An Integrative Review of Strength Milestoning in Mid-Stage Achilles Tendon Rehab

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor and Authors, I have reviewed the manuscript titled "A Integrative Review of of Strength Mile-Stoning in Mid-Stage 2 Achilles Tendon Rehab ". I believe that this manuscript has the potential to be published, but it requires some revisions to address some issues.

1. There seems to be an extra “of” in the title of the article. Please check.
2. The specific type of literature review adopted is not mentioned in the abstract. It is recommended to clearly state the review method of this article.
3. Line50: The statement of why 10mm clearance is the minimum threshold is very abrupt here and needs a little explanation or expansion here.
4. The article only gives the topics and keywords for literature screening, and recommends supplementing the literature inclusion and exclusion criteria, screening process, etc.
5. Line116: What is the amount of activity that "inactivity" refers to here? Does daily life need fall within this range?
6. Line305-311: Regarding the training volume and intensity in different periods, is there any corresponding literature support? If so, it is recommended to cite it.
7. The conclusions are relatively general and more introductory. It is recommended to put forward specific feasible clinical suggestions or research directions to help clinicians clarify the next research or practice direction.

Author Response

1. There seems to be an extra “of” in the title of the article. Please check.

Thanks for spotting that mistake we have deleted the extra of.

2. The specific type of literature review adopted is not mentioned in the abstract. It is recommended to clearly state the review method of this article.

We have amended the abstract and title to state that the review is an integrative review of the topic.

3. Line50: The statement of why 10mm clearance is the minimum threshold is very abrupt here and needs a little explanation or expansion here.

Agree, we have tried to segue into the topic better and have changed to.

“space of the tendon gap and activity level that the patient is returning to after rehabilitation, determining what method a surgeon will suggest, understanding that a gap of 10 mm or greater is the current minimum threshold where surgery is considered”

4. The article only gives the topics and keywords for literature screening, and recommends supplementing the literature inclusion and exclusion criteria, screening process, etc.

We are not sure what you are asking here given the focus of the integrative review. Could you elaborate please if you think it is important for us to address.

5. Line116: What is the amount of activity that "inactivity" refers to here? Does daily life need fall within this range?

The inactivity refers to cast immobilization or bed rest in which muscle atrophy is seen as early as 5 days.

6. Line305-311: Regarding the training volume and intensity in different periods, is there any corresponding literature support? If so, it is recommended to cite it.

We have added a citation to the sentence from Dravovitch er at. (2022) that explains a rehabilitation continuum that reinforces our statement.

7. The conclusions are relatively general and more introductory. It is recommended to put forward specific feasible clinical suggestions or research directions to help clinicians clarify the next research or practice direction.

We have added this sentence to the final paragraph, please let us know if you want us to drill down further. “It needs to be noted that a great deal of research is needed to determine the reliability and validity, as well as the feasibility of such an approach in a clinical setting.”

Reviewer 2 Report

Comments and Suggestions for Authors

This is a very well-analyzed paper. However, I have a few revision suggestions and questions.

 

1. Introduction

 

Lines 29–30:

“AT, the rupturing of this tendon is a relatively frequent injury”

→ Please provide an approximate incidence rate for Achilles tendon rupture along with an appropriate reference to support this claim.

 

Lines 45–46:

Please include specific examples of sport types commonly associated with ATR (e.g., basketball, soccer, running), to clarify the phrase "distribution across different types of sports."

 

Lines 54–56:

The claim that “shorter term cast immobilization followed by functional mobilization in a brace leads to a faster increase in dorsiflexion ROM and an expedited return to normal physical activity” is not sufficiently supported by a single reference.

Please strengthen this statement by adding additional literature or clinical data.

 

Lines 59–65 (healing phases):

The text provides a good chronological overview of the healing phases. However, to improve reader comprehension, consider presenting this information in a concise table that summarizes the characteristics and goals of each phase.

 

2. Search Strategy

 

Lines 90–91:

The phrase “their philosophical approach” is vague. Please briefly describe what is meant by this—e.g., is it based on clinical experience, biomechanical principles, or patient-centered care?

