PONE-D-24-29043Effect of Nordic Walking on Walking Ability in Patients with Peripheral Arterial Disease: A Meta-AnalysisPLOS ONE

Dear Dr. Qian,

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.

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Shukri AlSaif

Academic Editor

PLOS ONE

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Reviewers' comments:

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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

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

Reviewer #1: 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: No

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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: 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: This is a systematic review and meta-analysis of clinical studies on nordic walking's effects on walking capacity in PAD and IC.

Comments

1. The way the results are presented across the manuscript, it seems like NW is more beneficial to SET which is not the case. The results are not significant for either MWD or CD.

a. Lines 17-23. Please change the presentation to more simple terms, eg., Compared with SET, NW was NOT associated with an increase in MWD or CD during treadmill or 6-MWT testing in PAD patients. Lines 22-23 are not needed. In other words, the authors should not use wording such as there was an increase in MWD….but not statistically significant. If there is not significance, then there was no increased in MWD between SET and NW….

b. Lines 434-439: same as in lines 17-23… you cannot say that Nordic walking significantly outperformed SET!! Also, no need to report again SMD Z and p values in the discussion. Since you presented this in the results section, it is repetition.

2. Figures 9, 10 and 11, appear opposite to actual results – eg. Figure 9 shows that exercise duration favours NW but results report the opposite. All figures need to be re-checked if correct or not.

3. Line 27: “NW was more effective” might imply that both treatments increase sig. MWD but NW more. However, the data only shows the comparison between the two so we do not know if the control/unsupervised exercise also significantly increased MWD compared to no exercise.

4. Lines 29-31: these refer to a result that is based on one trial, and hence meta-analysis cannot be performed.

5. Same for lines 392-397: they are the same finding reported in the abstract. Since it is based on one trial only, no meta-analysis can be implemented and only qualitatively this result can be discussed. Same for lines 449-452 in discussion.

6. Only one trial used unsupervised NW based on Table 1., which was only used in the MWD between NW and unsupervised exercise therapy. It would be more accurate if the word “supervised” preceded NW (ie. “supervised NW”). NW vs unsupervised exercise findings on MWD are based on 2 trials where one used unsupervised NW and the other supervised NW. This means that the increase in MWD with NW compared to unsupervised exercise therapy may have been influenced by the supervision itself than the exercise modality and this should be discussed in the discussion.

7. Are the results based on week 12 or 24? A bit confused based on line 171.

8. In Table 1, does the N number on sample size include groups not studied in this analyses? Eg. Study by Katarzyna is on n=80 but one group was not used in these analyses.

9. Wherever you refer to ref 27, the name used should be replaced with the author’s last name; ie. instead of “Katarzyna” be replaced with “Kropielnicka”.

10. Please initial the authors that did the data extraction and quality assessment. Eg Lines 143 and 151, next to “two researchers” add the initials of those researchers if they are in the author list.

11. Minor comments:

a. Lines 85-87 needs rephrasing. Since various RCTs have been implemented, it is more accurate to report whether separate RCTs generated conflicting evidence, where a meta-analysis can be helpful in settling such controversies.

b. Please include the year of each of the 4 other meta-analyses presented on page 4. Eg. Cugusi….provided the initial evidence in 2017…etc.

c. Lines 94-97 need to be rephrased.

d. Suggestions: Line 82, “as people with PAD…”; line 72 ”…and uses a specific pair of”; line 97, Secondly is not correct since this is the 3rd meta-analysis?

e. Lines 98-101: this way of reporting actual results is a bit confusing and needs rephrasing.

f. Jansen et al. in a Cochrane meta-analysis and this needs to be mentioned due to their significance in the field of meta-analyses.

g. Lines 106-107: Didn’t 2 of these focus on NW effect on walking in PAD? 17 and 18 references.

h. Rephrase lines 107-109. Also mention up to which years did they cover…It needs to be more clearly stated why a new meta-analysis is needed, since already 4 covered this. Clearly state which years the two meta-analyses that focused on NW covered…

i. Line 171: “exercise were calculated…word duration missing?

j. Line 228: “total sample size…each study’s sample size?

k. Line 289: of each entry, what does that mean?

l. Line 294, limp trials?

m. Line 297, omit “with Bulinska et al”.

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Reviewer #1: No

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PONE-D-24-29043R1Effect of Nordic Walking on Walking Ability in Patients with Peripheral Arterial Disease: A Meta-AnalysisPLOS ONE

Dear Dr. Qian,

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.

==============================

ACADEMIC EDITOR: Please address the points raised by the reviewer below

==============================

Please submit your revised manuscript by Nov 08 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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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,

Shukri AlSaif

Academic Editor

PLOS ONE

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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: (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: Partly

**********

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

Reviewer #1: 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: (No Response)

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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

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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: Revision comments

1. The authors have now changed the direction of all figures, making results the opposite. I am unsure which is the right direction as they mention that they only changed Figures 9 and 10 but also Figures 5-8 were changed. So now Nordic walking appears better than SET, eg Figure 8. Moreover, Figure 9 now basically shows that claudication distance is lower after SET than NW. I think again the signs/label directions are problematic?

