The role of obesity in physiological stress, balance, and proprioception during repetitive manual material handling tasks

Sergio A. Lemus; Jaron Mohammed; Cheng-Bang Chen; Thomas M. Best; Eduard Tiozzo; Francesco Travascio

doi:10.1371/journal.pone.0324996

Peer Review History

Original SubmissionFebruary 5, 2025
5 Feb 2025 Author Response https://doi.org/10.1371/journal.pone.0324996.r001
18 Feb 2025 Decision Letter - Emiliano Cè, Editor PONE-D-25-03867THE ROLE OF OBESITY IN PHYSIOLOGICAL STRESS, BALANCE, AND PROPRIOCEPTION DURING REPETITIVE MANUAL MATERIAL HANDLING TASKSPLOS ONE Dear Dr. Travascio, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Apr 04 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. 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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: Dear Authors, one expert in the field reviewed your manuscript reporting several minor issues you should consider during the revision process. [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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The manuscript presents a technically sound study on the effects of obesity on physiological stress, balance, and proprioception during manual material handling tasks. The methodology is rigorous, and the statistical analysis is appropriate, though the small sample size (n=30) and reliance on BMI as an obesity measure may limit generalizability. Expanding the sample size, incorporating direct body composition assessments, and recruiting occupation-specific participants would enhance validity. The study is clearly written, with well-structured arguments and practical implications for workplace ergonomics. Minor revisions are recommended to improve external applicability and strengthen conclusions. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy . Reviewer #1: Yes: Anees Alyafei ******** [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.0324996.r002
Revision 1
19 Feb 2025 Author Response AResponses to Reviewers’ Comments Reviewer: Dr. Anees Alyafei Review Comments to the Author Reviewer #1: The manuscript presents a technically sound study on the effects of obesity on physiological stress, balance, and proprioception during manual material handling tasks. The methodology is rigorous, and the statistical analysis is appropriate, though the small sample size (n=30) and reliance on BMI as an obesity measure may limit generalizability. Expanding the sample size, incorporating direct body composition assessments, and recruiting occupation-specific participants would enhance validity. The study is clearly written, with well-structured arguments and practical implications for workplace ergonomics. Minor revisions are recommended to improve external applicability and strengthen conclusions. Response: We sincerely appreciate the reviewer's insightful comments and valuable suggestions. In response to his recommendations, we have revised the manuscript accordingly. Please find our detailed responses below, with revisions highlighted in yellow. In determining the total number of participants for this study (30 participants), a power analysis was conducted to ensure statistical robustness and meaningful results. This consideration has been incorporated into the Discussion section. Changes have been highlighted in lines 344-349: “A total of 30 participants (15 male and 15 female) were evaluated in the present study. While a larger sample size would have been preferable, results from the post-hoc power analysis indicated that the sample was sufficient to detect significant differences in EER and HR (power ≥ 95%) across BMI groups and sex. Additionally, the sample was adequate for detecting effects in balance/proprioception values (power ≥ 91.3%), considering EER and BMI as the main effects.” Regarding the incorporation of direct body composition assessment, the limitations of BMI and the use of waist circumference as a substitute were addressed in the Discussion section. These changes have been added and highlighted in lines 352-358: “Furthermore, BMI does not account for body fat percentage or its distribution. Although the researchers selected only obese participants with minimal to no reported exercise history, body fat percentage, which is a more precise indicator of physiological stress than BMI, was not directly measured. However, as stated in the Results section, waist circumference showed an almost perfect correlation with BMI, suggesting that the participants' BMI in this study is closely related to their body fat percentage (Bozeman et al. 2012) and can be used as a substitute.” Lastly, the limitation of recruiting occupation-specific participant was acknowledged in the Discussion section. Changes have been added and highlighted in lines 349-352: “In addition, the participants' job roles did not consistently involve MMH tasks. Future research should specifically examine the effects of physiological stress, balance, and proprioception on participants that perform MMH tasks as part of their occupation to draw more definitive conclusions.” Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0324996.r003