 

6. Maximal Strength Protocols

 

Line 206:

Please provide a clearer explanation of how passive stiffness was measured. Include the type of equipment or measurement technique used, if available.

 

9. Conclusions

 

Lines 364–367:

The paragraph mentions the availability of portable and affordable solutions for heel raise testing.

Are there specific examples of clinical cases or studies where these technologies have been successfully implemented? Including such cases would enhance the practical value of this section.

Author Response

Introduction

Lines 29–30:

“AT, the rupturing of this tendon is a relatively frequent injury”

→ Please provide an approximate incidence rate for Achilles tendon rupture along with an appropriate reference to support this claim.

We have added these incidence rates;

“Over the past few decades, the incidence of Achilles tendon rupture (ATR) has in-creased significantly, rising from 11 to 37 per 100,000 individuals13,⁶². Males, accounted for 25,374 ATR (77.1%), while female patients accounted for 7533 (22.9%) incidences in the U.S. The overall incidence of ATR for males and females was 3.2 and 0.9 per 100,000 persons/year, respectively. All injuries related to sport participation occurred more in high impact change of direction sports such as basketball (42.6%), soccer (9.9%), football (8.4%), tennis (6.9%), and running/ hiking/stretching (5.8%).

 

Lines 45–46:

Please include specific examples of sport types commonly associated with ATR (e.g., basketball, soccer, running), to clarify the phrase "distribution across different types of sports."

We have added the sports mentioned by the epidemiological researchers.

 

Lines 54–56:

The claim that “shorter term cast immobilization followed by functional mobilization in a brace leads to a faster increase in dorsiflexion ROM and an expedited return to normal physical activity” is not sufficiently supported by a single reference.

Please strengthen this statement by adding additional literature or clinical data.

Agreed. There is another study by Valklering et al (2017) that supports this claim as well. We have added this reference.

Lines 59–65 (healing phases):

The text provides a good chronological overview of the healing phases. However, to improve reader comprehension, consider presenting this information in a concise table that summarizes the characteristics and goals of each phase.

We have briefly mentioned the healing phases to give an overview, but it does not give a detailed overview as it is not the focus of the article. As such we are thinking a table is not needed given our focus, the brevity and the repetition that one reviewer has criticized us for.

Search Strategy

Lines 90–91:

The phrase “their philosophical approach” is vague. Please briefly describe what is meant by this—e.g., is it based on clinical experience, biomechanical principles, or patient-centered care?

This phrase is based on the references gathered from clinics and university sports medicine departments who publicly share their Achilles tendon rehabilitation protocols. These documents reference the literature on strength testing assessments of the plantar flexors but the assessment metrics on what constitutes adequate repetition, volume, and or work vary from clinic to clinic.

We have changed the sentence to reflect this – “based on their current understanding and application of the evidence base.”

 

Maximal Strength Protocols

Line 206:

Please provide a clearer explanation of how passive stiffness was measured. Include the type of equipment or measurement technique used, if available.

This sentence was added, “To measure passive stiffness an isokinetic dynamometer is typically used to move the plantarflexors  at a speed  of 5 deg/s from 10° of plantar flexion (neutral) to a static hold at 80% of the participant’s maximal passive dorsiflexion angle. In some cases, researchers attach electrodes to the plantarflexor muscles to ensure that no muscle activity is initiated (Bressel et al. (2004) and Don et al (2007).”

Conclusions

Lines 364–367:

The paragraph mentions the availability of portable and affordable solutions for heel raise testing.

Are there specific examples of clinical cases or studies where these technologies have been successfully implemented? Including such cases would enhance the practical value of this section.

The Silbernagel et al (2010) article is one such example of using a more mechanotransductive approach to quantifying heel raise assessment.  In the previous section we highlight some options that can be used, the reliability of which has been published.  We have added a sentence in this section to highlight those references, however, we are unaware of specific examples of clinical cases at this point in time, thus the New Perspectives paper and the need for future research.

