Augmentation of psychotherapy with exercise in adult populations affected by posttraumatic stress disorder: a systematic review of randomized controlled trials

<b>Background:</b> Several studies have demonstrated positive effects of exercise in posttraumatic stress disorder (PTSD), but it remains unclear how exercise can be optimally combined with psychotherapy. This systematic review aimed to evaluate the combinations of exercise and psychotherapy (concerning sequence, type, frequency, duration, administration, intensity) and their effect on PTSD symptom severity.<b>Methods:</b> After registration at PROSPERO (CRD42024502123), we conducted a systematic literature search up to 17 February 2025. Included were randomized controlled trials (RCTs) of exercise-augmented psychotherapy in adults with a PTSD diagnosis. PTSD symptoms were examined as the primary outcome. Two reviewers conducted the search and assessed the risk of bias (RoB-2) and reporting quality (CONSORT checklist).<b>Results:</b> Five studies were included, encompassing a total of 677 participants. Four study samples were predominantly female, while trauma types and sample types were heterogeneous throughout the studies. The quality of studies was overall satisfactory, with one study showing a high risk of bias. Between group effect sizes on PTSD symptoms ranged from small to large and three studies reported a positive effect. Promising designs for exercise-augmented psychotherapy included 20-30-minute sessions of aerobic exercise weekly, over 9-12 weeks, both alone or combined with resistance training, at moderate to vigorous intensity, both in an individual or group format. Exercise was combined with 90-minute sessions of psychotherapy, in different sequences, in an individual or group format. The length of the sessions was not systematically varied.<b>Discussion:</b> Various designs of psychotherapy combined with exercise hold promise for reducing PTSD symptoms. Due to the limited number and heterogeneity of studies, definitive conclusions regarding the most efficacious design are not yet possible. Further high-quality RCTs are needed.