PMEN-D-24-00076

Trauma clinicians' views of physical exercise as part of PTSD and CPTSD treatment A qualitative study

PLOS Mental Health

Dear Dr. Billings,

Thank you for submitting your manuscript to PLOS Mental Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Mental Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We ask you to expand the abstract for clarity on identified barriers and benefits, provide comprehensive details on study design, methodology, and data analysis. It's essential to deepen the discussion around the role of trauma clinicians, compare barriers to those in other mental disorders, and describe a trauma-informed exercise environment in detail. Incorporating client feedback and discussing neurobiology's role in PTSD/CPTSD treatment will strengthen your manuscript. Please also correct any statistical and grammatical issues. Your revised submission should address these concerns in a consolidated manner for re-evaluation.

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Please submit your revised manuscript by May 03 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at mentalhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pmen/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Hongru Zhu

Academic Editor

PLOS Mental Health

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Additional Editor Comments (if provided):

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Mental Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Mental Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The article is great, i enjoyed reading it :) The only thing is to expand a bit the abstract, in the Result section, so it will be more clear from the beginning, what kind of barriers were identified, and what kind of benefits.

Reviewer #2: Thank you for allowing me the opportunity to review this paper. I am however not sure that I can recommend this article for publication. I am not sure that the article would be of substantial interest or applied importance.

The article outlines the views of clinicians re the integration of exercise into the treatment of those individuals with PTSD or CPTSD. However, I have several thoughts.

Firstly, the sample is small. There is no mention of data saturation. Secondly, the article would benefit from more depth re the role of these trauma clinicians in determining treatment programs. In other words, are these the group of professionals who decide treatment approaches for the client.

The barriers and facilitators outlined are as would be expected. It would benefit from a discussion of how these compare and contrast with those relevant to clients with other mental disorders. In other words, are individuals with PTSD or CPTSD unique in any way?

There is talk of a trauma informed exercise environment? What would this look like? There is talk about individuals within the gym being able to support the individual if they were triggered. What would this look like? Would this require training to be put out across gym staff? Is this feasible? It would benefit from more of an in-depth discussion of gym exercise versus outdoor activity given the symptom profile associated with PTSD and CPTSD.

I know that there is a discussion of client factors, but it would also benefit from evidence from clients. Overall I just felt that this paper needed much more depth in order to be of applied importance. I wish the authors good luck in their future research

Reviewer #3: General comments and some key concerns:

1. It is an interesting study that is giving an insight on the Trauma clinicians' views of physical exercise as part of PTSD and CPTSD treatment. All along in literature, Exercise has been documents for be crucial in maintaining body and brain health with few studies done to support this. So any study like this one is vital in advancing the knowledge in this area. However, below are my comments.

2. Title

• Avoid abbreviations in the title – Write “PTSD and CPTSD” in full

3. Abstract

• What was the study design?

• How was the interviews conducted to collect the data?

• Conclusion is not based on the key findings of the study

3. Methods section

• How were the specialist traumas clinicians identified and recruited in the study? How was the study participants selected?

• In data collection, was the structured interviews conducted using a designed tool as a guide? Were responses to saturation able to be reached??

• The statement “Clinical contacts were also asked to circulate details of the study to other clinical colleagues in specialist trauma services----“What type of study design is this? The study design needs to be clearly explained!!!!!

• What were the variables captured?

• Which statistical package was used to summarize the data if any?

• How was the ethical issues handled i.e. study approval and number if possible or waiver was given?

4. Results

• Responses in table 1should be reported as % (n) or add another column for %.

• Characteristic item on “Occupation”, there was no Psychiatrist!!!

• 3.1. The Potential Benefits of Physical Exercise -All participants saw value in physical exercise. What were those values mentioned?

• 3.1.2. Mind and Body: holistic treatment – same as above

• 3.1.3. Reclaiming Life and the Body

• Physical exercise was perceived as a tool for reclaiming goals around life and their bodies. Many forms of physical exercise were used in treatment – what were those different forms encountered?

5. Discussion

• Discussion should also bring in the role of Neurobiology on Physical exercise and how it can be helpful in prevention of PTSD and CPTSD and how it can influence treatment of affected patients

6. Conclusion

• The key conclusion that can be drawn from the findings of the study are not well elaborated

• Grammar and tenses need to be addressed – See 2nd sentence

7. Acknowledgments: Missing

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PMEN-D-24-00076R1

Trauma clinicians' views of physical exercise as part of PTSD and Complex PTSD treatment: A qualitative study

PLOS Mental Health

Dear Dr. Billings,

Thank you for submitting your manuscript to PLOS Mental Health.  The reviewers believe that all major issues have been resolved. However, there are some minor issues that still need to be addressed, as outlined below. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 08 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at mentalhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pmen/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Hongru Zhu

Academic Editor

PLOS Mental Health

Journal Requirements:

1. Please provide separate figure files in .tif or .eps format.

For more information about figure files please see our guidelines:  LINK

https://journals.plos.org/mentalhealth/s/figures 

https://journals.plos.org/mentalhealth/s/figures#loc-file-requirements 

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

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2. Does this manuscript meet PLOS Mental Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Mental Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Comments:

Thanks for the revision and most of the comments have been addressed by the authors. However, some minor one below need to be addressed

1. General comments and some key concerns:

• Use past tense instead of future tense in sentence construction in the document

• Limit use of first and second person in sentence construction. Instead use third person.

2. Methods section

• Insert “Methodology” instead of “Methods”

• Which statistical package was used to summarize the data in table 1? Is this data qualitative or quantitative?

4. Results

• Responses in table 1- Insert “Responses (%, n)” as sub-title in the cell and then remove % on each of the figures

• The % should come first i.e. 75.0 (9) and Write % to 1 decimal place all through the table

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Trauma clinicians' views of physical exercise as part of PTSD and Complex PTSD treatment: A qualitative study

PMEN-D-24-00076R2

Dear Dr Billings,

We are pleased to inform you that your manuscript 'Trauma clinicians' views of physical exercise as part of PTSD and Complex PTSD treatment: A qualitative study' has been provisionally accepted for publication in PLOS Mental Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact mentalhealth@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Mental Health.

Best regards,

Hongru Zhu

Academic Editor

PLOS Mental Health

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Reviewer Comments (if any, and for reference):