Exercise for PTSD: how it helps alongside treatment, and how to make it feel safe

Get help straight away

The NHS says a mental health emergency should be taken as seriously as a physical one, and that you will not be wasting anyone's time.

• Call 999 or go to A&E if your life is at risk: for example, you have seriously harmed yourself or taken an overdose, or you feel you can't keep yourself safe.
• For urgent help in England, call 111 and select the mental health option, or use 111 online.
• Call Samaritans on 116 123. It is free, any time, day or night.
• In the US, call or text 988, the 988 Suicide and Crisis Lifeline, any time.

Sources 1, 2, 3, 4

Specialist support

• If you've been affected by rape, sexual assault or abuse and you're 16 or over in England or Wales: the Rape Crisis 24/7 Support Line, 0808 500 2222, free, or online chat. It isn't an emergency service: if you're in immediate danger, call 999.
• Veterans, reservists and people leaving the forces in England: Op COURAGE, the NHS mental health service for veterans. You can contact it yourself, or ask a GP or a charity to refer you.
• US veterans: call 988 and press 1 for the Veterans Crisis Line.

Sources 5, 6, 7

An add-on to treatment, never a replacement

The National Institute for Health and Care Excellence (NICE) recommends trauma-focused therapies, such as trauma-focused cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR), with medicines if you prefer. Exercise sits alongside these. The NHS says don't stop PTSD medicine unless a doctor tells you to, even if you feel better.

Sources 8, 9

No guideline recommends it, either way

NICE and the US Department of Veterans Affairs and Department of Defense (VA/DoD) looked at exercise and yoga and made no recommendation for or against, because the evidence was a few small trials. The US guideline adds that such activities might be encouraged to support overall wellness.

Sources 10, 11

Sleep and physical health are the clearer gains

In pooled trials, exercise improved sleep. In the best-known trial, strength training and walking also meant a smaller waist. PTSD is linked with a higher risk of heart disease, so being active matters for your body as well as your mind.

Sources 12, 13, 14, 15

Effects on PTSD symptoms are small and uncertain

Pooled small trials suggest exercise eases PTSD symptoms a little, but most didn't keep the assessors unaware of who had exercised, and two larger trials found no added benefit.

Sources 16, 17, 18, 19

Build up and stay in control

A racing heart and fast breathing can feel like trauma responses. Start with steady walking or cycling, choose where and how you exercise, and stop whenever you want to.

Sources 20, 21

Help is there

Adults can refer themselves to NHS talking therapies, and there are specialist services for survivors of sexual violence and for veterans: see the contacts above.

Sources 9, 5, 6

What PTSD is

The NHS: "PTSD (post-traumatic stress disorder) is a mental health condition caused by very stressful, frightening or distressing events." The main symptom is distressing thoughts about the event, such as flashbacks, intrusive images or nightmares. Others include avoiding reminders, feeling very anxious and looking for danger all the time, poor sleep, low mood, irritability or anger, feeling disconnected from yourself and the world around you, and repeated headaches, tummy problems or pain with no physical cause. Symptoms can start straight away, or months or even years later.

Source 9

What can cause it

A serious accident, physical or sexual assault, abuse, war, serious health problems such as being in intensive care, a difficult birth or a baby's death, or jobs such as police officer, paramedic or healthcare worker. You may have been through it yourself, seen it happen, or heard about it happening to someone close to you. Distress soon after a trauma is common and usually fades with time.

Sources 9, 22

How common it is

In England in 2023 to 2024, 5.7% of adults screened positive for PTSD in the past month, about 2.6 million people, up from 4.4% in 2014. A positive screen means enough symptoms to need an assessment, not a diagnosis. Rates were highest in 16 to 24 year olds (11.4%). In the US, about 5 in 100 adults have PTSD in a given year, and most people who go through a trauma don't develop it.

Sources 22, 7

Complex PTSD

Complex PTSD can follow severe trauma that is prolonged or repeated and hard or impossible to escape, such as child abuse or neglect, or ongoing domestic violence. On top of the symptoms of PTSD, it brings severe and lasting problems managing emotions, feeling worthless or defeated, and difficulty keeping relationships going.

Sources 8, 9

The body's alarm

The PTSD checklist used in England's national survey asks about "physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience", and about feeling "super alert" or "jumpy or easily startled". These are the same sensations hard exercise produces, which is why exercise can feel uncomfortable at first and why building up gradually matters.

Sources 22, 20

PTSD and your body

In 29 studies, people with PTSD were 9% less likely to be physically active, 31% more likely to be obese and 22% more likely to smoke. PTSD was linked with a higher risk of coronary heart disease, still 27% higher after allowing for depression, and about 4 in 10 people with PTSD had metabolic syndrome. In England, adults with a physical condition that limits them were about three times as likely to screen positive for PTSD.