Reviewer 3 Report

Comments and Suggestions for Authors

This integrative review provides an in-depth exploration of mid-stage rehabilitation protocols for Achilles tendon rupture (ATR), with a particular focus on strength milestone assessments. The authors address the heterogeneity in clinical practices and advocate for a more standardized, quantitative, and mechanotransduction-based approach to rehabilitation. The review succeeds in mapping current protocols, identifying gaps in evidence, and suggesting future directions for research and clinical practice.

Strengths

1. Comprehensive Scope:
   The article presents a well-structured overview of mid-stage ATR rehabilitation, emphasizing both strength-endurance and maximal strength protocols. The inclusion of a wide array of contraction types (isometric, isotonic, isokinetic) and loading conditions adds clinical richness.

2. Clinical Relevance:
   The paper makes a valuable contribution by proposing a periodized model of strength rehabilitation grounded in mechanobiology, which reflects current shifts toward more functional and tissue-specific interventions.

3. Use of Tables and Figures:
   Tables 1 and 2, and Figures 2 and 3, provide clear visual summaries of key milestones, loading parameters, and biomechanical considerations. These tools significantly enhance the practical value of the review.

4. Technological Integration:
   The discussion about implementing low-cost force-measurement technologies (e.g., portable dynamometers, force plates) is timely and critical for broadening access to precision rehabilitation.

Weaknesses and Limitations

1. Lack of Methodological Rigor in Source Selection:
   The search strategy is described as "hybrid," but lacks methodological transparency. There is no PRISMA flowchart or clear criteria for inclusion/exclusion of studies, limiting reproducibility and diminishing the rigor expected of an integrative review.

2. Excessive Heterogeneity Without Critical Appraisal:
   While the paper highlights variability in assessment protocols, it does not sufficiently evaluate the quality or validity of the included studies. The reader is left uncertain as to which protocols are most evidence-based.

3. Limited Consideration of Confounding Factors:
   The paper would benefit from deeper exploration of patient-specific variables (e.g., age, BMI, comorbidities) and their influence on rehabilitation outcomes and strength recovery trajectories.

4. Redundancy and Stylistic Issues:
   Several concepts (e.g., LSI thresholds, heel-rise testing, mechanotransduction) are reiterated multiple times, occasionally leading to verbose or repetitive prose. Streamlining sections would improve clarity and flow.

5. Potential Bias in Clinical Philosophy:
   The authors appear to advocate strongly for mechanotransductive and technology-based rehabilitation models, which, while innovative, may not yet be feasible or validated in all clinical settings. This emphasis may inadvertently downplay the utility of simpler, well-established protocols.

Potential Biases and Conflicts

• The authors are affiliated with institutions heavily invested in sports performance and rehabilitation, which may bias the emphasis toward high-performance metrics (e.g., explosive strength, isokinetics) over broader patient populations.

• Some cited sources appear to be clinical protocols from private clinics or internal guidelines, not peer-reviewed literature, potentially introducing confirmation bias.

Comments on the Quality of English Language

Areas Needing Improvement

1. Redundancy and Verbosity

• Many sections repeat concepts unnecessarily (e.g., multiple iterations of LSI explanation).

• Example:

  "The heel raise test is used to assess heel raise height and work, which is the number of reps × heel height. Heel height is calculated with a linear transducer..."

  Suggestion: Consolidate repeated definitions and shift them to a glossary or methods summary.

2. Grammatical Errors and Awkward Constructions

• Recurrent grammatical mistakes affect fluidity.

• Examples:

  • “The Achilles tendon (AT) is a one of the largest…” → "is one of the largest…"

  • “During this phase the AT will continue to remodel…” → better as “During this phase, the AT continues to remodel…”

  • “This contention providing the focus of this review.” → Sentence fragment; revise to “This contention forms the focus of the present review.”

3. Overuse of Passive Voice and Nominalizations

• Overuse of passive constructions can obscure meaning and reduce engagement.

• Example:

  • “This was fundamentally centered on reinforcing…” → could be “It aimed to reinforce…”

4. Imprecise or Vague Phrasing

• Terms like “different approaches,” “some researchers,” or “certain repetitions” lack specificity.

• More rigorous quantification or attribution would strengthen credibility.

5. Transitions Between Paragraphs

• Some sections (especially in Results and Discussion) feel like lists of findings rather than cohesive arguments.

• Suggested improvement: Add linking phrases such as “Consequently,” “In contrast,” “Therefore,” to clarify logical progression.

Author Response

1. Redundancy and Verbosity

• Many sections repeat concepts unnecessarily (e.g., multiple iterations of LSI explanation).
• Example:

"The heel raise test is used to assess heel raise height and work, which is the number of reps × heel height. Heel height is calculated with a linear transducer..."

Suggestion: Consolidate repeated definitions and shift them to a glossary or methods summary.

We have used Microsoft “Find” to identify these terms/concepts and amended where it made sense and didn’t affect flow and understanding. We felt we didn’t have enough terms for a dedicated glossary.

2. Grammatical Errors and Awkward Constructions

• Recurrent grammatical mistakes affect fluidity.
• Examples:
• “The Achilles tendon (AT) is a one of the largest…” → "is one of the largest…"
• “During this phase the AT will continue to remodel…” → better as “During this phase, the AT continues to remodel…”
• “This contention providing the focus of this review.” → Sentence fragment; revise to “This contention forms the focus of the present review.”

Thank you for the feedback. We have corrected those errors, used Microsoft editor spelling and grammar to check the article, as well as re-reading the article to improve grammar and flow.

 

3. Overuse of Passive Voice and Nominalizations

• Overuse of passive constructions can obscure meaning and reduce engagement.
• Example:
• “This was fundamentally centered on reinforcing…” → could be “It aimed to reinforce…

Agreed, we have scanned the article given your comments and made changes where passive voice was used.

.

4. Imprecise or Vague Phrasing

• Terms like “different approaches,” “some researchers,” or “certain repetitions” lack specificity.
• More rigorous quantification or attribution would strengthen credibility.

 

Agree with you and tried to address this as best we can, where we can.

 

5. Transitions Between Paragraphs

• Some sections (especially in Results and Discussion) feel like lists of findings rather than cohesive arguments.
• Suggested improvement: Add linking phrases such as “Consequently,” “In contrast,” “Therefore,” to clarify logical progression.

Thank you for that suggestion, we have reviewed the article with this in mind.

 

Weaknesses and Limitations

1. Lack of Methodological Rigor in Source Selection:
   The search strategy is described as "hybrid," but lacks methodological transparency. There is no PRISMA flowchart or clear criteria for inclusion/exclusion of studies, limiting reproducibility and diminishing the rigor expected of an integrative review.

As intimated early in the article it was an integrative review with certain aspects of a systematic review, but not a full on systematic review therefore a full PRISMA approach was not taken, especially given the “New Perspectives” focus.

1. Excessive Heterogeneity Without Critical Appraisal:
   While the paper highlights variability in assessment protocols, it does not sufficiently evaluate the quality or validity of the included studies. The reader is left uncertain as to which protocols are most evidence-based.

It needs to be noted that the quality of the studies was not important and impossible to deduct in much of the resources used i.e. assessment batteries from clinics and hospitals. Saying that most/ if not all of the isokinetic and heel raise assessments have reliability studies/statistics associated with them. The focus of the section was to highlight the assessments that are currently used in the field and show the commonality alongside the variability of these tests. By highlighting this across studies the reader has clear insight into some of the challenges associated with AT testing.

1. Limited Consideration of Confounding Factors:
   The paper would benefit from deeper exploration of patient-specific variables (e.g., age, BMI, comorbidities) and their influence on rehabilitation outcomes and strength recovery trajectories.

We feel that looking at these patient-specific variables would add little to the focus of the paper, which was certainly not on identifying “their influence on rehabilitation outcomes and strength recovery trajectories.”  We have reworded the focus statements of the review to make this clearer to the reader. “The aim of the article was to provide an overview of AT rehabilitation, with particular critique around mid-stage strengthening and the use of the heel raise assessment in mile-stoning rehabilitation progress. From this critique new perspectives in mid-stage strengthening are suggested and future research directions identified.” 

