.
