-->PONE-D-25-18010-->-->The effects of cervical spine posture on susceptibility to walking balance perturbations-->-->PLOS One

Dear Dr. Franz,

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Isamu Miura

Academic Editor

PLOS One

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Additional Editor Comments:

Reviewer 1 comments.

Cervical spondylotic myelopathy is a surgical pathology unless spontaneous movement of the myelomalacia region is lost and the patient's medical problems are at an acceptable level. A short-term collar may be needed after surgery. In my opinion, the authors have touched upon a very important issue. We use a neck brace that immobilizes the neck for every patient with neck pain. This study shows us that, not only in CSM patients but also in degenerative spine patients, pre-treatment gait analysis should be performed to determine whether or not to prescribe a cervical collar, or to warn the patient accordingly. Furthermore, new collar designs can be developed in the future.

Reviewer 2 comments.

The authors present an interesting study examining the effects of neck postural changes (due to variations in immobilization and bracing) on balance responses in cervical spondylotic myelopathy. The experimentation, results, and conclusions appear technically sound. As such, I think this paper presents a substantial contribution to the literature on balance impairments in cervical myelopathy. I do have some concerns about presentation that should be addressed.

I have no major concerns.

Minor concerns:

One issue that impacts the quality of the paper and it's potential impact is the usage of older terminology (e.g. cervical spondylotic myelopathy, [CSM]) rather than more recently accepted terminology (degenerative cervical myelopathy, [DCM]). The authors are encouraged to read Davies et al. 2024 (PMID: 35769029) for consideration of terminology. While the usage of CSM is not inherently wrong as it is the legacy term, it's use along with a reference list containing only studies using CSM suggest the authors may not be aware of the parallel terminology. This appears to have resulted in the authors missing some key papers on perturbation-based balance training and biomechanical responses to perturbations in DCM. Some of the perturbation literature in DCM that appears to have been missed includes Cheng et al. 2020 (PMID: 32154235 ), Boerger et al 2022 (PMID: 35080466) and Boerger et al. 2024 (PMID: 38412683). This issue appears to have resulted in the incorrectly proposing (for example at line 68 and similar language) that perturbation-based balance assessments have not been performed in this population. Notably, the present paper gives important context to the previously mentioned papers. It is interesting that simply immobilizing the head results in changes in balance responses.

Consistent with my above comment, I would recommend the authors include "degenerative cervical myelopathy" as a keyword if they chose to not use it in the title or abstract. This will help with indexing the term and increase the impact of the present paper as Medline filters do not consider the terms interchangeable at this time.

While it is acknowledged in the limitations, there are important distinctions between the post perturbation balance responses of people with DCM that are not explained by immobilization and these should be more accurately described in the discussion. Young adults with immobilization did not have changes in response times, however, that was a key observation of Boerger et al 2022 and Boerger et al 2024. See also Nardone et al. 2008 (PMID: 18758671). Therefore, the present study represents a limited model of the functional impact of DCM on balance. It is, however, a very useful study for the broader theoretical framework of what contributes to balance impairments in DCM and that some of the impairments may be related to underlying spondylotic degeneration alone.

As DCM induces increases in step width, it is unclear why the authors chose to not explicitly report alterations in baseline step width and MOS in the collar conditions as those would add to the validity of the model as a model of DCM.

The authors appear to not be in compliance with data sharing policies of the journal. This should be remedied.

[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: N/A

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: No

**********

-->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: Cervical spondylotic myelopathy is a surgical pathology unless spontaneous movement of the myelomalacia region is lost and the patient's medical problems are at an acceptable level. A short-term collar may be needed after surgery. In my opinion, the authors have touched upon a very important issue. We use a neck brace that immobilizes the neck for every patient with neck pain. This study shows us that, not only in CSM patients but also in degenerative spine patients, pre-treatment gait analysis should be performed to determine whether or not to prescribe a cervical collar, or to warn the patient accordingly. Furthermore, new collar designs can be developed in the future.

Reviewer #2: The authors present an interesting study examining the effects of neck postural changes (due to variations in immobilization and bracing) on balance responses in cervical spondylotic myelopathy. The experimentation, results, and conclusions appear technically sound. As such, I think this paper presents a substantial contribution to the literature on balance impairments in cervical myelopathy. I do have some concerns about presentation that should be addressed.

I have no major concerns.

Minor concerns:

One issue that impacts the quality of the paper and it's potential impact is the usage of older terminology (e.g. cervical spondylotic myelopathy, [CSM]) rather than more recently accepted terminology (degenerative cervical myelopathy, [DCM]). The authors are encouraged to read Davies et al. 2024 (PMID: 35769029) for consideration of terminology. While the usage of CSM is not inherently wrong as it is the legacy term, it's use along with a reference list containing only studies using CSM suggest the authors may not be aware of the parallel terminology. This appears to have resulted in the authors missing some key papers on perturbation-based balance training and biomechanical responses to perturbations in DCM. Some of the perturbation literature in DCM that appears to have been missed includes Cheng et al. 2020 (PMID: 32154235 ), Boerger et al 2022 (PMID: 35080466) and Boerger et al. 2024 (PMID: 38412683). This issue appears to have resulted in the incorrectly proposing (for example at line 68 and similar language) that perturbation-based balance assessments have not been performed in this population. Notably, the present paper gives important context to the previously mentioned papers. It is interesting that simply immobilizing the head results in changes in balance responses.

Consistent with my above comment, I would recommend the authors include "degenerative cervical myelopathy" as a keyword if they chose to not use it in the title or abstract. This will help with indexing the term and increase the impact of the present paper as Medline filters do not consider the terms interchangeable at this time.

While it is acknowledged in the limitations, there are important distinctions between the post perturbation balance responses of people with DCM that are not explained by immobilization and these should be more accurately described in the discussion. Young adults with immobilization did not have changes in response times, however, that was a key observation of Boerger et al 2022 and Boerger et al 2024. See also Nardone et al. 2008 (PMID: 18758671). Therefore, the present study represents a limited model of the functional impact of DCM on balance. It is, however, a very useful study for the broader theoretical framework of what contributes to balance impairments in DCM and that some of the impairments may be related to underlying spondylotic degeneration alone.

As DCM induces increases in step width, it is unclear why the authors chose to not explicitly report alterations in baseline step width and MOS in the collar conditions as those would add to the validity of the model as a model of DCM.

The authors appear to not be in compliance with data sharing policies of the journal. This should be remedied.

**********

-->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:  Ali Fahir Ozer

Reviewer #2: No

**********

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-->

The effects of cervical spine posture on susceptibility to walking balance perturbations

PONE-D-25-18010R1

Dear Dr. Franz,

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,

Isamu Miura

Academic Editor

PLOS One

Additional Editor Comments (optional):

All reviewer comments were addressed.

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

**********

-->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: N/A

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: 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

**********

-->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: I believe the authors have touched upon a very important issue. This study shows us that pre-treatment gait analysis should be performed not only in patients with cervical spondylotic myelopathy but also in patients with degenerative spine diseases to decide whether to prescribe a neck brace or provide appropriate guidance. Furthermore, new neck brace designs could be developed in the future. This article is suitable for publication.

Reviewer #2: (No Response)

**********

-->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: No

**********