Sources 23, 15, 24, 22

What NICE recommendsStrong evidence

Individual trauma-focused CBT, usually 8 to 12 sessions, for adults with PTSD or clinically important symptoms, including within the first month after a trauma; EMDR for trauma not related to combat, especially after 3 months; active monitoring for milder symptoms soon after a trauma; and venlafaxine or a selective serotonin reuptake inhibitor (SSRI) antidepressant, such as sertraline, if you'd prefer medicine. NICE advises against psychologically focused debriefing. Trauma-focused CBT includes "strategies for managing arousal and flashbacks": this is where people learn grounding skills.

Source 8

What the US guideline recommendsStrong evidence

The VA/DoD strongly recommends individual trauma-focused therapies, such as cognitive processing therapy, EMDR or prolonged exposure, over medicines, and paroxetine, sertraline or venlafaxine for people who choose medicine. It makes a weak recommendation for mindfulness-based stress reduction.

Source 11

Why there's no exercise recommendationStrong evidence

NICE reviewed 11 exercise studies, of which 2 randomised trials with 128 people qualified, and found "only small single studies", not enough for a recommendation. For yoga (3 trials, 194 people), it judged the uncertainty too high, noting that 46% dropped out of yoga against 15% of comparison groups. The VA/DoD found no studies of exercise that met its criteria.

Sources 10, 11

How well therapy worksEmerging evidence

In 119 adults with PTSD, 8 days of intensive trauma-focused treatment left 80% to 83% no longer meeting PTSD criteria, whether or not physical activity was added. In trials like this, the therapy does most of the work.

Source 19

Exercise added to therapyMixed evidence

In a trial of 130 adults, a 10-minute bout of aerobic exercise after each of nine weekly exposure therapy sessions made no difference at the end of treatment, but 6 months later PTSD scores were 12.1 points lower than with stretching, a moderate effect (0.6), and no harms linked to the exercise were reported. The 10 minutes is what the trial's published summary reports; the full trial report wasn't available to us. A 9-person pilot was also positive. But in 338 refugees, and in 119 adults in intensive treatment, adding physical activity made no difference.

Sources 25, 26, 27, 18, 19

An add-on, not a treatment on its ownStrong evidence

Guidelines recommend trauma-focused therapy, and medicines if you prefer them; none recommends exercise as a PTSD treatment. In the trials below, exercise was added to usual care, not used instead of it.

Sources 8, 10, 11

SleepEmerging evidence

Exercise improved sleep quality in people with PTSD by a small to moderate amount: 0.38 in 7 trials in one review, and 0.51 in another.

Sources 12, 13

Low mood and anxietyEmerging evidence

Depressive symptoms eased a little (about 0.2) in pooled trials. In anxiety and stress-related disorders, including PTSD, exercise reduced anxiety by a moderate amount (0.58 in 6 trials with 262 people), though reviews of PTSD trials alone differ on anxiety.

Sources 12, 13, 28

Physical healthEmerging evidence

In the best-known trial, 81 inpatients who added strength training and walking to their care ended with a smaller waist and less time sitting than with care alone. People with PTSD tend to be less active and more often obese or smokers, and PTSD is linked with heart disease, so the everyday benefits of exercise for the heart matter here.

Sources 14, 23, 15

PTSD symptomsMixed evidence

Pooled small trials found that exercise added to usual care eased PTSD symptoms by a small to moderate amount (effect sizes of about 0.34 to 0.49, across 11 to 16 trials). But in one review, 83% of trials didn't keep the assessors unaware of who had exercised; in another, the prediction interval (the range where a new trial's result would be expected to fall) crossed zero; and two larger trials, of 338 refugees and of 119 adults in intensive treatment, found no added benefit. Certainty is low to very low.

Sources 29, 13, 12, 16, 30, 17, 18, 19

Which type of exerciseMixed evidence

No type is clearly best. Yoga and strength training ranked highest in one review, but a comparison of 15 trials found no type clearly better, at very low confidence, and an overview found that programmes mixing several types may help. One analysis suggested a moderate weekly amount, roughly 3 hours of brisk walking, did best: an exploratory estimate.

Sources 16, 17, 31, 32

The trials behind itEmerging evidence

In 81 inpatients, 12 weeks of resistance-band training (one supervised 30-minute session and two home sessions a week) plus a walking programme lowered PTSD symptoms 5.4 points more than usual care. In 47 veterans, three 1-hour group sessions a week for 12 weeks, mixing aerobic and strength training with mindfulness practices, eased symptoms more than a waiting list. In 33 adults, 6 sessions on an exercise bike over 2 weeks reduced symptoms and the fear of body sensations, less so when people were prompted to focus on those sensations; there was no group that didn't exercise.

