Effects of physical activity on patients with posttraumatic stress disorder: A systematic review and meta-analysis of randomized controlled trials

Abstract

Background:

Although it is often known that physical activity can effectively reduce anxiety and despair, differing results have been found for patients with posttraumatic stress disorder (PTSD) symptoms. This study sought to comprehensively examine how physical activity affected the quality of sleep, anxiety, sadness, and PTSD in individuals suffering from PTSD.

Methods:

The Cochrane Library, PubMed, Web of Science, EMBASE, and Scopus databases in English were examined. Included were all randomized controlled trials (RCTs) that examined physical activity as a psychosocial remedy for PTSD sufferers. By the time of the meta-analysis search (February 2024), we had 12 RCT studies that met the eligibility requirements.

Results:

The study’s findings demonstrated that physical activity improved sleep quality (standardized mean differences [SMD] = −0.38, 95% CI [−0.59, −0.18], Z = 3.65, P = .0003), anxiety (SMD = −0.26, 95% CI [−0.47, −0.06], Z = 2.5, P = .01), depression (SMD = −0.19, 95% CI [−0.37, −0.01], Z = 2.09, P = .04), and PTSD (SMD = −0.34, 95% CI [−0.50, −0.17], Z = 3.99, P < .0001). Each intervention ≤ 60 (SMD = −0.52, I² = 0%, P < .00001), frequency of interventions ≤ 2 per week (SMD = −0.44, I² = 7%, P = .0004), intervention cycles > 10 (SMD = −0.46, I² = 8%, P < .0001), and the yoga group (SMD = −0.44, I² = 7%, P = .0004) had the best impact, according to subgroup analyses. Veterans with PTSD responded most significantly to physical activity (SMD = −0.60, I² = 0%, P = .002).

Conclusions:

It was discovered that people with PTSD can benefit from physical activity as an adjuvant method to enhance their PTSD, anxiety, despair, and sleep quality. Yoga has been found through research to help the symptoms of people with PTSD more than other sports. Due to limitations such as small sample size and some heterogeneity in this meta-analysis, further confirmation through more scientific and objective RCTs is needed in order to obtain definitive conclusions on physical activity for patients with PTSD.

1. Introduction

Posttraumatic stress disorder (PTSD) and other mental illnesses are more common in environments where there is conflict.^[1] Events like wars, natural disasters, tragedies, and other traumatic life events can cause PTSD, a persistent and frequently crippling mental health condition with potentially dangerous and far-reaching psychological implications.^[2,3] It is estimated that as many as 70% of people will experience a traumatic experience in their lifetime.^[4,5] Although most people tend to recover without professional intervention, approximately 3% to 7% will develop PTSD.^[6,7] The lifetime prevalence of PTSD in community samples is 8.3%, and a similar prevalence of 8.0% has been observed in military populations.^[8] Severe psychosocial dysfunction, poor academic performance, depression, suicide attempts, and a higher prevalence of substance addiction are among the negative consequences linked to PTSD.^[9,10]

It has been demonstrated that both psychological and pharmaceutical therapies are successful in treating PTSD symptoms,^[11,12] and for psychotherapy, few subjects continue to receive treatment.^[12] In the meanwhile, bodywork is a highly successful, scientifically validated technique for the prevention, treatment, and management of chronic physical and mental health disorders. It is also a low-risk, low-cost intervention.^[13–16] Youngjun Lee^[17] suggested that interventions tailored to promote recreational physical activity are expected to enhance mental health and reduce depression compared to interventions targeting general, work-related, or transportation-related physical activity. In general, aerobic, resistance, mind–body, and other exercise modalities can reduce posttraumatic stress symptoms, improve psychological quality of life, and have positive effects on the physical and psychological recovery of people with PTSD.^[18–20]

