As is well documented, post-traumatic stress disorder (PTSD) is a debilitating psychiatric condition with profound global implications, affecting millions of individuals annually. It is typically triggered by traumatic events such as war, violence, or natural disasters and is characterized by intrusive thoughts, nightmares, emotional dysregulation, and hyperarousal. Its prevalence is particularly high in conflict-affected regions, with PTSD rates reaching 26.51 % and comorbid depression at 22.31 % [1]. Beyond the personal suffering it inflicts, PTSD imposes a substantial burden on healthcare systems and society as a whole.

PTSD frequently co-exists with other psychiatric conditions, including depression, substance use disorders, and suicidal behavior. For instance, adolescents with PTSD have been reported to exhibit a 15-fold increase in suicide risk compared to their peers [2], largely ascribed to emotional dysregulation, impaired impulse control, and maladaptive coping behaviors [3]. These challenges highlight the urgent need for effective, multidimensional treatment strategies that address both psychological symptoms and neurobiological dysfunction.

Current clinical guidelines recommend several evidence-based interventions for the management of PTSD, including trauma-focused psychotherapy (TFP), cognitive behavioral therapy (CBT), exposure therapy (ET), and eye movement desensitization and reprocessing (EMDR) [4]. Among these, TFP is widely regarded as the first-line treatment. Pharmacological options, particularly selective serotonin reuptake inhibitors (SSRIs), have also been extensively prescribed to alleviate acute symptoms, but may be associated with adverse effects and long-term dependency [5]. In recent years, alternative interventions such as repetitive transcranial magnetic stimulation and acupuncture have shown promise, although their effectiveness requires further validation [6]. Despite their efficacy, these interventions may be time-intensive, costly, or inaccessible, especially in resource-limited settings.

As a complementary and accessible strategy, exercise has garnered increasing attention for its therapeutic potential in PTSD [7]. Structured physical activity, especially aerobic and resistance training, has been associated with improvements in both psychological well-being and neurobiological function. Several primary biological mechanisms have been proposed to account for these benefits. To begin, exercise enhances brain-derived neurotrophic factor (BDNF) levels and activates the BDNF-TrkB signaling pathway, thereby promoting neuroplasticity, emotional regulation, and memory reconsolidation [8]. Secondly, PTSD is associated with dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, elevated cortisol levels, hyperactivity of the amygdala, and reduced hippocampal volume. Moderate-intensity exercise has been shown to restore HPA axis reactivity and ameliorate hippocampal neurogenesis, thereby increasing stress resilience.

Additionally, PTSD is hallmarked by chronic low-grade inflammation, characterized by elevated levels of pro-inflammatory cytokines such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). These immune abnormalities may exacerbate neural circuit dysfunction and emotional dysregulation. Exercise mitigates these effects by downregulating the expression of the nuclear factor-kappa B (NF-κB) pathway and increasing the levels of anti-inflammatory cytokines such as IL-10, eventually mitigating systemic inflammation and alleviating PTSD symptoms, particularly in the domains of hyperarousal and mood instability [9,10].

Secondary mechanisms have also been proposed [11], including modulation of monoamine neurotransmitters (e.g., serotonin, dopamine), improvements in sleep quality, and enhanced social connectedness through group-based activities [12]. These effects may further amplify the therapeutic impact of exercise in PTSD patients.

Despite growing evidence supporting the benefits of exercise, critical knowledge gaps remain regarding the optimal type, intensity, frequency, and duration of exercise interventions. Earlier studies have suggested that high-intensity exercise may exacerbate anxiety or hyperarousal symptoms, whereas moderate-intensity, high-frequency, and long-duration regimens generally yield more favorable outcomes [13]. Moreover, inconsistencies across studies due to varying exercise protocols, populations, and outcome measures hinder the development of standardized exercise prescriptions [14].

This study aimed to address these gaps by conducting a Bayesian network meta-analysis of randomized controlled trials (RCTs) to systematically compare the efficacy of different exercise modalities and dosages in alleviating PTSD symptoms. The findings are expected to offer evidence-based recommendations to optimize treatment planning, identify mechanistic pathways worthy of further investigation, and empower patients with accessible, non-pharmacological treatment options.