PONE-D-24-45171Efficacy of Acupuncture on Lower Limb Motor Dysfunction Following Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.PLOS ONE

Dear Dr. Shao,

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Academic Editor

PLOS ONE

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Additional Editor Comments:

Hello ,

The reviewer's has commented the paper and requested for these minor revision . The paper would be considerable with these comment's get addressed

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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: Yes

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: No

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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: 1. General Evaluation

The manuscript titled "Efficacy of Acupuncture on Lower Limb Motor Dysfunction Following Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials" addresses the effectiveness of acupuncture for lower limb motor dysfunction in post-stroke patients. The study is relevant, considering the growing impact of stroke on public health and the challenges in motor rehabilitation. The analysis involves a meta-analysis of randomized controlled trials and utilizes recognized assessment parameters, such as the Fugl–Meyer Assessment (FMA-L), Berg Balance Scale (BBS), and Modified Barthel Index (MBI). The manuscript is well-structured and organized, but it presents important methodological limitations.

2. Objective and Rationale

The objective of evaluating the efficacy of acupuncture in improving lower limb motor function post-stroke is clearly established and well justified, based on literature data on the increasing prevalence of stroke and the role of acupuncture in traditional Chinese medicine. However, it would be advisable for the authors to describe in more detail the rationale behind the selection of specific outcomes assessed, as well as to include an introductory section on the possible mechanisms of action of acupuncture.

3. Methodology

The study adopts a robust methodology, searching eight databases for the selection of randomized controlled trials and conducting a rigorous data analysis with specialized software.

Inclusion and Exclusion Criteria: The inclusion criteria are well defined, covering only randomized controlled trials published in English and Chinese. However, excluding studies with combined acupuncture interventions may limit the generalizability of the findings, given the diversity of acupuncture techniques used.

Risk of Bias Analysis: The authors used Cochrane methods for risk of bias assessment, but only one included study applied allocation concealment. This suggests a high risk of bias and limitations in interpreting the results.

Statistical Methods: The choice of a random effects model is appropriate, given the heterogeneity among studies. The sensitivity analysis and publication bias tests contribute to the robustness of the conclusions. However, high heterogeneity in some analyses requires further exploration, which could include additional subgroup analyses based on specific study characteristics.

4. Results

The meta-analysis results suggest that acupuncture may benefit lower limb motor function and balance, although the benefits for walking ability and daily activities are limited.

Heterogeneity and Subgroup Analysis: Subgroup analysis is an appropriate approach to explore heterogeneity, but the findings lack robustness, raising questions about the consistency of the results.

Outcome Reporting: Outcomes are well presented, but the interpretation of effect sizes is limited by insufficient description of the magnitude of the observed clinical benefits.

5. Discussion and Conclusions

The discussion compares the findings with the existing literature and mentions the limitations, including risk of bias and methodological variability of the included studies. However, the authors could further explore limitations related to the diversity of acupuncture interventions and the absence of blinding.

Limitations: Limitations are mentioned in general terms, but a deeper analysis of the impact of selection bias and lack of blinding in the included studies would improve the transparency and reliability of the conclusions.

Suggestions for Future Research: The recommendation for future studies is appropriate, but the authors could provide more details on study designs that might mitigate the limitations identified in this study

Reviewer #2: The authors present a systematic review with meta-analysis of the effects of acupuncture alone and/or combined with rehabilitation on lower extremity motor dysfunction. A key conclusion was that acupuncture combined with rehabilitation was superior to acupuncture alone or rehabilitation alone.

The paper is substantially limited by lacking a strong theoretical framework for how acupuncture works at a physiological level. It is well known that acupuncture is popular in China, but that does little to help explain findings such as greater improvement in Berg Balance scale with acupuncture alone than rehabilitation alone (and other findings). I would revise the introduction and discussion to provide a stronger physiologically based theoretical framework.

Minor concerns

There are several grammatical errors. Please resolve. If necessary, please have the manuscript reviewed by a native English speaker.

There are a large number of abbreviations that detract from overall readability. Please revise.

Including figure captions in-text without associated figures made reading the manuscript more complicated. Unless this was a requirement of PLoS ONE, I would relocate those for any subsequent revisions.

The X-axes for the forest plots are not clear. Likewise, associated text in the results section are difficult to understand. Please re-write to improve clarity.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-45171R1Efficacy of Acupuncture on Lower Limb Motor Dysfunction Following Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.PLOS ONE

Dear Dr. Shao,

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 before accepting the manuscript for publication

Please submit your revised manuscript by Apr 05 2025 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,

Sangharsha Thapa

Academic Editor

PLOS ONE

Journal Requirements:

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.

Additional Editor Comments:

Reviewer #2: I appreciate the authors efforts in addressing my previous comments. I believe that largely my concerns have been addressed. However, I do think that some of the changes to setting up accupuncture from a physiological perspective need to be present in the Introduction. Please make changes to the Introduction itself to better introduce this topic.

The changes to the discussion are under cited. Please add in relevant citations throughout. 

[Note: HTML markup is below. Please do not edit.]

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: (No Response)

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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

**********

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

**********

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: The revision significantly improved the clarity and objectivity of the manuscript. The responses to the reviewers indicate an effort to improve the formatting, correct inaccuracies and better structure the sections. There was also greater detail in the methods and inclusion of essential information, which strengthens the quality of the work.

Reviewer #2: I appreciate the authors efforts in addressing my previous comments. I believe that largely my concerns have been addressed. However, I do think that some of the changes to setting up accupuncture from a physiological perspective need to be present in the Introduction. Please make changes to the Introduction itself to better introduce this topic.

The changes to the discussion are under cited. Please add in relevant citations throughout.

**********

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

**********

[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.

Efficacy of Acupuncture on Lower Limb Motor Dysfunction Following Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PONE-D-24-45171R2

Dear Dr. Shao,

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.

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Kind regards,

Sangharsha Thapa

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: