Post-Traumatic Stress Disorder in Firefighters: Physical Fitness Treatment Options

By John Hofman

Firefighters are often exposed to crime victim incidents, people who were "dead on arrival" (where the death was not caused by natural causes), and accidents where there were serious injuries. Many have reported that they had experienced stress associated with giving medical aid to children and infants. Stressors can also include unemployment and the loss of a loved one, which could trigger symptoms of post-traumatic stress disorder (PTSD)(1). Studies have found that anywhere between approximately 7 percent and 37 percent of firefighters meet criteria for a current diagnosis of PTSD (2). So what can we do to help our fellow firefighter suffering from PTSD? The University of West Florida has shown that aerobic exercise can help individuals diagnosed with PTSD. (3)

PTSD is defined as an anxiety disorder triggered by witnessing or experiencing a traumatic event. We can characterize PTSD as a dysfunction of the body's stress-coping system, which could lead to depression, substance abuse, and suicidal thoughts. It can be subdivided into three categories: re-experiencing the trauma (intrusive memories), the numbing of affect and the avoidance of trauma-related stimuli (emotional numbing), and symptoms of excessive arousal not present before the event (increased arousal). Some of the physiological effects of PTSD include the following:

(1) higher resting heart rate,

(2) higher resting blood pressure,

(3) cognitive and mood disturbances, and

(4) abnormal changes in cortisol and norepinephrine.

Fatigue is another common symptom associated with depression or PTSD. Many firefighters are so tired that they become inactive. Inactivity is associated with chronic medical conditions like hypertension, heart disease, diabetes, obesity, and osteoporosis. This could lead to depression and helplessness. PTSD sufferers commonly express a feeling of helplessness. Exercise can release into your bloodstream endorphins that act as the body's natural pain killer, which makes you feel GOOD. A well-structured exercise program can provide stability and develop one's confidence, because consistency is important in keeping your emotions more even. Stable?

How good is exercise for depression? A study performed at Duke University showed that after 10 months, the exercise only group had the highest remission compared with groups that took just medication and medication with exercise (4). Other studies have shown that exercise along with working with a trained mental health professional is even more successful in overcoming PTSD. Exercise recommendations for helping sufferers with depression or PTSD include 30 to 40 minutes of aerobic activity three to five days per week, and this regimen has been shown to reduce depressive symptoms by 50 percent. Make sure your firefighters keep the intensity low-moderate (60-70 percent max heart rate) because they may be on antidepressant medications, which cause an increased heart rate, insomnia, dizziness, drowsiness, or withdrawal. Training within the proper intensity range has shown to help elevate mood, reduce anxiety, and reduce stress. (5). Be warned: providing continuous high-intensity exercises without adequate rest may be counterproductive because over-exercise can actually increase depression. It is important to remember that you make the workouts fun, convenient, free of hassle, and slightly challenging. If any of these factors are not met it is very likely that the firefighter will not be able to benefit from the exercise--these factors would impede to any benefits the physical routine may offer.

Those suffering from PTSD may also experience a significant amount of weight gain. Eating is a source of nurturing and is often an unconscious act. When we eat, our brain releases a chemical, dopamine, that causes you to feel pleasure and teaches you about rewards. These neurotransmitters activate when good things happen, such as when you are eating your favorite foods, thus creating addictive behaviors. Researchers discovered that obese people had fewer dopamine receptors than non-obese people (6). This would cause obese persons to eat more because they are searching for that "good feeling." You and your crew could have a positive impact on a firefighter suffering from PTSD by simply encouraging them to eat better in the firehouse or by cooking more healthful foods for everyone. Studies have shown that a social support group may play an important role in buffering the firefighters from developing PTSD. (7)