Tan Vancampfort and other researchers examined the effects of mind–body exercises (yoga, tai chi, qigong, positive thinking exercises, etc) on PTSD patients in earlier meta-analyses.^[21,22] Laplaud and other scholars explored the effects on PTSD symptoms from the perspective of yoga.^[23] Yu and other researchers examined how various exercise therapies affected the symptoms of mental health conditions such schizophrenia, PTSD, anxiety, and depression.^[24] In their studies related to sports and physical and mental exercise, Frida Björkman, Leona Tan, and Lin Zhu^[21,25,26] did not identify any significant differences between the various types of exercise. Nevertheless, Jacinta Brinsley^[27] posited that yoga is an effective intervention for reducing depressive symptoms. Leona Tan^[21] and Lin Zhu^[26] employed physical and mental exercise interventions as a potential means of preventing PTSD and examined the impact of physical and mental exercise on PTSD symptoms in PTSD patients. The selected samples encompassed a range of physical and mental exercises, including positive thinking and breathing techniques. However, there is a dearth of research investigating the effects of physical activity on PTSD symptoms. The subjects in this study were primarily engaged in physical activities that could be classified as exercise.

Some studies have shown that yoga is beneficial for the reduction of PTSD and related physical and psychological symptoms as well as the improvement of quality of life.^[28–32] However, some studies have shown that yoga has no significant effect on related symptoms.^[33] Some studies have also shown that aerobic exercise can reduce PTSD symptoms,^[34,35] while others have shown that its efficacy is no better than that of other nonphysical activities.^[36] In light of this, the current study carried out a systematic review and meta-analysis with the primary goal of investigating how physical activity affects PTSD symptoms in patients and the secondary goal of figuring out how physical activity affects depression, anxiety, and sleep quality in PTSD patients.

2. Methods

2.1. Reporting and registration protocol

The International Prospective Registry of Systematic Evaluation PROSPERO has registered the systematic evaluation (registration number: CRD42024512372). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) standards were followed in the conduct of this systematic review and meta-analysis.^[37]

2.2. Databases and search strategy

Five English-language literature databases (PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library) were searched until February 2024. All articles retrieved from each database were sorted using EndNote (version X9) reference management software and checked for duplication. A search for English-language published randomized controlled trials (RCTs) examining the impact of physical activity on PTSD and related psychopathology in PTSD patients was carried out, in addition to reference monitoring of published trials and meta-analysis reviews in the field. Three search phrases (stress disorders, posttraumatic, exercise, and RCTs as topic) were used along with their Medical Subject Headings (MeSH) terms, keywords, and synonyms. Two researchers (Yang and Yuan) conducted the searches independently and if any discrepancies occurred, a third researcher (Peng) reviewed the different results to make a final decision (Supplementary Material S1, Supplemental Digital Content, http://links.lww.com/MD/O246).

2.3. Eligibility criteria

Inclusion criteria were established using the PICOS methodology (study subjects, interventions, comparisons, outcomes, and study design). A study was eligible for inclusion if it met the following criteria: (1) study population: adults (18 years of age or older) with PTSD, including active duty military, veterans, refugees, and the general population. Furthermore, the search was not limited to any specific population to ensure a comprehensive meta-analysis. (2) Interventions: inclusion of physical activity (e.g., aerobics, resistance, yoga, and other exercise modalities). There were no specific restrictions on the number, frequency, duration, and intensity of interventions. (3) Controls: different interventions (e.g., time-matched attentional controls, social controls, usual care, and supportive women’s health education) were used in the control group. (4) Study outcomes: outcome indicators should include data related to PTSD symptoms, depression, anxiety, and sleep. (5) Study design: peer-reviewed RCTs.

2.4. Exclusion criteria

The exclusion criteria were as follows (1): exclusion of reviews, letters, editorial comments, case reports, conference abstracts, unpublished articles, and non-English articles. (2) Those studies that did not have quantitative outcomes or lacked corresponding outcome measures were excluded. (3) Articles that were not available through various sources and methods were excluded. (4) Literature of poor quality was excluded. (5) Studies that lacked a control group and a control group with physical activity were excluded. (6) Studies without physical activity, such as orthomolecular therapy, breathing, and meditation, were excluded.

2.5. Study selection and data extraction

All retrieved documents were imported into EndNoteX9 software and deduplicated. Two researchers (Yang and Yuan) combed and screened the documents by reading the titles, abstracts, and full text. If there was disagreement about article inclusion, the final decision was made in consultation with a third researcher (Peng). The data we extracted from these studies included general information (authors, year of publication, country of the researcher, gender, age) and basic characteristics (sample size, type of intervention, length and duration of the intervention, weeks of duration, and outcome indicators). The primary outcome of this review was PTSD symptoms; secondary outcomes were anxiety, depression, and sleep quality. To extract and summarize outcome data (e.g., mean and standard deviation of raw data), 2 authors will extract data independently, and any disagreements will be resolved through discussion until consensus is reached or in consultation with a third author.

2.6. Quality assessment

The quality and reporting of included studies were assessed using the Test of Study Quality and Exercise Reporting Evaluation (TESTEX) scale. The TESTEX scale consists of 12 criteria with 15 items (each item is assigned a score of 1), with a maximum score of 15. The TESTEX scale has 5 criteria for study quality: (1) Eligibility criteria specified; (2) Randomization specified; (3) Allocation concealment; (4) Groups similar at baseline; (5) Blinding of assessor (for at least one key outcome). The TESTEX scale has 10 criteria for study reporting: (6) Outcome measures assessed in 85% of patients; (7) ‘Intention-to-treat’ analysis; (8) Between-group statistical comparisons reported; (9) Point measures and measures of variability for all reported outcome measures; (10) Activity monitoring in control groups; (11) Relative exercise intensity remained constant; (12) Exercise volume characteristics and energy expenditure. Higher scores on the TESTEX scale reflect better study quality and reporting.^[38] Study quality was categorized as high (≥12 points; maximum 15 points), good (7–11 points), or low (≤6 points) based on the total TESTEX score. The acceptable range for the TESTEX scale is therefore above 6 points. Any discrepancies between the 2 searchers (Yang and Yuan) were resolved in consultation with the third author (Peng).

2.7. Data analysis

Meta-analyses were performed using Review Manager 5.4 software provided by the Cochrane Collaboration and statistical significance was defined as a P-value < .05 (all reported P-values were 2-sided). During data analysis, we focused on PTSD, anxiety, depression, and sleep quality and considered them as continuous variables. We calculated standardized mean differences (SMD) and 95% confidence intervals (95% CI). Statistically, we used the chi-square test to assess between-study heterogeneity. I² (0–25%), I² (≥25%), I² (≥50%), and I² (≥75%) showed no heterogeneity, mild heterogeneity, moderate heterogeneity, and high heterogeneity, respectively. When I² ≥ was 50%, a random effects model was used to combine the data. When I² < was 50%, a fixed-effects model was used. Sensitivity analysis was performed using Stata SE 16.0 software to determine the stability and reliability of the results.

3. Results

3.1. Study selection

A literature search was conducted from the construction of the database to February 2024 according to the PRISMA 2020 guidelines.^[37] Of the 3961 articles identified in the database, 665 were from the PubMed database, 598 from the EMBASE database, 1185 from the Scopus database, 441 from the Cochrane Library database, and 1102 from the Web of Science database. Duplicates were removed using EndNote and 83 studies were selected based on inclusion criteria by reviewing titles and abstracts. These 83 studies were screened to exclude. The outcome measures were not complete (n = 30), unable to get data (n = 16), language is not English (n = 4), and designed only for experiments (n = 21), leaving 12 studies for detailed meta-analysis with a view to drawing accurate and reliable conclusions (Fig. 1).

Figure 1.

Flow diagram.

3.2. Study characteristics

A total of 12 RCTs were included in the literature for screening and exclusion. Supplementary Material S2, Supplemental Digital Content, http://links.lww.com/MD/O246 shows the main characteristics of the included literature. The total sample size of the included studies was 763 subjects. The included literature was mainly from 5 different countries, with 8 studies (60%) from the United States,^{[19,29,30,39–43]} 1 study (10%) from Canada,^[44] 1 study (10%) from Colombia,^[45] 1 study (10%) from Austria,^[46] and 1 study (10%) from the United Kingdom.^[47]

In terms of exercise interventions, they were categorized into yoga,^{[29,30,40,41,44,45]} resistance exercise,^[42,43] and combined exercise^{[19,39,46,47]} based on the type of intervention. The duration of the word interventions was divided into 2 categories including 60 minutes and less^{[19,39,41–43,45,46]} and more than 60 minutes.^{[29,30,40,44,47]} Intervention frequency was categorized as weekly including 2 times per week and less^{[29,30,40,41,44,45]} and more than 2 times per week.^{[19,39,42,43,46,47]} Intervention cycles ranged from week 2 to week 18, with a mean number of intervention weeks of 9.33 weeks.

