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Thank you for addressing the comments sent to you.
Thank you for your revised manuscript which appears to address the issues raised by the reviewers. Lines 215-216 state there is a statistically significant difference in BMI for the entire sample and in females, but not in males, yet Table 4 does not highlight that significance. Can you please either * the statistically significant result or alter the text to coincide? In the rebuttal letter you state that you have rectified the error in Line 58 by removing the word flexibility, but it remains in the text. There are also a couple of grammatical errors, line 175 should read the data were and line 186-187 should read the mean age of the children was 10.74 years and ranged from 8-14 years.
no comment
no comment
no comment
Author reported in the table 3 p-value unadjusted for multiple comparisons.
Author must checked the data in the table because the totals are incorrect
No concerns. The authors have been receptive to prior comments and have added appropriate references and clarified their work.
No concerns. This study appears to be within the scope of this journal, and the research question and analytic approach are clearly presented.
The Discussion and Conclusions are reasonable and well-supported based on study results and the literature.
Page 13, line 235: There is an error where the term females is used twice in the sentence, "Using cut-off ≥6, the prevalence of GJH was associated with BMI in females and not in females."
The authors' responsiveness to prior suggestions from the reviewers is greatly appreciated. The revised paper is much clearer.
When considering the revions small points have been adressed.
Still the most important issues still remain
I still fail to see the relevance of the study as the manuscript still is not consise enough
as mentioned previously
as mentioned previously
In my first comment
i still fail to see the relevance of the study
Thank you for this interesting manuscript on generalized joint hypermobility among school-aged children in Majmaah region, Saudi Arabia. Please review the reference list. It appears that there are only 4 references out of 29 that are less than 10 years old.
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In table 3 the p-value for the association between hypermobility at various site and sex should be reported
no comment
no comment
The manuscript is clearly written in professional English. It is appreciated that the raw data was provided and that the structure conforms to the standards of the journal.
The Introduction is clear overall. There are a few suggestions to improve the clarity of the text.
-In line 48, the term “flexibility” should be removed in this sentence and just state “normal range”. As the authors correctly state in the next sentence, joint hypermobility is related to ligamentous laxity, but the term flexibility implies mobility of musculotendinous tissue.
-In line 74, the authors also should mention other cutoff scores for GJH that are applied in populations of children. These are mentioned in the Discussion, but it would be useful to provide here in the Introduction to prepare the reader for the Methods where cutoff points of 4 and 6 are used.
-In line 78, a reference is needed to support that GJH in children is related to developmental delay in children.
-In line 83, the authors should indicate why the Majimaah region is of particular interest for this study.
The investigators aim to examine the prevalence of GJH and associated factors in school-aged children in the Majmaah region. This study appears to be within the scope of this journal. Although prevalence of GJH and associated factors have been studied in other populations of children around the world, this study is unique in that it is the first to examine this condition in the Saudi Arabia /Gulf region. This paper would add important information to this body of literature.
Overall, the research question is clear, but the analytic approach appears to deviate somewhat from the study objective. Specifically, it is not explained why the data were analyzed by sex (male/female) for some analyses but not shown for the whole sample; the research question and statistical analysis do not describe a plan for stratifying by sex. Another concern about the analyses by sex is that numbers in some cells end up being quite small (<5). This makes the results imprecise, and approaches using exact tests are needed. Also, variables that are continuous, like age and BMI, could be kept as continuous in models, particularly since the age categories of 8-11 and 11-14 may not be clinically meaningful for GJH and since the number of participants in the higher BMI categories is low, which leads to very small numbers for analyses.
The methods for data collection are presented with enough detail that this study could be replicated. To improve the rigor, the reliability of the two physical therapist examiners should be presented (line 122). Details are needed about how many schools were approached and agreed to participate and how many students were invited. These data would help with determining the success rate with enrollment and determining whether the results from the study sample are representative of the broader population.
The underlying data were provided and appear to be robust.
The authors should comment in the Discussion on why they think the prevalence of GJH was different in their region as compared to some other locations.
The conclusion that the prevalence of GJH in the present study was lower than other studies worldwide (line 240) differs somewhat from the literature presented in the Discussion. Line 182 suggests that the present study had similar results to Denmark, Egypt, and the United Kingdom, but was lower than Iceland, Italy, and India. The conclusion should reflect that the present study did agree with results from some populations.
The manuscript is well written and in the according format. However the relavance of the study as well as the basic rationality is not well enough described. Reporting prevalances in a region from which no prevalance data has been described is in my opinion not a really strong argument. In addition why authors try to predict the occurence of GJH is unclear. GJH does not equal pathology. The reasons for this study should be detailed more clearly
The design and statistical analyses are correct considering the research objectives (which are not yet logical in the current text). Still i find some methodological issues considering the choice of cut-off points for GJH. In 2017 Juul-Kristensen published the international consensus for classifying GJH and in the current manuscript older and outdated cutt-offs are utilized. This is a major concern for the design of the study, next to the previously mentioned relevance
As mentioned previously
The study is well written and logically constructed in terms of analysis. But i fail to see the utilty of prediciting the occurence of GJH. In my opinion this is a variation of normality and not the same as pathologgy
THe study of Jacky Clinch is often mentioned however the findings of this study was not that BMI is a predictor for GJH. But children with GJH and obesity are more vulnarable to pain.
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