The Mechanically Destabilizing Effect of Increased Heel Height in Women Is Not Enhanced by Dual-Task Interference

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript entitled “The Mechanically Destabilizing Effect of Increased Heel Height in Women is Not Enhanced by Dual-Task Interference.” investigates the impact of varying heel heights on postural balance in women under both single-task and dual-task conditions, aiming to determine whether cognitive load exacerbates balance deterioration associated with increased heel height. In the reviewer's opinion, the most outstanding highlight of this study is its investigation of the interaction between heel height and cognitive load on postural balance, providing insights into neuromuscular control under dual-task conditions. However, the shortcomings of this study include the lack of effect size reporting, limited discussion on practical applications, and the absence of consideration for dynamic movement conditions such as walking or landing. Specific comments are shown below:

Abstract:

Lines 29-31: The results section only describes trends without providing specific statistical values.

Introduction: Details on dual-tasking are missing and the overall logic needs to be reorganized.

Lines 41-43: For variations in ankle range of motion, their impact on postural control and injury risk has been argued by recent studies. To provide more effective evidence, the authors may consider referring to the following relevant studies: New insights optimize landing strategies to reduce lower limb injury risk (https://doi.org/10.34133/cbsystems.0126).

Methods:

Lines 87-101: The inclusion/exclusion criteria for participants were not detailed enough and did not mention factors such as exercise experience, balance, etc., that may affect the outcome. For the concurrent cognitive tasks, it is recommended that flowcharts be provided, combined with text where possible to illustrate.

Results:

Lines 260-263: The explanation of figures is unclear, as it does not specify whether error bars represent standard error (SE) or standard deviation (SD). Please provide additional, and more detailed, data results sections to fully justify the conclusions.

Discussion:

Lines 370-375: The limitations section is too general and does not specify potential sources of measurement error or experimental constraints.

Conclusion:

Lines 380-388: The conclusion does not adequately emphasize the practical significance of the findings.

Author Response

Please see the attached file.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear editor and authors, this  research offers a well-run analysis of how heel height and dual-tasking affect women's postural balance. It is pertinent, methodologically consistent, and adds to the body of work on cognitive interference and postural regulation. Though, some changes are required to fit the paper, they are below.

Title and Abstract - Include "observational study" or "cross-sectional study" in the title or abstract.

Lines 16–32 (Abstract):  Include at the start of the methods section in the abstract "This observational cross-sectional study..."

Lines 86–102: Include further information about the recruiting procedure. For example, "Flyers/email/social media..." lured participants.

Include a clear statement in Line 85: "This was an observational cross-sectional study conducted in a laboratory setting."

Good detail on variables in Lines 126–165 & 166–218 - Perhaps include a summary table defining all result variables—e.g., CoP path length, CoP sway—including

Lines 220–239: Indicate whether sphericity was assessed in repeated measures ANOVA; say, if relevant, how missing data were handled.

Lack of participant flow - Include a brief paragraph or flow chart showing how many people were first contacted, excluded, then tested.

Provide age group distribution and physical activity levels (IPAQ scores).

Lines 300–309: Before analyzing the findings, briefly reiterate each hypothesis.

Though they may be broadened, limitations are discussed in lines 370–379. Include debate about the generalizability of results—for example, highly active sample could not reflect general population.

Include a paragraph in the Discussion on the generalizability of results to older persons or chronic high-heel wearers.

Author Response

Please see the attached file.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank the authors for their efforts in improving the quality of their papers. The quality of the article has already improved a bit with the revisions. The age range (21–54 years) is broad, and the majority of participants had medium physical activity levels. Please clarify how these factors might influence the results and discuss the generalizability to other populations.

The cognitive tasks were not individualized, raising questions about whether they were sufficiently demanding for all participants. Please justify the fixed difficulty level or consider incorporating task calibration based on individual performance.

Lines 41-43: For variations in ankle range of motion, their impact on postural control and injury risk has been argued by recent studies. To provide more effective evidence, the authors may consider referring to the following relevant studies: New insights optimize landing strategies to reduce lower limb injury risk (https://doi.org/10.34133/cbsystems.0126).

The study focuses on quiet stance, but dynamic conditions (e.g., walking) are more ecologically relevant for high-heeled shoe wearers. Please address this limitation and suggest future research directions.

The discussion attributes balance deterioration to mechanical factors (e.g., reduced base of support) but lacks detailed neuromuscular or kinematic data (e.g., EMG, joint angles) to support these claims. Please expand on potential mechanisms.

While non-habitual wearers were selected, individual variability in prior experience (e.g., occasional use) may confound results. Please discuss how this was mitigated or its potential impact.

The null finding for dual-task interference contradicts some literature. Please discuss possible reasons (task design, participant characteristics) and compare them with studies showing posture-first strategies.

Author Response

Please see the attached file.

Author Response File: Author Response.docx