Physical Exercise as Treatment for PTSD: A Systematic Review and Meta-Analysis

ABSTRACT Introduction Post-traumatic stress disorder (PTSD) is a cluster of physical and psychiatric symptoms following military or civilian trauma. The effect of exercise on PTSD symptoms has previously been investigated in several studies. However, it has not been fully determined what type of exercise most impacts PTSD symptoms. The aim of the present study was to systematically review the effects of different types of exercise on PTSD symptom severity and symptoms of coexisting conditions in adults. Materials and Methods Electronic searches were conducted in the databases PubMed, APA PsycInfo, and SportDiscus, from database inception up until February 1, 2021. Inclusion criteria were randomized controlled trials published in English, participants having a PTSD diagnosis or clinically relevant symptoms, and participants randomly allocated to either a non-exercising control group or an exercise group. Data concerning the number of participants, age, exercise type and duration, PTSD symptom severity (primary outcome), and symptoms of coexisting conditions (secondary outcomes) were extracted. The subgroup analysis included high or low training dose, military trauma versus non-military trauma, the type of intervention (yoga versus other exercise), active or passive control condition, group training versus individual exercise, and study quality. The study quality and risk of bias were assessed using grading of recommendation assessment, development and evaluation (GRADE) guidelines. A meta-analysis was performed with a mixed-effects model and restricted maximum likelihood as model estimator, and effect size was calculated as the standardized difference in mean and 95% CI. Results Eleven studies were included in the present review. Results showed a main random effect of exercise intervention (0.46; 95% CI: 0.18 to 0.74) and a borderline significant interaction between more voluminous (>20 hours in total) and less voluminous (≤20 hours in total) exercise interventions (P = .07). No significant findings from the subgroup analysis were reported. The secondary outcome analysis showed a small but significant effect of exercise on depressive symptoms (0.20, 95% CI: 0.01 to 0.38), and a larger effect on sleep (0.51, 95% CI: 0.29 to 0.73). For substance use (alcohol and drugs combined) and quality of life, we found significant effects of 0.52 (95% CI: 0.06 to 0.98) and 0.51 (95% CI: 0.34 to 0.69), respectively. No significant effect was found for anxiety (0.18, 95% CI: −0.15 to 0.51), and no sign of publication bias was found. Conclusions Exercise can be an effective addition to PTSD treatment, and greater amounts of exercise may provide more benefits. However, as there were no differences found between exercise type, possibly due to the inclusion of a low number of studies using different methodologies, further research should aim to investigate the optimal type, dose, and duration of activity that are most beneficial to persons with PTSD.

Extended Example of TFPP Treatment

This chapter provides an extended case example of a 21 session treatment of a patient with TFPP. Pablo, a 27-year-old mixed Latino male Army Veteran who served in Afghanistan, presented with generalized anxiety, severe separation anxiety, and PTSD. In addition to his severe anxiety, panic attacks, hypervigilance, nightmares, and intrusive memories, Pablo complained of being in a “fog.” Symptoms began when a Humvee exploded next to Pablo. The therapist noted the patient’s description of feeling “trapped in a foxhole” with his painful memories of abuse and neglect in childhood and anger in current relationships. The therapist helped Pablo understand that he directed this anger toward himself, seeing himself as bad or inadequate, accepting his attackers’ view of him. The therapist linked the emotional impact of the Humvee explosion to a familiar set of anxieties and concerns following certain childhood experiences, and helped Pablo see how the pain of his early relationships and losses shaped his current fears and relationship choices. In the course of TFPP, Pablo became more comfortable expressing his anger and fears about his childhood, his military trauma and his current relationships. Symptoms and defenses and their origins and meanings were understood in the context of the relationship Pablo’s with his therapist (the transference). At termination Pablo was significantly improved; he no longer met DSM criteria for PTSD or other anxiety disorders. He felt much less affected by the “fog” and more capable of addressing problems in his life and moving forward with his goals and desires.

Utilization of machine learning for identifying symptom severity military-related PTSD subtypes and their biological correlates

We sought to find clinical subtypes of posttraumatic stress disorder (PTSD) in veterans 6–10 years post-trauma exposure based on current symptom assessments and to examine whether blood biomarkers could differentiate them. Samples were males deployed to Iraq and Afghanistan studied by the PTSD Systems Biology Consortium: a discovery sample of 74 PTSD cases and 71 healthy controls (HC), and a validation sample of 26 PTSD cases and 36 HC. A machine learning method, random forests (RF), in conjunction with a clustering method, partitioning around medoids, were used to identify subtypes derived from 16 self-report and clinician assessment scales, including the clinician-administered PTSD scale for DSM-IV (CAPS). Two subtypes were identified, designated S1 and S2, differing on mean current CAPS total scores: S2 = 75.6 (sd 14.6) and S1 = 54.3 (sd 6.6). S2 had greater symptom severity scores than both S1 and HC on all scale items. The mean first principal component score derived from clinical summary scales was three times higher in S2 than in S1. Distinct RFs were grown to classify S1 and S2 vs. HCs and vs. each other on multi-omic blood markers feature classes of current medical comorbidities, neurocognitive functioning, demographics, pre-military trauma, and psychiatric history. Among these classes, in each RF intergroup comparison of S1, S2, and HC, multi-omic biomarkers yielded the highest AUC-ROCs (0.819–0.922); other classes added little to further discrimination of the subtypes. Among the top five biomarkers in each of these RFs were methylation, micro RNA, and lactate markers, suggesting their biological role in symptom severity.

