Effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities: A systematic review and meta-analysis

Junjie Zhou; Yecheng Zhong; Wenhong Xu

doi:10.1371/journal.pone.0314664

Peer Review History

Original SubmissionMay 28, 2024
16 Jul 2024 Decision Letter - Domiziano Tarantino, Editor PONE-D-24-21189Effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities: A systematic review and meta-analysisPLOS ONE Dear Dr. xu, 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 Aug 30 2024 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. 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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 [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: Partly Reviewer #2: Partly Reviewer #3: No Reviewer #4: Yes Reviewer #5: Partly Reviewer #6: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes Reviewer #3: N/A Reviewer #4: Yes Reviewer #5: Yes Reviewer #6: 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 Reviewer #2: Yes Reviewer #3: No Reviewer #4: Yes Reviewer #5: Yes Reviewer #6: 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: No Reviewer #2: Yes Reviewer #3: No Reviewer #4: Yes Reviewer #5: Yes Reviewer #6: 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 think it is a different field that can be reviewed. but I do not find it appropriate to publish it because I think that the existing studies are not sufficient for meta-analysis and the results will be misleading. Reviewer #2: In this manuscript, the authors summarise the available evidence on the effectiveness of core stability exercises in improving balance in children and adolescents with intellectual disabilities. The topic is clinically relevant and the results emphasise the need for more primary studies on the subject. However, some questions need to be properly addressed: Abstract Line 39/41- “Core stability exercises are effective in improving dynamic balance in children and adolescents with ID. However, no significant effects were found on the improvement in static and static-dynamic balance in this population”. Please consider clarifying the content of this sentence adding information about heterogeneity in the included sources of evidence, and the lack of significant improvements in comparison with the control group. Methods Line 126/127- According to the inclusion criteria, the average age of the participants should be < 18 years. However, the mean is a measure of central location, not indicate sample extremes. For example, in a hypothetical sample of 2 participants, if one is 30 years old and the other is 2 years old, the average will be 16 years old. Line 128/129- The comparator is not properly described. The review aims to assess the effectiveness of core stability exercises against which intervention? Active? passive? placebo? The lack of a well-defined comparator may have resulted in the found heterogeneity. Line 134- In the methods section, specifically in the "data extraction" subsection, the data extraction tool is not described, nor is the data extracted from each study. While the PRISMA checklist states that page 9 describes the methods for assessing certainty in the evidence, no such procedure was carried out. Considering the Joanna Briggs Institute and Cochrane guidelines for systematic reviews of effectiveness, assessing the certainty of the evidence is a mandatory step in this type of review, and provides the reader with an indication of the strength of the evidence produced by the systematic review. In agreement, authors should consider assessing the certainty of the results using the GRADE approach. Results Line 198/199- “As illustrated in Table 1, three studies were conducted in Iran, followed by Egypt and Pakistan”. Please clarify this sentence. How many studies were conducted in Egypt and Pakistan? Table 1. While categories for severity of intellectual disability are presented in the results section, the reader is not previously informed on which system this classification is based. Table 3. Consider providing values for the intervention/ control effects. According to relevant guidelines, a summary of findings table should be provided. Consider adding this table in the final of the results section accompanied by a grading of the certainty in the evidence. Conclusion In this section, consider providing information regarding the effectiveness of core stability exercises in improving each of the outcomes of interest in light of the certainty in the summarized evidence. Reviewer #3: 1- number of articles in systematic review is very few 2- My major concern is that core stability exercises are not very useful and functional, nowadays. For example, functional training and postural re-education are very noticeable at the time being. Reviewer #4: 1. Please kindly make the necessary corrections in line 69 (Studies have shown that individual's balance performance is associated with their core stability and not individuals balance). 2. Please kindly indicate the number/percentage of articles conducted in the various countries (Line 198) Reviewer #5: Abstract This abstract needs to be written more robustly. Firstly, it not clear what the rationale or significance of the study is from the back ground. There methods section is extremely brief and the results need to be presented more succinctly. Your conclusion appears exaggerated especially based on two studies for a narrative synthesis and four studies for a meta-analysis. I suggest that you consider being more measured in your conclusions based on limited data/evidence. Introduction Well done on your introduction. Please consider these to improve the coherence. Discuss the burden/epidemiological data around balance in your population of interest (ID). Based on this discuss the need for balance training amongst this population. Discuss the effects of balance training. Consider reducing the definitions and critique the existing literature around the phenomenon. You say there are