Veterans Nature Therapy (Vet Hike)

Veterans Nature Therapy: A Pilot Randomized Trial of Hiking for Veterans With PTSD

This pilot study evaluates the feasibility of conducting a study to evaluate the impact of nature exposure/hiking in groups on symptoms of posttraumatic stress disorder in Veterans. Participants will be randomized to one of two groups: 1) nature hikes and 2) urban hikes.

Study Overview

• Status: Completed
• Conditions: Posttraumatic Stress Disorders
• Intervention / Treatment: Behavioral: Group nature hikes; Behavioral: Group urban hikes

Detailed Description

Objectives and hypothesis: Posttraumatic stress disorder (PTSD) is a tragically common problem among US Military Veterans. Current treatment options for PTSD are not uniformly effective and dropout rates are high. Treatment approaches that are evidence-based, effective, and acceptable to Veterans are needed. Nature therapy is a promising, low-cost intervention, yet there are few rigorous studies that have evaluated it as a therapeutic intervention in Veterans with PTSD.

The specific aims of this study are to lay the ground work for a full-scale study by assessing the feasibility and acceptability of: i) recruitment, screening, and data collection methods; and ii) the nature hiking and urban hiking control group interventions. The investigators hypothesize that the interventions will be feasible and the recruitment, screening, and data collection methods will be acceptable.

Key eligibility criteria for this two-arm pilot randomized controlled trial include being a Veterans with PTSD, physical fitness/ability sufficient to walk for at least 2 hours, and willingness to complete assessments. Eligible individuals will be randomized to one of two groups: 1) nature hiking group, 2) urban hiking group. The investigators will enroll up to 60 individuals, to randomize up to 15 participants per group. Note that the number enrolled and randomized are not expected to be the same since he investigators anticipate some individuals who enroll will be determined not to be eligible based on responses to the baseline questionnaire. Individuals randomized to groups 1 or 2 will be invited to participate in six hikes of 2-4 hours in duration, over approximately 12 weeks. Individuals will be asked to complete questionnaires at baseline and weekly for 12 weeks, and then again at 24 weeks. The primary outcomes for this study relate to feasibility and acceptability. The investigators will collect information on time to recruit the sample, retention and survey completion at each time point, and attendance at hikes. A secondary aim is to ascertain changes in PTSD symptoms (which will serve as the primary outcome of the full-scale trial), secondary outcomes (e.g., quality of life) and mediators of the intervention, including factors such as depression, perceived stress, affect, loneliness, anxiety, social connectedness, rumination, and nature connection.

• Study Type: Interventional
• Enrollment (Actual): 26
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Washington
    • Seattle, Washington, United States, 98108
      • VA Puget Sound Health Care System

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• U.S. Military Veteran;
• Active PTSD symptoms based on the PCL-5;
• No diagnosis of schizophrenia, bipolar disorder, or other psychotic disorders (based on self-report);
• Low risk of suicide (based on responses to the MINI Suicidal module);
• No inpatient admission in last 3 months (based on self-report);
• No current alcohol disorder/dependence (based on having a score<16 on the 10-item self-administered AUDIT questionnaire);
• No evidence of drug-related problems (based on having a score <3 on the DAST-10)
• Capable of safely participating in hikes as evidenced by no "yes's" on the Physical Activity Readiness Questionnaire (or approval of their primary care physician) and individual assertion that they can walk at least 2 hours at an easy to moderate effort with breaks;
• Willing to be randomized to one of two groups and complete all study procedures;
• Able to provide written informed consent to participate.

Exclusion Criteria:

• Schizophrenia, bipolar disorder or other psychotic disorder

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Nature hiking; Group hikes in a natural setting (e.g., park, wilderness area)	Behavioral: Group nature hikes; Six group nature hikes will be offered once every other week. Total duration of intervention is 12 weeks. Hikes will be co-lead by two experienced hike leaders.; Other Names: Nature hikes
Active Comparator: Urban hikes; Group hikes in a urban setting (e.g., downtown area)	Behavioral: Group urban hikes; Six group urban hikes will be offered once every other week. Total duration of intervention is 12 weeks. Hikes will be co-lead by two experienced hike leaders.; Other Names: Urban hikes

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recruitment	Time to recruit the sample	Baseline
Recruitment	Percentage of individuals contacted who are randomized	Baseline
Retention	Percentage of participants that complete assessments	12-week follow-up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PTSD symptoms	Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), 20 items, range 0-80; summed; higher = greater PTSD	Baseline and 6-, 12-, 24-week follow-ups
Quality of life/well-being: Satisfaction with Life Scale	Satisfaction with Life Scale; 5-items, range 5-35; summed; higher = greater life satisfaction	Baseline and 6-, 12-, 24-week follow-ups
Depression	Personal Health Questionnaire Depression Scale (PHQ-8); 8-items, range 3-24; summed; higher = greater depression	Baseline and 6-, 12-, 24-week follow-ups
Perceived stress	Perceived Stress Scale 4 (PSS-4); 4-items, range 0-16; summed; higher = greater stress	Baseline and 6-, 12-, 24-week follow-ups
Social connectedness	4-item Social Connectedness Scale; 4-items, range 4-28; summed; higher = greater connection to group	Baseline and 6-, 12-, 24-week follow-ups
Rumination	State rumination- Rumination Reflection Questionnaire 12-items, range 5-60; summed; higher = greater rumination	Baseline and 6-, 12-, 24-week follow-ups

Collaborators and Investigators

• Sponsor: University of Washington
• Collaborators: VA Puget Sound Health Care System; Recreational Equipment, Inc. (REI)
• Investigators: Principal Investigator: Alyson Littman, PhD, University of Washington

Publications and helpful links

General Publications

• Littman AJ, Bratman GN, Lehavot K, Engel CC, Fortney JC, Peterson A, Jones A, Klassen C, Brandon J, Frumkin H. Nature versus urban hiking for Veterans with post-traumatic stress disorder: a pilot randomised trial conducted in the Pacific Northwest USA. BMJ Open. 2021 Sep 23;11(9):e051885. doi: 10.1136/bmjopen-2021-051885.

Study record dates

Study Major Dates

• Study Start (Actual): May 10, 2019
• Primary Completion (Actual): February 1, 2020
• Study Completion (Actual): March 1, 2020

Study Registration Dates

• First Submitted: June 12, 2019
• First Submitted That Met QC Criteria: June 21, 2019
• First Posted (Actual): June 25, 2019

Study Record Updates

• Last Update Posted (Actual): June 14, 2021
• Last Update Submitted That Met QC Criteria: June 9, 2021
• Last Verified: June 1, 2021

More Information

Terms related to this study

• Keywords: physical activity; randomized controlled trial; feasibility; pilot study; nature; posttraumatic stress disorders
• Additional Relevant MeSH Terms: Mental Disorders; Trauma and Stressor Related Disorders; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
• Other Study ID Numbers: STUDY00006745

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No