 

1. Redundancy and Stylistic Issues:
   Several concepts (e.g., LSI thresholds, heel-rise testing, mechanotransduction) are reiterated multiple times, occasionally leading to verbose or repetitive prose. Streamlining sections would improve clarity and flow.

We have used Microsoft “Find” to identify these terms/concepts and amended where it made sense and didn’t affect flow and understanding.

1. Potential Bias in Clinical Philosophy:
   The authors appear to advocate strongly for mechanotransductive and technology-based rehabilitation models, which, while innovative, may not yet be feasible or validated in all clinical settings. This emphasis may inadvertently downplay the utility of simpler, well-established protocols.

You have made a good point here and so we have added this sentence to address your point here as the final sentence of the conclusions. “It needs to be noted that a great deal of research is needed to determine the reliability and validity, as well as the feasibility of such an approach in a clinical setting.”

 

 

Potential Biases and Conflicts

• The authors are affiliated with institutions heavily invested in sports performance and rehabilitation, which may bias the emphasis toward high-performance metrics (e.g., explosive strength, isokinetics) over broader patient populations.
• Some cited sources appear to be clinical protocols from private clinics or internal guidelines, not peer-reviewed literature, potentially introducing confirmation bias.

Again you have made some good points. We believe diversity is needed to advance practice and having a different lens might stimulate thought and advance physiotherapeutic practice. We have purposely kept our approach very simple and mentioned three strength measures we think important for the practitioner to understand. Current force plate technology can be overwhelming with near 200 variables that can be measured, thus our approach. Saying that we have a great cross-section of authors on the paper from Professors in Physical Therapy and Strength and Conditioning, Strength and Conditioning Coaches, a Sports Physician and a Senior Research Associate. We feel such a team can give a balanced perspective on potential next steps for the profession without bias, the validity/value of such a contention however will be some of the future research directions we take.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Summary of Review and Author Responses

The manuscript addresses an important and clinically relevant topic regarding Achilles tendon (AT) rehabilitation, specifically emphasizing mid-stage strengthening and the use of the heel raise test for rehabilitation mile-stoning. While the topic is timely and the authors demonstrate deep clinical and academic expertise, the initial review identified several structural, stylistic, and methodological limitations that required clarification or correction.

The authors have made efforts to address the reviewer’s concerns, but in several cases, the responses lack sufficient depth, transparency, or evidential support. Below is an analysis of how each key issue was addressed:

1. Redundancy and Verbosity

Reviewer concern: Multiple repetitions of key concepts (e.g., LSI, heel raise testing).

Author response: Terms were identified using the "Find" tool in Word, and edits were made where they “did not affect flow.”

Evaluation: While the authors acted on the suggestion, the reliance on automated tools is insufficient. A more strategic editorial consolidation (e.g., defining terms in a central section) would improve clarity and reduce cognitive load for the reader.

2. Grammatical Issues and Awkward Phrasing

Reviewer concern: Sentence fragments, misuse of articles, comma splices, and inconsistent tense.

Author response: Errors were corrected using Microsoft Editor and re-reading.

Evaluation: This response is generic and lacks examples of revised passages. While some errors may have been corrected, the overall academic tone and fluency would benefit from professional linguistic editing.

3. Overuse of Passive Voice and Nominalizations

Reviewer concern: Excessive passive constructions reduce clarity and engagement.

Author response: Authors scanned and revised where appropriate.

Evaluation: The acknowledgment is appreciated, but specific improvements are not demonstrated. A few before-and-after sentence examples would have increased reviewer confidence in the depth of revision.

4. Imprecise or Vague Language

Reviewer concern: Terms like “some researchers” or “certain repetitions” are too ambiguous for a scientific review.

Author response: Improvements made “where we can.”

