-->PONE-D-24-07775-->-->Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis-->-->PLOS ONE

Dear Dr. Ha,

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.

==============================

ACADEMIC EDITOR:   Please provide more detailed information regarding the inclusion and exclusion criteria used for selecting studies in your systematic review. This will enhance the transparency of your methodology.-->

Please ensure that the rationale for your chosen statistical tests is clearly stated. While you have identified several limitations, expanding this section to include potential biases in the included studies would strengthen your manuscript. Please review the formatting of your references to ensure consistency with the journal’s guidelines. A few references need to be double-checked for completeness.

I appreciate the effort you have put into this important research, and I believe that addressing these comments will significantly enhance the quality of your manuscript. I look forward to receiving your revised submission.

-->==============================

Please submit your revised manuscript by Nov 15 2024 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,

Sahreen Anwar, PhD Physical Therapy

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 the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. -->--> -->-->When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.-->--> -->-->3. 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.-->--> -->-->4. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following: -->--> -->-->A numbered table of all studies identified in the literature search, including those that were excluded from the analyses.  -->--> -->-->For every excluded study, the table should list the reason(s) for exclusion.  -->--> -->-->If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed. -->--> -->-->A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study: -->--> -->-->Name of data extractors and date of data extraction -->--> -->-->Confirmation that the study was eligible to be included in the review.  -->--> -->-->All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses. -->--> -->-->If data or supporting information were obtained from another source (e.g. correspondence with the author of the original research article), please provide the source of data and dates on which the data/information were obtained by your research group. -->--> -->-->If applicable for your analysis, a table showing the completed risk of bias and quality/certainty assessments for each study or outcome.  Please ensure this is provided for each domain or parameter assessed. For example, if you used the Cochrane risk-of-bias tool for randomized trials, provide answers to each of the signalling questions for each study. If you used GRADE to assess certainty of evidence, provide judgements about each of the quality of evidence factor. This should be provided for each outcome.  -->--> -->-->An explanation of how missing data were handled. -->--> -->-->This information can be included in the main text, supplementary information, or relevant data repository. Please note that providing these underlying data is a requirement for publication in this journal, and if these data are not provided your manuscript might be rejected.-->-->

Additional Editor Comments:

Comments from the staff editor team (plosone@plos.org): Please discuss the implications of the high level of heterogeneity between studies, and the high risk of bias.

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

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

Reviewer #1: 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

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-->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

**********

-->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: shoulder impingement is a common condition encountered by many clinicians in their clinical practice, this systematic review with meta analysis gives a summarized information from various parts of the world on the subject title.

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-->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: Yes:  Wajida Perveen

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[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.-->

-->PONE-D-24-07775R1-->-->Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis-->-->PLOS ONE

Dear Dr. Ha,

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.

==============================

The key areas that require your attention are as follows:-->

Statistical Heterogeneity : Many meta-analyses reported high I² values, which compromise interpretability. You are advised to explore sources of heterogeneity through subgroup or sensitivity analyses and discuss their impact in the manuscript.

Definition and Categorization of Interventions : The term “mobilization” is used to refer to a broad range of techniques. Clear operational definitions and subgroup analyses based on technique type are recommended.

Risk of Bias and Methodological Quality : A significant proportion of the included studies are at high risk of bias, particularly in blinding and outcome assessment. This should be discussed more explicitly as a limitation.

Limitations and Future Directions : The discussion section should better acknowledge the methodological limitations of the included studies and propose directions for future high-quality research.

==============================

Please submit your revised manuscript by Sep 12 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,

Saumya Srivastava, Ph.D.

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.

Additional Editor Comments:

Dear Dr. Won-Bae Ha and Co-authors,

Thank you for submitting your manuscript titled "Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis" (Manuscript ID: PONE-D-24-07775R1) to PLOS ONE. The manuscript addresses a clinically relevant and timely topic, and we appreciate the comprehensive approach taken to explore the effects of joint mobilization for shoulder impingement syndrome. However, after careful evaluation, we believe that major revisions are required before the manuscript can be considered further for publication. Please find the reviewers’ reports attached/at the end of this email.

We encourage you to respond to each comment systematically in a point-by-point response letter and revise your manuscript accordingly.

