PONE-D-21-18398

What are the biopsychosocial risk factors associated with pain in postpartum runners? Development of a clinical decision tool

PLOS ONE

Dear Dr. Christopher,

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. 

I have read each reviewers comments and I believe their suggestions made will improve the manuscript. Please address these recommendations and clarify where needed. I am looking forward to reading the revised paper.

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Kind regards,

Chris Harnish, PhD

Academic Editor

PLOS ONE

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2. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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: Yes

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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3. 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

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4. 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

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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: This manuscript is well written and clearly aims to fill a void within the running/postpartum literature.

Please consider adding more information to the CONSORT diagram to include a breakdown of those with/without postpartum pain (both included and excluded in the final analysis); number of participants with missing data that were included in the analysis.

Please identify which test was used for each comparison in Table #1 (t-test or Chi-square).

Please identify if the researchers were blinded to the presence of pain among the participants during development of the tool.

I would like to first point out that I am not an expert in clinical prediction rule methodologies; however, the methods seem to utilize classical techniques. Furthermore, I suspect the target audiences will likely mirror my experience in this area. Methodological citations are largely missing. These are necessary to increase clarity and to ensure reproducibility. Please add these to justify the data cleaning/conversion methods, the bivariate and multivariate regression methods, as well as the internal validation methods employed in this manuscript.

In addition to adding citations in the "Statistical Analysis for Data Modeling" section, I would suggest a brief statement(s) speculating the impact of using other CPR methods on the final model (particularly if different factor reduction techniques were utilized).

Please clarify the "Bivariate Logistic Regression Modeling" subsection. It seems as if both 19 individual tests were conducted along with a mystery number of construct tests were conducted to assist with factor reduction. Did the results from construct tests reduce the total number of individual tests? Was only 1 variable from a construct included in the multivariate test?

Please consider varying more of the diction and syntax used in the "Statistical Analysis for Data Modeling" section as it draws heavily from citation #23.

Biomechanical, musculoskeletal, and physiologic impairments are directly identified in the "Introduction" and "Abstract" as contributors to postpartum pain with running. The authors even detail a recent Delphi study (citation #13) that considered such factors. However, the survey created and administered for this manuscript seems to only graze the surface of the potential impact that biomechanical, musculoskeletal, and physiologic impairments may have. The lack of direct biomechanical, musculoskeletal, and/or physiologic measurements included in the initial model should be directly addressed.

Reviewer #2: Overall, this is a clear, concise, and well-written manuscript. The introduction is relevant and theory based. Information about the previous study findings is presented for readers to follow the present study rationale and procedures. This is a topic with little exploration and/or previous research into identifying risk factors associated with pain in postpartum runners. The methods are generally appropriate, although clarification of a few details should be provided. At the start of the methods section, it states that the survey was administered between December 2019 and January 2021 (line 103-104), later on in the paragraph regarding study variables, it states survey was modified due to COVID in April 2021 (line 137). Please verify and adjust the dates of study collection.

Eligible participants could have had a child within three years, was the data looked at regarding when they started to have pain; did they have complications with delivery (not just tears) or recovery after childbirth, did the pain come closer to due delivery or pain when more miles were accrued, did they have pain just this time engaging in physical activity or after second or third child? I know from experience that starting to run a few weeks to months after childbirth vs. three years later is a big difference ( from both a fatigue, physically and emotionally). Moreover, where they cleared to engage in high intensity physical activity by OB/GYN.

In addition, it might have been helpful to ask if they were now running most of the miles pushing a stroller or without. Many mothers will run with a stroller and this can alter their body mechanics which can lead to injuries as well.

Using PAFS and EDPS was a great capture of data in the surveys. Statistical analysis and handle of missing data was appropriate and explained well.

Line 193- cite the calculator website in the reference section instead of in the body of the manuscript.

Overall, the results are clear and compelling. In Table 1 Columns three and four, believe it would be better to have n (%) only. No Mean +/- SD are represented in these columns. Make sure that the titles are fulling seen in rows (it could just be the way it printed out for this reviewer) but the words are cut off onto another row and hard to read.

Interesting to see the COVID- 19 data added to this manuscript. Would have been helpful to see if childcare (lack of daycare and schools) or jobs impacted as well.

In results and in the discussion, it was noted that most recent delivery – vaginal was a factor. This should be explored more. As stated in discussion, did not ask about tears or other complications. Would have been interesting to see what prior injuries the runners had previous.

Interesting sentence at end regarding pain. Pain is subjective. Many runners/ athletes may not state they have pain because they use to higher levels of discomfort.

The authors makes a contribution to the research literature in this area of investigation. Overall, this is a high quality manuscript that has implications for the theoretical basis, development, and important clinical decisions.

I believe this article should be accepted after the minor revisions are noted above. This reviewer is looking forward to reading more about this topic in the future.

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Reviewer #1: No

Reviewer #2: No

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What are the biopsychosocial risk factors associated with pain in postpartum runners? Development of a clinical decision tool

PONE-D-21-18398R1

Dear Dr. Christopher,

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.

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Kind regards,

Chris Harnish, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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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: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

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

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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

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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 #1: The authors have considered the questions/suggestions from both reviewers carefully and considerately; all changes made to the manuscript reflect this point.

Line 110 of the redlined copy seems uncited (I assume: Eysenbach G. Improving the Quality of Web Surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004; 6(3): e34.). The correct citation should be added. Otherwise, I believe that this manuscript is ready for publication and have reflected this point in my recommendation to "accept" rather than require "minor revision."

Reviewer #2: Authors addressed comments well. No further actions are needed at this time. I believe this article is ready for publication

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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.

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: No