Regarding intervention outcomes, 12 studies assessed PTSD^{[19,29,30,39–47]} and 9 studies reported depression levels.^{[29,39–44,46,47]} Anxiety levels were reported in 7 studies.^{[29,40,42–44,46,47]} Seven studies reported sleep quality levels.^{[29,39,42–44,46,47]} The assessment scales chosen varied across studies, with the Clinician-Administered PTSD Scale,^[19,41,47] PTSD Checklist for DSM-5,^[39] Impact of Event Scale-Revised,^[29] PTSD Checklist – 17 items,^[44] PTSD Checklist – Civilian Version,^[40,45,46] PTSD Checklist – Military Version,^[30] Posttraumatic Diagnostic Scale for DSM-5^[42,43] being used to assess PTSD symptoms. The Patient Health Questionnaire-9,^[29,39] Depression Anxiety Stress Scales-21,^[44,46] Center for Epidemiologic Studies Depression Scale,^[40,42,43] Beck Depression Inventory-II (Depression),^[41] Quick Inventory of Depressive Symptomatology-Self Report^[47] were used to assess depression, State-Trait Anxiety Inventory,^{[29,40,42,43]} Depression Anxiety Stress Scales-21,^[44,46] Anxiety Sensitivity Index^[47] were used to assess anxiety, Pittsburgh Sleep Quality Index,^{[29,39,42,43,46]} Insomnia Severity Index^[44,47] were used to assess sleep quality.

3.3. Risk of bias

Table 1 shows the qualitative evaluation of the included studies. According to the TESTEX scale (0–15), all studies scored above 9. In terms of study quality, the most common problem was lack of assessor blinding (83%).^{[19,29,30,39,40,42–45,47]} In terms of study reporting, the most common problems were lack of activity monitoring in the control group (66.7%),^{[29,39,42–47]} lack of intention-to-treat analyses (58.3%),^{[29,30,42–46]} and lack of adverse event reporting (66.7%).^{[19,29,30,39,40,42,44,46]}

Table 1.

The Test of Study Quality and Exercise Reporting Evaluation (TESTEX) scale.

References		Items					Points of study quality	Items							Points of study reporting	Total points
		1	2	3	4	5		6	7	8	9	10	11	12
1	Goldstein (2017)	1	1	1	1	0	4	1	1	2	1	1	0	1	7	11
2	Hall (2020)[39]	1	1	1	1	0	4	2	1	2	1	0	1	1	8	12
3	Huberty (2020)[29]	1	1	1	1	0	4	2	0	2	1	0	1	1	7	11
4	Jindani (2015)[44]	1	1	1	0	0	3	2	0	2	1	0	1	1	7	10
5	Mitchell (2014)[40]	1	1	1	1	0	4	1	1	2	1	1	1	1	8	12
6	Quiñones (2015)[45]	1	1	1	1	0	4	2	0	2	1	0	1	1	7	11
7	Reinhardt (2017)[30]	1	1	0	1	0	3	2	0	2	1	1	1	1	8	11
8	Rosenbaum (2015)[46]	1	1	1	1	1	5	1	0	2	1	0	1	1	6	11
9	van der Kolk (2014)[41]	1	0	0	1	1	3	2	1	2	1	1	1	1	9	12
10	Voorendonk (2023)[47]	1	1	1	1	0	4	3	1	2	1	0	1	1	9	13
11	Whitworth-1 (2019)[42]	1	1	0	1	0	3	1	0	2	1	0	1	1	6	9
12	Whitworth-2 (2019)[43]	1	1	0	1	0	3	2	0	2	1	0	1	1	7	10

1: Eligibility criteria specified; 2: Randomization specified; 3: Allocation concealment; 4: Groups similar at baseline; 5: Blinding of assessor (for at least one key outcome) 6: Outcome measures assessed in 85% of patients; 7: ‘Intention-to-treat’ analysis; 8: Between-group statistical comparisons reported; 9: Point measures and measures of variability for all reported outcome measures; 10: Activity monitoring in control groups; 11: Relative exercise intensity remained constant; 12: Exercise volume characteristics and energy expenditure. The bold values are mainly calculated for points of study quality and points of study reporting and the total value.