Best regards,

Dr Saumya Srivastava,

Academic Editor, PLOS ONE

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

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

Reviewer #3: (No Response)

**********

-->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

Reviewer #3: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

-->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

Reviewer #3: 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

Reviewer #3: 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: the keywords are missing in abstract.

I believe that the Language is appropriate and manuscript may be proceeded for publication.

Reviewer #2: Suggest to also add statements on exclusion and exclusion with relation to year of publication and language . Have you accepted all primary and secondary SAS, patients with previous surgeries, previous fractures etc..

Reviewer #3: Dear authors,

Congratulations on this strong research idea. The article is well structured and accompanied by relevant information. However, there are a few aspects that should be improved.

Abstract- keywords

a. Include important information about the method that was used in this systematic review and meta-analyses – PRISMA.

b. In the conclusion of the abstract, the study's limitations are highlighted: “Owing to the clinical heterogeneity, uncertain risk of bias, and small number of studies, high-quality studies evaluating the effectiveness of mobilization are warranted”.

Given the significant limitations mentioned, I suggest reformulating the approach to provide a clearer direction for future research.

Introduction

a. Since the sham mobilization was used as a comparison in row 34, I suggest inserting information about this in the Introduction section. It is a new concept, and adding information in the Introduction section will help emphasize its relevance.

Methods

a. Please provide in this section the link for Data Availability.

b. Please provide a reference for the Cochrane Handbook for Systematic Reviews of Interventions. And also for the PRISMA guideline (rows 80-81).

Database selection and search

a. For selecting relevant keywords, it was preferred to use an automated tool, such as MeSH or the Word Frequency Analyzer Tool.

b. Please explain why the searching strategy was used: “mobilization” and “mobilization” – row 91?

Inclusion and exclusion criteria

a. Please improve this section to add clarity and flow.

b. It is essential to include the abbreviations for participants, interventions, comparisons, outcomes, and study designs that refer to PICOS- rows 95-96.

b. Additionally, since PICOS was used, the exclusion criteria need to follow the structure to ensure methodological consistency.

Literature selection and analysis

a. Please remove the duplicate of the subtitle – rows 106- 107

b. Please mention where the selected articles were exported by the two researchers (GL and WH)- 112-113. In the abstract, it is noted that EndNote 20 was used.

c. Before applying Rob 2.0 to identify the risk of bias, a tool was used to screen and select studies? This step is crucial to ensure that only eligible studies are included in the meta-analysis, especially through the peer-blinding process. E.g., Ryyan?

3. Discussion

a. In rows 370-371, it is mentioned that the meta-analysis was performed on 11 studies out of the 19. Please argue why the meta-analysis was made on 11 studies and why it isn’t mentioned in the Method section.

b. Regarding some indices, a high level of heterogeneity was noted in the Result section (eg, rows 192, 195, 200, 205, 211), which could affect the ability to draw firm conclusions about the effectiveness of joint mobilization (rows 372, 273).

c. Since the aim of the study was to examine the clinical effectiveness of mobilization for SIS, it is highly suggested to focus on this, not on clinical implications- this subsection could be just an introduction for the summary.

General recommendation:

a. While the topic is relevant and valuable for the physical therapy area, several methodological aspects require clarification; please see the aforementioned points.

b. Strongly recommend keeping “joint mobilization” and not “mobilization”, as this is the term mentioned in the title and abstract as well.

**********

-->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: Yes:  Wajida Perveen

Reviewer #2: Yes:  Ahmed Ibrahim Al Kharusi

Reviewer #3: Yes:  Dan Iulian Alexe

**********

[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.

-->PONE-D-24-07775R2-->-->Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis-->-->PLOS One

Dear Dr. Ha,

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.

==============================

ACADEMIC EDITOR: Please insert comments here and delete this placeholder text when finished.  Be sure to:-->

1. Clarify and emphasize the conceptual and clinical heterogeneity of the various “mobilization” techniques included.
2. More explicitly discuss the implications of high heterogeneity observed in several meta-analyses.
3. Temper the conclusions to reflect the adjunctive and primarily short-term nature of the observed effects.

-->Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

For Lab, Study and Registered Report Protocols: These article types are not expected to include results but may include pilot data.

==============================

Please submit your revised manuscript by Mar 26 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,

Saumya Srivastava, Ph.D.

Academic Editor

PLOS One

Journal Requirements:

1. 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.

2. 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.

