The Effect of Joint Mobilization and Manipulation on Proprioception: Systematic Review with Limited Meta-Analysis
, Michalis A. Efstathiou, Elena Papamichael, Christina Michailidou and Manos Stefanakis *
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThese are just minor details that I believe could improve your already excellent work.
- In the introduction, line 47, the acronym JPSE appears, but its meaning is not explained beforehand.
- In the introduction section, line 40, the description of JPS appears for the first time, so I believe that from that point onwards, only the acronym should be used, and the definition and acronym should not be repeated, as happens in lines 67 of the same section and 111 of materials and methods.
- In the introduction section, line 57, the description of HVLA appears for the first time, so I believe that from that point onwards, only the acronym should be used, and the definition and acronym should not be repeated, as is the case in line 110 of the materials and methods section.
- Just as a suggestion, but I think the objective of the study could be expressed more clearly.
- In the section on materials and methods, SD appears in line 133, but there is no indication that this refers to standard deviation.
- In the section on materials and methods, in the data synthesis section, lines 152-154 mention the effect size values, but they do not indicate the statistic used, instead expressing it directly with its symbol in the results section (line 198). It would be advisable to indicate that they are using the partial eta-squared coefficient (η²p), and at this point they are also missing the bibliographic reference they use to establish the values of this effect size.
- In Table 3, the first column lists the study (year), but the subsequent rows do not include the year for each study. This data should be standardised, as should the tables, since Table 2 no longer includes the reference to the year.
Author Response
Comment 1: In the introduction, line 47, the acronym JPSE appears, but its meaning is not explained beforehand.
Response: Thank you for this comment. We have revised the Introduction to define the acronym at first mention. Specifically, ‘JPSE’ is now introduced as ‘joint position sense error (JPSE)’ in the relevant sentence (Introduction, line 47)
Comment 2: In the introduction section, line 40, the description of JPS appears for the first time, so I believe that from that point onwards, only the acronym should be used, and the definition and acronym should not be repeated, as happens in lines 67 of the same section and 111 of materials and methods.
Response: Thank you for this suggestion. We revised the manuscript to avoid repeating the term definition after its first introduction. Specifically, after defining joint position sense (JPS) at first mention in the Introduction, we now use only ‘JPS’ throughout the remainder of the Introduction (previously repeated around line 67) and in the Materials and Methods (previously repeated around line 111)
Comment 3: In the introduction section, line 57, the description of HVLA appears for the first time, so I believe that from that point onwards, only the acronym should be used, and the definition and acronym should not be repeated, as is the case in line 110 of the materials and methods section.
Response:
Thank you for this comment. We revised the manuscript to avoid repeating the definition of HVLA after its first introduction in the Introduction. Accordingly, subsequent occurrences now use only ‘HVLA’, including the instance in the Materials and Methods section (previously around line 110).
Comment 4: Just as a suggestion, but I think the objective of the study could be expressed more clearly
Response:
Thank you for this suggestion. We revised the final paragraph of the Introduction to state the study objective more explicitly. The Introduction now clearly specifies the primary objective (to synthesise controlled-trial evidence on the effects of articular manual therapy on quantitative proprioceptive outcomes compared with sham/placebo or no-intervention controls) and the secondary objective (to explore differences by technique type, anatomical region, symptomatic status, and timing of outcome assessment).
Comment 5: In the section on materials and methods, SD appears in line 133, but there is no indication that this refers to standard deviation.
Response:
Thank you for noting this. We revised the Materials and Methods section to define the abbreviation at first mention. Specifically, ‘means/SDs’ has been revised to ‘means and standard deviations (SDs)’ in the Data Extraction section. In addition, SD is included in the manuscript abbreviations list.
Comment 6: In the section on materials and methods, in the data synthesis section, lines 152-154 mention the effect size values, but they do not indicate the statistic used, instead expressing it directly with its symbol in the results section (line 198). It would be advisable to indicate that they are using the partial eta-squared coefficient (η²p), and at this point they are also missing the bibliographic reference they use to establish the values of this effect size.
Response:
Thank you for this important point. We revised the Data Synthesis section to specify the effect-size statistic(s) used and to cite the source for the interpretation thresholds. Specifically, we now state that studies reporting partial eta-squared are presented as partial eta-squared (η²p) and interpreted using Cohen’s conventional benchmarks (0.01 small, 0.06 medium, 0.14 large; Cohen, 1988). We also clarified in the Results that the reported η²p values refer to partial eta-squared.
