Effectiveness of Pilates and Yoga to improve bone density in adult women: A systematic review and meta-analysis

Rubén Fernández-Rodríguez; Celia Alvarez-Bueno; Sara Reina-Gutiérrez; Ana Torres-Costoso; Sergio Nuñez de Arenas-Arroyo; Vicente Martínez-Vizcaíno

doi:10.1371/journal.pone.0251391

Peer Review History

Original SubmissionFebruary 3, 2021
7 Apr 2021 Decision Letter - Jose M. Moran, Editor PONE-D-21-03751 Effectiveness of Pilates and Yoga to improve bone health in adult women: a systematic review and meta-analysis. PLOS ONE Dear Dr. Alvarez-Bueno, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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. The requirements of the reviewers must be addressed accurately in order to consider the manuscript for publication. Please submit your revised manuscript by May 21 2021 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 plosone@plos.org. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 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: 1) First of all the title of the manuscript could be change to "Effectiveness of Pilates and Yoga to improve Bone Density in adult women" instead of Bone Health which carries a broader apprehension of musculo-skeletal well being. The only evaluation criterium used in the review is Bone Density. 2) To increase the practical value of the review, authors should consider separately: a) Postmenopausal reports b) Intensity of exercises c) Differences between Yoga and Pilates d) Short and long durations of exercises and e) Other physical benefits 3) It might not be possible to include the additional data as proposed, authors could at least discuss about the variants, using information provided within or outside the systematic study. Reviewer #2: In this meta-analysis, the authors investigate the effects of pilates and yoga on BMD in (mostly postmenopausal) women. They found no effect. The work is adequately performed. It was registered with PROSPERO and reported according to PRISMA guidelines. I have the following specific comments: 1/ The conclusion should not necessarily be that "additional high-quality studies with an adequate intervention length are needed to provide a more accurate picture of the evidence". I believe that yoga/Pilates is unlikely to change BMD, and the effect size here excludes a large effect. I suggest to remove this eternal "more evidence needed" mantra. 2/ Explain all abbreviations upon first use (e.g. ES, CI in the abstract) 3/ The authors should explain in the Introduction what exactly Pilates is and how it differs from Yoga. ****** 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. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes:** Michaël R. Laurent [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. https://doi.org/10.1371/journal.pone.0251391.r001
Revision 1
14 Apr 2021 Author Response Reviewer #1: Reviewer’s comment: 1. First of all, the title of the manuscript could be change to "Effectiveness of Pilates and Yoga to improve Bone Density in adult women" instead of Bone Health which carries a broader apprehension of musculo-skeletal well-being. The only evaluation criterium used in the review is Bone Density. Authors: We appreciate this reviewer’s suggestion. As suggested, we have modified the title of the manuscript: “Effectiveness of Pilates and Yoga to improve bone mineral density in adult women: a systematic review and meta-analysis”. Reviewer’s comment: 2. To increase the practical value of the review, authors should consider separately: a) Postmenopausal reports b) Intensity of exercises c) Differences between Yoga and Pilates d) Short and long durations of exercises and e) Other physical benefits Authors: We would like to thank the reviewer’s comment. We have carefully considered all the comments and incorporated them to the manuscript. a) We have conducted an additional subgroup meta-analysis based on the menopausal status of the participants, which are available in S8 and S9 Figs. We have properly modified methods, results, and discussion sections. “Additionally, subgroup analyses based on (…) menopausal status as well as meta-regression(...). “Lastly, meta-analyses for interventions vs CG and for the pre-post intervention analysis according to menopausal status are available in S8 and S9 Figs.” b) Because of the impossibility to estimate the intensity of exercises, we have included this fact as a limitation of our study. “In this sense, it is supposed that high volume trainings lead to a smaller decrease of BMD in postmenopausal women (7) and also that the level of strain and body position during each exercise task may affect the load of the exercise impacting on BMD, (47) but these factors cannot be addressed in our study.” c) The differences between Yoga and Pilates have been presented by subgroup analyses and discussed in discussion section. “As afore-mentioned and in line with our data, it seems that body position and physical demands during Pilates’ exercises produced more mechanical stress on bone when compared with Yoga exercises.” d) Aspects related with the duration of exercises have been addressed by subgroup based on the length, ≤ 24 weeks or >24 weeks, as well as meta-regression considering the weeks of the intervention. Method, result and discussion sections have been properly modified. “Additionally, subgroup analyses based on the type of intervention (Pilates vs Yoga), length (≤ 24 weeks or >24 weeks) and menopausal status as well as meta-regression models by mean age, baseline BMD values after adjusting for height and baseline body mass index (BMI) and length were conducted to determine their potential effect on the pooled ES estimates.” “The subgroup analysis based on the length, ≤ 24 weeks or >24 weeks, was conducted in the pre-post intervention showing a pooled ES of 0.13 (95% CI: 0.00 to 0.25; I2=40.5%) and 0.06 (95% CI: -0.07 to 0.19; I2=0.0%), respectively (S7 Fig).” “(..) neither were the meta-regression models based on baseline BMD values after adjusting for height (p=0.36) or those based on BMI values (p=0.45) (S4 Table) or length of the intervention (p=0.57) (S10 Fig).” “In this sense, it is well established that physical training should be maintained for at least one year to demonstrate substantial benefits in bone mass since the physiological cycle of bone remodelling lasts between four and six months,(48) and only two of the studies included in this review accomplished this.(31,36)” e) Other physical benefits accomplished by mind-body exercises such as Pilates and Yoga have been discussed in the discussion section. “Finally, because the type of exercise may modify the effect on BMD,(43) multicomponent strength and balance trainings have been recommended(39,44) for improving not only bone health, but also physical function in daily life activities, and for preventing falls and osteoporosis-related fractures associated with the decline of BMD” Reviewer’s comment: 3. It might not be possible to include the additional data as proposed, authors could at least discuss about the variants, using information provided within or outside the systematic study. Authors: Thank you for this suggestion. As it has not been possible to include some of the additional data proposed, we have discussed these items and included them as limitations of our study. Reviewer #2: In this meta-analysis, the authors investigate the effects of pilates and yoga on BMD in (mostly postmenopausal) women. They found no effect. The work is adequately performed. It was registered with PROSPERO and reported according to PRISMA guidelines. I have the following specific comments: Reviewer’s comment: 1. The conclusion should not necessarily be that "additional high-quality studies with an adequate intervention length are needed to provide a more accurate picture of the evidence". I believe that yoga/Pilates is unlikely to change BMD, and the effect size here excludes a large effect. I suggest to remove this eternal "more evidence needed" mantra. Authors: We appreciate this recommendation. As suggested, we have modified the sentence in the Abstract section: “Despite of the non-significant results, the BMD maintenance in the postmenopausal population, when BMD detrimental is expected, could be understood as a positive result added to the beneficial impact of Pilates-Yoga in multiple fracture risk factors, including but not limited to, strength and balance.” Reviewer’s comment: 2. Explain all abbreviations upon first use (e.g., ES, CI in the abstract) Authors: We would like to apologize for this mistake. As suggested, it has been corrected. Reviewer’s comment: 3. The authors should explain in the Introduction what exactly Pilates is and how it differs from Yoga. Authors: We appreciate the reviewer’s suggestion. We have briefly described Pilates in the introduction section and the main differences with Yoga exercises. “Despite of the combined classification in Mind-body techniques, Pilates and Yoga present differences that may have influence on bone. For instance, Pilates is a therapeutic exercise highly focused on core-strengthening while Yoga is more related to breathing and meditation exercises.” Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0251391.r002
26 Apr 2021 Decision Letter - Jose M. Moran, Editor Effectiveness of Pilates and Yoga to improve bone health in adult women: a systematic review and meta-analysis. PONE-D-21-03751R1 Dear Dr. Alvarez-Bueno, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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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 #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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 ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE 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 ****** 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 #1: It is an interesting review but to draw any conclusion is probably unmeaningful. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXx Reviewer #2: The authors have sufficiently addressed all of my comments. Requiring this answer to consist of more than 100 characters is a stupidity in the Plos Editorial Manager. ****** 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. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes:** Michaël Laurent https://doi.org/10.1371/journal.pone.0251391.r003
Formally Accepted
28 Apr 2021 Acceptance Letter - Jose M. Moran, Editor PONE-D-21-03751R1 Effectiveness of Pilates and Yoga to improve bone density in adult women: a systematic review and meta‑analysis Dear Dr. Alvarez-Bueno: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Jose M. Moran Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0251391.r004

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