IMU-Based Assessment of Arm Movement in Breast Cancer Survivors: An Exploratory Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

First of all, I would like to acknowledge the effort made by the authors in conducting the testing and preparing this manuscript. Functional evaluation is crucial for women after breast cancer surgery, and the use of inertial devices may offer an interesting opportunity to provide reliable and easily obtainable data, which could be useful for the future design of interventions. In my view, this could represent the most relevant contribution of the present study. Therefore, the authors should strengthen both the Introduction and Discussion sections to better synthesize existing knowledge on the use of inertial devices in this population, and to clarify what this approach can add to the current scientific evidence. Some of the points discussed in the manuscript are not directly relevant to this aim (see specific comments below), while the central idea should be more clearly explained and emphasized.

Overall, the writing of the manuscript does not reach an adequate level and requires substantial revision. I strongly recommend consulting English language experts or professional editing systems to ensure a more understandable version. Several sentences are difficult to follow, while others do not read naturally in English.

Regarding the sample, the inclusion and exclusion criteria are not well defined. Moreover, the study includes a small and heterogeneous group of participants, with differences in clinical conditions (some having received additional treatments) and in the time since surgery. Important information is also missing, such as the number of recurrences and comorbidities.

The only outcome evaluated is angular velocity, which—unsurprisingly—shows differences between the operated and non-operated arm. Reporting only this finding does not contribute sufficiently to the scientific field. In this regard, I suggest two possible approaches:

1. Focus on the novelty of the inertial device measurements. For this, the authors should recruit a larger sample and assess whether the outcomes obtained with this new device are comparable to those measured by other established methods, and clarify what specific advantages it provides.
2. To conduct a true functional asymmetry evaluation. This would require including additional functional performance tests of the upper limb, comparing performance between both arms, and analyzing which specific outcomes are more sensitive to asymmetry in this population.

Finally, the overall structure should more closely follow the style of a scientific paper, particularly in some subsections of the Methods. I recommend consulting other relevant and similar publications for guidance and inspiration.

 

Concret comments:
- Revise correct number afilliations

Abstract: Aim sentence should be shortened to be more concise and clear
- Overall, English writing should be revised. Some sentences are expressed in a non clear way and result difficult to understand the meaning.

Introduciton:
- Lines 48-52: Too long sentence
- Provide more context and background for the use of inertial devices in onchological population
- The introduction section provides a good overall summary of the existence of functional limitations after breast cancer treatment, due to various factors. But t may be too lengthy specially in points non strictly-related to the purpose of the study, with some obvious statements (e.g., “These adverse effects could be accentuated in the upper body, especially the arm and shoulder, given that surgery is mainly performed in this area”).

Furthermore,, it falls short in properly justifying the relevance and necessity of the present study.  A comprehensive background on arm performance and functional testing in the breast cancer population is lacking, as is a clear discussion of the specific use of inertial devices to obtain objective and precise measurements.

Methods:
- What does "intentional sample selection" mean?

- Line 87: Units should be indicated.
- It is also necessary to provide a clearer explanation of how surgical procedures were considered in the inclusion process. Since breast cancer treatment may involve different surgical approaches, as well as the possibility of lymphadenectomy or other more aggressive modalities, these factors are likely to influence arm mobility and overall functionality.
- It is not specified whether the included participants had experienced recurrences, or whether the surgical approach was complemented with other treatments such as chemotherapy or radiotherapy, which also have a clear impact on upper-limb function.
- The information regarding Clinical Status should be placed in the results section
- Lines 94-07: What protocol? Do you mean functional evaluation protocol? Then, "complet" is not the most correct word, since it is only one day evaluation. Anyway, this case should be stated as inclusion criteria
- Indicate the reliability values and the ICC coefficients reported for this device.
-  Explain what is "lateral opening test"
- Apart from explaining how the testing protocol was conducted, the authors should also specify which outcomes (e.g., angular velocity) will be obtained, and how the device provides these data
- Since Statistical Analysis belongs to the Methods section, the authors should not report the results obtained from these analyses in this subsection. I recommend that the authors review similar published papers to see how this section is typically structured and written.

Author Response

Dear Reviewers of Women,

We would like to sincerely thank you for the time and dedication you have invested in reviewing our manuscript and for providing such valuable and constructive feedback. We truly believe that your thoughtful suggestions have significantly enhanced the quality, clarity, and overall rigor of our work.

We remain fully open to making any additional improvements you may consider necessary or to clarifying any aspect of our reasoning that might not be entirely clear. It has been a pleasure to receive such insightful feedback, and we deeply appreciate your contribution to strengthening our manuscript.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Although the manuscript addresses an important and understudied topic, there are several issues requiring clarification and improvement before the manuscript can be considered for publication, as detailed below.

Journal Guidelines: The manuscript is not structured according to the journal’s guidelines. Formatting, section organization, and presentation style require substantial revision to comply with the editorial standards of Women.

Abstract: The abstract does not provide sufficient numerical data to support the reported findings. Please consider including detailed information regarding the sample characteristics, dependent and independent variables, key statistical outcomes, etc.

Introduction: While informative, the introduction is overly broad and somewhat repetitive. Please consider narrowing the focus on the research gap and the specific rationale for the study leading to the hypothesis and the aim of the study.

Study Design: The study design section is weak and scarcely described. Consider improving it with more information.

Methods: The methods are not described in sufficient detail to ensure reproducibility. Several aspects, such as inclusion/exclusion criteria, recruitment process, data handling, and statistical approach should be implemented.

Results: The data and results are not adequately presented. Tables and figures should be better presented and professional, and the interpretation of findings should be better supported by clear numerical evidence.

Discussion: The discussion section tends to be descriptive rather than critical. Consider comparing your findings with relevant literature and highlight the true contribution of the work, as well as acknowledging the limitations of the study.

Author Response

Dear Reviewers of Women,

We would like to sincerely thank you for the time and dedication you have invested in reviewing our manuscript and for providing such valuable and constructive feedback. We truly believe that your thoughtful suggestions have significantly enhanced the quality, clarity, and overall rigor of our work.

We remain fully open to making any additional improvements you may consider necessary or to clarifying any aspect of our reasoning that might not be entirely clear. It has been a pleasure to receive such insightful feedback, and we deeply appreciate your contribution to strengthening our manuscript.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

This manuscript explores functional asymmetry in breast cancer survivors using inertial devices during a lateral opening test. The topic is clinically relevant, and the attempt to introduce inertial technology into oncological rehabilitation is commendable. However, several methodological and interpretative shortcomings limit the impact of the work in its current form.

Strengths:

1. Novel use of inertial devices for unilateral functional assessment in breast cancer survivors.

2. Clear rationale for exploring angular velocity as a sensitive marker of asymmetry.

3. Ethical approval, informed consent, and open data availability enhance transparency.

Major concerns:

1. Sample Size and Power

   • The study includes only 22 participants, with no reported sample size or power calculation. This raises concerns regarding statistical power and the robustness of the findings.

   • The conclusions appear overstated given the small effect sizes reported (Hedges’ g ~0.35).

2. Clinical Variables Not Controlled

   • Important variables such as type of surgery (mastectomy vs. lumpectomy), reconstruction status, radiotherapy, chemotherapy, lymphedema severity, pain levels, fatigue, and limb dominance are not adequately described or analyzed. These factors can strongly influence upper-limb function.

3. Methodological Limitations of the Test

   • The lateral opening test is described in detail, but its clinical validity as an assessment for oncological rehabilitation is not sufficiently justified or referenced.

   • Only one functional test was used, limiting external validity. Triangulating with other measures (ROM, strength, PRO questionnaires) would strengthen the conclusions.

4. Interpretation of Results

   • The authors emphasize “clinically relevant” asymmetries, but effect sizes are small-to-moderate and should be interpreted with caution.

   • Statements suggesting direct application of the findings for exercise prescription are premature given the limitations of design and sample.

5. Discussion and Literature Contextualization

   • The discussion reiterates known limitations in shoulder function after breast cancer treatment but does not sufficiently integrate findings with prior velocity-based assessments or comparable kinematic measures.

   • The potential role of inertial measurement units in long-term follow-up or clinical decision-making should be critically evaluated rather than assumed.

Minor Concerns:

1. Terminology – “lateral opening test” should be clearly defined at first mention, with reference to standardized nomenclature.

2. Figures and Tables – Figure 1 adds little value; consider integrating photos/drawings that clarify movement execution.

3. Formatting – Several references do not conform precisely to journal style (e.g., missing italics, spacing issues).

4. Clarity – The abstract should be more balanced, including both strengths and limitations. Currently, it emphasizes significance without highlighting the small sample and limited external validity.

 

Recommendations for Improvement

• Provide a power calculation and justify the sample size.

• Include (or at least discuss) more clinical variables relevant to functional status.

• Acknowledge more explicitly the limitations regarding sample size, single test selection, and generalizability.

• Temper the conclusions to align with the modest effect sizes and exploratory nature of the study.

• Consider including additional outcome measures in future studies (strength, ROM, quality of life, patient-reported outcomes).

Final Recommendation:

Major Revisions.
The manuscript addresses a relevant problem and has potential, but the current version does not meet the methodological and interpretative standards expected in a high-impact journal. Substantial revisions are needed before reconsideration.

Comments on the Quality of English Language

The English is overall understandable but needs improvement. Several sentences are unnecessarily long or awkwardly structured, reducing clarity. The discussion, in particular, could benefit from tighter, more concise phrasing. A thorough language edit by a native speaker or professional editor is strongly recommended to improve readability and impact.

Author Response

Dear Reviewers of Women,

We would like to sincerely thank you for the time and dedication you have invested in reviewing our manuscript and for providing such valuable and constructive feedback. We truly believe that your thoughtful suggestions have significantly enhanced the quality, clarity, and overall rigor of our work.

We remain fully open to making any additional improvements you may consider necessary or to clarifying any aspect of our reasoning that might not be entirely clear. It has been a pleasure to receive such insightful feedback, and we deeply appreciate your contribution to strengthening our manuscript.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to congratulate the authors for their effort in providing an improved revised version, in which a great deal of work is evident to address the reviewers’ inquiries and enhance the overall quality of the paper. This new version offers a more detailed explanation of the methods, and the discussion is now better aligned with the findings, appropriately acknowledging the study’s limitations.

However, some issues could not be fully resolved due to the nature of the research (e.g., the lack of detailed description of the surgical procedures, or the decision not to perform subgroup analyses because of the small sample size).

Therefore, being critical yet pragmatic, I consider the work to be interesting, despite its limitations regarding the generalizability of the findings, provided that the scope of the study is slightly adjusted. I do not believe this research should be considered a pilot study, since the term “pilot” should not be used to describe studies with limited generalizability but rather those with a small sample size. Unfortunately, in some cases, papers are incorrectly labeled as “pilot studies,” under the mistaken assumption that adding this term justifies methodological shortcomings.

Accordingly, I propose several points to be re-scoped and other aspects to be further improved.

In accordance with the modifications made to the text, I consider that the title should be changed as follows. By focusing on the measurement performed and being more specific about the type of functional evaluation conducted, I propose the following title, open to further modification:

Inertial measurement unit (IMU) assessment of angular velocity in arm movement among breast cancer survivors: an exploratory study.

Please review the references: the order of appearance in the text is incorrect, and there appears to be a mismatch between the in-text citation numbers and the reference list at the end of the article

In writing the hypothesis, make sure to include the population you are studying.

In the first sentence of the discussion, when you summarize the findings, also indicate that angular velocity was measured with IMUs

Appart from larger sample sizes, future studies should also consider the treatment and surgeries that BC subjects had undergone

Author Response

Please see the attachment.

We would like to sincerely thank all reviewers for their careful reading of our manuscript and for the valuable comments and suggestions provided throughout the review process. Their detailed feedback has been instrumental in improving the clarity, methodological rigor, and overall quality of our work.

We truly appreciate the time and effort each reviewer dedicated to providing thoughtful and constructive recommendations. Thanks to their contributions, we believe that the current version of the manuscript is much more complete, coherent, and scientifically sound. The authors are deeply grateful for the reviewers’ role in guiding us toward a stronger and more refined final version of our study.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The revised version shows clear progress compared with the first submission. The manuscript is now better aligned with the Women journal structure, includes more detailed statistical information, and provides a stronger discussion. However, several methodological and presentation issues remain.

The study design section remains essentially procedural and lacks a conceptual framework linking the asymmetry problem to the chosen methodological approach. The description should not only indicate what was done but explain why this specific design was selected, how it fits the research question, and how it ensures internal validity.

The quality of the figures remains poor. The images appear to have low resolution, inconsistent font sizes, and variable line thicknesses. Legends are sometimes incomplete and do not always specify sample sizes, statistical significance, or measurement units. Please consider to recreate images with high resolution and better consistency with text.

Table 1 also requires revision to achieve stylistic consistency with the rest of the tables. At present, it uses a different layout and numerical formatting. It should adopt the same typographic style, decimal format, and structure used in the later tables. A concise note specifying the meaning of all abbreviations and the format of the data (for example, “mean ± SD”) is recommended. If appropriate, adding a column indicating baseline comparisons would enhance interpretability.

Minor suggestions

The introduction, although informative, remains somewhat repetitive; it could be slightly condensed to focus on the central research gap.

The terminology used to describe the limbs and asymmetry should be fully consistent throughout the text.

Legends for tables and figures should explain all symbols and abbreviations clearly.

Author Response

Please see the attachment.

We would like to sincerely thank all reviewers for their careful reading of our manuscript and for the valuable comments and suggestions provided throughout the review process. Their detailed feedback has been instrumental in improving the clarity, methodological rigor, and overall quality of our work.

We truly appreciate the time and effort each reviewer dedicated to providing thoughtful and constructive recommendations. Thanks to their contributions, we believe that the current version of the manuscript is much more complete, coherent, and scientifically sound. The authors are deeply grateful for the reviewers’ role in guiding us toward a stronger and more refined final version of our study.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

I have reviewed your manuscript with interest. The study explores an important issue—quantifying upper-limb functional asymmetry in breast cancer survivors—using wearable inertial sensors. The topic is timely and relevant; however, the current version requires substantial revision to meet publication standards.

Major issues that require attention:

Study design limitations

The absence of a control group prevents interpretation of asymmetries as pathological. Please justify this design choice explicitly and discuss how it affects generalizability.

The small sample (n=22) and heterogeneous postsurgical time frames should be acknowledged as major constraints to internal validity.

Methodological transparency

Provide detailed information on IMU calibration, orientation, and filtering. Clarify whether both limbs were tested simultaneously and how sensor synchronization was ensured.

Include reliability metrics (intra-rater, intertrial) or cite prior validation studies for this setup.

Statistical and analytical rigor

The results are underpowered; please report effect sizes and confidence intervals for all key comparisons.

Reconsider the use of parametric tests given the small sample. Nonparametric or bootstrapped analyses might be more appropriate.

Interpretation and discussion

Limit your conclusions to what the data actually support. Statements implying clinical applicability or individualized exercise prescription are premature.

Reframe the manuscript as a feasibility or pilot study, emphasizing the methodological lessons learned rather than clinical recommendations.

Presentation and literature update

Condense the Introduction to focus on the research gap and update references (include recent studies on IMU-based rehabilitation monitoring).

Simplify redundant tables, improve figure clarity, and ensure consistent terminology (e.g., “affected vs. unaffected limb”).

Minor issues

Moderate English editing is required to improve flow and precision.

Please provide exact p-values rather than rounded thresholds (e.g., p = 0.047 instead of p < 0.05).

Consider adding a brief paragraph in the Discussion on future directions, such as integrating IMU-based monitoring with digital rehabilitation platforms.

 

In summary, the manuscript is methodologically interesting but scientifically underdeveloped in its current form. I encourage you to strengthen the methodological description, reframe the paper as an exploratory feasibility study, and refine your interpretation accordingly.

If these substantial revisions are addressed, the paper could become suitable for publication in Women.

Kind regards :)

Author Response

Please see the attachment.

We would like to sincerely thank all reviewers for their careful reading of our manuscript and for the valuable comments and suggestions provided throughout the review process. Their detailed feedback has been instrumental in improving the clarity, methodological rigor, and overall quality of our work.

We truly appreciate the time and effort each reviewer dedicated to providing thoughtful and constructive recommendations. Thanks to their contributions, we believe that the current version of the manuscript is much more complete, coherent, and scientifically sound. The authors are deeply grateful for the reviewers’ role in guiding us toward a stronger and more refined final version of our study.

Author Response File: Author Response.docx

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to congratulate the authors for the work committed in improving the manuscript. I consider it now has an acceptable level for publication. COngratulations

Author Response

We sincerely thank the reviewer for the kind words and positive assessment of our revised manuscript. We truly appreciate the recognition of our efforts to improve the quality of the paper and are grateful for the constructive feedback that contributed to its refinement.