Comment 7: In Table 3, the first column lists the study (year), but the subsequent rows do not include the year for each study. This data should be standardised, as should the tables, since Table 2 no longer includes the reference to the year.
Response:
We standardized the table formatting across the manuscript. Specifically, we revised Tables 2 and 3 so that the first column consistently reports the study as ‘Author (year)’ for each entry, and updated the column heading accordingly (‘Study (year)’), ensuring uniform presentation across all tables.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe manuscript entitled “The effect of joint mobilization and manipulation on proprioception: Systematic review with meta-analysis” was reviewed. The article provides interesting information on the topic; however, adjustments need to be made so that the article can continue the path to publication. I kindly ask if all changes made to the text be highlighted in yellow or a different color in the text.
Below are the reviewer's considerations to be adjusted in the manuscript.
Abstract:
1- Please separate "Background" from "Objectives," describing each item before the respective topics.
2- Systematic reviews should not limit searches to a specific time frame; they should conduct a comprehensive literature scan.
3- State whether there were language restrictions and why only these databases were used in the searches.
4- Show how many studies were found and how many were excluded so that only seven could be used.
5- Since 2010, have you only found clinical trials from 2018 onwards on this topic?
6- Provide more detailed results, presenting more quantitative information on the topic.
7- The conclusion should be more assertive to directly answer the proposed objectives; please adjust it.
Keywords:
8- Words presented in the title should not be presented as keywords; please replace them with synonyms.
Introduction:
9- The introduction needs to begin with epidemiological and clinical information about the patients' profile.
10- You also need to explain in more detail the information about the molecular and neural mechanisms responsible for the effects of the intervention on patients.
11- Present more clearly the current state of the art and how this review can fill the knowledge gap.
12- At the end of the introduction, adjust the objective to align with what is presented in the abstract, as well as present the guiding questions.
Materials and Methods:
13- In the eligibility criteria, you state that the language was only English and the search period was 15 years. I believe this is a significant limitation, since systematic reviews should not have this type of restriction.
14- In the search strategies, what was the reason for limiting the search to only these databases? It is worth remembering that a systematic review should include as many databases as possible.
15- Please provide a detailed description of the search strategy for each of the databases.
Results:
16- Begin writing the results by stating how many articles were found in each database and in which databases duplicates were found.
17- Figure 1 has low resolution and the "identification" item is outside the blue area. Please adjust.
18- In the results, the information presented in the text should precede the figures or tables; please adjust.
19- Figures 2 and 3 have low resolution; please adjust. In addition, the information in Figure 3, which represents the meta-analysis, should have captions and be better organized so that the reader can understand more clearly what is being analyzed; as it is, the interpretation is confusing. See other meta-analysis reviews as a model to improve this figure and, if possible, bring in new analysis information.
Discussion:
20- The discussion needs to be more explanatory regarding the findings; you should present both favorable and opposing data regarding the analyzed technique and explain the reasons why these results were found.
21- Try to explain the results based on clinical studies and basic research, attempting to provide explanations at the molecular and physiological levels.
22- The study's limitations need to be adjusted considering the reviewer's comments.
Conclusions:
23- The conclusions must be aligned with the objectives. You need to reorganize them to make them more assertive in answering what was proposed. In the end, it is possible to describe future perspectives, but that is not the focus.
Author Response
Abstract:
1- Please separate "Background" from "Objectives," describing each item before the respective topics.
Response:
We revised the Abstract to separate the combined ‘Background/Objectives’ heading into distinct ‘Background’ and ‘Objectives’ sections, with the background information presented under ‘Background’ and the study aim stated explicitly under ‘Objectives’.
2- Systematic reviews should not limit searches to a specific time frame; they should conduct a comprehensive literature scan.
Response:
We agree and removed the time restriction from the search strategy. We updated the Methods and Abstract to indicate that databases were searched from inception to November 2025 (no date limits). After removing the date limit, no additional eligible studies were identified. The full electronic search strategies and applied filters are reported in Supplementary Table S2.
3- State whether there were language restrictions and why only these databases were used in the searches.
Response:
We clarified the eligibility criteria and search strategy regarding language. Searches and inclusion were limited to English-language publications due to feasibility constraints and lack of translation resources. We also added a brief justification for database selection: PubMed and MEDLINE Complete were used for biomedical coverage, CINAHL for allied-health/rehabilitation literature, and Scopus for broad interdisciplinary indexing and citation coverage. In addition, we screened reference lists and conducted forward citation tracking to minimise the risk of missing relevant trials
4- Show how many studies were found and how many were excluded so that only seven could be used.