studies existing in this area but these studies have not been systematically reviewed. Is that the rationale for your study? You need to be clear why there needs to be a systematic review in this area. Are these studies contrasting? Do you need to pull them together to firm up their conclusions although they all conclude on the same things? The biomechanics of core stability should be discussed robustly as well to link to the need to conduct this systematic review. Please consider these to improve the introduction. Information sources and search strategy What process will you use to ensure or assess inter-rater reliability of the data search, identification and extraction? Inclusion criteria Consider using a more robust and scientific approach to writing your inclusion criteria. Also, you need to provide an exclusion criteria. Data extraction What evidence informed your approach to data extraction? Again, this needs to be written more scientifically and backed by evidence. Discussion Your discussion is well written. However, I'm concerned about the firm conclusions you are drawing on effectiveness based on six studies. You need to consider whether the effect sizes are clinically meaningful also. Again, there should be a section that discusses the evidence for core stability exercises and its effect on balance more clearly. The strength of existing evidence should be discussed. Reviewer #6: I am happy to read through this systematic review and metanalysis of the effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities. To the best of my knowledge, the manuscript is sound and analysis well presented. I recommend that the work be accepted for publication if the necessary grammatical check is completed. Thank you ****** 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: No Reviewer #3: No Reviewer #4: No Reviewer #5: No Reviewer #6: Yes: Nonso Asouzu ******** [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. Attachments Attachment Submitted filename: PLOS one.docx Attachment Submitted filename: PONE-D-24-21189.pdf https://doi.org/10.1371/journal.pone.0314664.r001
Revision 1
22 Aug 2024 Author Response Dear reviewers: Thank you for your letter and the reviewers’ comments on our manuscript entitled “Effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities: A systematic review and meta-analysis” [PONE-D-24-21189]. Those comments are very helpful for revising and improving our paper. We have studied the comments carefully and made corrections which we hope to meet with approval. The main corrections are in the manuscript and the response to the reviewers’ comments are as follows (the replies are highlighted in bold). Replies to the reviewers’ comments: Reviewer #1: (1) I think it is a different field that can be reviewed. but I do not find it appropriate to publish it because I think that the existing studies are not sufficient for meta-analysis and the results will be misleading. Response: Thank you for your comments. We have taken into account your suggestions and those of other reviewers and have endeavoured to improve our study. In addition, we have given due consideration to the certainty of the evidence and reached our conclusions with care. The positive attributes of core stability exercise, such as being low cost, and easy to implement, have made it an ideal option for balance improvement for individuals with disabilities, such as hearing impairment [1], visual impairment [2], and cerebral palsy [3]. Therefore, we hope to aggregate evidence from relevant trials to clearly illustrate the effectiveness of core stability exercises in improving balance performance for children and youth with ID. Our meta-analysis highlighted large effect size improvements over active control groups in both static and static-dynamic balance, though the results were not statistically significant. The limited number of eligible studies may reduce the reliability of results, but it emphasises the need for additional research in this domain. Future studies focusing on core stability exercises should include standardised clinical measures to assess balance and individualised approaches taken into account by clinical profiles. This will help develop core stability intervention strategies to support balance performance in children and adolescents with ID. Therefore, the results and perspectives provided in this systematic review and meta-analysis may provide an important contribution to understanding the impact of core stability exercises on improving balance and can have a broader impact on practice and research. [1] Zarei H, Norasteh AA. Effects of proprioception and core stability training followed by detraining on balance performance in deaf male students: a three-arm randomized controlled trial. Somatosens Mot Res. 2023;1–9. [2] Salar S, Karimizadeh Ardakani M, Lieberman LJ, Beach PS, Perreault M. The effects of balance and core stability training on postural control in people with visual impairment: A systematic review. Br J Vis Impair. 2022; 41(3): 528-541. [3] Huang C, Chen Y, Chen G, Xie Y, Mo J, Li K, et al. Efficacy and safety of core stability training on gait of children with cerebral palsy. Med. 2020; 99(2): e18609. Reviewer #2: In this manuscript, the authors summarise the available evidence on the effectiveness of core stability exercises in improving balance in children and adolescents with intellectual disabilities. The topic is clinically relevant and the results emphasise the need for more primary studies on the subject. However, some questions need to be properly addressed: (1) Abstract: Line 39/41- “Core stability exercises are effective in improving dynamic balance in children and adolescents with ID. However, no significant effects were found on the improvement in static and static-dynamic balance in this population”. Please consider clarifying the content of this sentence adding information about heterogeneity in the included sources of evidence, and the