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The authors repplied to my concern. I hane no more remarks to add.
improved
manuscript improved in this section
No more comments to add
The presentation of the Introduction was improved.
The presentation of the Experimental design was improved.
This manuscript brings important new findings in the field of the study.
The presentation of the manuscript was improved, and I am recommending its acceptance.
We have received 4 reviews for the manuscript, all of which have raised serious concerns, particularly with regard to the methodology. I would give the authors the opportunity to address these substantial limitations in an extensive revision. This should include an updated database search to find further important studies in this field (see comments of reviewers 1 and 3)
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Title: Effect of whole-body vibration training on bone mineral density in older adults: A systematic review and meta-analysis
PeerJ
Manuscript ID: #105141
The current study aimed through this systematic review to analyze the effects of WBV training on bone mineral density (BMD) at anatomical sites most affected by osteoporotic fractures in older adults.
The approach is original. The manuscript reads smoothly and is easy to understand. The aims, scope, and results of the study are clearly stated. I have very much enjoyed reading this paper. I find it interesting and clearly written and satisfying also all the other publication criteria of the “PeerJ”. The study provides a very valuable addition to this line of research and adds relevantly to the subject with additional original findings. I thus find that this paper definitively delivers results that will surely be of interest to the readership of the “PeerJ”. I recommend the publication of this paper after revision. The authors must develop the limitations of the study. The authors must use REF from serious journals and indexed. I recommend the addition of the following references that will increase the methodology and discussion sections that appears still poor. They are helpful of this area of this research and must be used like a reference of methodology.
• Wuestefeld A, FuermaierABM, Bernardo-Filho M, da Cunhade Sa ́-CaputoD, Rittweger J, Schoenau E, et al. (2020). Towards reporting guidelines of research using whole-body vibration as training or treatment regimen in human subjects—A Delphi consensus study. PLoSONE, 15(7):e0235905 https://doi.org/10.1371/journal.pone.0235905
• Acute Effects of Whole-Body Vibration on the Pain Level, Flexibility, and Cardiovascular Responses in Individuals With Metabolic Syndrome. Dose-Response: October-December 2018:1-9. https://doi.org/10.1177/1559325818802139.
• Relevance of Whole-Body Vibration Exercises on Muscle Strength/Power and Bone of Elderly Individuals. DOI https://doi.org/10.1177/1559325818813066
• Whole-body vibration improves the functional parameters of individuals with metabolic syndrome: An exploratory study. DOI https://doi.org/10.1186/s12902-018-0329-0
• Do whole body vibration exercises affect lower limbs neuromuscular activity in populations with a medical condition? A systematic review. DOI https://doi.org/10.3233/RNN-170765
• Whole-body vibration improves the functional parameters of individuals with metabolic syndrome: An exploratory study. https://doi.org/10.1186/s12902-018-0329-0
• Potential application of whole body vibration exercise for improving the clinical conditions of covid-19 infected individuals: A narrative review from the world association of vibration exercise experts (wavex) panel DOI 10.3390/ijerph17103650
• Whole-body vibration improves the functional parameters of individuals with metabolic syndrome: An exploratory study 10.1186/s12902-018-0329-0
• Attitudes to knee osteoarthritis and total knee replacement in Arab women: A qualitative study 10.1186/1756-0500-6-406
• Moreira-Marconi, E. et al. Evaluation of the temperature of posterior lower limbs skin during the whole body vibration measured by infrared thermography: Cross-sectional study analysis using linear mixed effect model (2019) PLoS ONE, 14 (3), art. no. e0212512,
Dear Authors. Congratulations. The subject of this study is highly relevant and you are presenting important contributions in this field involving bone and WBV effects. However, the presentation of the manuscript must be improved. Please, find in the attached file my suggestions and comments.
It is fine.
The subject of this study is highly relevant and you are presenting important contributions in this field involving bone and WBV effects.
No additional comments.
The article says that it followed the PRISMA recommendations, however, some items were not followed, such as analysis of the certainty of evidence using the GRADE system, an essential item in systematic review and meta-analysis studies.
The validity of the finding is compromised, particularly by the fact that several eligible studies were not included, as shown in the examples below:
Leung KS, Li CY, Tse YK, Choy TK, Leung PC, Hung VWY, Chan SY, Leung AHC, Cheung WH (2014) Effects of 18-month low-magnitude high-frequency vibration on fall rate and fracture risks in 710 community elderly - a cluster - randomized controlled trial. Osteoporos Int 25:1785–1795. https:// doi. org/ 10. 1007/s00198- 014- 2693-6
Gusi N, Raimundo A, Leal A (2006) Low-frequency vibratory exercise reduces the risk of bone fracture more than walking: a randomized controlled trial. BMC Musculoskelet Disord 7:92. https:// doi. org/ 10. 1186/ 1471- 2474-7-9
An exclusion criterion was the administration of supplementation (e.g., calcium and vitamin D) associated with WBV. However, if the use of supplementation was equal in the WBV and control groups, this may not be relevant.
There are several serious problems with this review/meta-analysis, and I will give one example:
The authors mistakenly repeat the same study within the meta-analysis, resulting in double and often triple counting of participants. See the Cochrane Handbook: https://training.cochrane.org/handbook
The study presents fatal problems that are impossible to overcome.
The paper is well-written and done per the guidance for systematic reviews and meta-analyses. The topic is relevant. However, some inconsistencies in the use of terms and data presentation require revision and broader insights. Please see my specific comments as additional comments (Section 4)
The study is done per the guidance for meta-analyses and is thus properly done. Please see my specific comments as additional comments (Section 4)
Partly ambiguous presentation of the data and apparent inclusion of non-randomized studies in the analysis need further consideration. The main finding is that mere WBV training confers no clinically meaningful effect on proximal femur and lumbar spine DXA-measured aBMD. Please see my specific comments as additional comments (Section 4)
In this properly conducted systematic review and meta-analysis of eight studies with a total of 301 participants, Massimo and colleagues evaluated the effect of mere whole-body vibration (WBV) training on DXA-measured areal bone mineral density (aBMD) of clinically relevant proximal femur and lumbar sites in older adults aged 55 years or more. This meta-analysis differs from earlier meta-analyses on the same topic in that it excluded WBV trials that used also other exercises in combination with WBV training or were affected by relevant confounding factors (e.g., a specific patient group). In sum, this meta-analysis aimed to evaluate the effect of mere WBV training on aBMD among apparently healthy older adults. To me, this is the novel aspect of this study. In many intervention trials, WBV training has been “contaminated” by other types of physical training performed either on the vibrating platform or as additional exercises. The main finding is that the mere WBV training without any additional training elements confers only a marginal, if any, effect on femur and no effect on lumbar spine.
I have some specific comments to the text which are presented in the order of appearance below.
Line 27 (this comment applies to the entire manuscript). Bone mineralization is a misleading term and pertains to a material property of bone tissue. Instead of using the term “mineralization”, please write "... increase l bone mineral density (BMD). Whenever BMD refers to DXA-measured bone mineral density (aBMD), please use this term. Also, please check the entire text for appropriate terminology and remove indications to bone mineralization (e.g., lines 76, 369, and 379)
Line 33. Please add acronym DXA and use it throughout the text as appropriate.
Line 41. “In the absence of heterogeneity …” This is confusing. Should this be "… with high heterogeneity" or "… in the presence of heterogeneity" in contrast to what was previously presented?
Line 57. The sentence starting with “BMD reflects …” is misleading. Please rephrase as follows “BMD reflects the amount of bone mineral mass within the bone region of interest ... The references after this first part of sentence may be omitted.
Line 65. Albeit correct, this is a bit complicated way to express the rate of fractures. Perhaps rephrasing this part as follows, “... a global annual rate of almost 10 million fractures.” would be a more scientific way to express the rate.
Line 91. Piezoelectric effect is questionable in a living bone. This may apply to a dry bone, but not necessarily to bone in vivo. Please omit piezoelectric effect here as an irrelevant topic.
Line 142. This search criterion (45+) contradicts 55+ years used as an inclusion criterion (line 156). Please explain this discrepancy.
Line 157. Please specify the analyzed skeletal sites as clearly as possible. For example, as presented now, it remains unclear, what is the difference between femur and total hip? Ambiguous sites like the Ward's triangle (definitions vary between the DXA brands) should be omitted from the analysis. For clarity, the analysis may be limited to total hip aBMD, femoral neck aBMD, and lumbar aBMD.
Further, there are between-DXA brand differences in definitions even in the most common sites (e.g., the number of lumbar vertebrae may vary) which may confound the results to some extent and may warrant some discussion.
Line 191. It remains unclear in the abstract whether also non-randomized studies were included (apparently two trials were non-randomized). I suggest that non-randomized studies are excluded as it is well-known that the effect-sizes in such trials tend to be systematically somewhat larger. Please focus on the strongest evidence or provide strong arguments for why non-randomized studies were included (if this was the case). If non-randomized studies are included, this should be properly argued in the discussion and the study type should be indicated in the Table 2 (RCT or non-RCT)
Line 236. The categorization of effect sizes as per Hopkins et al. seems to be somewhat stricter than the commonly used approach proposed by Cohen. Please give arguments for this choice. Obviously, this does not change the interpretation of present findings.
Line 261. This effect size is quite close to a trivial effect (g=0.20 vs.0.19) and to the trivial one observed in the sensitivity analysis (g=0.16). The authors should discuss whether the observed findings have any clinical bearing and make proper conclusions and pinpoint the need for high-quality RCTs on the topic. To me, it seems that mere WBV training does not improve either femoral or lumbar aBMD among apparently healthy older adults to a clinically meaningful extent.
Lines 311-313. The two last sentences of this paragraph are discussive by nature and should be moved to Discussion.
Line 320. The duration of training and age were associated with the response to training but was the adherence to WBV training associated with the response? This is an important factor accounting for the response in any training study. This issue needs to be discussed.
Line 332. Variables of WBV training are well defined (amplitude, frequency, duration of a bout, number of bouts in a single training session, number of weekly sessions, description of progression, and the total duration of WBV training. However, effective variables are not yet fully known. Please state "Variables of effective WBV ..."
Line 337. It is true that high-frequency training can be harmful, if high amplitudes (platform g-forces can get very high, at least theoretically) are used. For example, 90 Hz WBV training at <0.3 g level has been found effective and safe (Rubin C et al., J Bone Miner Res 2009). This sentence needs to be rephrased so that it does not give a wrong impression.
Lines 370-371. Low plasticity of bone tissue is not true. For example, consistent findings from "natural experiments" of athletes' bones (e.g. tennis players) demonstrate substantial potential to adapt to exercise loading in humerus, the effect depending on the age (Kannus P et al. Annals Intern Med 1995) or femoral neck (Nikander R et al. Osteoporosis Int 2010). Given the above, the claim regarding minimal plasticity should be rephrased as bone tissue has basically huge potential to adapts its structure and geometry to loading, if the stimulus is great enough. As regards WBV training, this may not be the case, however. Further, substantial attenuation of vibration magnitude through the body is likely to diminish the osteogenic effect. Please see my next comment.
Line 374. Human musculoskeletal system is a highly complex biomechanical apparatus. One important factor modifying the response is the attenuation of the vibration stimulus (Kiiski J et al J Bone Miner Res 2008). This issue warrants discussion.
Line 397. This is one of the reasons why non-randomized studies should not be included in meta-analyses that aim to show most convincing evidence. Aat least they should be analyzed separately or separated from proper RCTs in the sensitivity analysis.
Line 433. I wonder whether small training effects, albeit significant, would have any clinical bearing. In contrast, a small number of studies is a limitation, and in particular so, as it prevent performing relevant subgroup analyses.
Lines 446-450. In addition to these important issues, the authors should bring up the recommendations for conducting WBV interventions properly (Rauch F et al. J Musculoskeletal Neuronal Interact 2010).
Line 454. Significant effect on femur region but not on total hip region is confusing. As I pointed out earlier, it is highly important that the regions are well defined and unambiguous. Please pay attention on this issue. I wonder whether the hip regions truly differ from femur regions, and on what grounds.
I'm also a bit dubious whether pooling all femur regions is arguable. For example, the somewhat vague-defined and small Ward's triangle regions show the highest responses. Precision of the Ward’s triangle aBMD measurement is not good and therefore not very reliable. If these Ward’s results were omitted, the significance would likely disappear.
Table 2. Focusing only on femoral neck aBMD, total femur aBMD and lumbar aBMD would clarify this paper and remove some spurious findings.
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