-->PONE-D-25-56497-->-->Effectiveness of a home-based exercise program for improving upper limb function in community-dwelling older people: a pragmatic randomized controlled trial-->-->PLOS One

Dear Dr. Bates,

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 Mar 21 2026 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 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,

Gurkan Gunaydin

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. We note that your Data Availability Statement is currently as follows:

“All relevant data are within the manuscript and its Supporting Information files.”

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

3. Please upload a new copy of Figure 1  as the detail is not clear. Please follow the link for more information:  https://journals.plos.org/plosone/s/figures

4. 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.

Additional Editor Comments:

Dear authors, please provide a point-by-point response to the reviewers' comments

[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: 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 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: GENERAL COMMENTS

Thank you for the opportunity to review manuscript # PONE-D-25-56497) titled “Effectiveness of a home-based exercise program for improving upper limb function in

community-dwelling older people: a pragmatic randomized controlled trial”. Overall, I think this is an important and well-done study and I enjoyed reading it. I am especially encouraged that the authors submitted this manuscript despite what were essentially null results. Why? Two reasons – First, the quality of any manuscript should be driven by the quality of the methods and not the results. Second, knowing what might not work, as well as what does work, are both important.

SPECIFIC COMMENTS

*Page 3, lines 53 and 54 (Abstract) – Since you say here in your Conclusions that people “can successfully learn and adhere to a home-based exercise...” I would suggest that you briefly report your results for adherence somewhere in the Results section of your abstract.

*Page 4 (Introduction) – I think this is a nice introduction. I only have one suggestion. Somewhere in your Introduction, briefly describe, with appropriate citations, the economic costs associated with upper limb dysfunction. This would provide additional justification for your study.

*Pages 8 through 14 (Materials and Methods) – In either a separate section at the end of your Methods or throughout your Methods section, please describe any post hoc changes to your a priori protocol, including the reasons for those changes.

*Page 9, lines 195 and 196 (Materials and Methods, Study Design) – Since you followed the CONSORT guidelines, and in addition to reference #39 (CONSORT 2010 Statement), it would be better to also include the CONSORT guidelines extension statement for pragmatic trials. Here’s the reference: Zwarenstein M, Treweek S, Gagnier JJ, et al. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ. 2008;337:a2390. Doi: 10.1136/bmj.a2390. This may also be helpful to you in the reporting of your entire study.

*Pages 10 through 12, lines 217 through 252 (Materials and Methods, Intervention) – Please specify the number of sets of each exercise that participants performed at each session. I’m assuming one but am not sure. Assuming this is accurate, maybe on lines 219 and 220 something like …”consisted of one set of eight exercises,… versus “…”consisted of a set of eight exercises,…” Also, on lines 230 and 231 could you please describe the “strategies to progressively increase the difficulty of the exercises as they advanced through the program.” I think some readers, including myself, would be especially interested in this. Finally, on lines 242 and 243, I’m encouraged to see you mention the behavioral intervention that you used.

*Pages 12 and 13 (Materials and Methods, Outcome measures, Primary outcome, Secondary outcomes) – In my opinion, a nice description of your primary and secondary outcomes.

*Page 14 (Materials and Methods, Data analysis) – Overall, a nice data analysis section. However, while you mention clinical relevance back in your abstract as well as in your Results, I do not see any information regarding what you considered to be a minimal clinically important difference (MCID) for your primary and secondary outcomes. I do however see data regarding a statistically significant difference for your primary and secondary physical outcomes, i.e., “…10% between-group difference in the DASH total score and the secondary physical outcomes, with a 15% loss to follow up (38).” Please elaborate. Also, please describe exactly what linear regression models you used with appropriate citations where necessary. Furthermore, please tell the reader if any adjustment was made for the multiple statistical tests you conducted and how this was done. If no adjustments were made, then this should also be stated. Finally, on line 303, please tell the reader if your tests for statistical significance were one-tailed or two-tailed.

*Page 15 (Table 2) – It would be nice to see 95% confidence intervals for this data.