4. Meta-analysis

4.1. PTSD

All 12 articles included assessments regarding PTSD symptoms, and Figure 2 shows the meta-analysis of the 12 studies. The results showed that the combined sample size was 638 (334 in the intervention group and 304 in the control group), and the combined effect was statistically significant (SMD = −0.45, 95% CI [−0.70, −0.20], Z = 3.47, P = .0005). The small diamond-shaped square falls to the left of the null line, which implies that physical activity is effective in the treatment of PTSD in patients with traumatic stress disorder. Heterogeneity was observed in this study (P = .008 for the heterogeneity test, I² = 57%), which was detected as moderate heterogeneity using a random effects model. The reason for its heterogeneity is mainly based on this article by Jindani 2015^[43] whose study subjects PTSD symptoms experimental and control groups were differentiated at baseline levels. After removing this study, the combined effect was statistically significant (SMD = −0.34, 95% CI [−0.50, −0.17], Z = 3.99, P < .0001), and the study observed low heterogeneity (P = .21, I² = 24%) (Fig. 3).

Figure 2.

Forest plot of physical activity on PTSD symptoms. PTSD = posttraumatic stress disorder.

Figure 3.

Forest plot of physical activity on PTSD symptoms. PTSD = posttraumatic stress disorder.

4.2. Depression

Of the included studies, 9 reported the effect of physical exercise on depression in PTSD patients, involving a total of 486 subjects (257 in the intervention group and 229 in the control group) (Fig. 4). The results of the analysis showed that there was a significant difference in the level of depression between the intervention group and the control group, and that physical exercise had a positive effect on reducing depressive symptoms (SMD = −0.19, 95% CI [−0.37, −0.01] Z = 2.09, P = .04). Through detailed data analysis, we found low heterogeneity between these studies (heterogeneity test P = .04, I² = 41%). We used a fixed-effects model for the analysis.

Figure 4.

Forest plot of physical activity on depression.

4.3. Anxiety

Among the included studies, 7 reported the effect of physical exercise on anxiety in PTSD patients, involving a total of 368 subjects (189 in the intervention group and 179 in the control group) (Fig. 5). Analysis of the results showed that there was a significant difference in anxiety levels between the intervention and control groups, and that physical exercise had a positive effect on reducing anxiety symptoms (SMD = −0.26, 95% CI [−0.47, −0.06] Z = 2.5, P = .01). Through detailed data analysis, we found no heterogeneity between these studies (heterogeneity test P = .53, I² = 0%). We used a fixed-effects model for the analysis.

Figure 5.

Forest plot of physical activity on anxiety.

4.4. Sleep quality

Among the included studies, 7 reported the effect of physical exercise on sleep quality in PTSD patients, involving a total of 384 subjects (205 in the intervention group and 179 in the control group) (Fig. 6). The results of the analysis showed that there was a significant difference in sleep quality between the intervention and control groups, and that physical exercise had a positive effect on the improvement of sleep quality (SMD = −0.38, 95% CI [−0.59, −0.18] Z = 3.65, P = .0003). Through detailed data analysis, we found no heterogeneity between these studies (heterogeneity test P = .48, I² = 0%). We used a fixed-effects model for the analysis.

Figure 6.

Forest plot of physical activity on sleep quality.

5. Sensitivity analysis

Sensitivity analyses are able to test the robustness and reliability of results by systematically removing individual studies to assess the impact of each on the overall outcome. In this meta-analysis of physical activity on PTSD in patients with PTSD, we conducted sensitivity analyses to gain a deeper understanding of the effects of physical activity interventions (Fig. 7).

