Dear Dr. Seyedhoseinpoor,

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 Nov 10 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'.
• 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,

Seyed Hamed Mousavi

Academic Editor

PLOS ONE

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements.-->--> -->-->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 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.-->--> -->-->3. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. ?>

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1:  Dear Authors

I would like to thank you for giving me an opportunity to consider this work for publication. You well done the a point by point answer to the comments of the reviewers about previous revision. Paper needs few minor edits actually now:

- I recommend adding a few sentences in the introduction, about the effectiveness and usefulness of the Effects of Breathing Exercise in various musculoskeletal disorders, neck pain, shoulder pain, low back pain.

- Discussions should be reviewed in light of the overall improvement of the paper. Redundant sentences and prewritten information should be avoided. Focus on take-home messages and how that information impacts the clinical practice of management these patients.

- I suggest to add this reference:

Cefalì A, Santini D, Lopez G, Maselli F, Rossettini G, Crestani M, Lullo G, Young I, Dunning J, de Abreu RM, Mourad F. Effects of Breathing Exercises on Neck Pain Management: A Systematic Review with Meta-Analysis. J Clin Med. 2025 Jan 22;14(3). doi: 10.3390/jcm14030709. Review. PubMed PMID: 39941380; PubMed Central PMCID: PMC11818914.

Reviewer #2:  This is a well-structured systematic review and meta-analysis examining the effects of breathing exercises and thoracic techniques on pain and disability in patients with low back pain (LBP). The study addresses an important clinical topic, given the high prevalence of LBP and the need for non-invasive interventions. The methods are rigorous, adhering to PRISMA guidelines, with a registered protocol on PROSPERO, comprehensive search strategy, appropriate risk of bias assessment using RoB 2, and quality evaluation via GRADE. The inclusion of subgroup and sensitivity analyses to address heterogeneity is commendable. However, the high heterogeneity in results, low quality of evidence, and potential publication bias limit the strength of conclusions. The revised version incorporates an updated search (to May 1, 2025) and additional studies, strengthening the analysis compared to prior iterations.

Major Comments:

1. Heterogeneity: High heterogeneity (I² > 85% for pain, >90% for disability) persists despite subgroup analyses. While some reductions occur (e.g., I² = 30.5% for >4 weeks treatment in disability), sources remain unclear. Discuss potential unmeasured factors (e.g., LBP chronicity, co-interventions, outcome measurement timing) more deeply. Consider meta-regression if data allow, or explicitly state why it was not performed. In the revised version, the shift to SMD in some sections (e.g., page 67) is inconsistent with Morris' dppc—clarify and standardize.

2. Quality of Evidence and Interpretation: GRADE rates evidence as low/very low, yet conclusions emphasize effectiveness (e.g., "thoracic techniques are more effective"). Temper claims to reflect this (e.g., "may be effective based on low-quality evidence"). Highlight implications for practice: given low evidence, these interventions should be adjunctive, not first-line. Address why thoracic techniques show larger effects— is it due to higher bias in those studies?

3. Publication Bias: Funnel plots suggest bias for disability (and pain in some versions), but Egger's/trim-and-fill do not. This discrepancy warrants discussion. The jackknife method identifies one influential study (Ho-Hee 2015) for disability—exclude it in sensitivity analysis and report if results change substantially.

4. Search Update: The search ends May 1, 2025, but the current date is September 24, 2025. While the revision addresses prior PLOS ONE concerns, perform a quick update to ensure no new studies (e.g., via PubMed alert). If none, state this. The inclusion of non-English studies (Korean, Chinese, Spanish) is a strength, but confirm translations were accurate.

5. Outcome Measures: Pain and disability are primary, but tools vary (VAS/NRS for pain, ODI/RMQ for disability). Discuss if this contributes to heterogeneity. Consider pooled results by specific tool in subgroups. Also, the abstract reports 36 studies in meta-analysis, but text specifies 31 for pain/24 for disability—clarify.

Minor Comments:

- Abstract: Update to reflect revised effect sizes (e.g., large for disability). Specify "thoracic manual techniques" for clarity.

- Methods: Search syntax in S1 Appendix is noted—ensure it's included. Define "thoracic techniques" more precisely (e.g., HVLA vs. mobilization).

- Results: Tables 2-4 are clear, but label effect sizes consistently (Morris' dppc vs. SMD in revisions). Figures 3-7 need legends for clarity.

- Discussion: Integrate recent studies (added in revision) more explicitly. Compare to Fabero-Garrido et al. (2024) on respiratory muscle training.

- References: Up-to-date, but check formatting (e.g., DOI consistency).

- Writing and Clarity: Minor typos (e.g., "Based on of the included studies" in conclusion; "dppc" vs. "SMD" inconsistencies). Ensure consistent terminology (e.g., "CLBP" vs. "LBP").

