PONE-D-24-55797MSKP INDEX: RISK MODEL OF MUSCULOSKELETAL PAIN IN A COLOMBIAN ADOLESCENT SAMPLEPLOS ONE

Dear Dr. Uribe-Laverde,

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 May 01 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,

Alejandro Botero Carvajal, MD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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

2. Please note that funding information should not appear in any section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript.

3. Thank you for stating the following financial disclosure:

 “This study was funded by the University of La Sabana (2020 – Convocatoria Interna Para La Financiación De Proyectos De Investigación, Creación, Desarrollo Tecnológico E Innovación). Project Id: ENF-59-2020.” 

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

4. Please note that your Data Availability Statement is currently missing the repository name and/or the DOI/accession number of each dataset OR a direct link to access each database. If your manuscript is accepted for publication, you will be asked to provide these details on a very short timeline. We therefore suggest that you provide this information now, though we will not hold up the peer review process if you are unable.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

[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: No

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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

**********

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

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

Reviewer #1: Yes

Reviewer #2: 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: Authors and Editor, Dear

This manuscript, "MSKP INDEX: RISK MODEL OF MUSCULOSKELETAL PAIN IN A COLOMBIAN ADOLESCENT SAMPLE," presents an intriguing effort to develop a logistic regression-based risk model for musculoskeletal pain (MSKP) among Colombian adolescents. The study leverages a sizable sample (n=680) and addresses a regionally underexplored issue, proposing a novel MSKP index and risk scale with potential practical applications. The use of validated tools and advanced statistical methods (e.g., Lasso regularization, cross-validation) demonstrates methodological ambition. However, the manuscript requires significant revisions to meet the rigorous standards of a JCR-indexed journal like PLOS ONE. Key concerns include methodological ambiguities (e.g., MSKP index validation, feature selection details), statistical shortcomings (e.g., lack of overfitting checks, unadjusted odds ratios), and interpretive overreach (e.g., implied causality in a cross-sectional design). Below, I outline the main criticisms for each section, offering specific recommendations to enhance clarity, rigor, and impact. I recommend major revisions to address these issues, confident that the study’s potential can be realized with careful refinement.

Title and Keywords

� Revise the title to eliminate redundancy (e.g., "Development of the MSKP Index: A Risk Model for Musculoskeletal Pain in Colombian Adolescents") and consider adding methodological specificity (e.g., "Logistic Regression Model").

� Replace "Physiotherapy" in keywords with "Logistic Regression" or "Risk Assessment" to align with the study’s core methodology.

Abstract

� Specify the MSKP prevalence (e.g., "22.6% of participants reported MSKP") to enhance informativeness.

� Detail the methods by briefly mentioning feature selection (e.g., "using correlation analysis and Lasso regularization") and validation (e.g., "cross-validated on a test set").

� Trim the abstract to fit PLOS ONE’s 200–250-word limit while retaining essential details, ensuring conciseness without sacrificing clarity.

Introduction

� Expand the literature review to include a broader geographical and methodological scope (e.g., European studies like Hestbaek et al., 2006, Spine).

� Use cautious language to avoid unsupported causal claims (e.g., "may contribute to" instead of "trigger" for posture and pain).

� Substantiate the Latin American research gap with evidence (e.g., cite a review or meta-analysis).

� Articulate a specific hypothesis (e.g., "We hypothesized that mobile dependency and sleep quality would be significant predictors of MSKP") to provide a theoretical foundation.

Methods

� Address potential seasonal effects of data collection (September–October 2022) on physical activity or pain reporting.

� Recalculate sample size using a realistic prevalence estimate (e.g., 20–30% from prior studies) instead of the unjustified 50%, and report a power analysis.

� Acknowledge non-probabilistic sampling as a limitation and clarify vague exclusion criteria (e.g., specify types of "diagnosed disabilities").

� Validate the MSKP index cutoff (≥4) against clinical standards (e.g., pain duration, functional impairment) and justify pain intensity categories (1–3, 4–7, >7) with psychometric evidence.

� Provide reliability statistics for all instruments (e.g., IPAQ, sleep scale), not just TDM.

� Detail feature selection by specifying the correlation threshold and Lasso regularization parameters (e.g., lambda).

� Justify the cross-validation scheme (20x 3-fold) relative to sample size and clarify the standardization method (e.g., z-scoring).

� Adjust odds ratios (ORs) for multiple comparisons (e.g., Bonferroni) to reduce type I error risk.

Results

� Add confidence intervals or p-values to Table 1 for prevalence estimates and contextualize the mobile dependency score (e.g., clinical cutoff).

� Discuss the correlation dendrogram (Figure A.1) in the text to guide interpretation.

� Benchmark the Lasso model AUC (0.78) against simpler models (e.g., univariate regression) and quantify ROC curve variance (e.g., SD of AUC).