Sources 14, 33, 34, 35

Preventing PTSD after a traumaMixed evidence

Mind-body exercise soon after a trauma didn't clearly prevent PTSD in 6 studies with 399 people.

Source 36

What it is

Trauma-sensitive yoga is taught with invitational language and no pressure: you choose what to do, and the teacher shares control with the class. The version tested in the largest trial focuses on noticing body sensations, making choices and taking action.

Source 37

The trialsMixed evidence

In 64 women with long-lasting PTSD that hadn't responded to treatment, 10 weekly 1-hour classes left 52% no longer meeting PTSD criteria, against 21% with health education. In 131 women veterans, 10 weekly 1-hour classes did about as well as 12 weekly group sessions of cognitive processing therapy on most measures, though on one self-rated measure at 3 months the result fell slightly outside the range set for "as good as"; 65% finished yoga against 46% who finished therapy, and no clinically significant harms were reported. Across 20 trials, yoga improved self-rated PTSD but not PTSD rated by clinicians, and a review of trials in women found marginal to no effects.

Sources 38, 37, 39, 40

What the guidelines sayStrong evidence

NICE judged the uncertainty too high to recommend yoga and noted high dropout from yoga in the trials it reviewed; the VA/DoD found too little evidence to recommend for or against yoga, tai chi or qigong. It's a helpful addition for some people, not a replacement for trauma-focused therapy.

Sources 10, 11

If you try a class: our suggestions

Keep your eyes open, skip any pose, sit near the door, and ask the teacher not to use hands-on adjustments. If a pose or a relaxation brings up distressing memories, open your eyes, sit up and use slow breathing. Our guide to yoga for stress, anxiety and sleep says the same.

Sources 21, 37

You're in control

Trauma-informed practice rests on 6 principles: safety, trust, choice, collaboration, empowerment and cultural consideration. It tries to avoid re-traumatisation, which is "generally triggered by reminders of previous trauma". In practice: you decide the pace, the moves and when to stop.

Sources 21, 37

Where you exercise

Women veterans described "feeling unsafe in gyms", and most preferred home-based, group-supervised and moderate-intensity exercise. Choose a quiet time, a spot with your back to a wall and a view of the door, a treadmill or bike if being outdoors feels exposed, or a friend or group if company helps. Free weekly events such as parkrun welcome walkers as much as runners.

Sources 41, 20

A racing heart

A faster heart and faster breathing are expected with effort, and they settle as you slow down. Some people find these sensations too close to how trauma felt, and they can set off panic; others find exercise helps them use up adrenaline. Build up gradually, and you don't need to focus on your heartbeat: in one trial, prompting people to notice body sensations reduced the benefit.

Sources 20, 35

Positions and senses

Keep your eyes open, and skip lying face down, lying still with your eyes closed, or any position that feels trapped. Music is your choice: some people find it helps them settle, and others prefer to stay alert to their surroundings.

Source 20

If a flashback or panic starts

Stop, sit with your feet on the floor, look around and name where you are, and breathe slowly. Tell your therapist, so you can plan for it: trauma-focused therapy includes ways of managing arousal and flashbacks.

Source 8

Coaches and instructors

Trauma-informed coaches and instructors know the limits of their role and refer people on for support. Trauma-informed practice doesn't aim to treat trauma: that's what therapy is for.

Sources 42, 21

The guideline amounts

At least 150 minutes a week of moderate activity, such as brisk walking, plus strength exercises on 2 days. Moderate means you can still talk, but not sing.

Sources 43, 44

What the trials used

Strength training with resistance bands 3 times a week for 12 weeks, plus walking; three 1-hour group sessions a week for 12 weeks; and weekly 1-hour yoga classes for 10 weeks. In one review, programmes of about 3 sessions a week, 30 to 60 minutes each, for around 12 weeks looked best, though this came from comparing subgroups of trials.

Sources 14, 33, 34, 16, 38, 37

Exercise around therapy sessions

In one trial, people did 10 minutes of aerobic exercise after each exposure therapy session; in a 9-person pilot, they did 30 minutes on a treadmill at about 70% of maximum heart rate before each session. If your therapist suggests a walk or a short workout after sessions, there's a trial behind the idea. Tell your therapist what you're doing.

Sources 25, 27

A starting fortnight: our editorial starting point

Week 1: three 15 to 20-minute walks at a steady pace, at times and places that feel safe, and one short strength session. Week 2: three 20 to 30-minute walks or bike rides, two strength sessions, and the trauma-sensitive yoga practice if you'd like. From week 3: build towards 150 minutes a week and 2 strength days, adding harder efforts only when steady sessions feel familiar.

Sources 43, 20

Call 999 (911 in the US) or go to A&E now

Call 999 or go to A&E if:

• Your life is at risk: for example, you have seriously harmed yourself or taken an overdose.
• You feel you may be about to harm yourself, or you can't keep yourself or someone else safe.
• During exercise, you have chest pain that feels tight or like squeezing, or spreads to your arms, neck or jaw, or severe difficulty breathing, or someone passes out and isn't responding normally.