Figure 7.

Sensitivity analysis of the PTSD. PTSD = posttraumatic stress disorder.

A meta-analysis of physical activity interventions on PTSD symptoms in PTSD patients produced statistically significant results. The ratio was −0.34 with a 95% CI of −0.51 to −0.18. In sensitivity analyses, we found that the effect of physical activity interventions for PTSD remained significant even after exclusion of individual studies, and the results of the original meta-analysis were not significantly altered by changes in the number of studies, demonstrating the robustness of the results.

6. Subgroup analysis

Intervention modality, duration of a single intervention, frequency of intervention, period of intervention, and target of intervention were the main factors included in subgroup analyses. Different levels of heterogeneity were identified within these subgroups. Below is a description of the PTSD subgroup analyses (Table 2).

Table 2.

Subgroup analysis of physical activity on PTSD.

Group	Subgroup	K	N	SMD 95% CI	P	I2
Intervention program	Yoga	5	267	−0.44 [−0.69, −0.20]	.37	7%
	Other physical activity	6	321	−0.25 [−0.47, −0.02]	.18	34%
Intervention time (min)	≤60	7	356	−0.52 [−0.73, −0.30]	.79	0%
	>60	4	232	−0.07 [−0.33, 0.19]	.34	10%
Intervention frequency (weekly)	≤2	5	267	−0.44 [−0.69, −0.20]	.37	7%
	>2	6	321	−0.25 [−0.47, −0.02]	.18	34%
Intervention duration (week)	≤10	5	241	−0.17 [−0.42, 0.09]	.29	19%
	>10	6	347	−0.46 [−0.67, −0.24]	.37	8%
Research object	Veteran	3	116	−0.60 [−0.99, −0.22]	.78	0%
	Nonveteran	7	434	−0.31 [−0.50, −0.12]	.26	33%

Regarding the intervention modality was divided into yoga and other physical activity groups. Yoga group (SMD = −0.44, I² = 7%, P = .0004) was more beneficial than other physical activity (SMD = −0.25, I² = 34%, P = .03) in reducing PTSD in patients (Fig. 8A). In terms of intervention time, each intervention ≤ 60 (SMD = −0.52, I² = 0%, P < .00001) was statistically significant, whereas each intervention > 60 was not statistically significant (Fig. 8B). Intervention frequency ≤ 2 per week (SMD = −0.44, I² = 7%, P = .0004) was more beneficial in reducing PTSD in patients than > 2 (SMD = −0.25, I² = 34%, P = .03) (Fig. 8C). Intervention cycles > 10 (SMD = −0.46, I² = 8%, P < .0001) were statistically significant, whereas interventions ≤ 10 weeks were not statistically significance (Fig. 8D). Physical activity was more beneficial for veterans (SMD = −0.60, I² = 0%, P = .002) than nonveterans (SMD = −0.31, I² = 33%, P = .001) in reducing patients’ PTSD symptoms (Fig. 8E).

Figure 8.

(A) Intervention program; (B) intervention time (min); (C) intervention frequency (weekly); (D) intervention duration (week); (E) research object.

7. Discussion

This meta-analysis’s objective was to methodically evaluate, using data from 12 relevant RCTs, the impact of physical activity on individuals with PTSD. A person with PTSD may experience serious psychological and physical side effects. There is strong evidence linking risk factors such obesity, dyslipidemia, hypertension, diabetes, and cardiovascular disease to persistent PTSD.^[48–50] Prolonged intrusive, avoidant, and hyperarousal symptoms, significant social and interpersonal issues, and co-occurring psychological disorders like depression all negatively impact the quality of life for those who suffer from PTSD.^[51–53] Numerous integrative mind–body intervention techniques are being developed to treat PTSD, and these techniques have shown how beneficial mind–body therapies are for PTSD patients’ quality of life, ability to cope with stress, and improved health outcomes. techniques are being developed to treat PTSD, and these techniques have shown how beneficial mind–body therapies are for PTSD patients’ quality of life, ability to cope with stress, and improved health outcomes.^[47–50] In 2010, 39% of patients with PTSD used mind–body exercises combining various types of stretching exercises and postures with deep breathing as a complement to, and an alternative to medical interventions.^[47] Moderate to high-intensity aerobic exercise can improve mental health and lessen symptoms of anxiety and depression in adults, children, and adolescents. Furthermore, physical health can be enhanced by increasing amounts of physical activity.^[54] Our meta-analysis suggests that physical activity has a contributory effect on PTSD, depression, anxiety, and sleep quality in patients with traumatic stress disorder.