Evaluation: While the attempt is noted, the response appears to underappreciate the importance of specificity in an academic manuscript. Instances of vague phrasing likely remain unless changes are evidenced.

5. Paragraph Cohesion and Transitions

Reviewer concern: The flow in Results and Discussion lacks cohesion, reading like lists of findings.

Author response: The article was reviewed with attention to transitions and linking phrases.

Evaluation: Positive step, though it would be helpful to have examples of improved transitions to verify logical progression between concepts.

6. Methodological Rigor and Transparency

Reviewer concern: Lack of a PRISMA diagram or systematic inclusion/exclusion criteria for an integrative review.

Author response: Justified as a “New Perspectives” piece with partial systematic elements.

Evaluation: Acceptable if positioned explicitly as an integrative/scoping review, but clarity is still needed in the methods to ensure transparency and reproducibility.

7. Heterogeneity and Critical Appraisal

Reviewer concern: The manuscript highlights variability in protocols but does not evaluate study quality or evidence strength.

Author response: Authors emphasize this was outside the scope given the nature of the data sources (e.g., clinical assessments, not trials).

Evaluation: This is a reasonable limitation, but a clearer disclaimer in the methods section about lack of formal quality appraisal would strengthen transparency.

8. Confounding Variables

Reviewer concern: Limited exploration of age, BMI, comorbidities, etc., in rehabilitation outcomes.

Author response: Clarified that this was not the focus of the review and revised the aim statement.

Evaluation: The clarification is appropriate. Explicitly stating this exclusion in both the methods and discussion would improve reader understanding.

9. Philosophical and Practical Bias

Reviewer concern: Potential overemphasis on mechanotransduction and tech-heavy assessments not feasible in all clinical settings.

Author response: Added disclaimer in the conclusion acknowledging need for validation and feasibility studies.

Evaluation: This addition is appreciated and appropriately addresses the concern of overgeneralization.

10. Conflicts of Interest and Institutional Bias

Reviewer concern: Emphasis on performance metrics may reflect institutional biases.

Author response: Highlighted the multidisciplinary team and diversity of clinical experience as a safeguard against bias.

Evaluation: The explanation is convincing. However, further clarity about funding sources and potential institutional ties (if any) would still be advisable in a conflict of interest statement.

Comments on the Quality of English Language

See my comments to the authors

Author Response

The manuscript addresses an important and clinically relevant topic regarding Achilles tendon (AT) rehabilitation, specifically emphasizing mid-stage strengthening and the use of the heel raise test for rehabilitation mile-stoning. While the topic is timely and the authors demonstrate deep clinical and academic expertise, the initial review identified several structural, stylistic, and methodological limitations that required clarification or correction.

The authors have made efforts to address the reviewer’s concerns, but in several cases, the responses lack sufficient depth, transparency, or evidential support. Below is an analysis of how each key issue was addressed:

 

1. Redundancy and Verbosity

Reviewer concern: Multiple repetitions of key concepts (e.g., LSI, heel raise testing).

Author response: Terms were identified using the "Find" tool in Word, and edits were made where they “did not affect flow.”

Evaluation: While the authors acted on the suggestion, the reliance on automated tools is insufficient. A more strategic editorial consolidation (e.g., defining terms in a central section) would improve clarity and reduce cognitive load for the reader.

We have included a glossary of abbreviations as requested; however, we would like to point out that only 4 abbreviations do not appear in keys where they are defined. We are criticized for verbosity and redundancy; however, it seems strange to us ask to include such a section nonetheless we have done so.

Line 108: A glossary of terms is provided for the reader to improve clarity and readability.

 

2. Grammatical Issues and Awkward Phrasing

Reviewer concern: Sentence fragments, misuse of articles, comma splices, and inconsistent tense.

Author response: Errors were corrected using Microsoft Editor and re-reading.

Evaluation: This response is generic and lacks examples of revised passages. While some errors may have been corrected, the overall academic tone and fluency would benefit from professional linguistic editing.