Sources 1, 2, 45

Get urgent help today

• In England, call 111 and select the mental health option, use 111 online, or ask for an urgent GP appointment.
• Call Samaritans free on 116 123, any time, day or night (UK and Ireland). If you're under 19, you can also call Childline on 0800 1111.
• Text SHOUT to 85258, any time.
• Contact your mental health crisis team if you have one.
• In the US, call or text 988, the 988 Suicide and Crisis Lifeline, any time. Veterans can call 988 and press 1.
• After rape, sexual assault or abuse (England and Wales, aged 16 or over): the Rape Crisis 24/7 Support Line, 0808 500 2222.

Sources 1, 2, 3, 4, 7, 5

See a GP soon

If you're 18 or over (or 16 or over in some areas), you can also refer yourself to NHS talking therapies without seeing a GP.

• You think you have symptoms of PTSD, or you've been diagnosed and treatments are not helping (or speak to your mental health specialist if you have one).
• Symptoms are troubling you after a recent trauma: you don't need to wait a month, because NICE recommends trauma-focused CBT even in the first month for clinically important symptoms.
• Exercise is becoming compulsive, or a way to control your weight: exercising too much can be a sign of an eating disorder.
• You're relying on alcohol or drugs to cope.

Sources 9, 8, 46

Veterans and service leavers

In England, Op COURAGE is the NHS mental health service for people leaving the forces, reservists, veterans and their families. You can contact it yourself or through a GP or a charity, however long ago you left.

Source 6

During or after exercise

• Chest pain, severe breathlessness, palpitations that don't settle, or fainting: call 999, whatever you think the cause is.
• A flashback, panic or feeling cut off from your surroundings: stop, sit with your feet on the floor, look around and breathe slowly, then tell your therapist (our suggestion).
• If exercise keeps making symptoms worse, change the setting or the type, for example indoors, with someone or at a steadier pace, rather than pushing through, and talk to your therapist (our suggestion).

Sources 45, 47, 20

Medicines

The NHS says don't stop taking PTSD medicine unless you're told to by a doctor, even if you feel better, and don't stop an antidepressant suddenly. Some antidepressants can make you dizzy or drowsy, so get up slowly after floor work. Some antidepressants and antipsychotics affect how your body controls its temperature, so take extra care exercising in hot weather.

Sources 9, 48, 49

"Exercise can replace trauma therapy"Strong evidence

NICE reviewed exercise and found only small single studies, not enough for a recommendation, and the VA/DoD found too little evidence. When physical activity was added to intensive therapy, 80% to 83% got better with or without it, and in 338 refugees adding activity changed nothing. Trauma-focused therapy and, if you choose, medicines are the treatments.

Sources 10, 11, 19, 18, 8

"Hard exercise will set off flashbacks, so keep your heart rate low"Emerging evidence

A faster heart is expected with effort. In a trial of 33 people, six cycling sessions reduced PTSD symptoms and the fear of body sensations, and when a short aerobic bout was added after exposure therapy sessions, no harms linked to it were reported. Some people do find the sensations too close to trauma responses, so build up gradually and keep control of the pace.

Sources 35, 25, 20

"Trauma is stored in your hips, and stretching or shaking releases it"Mixed evidence

No trial tests this. Studies of trauma releasing exercises (TRE) "were not consistently rigorous", somatic experiencing has only preliminary evidence of mixed quality, and the VA/DoD found too little evidence to recommend somatic experiencing. Strong feelings can come up during stretching or lying still; that's a reason for trauma-sensitive teaching, not proof of stored trauma.

Sources 50, 51, 11

"Yoga is as good as trauma therapy"Mixed evidence

In one trial, trauma-sensitive yoga did about as well as group cognitive processing therapy on most measures, and more people finished it. But pooled trials show benefits on self-rated, not clinician-rated, PTSD, a review of trials in women found marginal to no effects, and NICE noted high dropout from yoga. It's a helpful addition for some people.

Sources 37, 39, 40, 10

"Exercising straight after a trauma prevents PTSD"Mixed evidence

Mind-body exercise soon after a trauma didn't clearly prevent PTSD in 6 studies. Being active is good for you, but if symptoms trouble you after a trauma, see a GP: NICE recommends trauma-focused CBT, even in the first month, for people with clinically important symptoms.

Sources 36, 8

"Exercise works for everyone with PTSD"Mixed evidence

The pooled benefit is small, with wide uncertainty, and some trials found none. If one kind of exercise doesn't suit you, another might, and if exercise makes things worse, change the setting or type and talk to your therapist.

Sources 17, 18, 20