lack of significant improvements in comparison with the control group. Response: We really appreciate your suggestions. We have revised the abstract section and reported more details in the discussion section as suggested. The revised text reads: “Core stability exercises appear to be a promising and acceptable intervention for the improvement of dynamic balance in children and adolescents with ID. Despite pooled analyses also highlighted improvements over active control groups in static and static-dynamic balance with large effect sizes, results were not statistically significant and should be interpreted with caution given the wide confidence intervals. The heterogeneity among the identified literature and the limited number of eligible studies may reduce the reliability of results, but it emphasises the need for additional research in this domain.” In addition, we have explained possible sources of heterogeneity in the discussion section (Lines 426-435 on pages 27-28 of the Manuscript). (2) Methods-Line 126/127- According to the inclusion criteria, the average age of the participants should be < 18 years. However, the mean is a measure of central location, not indicate sample extremes. For example, in a hypothetical sample of 2 participants, if one is 30 years old and the other is 2 years old, the average will be 16 years old. Response: Thank you very much for pointing out this problem. We revised the age of the inclusion criteria (Lines 150-152 on pages 8-9 of the Manuscript) after carefully reviewing the relevant systematic reviews and meta-analyses for populations of children and adolescents [1,2]. Meanwhile, we report the age range of participants included in the study in Table 1. [1] McGarty A M, Downs S J, Melville C A, et al. A systematic review and meta‐analysis of interventions to increase physical activity in children and adolescents with intellectual disabilities. J Intellect Disabil Res. 2018; 62(4): 312-329. [2] Zhou Y, Qi J. Effectiveness of Interventions on Improving Balance in Children and Adolescents With Hearing Impairment: A Systematic Review. Front Physiol. 2022; 13: 876974. (3) Methods: Line 128/129- The comparator is not properly described. The review aims to assess the effectiveness of core stability exercises against which intervention? Active? passive? placebo? The lack of a well-defined comparator may have resulted in the found heterogeneity. Response: Thank you for pointing this out. We have revised the details of the comparator. The revised text reads: “A standardised supervised conventional physical therapy program or any other training not focused on core exercising would be used as an active control group”. (4) Methods: Line 134- In the methods section, specifically in the “data extraction” subsection, the data extraction tool is not described, nor is the data extracted from each study. Response: Thank you very much for pointing out this problem. We have added details of the data extraction tool and the data extracted from each study (lines 176 on page 10 of the Manuscript). (5) While the PRISMA checklist states that page 9 describes the methods for assessing certainty in the evidence, no such procedure was carried out. Considering the Joanna Briggs Institute and Cochrane guidelines for systematic reviews of effectiveness, assessing the certainty of the evidence is a mandatory step in this type of review, and provides the reader with an indication of the strength of the evidence produced by the systematic review. In agreement, authors should consider assessing the certainty of the results using the GRADE approach. Response: We are very grateful for your advice. We have added details on assessing the certainty of the body of evidence using the GRADE approach (lines 202 on page 11 of the Manuscript). (6) Results: Line 198/199- “As illustrated in Table 1, three studies were conducted in Iran, followed by Egypt and Pakistan”. Please clarify this sentence. How many studies were conducted in Egypt and Pakistan? Response: Thank you very much for your advice, we have added relevant details. The revised text reads: “As illustrated in Table 1, three studies (50%) were conducted in Iran, followed by Egypt (n = 2, 33.3%) and Pakistan (n = 1, 16.7%)”. (7) Table 1. While categories for severity of intellectual disability are presented in the results section, the reader is not previously informed on which system this classification is based. Response: Thank you very much for your advice. Based on the inclusion of the studies in this review, we adopted the Diagnostic and Statistical Manual of Mental Disorders (4th edition) [1] for categorizing the severity of intellectual disability: Mild (IQ level 50-55 to approximately 70), Moderate (IQ level 35-40 to 50-55), Severe (IQ level 20-25 to 35-40) and Profound (IQ level below 20 or 25). We have added information about the classification criteria in the results section (lines 267-271 on page 14 of the Manuscript). [1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994. (8) Table 3. Consider providing values for the intervention/ control effects. Response: Thank you very much for your advice. We have added values for the intervention/ control effects in Table 3. (9) Results: According to relevant guidelines, a summary of findings table should be provided. Consider adding this table in the final of the results section accompanied by a grading of the certainty in the evidence. Response: Thank you very much for pointing out this problem. We have added the grading results suggested by the GRADE system to Table 4, along with a description of the evidence grading results in the results section (lines 330 on page 22 of the Manuscript). (10) Conclusion: In this section, consider providing information regarding the effectiveness of core stability exercises in improving each of the outcomes of interest in light of the certainty in the summarized evidence. Response: Thank you very much for pointing out this problem. We