The effectiveness of high-intensity interval training versus moderate intensity continuous training in prehabilitation among patients undergoing major abdominal surgery: A study protocol

Suriah Ahmad; Nor Azura Azmi; Nur Ayub Md Ali; Md Ali Katijjahbe; Ian Chik; Syarifah Noor Nazihah Sayed Masri; Adzim Poh Yuen Wen

doi:10.1371/journal.pone.0332361

Peer Review History

Original SubmissionMarch 26, 2025
21 May 2025 Decision Letter - Frederick Hong-Xiang Koh, Editor Dear Dr. Azmi, 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 Jul 05 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. 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'. 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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, Frederick Hong-Xiang Koh, MBBS, FRCSEd, PhD 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. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. 3. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF. 4. Please upload a copy of your study protocol that was approved by your ethics committee/IRB as a Supporting Information file. By the study protocol, we mean the complete and detailed plan for the conduct and analysis of the trial approved by the ethics committee/IRB. Please send this in the original language. If this is in a language other than English, please also provide a translation. [https://journals.plos.org/plosone/s/submission-guidelines#loc-guidelines-for-specific-study-types Additional Editor Comments: Please address the statistical plan and comments from the 2 reviewers before our reconsideration. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses??> Reviewer #1: No Reviewer #2: Partly ****** 3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable??> Reviewer #1: No Reviewer #2: Yes ****** 4. Have the authors described where all data underlying the findings will be made available when the study is complete??> The PLOS Data policy Reviewer #1: No Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics. You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. Reviewer #1: This study protocol intended to study the prehabilitation effectiveness for patients with upper abdominal surgery. A two-armed randomized controlled trial was designed to compare high versus moderate intensity training programs with a one to one ratio. The primary outcomes are the 6-minute walk test and maximal inspiratory pressure. The secondary outcomes include 1 minute sit to stand, short physical performance battery, the hospital anxiety and depression scale, hand grip strength, euroQol, self-assessment of physical activity questionnaire, fatigue severity scale etc. Multiple visit times will be investigated and data will be in a follow-up format. I think your sample size calculation is currently wrong. We usually do not use type I error rate of 0.9 in a sample size calculation. In addition to effect size of 30 meters difference in 6MWT, you also need to have a sensible value for the standard deviation. The results of only requiring 46 subjects probably are based on the assumption that you have very strong effect and very low variability. The statistical analysis is a typical longitudinal data analysis plan and looks straightforward to me. Change “two-tailed” to “two-sided” on page 19. Are there any potential side effects that you need to discuss? Reviewer #2: Thank you for your submission, it is a meaningful piece of work, and the results will make an impact on consideration of pre-habilitation exercise parameters for clinicians. These are points for consideration: 1) The max HR formula/ Karvonen method of calculation may not be suitable for all patient groups, there are other formulas which may be more suitable and considers past medical history such as if there are on beta blockers or not. This concerns safety, and is a necessary consideration 2) Other outcome measures such as 10m walk test ie walking speed can be considered. And also 1 minute STS vs 30s STS vs FTSTS has different advantages. Unless the patients have COPD? 3) Noted that PRE is a component of the exercise programme but there are no components of strength in the pre and post outcome measurement 4) May I check: Where is this exercise programme adopted from? 5) This exercise programme has multi components- including PRE and IMT, but the only difference between the the 2 groups are the aerobic component? Please clearly state under the intervention group, that they will also be receiving the same PRE and IMT training if so. ****** 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: Mah Shi Min ******** [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.0332361.r001
Revision 1
11 Aug 2025 Author Response We would like to thank the editor and the reviewers for the constructive feedback provided on our original submission. We have carefully addressed all comments and suggestions. We believe the revisions have significantly improved the clarity, scientific rigor, and presentation of the manuscript. A detailed, point-by-point response to each comment is provided in the table response to the reviewers below, along with marked and clean versions of the revised manuscript. In addition to addressing the reviewers’ comments, we would like to inform you of several amendments to the study protocol that were made prior to and independent of the reviewers’ feedback, and which have been approved by our institutional ethics committee. Firstly, we have revised our study population from patients undergoing “upper abdominal surgery” to those undergoing “major abdominal surgery”. This change was made primarily due to improved accessibility to an adequate sample size, which is crucial for ensuring the statistical power and generalizability of our findings. Additionally, the broader classification of major abdominal surgery still encompasses upper abdominal procedures and allows for a more inclusive representation of surgical patients who may benefit from prehabilitation. This adjustment aligns with similar protocols in existing literature and supports the feasibility of recruitment within the study timeframe. This amendment to the study population has been approved by the institutional ethics committee (please refer to the letter of ethical approval of the proposal amendment, 24th June 2025). Secondly, we also revised the study’s sample size from n= 60 to n=70, a decision made prior to receiving reviewer feedback. Additional amendments include: i) Removal of the inclusion criterion requiring participants to achieve a 6-minute walk distance of at least 300 m, due to the limited number of eligible patients and the absence of this requirement in previous related studies; ii) The age range for participants has been updated from 18-75 years to 18 years and above to broaden the recruitment pool, iii) Removal of the Hospital Anxiety and Depression Scale (HADS) as a screening tool, as HADS will be used as one of the outcome measures in this study. These amendments have been reviewed and approved by the institutional ethics committee (please refer to the letter of ethical approval of the proposal amendment, 6th August 2025). Thank you. Attachments Attachment Submitted filename: Rebuttal Letter Response to Reviewers.pdf https://doi.org/10.1371/journal.pone.0332361.r002
1 Sep 2025 Decision Letter - Frederick Hong-Xiang Koh, Editor The effectiveness of high-intensity interval training versus moderate intensity continuous training in prehabilitation among patients undergoing major abdominal surgery: A study protocol PONE-D-25-08010R1 Dear Dr. Azmi, 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, Frederick Hong-Xiang Koh, MBBS, FRCSEd, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? Reviewer #1: Yes ******** 2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses??> Reviewer #1: Yes ****** 3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable??> Reviewer #1: Yes ****** 4. Have the authors described where all data underlying the findings will be made available when the study is complete??> The PLOS Data policy Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics. You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. Reviewer #1: Authors now fully addressed all my previous comments. They corrected their original sample size formula and now I see no more serious issues. ****** 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 ******** https://doi.org/10.1371/journal.pone.0332361.r003
Formally Accepted
Acceptance Letter - Frederick Hong-Xiang Koh, Editor PONE-D-25-08010R1 PLOS ONE Dear Dr. Azmi, 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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 A/Prof Frederick Hong-Xiang Koh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0332361.r004

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