1. Introduction

Post-traumatic stress disorder (PTSD) is defined by a cluster of physical and psychological symptoms which can arise as a result of exposure to a traumatic experience [1–3]. Diagnostic criteria for PTSD include persistent re-experiencing, causing a person to relive the traumatic event vividly and involuntarily; avoidance, such as of specific people or places which serve as reminders of the traumatic event; and hyper-arousal, commonly experienced as hypervigilance to current perceived threat [3]. Further difficulties may include adverse changes in cognition, mood and reactivity [1–3].

Complex post-traumatic stress disorder (CPTSD) is a recently recognised diagnosis in the International Classification of Diseases-11 (ICD-11) characterised by symptoms of PTSD plus an additional triad of symptoms: affect dysregulation, negative self-concept and interpersonal disturbances [3–5]. These include feelings of worthlessness, shame and guilt, difficulty regulating emotions, and problems connecting with others [3]. The experience of trauma in cases of CPTSD is more likely to have been either prolonged or repeated. It is often associated with childhood abuse or neglect, domestic violence, sexual abuse, war, slavery or torture [5–7].

Physical health symptoms and conditions commonly co-occur in PTSD and CPTSD [8] including poorer physical health-related quality of life, cardiovascular diseases, chronic lung diseases, gastrointestinal issues, greater musculoskeletal pain [9–11] sleep disturbances [12, 13], chronic pain [14] chronic fatigue [15, 16], autoimmune diseases [8], headaches [17], fibromyalgia, dizziness, chest pains [16], and cancer [16, 18]. Adverse childhood experiences (ACEs) have been found to be associated with negative physical health outcomes in adulthood, with patients who experienced four or more ACEs at significantly higher risk of diseases than people who had not been through an ACE [19]. Physical injury resulting from traumatic experiences can also be associated with PTSD [20, 21], with more severe injuries being associated with increased PTSD symptomatology [22].

Further physical effects of trauma on the body have been cited. Considering the neurobiology of PTSD, the presence and severity of PTSD symptoms have been associated with structural changes in the brain, including reduced volume in the hippocampus and anterior cingulate [23, 24] and reduced volume or thickness in the precuneus, insula, and prefrontal cortex [25]. These structural changes have been correlated with alterations of brain function, such as activation and connectivity in the amygdala and hippocampus [26–29] and functioning of the Hypothalamic Pituitary Axis (HPA), [30, 31]. A review suggests that the HPA response within someone diagnosed with PTSD is characterized by an exaggerated cortisol response [31] and increased inflammatory activity [32–35].

Modern medicine has tended to perpetuate a separation between body and mind, with advances in treatment for mental health difficulties focusing on developing pharmacological solutions and problem-focused talking therapies. Interventions for conditions directly caused by experiencing traumatic events, including PTSD and CPTSD, are no exception. However, people who suffer from the effects of trauma are unlikely to do so solely in their minds [36]. Symptoms, in most cases, manifest in clients’ physiology or, in other words, “the body keeps the score” (ibid) of the experienced traumatic events. Indeed, in the past decade, there has been a growing interest in the effects of physical exercise on PTSD symptoms and the potential benefit of including body-focused therapeutic interventions in PTSD and CPTSD treatment.

Physical exercise refers to physical activity that is planned, structured, repetitive, and intended to improve or maintain physical fitness [37]. The WHO states that physical activity has significant health benefits, contributing to preventing and managing diseases such as cardiovascular diseases, cancer and diabetes and reducing symptoms of depression and anxiety [37]. Some research suggests that effectiveness is competitive to pharmacology and psychotherapy in improving overall cognitive function and well-being [38].

There is a growing evidence base for physical exercise as a supportive intervention for PTSD and CPTSD symptoms. In a narrative review of 19 studies that examined aerobic exercise and PTSD symptomatology, Hegberg et al. [39] reviewed nine observational studies and ten intervention studies and concluded that physical interventions alone or as an adjunct to standard treatment might positively impact PTSD symptoms. In a meta-analysis of eleven studies across three countries, Björkman & Ekblom [40] concluded that physical exercise has the potential to be a helpful, supportive intervention, reporting a small to medium effect of exercise on PTSD symptom severity. Bjorkman & Ekblom [40] also reported positive effects of physical exercise on depressive symptoms, sleep disturbances, and substance use disorder. More recently, Jadhakhan et al. [41] conducted a systematic review of 13 studies from four countries and reported that combined exercise interventions had the best evidence for a beneficial effect on PTSD symptoms. None of the studies included specifically considered the impact of physical exercise on CPTSD symptoms.

There is some debate about what type, dosage and duration of exercise might be most helpful. Björkman & Ekblom [40] suggested that more significant amounts of exercise might provide more benefits. In their meta-analysis they explored whether there is a difference in the effect on PTSD symptoms between high- and low-intensity activities (yoga versus other exercises) or between group and individual exercises, and found no significant differences. The authors concluded that there is no established optimal dose, duration or type of exercise. In contrast, Jadhakhan et al. [41] explored which forms of exercise or physical activity have the most significant effect on PTSD outcome scores. They found that combined exercises (resistance training, aerobics, strength, and yoga) administered over 12 weeks, three times a week for 30–60 minutes, showed more significant effects on PTSD symptoms than individual forms of exercise.