have added information about the effectiveness of core stability exercises in improving each of the outcomes of interest in the conclusions section. The revised text reads: “This review indicates that core stability exercises may be a promising means to improving dynamic balance in children and adolescents with ID, suggesting the potential feasibility of incorporating it into an important part of the physical and social rehabilitation program for these children. In addition, despite the quantitative results highlighting improvements over active control groups in static and static-dynamic balance with large effect sizes, results were not statistically significant and should be interpreted with caution, given the wide confidence intervals. Therefore, further rigorous studies are needed to strengthen the evidence in this area, given the quality of the underlying evidence base is currently low.” Reviewer #3: (1) number of articles in systematic review is very few Response: We agree with your valuable comments. In recent years, several studies [1,2] have reported that core stability exercises improve the balance ability of individuals with disabilities. Therefore, we hope to aggregate evidence from relevant trials to clearly illustrate the effectiveness of core stability exercises in improving balance performance for children and adolescents with ID. Despite the limited number of eligible studies that may reduce the reliability of results, it emphasises the need for additional research in this domain. Future studies and limitations are discussed in this study. Therefore, the results and perspectives provided in this systematic review and meta-analysis may provide an important contribution to understanding the impact of core stability exercises on improving balance and can have a broader impact on practice and research. [1] Salar S, Ardakani M, Lieberman L, Beach P, Perreault M. The effects of balance and core stability training on postural control in people with visual impairment: A systematic review. Br J Vis Impair. 2022;026461962210772. [2] Zarei H, Norasteh AA. Effects of proprioception and core stability training followed by detraining on balance performance in deaf male students: a three-arm randomized controlled trial. Somatosens Mot Res. 2023; 40(2): 47–55. (2) My major concern is that core stability exercises are not very useful and functional, nowadays. For example, functional training and postural re-education are very noticeable at the time being. Response: We are very grateful that you have recommended two very valuable interventions. Currently, functional training and postural re-education have also acquired our attention. Some studies [1,2] have shown that functional training is effective in improving balance in individuals with intellectual disabilities, but some rigorous RCTs seem to be lacking. Several studies have shown that postural re-education appears to be an effective exercise rehabilitation program to improve neck and lower back pain [3][4]. However, postural reeducation seems to have little research on improving balance ability, and has not been widely used in children and adolescents. Core stability exercises are characterised by their low cost, ease of implementation, and alignment with the physical and mental capabilities of children with intellectual disabilities [5]. Therefore, it is necessary to demonstrate the effectiveness of core stability exercises in improving balance performance in children with intellectual disabilities and to apply them in physical and social rehabilitation programs. [1] Mikolajczyk E, Jankowicz-Szymanska A. The effect of dual-task functional exercises on postural balance in adolescents with intellectual disability – a preliminary report. Disabil Rehabil. 2014; 37(16):1484–9. [2] Mikolajczyk E, Jankowicz-Szymanska A. Does extending the dual-task functional exercises workout improve postural balance in individuals with ID? Res Dev Disabil. 2015; 38: 84–91. [3] Fernandes TM, Méndez-Sánchez R, Puente-González AS, Martín-Vallejo FJ, Falla D, Carolina VC. A randomized controlled trial on the effects of “Global Postural Re-education” versus neck specific exercise on pain, disability, postural control, and neuromuscular features in women with chronic non-specific neck pain. Eur J Phys Rehabil Med. 2023; 59(1): 42. [4] Cavalcanti IF, Antonino GB, Monte-Silva KK do, Guerino MR, Ferreira AP de L, das Graças Rodrigues de Araújo M. Global Postural Re-education in non-specific neck and low back pain treatment: A pilot study. J Back Musculoskelet Rehabil. 2020; 33(5): 823–8. [5] Ghaeeni S, Bahari Z, Khazaei AA. Effect of Core Stability Training on Static Balance of the Children with Down Syndrome. Phys Ther. 2015; 5(1): 49-53. Reviewer #4: (1) Please kindly make the necessary corrections in line 69 (Studies have shown that individual’s balance performance is associated with their core stability and not individuals balance). Response: Thank you very much for your valuable comment. We have made the necessary changes to the sentence (lines 88 on page 5 of the Manuscript). (2) Please kindly indicate the number/percentage of articles conducted in the various countries (Line 198). Response: Thank you very much for pointing out this problem. We have revised this section. The revised text reads: “As illustrated in Table 1, three studies were conducted in Iran, followed by Egypt (n = 2, 33.3%) and Pakistan (n = 1, 16.7%)”. Reviewer #5: (1) Abstract: This abstract needs to be written more robustly. Firstly, it not clear what the rationale or significance of the study is from the background. There methods section is extremely brief and the results need to be presented more succinctly. Your conclusion appears exaggerated especially based on two studies for a narrative synthesis and four studies for a meta-analysis. I suggest that you consider being more measured in your conclusions based on limited data/evidence. Response: Thank you very much for your valuable comment. We have rewritten the abstract section to make it more rigorous (lines 14-46 on pages 2-3 of the Manuscript). (2) Introduction: Well done on your introduction. Please consider these to improve the coherence. Discuss the burden/epidemiological data around balance in your population of interest (ID) Attachments Attachment Submitted filename: Response to reviewers.doc https://doi.org/10.1371/journal.pone.0314664.r002