- Supplementary Materials: PRISMA checklist is referenced—verify completion. Include flow diagram (Fig 1) details.

**********

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:  Sarvenaz Karimi

**********

[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.

Dear Dr. Seyedhoseinpoor,

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 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.

• 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 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,

Seyed Hamed Mousavi

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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

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??>

Reviewer #1: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Dear Authors

I would like to thank you for giving me an opportunity to consider this work for publication. You well done the a point by point answer to the comments of the reviewers Thanks

Reviewer #2: This revised manuscript shows substantial and meaningful improvement compared with the original version. The authors have carefully addressed most major reviewer comments raised in the first round, particularly those concerning methodological clarity, conceptual depth, and consistency in reporting. The study is now more coherent, transparent, and aligned with PRISMA and GRADE standards.

The topic remains highly relevant, as it investigates the effects of breathing exercises and thoracic manual techniques—an innovative, non-invasive approach to low back pain (LBP) rehabilitation. The revision strengthens the overall scientific and clinical credibility of the work. However, a few issues related to residual heterogeneity, limited exploration of moderators, and overinterpretation of low-certainty evidence still need refinement before acceptance.

Minor Comments

Include abbreviations in table footnotes for clarity (e.g., RMQ = Roland–Morris Questionnaire, ODI = Oswestry Disability Index).

Ensure figure legends clearly describe the direction of effect and metric (Morris’ dppc).

Confirm that all supplementary materials (search syntax, PRISMA checklist, flow diagram) are included and updated.

Check reference formatting (consistent DOI presentation)

**********

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:  Sarvenaz Karimi-ghasemabad

**********

[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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures 

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. 

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Effects of Breathing Exercise and Thoracic Techniques on Pain and Disability in Low Back Pain: A Systematic Review and Meta-analysis

PONE-D-25-26341R2

Dear Dr. Seyedhoseinpoor,

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.

Reviewer2 raised a few minor comments that can be addressed during the proofing stage.

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,

Seyed Hamed Mousavi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

**********

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

Reviewer #2: (No Response)

**********

Reviewer #2: PLOS ONE Peer-Review Report

Manuscript Number: PONE-D-25-26341R2

Title: Effects of Breathing Exercise and Thoracic Techniques on Pain and Disability in Low Back Pain: A Systematic Review and Meta-analysis

Overall Recommendation: ACCEPT with very minor revisions

(The manuscript is now of publishable quality for PLOS ONE, and the authors have satisfactorily addressed almost all previous concerns.)

Summary

This R2 version represents a clear and substantial improvement over the original submission and R1. The authors have carefully responded to both reviewers, updated supplementary files, clarified statistical methods, improved figure legends, ensured consistent abbreviation definitions, and moderated the language in the Conclusion to better reflect the low/very low certainty of evidence according to GRADE.

The topic remains highly clinically relevant: combining breathing/retraining of the diaphragm with thoracic manual therapy is an emerging, low-risk approach in non-specific low back pain, and this is the most comprehensive meta-analysis on this specific combination to date .

Strengths

• Comprehensive, pre-registered (PROSPERO), PRISMA-compliant search with no language restrictions and translation of non-English trials

• Appropriate use of Morris’ dppc2 (pre-post-control effect size) for the predominant study designs

• Transparent risk-of-bias assessment (RoB 2 + robvis figures) and correct application of GRADE (downgraded for inconsistency, imprecision, and risk of bias)

• Subgroup and sensitivity analyses that partially explain the high heterogeneity

• Clinically useful distinction between “breathing exercises only” vs. “thoracic manual techniques” (the latter showing clearly superior effects)

• Balanced discussion of mechanisms (diaphragm–core synergy, thoracic stiffness, regional interdependence)

Remaining very minor issues (can be corrected in proof stage)

1. Abstract (line about heterogeneity): the sentence “However, statistical heterogeneity remained across studies” is correct but slightly understates the issue. Consider changing to: "However, substantial statistical heterogeneity (I² > 85%) persisted in most analyses.”

2. Table 1 (Characteristics of included studies): Please add one column indicating “LBP duration” (acute/subacute/chronic/mixed) for each study – this is a major source of clinical heterogeneity and would take only a few minutes to insert.

3. Figure legends (Forest plots): Already much improved, but add one short sentence to each: Negative values favour the thoracic/breathing intervention.”

4. Discussion – page ~29: Add one small typo: “catious” → “cautious”

Final decision

The manuscript is now suitable for publication in PLOS ONE.

Decision: ACCEPT with very minor revisions

(The above four points can be addressed by the editorial office during copy-editing or by the authors in proof. No further peer-review round is required.)

Congratulations to the authors on a well-conducted and clinically meaningful systematic review.

**********

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 #2: Yes:  Sarvenaaz Karimi-ghasemabad

**********