28 Mar 2025 Decision Letter - Emiliano Cè, Editor PONE-D-25-03867R1THE ROLE OF OBESITY IN PHYSIOLOGICAL STRESS, BALANCE, AND PROPRIOCEPTION DURING REPETITIVE MANUAL MATERIAL HANDLING TASKSPLOS ONE Dear Dr. Travascio, 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: Dear Authors, your R1-manuscript version was re-assigned to two experts in the field that still reported some minor points you should consider during the revision process.============================== Please submit your revised manuscript by May 12 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, Emiliano Cè, Ph.D. 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 #1: All comments have been addressed 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 #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: 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 study employs a rigorous experimental design, including controlled testing conditions for balance, proprioception, and physiological stress. Appropriate statistical methods (two-way ANOVA, mixed-effects models) were used to compare groups. Energy Expenditure Rate (EER) and Heart Rate (HR) as physiological markers are well-chosen and valid indicators of fatigue and stress. The study follows ethical research guidelines, with Institutional Review Board (IRB) approval and informed consent obtained. Small Sample Size (n=30): Although a post-hoc power analysis justifies the sample size, a larger sample would improve generalizability. BMI is used as the primary obesity classification metric. While the authors include waist circumference, more precise. Long and Complex Sentence Structures: Original: "Manual laborers are prone to fatigue-related incidents, increasing the risk of balance disturbances and falls. Our previous work showed that obese individuals can reach critical fatigue levels during repetitive lifting, as defined by National Institute for Occupational Safety and Health (NIOSH). Therefore, assessing fatigue levels during manual handling activities beyond lifting is crucial to determine if this body mass index (BMI)-based pattern persists." Issue: The sentence is long and contains multiple ideas that could be broken down for clarity. Suggested Revision: "Manual laborers often experience fatigue-related incidents, which increase their risk of balance disturbances and falls. Previous research indicates that obese individuals may reach critical fatigue levels during repetitive lifting. This study examines whether this BMI-based fatigue pattern also applies to other manual handling activities." Original: "Additionally, evaluating balance loss when physiological stress becomes critical will help quantify the increased fall risk for obese individuals." Issue: The phrase "evaluating balance loss when physiological stress becomes critical" is somewhat ambiguous. Suggested Revision: "Assessing balance impairment under high physiological stress conditions will help quantify the increased fall risk in obese individuals." ⚠ Minor Typographical and Grammatical Errors: Original: "Results indicated a positive correlation between BMI and EER for both carrying (p = 0.003) and pushing/pulling (p = 0.013). In the mixed-effects model, BMI (p = 0.032) and EER (p = 0.037) were positively correlated with knee proprioception loss, whereas EER was negatively correlated with balance (p = 0.020). These findings confirm that obese individuals face a critical fatigues levels and impaired proprioception and balance during repetitive handling tasks." Issue: "face a critical fatigues levels" contains a grammatical error ("fatigues" should be "fatigue"). Suggested Revision: "These findings confirm that obese individuals face critical fatigue levels, as well as impaired proprioception and balance, during repetitive handling tasks." Original: "Carrying and pushing/pulling tasks were performed by 30 participants, with weights calculated using the Liberty Mutual Equations to meet NIOSH criteria." Issue: "Carrying and pushing/pulling tasks were performed by 30 participants" is slightly awkward in construction. Suggested Revision: "Thirty participants performed carrying and pushing/pulling tasks, with weights determined using the Liberty Mutual Equations to align with NIOSH criteria." Reviewer #2: (No Response) ****** 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: Yes: Anees Alyafei 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. https://doi.org/10.1371/journal.pone.0324996.r004
Revision 2
30 Mar 2025 Author Response Responses to Reviewers’ Comments Reviewers: Anees Alyafei, Reviewer #2 Review Comments to the Author Reviewer #1: The study employs a rigorous experimental design, including controlled testing conditions for balance, proprioception, and physiological stress. Appropriate statistical methods (two-way ANOVA, mixed-effects models) were used to compare groups. Energy Expenditure Rate (EER) and Heart Rate (HR) as physiological markers are well-chosen and valid indicators of fatigue and stress. The study follows ethical research guidelines, with Institutional Review Board (IRB) approval and informed consent obtained. Small Sample Size (n=30): Although a post-hoc power analysis justifies the sample size, a larger sample would improve generalizability. BMI is used as the primary obesity classification metric. While the authors include waist circumference, more precise. Response: We sincerely appreciate the reviewer's feedback and valuable suggestions. In response to his recommendations, we have revised the manuscript accordingly. Please find our detailed responses