Response:
We revised the Abstract (Results) to report the study selection counts, including the number of records identified, screened, full texts assessed, and excluded, and the final number of included trials (n = 7), consistent with the PRISMA flow diagram (Figure 1)
5- Since 2010, have you only found clinical trials from 2018 onwards on this topic?
Response:
Yes—when applying our prespecified eligibility criteria (randomized or sham-controlled trials, articular manual therapy only, and direct quantitative proprioceptive outcomes), the included trials were published between 2018 and 2025. Earlier publications were identified during screening, but they did not meet eligibility criteria (e.g., non-randomized/uncontrolled designs, lack of direct quantitative proprioceptive outcomes, or non-eligible comparators/interventions). We have clarified this in the Abstract and in the Results (Characteristics of included studies).
6- Provide more detailed results, presenting more quantitative information on the topic.
Response:
We revised the Abstract (Results) to include more quantitative information, including the total sample size across included trials, representative numerical pre–post changes from key comparisons, and the reported effect-size metrics (e.g., η²p) alongside the pooled meta-analytic estimate (Hedges’ g with 95% CI and I²)
7- The conclusion should be more assertive to directly answer the proposed objectives; please adjust it.
Response:
We revised the Abstract conclusion to more directly and assertively address the study objectives. The revised conclusion now states the overall direction of effects of articular manual therapy on quantitative proprioceptive outcomes, while also acknowledging the observed heterogeneity and the limited feasibility of pooling.
Keywords:
8- Words presented in the title should not be presented as keywords; please replace them with synonyms.
Response: We revised the keywords to avoid repeating terms already present in the title and replaced them with appropriate synonyms/related indexing terms (e.g., ‘Spinal manipulation; peripheral joint mobilization; sensorimotor control; joint position sense error; joint repositioning error), while maintaining alignment with the scope of the review
Introduction:
9- The introduction needs to begin with epidemiological and clinical information about the patients' profile.
Response:
We revised the Introduction to begin with epidemiological and clinical context describing the burden and typical clinical presentation of musculoskeletal conditions (including spine and peripheral joint disorders). We then link this clinical context to the rationale for focusing on proprioception and evaluating the effects of articular manual therapy on quantitative proprioceptive outcomes.
10- You also need to explain in more detail the information about the molecular and neural mechanisms responsible for the effects of the intervention on patients.
Response:
We expanded the Introduction to provide a more detailed mechanistic rationale for how articular manual therapy may influence patient outcomes. Specifically, we added a paragraph describing proposed neural mechanisms (afferent discharge from mechanoreceptors/proprioceptors, modulation of spinal processing, and engagement of supraspinal and descending inhibitory pathways) and molecular/neurochemical pathways (e.g., monoaminergic modulation and neuroimmune signalling reported in preclinical studies). Appropriate references have been added to support these mechanisms.
11- Present more clearly the current state of the art and how this review can fill the knowledge gap.
Response: We clarified the current state of the evidence and the knowledge gap in the Introduction. We now explicitly note that existing systematic reviews of manual therapy primarily synthesise clinical outcomes (pain, disability, function) [45–48], while reviews focusing on proprioception/sensorimotor control predominantly emphasise exercise-based or multimodal interventions [7–9], limiting attribution to articular manual therapy. We then state how this review addresses the gap by focusing on randomized/sham-controlled trials of articular manual therapy and direct quantitative proprioceptive outcomes, with meta-analysis and moderator exploration where feasible.
12- At the end of the introduction, adjust the objective to align with what is presented in the abstract, as well as present the guiding questions.
Response:
We revised the final paragraph of the Introduction to align the stated objective with the Abstract. Specifically, we now describe the aim as synthesising evidence from randomized or sham-controlled trials on the effects of articular manual therapy (joint mobilization and/or HVLA thrust manipulation) on direct quantitative proprioception outcomes in humans. We also added explicit guiding questions outlining the primary comparison and planned subgroup considerations (technique type, anatomical region, participant status, and timing of outcome assessment), and the pooled effect estimate where meta-analysis is feasible.
Materials and Methods:
13- In the eligibility criteria, you state that the language was only English and the search period was 15 years. I believe this is a significant limitation, since systematic reviews should not have this type of restriction.
Response: We clarified that database searches were conducted from inception to November 2025 (no date limits) and removed any wording that could be interpreted as a time restriction. Inclusion remained limited to English-language publications due to feasibility and lack of translation resources; we acknowledge this as a limitation and have added it explicitly to the Limitations section.
