PONE-D-24-41399Efficacy of virtual reality balance training on rehabilitation outcomes following anterior cruciate ligament reconstruction: A systematic review and meta-analysisPLOS ONE

Dear Dr. Liu,

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Academic Editor

PLOS ONE

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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: No

Reviewer #2: Partly

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

Reviewer #1: No

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: 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

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript addresses a significant and current topic in rehabilitation science, specifically the application of VR balance training following anterior cruciate ligament reconstruction. While the research question is valuable, the execution of the review and meta-analysis has several methodological weaknesses and areas for improvement in both the writing and statistical analysis.

Major Comments:

o The manuscript reports high heterogeneity in key outcomes such as the International Knee Documentation Committee (IKDC) score (I² = 90%). Although a sensitivity analysis was conducted, the sources of this heterogeneity are not adequately discussed. This raises concerns about the validity of the pooled results. High heterogeneity weakens the reliability of the findings and suggests that the included studies might differ significantly in their methods or patient characteristics. Further subgroup analyses or exploration of potential sources of heterogeneity (e.g., differences in rehabilitation duration or virtual reality training intensity) would strengthen the paper. Please provide a more thorough exploration of potential sources of variability (e.g., differences in intervention duration, VR systems used, patient characteristics). A deeper discussion of how the heterogeneity impacts the reliability of the meta-analysis results is required.

o The GRADE approach reveals that many of the included outcomes are based on low or very low-quality evidence. The manuscript should emphasize the limitations this places on the conclusions. While the authors acknowledge the need for more high-quality studies, the current conclusions seem stronger than what the data supports.

o Consider revising the tone of the conclusions to reflect the low certainty of evidence more clearly. Thus, while the study attempts to draw conclusions about the benefits of virtual reality balance training after ACL reconstruction, the limitations in data quality, heterogeneity, and small sample size weaken the strength of the conclusions.

Minor Comments:

o The manuscript contains several grammatical errors and awkward phrasing. A professional language review is necessary.

o It is not clear what the authors consider as VR. Please elaborate on your definition of VR. For example, do you consider exergames as VR?

o The details about the VR balance training interventions across studies are somewhat vague. Were the VR systems and training protocols comparable? More discussion on the variations in VR systems used (e.g., VR hardware, software, immersion level) would improve the interpretation of the findings.

o The presentation of tables and figures is generally clear, but some could benefit from more descriptive legends to help readers interpret the results without needing to refer back to the text.

o Figure 6 is missing a caption

o Given the significant heterogeneity in some outcomes, have you considered conducting subgroup analyses (e.g., based on age, gender, or duration of intervention)?

o How do you account for potential variations in the quality of virtual reality systems used across the studies? Could differences in the systems affect the outcomes?

o The GRADE assessment resulted in "very low" or "low" quality of evidence for most outcomes. How confident are you in the clinical relevance of the findings, and how would you suggest these results be used in practice?

Introduction:

o Better explain how VR is used in ACLR rehabilitation. As you talk about the potential of VR to "revolutionize ACLR rehabilitation" please make clear how exactly VR support the rehabilitation process.

o You intriduced the abbreviation VR in the introduction but cnstantly write virtual reality. keep it consistent.

o “Despite ACLR being a common procedure, the rate of successful return to pre-injury functional status is not as high as desired, with only around 24% of patients achieving this outcome.” – The phrase "not as high as desired" is vague and not appropriate for a research paper.

Methods

o "The intervention for the patients in the treatment group was combined with virtual reality balance training based on the control group". This is not clear.

o More detailed descriptions of the virtual reality interventions used in the included studies would be helpful. For example, what specific types of virtual reality balance training were applied (e.g., immersive vs. non-immersive VR)

o What is knee reaction time? There is no reference for this parameter

o What is routine rehabilitation (i.e. in table 1)? Be precise in describing the intervention for the CG.

o The manuscript switches between fixed and random effects models depending on the level of heterogeneity, but the rationale for these choices is not fully explained. The choice to use fixed effects for outcomes with lower heterogeneity is valid, but more justification is needed for how these models were selected and how they influence the interpretation of the data.

o Although the manuscript correctly states that the small number of included studies limits the utility of the funnel plot and Egger's test for detecting publication bias, it still includes these analyses.