2. Comment 6 response: Perhaps also replacing NW with supervised NW is also suitable in the results section for NW versus SET since no study used unsupervised NW. I understand this is already entered in Table 1, yet it should be also highlighted in the results section and the discussion. I believe unsupervised NW was only used compared to unsupervised therapy (Figure 10) where NW should be left as is. But for the prior results, maybe supervised NW is a better option to describe NW. Eg. lines 373 calling it supervised NW, lines 381, line 389, 398 etc. Same in lines 451, 521, 522, 525. All those places should call NW as supervised NW because otherwise it appears that NW is as effective as SET, yet if both are supervised, this should be mentioned because otherwise it makes NW appear as a better option (if thought as unsupervised).

3. It might be better replacing word “control” in the figures footnotes where Collins et al study is described with SET.

4. Lines 359-362: Please use past tense. Eg. “All included trials obtained approval from the local….” “Participants provided written? Informed consent before enrollment, …”

5. Lines 127-129: Although…introduces a subordinate clause but no main clause follows.

6. While the authors made a great effort to incorporate all reviewer’s suggestions, maybe some of the lines in the introduction could be moved to the discussion. I do appreciate that they added all the new information regarding the 4 prior meta-analyses, perhaps they could be a bit more succinct in the introduction and more expansive in the discussion? The introduction is 5 pages long in the current version. It is highly important to point out what new this meta-analysis adds to the literature beyond the 4 prior ones, yet in a more concise manner.

7. The study by Langbein (REF 24) did not use exercise in control. This has to be entered in Figure 10 and in results section because currently Figure 10 wrongly reports this control as unsupervised ET. Similarly line 418 report it as unsupervised therapy, giving the impression this study did use unsupervised exercise. This is also mentioned in lines 454-455. Same lines 460-463, it appears this study used unsupervised exercise. In fact, pooling these two studies is not that appropriate since the controls were quite different (no exercise vs unsupervised exercise)…If done, it has to be well-defined in the Figure and results and discussion etc. so the reader is fully aware of this. This can be also entered in the limitations section.

8. Lines 463-465: To which two studies do these line refer to?

9. Lines 585-586. This is not really an outcome of this meta-analysis since they are outcomes based on one trial each (one trial using non-exercise and one using unsupervised exercise).

10. Table 1 and Table 2 are larger than the page margins; the authors should make sure it will fit within the journal’s margins.

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Reviewer #1: No

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PONE-D-24-29043R2

Effect of Nordic Walking on Walking Ability in Patients with Peripheral Arterial Disease: A Meta-Analysis

PLOS ONE

Dear Dr. Qian,

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 Dec 12 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,

Shukri AlSaif

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.

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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: (No Response)

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: Partly

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: (No Response)

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

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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: Thank you for addressing the comments but I still believe there is an issue with the forest plots directions.

For example, in Figure 5, the first study by Bulinska has a mean of 364 in Nordic walking versus 290 in SET. This means that the difference is favouring Nordic walking by 74m in max walking distance. However, the plot shows that it favours the control. For Collins study, it is 612 m in Nordic vs 889 in SET, hence SET patients walked on average more than Nordic by 277m, but the plot shows that a favoring for Nordic walking while it should be showing SET. Same for the rest of studies.

Then the same applies to Figure 6, Figure 7, Figure 8 and Figure 9.

As an example, please check how forest plots directions are in the meta-analysis by Parmenter et al. 2020, “Resistance training as a treatment for older persons with peripheral artery disease: a systematic review and meta-analysis” Br J Sports Med 2020;54:452–461. doi:10.1136/bjsports-2018-100205

Here to also note that label Control in the plot and footnotes would be more informative if it was replaced by the word “SET”.

Reviewer #2: The authors undertook to investigate how Nordic walking affects the ability to walk in patients with PAD. Publications covering treadmill tests and 6-MWT were included in the meta-analysis. The selection of manuscripts was carried out correctly. The duration of the intervention, ranging from 12 to 24 weeks, was also taken into account. Indicating that NW improves the patient's MWD compared to other treatment methods (except SET), but it depends on the monitoring itself, not on the exercise style.

The discussion was prepared correctly and includes the available literature.

In conclusion, I propose to accept the publication in its current form.

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes:  Artur Kruszewski

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PONE-D-24-29043R3Effect of Nordic Walking on Walking Ability in Patients with Peripheral Arterial Disease: A Meta-AnalysisPLOS ONE

Dear Dr. Qian,

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 ADDRESS THE ISSUE WITH THE FOREST PLOT.

Please submit your revised manuscript by Dec 29 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,

Shukri AlSaif

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.

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Effect of Nordic Walking on Walking Ability in Patients with Peripheral Arterial Disease: A Meta-Analysis

PONE-D-24-29043R4

Dear Dr. Qian,

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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Shukri AlSaif

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

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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

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

Reviewer #1: Yes

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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: (No Response)

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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

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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: (No Response)

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Reviewer #1: No

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