PTSD also affects a firefighter's hormonal levels, more specifically cortisol. Cortisol is produced by the adrenal gland and released in response to stress. Its primary functions are to increase blood sugar; suppress the immune system; regulate blood pressure; and help metabolize fat, carbohydrates, and protein. In summary, it's our "fight-or-flight" response system. This is a good thing when facing danger, but it will take its toll on the body over the long haul. For many people, cortisol peaks in the morning and decreases as the day goes on. Those who suffer from depression will have their cortisol peaks earlier in the morning, yet it does not decrease throughout the day. This continuous elevated cortisol may induce clinical depression, affecting other neurotransmitters within the brain. (8) If your body constantly has high levels of cortisol, you will be more susceptible to illness or infection. Exercise can help--so long as you use a program divided into periods that incorporate proper training intensities, progressions, and recovery strategies. Exercise is perceived as a stress and, therefore, will force the body to change from its normal state to causing the adrenal gland to produce cortisol. However, regular exercise training will decrease this effect, causing the body to have a better response to stress and require the release of less cortisol. The more exercise you do, the better your body will become at dealing with physical stresses, and you will lessen its need to release cortisol.

Over a 30-year career, firefighters will be exposed to small traumatic situations that will affect them mentally and physically. According to researchers at the University of California- San Francisco, these traumatic exposures over a lifetime or career will boost inflammation in the body, even if they do not lead to PTSD (9). It was discovered that the greater the traumatic stress, the higher levels of inflammation within the body. Individuals with higher levels of inflammation tend to have an increased risk of having a heart attack. Even if the firefighter adjusted to these traumatic events, the inflammation remained constant over a period of time. So the stress of the job can impact your health even if you don't have certain mental or physical symptoms. Intervention strategies to help combat stress such as exercise, yoga, and other health-related activities should be integrated throughout a firefighter's career.

***

PTSD is a serious issue. Do not try to push through. Seek help when needed, and know the signs. Encourage others to seek treatment, and know what employee assistance program your department provides.

(5) Bryant, RA, & Harvey, AG. (1995). "Posttraumatic stress in volunteer firefighters: Predictors of distress," Journal of Nervous and Mental Disease, 183, 267-271.

(6) Del Ben, KS, Scotti, JR, Chen, Y, & Fortson, BL. (2006). "Prevalence of posttraumatic stress disorder symptoms in firefighters," Work and Stress, 20, 37-48.

(7) American College of Sports Medicine. (2011) "Exercise Should Be Considered for PTSD Therapy," Medical News Today. MediLexicon, Intl., 3 Jun.

(8) Blumenthal JA, Babyak MA, and Moore KA, et al. (1999) "Effects of exercise training on older patients with major depression," Arch Intern Med., 159:2349–2356.

(9) Cohen, GE, & Shamus, E. (2009). "Depressed, low self-esteem: What can exercise do for you? "The Internet Journal of Allied Health Science and Practice, 7(2).

(10) Gene-Jack Wang, et al. (2001). "Brain Dopamine and Obesity," The Lancet; Feb. 3.

(11) Haslam, C, & Mallon, K. (2003). "A preliminary investigation of post traumatic stress symptoms among firefighters," Work and Stress, 17, 277-285.

(12) Tafet, G.E., et. al. (2001) "Correlation between cortisol level and serotonin uptake in patients with chronic stress and depression," Cognitive, Affective, & Behavioral Neuroscience 1.4 :388-393(6).

(13) O'Donovan A, Neylan TC, Metzler T, Cohen BE. "Lifetime exposure to traumatic psychological stress is associated with elevated inflammation in the Heart and Soul Study," Brain Behav Immun, 2012 May; 26(4):642-9. Epub 2012 Feb 15.

John HofmanJohn Hofman is the strength and conditioning coach for the Sacramento (CA) Fire Department, He oversees the Wellness Center; coordinates the department's medical and fitness assessments; develops recruit fitness training, pre-employment medical and fitness evaluations; and assists the department's 20 certified Peer Fitness Trainers. In addition, he is the strength and conditioning coach for the California Regional Fire Academy, Sierra Fire Technology Program, Rocklin Fire Department, and South Placer Fire District. He also consults with the Fire Agency Self-Insurance System of California. Visit John's Web site at www.firefighterfitnessonline.com.

In an effort to help keep firefighters safe Strength & Conditioning Coach John Hofman authored Beyond the Turnouts: A Comprehensive Guide to Firefighter Health & Wellness -- where he combined the latest research and his years of experience developing firefighter health and wellness programs within the fire service. CLICK HERE for more info about the book.

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