Review of Military Casualties in Modern Conflicts—The Re-emergence of Casualties From Armored Warfare

ABSTRACT Introduction The re-emergence of armored warfare in modern conflicts has resulted in a higher number of extremity injuries, burns, and brain injuries. Despite this dramatic increase, little is reported on the type of injuries caused and their management. This review summarizes the publicly available literature and reports on the rate and type of injuries related to armored warfare, their medical outcomes, and management limitations. Materials and Methods This rapid evidence review involves a systematic literature search, followed by a non-systematic literature review. The reason for choosing this approach was the inherent lack of quantitative outcome data in the literature to satisfy the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study also used content analysis to study all peer-reviewed articles, focusing on similarities and differences in the findings necessary to formulate tentative results. The electronic search included PubMed, Scopus, and Web of Science, using the following search string: “Armored; Injuries; Mechanized; Morbidity; Mortality; War; Warfare”, alone or in combination. Results Modern conflicts are associated with higher number of extremity injuries, burns, and brain injuries among military casualties. Several publications claim that the characteristics of armored warfare and anticipated injuries in this type of warfare might require the far forward deployment of medical support supported by a reliable casualty evacuation chain. Still the quality of the available casualty data is low. Conclusions Because of the limited availability of reliable data or military trauma registries, up-to-date military casualty estimation remains a recognized knowledge gap, which needs to be addressed by armed forces worldwide. The future management of modern war casualties requires professional and well-trained staff in all levels, indicating a need for educational initiatives to provide both nurses and medics a greater proportion of medical care and management capabilities and responsibilities than in past conflicts.

Family and occupational functioning following military trauma exposure and moral injury

IntroductionEvidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual’s occupational and familial functioning remains poorly understood.MethodThirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews.ResultsWhile many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial.ConclusionsThis study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans’ familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms.

Hypocalcemia in Military Casualties From Point of Injury to Surgical Teams in Afghanistan

ABSTRACT Introduction Hypocalcemia is a known sequela of citrated blood product transfusion. Civilian data suggest hypocalcemia on hospital admission is associated with worse outcomes. Initial calcium levels in military casualties have not previously been analyzed. The objective of this retrospective review aimed to assess the initial calcium levels in military trauma casualties at different Forward Surgical Teams (FST) locations in Afghanistan and describe the effects of prehospital blood product administration on arrival calcium levels. Materials and Methods This is a retrospective cohort analysis of military casualties arriving from point of injury to one of two FSTs in Afghanistan from August 2018 to February 2019 split into four locations. The primary outcome was incidence of hypocalcemia (ionized calcium < 1.20 mmol/L). Results There were 101 patients included; 55 (54.5%) experienced hypocalcemia on arrival to the FST with a mean calcium of 1.16 mmol/L (95% confidence interval [CI], 1.14 to 1.18). The predominant mechanism of injury consisted of blast patterns, 46 (45.5%), which conferred an increased risk of hypocalcemia compared to all other patterns of injury (odds ratio = 2.42, P = .042). Thirty-eight (37.6%) patients required blood product transfusion. Thirty-three (86.8%) of the patients requiring blood product transfusion were hypocalcemic on arrival. Mean initial calcium of patients receiving blood product was 1.13 mmol/L (95% CI, 1.08 to 1.18), which was significantly lower than those who did not require transfusion (P = .01). Eight (7.9%) of the patients received blood products before arrival, with 6/8 (75%) presenting with hypocalcemia. Conclusions Hypocalcemia develops rapidly in military casualties and is prevalent on admission even before transfusion of citrated blood products. Blast injuries may confer an increased risk of developing hypocalcemia. This data support earlier use of calcium supplementation during resuscitation.

Military trauma and orthopaedics experience of the UK COVID-19 pandemic: a lesson in versatility and how it can influence our deployed role

The COVID-19 pandemic necessitated unprecedented change within the NHS. Some medical staff have been deployed into unfamiliar roles, while others have been exposed to innovative ways of working. The embedded military Trauma and Orthopaedic (T&O) cadre have been integral to this change. Many of these new skills and ways of working learnt will be transferable to deployed environments. Feedback from the T&O military cadre highlighted key areas of learning as changes in T&O services, use of technology, personal protective equipment, redeployment and training. This paper aims to discuss how these changes were implement and how they could be used within future military roles. The T&O cadre played important roles within their NHS trusts and the skills they learnt will broaden their skills and knowledge for future deployments.

Regional Anaesthesia in a Combat Setting

Background: Recent advances in combat casualty care have contributed signifi cantly to higher survival rates in previously fatal injuries from military trauma. However, most of the literature comes from international data during Operation Enduring Freedom and Operation Iraqi Freedom. Despite having conflicts, counter insurgency operations spanning over decades, very few studies in Indian scenario have analyzed injuries related to Combat and Military Trauma. Method: A retrospective observational study was done based on the records of management of military trauma cases in a zonal hospital deployed in an operational area. All trauma/ combat casualties over a one year period from Oct 2018 to Oct 2019 were included and data was segregated based on type of mechanism of trauma, limb injuries involved, and choice of anaesthesia given based on type of surgery. Results: Total 371 combat casualties were included in the study, maximum patients had splinter injuries with grenade blast (43.4%), followed by gunshot wounds (39.9%). Other injuries included mine blast (11.3%) and miscellaneous including road traffi c accidents (5.4%). Due to predominant involvement of limbs, regional anaesthesia was used most commonly (78%) and general anaesthesia was used only in 23.7% of cases. Conclusion: In our study maximum casualties were peripheral limb injuries both upper and lower limbs. Regional anaesthesia, peripheral nerve blocks for upper limb injuries and sub arachnoid block for lower limb injuries, were more commonly used in comparison to general anaesthesia (GA), while injuries involving body regions other than limbs were performed exclusively under GA.