23 Sep 2024 Decision Letter - Domiziano Tarantino, Editor PONE-D-24-21189R1Effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities: A systematic review and meta-analysisPLOS ONE Dear Dr. xu, 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 Nov 07 2024 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, Domiziano Tarantino, MD 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. [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 #2: All comments have been addressed Reviewer #5: 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 #2: Partly Reviewer #5: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #5: 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 #2: Yes Reviewer #5: 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 #2: No Reviewer #5: 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 #2: I congratulate the authors as the new version of the manuscript presents substantial improvements. All my initial concerns were addressed by the authors in the first review of the manuscript. The conclusion described in the abstract ‘Core stability exercises appear to be a promising and acceptable intervention for the improvement of dynamic balance in children and adolescents with ID’ seems abusive to me, considering the scarcity of studies included, the results of the studies and the certainty of the evidence synthesised. In order to be published, the manuscript must be reviewed idiomatically and scientifically in terms of writing style. Reviewer #5: Well done on putting this manuscript together. You have addressed all my comments very well. All the best! ****** 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 #2: No Reviewer #5: 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. https://doi.org/10.1371/journal.pone.0314664.r003
Revision 2
4 Oct 2024 Author Response Dear reviewers: Thank you once again for your constructive comments on our revised manuscript titled “Effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities: A systematic review and meta-analysis” [PONE-D-24-21189R1]. Your insights have been invaluable in refining our work, and we have carefully addressed each of your suggestions in this second round of revisions. The main corrections are in the manuscript and the response to the reviewers’ comments are as follows (the replies are highlighted in bold). Replies to the reviewers’ comments: Reviewer #2: I congratulate the authors as the new version of the manuscript presents substantial improvements. All my initial concerns were addressed by the authors in the first review of the manuscript. The conclusion described in the abstract ‘Core stability exercises appear to be a promising and acceptable intervention for the improvement of dynamic balance in children and adolescents with ID’ seems abusive to me, considering the scarcity of studies included, the results of the studies and the certainty of the evidence synthesised. In order to be published, the manuscript must be reviewed idiomatically and scientifically in terms of writing style. Response: Thank you for your positive comments. We have revised the conclusion section of the abstract. The revised text reads: “Core stability exercises may improve dynamic balance in children and adolescents with ID, but given the scarcity of studies included, definitive conclusions cannot yet be drawn.” (Page 3, lines 39-41). Our manuscript has been meticulously edited by professional editors from AJE’s editing team to ensure correct English language, grammar, punctuation, spelling, and overall style (you can verify this using the verification code 5833-2A66-21B7-AB08-9768 on the AJE website). Reviewer #5: Well done on putting this manuscript together. You have addressed all my comments very well. All the best Response: Thank you very much for your encouragement. We are glad to hear that we have effectively addressed your comments. Your thorough review and constructive feedback have been instrumental in improving our manuscript. We appreciate your time and effort and wish you all the best as well. Kind regards Sincerely, Junjiie Zhou (The First Author) E-mail: zhoujunjie@zjnu.edu.cn Wenhong Xu (Corresponding author) E-mail: xuwenhong@zjnu.edu.cn 04 October, 2024 College of Physical Education and Health Sciences Zhejiang Normal University Jinhua, China Attachments Attachment Submitted filename: Response to reviewers.doc https://doi.org/10.1371/journal.pone.0314664.r004
14 Nov 2024 Decision Letter - Domiziano Tarantino, Editor Effects of core stability exercises on balance ability of children and adolescents with intellectual disabilities: A systematic review and meta-analysis PONE-D-24-21189R2 Dear Dr. Xu, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Domiziano Tarantino, MD 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 #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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #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 #2: I congratulate the authors on the final version of the manuscript. All my initial concerns have been properly addressed. ****** 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 #2: No ******** https://doi.org/10.1371/journal.pone.0314664.r005
Formally Accepted
9 Dec 2024 Acceptance Letter - Domiziano Tarantino, Editor PONE-D-24-21189R2 PLOS ONE Dear Dr. xu, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Domiziano Tarantino Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0314664.r006

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