14- In the search strategies, what was the reason for limiting the search to only these databases? It is worth remembering that a systematic review should include as many databases as possible.
Response:
Thank you for this comment. We expanded the Methods to justify the database selection. PubMed and MEDLINE Complete were used for biomedical coverage, CINAHL for allied-health/rehabilitation literature, and Scopus for broad interdisciplinary indexing and citation coverage. Database selection was also guided by feasibility and institutional access and by known overlap across major platforms. To mitigate the risk of missing eligible trials, we additionally screened reference lists and performed forward citation tracking. We also acknowledge in the Limitations that not all databases (e.g., Embase/Web of Science) were searched and that this may have led to missed studies.
15- Please provide a detailed description of the search strategy for each of the databases.
Response:
Thank you for this comment. We revised Supplementary Table S2 to provide the complete, database-specific search strategy for each information source (PubMed, Scopus, CINAHL, and MEDLINE Complete), including the exact search strings as run (with database-specific syntax, controlled vocabulary where applicable, field tags/operators, and applied limits), the platform/interface, and the date of the search, in line with PRISMA-S guidance. The combined database search yielded 66 records prior to de-duplication (as shown in the PRISMA flow diagram); per-database record counts were not retained/exported at the time of searching.
Results:
16- Begin writing the results by stating how many articles were found in each database and in which databases duplicates were found.
Response:
We revised the Study Selection section to report the number of records retrieved from each database (Scopus n = 332; PubMed n = 79; CINAHL n = 42; MEDLINE Complete n = 30) and updated the PRISMA flow diagram accordingly. Duplicate records were identified during de-duplication (primarily by DOI and, when unavailable, by title matching) and were most commonly observed across PubMed–Scopus and PubMed–CINAHL/MEDLINE Complete; the total number of duplicates removed (n = 112) is now reported in the PRISMA flow diagram and the Results.
17- Figure 1 has low resolution and the "identification" item is outside the blue area. Please adjust.
Response:
We have replaced Figure 1 with a higher-resolution version (300 dpi) and corrected the layout so that the ‘Identification’ label is fully contained within the blue sidebar. The updated figure has been included in the revised manuscript.
18- In the results, the information presented in the text should precede the figures or tables; please adjust.
Response:
We revised the Results section to ensure that the narrative description of findings precedes the corresponding figures and tables. Specifically, we re-ordered the text so that key results are first reported in the main text and then followed by the relevant figure/table citations (e.g., study selection is described before referring to the PRISMA flow diagram, and risk-of-bias and meta-analysis results are described before Figures 2 and 3).
19- Figures 2 and 3 have low resolution; please adjust. In addition, the information in Figure 3, which represents the meta-analysis, should have captions and be better organized so that the reader can understand more clearly what is being analyzed; as it is, the interpretation is confusing. See other meta-analysis reviews as a model to improve this figure and, if possible, bring in new analysis information.
Response:
We have replaced Figures 2 and 3 with high-resolution versions (300 dpi). In addition, we redesigned the meta-analysis figure (Figure 3) following conventional forest-plot reporting to improve clarity. The updated Figure 3 now explicitly states the population, comparison and outcome being analyzed (knee JPSE at 60° in patellofemoral pain), and includes study-level effect sizes with 95% CIs, study weights, and random-effects heterogeneity statistics (I² and τ²), along with a revised caption to aid interpretation
Discussion:
20- The discussion needs to be more explanatory regarding the findings; you should present both favorable and opposing data regarding the analyzed technique and explain the reasons why these results were found.
Response:
We revised the Discussion to provide a more explanatory and balanced interpretation of the findings. We now explicitly present both favorable and null/contradictory results by region and technique (e.g., cervical HVLA vs mobilization; lumbopelvic manipulation immediate vs multi-session protocols; symptomatic vs asymptomatic cohorts) and discuss plausible reasons for discrepant findings, including baseline deficits/ceiling effects, intervention dose and timing of assessment, comparator type and blinding (sham vs no-treatment), heterogeneity in proprioception tasks and angles tested, and methodological limitations such as underpowered secondary outcomes. We also expanded the mechanisms section to link these factors to predominantly short-term neuromodulatory effects versus longer-term adaptations requiring task-specific sensorimotor training.
21- Try to explain the results based on clinical studies and basic research, attempting to provide explanations at the molecular and physiological levels.
