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PTSD & Exercise: What every exercise professional should know
LSang Hwan Kim, M.S., Len Kravitz, Ph.D., and Suzanne Schneider, Ph.D.

Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that is 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 (e.g., rape, mugging, or domestic violence), childhood abuse, natural disasters, accidents and life-threatening illnesses. Cohen et al. (2009) note that 8% to 12% of all adults will suffer from PTSD at some point in their lives and with military veterans the prevalence of PTSD is 13% to 31%. Given these statistics, it is highly likely that exercise professionals in a wide variety of settings will interact with clients with PTSD. Understanding the way PTSD impacts an individual's physical and mental health can be key to designing and implementing a successful exercise program for these clients.

Understanding More About PTSD
PTSD is fundamentally a dysfunction of the body's stress-coping system that results in serious health effects. A complex cluster of symptoms described as intrusive memories, emotional numbing and anxiety arousal may characterize it. With intrusive memories or flashbacks, intense thoughts are aroused from the thought of the traumatic event. In emotional numbing the traumatic stress blunts or impairs normal emotional function. This may lead the person to turn to substance abuse and alcohol. With 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 experience helplessness and a diminished sense of self-control in their lives. These symptoms can be intermittent or chronic and vary in severity from person to person. Without intervention, PTSD can increase the chances of a person developing severe depression, substance abuse, and suicidal thoughts.

How Can Exercise Help?
The absence of a cure makes PTSD treatment a multifaceted challenge. There is emerging evidence that exercise can be a valuable component of a comprehensive PTSD treatment plan (Tsatsoulis and Fountoulakis, 2006). Low-to-moderate intensity exercise can elevate mood, reduce anxiety (Cohen and Shamus, 2009) and act as an overall stress-buffer (Tsatsoulis and Fountoulakis). 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 and Shamus).

Designing an Exercise Program for PTSD Clients?
One of the barriers to exercise for PTSD sufferers is the presence of other mental health conditions (depression or substance abuse) as well as physical conditions such as a debilitating injury suffered as part of the original traumatic event (including traumatic brain injury), and diseases (cardiovascular disease, diabetes or 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 exercise and a healthy lifestyle (See Side Bar 1 for several other suggestions for the exercise professional).

Because the needs of each client with PTSD can be very different, it is important to individualize instruction and emphasize communication. One of the key considerations in designing an exercise program for clients with PTSD is to include low-to-moderate intensity body awareness movement activities (e.g., Pilates, Yoga, Nia, Therapeutic Dance, Tai Chi, or Qigong), which are known for their effectiveness in reducing symptoms of anxiety and depression and have shown positive results in PTSD sufferers (Netz, and Lidor, 2003). Also, regularly do diaphragmatic (or pranayama) breathing and muscle relaxation exercises, which have a natural calming effect.

Unique Concerns for Exercise Professionals Working with PTSD Clients
When working with clients who have PTSD, it is important to 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 will be critical to success in not only designing an exercise program, but in ensuring compliance in the long-term. Importantly, provide a safe environment in which clients can relax and focus on the health and well-being during the exercise session.

Fatigue is a common symptom among clients with depression and/or PTSD, particularly those who are taking antidepressants. Be aware of what medications each client is taking and adjust the intensity and duration of activity so as not to over tire the client. Be aware that some PTSD sufferers may find in a structured exercise program the control they feel absent in other aspects of their lives, and start to develop unhealthy or unsafe approaches to exercise. The exercise professional needs to make sure this person doesn't let exercise become an excessive behavior.

Finally, there may be social barriers to exercise for those clients who experience symptoms of avoidance or withdrawal. For individuals suffering from PTSD avoidance symptoms, exercising one-on-one in a private setting may be the best strategy. As these clients build confidence, a possible outcome would be to transition into a small group setting where positive social interactions will contribute further to their mental well-being.

PTSD Final Thoughts
Exercise can play an important role in helping clients with PTSD to recover and regain confidence. It also has the added benefit of addressing many of the mental and physical health problems commonly associated with chronic PTSD, including cardiovascular disease and depression. While there may be some 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 their quality of life.

Sidebar 1. Ten Key Suggestions to Exercise Professionals Working with PTSD Clients
Among the key points to keep in mind when designing an exercise program for clients with PTSD are the following:
1) Be Repetitive: By being repetitive the client will eventually master the exercises, which builds confidence and self-efficacy.
2) Be Predictable: Predictability helps to reduce the anxiety arousal symptoms that trigger PTSD incidences.
3) Be Non-Competitive: Competitive environment can activate the sympathetic nervous system leading to undesirably increases in stress levels. A goal of the exercise professional is to reduce the pressure placed upon the PTSD client, not increase it.
4) Be Reflective: Help the client develop their internal awareness to the body's response to the mild stresses of exercise. This in turn will help the client become more capable to better handle the stresses of daily life.
5) Be Patient: PTSD is an anxiety disorder resulting from exposure to an uncontrollable traumatic experience. Be patient and provide an individual-paced strategy that promotes skill acquisition, self-control and improved quality of life through exercise.
6) Be realistic: Help the PTSD client develop honest and realistic fitness goals.
7) Be flexible: Be flexible in coping with whatever happens. For example, when facing an unexpected situation with a PTSD client (i.e., such as getting a flat tie on an outdoor cycling exercise session), the exercise professional needs to act with calm so the client feels secure.
8) Be nonjudgmental: Don't expect PTSD clients to respond in the same way to instructions and exercise cueing as all other clients.
9) Be prepared: The exercise professional should be prepared for clients who tend to experience mood alternations. Stop, talk and listen to the client.
10) Be knowledgeable: By regularly staying informed with the client's health status and medication changes the exercise professional can readily adapt the exercise program to meet the needs of the client.

Sidebar 2. Pranayama Breathing
Pranayama (e.g. abdominal or diaphragmatic) breathing has been shown to positively affect 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, the breathing focus includes the expansion of the rib cage during the inhalation. To help a client learn this, try placing the edge of the hands along side the rib cage (at the level of the sternum); correct diaphragmatic breathing will elicit a noticeable lateral expansion of the rib cage.

Sang Hwan Kim, is a Ph.D. candidate in Exercise Science at the University of New Mexico (UNM). His research focuses on clinical exercise physiology as it relates to stress response. He is currently conducting a randomized clinical trial on the effect of low-to-moderate intensity exercise on the PTSD symptom severity as part of his doctoral dissertation research.
Len Kravitz, Ph.D., is an associate professor and the program coordinator of Exercise Science at UNM.
Suzanne Schneider, Ph.D. is a professor emeritus of Exercise Science at UNM.

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