PICO by Jarred Wolfe

Background The Veterans Health Administration (VHA) treatment guideline for Posttraumatic Stress Disorder (PTSD) includes exercise as a Complementary and Integrated Health practice (CIH) that can safely and effectively treat PTSD (The Management of Posttraumatic Stress Disorder Work Group, 2017). Veterans with combat-related PTSD have better outcomes in treatment when group cohesion is attained during treatment (Ellis, Peterson, Bufford, & Benson, 2014).

GAPS Analysis Traditional PTSD VHA sponsored PTSD treatment programs do not include an exercise regimen in their programming. Group cohesion is attained through traditional methods such as group therapy and admitting patients in cohorts during treatment in PTSD Residential Rehabilitation Treatment Program (RRTP).

PICO QUESTION In Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND) male and female veterans diagnosed with PTSD and enrolled in a PTSD treatment program, what is the effect of adding a Crossfit ® exercise regimen on PTSD symptoms compared with the standard program treatment plan?   Therapy/Intervention Template used

PICO Definitions Participants identified Intervention OIF/OEF/OND Male and female veterans age 18-65 enrolled in a PTSD treatment Program Intervention Crossfit ® work out 1 hour per day, 5 days per week throughout duration of PTSD RRTP Other interventions to compare to Routine care in PTSD RRTP Type of outcome measures PTSD Symptoms such as flashbacks, depression, anger outbursts Rating group cohesion in cohorts

Population According to the U. S. Department of Veterans Affairs (2017), there are currently 422,167 OIF/OEF/OND veterans utilizing VHA facilities for potential or provisional PTSD. The focus of this study will be those veterans enrolled in a Specialized Intensive PTSD Program (SIPP) such as PTSD RRTP. Males and females will be eligible. Age group 18-65 years old.

Intervention Greg Glassman defines Crossfit ® as “constantly varied, high-intensity functional movement” (Crossfit®, 2011). 1 hour workouts would be offered 5 days per week to study participants over the course of their PTSD RRTP treatment.

Comparison Group Routine care in the PTSD RRTP includes (U. S. Department of Veterans Affairs, 2016): Health assessments and testing on a 1:1 basis Pharmacology Family therapy and 1:1 psychotherapy Group Therapy

Outcome Primary outcome – a measurement of post-intervention PTSD symptomology (depression, anger outburst, nightmares, flashbacks, etc.) will be less than baseline as rated by a scale such as the PTSD Checklist for DSM-5 (PCL-5). Secondary outcome – cohorts will rate group cohesion as stronger in intervention groups than non-intervention groups as rated by a scale such as the California Psychotherapy Alliance Scale – Group Version.

References CrossFit ®. (2011). Greg Glassman - Defining Crossfit ®. Retrieved from https://www.youtube.com/watch?v=XvM8aY1_tfI Ellis, C. C., Peterson, M., Bufford, R., & Benson, J. (2014). The importance of group cohesion in inpatient treatment of combat-related PTSD. International Journal of Group Psychotherapy, 64(2), 208-226. doi: 10.1521/ijgp.2014.64.2.208 The Management of Posttraumatic Stress Disorder Work Group. (2017). VA/DOD clinical practice guidelines for the management of posttraumatic stress disorder and acute stress disorder. Retrieved from https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal.p df

References U. S. Department of Veterans Affairs. (2016). PTSD: National Center for PTSD. Retrieved from https://www.ptsd.va.gov/public/treatment/therapy- med/va-ptsd-treatment-programs.asp U. S. Department of Veteran Affairs. (2017). Report on VA specific Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans diagnosed with potential or provisional PTSD: Cumulative from 1st qtr FY 2002 through 3rd qtr FY 2015 (October 1, 2001 – June 20, 2015). [Data file]. Retrieved from https://www.publichealth.va.gov/docs/epidemiology/ptsd- report-fy2015-qrt3.pdf