*Page 17 (Results, Effect of intervention, Secondary outcomes) – Please tell the reader if the differences you observed were considered to be clinically important.

*Page 18 (Table 3) – In addition to absolute difference, please also report relative, i.e., percent, changes.

*Page 20 (Results, Adherence with the program) – Overall, a very nice description of adherence. I just have one suggestion. In the first paragraph, suggest that you report 95% confidence intervals for your percent adherence data.

*Page 21 (Acceptability of the intervention) – Overall, a very nice description here. Along those lines, it does not appear that kinesiophobia is a major issue for these folks.

*Pages 21 through 25 (Discussion) – Overall, a nice Discussion. However, for ease of reading, I would suggest that you partition your Discussion into the following subsections and address: (1) Overall findings, (2) Implications for research, (3) Implications for practice, (4) Implications for policy, if any, and (5) Strengths and potential limitations. Also, I think it is important to point out somewhere that “absence of evidence” is not “evidence of absence”.

END OF REVIEW

Reviewer #2: Thank you for the opportunity to review this manuscript.

A few points to consider

Introduction

- When referring to articles consider adding the date ex: Kim et al., (XXXX)

- I think the introduction can be made more concise. Consider condensing the concepts of shoulder dysfunction as well as condense your rationale for exercise interventions in the shoulder. Refer to systematic reviews and meta-analyses were appropriate to help summarize the literature more concisely.

- Maybe highlight the literature around the DASH to help justify it’s use as your primary outcome

Methods:

- I wonder if the Otago program was challenging enough for this demographic for the LL group, maybe biasing the upper extremity group

- Include a sample size calculation

- Lines ~217–233, 388–403

• The intervention relies on limited supervision (three sessions over 12 months).

• Average adherence (~2 sessions/week) falls below the prescribed dose.

• Exercises were performed seated, with modest resistance

• Clarify whether the intervention was designed as maintenance, prevention, or strength-building, and explicitly discuss whether the dose and progression were sufficient to elicit physiological adaptation in older adults.

- Strength and ROM were assessed only to 6 months, whereas DASH extended to 12 months.

Results:

- Lines ~349–364

• Results focus on statistical significance without adequate discussion of clinical relevance, particularly given low baseline impairment.

- Lines ~375–386

• The interaction with prior falls is interesting but underpowered and exploratory.

• Interpretation risks overstating importance.

Discussion

- Lines ~432–458 (Initial interpretation of findings)

• The discussion attributes null findings largely to adherence and supervision but does not sufficiently consider measurement sensitivity, baseline function, or comparator effects.

- Lines ~527–539

• Statements risk being interpreted as “home-based UL exercise is ineffective,” which is broader than supported by the data.

Minor Suggestions:

- Terms such as upper limb dysfunction, shoulder dysfunction, and shoulder pain are used interchangeably.

- In the discussion more explicitly distinguish acceptability, feasibility, and effectiveness to avoid conceptual overlap.

**********

-->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: 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.]

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.

<p>Effectiveness of a home-based exercise program for improving upper limb function in community-dwelling older people: a pragmatic randomized controlled trial

PONE-D-25-56497R1

Dear Dr. Bates,

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,

Gurkan Gunaydin

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: (No Response)

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: No

**********

-->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: GENERAL COMMENTS

Thank you for the opportunity to review revised manuscript # PONE-D-25-56497R1 titled “Effectiveness of a home-based exercise program for improving upper limb function in community-dwelling older people: a pragmatic randomized controlled trial”. In my opinion, the authors have done an excellent job in responding to my previous comments and suggestions, including an appropriate response to not adhering to several of my previously suggested changes. I only have one remaining comment, detailed below.

SPECIFIC COMMENT

*Pages 9 through 15, lines 184 and 328 (Materials and Methods) – Thank you for the information that there were no changes to your a priori protocol. However, I would suggest that you also insert this information at beginning or end of your Methods so that the reader is aware of such.

END OF REVIEW

Reviewer #2: Thank you for the opportunity to re-review the manuscript. The manuscript is well written and all my comments were addressed. I have no further comments.

**********

-->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:Christina Ziebart

**********