The evidence on physical exercise as a supportive intervention for PTSD and CPTSD from systematic reviews and meta-analyses is still limited, possibly due to high heterogeneity in randomized control trials (RCTs) investigating various outcomes and using different measures of PTSD and CPTSD. In addition, adequately powered RCTs are required to provide more definitive evidence of a causal relationship between physical exercise and reduction in PTSD and CPTSD symptoms. Nevertheless, emerging evidence suggests that physical exercise could potentially play a role in PTSD and CPTSD treatment and could be an affordable, acceptable and scalable intervention, which could be included in future treatment guidelines.

To date, however, little is known about trauma clinicians’ views on including physical exercise in treatment. Specialist trauma clinicians play a key role in deciding, together with their clients, what approach to take to treatment and the phasing and sequencing of interventions [42]. Understanding specialist trauma clinicians’ views about exercise, whether this is something they endorse, and why or why not, is therefore crucial in considering the potential inclusion of physical exercise interventions as an adjunct to treatment of PTSD and CPTSD. Thus, this paper had the following research aims:

1. To explore trauma clinicians’ perspectives on the role of physical exercise in PTSD and CPTSD treatment.
2. To understand trauma clinicians’ perceptions of the key barriers and facilitators to recommending physical exercise as a supportive treatment for PTSD and CPTSD.

2. Methodology

3. Results

Twelve UK based specialist trauma clinicians participated in this study. The gender, ethnicity and roles of participants are shown in Table 1.

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Table 1. Participant characteristics.

https://doi.org/10.1371/journal.pmen.0000114.t001

Interviews took place between August and October, 2022 and lasted between 14 and 27 minutes.

We identified three main themes relating to clinicians’ views on the inclusion of physical exercise in PTSD and CPTSD treatment. Using a semi-inductive, semi-deductive approach, the themes identified included potential benefits of physical exercise, barriers to including physical exercise, and individualised care underpinning the benefits and barriers. The relationships between themes are illustrated in Fig 1.

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Fig 1. Themes and subthemes explaining clinicians’ view on physical exercise in PTSD/CPTSD treatment.

https://doi.org/10.1371/journal.pmen.0000114.g001

4. Discussion

In this study we explored specialist trauma clinicians’ views regarding the adjunctive use of physical exercise in PTSD and CPTSD treatment and their perceptions of potential barriers and facilitators to including physical exercise as a supportive intervention. Potential benefits of physical exercise were perceived in holistically addressing clients’ health issues and treating the effects of trauma through physiological and psychological pathways. Some clinicians deliberately recommended exercise to treat physiological symptoms such as hyper-arousal. Some viewed it as general health advice that is part of maintaining wellbeing. Clinicians often brought up including physical exercise in reclaiming life goals, using it as a vehicle for achieving goals via socialising or getting outside more, rather than necessarily exercise being the goal itself.

Emerging evidence suggests that physical exercise can modulate neurobiological mechanisms implicated in stress responses, such as reducing cortisol levels and enhancing neuroplasticity [46]. Indeed, a recent review found that physical activity showed a good protective effect in those who engaged in high level of physical activity before traumatic events [47]. Integrating physical exercise into trauma-focused interventions may thus capitalise on its potential to mitigate the neurobiological alterations associated with trauma exposure, offering a multifaceted approach to addressing PTSD and CPTSD.

The findings of our study are consistent with those of Björkman & Ekblom [40] who concluded that exercise has the potential to be a helpful, supportive intervention for treating PTSD, with the clinicians we spoke to reporting physical exercise as beneficial for their clients in many ways. However, there were varied ideas amongst trauma clinicians about the potential benefits of physical exercise and, therefore, incorporating it in clients’ treatment. For example, whether it should be deliberately included to help alleviate specific symptoms and reconnect clients to their bodies, as general wellbeing advice, or as a reclaiming life goal. Perhaps, such breadth of views emerges from the participants’ creativity and ability to meet the needs of a vastly heterogeneous group of clients.

Björkman & Ekblom [40] recommended that future research investigates the optimal dose and type of exercise and suggested that more significant amounts of exercise may provide more benefits. A clear and opposing finding of the current research study is that experienced trauma clinicians believed that physical exercise in any form should be individually tailored to each client. Therefore, looking for an optimal dose or type of exercise could be counterproductive in light of the findings of this study. Clinicians reported that clients seemed to respond differently to various forms of physical exercise, with some benefiting from boxing and some finding running or yoga useful. There might be some clients who find physical exercise redundant. The current study underlines that clinicians need to meet the clients where they are regarding the intensity of exercise and the nature of the physical activity, bearing in mind the specific trauma(s) they may have experienced.

The current study is in contrast to the findings of the systematic review by Jadhakhan et al. [41] that aimed to determine the optimal form of exercise that most significantly affects PTSD outcomes. Jadhakhan et al. [41] concluded that combined exercise interventions administered over 12 weeks, three times a week for 30–60 min, showed more significant effects on PTSD symptoms than individual (non-combined) forms of exercise. Given the variety of functions which physical exercise may serve in recovery from PTSD and CPTSD, as highlighted by the specialist trauma clinicians in this study, such recommendations may be unhelpfully reductionistic. Defining an optimal type, dose, duration and intensity of exercise may therefore not be possible nor desirable. In the views of our participants, the inclusion of physical exercise as an adjunctive intervention should be underpinned by the principle of an individualised approach to care.

There was a clear consensus amongst the trauma clinicians we spoke to that engaging their trauma-affected clients in physical exercise could benefit their wellbeing and help to alleviate symptoms of PTSD and CPTSD. Clinicians also perceived that there were environmental barriers interacting with several challenges that clients may face in the process of treatment. It is imperative to note that each setting would not be adequately prepared or resourced to facilitate helping trauma-affected individuals and every clinician may not feel skilled to recommend physical exercise to their clients or able to find the time to do so in time-limited therapy.

Some of the barriers identified in our study share similarities with those observed in other mental health disorders [48, 49]. For example, access to resources and facilities has been recognized as a common barrier to exercise participation among individuals with various mental health conditions [50]. Additionally, environmental factors, such as the atmosphere of exercise spaces, can act as triggers for individuals with PTSD, similarly contributing to exercise avoidance as observed in other disorders [51]. Lack of motivation and low mood are prevalent barriers across different mental health disorders, indicating a shared challenge in promoting physical activity within these populations [49, 52]. Other barriers specific to people with PTSD/CPTSD were also identified in our study. Triggers related to specific traumatic experiences may lead to re-experiencing symptoms and strong emotional and behavioural reactions, making it particularly hard for this client group to engage in certain types of physical activities [53]. Specific to trauma survivors, especially those with interpersonal trauma experiences, shame could further impact willingness to participate in exercise interventions, particularly those in shared exercise spaces [54]. These findings suggest that while there are shared barriers to exercise across mental health disorders, there are some unique PTSD-related barriers which highlight the need for tailored approaches in promoting physical activity within this population.

Our study found that many of the barriers interact with each other, which further contributes to their maintenance. Similar findings were reported in a recently published qualitative study exploring healthcare professionals’ views of barriers to delivering trauma-focused interventions for people with psychosis and post-traumatic stress disorder [55]. Similar barriers included staff confidence, knowledge and beliefs. In the current study, some clinicians explained experiencing a lack of confidence and knowledge in recommending physical exercise, whether due to lack of access to sufficient evidence and policies that would provide guidance or lack of training in physical health interventions. Some clinicians were cautious of recommending exercise due to their beliefs about client barriers, such as physical health issues or possibly evoking feelings of shame. Other similar barriers related to structural support, notably service configuration. In this study we also identified gaps in services as a barrier, with professionals in uni-disciplinary psychology services describing lack of access to medical advice as a limiting factor in recommending exercise and a lack of clarity about the practicalities of making referrals for physical exercise. Another study focused on the implementation of intensive treatments for PTSD identified barriers similar to our current study [56]. Namely, staff attitudes, such as lack of their early “buy-in” to the effectiveness of the provided care, limited access to resources, and lack of flexibility within the system are in accordance with our findings, especially lack of confidence in clinicians, limited access to time and funds, and systemic limitations due to gaps in services.

Our study findings highlight the need for trauma-informed and culturally adapted exercise spaces. Cultural safety within trauma and violence informed care (TVIC) would ensure culturally sensitive and equitable opportunities to engage in exercise interventions (Browne et al., 2015). This entails more than just the physical layout of spaces such as gyms; it requires a comprehensive approach that considers cultural factors, language preferences, and potential triggers for individuals with PTSD and CPTSD [5, 53]. In such spaces, gym staff would receive specialised training in recognising signs of distress and responding with empathy and sensitivity [53]. For example, staff could be trained to provide verbal reassurance, offer a safe space for individuals to take a break, or provide access to supportive resources if needed [53]. A potential barrier for sustaining staff competency would be access to additional funding. Nature-based activities, such as hiking or outdoor group workouts, can provide opportunities for grounding, relaxation, and connection with the natural environment, which may be particularly beneficial for trauma survivors [57]. Therefore, a trauma-informed approach to exercise interventions should consider both indoor and outdoor-based activities, adapting the environment and support mechanisms to meet the diverse needs of individuals while promoting physical and mental well-being.

5. Conclusions

This study provides a preliminary analysis of specialist trauma clinicians’ views of the role of physical exercise in treatment for PTSD and CPTSD. We found that there were general and specific perceived benefits and barriers of including physical exercises in trauma focused treatments. Clinicians recognized that each service user’s needs were unique, and that the principle of individualized care should underpin delivery. Further research is needed to determine how physical exercise could better fit into treatment protocols, inform future policies and provide guidance for trauma clinicians.

Supporting information

Acknowledgments

We would like to thank the trauma clinicians who generously invested their time to take part in this study.