Corrections 2-5: We have reread the entire manuscript and cleaned up all grammatical, passive tone, passage transitions, and article issues we saw that needed improvements. All alterations for round 2 of the paper revisions are highlighted in green.  It needs to be noted that some of the changes won’t be seen (repetition and redundancy) as we have deleted these. Also, it needs to be noted that some of the changes you are seeing, we are not seeing as these sometimes are personal preferences, which is confirmed by the other two reviewers not commenting on Points 2-5. Saying that we have done the best we can, and if you want us to change anything please be more specific.  Thanks.

 

3. Overuse of Passive Voice and Nominalizations

Reviewer concern: Excessive passive constructions reduce clarity and engagement.

Author response: Authors scanned and revised where appropriate.

Evaluation: The acknowledgment is appreciated, but specific improvements are not demonstrated. A few before-and-after sentence examples would have increased reviewer confidence in the depth of revision

 

4. Imprecise or Vague Language

Reviewer concern: Terms like “some researchers” or “certain repetitions” are too ambiguous for a scientific review.

Author response: Improvements made “where we can.”

Evaluation: While the attempt is noted, the response appears to underappreciate the importance of specificity in an academic manuscript. Instances of vague phrasing likely remain unless changes are evidenced.

 

5. Paragraph Cohesion and Transitions

Reviewer concern: The flow in Results and Discussion lacks cohesion, reading like lists of findings.

Author response: The article was reviewed with attention to transitions and linking phrases.

Evaluation: Positive step, though it would be helpful to have examples of improved transitions to verify logical progression between concepts.

 

6. Methodological Rigor and Transparency

Reviewer concern: Lack of a PRISMA diagram or systematic inclusion/exclusion criteria for an integrative review.

Author response: Justified as a “New Perspectives” piece with partial systematic elements.

Evaluation: Acceptable if positioned explicitly as an integrative/scoping review, but clarity is still needed in the methods to ensure transparency and reproducibility.

We have mentioned another three times that this is an integrative review and given the details of the search strategy, we feel we have provided enough information to be fully transparent and the methods reproducible for the reader.

 

7. Heterogeneity and Critical Appraisal

Reviewer concern: The manuscript highlights variability in protocols but does not evaluate study quality or evidence strength.

Author response: Authors emphasize this was outside the scope given the nature of the data sources (e.g., clinical assessments, not trials).

Evaluation: This is a reasonable limitation, but a clearer disclaimer in the methods section about lack of formal quality appraisal would strengthen transparency.

We have added this section to address your concern:

Line 98: It needs to be noted that the quality of the studies were not quantified for two reasons: 1) many of the resources compiled were assessment batteries from clinics and hospitals; and, 2) the focus of the section was to highlight the assessments that were currently used in the field and show the commonality alongside the variability of these tests,  highlighting this across studies providing reader insight into some of the challenges associated with AT testing. Given this approach there was limited exploration of the effects of age, BMI, comorbidities, etc. on the assessment of the AT.

 

8. Confounding Variables

Reviewer concern: Limited exploration of age, BMI, comorbidities, etc., in rehabilitation outcomes.

Author response: Clarified that this was not the focus of the review and revised the aim statement.

Evaluation: The clarification is appropriate. Explicitly stating this exclusion in both the methods and discussion would improve reader understanding.

We have addressed this concern in #7.

 

9. Philosophical and Practical Bias

Reviewer concern: Potential overemphasis on mechanotransduction and tech-heavy assessments not feasible in all clinical settings.

Author response: Added disclaimer in the conclusion acknowledging need for validation and feasibility studies.

Evaluation: This addition is appreciated and appropriately addresses the concern of overgeneralization.

 

10. Conflicts of Interest and Institutional Bias

Reviewer concern: Emphasis on performance metrics may reflect institutional biases.

Author response: Highlighted the multidisciplinary team and diversity of clinical experience as a safeguard against bias.

Evaluation: The explanation is convincing. However, further clarity about funding sources and potential institutional ties (if any) would still be advisable in a conflict-of-interest statement.

No funding sources were sought for this paper and one author has shares in an un-named technology company.