� Assess overfitting risk in the final model (e.g., via calibration plots or Brier score) and report sensitivity/specificity for each risk scale cutoff (Figure 4c).

� Test linearity assumptions for ORs (e.g., sleep_factor_5 OR = 7.89) and discuss coefficient instability indicated by wide CIs (e.g., [4.72–11.9]).

Discussion

� Use precise language (e.g., "associated with" instead of "correlated") to reflect logistic regression results accurately.

� Balance emphasis on mobile dependency (OR = 1.72) relative to stronger predictors like sleep factors, avoiding overhyping its role.

� Hypothesize mechanisms for football’s protective effect (OR = 0.66), such as aerobic fitness or coordination, to deepen interpretation.

� Engage critically with prior studies (e.g., explain differences from Thailand/Japan findings) rather than offering superficial comparisons.

� Benchmark the MSKP index against existing tools (e.g., Nordic Musculoskeletal Questionnaire) to substantiate novelty claims.

Conclusion

� Specify the MSKP index’s intended application (e.g., "for screening high-risk adolescents") rather than using vague terms like "promising."

� Avoid causal language (e.g., "contributing to this risk") given the cross-sectional design, emphasizing the need for longitudinal validation.

Limitations

� Acknowledge additional limitations: non-probabilistic sampling, lack of external validation, and potential overfitting risk.

� Clarify the ambiguous suggestion of "multiple regression models" (e.g., specify multinomial logistic regression or another approach).

Additional Sections

� Complete funding details per PLOS ONE guidelines (e.g., include grant amount for Project ID: ENF-59-2020).

� Resolve the placeholder Harvard Dataverse DOI ("XXX") with a functional link.

� Update references to include key predictive modeling studies (e.g., Hestbaek et al., 2006; Dunn et al., 2013) and address timeline issues (e.g., remove or justify 2024 citations post-dating 2022 data collection).

Reviewer #2: Peer Review for Manuscript PONE-D-24-55797: MSKP INDEX: RISK MODEL OF MUSCULOSKELETAL PAIN IN A COLOMBIAN ADOLESCENT SAMPLE

General Assessment

The study presents a risk model for musculoskeletal pain (MSKP) in Colombian adolescents, addressing an important topic. However, several issues related to methodology, data presentation, and interpretation need to be addressed for clarity and scientific rigor.

Major Comments

1. Introduction

• The study lacks a clear theoretical framework explaining how risk factors (e.g., mobile dependency, sleep disorders) contribute to MSKP.

• The global prevalence of adolescent MSKP should be briefly discussed to highlight the study’s significance.

2. Methodology

• The broad age range (10–18 years) is not justified. Adolescents experience different developmental changes, so age-stratified analysis is recommended.

• The case definition (MSKP score ≥4) needs validation. Why was this threshold chosen?

• The feature selection method (Lasso Regression) should be justified against alternatives like PCA or stepwise regression.

• Confounding factors (nutrition, mental health, socioeconomic status) are not considered but could influence MSKP risk.

3. Results

• The 22.6% prevalence of MSKP should be reported with confidence intervals for accuracy.

• Regression coefficients should include effect sizes and confidence intervals to assess the strength of associations.

• The logistic regression model (AUC = 0.83) is promising but needs calibration plots and sensitivity/specificity values to confirm robustness.

4. Discussion

• The study suggests causal relationships, but given its cross-sectional design, only associations can be inferred.

• The sample is region-specific (Colombia), limiting generalizability. This should be acknowledged.

• A stronger comparison with existing research would help contextualize the findings.

5. Limitations

The limitations section should be included, highlighting:

• The cross-sectional nature (no causal conclusions).

• The lack of objective measures for physical activity and sleep quality.

Minor Revisions

• Abstract: Should briefly mention key limitations (e.g., cross-sectional design, self-reported data).

• Figures & Tables:

o Add scatterplots for key correlations (e.g., mobile dependency vs. MSKP risk).

o Ensure confidence intervals are included in tables.

• References: Ensure citations follow PLOS One formatting and include key MSKP studies.

**********

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: Yes:  Cihan Aygün

**********

[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.pdf

DEVELOPMENT OF THE MSKP INDEX: RISK MODEL OF MUSCULOSKELETAL PAIN IN COLOMBIAN ADOLESCENTS

PONE-D-24-55797R1

Dear Dr. Uribe-Laverde,

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. For questions related to billing, please contact billing support .

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,

Alejandro Botero Carvajal, Ph.D

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

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: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: (No Response)

Reviewer #2: The authors have comprehensively addressed reviewer comments with appropriate methodological enhancements and a clearer presentation. The revisions demonstrate good scientific practice and significantly strengthen the manuscript's quality.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

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

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

Reviewer #1: No

Reviewer #2: Yes:  Cihan Aygün

**********