Response:
We expanded the ‘Potential mechanisms’ section to integrate both clinical and basic research evidence. The revised Discussion now explains how articular manual therapy may influence proprioceptive outcomes via (i) increased peripheral mechanoreceptor input and altered afferent inflow, (ii) modulation of spinal nociceptive processing and endogenous pain modulation, (iii) engagement of supraspinal sensorimotor circuitry (e.g., changes in corticospinal excitability), and (iv) potential neurochemical/neuroimmune mechanisms suggested by experimental work (e.g., anti-inflammatory cytokine signaling such as IL-10). We also clarify that much mechanistic evidence derives from pain-modulation literature and therefore likely supports predominantly short-term, state-dependent effects on JPS/JPSE, which is consistent with the heterogeneous findings across included trials.
22- The study's limitations need to be adjusted considering the reviewer's comments.
Response:
We revised the Limitations and future directions section to better reflect the issues raised during peer review and the updates made in the manuscript. Specifically, we clarified limitations related to (i) heterogeneity and limited poolable comparisons, (ii) small samples/short follow-up and outcomes often being secondary and underpowered, (iii) risk-of-bias concerns (randomization, allocation concealment, and blinding/sham credibility), and (iv) review-level constraints including English-language restriction, database coverage (no Embase/Web of Science), lack of grey literature/trial registry searching, and inability to formally assess publication bias due to few pooled studies.
Conclusions:
23- The conclusions must be aligned with the objectives. You need to reorganize them to make them more assertive in answering what was proposed. In the end, it is possible to describe future perspectives, but that is not the focus.
Response:
We revised the Conclusions to align directly with the objectives and to provide a more assertive answer, explicitly summarizing the overall effect versus sham/no-intervention controls and the meta-analysis result, while limiting future perspectives.
Reviewer 3 Report
Comments and Suggestions for AuthorsThis manuscript presents a systematic review with meta-analysis examining the effects of joint mobilization and manipulation on proprioceptive outcomes, primarily joint position sense (JPS). The topic is clinically relevant and addresses a meaningful gap in the manual therapy literature, as proprioception has been underrepresented in previous quantitative syntheses. The authors follow established methodological standards (PRISMA 2020, PROSPERO registration, RoB 2, GRADE), and the manuscript is generally well structured, clearly written, and methodologically transparent.
Overall, the study demonstrates scientific rigor and contributes novel insights, particularly through its focus on direct quantitative proprioceptive measures and its cautious interpretation of heterogeneous findings.
Moreover, the manuscript addresses an important and underexplored topic and is methodologically sound. However, the limited scope of the meta-analysis, substantial heterogeneity, and the need for clearer alignment between objectives, results, and claims warrant revision before acceptance. These issues are correctable and do not undermine the fundamental value of the study.
Below you can find my comments on your manuscript.
Minor comments
Comment 1: Abstract Precision
Consider clarifying in the abstract that only one outcome was suitable for meta-analysis, to avoid potential reader misinterpretation.
Comment 2: Terminology Consistency
Terms such as “proprioceptive accuracy,” “proprioceptive acuity,” and “joint position sense” are sometimes used interchangeably. Minor editorial refinement could improve conceptual clarity.
Comment 3: Figures and Tables
-The risk-of-bias figure is informative but could benefit from a brief interpretive summary in the Results section.
-Tables summarizing study characteristics are comprehensive but dense; minor formatting adjustments could improve readability.
Comment 4: Future Directions
The limitations section could be strengthened by more explicitly identifying methodological priorities for future trials (e.g., standardized proprioceptive protocols, longer follow-up).
Major Comments
Comment 1: Limited Quantitative Synthesis
Only one meta-analysis was feasible (knee JPSE at 60° flexion), which substantially limits the strength of quantitative conclusions. While this limitation is acknowledged, the title and abstract may overemphasize the meta-analytic component relative to the actual scope of quantitative pooling.
Comment 2: Heterogeneity of Interventions and Outcomes
The included studies vary considerably in:
-Anatomical regions (cervical spine, lumbar spine, knee, elbow),
-Manual therapy techniques (thrust vs non-thrust, Mulligan, peripheral vs spinal),
-Outcome measurement protocols.
This heterogeneity limits comparability and reduces confidence in cross-study synthesis, even at the narrative level.
Author Response
Comment 1: Abstract Precision
Consider clarifying in the abstract that only one outcome was suitable for meta-analysis, to avoid potential reader misinterpretation.