Discussion

o “Proprioception is transmitted by nerves and plays an important role in joint stability, posture, and motor control.” This sentence does not make sense.

o "In a study [38] in which virtual reality balance training improved peripheral nerve damage, it was found that the improvement in proprioception was most likely achieved due to visual activation in virtual reality." Your reference [38] does not state anything about improved nerve damage following VR balance training nor about improved proprioception. In addition, this study did not use VR, but simple visual biofeedback of ankle motion on a screen. Your interpretation of the findings from [38] are a very far fetch.

o “The exercise process included in it may reduce pain by raising the pain threshold or increasing endogenous paroxysmal substances, among other pathways.” – The term “endogenous paroxysmal substances” is unclear and is completely out of context.

o Location where items are reported in the text are not correct in the Prisma Checklist.

Language

While the manuscript is generally intelligible, there are several grammatical issues and awkward phrasing that affect the clarity of the writing. Some examples include:

a) "The objective of this systematic review and meta-analysis is to clarify the effect the rehabilitation efficacy..." should be rephrased as "The objective of this systematic review and meta-analysis is to clarify the rehabilitation efficacy..."

b) "The prevalence of ACL injuries is relatively high among the younger population..." must be made more precise and concise.

c) “The IKDC score metrics were more heterogeneous, and a sensitivity analysis was performed on them, which revealed that the heterogeneity of the IKDC metrics was significantly reduced.” – The repetition of “IKDC metrics” and “heterogeneity” makes this sentence cumbersome.

d) “At the same time, due to the special physiological structure of women, the results may be different, so the gender should be distinguished in the design of the program and the differences in rehabilitation effects between different genders should be explored.” This sentence is cumbersome and unclear.

e) “[…] virtual reality balance training group rehabilitated a significant reduction in knee VAS scores, and the difference was statistically significant.”

f) “Controversial results were addressed by consulting with a third author when disagreements were encountered, they were discussed in consultation with a 3rd researcher (T.-C.G.).

These are just a few of the many grammatical and stylistic problems impair the readability and clarity of the text. To improve comprehensibility, a thorough language revision is required.

Reviewer #2: Title: report main findings in the title

abstract

any hypothesis?

what key words were used ?

conclusions: coehrent

introduction

too long and confusing

focus on your topic

report the necessity for this systematic review

report the rationale for your study

finish with aim and hypotheiss

methods

very well reported

results

too long try to reduce

discussion

start with main findings of your paper

report what Is new

analyze current literature

improve limitations

highlight clinical impact of your study

conclusions

coherenet

references

add following

Loucas M, Loucas R, D'Ambrosi R, Hantes ME. Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review. Orthop J Sports Med. 2021 Jul 2;9(7):23259671211024591. doi: 10.1177/23259671211024591. PMID: 34277881; PMCID: PMC8255613.

D'Ambrosi R, Valli F, Di Feo F, Marchetti P, Ursino N. Use of tourniquet in anterior cruciate ligament reconstruction: Is it truly necessary? A prospective randomized clinical trial. J Orthop Surg (Hong Kong). 2024 Sep-Dec;32(3):10225536241293538. doi: 10.1177/10225536241293538. PMID: 39418227.

D'Ambrosi R, Carrozzo A, Meena A, Corona K, Yadav AK, Annibaldi A, Kambhampati SBS, Abermann E, Fink C. A slight degree of osteoarthritis appears to be present after anterior cruciate ligament reconstruction compared with contralateral healthy knees at a minimum of 20 years: A systematic review of the literature. J Exp Orthop. 2024 Apr 4;11(2):e12017. doi: 10.1002/jeo2.12017. PMID: 38577065; PMCID: PMC10993150.

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Reviewer #1: No

Reviewer #2: No

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Efficacy of virtual reality balance training on rehabilitation outcomes following anterior cruciate ligament reconstruction: A systematic review and meta-analysis

PONE-D-24-41399R1

Dear Dr. Liu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Khalid Taher Mohammed Al-Hussaini, Ph.D

Academic Editor

PLOS ONE

Additional 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

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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 #2: Yes

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

Reviewer #2: 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 #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

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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 #2: the article deserve to be considered for publication after all the revisions that have been performed by the authors

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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 #2: No

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