Patients with PTSD who have experienced wars, earthquakes, etc develop PTSD symptoms, depressed mood, anxiety, frustration, anger, insomnia, and other psychological symptoms.^[19,55,56] Physical activity has been found to have a significant effect on psychological symptoms associated with PTSD patients in several studies.^[19,28] However, some studies also showed that physical and mental activities had no significant effect on the associated symptoms.^[33] Consequently, a more thorough statistical analysis was carried out, and the combined findings demonstrated that physical activity significantly improved PTSD, sadness, anxiety, and sleep quality in traumatic stress disorder patients. Yoga exercise, exercise lasting <60 minutes, exercise occurring 2 or less times per week, and an intervention period exceeding 10 weeks were all more beneficial for reducing PTSD in patients, according to a subgroup study of PTSD. The study results indicate that yoga exercises can be practiced 1 to 2 times per week (for a duration of 30–60 minutes per session) for a period exceeding 10 weeks. Alternatively, a combination of exercises may be undertaken 3 to 5 times per week (with each session lasting between 30 and 45 minutes) to improve PTSD, depression, and anxiety symptoms, as well as sleep quality, in patients with PTSD. Using a fixed-effects model, the study’s findings for depression, anxiety, and sleep quality in traumatic stress disorder patients show a significant difference between the experimental and control groups, with little inter-article heterogeneity.

The study does have some drawbacks, though. Performance bias was unavoidable in all trials, and publication bias might have existed because the article was unable to blind participants and assessors to the trials. (2) The minimal number of included studies and the fact that some physical performance outcome indicators were not examined in this study resulted in a small sample size for our meta-analysis. (3) The results of the subgroup analysis may potentially be biased due to the small number of studies in some subgroups. A sufficient number of randomized controlled studies is required in order to examine in further depth how physical activity affects psychological symptoms associated with patients suffering from traumatic stress disorder. The results should be regarded cautiously because the aforementioned limitations may compromise the trustworthiness of our findings. Research on the relationship between physical activity and traumatic stress disorder should begin with how physical activity affects the patients’ physical functioning. Alternatively, it can focus on the various forms of exercise and examine how each affects PTSD patients.

8. Conclusion

A substantial body of research has demonstrated that physical activity can effectively alleviate depression, anxiety, and sleep disturbances in individuals with PTSD. Furthermore, it has been shown to enhance daily functioning, improve overall quality of life, and facilitate a more optimal state of well-being. In particular, yoga can be incorporated into PTSD treatment programs as a straightforward and viable intervention for patients, offering an additional treatment option in conjunction with other therapies. Subgroup analyses indicate that clinicians tailor intervention programs to align with patients’ individual circumstances, including factors such as athletic ability and psychological status. It is recommended that future research should focus on the integration of these physical activities into existing treatment programs, with a view to enhancing their clinical application. To draw firm conclusions on physical activity for PTSD patients, well-designed research with bigger sample numbers and more thorough results are required due to several limitations of this meta-analysis.

Author contributions

Conceptualization: Zhichao Yuan, Chenggen Peng, Linlin Yang.

Data curation: Chenggen Peng, Linlin Yang, Houjin Chen.

Formal analysis: Linlin Yang.

Investigation: Linlin Yang.

Methodology: Zhichao Yuan, Chenggen Peng, Linlin Yang.

Project administration: Zhichao Yuan.

Supervision: Zhichao Yuan, Chenggen Peng.

Software: Houjin Chen.

Validation: Zhichao Yuan.

Writing – original draft: Zhichao Yuan, Chenggen Peng, Linlin Yang, Houjin Chen.

Writing – review & editing: Zhichao Yuan, Chenggen Peng, Houjin Chen.