below, with revisions highlighted in yellow. Regarding the sample size of 30 participants, we acknowledged this as a limitation in the Discussion section, mentioning the inclusion of a post-hoc power analysis and that a larger sample size would be ideal. This was included and highlighted in lines 342-347: “A total of 30 participants (15 male and 15 female) were evaluated in the present study. While a larger sample size would have been preferable, results from the post-hoc power analysis indicated that the sample was sufficient to detect significant differences in EER and HR (power ≥ 95%) across BMI groups and sex. Additionally, the sample was adequate for detecting effects in balance/proprioception values (power ≥ 91.3%), considering EER and BMI as the main effects.” Long and Complex Sentence Structures: Original: "Manual laborers are prone to fatigue-related incidents, increasing the risk of balance disturbances and falls. Our previous work showed that obese individuals can reach critical fatigue levels during repetitive lifting, as defined by National Institute for Occupational Safety and Health (NIOSH). Therefore, assessing fatigue levels during manual handling activities beyond lifting is crucial to determine if this body mass index (BMI)-based pattern persists." Issue: The sentence is long and contains multiple ideas that could be broken down for clarity. Suggested Revision: "Manual laborers often experience fatigue-related incidents, which increase their risk of balance disturbances and falls. Previous research indicates that obese individuals may reach critical fatigue levels during repetitive lifting. This study examines whether this BMI-based fatigue pattern also applies to other manual handling activities." Response: We have addressed it as suggested and incorporated the following revisions in lines 002–005: “Manual laborers often experience fatigue-related incidents, which increase their risk of balance disturbances and falls. Previous research indicates that obese individuals may reach critical fatigue levels during repetitive lifting. This study examines whether this BMI-based fatigue pattern also applies to other manual handling activities.” Original: "Additionally, evaluating balance loss when physiological stress becomes critical will help quantify the increased fall risk for obese individuals." Issue: The phrase "evaluating balance loss when physiological stress becomes critical" is somewhat ambiguous. Suggested Revision: "Assessing balance impairment under high physiological stress conditions will help quantify the increased fall risk in obese individuals." Response: Suggested revisions have been added and highlighted in lines 005-007: “Therefore, assessing balance impairment under high physiological stress conditions will help quantify the increased fall risk in obese individuals.” Minor Typographical and Grammatical Errors: Original: "Results indicated a positive correlation between BMI and EER for both carrying (p = 0.003) and pushing/pulling (p = 0.013). In the mixed-effects model, BMI (p = 0.032) and EER (p = 0.037) were positively correlated with knee proprioception loss, whereas EER was negatively correlated with balance (p = 0.020). These findings confirm that obese individuals face a critical fatigues levels and impaired proprioception and balance during repetitive handling tasks." Issue: "face a critical fatigues levels" contains a grammatical error ("fatigues" should be "fatigue"). Suggested Revision: "These findings confirm that obese individuals face critical fatigue levels, as well as impaired proprioception and balance, during repetitive handling tasks." Response: We have corrected this sentence and highlighted the changes in lines 014–016: “These findings confirm that obese individuals face critical fatigue levels, as well as impaired proprioception and balance, during repetitive handling tasks.” Original: "Carrying and pushing/pulling tasks were performed by 30 participants, with weights calculated using the Liberty Mutual Equations to meet NIOSH criteria." Issue: "Carrying and pushing/pulling tasks were performed by 30 participants" is slightly awkward in construction. Suggested Revision: "Thirty participants performed carrying and pushing/pulling tasks, with weights determined using the Liberty Mutual Equations to align with NIOSH criteria. Response: Suggested revision was added and highlighted in lines 007–008: “Thirty participants performed carrying and pushing/pulling tasks, with weights determined using the Liberty Mutual Equations to align with NIOSH criteria.” Reviewer #2: (No Response) Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0324996.r005
5 May 2025 Decision Letter - Emiliano Cè, Editor THE ROLE OF OBESITY IN PHYSIOLOGICAL STRESS, BALANCE, AND PROPRIOCEPTION DURING REPETITIVE MANUAL MATERIAL HANDLING TASKS PONE-D-25-03867R2 Dear Dr. Travascio, 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, Emiliano Cè, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0324996.r006
Formally Accepted
Acceptance Letter - Emiliano Cè, Editor PONE-D-25-03867R2 PLOS ONE Dear Dr. Travascio, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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 Prof. Emiliano Cè Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0324996.r007

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