Additional Editor Comments:

Dear Dr. Ha,

Thank you for submitting the revised version of your manuscript entitled “Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis” (Manuscript ID: PONE-D-24-07775R2) to PLOS ONE.

I have now completed the assessment of the second revised manuscript. I would like to commend the authors for the substantial improvements made in response to the previous editorial and reviewer comments. The manuscript has improved notably in terms of methodological transparency, reporting clarity, and overall structure. The study addresses a clinically relevant question and is generally consistent with PLOS ONE’s publication criteria regarding technical soundness and reproducibility.

However, after careful consideration, I find that a small number of issues still require attention before the manuscript can be accepted for publication. These issues primarily relate to clarification of interpretation and appropriate framing of conclusions.

These revisions are considered minor but essential to ensure that the manuscript’s conclusions are appropriately balanced and accurately reflect the underlying evidence base.

Regards,

Dr Saumya Srivastava,

Academic Editor,

PLOS One

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

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 #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

**********

-->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 #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: 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 #3: Yes

Reviewer #4: Yes

Reviewer #5: 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 #3: Yes

Reviewer #4: Yes

Reviewer #5: 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 #3: The authors have responded to the comments and made the necessary adjustments.

I have no further comments to make.

Reviewer #4: The manuscript has been substantially improved in this revised version, only minor revisions are recommended:

Abstract:

In the Results section of the abstract, the term physiotherapy is used to refer to physical therapy. Please use consistent terminology throughout the abstract and manuscript.

Introduction:

Lines 70–74: This paragraph introduces the importance of sham mobilization before sham mobilization is clearly defined earlier in the manuscript. Please revise this paragraph for clarity by first defining sham mobilization in clear terms

Line 79: The statement that “no studies have reported the effectiveness of mobilization for SIS” is unclear. If the intention is to state that no prior systematic reviews have evaluated this question, please revise and re-write.

Methods:

Classification of Physical Therapy:

Please provide a brief rationale for grouping different physical therapy modalities under the single category of physical therapy in the analysis. You need to show that it can be combined!

Line 89: The inclusion of database URLs in parentheses is unnecessary and can be removed.

Line 93: The term “mobilization” appears to be repeated; please correct for clarity.

Line 109: The phrase “received interventions overlapping with mobilization that could not be separated” is unclear, particularly since studies including mobilization plus other interventions were allowed under the inclusion criteria. Please clarify what is meant by “overlapping” and how “could not be separated” was operationally defined.

Line 116: The phrase “or study design” may be misleading, as only randomized controlled trials were included. Please revise to reflect that study design was, in fact, restricted to RCTs.

Results:

The Results section provides detailed descriptions of individual trials prior to presenting pooled estimates. Consider condensing trial-level narrative and placing greater emphasis on meta-analytic results, as study-level details are already summarized in tables.

Figures:

Figure 8: One study is labeled as “not estimable.” Please explicitly state the reason (e.g., insufficient variance information or inability to calculate a standard error for the inverse-variance model) in the Results.

Reviewer #5: Abstract: Temper conclusion with cautionary language

Methods: Justify model choice (please justify your choice of the random-effects model (e.g., “due to anticipated clinical and methodological heterogeneity”)), add publication bias assessment (describe whether funnel plots or Egger’s tests were planned/performed, especially for meta-analyses with ≥10 studies. If not performed, please explain why) and clarify missing data handling (the statement “we used a method that did not include missing data” is vague). Please specify the approach (e.g., complete-case analysis) and whether sensitivity analyses were conducted to assess robustness).

Results: Comment on high heterogeneity (when reporting I² values >90%, please add a brief comment on the implications for interpretability (e.g., “Results should be interpreted with caution due to substantial heterogeneity.”), and add sensitivity analysis for high RoB studies.

Discussion: Expand limitations (publication bias, multiple testing, subgroup caution)

Editorial: Remove duplicate abstract, complete tables, and clarify search date

**********

-->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 #3: Yes:  Dan Iulian Alexe

Reviewer #4: No

Reviewer #5: Yes:  Shumi Negawo, Madda Walabu University, Ethiopia

**********

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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.

