-->PONE-D-26-20182-->-->Effectiveness of Exercise-Based Rehabilitation for Depressive Symptoms, Anxiety, and Health-Related Quality of Life in Adults With Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials-->-->PLOS One

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #2: Yes

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Reviewer #1: Title: Effectiveness of Exercise-Based Rehabilitation for Depressive Symptoms, Anxiety, and Health-Related Quality of Life in Adults With Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

General:

This is an interesting and clinically relevant study addressing rheumatoid arthritis (RA), a condition well known not only for joint pain and functional limitation, but also for its substantial psychological burden, including depression, anxiety, and impaired health-related quality of life (HRQoL). The topic is important because many patients with RA are often reluctant to engage in exercise due to fear that physical activity may worsen pain or joint damage. The authors appropriately highlighted that evidence regarding exercise as an adjunctive therapy for psychological outcomes in RA remains heterogeneous and inconsistent, which provides a strong rationale for conducting this systematic review and meta-analysis.

Several methodological and reporting issues should be clarified and strengthened.

Introduction:

1. The introduction is relatively lengthy and somewhat repetitive in several sections.

2. Some theoretical explanations are overly extensive and delay the presentation of the primary research objective.

3. It remains unclear whether the authors intended to evaluate exercise interventions broadly or compare the effectiveness of different exercise modalities.

Suggestion: The authors may consider discussing fear-avoidance behavior or kinesiophobia in RA patients, as this is highly relevant to exercise adherence and rehabilitation participation.

Methods:

1. The manuscript should more explicitly emphasize adherence to the PRISMA 2020 guideline. Although PRISMA was mentioned, this reporting framework should be highlighted more prominently as the methodological standard.

2. The inclusion criteria regarding exercise interventions were very broad.

The review combined aerobic exercise, resistance training, walking programs, yoga, Tai Chi, and Yi Jin Jing into pooled analyses, which may substantially increase clinical heterogeneity.

3. The exclusion criteria were insufficiently described.

The manuscript only briefly mentioned exclusion of mixed inflammatory populations when RA data were unavailable separately. It remains unclear: whether non-English studies were excluded, whether grey literature was included, whether conference abstracts were considered, whether patients with severe psychiatric disorders were excluded, or whether co-interventions were allowed.

4. The manuscript did not sufficiently explain how different psychological instruments were harmonized beyond the use of standardized mean differences.

5. Publication bias and small-study effects were only briefly discussed.

Suggestion:

Additional subgroup analyses based on: exercise intensity, supervision, intervention duration, disease activity, baseline depression severity,

may improve clinical interpretability.

Results:

1. Clinical heterogeneity was substantial regarding: exercise modality, intervention duration, frequency, comparator groups, outcome instruments.

2. Most outcomes relied on self-reported questionnaires, increasing susceptibility to expectancy bias.

3. Several included studies had relatively small sample sizes (<60 participants).

4. Minimal clinically important differences (MCID) were not discussed.

Suggestion: Consider adding a dedicated table summarizing FITT principles (frequency, intensity, time, type), additional analyses comparing supervised versus home-based exercise may be clinically valuable, reporting absolute effects alongside SMDs may improve interpretability for clinicians.

Discussion:

1. The discussion is overly long and occasionally repetitive.

2. Some mechanistic explanations are speculative and excessively broad.

3. Certain sections resemble a narrative review rather than a focused interpretation of study findings.

Conclusion:

1. Practical recommendations for clinicians remain somewhat limited.

Final Recommendation

This manuscript addresses a clinically important and underrecognized aspect of RA management, namely the psychological impact of the disease and the potential role of exercise-based rehabilitation. The systematic review and meta-analysis are generally well conducted and aligned with PRISMA methodology. However, several methodological clarifications and improvements are needed, particularly regarding heterogeneity, exclusion criteria, and interpretation of clinical significance, before publication.

Reviewer #2: The study aimed to investigate the effects of structured exercise interventions with depressive symptoms, anxiety, and HRQoL in adults with RA, as well as to explore whether the effects differed between conventional exercise and mind-body exercise.

The manuscript is well delimited and follows the available reporting guidelines. The introduction is well grounded and appropriately contextualizes the research problem. In addition, the discussion and conclusion are consistent with and limited to the findings presented in the results.

However, the absence of the supplementary files (eTables) prevented a proper assessment of whether each methodological step was rigorously conducted, as well as verification of the information reported in the manuscript. I am unsure whether this omission was due to an issue on the part of the journal or the authors.

Additionally, instead of using the ROB tool, the authors could consider adopting the RoB 2 tool, which may provide a more robust assessment of risk of bias for randomized studies.

Finally, given the heterogeneity of the interventions included, I suggest that the authors consider the possibility of conducting a network meta-analysis.

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Reviewer #1: No

Reviewer #2: Yes:  Danilo Reis Coimbra

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Effectiveness of exercise-based rehabilitation for depressive symptoms, anxiety, and health-related quality of life in adults with rheumatoid arthritis: A systematic review and meta-analysis of randomized controlled trials

PONE-D-26-20182R1

Dear Dr. yan xiao,

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.

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Kind regards,

Marwan Salih Al-Nimer, MD, PhD

Academic Editor

PLOS One

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