Response: We clarified in the Abstract that only one outcome/time-point comparison was sufficiently comparable for meta-analysis (knee JPSE at 60° flexion in patellofemoral pain; two trials), while the remaining outcomes were synthesized narratively due to heterogeneity and incompatible reporting.
Comment 2: Terminology Consistency
Terms such as “proprioceptive accuracy,” “proprioceptive acuity,” and “joint position sense” are sometimes used interchangeably. Minor editorial refinement could improve conceptual clarity.
Response: We revised the manuscript to ensure terminology consistency and conceptual clarity. We now define proprioception as the umbrella construct, specify joint position sense (JPS) as the repositioning ability, and joint position sense error (JPSE) as the quantitative error metric derived from JPS tasks (lower values indicate better performance). Throughout the manuscript we standardized wording by referring to measured endpoints as ‘quantitative proprioceptive outcomes’ or ‘proprioceptive performance’ (e.g., JPSE/JPS error) and avoided using ‘accuracy’ and ‘acuity’ interchangeably.
Comment 3: Figures and Tables
-The risk-of-bias figure is informative but could benefit from a brief interpretive summary in the Results section.
Response: We added a brief interpretive summary to the Results (Section 3.4) highlighting the overall pattern of RoB 2 judgments and the primary domains driving risk-of-bias concerns, to help readers interpret Figure 2 more easily.
-Tables summarizing study characteristics are comprehensive but dense; minor formatting adjustments could improve readability.
Response: We revised Tables 1 and 2 to improve readability while retaining all key information. Specifically, we reduced text density within cells by summarizing the main findings more concisely, standardized terminology/abbreviations and effect reporting, simplified repetitive significance statements (e.g., NS vs Sig with direction), and improved table layout (alignment, spacing, and consistent formatting). These changes reduce line wrapping and make the tables easier to interpret.
Comment 4: Future Directions
The limitations section could be strengthened by more explicitly identifying methodological priorities for future trials (e.g., standardized proprioceptive protocols, longer follow-up).
Response: We strengthened the Limitations/Future directions section by explicitly outlining methodological priorities for future trials, including standardized proprioception assessment protocols, prespecified primary outcomes with adequate power, rigorous randomization/blinding with credible sham comparators, and longer follow-up with repeated assessments to evaluate durability. We also highlighted the need for harmonized reporting to enable robust meta-analysis.
Major Comments
Comment 1: Limited Quantitative Synthesis
Only one meta-analysis was feasible (knee JPSE at 60° flexion), which substantially limits the strength of quantitative conclusions. While this limitation is acknowledged, the title and abstract may overemphasize the meta-analytic component relative to the actual scope of quantitative pooling.
Response: We agree that quantitative pooling was limited (only one outcome/time-point comparison could be meta-analyzed). To avoid overemphasizing the meta-analytic component, we revised the title to reflect a systematic review with limited meta-analysis and edited the abstract to explicitly state that pooling was possible for only one comparison, with the remaining outcomes synthesized narratively due to heterogeneity and incompatible reporting. We believe these changes better align reader expectations with the actual scope of quantitative synthesis.
Comment 2: Heterogeneity of Interventions and Outcomes
The included studies vary considerably in:
-Anatomical regions (cervical spine, lumbar spine, knee, elbow),
-Manual therapy techniques (thrust vs non-thrust, Mulligan, peripheral vs spinal),
-Outcome measurement protocols.
This heterogeneity limits comparability and reduces confidence in cross-study synthesis, even at the narrative level.
Response: We agree that heterogeneity across anatomical regions, manual therapy techniques (thrust/non-thrust/Mulligan; spinal vs peripheral), intervention dose, comparators, and proprioception measurement protocols limits comparability and reduces confidence in cross-study synthesis. To address this, we (i) clarified in the Methods that the narrative synthesis was structured a priori by region, technique, participant status, and protocol/timing, and that cross-study generalizations were avoided when studies were not comparable; (ii) expanded the Results to explicitly describe the main sources of heterogeneity (region, technique, dose, comparator, and measurement protocol); and (iii) strengthened the Discussion/Limitations to emphasize that conclusions are condition-, technique-, and outcome-specific, and that heterogeneity constrained both narrative interpretation and meta-analysis.
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsDear authors,
Thank you for providing the revised version of the manuscript. After reviewing the text, I noted significant improvement. Therefore, I suggest that the work be accepted for publication.
Reviewer 3 Report
Comments and Suggestions for AuthorsI would like to thank the authors for their efforts in responding to all my comments. I think that the manuscript can proceed for publication in the current form.