Reviewer 2 Report

Comments and Suggestions for Authors

The paper is now suitable for publication.

Author Response

We sincerely thank the reviewer for the kind words and positive assessment of our revised manuscript. We truly appreciate the recognition of our efforts to improve the quality of the paper and are grateful for the constructive feedback that contributed to its refinement.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting your manuscript to Women. The study offers a timely and innovative contribution by applying inertial measurement units (IMUs) to the quantitative assessment of arm kinematics in breast cancer survivors. The methodological rigor, clarity of reporting, and clinical relevance are notable strengths. I commend the authors for a well-conceived and clearly articulated paper.

The following minor comments are intended to help refine the manuscript before final acceptance.

1. Title

• The title accurately reflects the study scope. You might consider shortening it slightly for conciseness without losing precision, e.g.:
  “IMU-Based Assessment of Arm Movement in Breast Cancer Survivors: An Exploratory Study.”

• Ensure inclusion of standardized terminology such as “Breast Neoplasms,” “Upper Limb Function,” and “Inertial Sensors” for better indexing.

2. Abstract and Keywords

• The abstract is well structured and informative. You could improve clarity by briefly mentioning the sample size and main statistical indicators (e.g., effect sizes or significance levels).

• Replace causal or confirmatory language (“demonstrated differences”) with descriptive phrasing (“showed differences” or “suggested patterns”).

• Ensure keywords correspond to MeSH terms and avoid overlap with the title.

3. Introduction

• The background is thorough and well referenced, though slightly long in the first two paragraphs. Consider condensing general information on breast cancer survivorship to focus more directly on the knowledge gap—the absence of objective kinematic measures in functional assessment post-treatment.

• Add one sentence at the end of the Introduction explicitly stating the study’s exploratory nature and hypotheses.

4. Materials and Methods

• The methods are well presented and reproducible. A few clarifications would enhance transparency:

  • Specify whether the data analysis was performed under an intention-to-treat or per-protocol approach.

  • Mention if covariates such as time since surgery, treatment type, or age were examined or controlled for.

  • Confirm that participants performed the movement tasks in a standardized environment (same posture, side tested first, etc.).

  • Provide the exact sampling rate of the IMU sensors in Hz for full reproducibility.

• Consider briefly describing how missing or noisy IMU data (if any) were handled.

5. Results

• The results are clearly presented, with appropriate statistical tests and consistent reporting of F, p, and η² (or Hedges’ g).

• To enhance interpretability, consider adding a short paragraph commenting on the clinical significance of observed differences (not only statistical ones).

• Ensure all figures and tables have clear legends including units (°/s) and sample size per group.

• Check for minor typographical inconsistencies (e.g., spacing around “°/s”).

6. Discussion

• The discussion is well developed, balanced, and correctly acknowledges the exploratory nature of the findings.

• However, some sentences are phrased too conclusively—for example, avoid wording such as “IMUs confirmed the deficits,” and use instead “IMUs identified potential differences or patterns in arm kinematics.”

• You may briefly expand on clinical applications—how these findings could inform individualized rehabilitation programs or early detection of movement impairments.

• Limit speculation regarding underlying biomechanical mechanisms unless directly supported by the data.

7. Conclusions

• The conclusions are clear and concise.

• You might slightly adjust tone to emphasize that results are preliminary and encourage further validation in larger, longitudinal cohorts.

8. Figures and Tables

• Figures and tables are of high quality and clearly presented.

• Ensure all visual elements include axes labels, units, and statistical markers (e.g., p < 0.05).

• If possible, merge any redundant tables (e.g., demographic and baseline characteristics) for a cleaner presentation.

9. Formal and Language Issues

• The manuscript is well written, with precise and professional English.

• Consider a final language polishing pass to improve flow and remove occasional redundancies.

• Verify consistency in citation style and check for duplicate references (e.g., ref. 39 and 41 appear to be identical).

• Maintain uniformity in abbreviations (e.g., use “IMU” consistently rather than alternating with “sensor”).

10. Overall Assessment

This is a strong and well-prepared manuscript that presents a promising sensor-based method for evaluating upper-limb function after breast cancer treatment. The study is methodologically sound and clinically relevant. Once the minor editorial and stylistic adjustments listed above are addressed, I would fully support its acceptance.

Sincerely :)

Author Response

Please see the attachment.

Author Response File: Author Response.docx