-->

-->PONE-D-24-07775R3-->-->Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis-->-->PLOS One

Dear Dr. Ha,

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 briefly comment on how the high heterogeneity affects clinical applicability of the findings.
• Consider adding a short paragraph outlining practical clinical implications (e.g., patient subgroups or scenarios where mobilization may be most beneficial).
• Where possible, briefly comment on whether observed effects reach clinically meaningful thresholds (e.g., MCID).
• Further streamline the Results section by minimizing repetition of individual study findings and emphasizing pooled outcomes.

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Dr. Saumya Srivastava, Ph.D.

Academic Editor

PLOS One

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Additional Editor Comments:

Dear Dr. Ha

Thank you for submitting the revised version of your manuscript entitled “Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis” (Manuscript ID: PONE-D-24-07775).

I appreciate the thorough and thoughtful revisions made in response to the reviewers’ and editorial comments. The manuscript has improved substantially in terms of methodological clarity, transparency, and balance of interpretation. In particular, the clarification of heterogeneity, justification of statistical methods, and appropriate tempering of conclusions are commendable.

Based on the current revision, I am pleased to inform you that your manuscript is acceptable for publication in PLOS ONE. Before final acceptance, I request that you address the following minor points to further strengthen the manuscript:such as-

Add a short paragraph outlining practical clinical implication, please briefly comment on how the high heterogeneity affects clinical applicability of the findings. Please review the manuscript for minor grammatical issues.

Once these points are addressed, your manuscript will be ready for final acceptance and production.

Thank you for your valuable contribution to the field.

Sincerely,

Dr Saumya Srivastava,

Academic Editor

PLOS ONE

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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 #4: All comments have been addressed

Reviewer #5: (No Response)

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

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Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #4: Yes

Reviewer #5: Yes

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-->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 #4: (No Response)

Reviewer #5: 1. Suggestion Title: Consider whether “joint mobilization” accurately reflects the umbrella definition you later use (including neuromobilization and soft tissue mobilization). The title may slightly underrepresent intervention heterogeneity.

2. Minor suggestion in Abstract (background): Replace “clinical evidence” with “clinical effectiveness” for consistency.

3. Important issue in Abstract (Methods and Result): You report mean differences (MD) but do not indicate scale units (e.g., VAS 0–10? 0–100?). Clinical interpretability is limited. No heterogeneity (I²) values were reported in the abstract despite very high I² in the results.

4. Suggestion in Introduction (Rationale): Add 1–2 sentences explaining why pooling heterogeneous mobilization types is clinically meaningful (you later discuss heterogeneity, but early framing helps).

5. Minor suggestion in Methods (operational definition): When grouping TENS, ultrasound, and heat under “physical therapy,” add 1 citation supporting this classification as standard conservative care.

6. Results General comments:

Major Concern: Very High Heterogeneity (I² > 90%)

This is the most critical methodological issue.

When I² > 90%:

Pooling may not be clinically meaningful.

Summary estimate precision is compromised.

You now appropriately caution good interpretation.

However, consider adding:

Exploration of heterogeneity (subgroup by type of mobilization? dosage? acute vs chronic?)

Meta-regression (if feasible).

7. Discussion part:

i) Discuss clinical significance (not just statistical significance).

Is MD=1.72 on VAS clinically meaningful?

Minimal clinically important difference (MCID) discussion recommended.

ii) Clarify duration of effect (short-term only?).

ii) Explicitly state that evidence certainty is low (if GRADE was not performed, acknowledge that certainty grading was not conducted).

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Reviewer #4: No

Reviewer #5: No

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Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis

PONE-D-24-07775R4

Dear Dr. Ha,

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.

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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,

Saumya Srivastava, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Dear Dr. Ha,

Thank you for submitting the revised version of your manuscript entitled "Clinical efficacy of joint mobilization for shoulder impingement syndrome: a systematic review and meta-analysis."

The revised manuscript has been carefully evaluated together with your detailed responses to the comments raised during the previous review rounds. The revisions have substantially improved the manuscript, particularly with respect to the discussion of heterogeneity, clinical applicability, clinical significance of findings, reporting transparency, and overall readability.

I appreciate the thorough manner in which you have addressed the concerns raised by the reviewers and the Academic Editor.

I am pleased to inform you that the manuscript is considered suitable for publication in PLOS ONE and is recommended for acceptance.

Thank you for your careful revisions and for choosing PLOS ONE for the dissemination of your work.

Kind regards,

Dr. Saumya Srivastava

Academic Editor

PLOS ONE

Reviewers' comments: