Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstruction

Bernard X. W. Liew; Julian A. Feller; Kate E. Webster

doi:10.1371/journal.pone.0266029

Peer Review History

Original SubmissionJanuary 18, 2022
22 Feb 2022 Decision Letter - Richard Evans, Editor PONE-D-22-01655Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstructionPLOS ONE Dear Dr. Liew, 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. Please submit your revised manuscript by Apr 08 2022 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ 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 academic 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'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Richard Evans Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. 3. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 5. 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. Editor Comments: General comments 1. Figure 1 is excellent 2. This manuscript has a nice balance of explaining the basics of Networks and presenting the new results. Major point: Many statistical tests were performed in this study, each with a 5% chance of being false positive (Type I error). I'm not sure how many test were performed, but at least 66 (the number of tests comparing "12-month yes" to "12-month no" edges, see lines 209+). Sixty-six tests, each with alpha=0.05 gives a studywise error rate of 96.6%. That means that there is a 96.6% chance that at least one of your statistically significant results is a Type I error. Moreover, we would expect about 3 tests (66x0.05) to be Type I errors. That's the number of statistically significant results reported in lines 209 to 213 So, it is unlikely that your results were, in the statistical sense, shown to be more real than noise. You have several options at this point. One would be to consult a statistician who should be knowledgable in the myriad ways of accounting for Type I error inflation. Alternatively, treat the study as an exploratory study. Don't chose a 0.05 cutoff and don't use the words "statistically significant." Simply note that the lower p-values suggest the strongest results, and those results require a confirmatory study. Minor points. 1. Line 64. It should read: The total score has disadvantages. 2. Table 2. There are numbers across from "Sex" (e.g., 3.24). What do they represent? [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 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 ****** 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 ****** 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: I congratulate the authors on an excellent analysis of associations between psychological factors and return to sport after an ACL reconstruction. They used the 12-item ACL-RSI, exploring relationships between specific questions relating to confidence, emotions and risk appraisal. The main clinical implication is that treatments targeting knee confidence may need to be considered to optimise an individual’s readiness for return to sport. The abstract is written well. I suggest that the Conclusion should be aligned more clearly with that at the end of paper. Delete the first sentence (of the abstract conclusion), and focus on the most important results. The introduction offers relevant background, outlining the ACL-RSI and also explaining principles of network analyses – which, as a non-expert in that method, I found very useful, and will be useful for readers. A large cohort of 441 participants were included in the study. As indicated, I am not an expert in network analysis, thus cannot comment about the analysis. Supplementary Table: this is very useful, but should be reformatted. I suggest adding the question numbers, and providing the means (SD) in three columns for the whole cohort, those who have not returned, and those who have returned to sport respectively. Relationships between the items are discussed clearly. An interesting findings is that there is a weakening of the association between ‘being nervous’ and ‘fear of injury’. That indicates that those who return to sport may have a fear of re-injury, but no longer feel nervous about the risk. I wonder whether that reflects the ability to manage their emotions of ‘nervousness’, while still having the rationale knowledge that there is a high risk of re-injury when returning to sport? Task-specific confidence is discussed clearly in the paragraph starting in line 265. Minor comments Line 28: Replace ‘A total [of] three network analysis’ with ‘Three network analyses were used to ….’ Lines 71 and 254: ‘may be’ instead of ‘maybe’. Line 227: delete the first ‘greater’ Line 237: I found the sentence “even though network analysis…’ difficult to follow. I suggest dividing it into 2 sentences. Line 252: ‘reflecting’ instead of ‘refecting’ Line 289: ‘athletes’ instead of ‘athlete’ ****** 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: Yes:** Gisela Sole [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.0266029.r001
Revision 1
8 Mar 2022 Author Response Please see the uploaded response to view the corrections with proper formatting. Comments are in bold, response in normal typeset, and excerpts from manuscript are in italics. Editor Comments General comments 1. Figure 1 is excellent 2. This manuscript has a nice balance of explaining the basics of Networks and presenting the new results. Reply: We thank the Editor for the positive comments, and will address all feedback below. Major point: Many statistical tests were performed in this study, each with a 5% chance of being false positive (Type I error). I'm not sure how many test were performed, but at least 66 (the number of tests comparing "12-month yes" to "12-month no" edges, see lines 209+). Sixty-six tests, each with alpha=0.05 gives a studywise error rate of 96.6%. That means that there is a 96.6% chance that at least one of your statistically significant results is a Type I error. Moreover, we would expect about 3 tests (66x0.05) to be Type I errors. That's the number of statistically significant results reported in lines 209 to 213 So, it is unlikely that your results were, in the statistical sense, shown to be more real than noise. You have several options at this point. One would be to consult a statistician who should be knowledgable in the myriad ways of accounting for Type I error inflation. Alternatively, treat the study as an exploratory study. Don't chose a 0.05 cutoff and don't use the words "statistically significant." Simply note that the lower p-values suggest the strongest results, and those results require a confirmatory study. Reply: We thank the Editor for this important comment. Yes, the Editor is correct. We have taken the advice of the Editor’s second recommendation, and have reworded the Methods and Discussion sections as follows: Methods in L178 A previous study used a threshold of 0.05 to determine statistical significance during NCT [33]. Given the exploratory nature of the present study, we did not adjust this threshold for multiple comparisons. Hence, we considered between-group differences with a P value < 0.05 as having more evidence in favour of the alternative hypothesis, than differences with a P value ≥ 0.05. Discussion in L288 Lastly, given the exploratory nature of our between-group network comparisons, our findings require a confirmatory study. Minor points. 1. Line 64. It should read: The total score has disadvantages. Reply: We have changed the sentence as requested. 2. Table 2. There are numbers across from "Sex" (e.g., 3.24). What do they represent? Reply: We thank the Editor for identifying this typographical mistake. We have removed this from Table 2. Reviewer #1 I congratulate the authors on an excellent analysis of associations between psychological factors and return to sport after an ACL reconstruction. They used the 12-item ACL-RSI, exploring relationships between specific questions relating to confidence, emotions and risk appraisal. The main clinical implication is that treatments targeting knee confidence may need to be considered to optimise an individual’s readiness for return to sport. The abstract is written well. I suggest that the Conclusion should be aligned more clearly with that at the end of paper. Delete the first sentence (of the abstract conclusion), and focus on the most important results. Reply: We have reworded the Abstract’s Conclusion in L 293 to read as: Fear of re-injury and being relaxed about playing sport were the two most important nodes in the network models that describe the return to sport readiness. Athletes who returned to sport had a greater Strength index for the variable of knee confidence, compared to those who did not return. Our findings provide candidate therapeutic targets that could inform future interventions designed to optimize return to sport rates in athletes post ACL reconstruction. The introduction offers relevant background, outlining the ACL-RSI and also explaining principles of network analyses – which, as a non-expert in that method, I found very useful, and will be useful for readers. A large cohort of 441 participants were included in the study. As indicated, I am not an expert in network analysis, thus cannot comment about the analysis. Supplementary Table: this is very useful, but should be reformatted. I suggest adding the question numbers, and providing the means (SD) in three columns for the whole cohort, those who have not returned, and those who have returned to sport respectively. Reply: We have altered this Table’s format to read as: Table 1. Anterior Cruciate Ligament Return to Sport after Injury individual item mean (1 standard deviation) scores. Items Whole cohort (n = 441) Did not return to sport (n = 326) Return to sport (n = 115) Q1 80.78 (22.94) 71.74 (26.36) 89.3 (14.8) Q2 67.34 (26.02) 59.82 (25.49) 74.44 (24.53) Q3 59.34 (31.15) 47.92 (28.53) 70.1 (29.69) Q4 74.15 (25.68) 63.77 (26.73) 83.94 (20.29) Q5 67.72 (29.73) 54.86 (29.66) 79.84 (24.24) Q6 50.56 (34.47) 39.87 (30.68) 60.63 (34.87) Q7 53.88 (31.49) 42.57 (28.11) 64.54 (30.84) Q8 74.71 (24.23) 65.42 (24.86) 83.46 (20.06) Q9 54.74 (30.93) 43.55 (27.77) 65.3 (30.09) Q10 69.57 (31.78) 56.58 (33.31) 81.81 (24.69) Q11 74.92 (26.09) 63.25 (27.63) 85.91 (18.85) Q12 67.94 (27.95) 55.06 (27.81) 80.07 (22.08) Relationships between the items are discussed clearly. An interesting findings is that there is a weakening of the association between ‘being nervous’ and ‘fear of injury’. That indicates that those who return to sport may have a fear of re-injury, but no longer feel nervous about the risk. I wonder whether that reflects the ability to manage their emotions of ‘nervousness’, while still having the rationale knowledge that there is a high risk of re-injury when returning to sport? Task-specific confidence is discussed clearly in the paragraph starting in line 265. Reply: We thank the Reviewer for this very interesting observation. Yes, we agree with the views of the Reviewer which is evidenced from Figure 1. Moving from not returning to returning to sports, the correlation between Q3 (nervousness) and Q7 (fear) reduces, but the correlation between Q7 and Q2 (risk) increases. This could mean that being in a state of nervousness is less of a determinant of fear, but that fear is driven more by risk appraisal in those who returned to sport compared to those that did not. In our Discussion, we focused on discussing between-group differences with greater statistical evidence in support of it. With network analysis, there can be an overwhelming number of discussion points to be made. Hence, whilst the observation made by the Reviewer is interesting, we have not included it into the Revised manuscript and have instead focused on those with the greatest evidence. Minor comments Line 28: Replace ‘A total [of] three network analysis’ with ‘Three network analyses were used to ….’ Reply: We have reworded this sentence. Lines 71 and 254: ‘may be’ instead of ‘maybe’. Reply: We have changed it to “may be”. Line 227: delete the first ‘greater’ Reply: We have delted the first “greater”. Line 237: I found the sentence “even though network analysis…’ difficult to follow. I suggest dividing it into 2 sentences. Reply: We have split the sentence in L239 into two to read as: Network analysis cannot differentiate whether a node serves as a common cause, a common effect, or acts as a mediator. However, network analysis may serve as a highly exploratory hypothesis-generating technique to identify potential treatment targets. Line 252: ‘reflecting’ instead of ‘refecting’ Reply: We have changed it to “reflecting” Line 289: ‘athletes’ instead of ‘athlete’ Reply: We have changed it to “Athletes” Attachments Attachment Submitted filename: ResponseReviewers_R1_v2.docx https://doi.org/10.1371/journal.pone.0266029.r002
14 Mar 2022 Decision Letter - Richard Evans, Editor Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstruction PONE-D-22-01655R1 Dear Dr. Liew, 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. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. 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 onepress@plos.org. Kind regards, Richard Evans Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0266029.r003
Formally Accepted
16 Mar 2022 Acceptance Letter - Richard Evans, Editor PONE-D-22-01655R1 Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstruction Dear Dr. Liew: 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. Richard Evans Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0266029.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .